Table of contents(17 chapters)
Part I Introduction to Volume
This chapter provides both an introduction to the volume and a brief review of literature on women, gender, and health and health-care services as well as racial/ethnic minorities in the same areas.
The chapter argues for the importance of greater examination of women, issues of gender, and racial and ethnic minorities in health and health-care services.
The chapter reviews the issues of women and racial and ethnic minorities and previews this book.
Part II Women and Reproductive Related Health and Health Care Concerns
Past research suggests that whether pregnancies are wanted, unwanted, or mistimed may influence breastfeeding behavior. The purpose of this chapter is to develop a more precise understanding of this relationship. Specifically, this chapter asks three questions: first, do pregnancy intentions matter most in sustaining breastfeeding for long or for short durations postpartum; second, at what time postpartum are rates of breastfeeding discontinuation most differentiated by pregnancy intentions; and third, how does poverty (measured here by Medicaid receipt) moderate the relationship between pregnancy intentions and breastfeeding duration.
Logistic regression analysis of survey data from a national sample representative of US mothers is used to determine the relationship of pregnancy intentions to whether breastfeeding continues for various durations and through various intervals after birth. Interaction terms between pregnancy intentions and mother’s Medicaid status are used to test for relationships specific to poor or nonpoor mothers between pregnancy intentions and breastfeeding duration.
Results show that pregnancy timing matters most for sustaining breastfeeding for durations past 6 months and that differences in rates of breastfeeding discontinuation between mothers with wanted, unwanted, and mistimed pregnancies are most pronounced in the 3–7 months postpartum period. In addition, findings show that Medicaid recipients (but not nonrecipients) are less likely to exclusively breastfeed for 6 months when their pregnancies are mistimed.
The literature on fundamental causes of health disparities typically suggests that poverty impairs access to resources necessary for effective planning to achieve desirable health outcomes. This study’s results, however, show that planning of pregnancies is more critical for poor mothers to sustain exclusive breastfeeding. Further research is needed to explain this relationship. The results also suggest that policy interventions to help mothers with unplanned pregnancies to sustain breastfeeding should target the period from 3 to 7 months postpartum.
These findings can help shape policies for facilitating the continuation of breastfeeding for durations recommended by health authorities and advance our understanding of the effects of poverty on health behaviors.
Most women seeking abortion pay out-of-pocket for care, partly due to legal restrictions on insurance coverage. These costs can constitute a hardship for many women. Advocates have sought to ensure insurance coverage for abortion, but we do not know whether the intermediaries between policy and patient – abortion-providing facilities – are able and willing to accept insurance.
We interviewed 22 abortion facility administrators, representing 64 clinical sites in 21 states that varied in their legal allowance of public and private insurance coverage for abortion, about their facility’s insurance practices, and experiences.
Respondents described challenges in accepting public and/or private insurance that included, but were not limited to, legal regulations. When public insurance broadly covered abortion, its low reimbursement failed to cover the costs of care. Because of the predominance of low income patients in abortion care, this caused financial challenges for facilities, leading one in a state that allows broad coverage to nonetheless decline public insurance. Accepting private insurance carried its own risks, including nonpayment because costs fell within patients’ deductibles. Respondents described work-arounds to protect their facility from nonpayment and enable patients to use their private insurance.
The structure of insurance and the population of abortion patients mean that changes at the political level may not translate into changes in individual women’s experience of paying for abortion.
This research illustrates how legal regulations, insurer practices, and the socioeconomics of the patient population matter for abortion-providing facilities’ decision-making about accepting insurance.
Relational autonomy proposes that persons are socially embedded, with decisions being made within social relationships. Through this theoretical lens, this article explores how the healthcare professional–patient relationship can affect pregnant women’s decisions to accept pertussis and influenza vaccines.
Hackney was chosen as the study site as it has very low vaccine uptake rates. In-depth interviews were conducted with 40 pregnant and recently pregnant women, as well as 10 healthcare professionals. Interviews explored experiences of the UK's National Health Service (NHS) health care and views towards vaccination in pregnancy. An observation of a consultation between a pregnant patient and her General Practitioners (GPs) was also conducted in order to understand how the vaccination discussion takes place.
