Black Women in Rural Communities: Unraveling Health Disparities

1. Faye A. Gary Case Western Reserve University Gloria B. Callwood University of the Virgin Islands Hossein N. Yarandi Doris W. Campbell University of South Florida (Ret) University of the Virgin Islands Suzette Lettsome University of the Virgin Islands Edith Ramsey Johnson University of the Virgin Islands Black Women in Rural Communities: Unraveling Health Disparities

2. Purpose • Discuss factors influencing women’s health issues in local communities---including conceptual frameworks • Present findings from an Empirical Study about African American Women in a Rural Community • Share qualitative data from Focus Groups of African American Women • Provoke discussions about the health status of women and its relationship to the social determinants of health

3. WHO • Gender is used to describe those characteristics of women and men which are socially constructed • Sex is biologically determined • People are born female or male but learn to be girls and boys ----who grow into women and men. This learned behavior makes up gender identity and determines gender roles.

4. Source: Abou-Gareeb, Lewallen, Bassett and Coutright. Gender and blindness: a meta-analysis of population based prevalence surveys. Opthalmic Epidemiology 2001; 8:39-56 BURDEN OF BLINDNESS IN MEN AND WOMEN Source: Abou-Gareeb, Lewallen, Bassett and Coutright. Gender and blindness: a meta-analysis of population based prevalence surveys. Ophthalmic Epidemiology 2001;8:39-56; Barry, M. (2004) Yale University

5. Frameworks • Numerous Frameworks Developed to Examine Health Disparities • Comprehensive framework of the determinants of health. George Kaplan, 1999. • Framework for human development and the social determinants of health.Hertzman, 1999. • Model for the pathways by which SES may affect health. Baum et al., 1999. • MacArthur Foundation Research Network in Socioeconomic Status and Health model of pathways from SES to health, 2000 • Social Determinants of Health. Marmot & Wilkerson, 1999; 2006.

6. Social and Economic Policies & Institutions Life course Neighborhood/Communities Living Conditions Social Relationships Individual Risks Genetic/Constitutional Factors Pathophysiological pathways Environment Individual/Population Health Kaplan, 1999

7. Human Life Cycle Social Birth Network Death Civil Society National Socio-Economic Environment Hertzman, 1999

8. SES Neighborhood or Community Hazards and Supports Social Conditions (e.g., Discrimination, Exclusion) That Are Correlated With SES Other Aspects of SES That Affect Health (e.g., Access to Medical Care, Nutrition, Role Models) STRESS • Behaviors That Impair or Support Good Health • Tobacco Use • Exercise • Changes in Illness-Related Behavior • Prevention • Early detection • Biological Changes in Systems • Immune System • Endocrine System Health Outcomes

9. Health Outcomes Environmental Resources & Constraints Neighborhood Factors Social Capital Work Situation Family Environment Social Support Discrimination Access to Medical Care Health Cognitive Function Physical Function SES Education Occupation Income Subjective SES SES Inequality Exposure to Carcinogens & Pathogens Disease Race Gender Disease Trajectories Recovery Relapse Secondary Events Health-Related Behaviors Psychological Influences Resilience/Reserve Capacity Negative Affect (anxiety, depression, hostility) Negative Expectations Perceived Discriminations Reactive Responding Central Nervous System & Endocrine Response Mortality Life Course

10. Social Determinates of Health Social Structure Material Factors Work Psychological Social Environment Brain/Neuro- Endocrine & Immune Response Health Behaviors Pathophysiological Changes Early life Genes Genotypes Well-being Morbidity Mortality Culture Ethnicity Marmot, M., &. Wilkinson. (2006). Social Determinants of Health. New York: Oxford University Press.

11. Women’s Health An Empirical Study

12. Relationship between Personal Knowledge, Social Support Systems, Menopausal Symptoms, Self-care, Depressive Symptoms, Stress, and Health Status among Southern Rural African American Menopausal Women

13. Introduction • The social determinants of health and its relationship to the well-being of Black women is seldom researched and often overlooked in practice and health policy • Stress manifests itself as a disturbance in mood with common symptoms such as persistent sadness or despair, insomnia, decreased appetite, hopelessness, irritability, low self-esteem and suicide

14. Background • Black women are on the top 10 list of diseases and disorders • They typically are undiagnosed or under diagnosed with depression, anxiety, sleep disorders, and other mental health related disorders • Blacks are more likely to receive care in the primary care sector, but disparities exist in both the recognition of psychological stress disorders, and subsequent treatment

15. Stress • Irritating, conflicting, frustrating, and distressing demands that occur in everyday transactions • Examples include • Arguments with family members or friends • Deadline pressures • Financial difficulties • Sleep disturbance • Multiple responsibilities that need attention

16. Health • Differences in Health Status Among Black Women Related to: • Lower Socioeconomic Status • Daily Hassles • Unfair Treatment in Society • Acute Life Events • Cumulative Stress

17. Participants • The sample consisted of 206 Black women at various rural sites within a 50-mile radius of a large university. • The participants were between 40 and 60 years of age, and all of them resided in rural communities.

