Primary Care – Black Women’s Health
Introduction
African Americans tend to experience worse health than white Americans, and racial inequalities in health have persisted across time despite major advances in the post-Civil Rights era (Williams and Sternthal 2010). Specifically, African Americans have higher mortality rates than Americans of European descent for the majority of the fifteen leading causes of death, including cancer, hypertension, heart disease, and diabetes (Kung et al. 2008). Research also indicates that low-income African Americans may encounter more environmental factors conducive to negative health outcomes, such as exposure to harmful toxins and pollution (Williams and Mohammed 2009). Additionally, low-income urban African Americans are disproportionately exposed to violence and crime, which can increase stress and contribute to negative physical and mental health outcomes including low birth-weights and post-traumatic stress disorder (Morenoff 2003, Dohrenwend et al. 1992). Because African Americans, on average, have lower socioeconomic status than those of European descent in the United States, they also disproportionately experience the negative effects of poverty on health, further compounding inequalities tied to race (Nguyen and Peschard 2003).
Though use of health services is only one of many factors, research has consistently identified underutilisation to be significantly correlated with poor health outcomes (LaVeist et al. 2003). Broadly, African American men and women tend to use health services less than their white counterparts – meaning health problems are frequently diagnosed later when they are more serious, contributing to worse outcomes (Wright and Perry 2010, Zuvekas and Fleishman 2008). These patterns of underutilisation are particularly problematic since low-income women of color are disproportionately in need of health services (Wyn et al. 2004). For instance, African American women are more likely than white women to identify their health as fair to poor and more likely to report a physical condition that limits routine activities (Wyn et al. 2004). Further, low-income African American women may experience worse mental and physical health due to the compounding effects of their gender, race, and class statuses such that they may simultaneously encounter sexism, racial discrimination, and classism in their daily lives (Perry et al. 2013).
Despite the health implications of racial and gender disparities in utilisation, the majority of research in this area focuses on acute physical or mental health services, and service utilisation among the elderly (Shenson et al. 2012, Ojeda and Bergstresser 2008, Williams and Mohammed 2009). In addition, with the exception of studies examining end of life care and cancer treatment decisions, few existing utilisation studies examine the role of factors like religiosity, cultural attitudes and experiences, and social support that may be particularly relevant to African American women (Gerend and Pai 2008, Johnson et al. 2005). Importantly, the findings of this extant research cannot be expected to translate to preventative care utilisation. That is, given the differences between making time-sensitive, life-or-death decisions and making less urgent, “everyday” choices about basic health maintenance, arguing that factors influencing these differing types of choices operate similarly is untenable. These gaps in the literature are also problematic since preventative care – especially having a yearly comprehensive physical exam – is essential for maintaining good health through early disease identification and the management of chronic conditions like hypertension and diabetes that are prevalent among African Americans (Williams and Mohammed 2009). Further, preventative care in the United States often serves as a gateway to accessing other services, such as care from specialist physicians.
The purpose of this research is to expand our knowledge of the mechanisms underlying African American women’s usage of preventative care services; specifically, having received an annual physical exam. Using survey data from 206 low-income, urban African American women, self-reported barriers to preventative care and alternative sources of health information are first described. Subsequently, we examine the relationship between having an annual physical and a variety of culturally relevant factors, with a particular emphasis on how differing levels of social support from friend and family networks and experiences of racist life events and cultural mistrust are associated with patterns of utilisation among this underserved population.
Access to services
Since early in the development of health services research, economic and access factors have been considered key determinants of utilisation. For example, according to Andersen’s Health Behavior Model (1968), high socioeconomic status (SES) and living in advantaged communities predispose individuals to use health services. Likewise, income, insurance status, and the affordability of care enable a person with health care needs to seek services. Research suggests that this is especially true for those seeking preventative care services, as lower-SES adults are less likely to have physical examinations, immunisations, and other basic forms of preventative care (Wright and Perry 2010, Maciosek et al. 2010, Prus 2007).