The findings of this study indicate that advice from friends and family can greatly influence a pregnant woman’s vaccination decisions. The patient’s social context, including influences on her decisions, must be understood by healthcare professionals, so that discussions about concerns can take place. If close relationships with patients are formed, healthcare professional advice is more likely to be trusted. With support from healthcare professionals, patients feel competent, empowered to make the right decision for them, and are more likely to vaccinate.
This research will help to inform contextualised policies aimed at increasing vaccination acceptance and reducing inequality in access to vaccination during pregnancy in Hackney.
To the author’s knowledge, this chapter is the first to apply the theory of relational autonomy to views towards maternal vaccination and decision making. It provides valuable insights into how healthcare professionals’ interactions with their pregnant patients can influence vaccination acceptance. The chapter contains advice on how both healthcare professionals and policy-makers can include mothers in vaccine decision-making processes in more personalised ways, by adopting a dialogue that appreciates and understands the social processes around vaccination concerns.
Health-seeking behaviors (HSB) for infertility are influenced my multiple factors. The Behavioral Model of Health Services Utilization states that enabling resources and predisposing factors are essential in predicting HSB, and this study examined the relationship between state-level mandates that insurance providers cover infertility service on the rates of HSB for infertility among a nationally representative sample of women.
This study used data from the National Survey of Family Growth, identified 15 states with state-level mandates as enabling resources, and used sociodemographic characteristics as predisposing resources. Using discrete-time event-history analyses, and retrospective accounts of infertility HSB, these variables were examined to determine if residing in a state with state-level insurance mandates would increase the likelihood of HSB for infertility.
Results indicated an impact of state-level mandates on HSB for infertility. Specifically, the rates of HSB for infertility were higher among women residing in states with state-level mandates.
A limitation in this research stems from a data restriction that forced identifying a place-of-residence before or after 2000. To overcome this, multiple analyses, and a nested model comparison were tested to measure the effect of state-level mandates on HSB.
The comparative analysis of the rates of HSB for women residing in states with state-level mandates has not been considered before, and the results provide further detail into the infertility experience for women and their partners.
Part III Health Care Practitioners and Health and Health Care
This research examines effects on emotional burnout among “maternity support workers” (MSWs) that support women in labor (labor and delivery (L&D) nurses and doulas). The emotional intensity of maternity support work is likely to contribute to emotional distress, compassion fatigue, and burnout.
This study uses data from the Maternity Support Survey (MSS) to analyze emotional burnout among 807 L&D nurses and 1,226 doulas in the United States and Canada. Multivariate OLS regression models examine the effects of work–family conflict, overwork, emotional intelligence, witnessing unethical mistreatment of women in labor, and practice characteristics on emotional burnout among these MSWs. We measure emotional burnout using the Professional Quality of Life (PROQOL) Emotional Burnout subscale.
Work–family conflict, feelings of overwork, witnessing a higher frequency of unethical mistreatment, and working in a hospital with a larger percentage of cesarean deliveries are associated with higher levels of burnout among MSWs. Higher emotional intelligence is associated with lower levels of burnout, and the availability of hospital wellness programs is associated with less burnout among L&D nurses.
While the MSS obtained a large number of responses, its recruitment methods produced a nonrandom sample and made it impossible to calculate a response rate. As a result, responses may not be generalizable to all L&D nurses and doulas in the United States and Canada.
This research reveals that MSWs attitudes about medical procedures such as cesarean sections and induction are tied to their experiences of emotional burnout. It also demonstrates a link between witnessing mistreatment of laboring women and burnout, so that traumatic incidents have negative emotional consequences for MSWs. The findings have implications for secondary trauma and compassion fatigue, and for the quality of maternity care.
We explored how clinicians assisting low-income US Latino patients with diabetes and limited English proficiency (LEP) made sense of language-discordant care in the context of the social determination of health.
