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To determine the priorities of low-income women regarding health, relationship, and social concerns.
Street-intercept surveys conducted with 161 low-income urban women (M = 27 years; 85% African-American; 80% single mothers) regarding their perceptions of the threat associated with 48 health and social problems.
Women rated AIDS as their most important health, social, or relationship concern; nearly one-half of all women indicated that they would attend risk reduction programs to learn how to avoid infection with HIV.
AIDS is perceived as a serious threat to women’s health, and that interventions to reduce risk are welcomed.
Low-income women face many threats to their health and well-being. Relative to men, women are more vulnerable to many diseases [e.g., breast cancer, sexually transmitted diseases (STDs)] and have less access to health care services (1). Relative to more affluent women, low income women experience enhanced vulnerability to almost every disease and show higher rates of mortality (2).
Women are also increasingly vulnerable to HIV and AIDS as they now account for 22% of new adults cases (3). The rate of increase in AIDS incidence among women exceeds that of any other demographic group (4), and women of color are affected disproportionately. Calls for increased efforts to develop prevention programs for women have been tempered by the recognition that low-income women face many threats, and HIV and AIDS may not be the most urgent (5). That is, women may not respond to HIV-risk reduction opportunities because, relative to other health and social threats, AIDS is a distal rather than a proximate concern.
Support for the view that the muted threat portended by HIV reflects the prominence of other, more salient problems comes from several studies that have assessed women’s perceptions of AIDS. One study surveyed urban women to determine perceptions of AIDS susceptibility relative to 7 other social problems (6). Results indicated that even women at high risk for HIV infection viewed this STD as less serious than social problems such as unemployment, inadequate childcare, and crime. A follow-up study three years later indicated that AIDS was rated as less of a threat than unemployment, drug abuse, crime, discrimination, and teen pregnancy, and equivalent to transportation concerns (7). However, these data were collected prior to recent evidence of the emerging HIV threat to women, and focused only on eight social problems. It is uncertain if women continue to hold such beliefs; also, the perceived threat of AIDS relative to a wider range of health, social, and interpersonal threats remains unstudied.
This study sought to clarify the priorities of low-income women regarding an array of their health, relationship, and social concerns. We were also interested in whether women’s concerns influenced their willingness to attend health education or risk reduction groups. Our survey was informed by previous qualitative research (8), and we employed street-intercept methods because such methods can enhance the participation of low-income women (9).
Participant recruitment and data collection occurred in Syracuse, New York. Syracuse is located in the geographic center of New York State, 250 miles from New York City; the Metropolitan Statistical Area has a population of approximately 742,000. Marketers view Syracuse as a “mini-America” due to the similarity between local and national demographics (e.g., nationwide, 84% Caucasian, 12% African-American, 4% Other; in Syracuse, 81%, 16%, 3%, respectively). Marketing experts agree that data obtained in Syracuse are desirable because they reflect national patterns. The AIDS rate in the Syracuse metropolitan area (29.8/100,000) is nearly identical to the rate for the US as a whole (29.3/100,000) (3).
Women were recruited outside of County health and social services offices that are easily accessible to low income women. Those women who appeared to be 18–50 years of age were approached by one of the research staff using street-intercept methods. Potential participants were informed that the survey (a) would take less than 10 minutes, (b) consisted of questions concerning their opinions about health and social issues, and (c) could be stopped at any time. Once informed about the study, women were invited to participate. One hundred and sixty-one women agreed to take part, 94% of those approached.
Participants (N=161) tended to be young (M age = 26.8 yrs), African-American (85%), never married (70%), mothers (92%) with a median of 2 children. Eighty percent were single mothers. The average educational attainment was 11 years, with 49% having a high school degree. Most women (76%) reported an annual income of less than $10,000, and the majority (78%) did not work outside the home. Only 22% reported any form of medical insurance.