Empirical research examining delays and abstention from usage of health services among African American women has consistently found that economic factors influence utilisation (Wyn et al. 2004). Broadly, regardless of race, research shows that those with insurance are more likely to utilise health services when compared to those without insurance (Patel et al. 2010, DeVoe et al. 2003). This trend may have special relevance for African American women, as estimates suggest that over 20% of African American women have no health insurance, and they are less likely to have employment-based insurance than white women (Snipes et al. 2009, Wyn et al. 2004).
Continuity of care has also been identified as a factor influencing utilisation choices. Namely, those who have a regular physician tend to use health services more consistently (Blackwell et al. 2009, DeVoe et al. 2008, Ettner 1999, Sox et al. 1998). Additionally, individuals with a usual source of care tend to have fewer emergency department visits and shorter hospitalisations (DeVoe et al. 2003). This research indicates that having a usual physician may be of paramount interest when examining preventative care utilisation.
Racial attitudes and experiences
In addition to examining more traditional predictors of utilisation, it is also critical to link low-income African American women’s help-seeking decisions to their culturally-specific attitudes and experiences. Importantly, experiences of racism and sexism linked to both racial and broader cultural differences with dominant European American society have significant effects on people of color. While it is well established that racial discrimination can have myriad consequences on morbidity and mortality through the stress process and other pathways, less is understood about how such experiences might shape health service utilisation (Thoits 2010, Todorova et al. 2010, Higginbottom 2006). Some research suggests that the Eurocentric orientation of medical institutions (i.e. emphasis on Western biomedical beliefs and practices coupled with little recognition of alternative beliefs and healing practices, etc.) may foster sentiments of cultural mistrust among African Americans whose beliefs or values are marginalised in these settings (Chandler 2010, Blank et al. 2002). For example, fear of racial discrimination in medical facilities has been found to deter African Americans from utilising available services (Shavers et al. 2012, Lee et al. 2009). Further, when compared to whites, African Americans report lower levels of trust in both their physician and in the health care system, and express greater concerns regarding the quality of care (Wyn et al. 2004). In turn, African American women with low levels of trust in their primary care provider are less likely to use and recommend preventative services (Yang et al. 2011). In all, racial attitudes and experiences may have a greater and more measureable impact on the use of some preventative care services, like an annual physical, which are perceived as less urgent or necessary than other types of health care services.
Social support
In addition to discrimination and cultural mistrust, social networks – and particularly social support – may be an especially important consideration when examining patterns of health care utilisation among low-income African American women. African American women are embedded in social networks that influence health decisions and help-seeking behaviors, and evidence suggests their networks are typically large, highly supportive, and comprised of extended kin (Brown 2008). While past research has already found social support to be an important resource for African American women with severe medical needs, considerably less is known about the effect of African American women’s extended kinship networks on usage of preventative care services (Tang et al. 2008). Utilisation models have highlighted the role of social networks and support more broadly. Most notably, the Network-Episode Model (NEM) is a theory of health service utilisation that emphasises the critical and dynamic role that social support resources and social interaction with network members play in the process of decision making (Pescosolido 1991).
The NEM suggests that decisions regarding health service utilisation are shaped by the attitudes and actions of friends and family members. The NEM recognizes that individuals often confer with members of their networks when making health decisions, and that the emotional support, advice, and information they receive from these people can have a significant and measureable influence on their health behaviors and utilisation choices. Often, supportive networks contribute to early entry into health services and compliance with treatment plans (Perry and Pescosolido 2010). Alternatively, having a very strong social safety net could lead to overregulation and the perception that formal health services are unnecessary (Durkheim 1951). Likewise, networks characterized by negative attitudes toward health professionals or medical care could provide well-intentioned support that “pushes” individuals away from formal (i.e. professional) health care services (Pescosolido 1991).