We interviewed 14 physicians in an urban teaching hospital, recorded and transcribed the interviews, and read transcripts to identify themes and interpret meanings. We used a mixed qualitative approach and drew from the Marxian tradition that illuminates how the dynamic of the clinical encounter tends to reproduce the social order by excluding its critical appraisal.
Participants believed that language barriers undermine the quality of the clinical encounter and diabetes outcomes, were eager to serve disadvantaged patients, and were well schooled in the social determination of health and its role in diabetes inequalities. However, they appeared unable to conceptualize macro-level changes that may achieve greater health equity.
The structure of medical discourse appears to limit the ability of individual clinicians to conceptualize and engage in social change on behalf patients. Recent debates in primary care indicate that this limitation is currently being challenged. Health services for persons with diabetes and limited English proficiency in the United States and elsewhere require significant improvements in interpreter services. At a broader level, clinicians should consider stepping beyond the limited, traditional role of medical/behavioral advisor to engage in political action toward greater social equity, which would result in better health.
Research in the various dimensions of language discordance is largely quantitative thus the need for qualitative studies to inform practice and policy.
Scholarship has demonstrated important consequences of segregation on health and health care outcomes, yet the mechanisms behind this association remain poorly understood. Several recent studies have shown inequities in the distribution of a wide variety of health-related organizations across urban neighborhoods, which may account for some portion of this negative health association. Though, within this literature, relatively little attention has been given to the distribution of health care facilities in particular.
Here, I consider how segregation is related to the distribution of several auxiliary health care practitioners in a series of spatial regression models of zip codes across the United States using data from the 2010 US Census and County Business Patterns (CBP).
I find that both Black and Latino segregation is negatively related to the density of a number of auxiliary health care practitioners, including mental health providers, dentists, physical/occupational/speech therapists, chiropractors, optometrists, podiatrists, and miscellaneous health care practitioners. However, this association is reduced (in certain instances to non-significance) with the inclusion of socioeconomic indicators, chiefly the percent of college educated individuals and the unemployment rate of the zip code. This is association is reduced for both Black and Latino segregation, with a larger reduction in the size of the effects for Latino segregation.
This research suggests that segregation plays an important role in the distribution of health care facilities, but that policy and public health interventions should focus on the intersection between racial residential segregation and socioeconomic considerations.
Part IV Racial and Ethnic Minorities and Health and Health Care
This study investigated disparities in dual diagnosis (comorbid substance use and depressive/anxiety disorders) among US adults by nativity and racial–ethnic origin and socioeconomic, cultural, and psychosocial factors that may account for the observed disparities.
The study drew on data from two waves of the National Epidemiological Survey on Alcohol and Related Conditions. Racial–ethnic categories included African, Asian/Pacific Islander, European, Mexican, Puerto Rican, and other Hispanic/Latino. Substance use and depressive/anxiety disorders were assessed per DSM-IV. A four-category measure of comorbidity was constructed: no substance use or psychiatric disorder; substance use disorder only; depressive/anxiety disorder only; and dual diagnosis. The data were analyzed using multinomial logistic regression.
The prevalence of dual diagnosis was low but varied by nativity, with the highest rates among Europeans and Puerto Ricans born in US states, and the lowest among Mexicans and Asians/Pacific Islanders. The nativity and racial–ethnic effects on likelihood of having dual diagnosis remained significant after all adjustments.
The limitations included measures of immigrant status, race–ethnicity, and stress and potential misdiagnosis of mental disorder among ethnic minorities.
This new knowledge will help to guide public health and health care interventions addressing immigrant mental and behavioral health gaps.
This study addressed the research gap in regard to the prevalence and correlates of dual diagnosis among immigrants and racial–ethnic minorities. The study used the most current and comprehensive data addressing psychiatric conditions among US adults and examined factors rarely captured in epidemiologic surveys (e.g., acculturation).