18. Methods • Survey data from 206 black women were used in this study • Face-to-face interviews that lasted about one hour in duration • Items were read aloud to the women to avoid the need to query them about their reading levels

19. Measures • Demographic Data Form • Menopausal Health Survey • Life Stress Questionnaire • Beck Depression Inventory • People in Your Life Inventory

20. Marital Status

23. Health Status (Self Report)

24. Payment for Medical Care

25. Demographic Characteristics • Mean Age = 48.09 (SD = 6.45) • Mean Education = 13.5 (SD = 7.02) • Married = 61% • Employed = 62% • Protestant = 89% • Insurance = 89%

26. Menopause Knowledge: After menopause, women’s risks of heart attachs:

27. Menopause Knowledge: Hot flashes can be reduced by:

28. Health Promotion I watch my diet

29. Health Promotion I do planned exercises

30. Health Promotion I take vitamins, herb, mineral or calcium supplements

31. Take on a greatly increased workload How stressful was the event to you?

32. Separated from mate for more than two weeks due to argument or discord How Stressful was the event to you?

33. Close Friend or relative had major change in health status How stressful was the event to you?

34. Close friend or family member involved in crime or legal matter How stressful was the event to you?

35. Chronic Financial Stress How stressful was the event to you?

36. Findings • No Association between Health Status & Insurance • Positive Relationship between Health Status & Employment (chi-square = 33.26, p = 0.0001) • Odds Ratio of Unfavorable Health Status & Unemployment Was 6.17 Times Higher Than Women with Favorable Health Status & Employed

37. Findings • Among Those with Unfavorable Health Status, 66.67% Were Unemployed, While Only 24.48% of Those with Favorable Health Status Were Not Fully Employed. • A Non Employed Black Woman Had a 86.05% Probability of Having an Unfavorable Health Status

38. Findings • Characteristics of the Women with Favorable Health Status: • More Educated ( t = 2.98, p < 0.0032) • Higher Incomes (z = 4.34, p < 0.0001) • Incurred Less Out of Pocket $ for Medications( t = 8.40, p < 0.0001) • Higher Scores in Health Knowledge(z = 4.15, p < 0.0001) • Higher Scores in Decision Making (z=8.98, p <0.0001) • Higher Scores in Controlling Menopause Symptoms (z = 8.98, p <0.0001) • Higher Scores in Health Promotion (z = 6.96, p <0.0001) • Higher Score in Self Perceptions (z = 5.82, p < 0.0001) • Lower Score in Life Experiences (z = 6.09, p <0.0001)

39. Findings • Characteristics of the Women with Favorable Health Status • Fewer Unpleasant/Distressing Social Interactions (z = 7.88, p < 0.0001) • More Pleasant Events in Their Lives(z = 7.66, p <0.0001) • More Active in Participating in Support Groups and Health Related Organizations (z = 3.00, p = 0.0027). • Between the two groups, no significant differences in • the Mean Age (t = 1.37, p = 0.1731), • Beck Depression Score (z = 0.33, p = 0.7387), • Life Stress Score (z = 1.077, p = 0.2826), • People Interactions Score (z = 0.99, p = 0.3193)

40. Findings: Logistic Regression • Statistically Significant Variables Were: • Health Knowledge • Controlling Menopause Symptoms • Experiencing Pleasant Life Events • Unpleasant/Distressing Social Interactions • Self Perceptions • Women who self-reported favorable heath status had: • 1.83 times higher health knowledge, • 1.61 times better control of menopause symptoms, • 1.65 times more pleasant life events, • 2.43 times higher self perceptions than those who reported unfavorable heath status

41. Beck Depression Scale Total Score Distribution

42. Beck Depression Scale Total Score Distribution for the Sample

43. Factor Analysis of DBI-II • Evidence of the BDI factorial validity is provided by the intercorrelations among the 21 BDI items, which were first calculated from the responses of the sample of 206 Black Women. • Kaiser's measure of sampling adequacy for this matrix was 0.92, a value that Kaiser considered to be “marvelous.” • An iterated principal-factor analysis was performed in which squared multiple correlations were employed for the initial communality estimates, and a Promax (oblique) rotation was used to identify the self-reported dimensions of depression.

44. Factor Analysis of DBI-II • Two factors were extracted, they explained 83% of the common variance. • Two comparably sized eigenvalues of 5.34 and 5.53 were found for the reduced correlation matrix and the correlation between the two oblique factors was 0.57 (p < 0.001).

45. Pattern Matrix for the Factor Analysis of Beck Depression Scale-II

46. Factor Interpretation • Symptoms such as Pessimism, Worthlessness, Punishment Feelings, Sadness, Self-Dislike, Loss of Interest, Indecisiveness, and Past Failure tended to load high on the first factor. All of these symptoms were psychological and cognitive in nature. Therefore, this factor was considered to reflect a Cognitive dimension of self-reported depression.

47. Factor Interpretation • The second factors explained somatic symptoms, such as Tiredness or Fatigue, Loss of Energy, Concentration Difficulty, Irritability, Changes in Appetite, Changes in Sleeping Pattern, Loss of Interest in Sex, and Loss of Pleasure. The factor was considered to represent a Somatic- Affective dimension of self-reported depression.

48. Naming the Factors • Factor I can be named as “critical self appraisal.” The variables included in Factor 1 are cognitive in nature and indicate that the women are critical of themselves, devalue their significance, and internalize thoughts that constitute a negative self-view. • Factor II can be named “deregulation of arousal.” It is related to physiological changes that occur among individuals.

49. Focus Group • Two focus groups were conducted. • Each focus group consisted of 10 participants. • The participants were chosen randomly from the sample of 206 African American Women.

50. Responses to One Query • What Do You Think are the Barriers or the Stumbling Blocks to Black Women Receiving Good/High Standard Healthcare?