Identifying the linkages between social support and health services utilisation is complex, in part because the direction of the effect may depend on the composition and “content” (i.e. the attitudes, advice, experiences) of the network that is providing support (Perry and Pescosolido 2010). Additionally, some research finds that health needs moderate the impact of social support such that the combination of high need and low social support increases use of ambulatory services (Kouzis and Eaton 1998, Penning 1995). This seems to suggest that supportive networks buffer either actual or perceived need for health services, but much less is known about how social support affects use of preventative services, which are not need-dependent and are more likely to be influenced by access issues (Wyn et al. 2004). Further, research of this kind has never been conducted using a sample of low-income African American women, so it is unclear how social support from family and friends influence preventative care help-seeking decisions. Specifically, social support may be of particular importance among those with limited resources, who may be disproportionately likely to rely on lay members of their social network to fill gaps in formal help-seeking. Understanding the influence of social support for this at-risk population is needed to provide insight into pathways to regular preventative health services utilisation and early detection of disease among African American women, potentially contributing to improvements in the health and longevity of members of this minority group.
Religiosity
African Americans, especially women, consistently report higher levels of religious involvement than other ethnic groups, and religion has been called the “cornerstone” of African American communities (Chandler 2010, Watlington and Murphy 2006). High levels of church attendance enhance the solidarity of these communities, and the church holds an important place as a social and cultural institution (Blank et al. 2002, Chandler 2010). Consequently, past research has examined the effects of spiritual beliefs on African Americans’ use of health services (Ward et al. 2009, Kinney et al. 2002, Mitchell et al. 2002). Though findings are mixed, they generally indicate that more religious African American women tend to use preventative and screening services less frequently, relying more on spiritual beliefs than formal medical services to manage their health (Kinney et al. 2002, Mitchell et al. 2002). The results of this research, coupled with the well-established importance of religion and spirituality in African American communities, demonstrate the necessity of considering religiosity when examining patterns of utilisation among African American women.
In sum, though the existing empirical research has linked culturally-specific factors to African American women’s use of certain types of health services, further research is needed to examine how these factors relate specifically to preventative care utilisation(Chandler 2010, LeVeist et al. 2003). This lack of research is especially evident as it relates to vulnerable populations, such as low-income women, who are among those most in need of preventative services and least likely to use them. In response to these gaps in the literature, this research explores self-reported barriers to utilisation among low-income African American women, and investigates the impact of cultural and social factors on one type of preventative health service – having a physical exam in the past year. Specifically, we examine African American women’s likelihood of having a physical exam as a function of 1) access and economic factors; 2) racial experiences and attitudes; 3) social support from friends and family; and 4) religiosity.
Methods
Sample
The data used in this research are from the first wave of the B-WISE (Black Women in a Study of Epidemics) Project. This data was collected between 2008 and 2009 in an urban setting as part of an ongoing project evaluating the health consequences of substance use among African American women. In addition to the community sample used in these analyses, the B-WISE Project includes a sample of African American female probationers and a sample of incarcerated African American women. Drug users were over sampled due to higher rates of drug use among women in the criminal justice system. This stratified sampling technique ensured that approximately 100 of the women in the community sample had used illicit drugs in the year prior to their recruitment.
The community sample was recruited through advertisements in local newspapers and flyers posted in areas with high percentages of African American residents. Women interested in participating called the study offices and were screened by interviewers to determine eligibility. To participate, respondents had to be 18 years or older, self-identify as African American and female, and not be under supervision of the criminal justice system. Eligible women were interviewed by trained African American female interviewers in private locations, including meeting rooms at public libraries and the study office. All data were collected with computer assisted personal interviewing (CAPI) to reduce response and data entry error. Study participants were compensated for their time, earning $20 for the baseline interview with additional incentives up to $40 for completing optional drug and disease testing.
The community sample used for these analyses includes 205 African American women, with an average age of 36.55 years. Most of the women are unmarried (86.82%). On average, respondents have 12.74 years of education and the mean household income is $20,760. African American women in the sample are significantly less likely to be married than those in the targeted zip codes (13.17% compared to 29.00%; Z=4.57; 2000 Census), but are otherwise representative of the population sampled. Though this sample is not representative of African American women within the U.S. generally, it does mirror the demographics of low-income, urban African American women in the United States.
Measures
Barriers to healthcare
Respondents were asked to report reasons why they “didn’t get health care or even an annual physical exam during the past year”. Thirty potential responses were presented and participants selected all that applied. Barriers reported with the greatest frequency and those which related directly to independent variables examined in the quantitative analysis were selected. Their frequencies were reported in Table 2 both for descriptive purposes and to assess the validity of the regression results.