Although Black individuals are disproportionately affected by hypertension as evidenced by higher prevalence and lower control rates, few studies have investigated this disparity from the lens of those most affected by this condition. This chapter explores how Black men make sense of their hypertension and how they negotiate this condition within their everyday lives, illuminating how racism and power dynamics embedded within their environments affect their experiences living with hypertension.
Critical Race Theory tenets were utilized alongside a narrative design to elicit stories of hypertension experiences of four Black men living in Ontario, Canada. Eight semistructured in-depth interviews were conducted, transcribed, and thematically analyzed to illuminate how participants create meaning in regard to their hypertension.
Participants’ experiences with discrimination, isolation, and migration raise awareness of how power relations embedded within social, political, and historical contexts can affect hypertension experiences.
The findings of this study are bounded by its narrative context, and the characteristics of the individuals who shared their experiences.
This study highlights the importance of how discussions concerning hypertensive minority men should be broadened to include the voices of such men, as well as the structures that discriminate against and oppress minority individuals.
Since health behaviors of elderly Asian Americans are often underreported, the study, based on the health behavioral model (Andersen’s model), was to examine if there is a reciprocal relationship between healthcare utilization and health outcomes, and how social characteristics play their role in this relationship between US-born and foreign-born elderly Asian Americans.
Using structural equation modeling, this research examined the proposed hypotheses which consisted of direct and indirect effects among health outcomes, healthcare utilization and social characteristics, as well as the disparities of the effects between US-born and foreign-born elderly Asian Americans (65 + ). A sample size of elderly Asian Americans was divided into a US-born group (N = 1,305) and a foreign-born group (N = 4,902) from the National Health Interview Survey (NHIS) 1998–2012. Health outcomes consisted of current health status and health change. Healthcare utilization included general doctor visit, ER, and mental health professional visit. Social characteristics of population included predisposing characteristics (such as age, sex, marital status, and region of residency) and enabling resources (such as education, family size, and family income).
Results from the study indicated that first, there was a reciprocal relationship between health outcomes and healthcare utilization for both groups. Second, predisposing characteristics had a direct effect on health outcomes, and enabling resources had an indirect effect on health outcomes via healthcare utilization. In addition, living in the West had both direct and indirect effects on health outcomes. Third, regarding disparities of the effects between both groups, the US-born elderly are more likely to attain health benefits from healthcare utilization and their social characteristics than the foreign-born. As a result, the interactive relationship between health outcomes, healthcare utilization, and social characteristics, as well as disparities of healthcare outcomes through health utilization and social characteristics for elderly Asian Americans is highlighted.
First, due to the design of NHIS, this research was limited to fully present the needs and more characteristics of elderly Asian Americans. This shows the great need for a large scale, representative study for health behaviors of elderly Asian Americans. Second, in the dataset, the study was limited to explore health behaviors of elderly Asian Americans into each Asian ethnic subgroup. Since the culture of Asian Americans is heterogeneous, it is recommended that future research can explore differences and commonalities of the health behaviors between Asian subgroups. Third, based on the health behavioral model and the design of the dataset, this study was limited to illustrate variations of life experiences between both groups. These differences regarding their needs and desires for healthcare services and health outcomes can become an important foundation for service providers and policy makers to provide appropriate services that improve the quality of the later lives of elderly Asian Americans.
First, the study applied the health behavioral model and proved that the effect of healthcare utilization and social characteristics on health outcomes is greater for the US-born elderly Asian Americans than for the foreign-born. Second, this study confirmed that the healthcare services in US society are still beneficial for the health outcomes of elderly Asian Americans. Third, the study found that when family is used to explain the social behaviors of elderly Asian Americans, researchers need to be more careful to identify various family factors in accordance to its dynamics, such as interpersonal relationship, material supply, and emotional support.
Research on behavioral functioning among Mexican-origin children primarily uses an individual-centered approach that ignores the residential context. In addition, most studies have been unable to consider an important measure of inequality for this population, legal status; and mental health of children with undocumented parents is underexplored. We address these gaps by investigating the influence of parental legal status and neighborhood characteristics on Mexican-origin children’s behavioral functioning using a multilevel approach.