Women were then asked to complete a health concerns survey. The content of the survey was developed following focus groups with women in the community and discussions with women’s health care professionals (8). The survey asked women to rate 48 health and social issues on a 4-point scale in terms of personal concern and importance to them (1= “not a personal concern, not important to me” to 4 = “serious personal concern, very important to me”). Participants were also asked to indicate whether or not they would attend an educational or self-help program on each topic. Women completed the survey in private, although staff members were available to assist or answer questions. Women were paid $1 for their participation.
Table 1 provides women’s mean rating of 48 health and social concerns as well as the percentage of participants who indicated that they would attend an educational or self-help program on this topic if it were offered. The items were sorted independently by two raters into four problem categories: somatic health, mental health, social, and relationship concerns (kappa = .86; all alphas > .75). Three items were not included in these sorts, namely, AIDS, alcohol use, and drug use because of their special interest to us and their unique multidimensional nature.
Comparisons among the categories indicated that they were not rated equivalently, F (4, 150) = 705.89, p < .0001. Comparisons among the categories indicated that social concerns were rated as more important (M = 3.12) than relationship concerns (M = 2.89), which were rated as more important than were somatic and mental health (Ms = 2.65 and 2.59) concerns (all ps < .0001). As a single item, AIDS was identified as the threat that raised the most concern for women (M = 3.56). AIDS was rated as significantly more important than any of the four categories of problems (ps < .0001), as well as more important than 44 of the remaining 47 health, social, and relationship concerns. Only three concerns (viz., jobs, money, relationships with children) were equivalent to AIDS in the concern that they evoked.
Women’s interest in attending groups paralleled their interest in the topics [F (4, 150) = 31.41, p < .0001], with the largest percentages interested in social (26%) and relationship (25%) issues, and lesser interest in mental and somatic health concerns (21% for both). The percentage of women (46%) who were interested in attending educational or self-help groups was strongest for AIDS, and greater than all categories and individual concerns (all ps < .05).
The priority given to AIDS as an urgent concern contrasts with findings from earlier research (6, 7), and suggests that women increasing recognize their vulnerability to HIV. These perceptions parallel epidemiological data documenting increased AIDS cases among women (3). Moreover, these data confirm women’s interest in educational and other self-help programs to reduce their risk of HIV infection. Given that a growing body of research suggests that brief, theoretically-guided interventions can reduce women risk (10–13), this receptivity bodes well for the public health.
The greater threat perceived for AIDS, relative to heart disease, diabetes, and other chronic illnesses, is not surprising given the young age of women in this sample. Indeed, AIDS continues to be a leading cause of death among adults aged 25 – 44 years of age (14), whereas chronic illnesses tend to affect older adults. The relatively lower priority assigned to health concerns, in general, is noteworthy. That is, participants expressed stronger concerns regarding the more immediate threats associated with unemployment, economic instability, lack of childcare, violence, and crime. These findings indicate that HIV and other health promotion efforts for women will need to be developed mindful of these priorities and the larger social context (15).
These results need to be interpreted mindful of the study’s limitations. For example, it is possible that our participants, who were recruited nearby settings that provide social and health benefits, may be more aware and/or more vulnerable (than are more affluent women) to the social and health threats that we studied. This increased vulnerability may have led them to prioritize these threats differently than would the entire population of low income women. Also, as with any study conducted at a single site, these results may not be representative of women in other urban settings.
Findings from this study -- one of the few to assess directly the perceptions of low income, primarily ethnic minority, women regarding common health, interpersonal, and social threats -- underscore the importance of addressing health problems, including HIV, in the context of other social problems. The findings also confirm that AIDS is now seen as a major health threat, and that women welcome interventions to reduce their risk. Continued monitoring of women’s concerns is advisable in order to enhance the sensitivity of health interventions, and their likely reception in community-based samples.
This research was supported by a grant from the National Institute of Mental Health (K02-MH01582) to Michael P. Carey. The authors thank the participants for their contributions, K. C. Pearson for her assistance with data collection, and Kate B. Carey for her helpful comments on an earlier version of this paper.