We use data from the Los Angeles Family and Neighborhood Study and 2000 decennial census. Our primary focus is variation in internalizing and externalizing behavior problems among Mexican-origin youth (N = 2,535) with mothers who are undocumented, documented or naturalized citizens, or US-born using multilevel models.
The multilevel results show the importance of considering parental legal status. Mexican children of unauthorized mothers are more likely to exhibit internalizing and externalizing problems than all other groups of Mexican children. Furthermore, neighborhood-concentrated disadvantage is significantly associated with internalizing behavior problems, and neighborhood-concentrated affluence is significantly associated with externalizing behavior problems. In short, the results demonstrate the importance of considering both parental legal status and neighborhood contexts for understanding behavior problems of Mexican-origin children.
Our findings suggest that Mexican children’s mental health outcomes – measured by internalizing and externalizing behavior problems – vary significantly by parental legal status and neighborhood contexts. This study provides important nuances for public policy for health care prevention and interventions.
Racial and ethnic minorities utilize less healthcare than their similarly situated white counterparts in the United States, resulting in speculation that these actions may stem in part from less desire for care. In order to adequately understand the role of care-seeking for racial and ethnic disparities in healthcare, we must fully and systematically consider the complex set of social factors that influence healthcare seeking and use.
Data for this study come from a 2005 national survey of community-dwelling Medicare beneficiaries (N = 2,138). We examine racial and ethnic variation in intentions to seek care, grounding our analyses in the behavioral model of healthcare utilization. Our analysis consists of a series of nested multivariate logistic regression models that follow the sequencing of the behavioral model while including additional social factors.
We find that Latino, Black, and Native American older adults express greater preferences for seeking healthcare compared to whites. Worrying about one’s health, having skepticism toward doctors in general, and living in a small city rather than a Metropolitan Area, but not health need, socioeconomic status, or healthcare system characteristics, explain some of the racial and ethnic variation in care-seeking preferences. Overall, we show that even after comprehensively accounting for factors known to influence disparities in utilization, elderly racial and ethnic minorities express greater desire to seek care than whites.
We suggest that future research examine social factors such as unmeasured wealth differences, cultural frameworks, and role identities in healthcare interactions in order to understand differences in care-seeking and, importantly, the relationship between care-seeking and disparities in utilization.
This study represents a systematic analysis of the ways individual, social, and structural context may account for racial and ethnic differences in seeking medical care. We build on healthcare seeking literature by including more comprehensive measures of social relationships, healthcare and system-level characteristics, and exploring a wide variety of health beliefs and expectations. Further, our study investigates care seeking among multiple understudied racial and ethnic groups. We find that racial and ethnic minorities are more likely to say they would seek healthcare than whites, suggesting that guidelines promoting the elicitation and understanding of patient preferences in the context of the clinical interaction is an important step toward reducing utilization disparities. These findings also underscore the notion that health policy should go further to address the broader social factors relating to care-seeking in the first place.
This chapter compares smoking among American women employed outside the home with those of full-time homemakers at two points in time: 1979 and 2014.
Data are from the 1979 National Household Survey on Drug Abuse (NHSDA) and from the 2014 National Survey on Drug Use and Health (NSDUH). The NHSDA is the precursor to the present-day NSDUH and part of the same continuum of nationwide surveys on drug use. The analysis uses logistic regression models and the survey suite of commands in Stata 13 to include 1979/2014 sample weights and adjustments for the complex sample design.
Results show that smoking is most prevalent among homemakers in small communities. This outcome supports earlier studies citing smoking as a major causal factor for the decline in female life expectancy among less-educated white women in certain low-income and rural counties in the United States. The premise that female smoking is strongly associated with the workplace appears to be no longer true.
These data provide only a limited test of health lifestyle theory because many of the model’s structural variables are not included. Otherwise the findings support the model.
This study finds that smoking is greatest among women who are full-time homemakers in medium and especially small towns. This is a new development and suggests the locus of smoking among women has moved away from its association with the job in cities to the home in less populated areas.