The purpose of this paper was to explore the social context and psychosocial beliefs of low-income Black and Latina women that may influence their ability to follow health recommendations and behaviors. We found that the social context of these women’s lives was heavily influenced by a number of interconnected major life stressors that hinder health promotion in general, and the ability to follow behavioral recommendations in particular. These included: negative and inaccurate perceptions of cancer; fatalistic beliefs; competing health issues; economic hardship; abusive and difficult relationships; demanding caretaking responsibilities; cancer-related experiences of friends/family; insurance struggles; mistrust of health care providers; and unsupportive employment policies.
The burden of the social context of socially disadvantaged populations has not been adequately described, especially as it relates to health behaviors and adherence, and is particularly poignant when viewed through the eyes of participants. In general, there has been a tendency in public health and medicine to focus on health behaviors and diseases in isolation, without full consideration of the broader social context.11,21
However, as these narratives demonstrate, women’s health is intimately connected to their social and contextual life circumstances. In the context of the major life stressors and competing priorities described by the women in this study, it should not be surprising that many have difficulty making their own health care a priority. These findings are consistent with prior research on gender-defined roles, responsibilities, and expectations that often result in women taking on a disproportionate burden of caretaking and household duties and facing competing work/family demands,22–24
demands that often interfere with women completing behavioral health recommendations.25–27
Some themes that arose were differentially influential by race and ethnicity. Latinas expressed challenges to self-care related to immigration, documentation, difficult transitions to the U.S. (i.e., language barriers), and social isolation. Similar themes have arisen in life history interviews previously conducted among working-class, multi-ethnic populations in the same geographical area.12
Black women more often described experiences of discrimination, often in relation to distrust of health care providers, the health system and medical research, as has been previously documented in the literature.28–30
Other studies have documented that mistrust is rooted in the history of harmful treatment of Blacks, ranging from slave experimentation, the Tuskegee Syphilis Study, and inequities in health care access and treatment.2,31,32
Researchers may want to investigate how immigration-related difficulties, discrimination and medical mistrust impact adherence to behavioral recommendations, since these factors have only recently begun to be explored.
Limitations of this research should be highlighted. First, we caution against generalizing these findings beyond the population examined here. These findings are not intended to capture all of the life experiences of urban, lower-income Black and Latina women, but are useful in generating hypotheses that can be tested in future research. We were not able to explore differences across the myriad groups that constitute Black and Latina communities, for example by region or country of origin. We recognize the tremendous heterogeneity within these populations, but were limited by sample size. In addition, while a sense of resilience and strength emerged from the interviews, the majority of themes focused on the hardships and challenges that women faced across multiple life domains. While this is reflective of the life circumstances of these women, future research should explore the strengths, assets, resources, and resiliency of underserved populations in more detail.
Despite these limitations, this study offers a number of strengths. We used an in-depth qualitative methodology that is well-suited to achieving our research aims and is effective in establishing trust and rapport with minority women, and collecting their thoughts and opinions in their own words. This large qualitative dataset provided detailed exploration of social contextual factors from the perspective of low-income Black and Latina women themselves. This research provides rich narratives that can help inform future research and conceptual models among similar populations of lower-income women, and can be used to inform quantitative measures that seek to measure aspects of social context. These findings may also be useful in guiding interventions and policies to encourage and support adherence to behavioral recommendations among lower-income, multi-ethnic women.
There are a number of implications that follow from this research. Qualitative data that considers the complex social, contextual, and material context of people’s lives, as was collected here, is particularly useful for informing the design of socially and culturally appropriate policies and interventions.12,33
Given that the themes and health-related barriers arose at multiple levels (i.e. individual, interpersonal, organizational, community, and societal levels), it is critical that future interventions and programs take a multi-level approach and address multiple levels for change. In the case of promoting follow-up after an abnormal mammogram, most interventions have provided patient-level education (i.e. through phone counseling, personalized letters).34
Clearly, improved communication and health education is important, particularly among racial/ethnic minority populations who more commonly cite communication difficulties with physicians.35,36
Some of the cancer-related misperceptions and fatalistic beliefs that emerged here highlight the need for providers to understand patients’ health belief systems; improved understanding of these culturally-informed beliefs may help improve patient/provider interactions, and ultimately health behaviors and outcomes.36
Awareness of the social context of low-income women can also help increase physicians’ understanding of the competing demands women face - demands that may take priority over health-related needs out of necessity.
While individual-level interventions are important and may be particularly useful for educating patients about cancer prevention, systems- and policy-level interventions hold greater promise for long-term, sustainable change.11
This is especially the case for disadvantaged populations who have received less benefit to date from individual behavior-change interventions and suggests the need for novel and more contextually-based approaches that recognize the complexity of people’s lives.11
Health care provider- and systems-level interventions might include phone notification of results or reminders, centralized services, and patient navigators.37
Patient navigator and lay health advisor programs are a particularly promising avenue, given that they can help address some of the challenges that low-income women face. For example, navigators provide centralized care and have been found to decrease barriers and anxiety, improve trust and communication, and improve behavioral adherence.38–41
To facilitate trust, women in our study also identified the importance of having female health care providers of the same race/ethnicity and providers who spoke their language, aspects of programs and programs that also hold great promise.
Given the stressful social contexts that we have documented here, delivery of health services must address the multiple challenges low-income populations face, and it is imperative that health care services must be made as accessible, convenient, affordable, comprehensive, and integrated as possible. Those in this study, who experienced multiple health issues and had to juggle multiple responsibilities and roles, faced sometimes insurmountable barriers to access of care. In a context where health services have become increasingly specialized and disaggregated, these women would greatly benefit from health services that are integrated across disease entities, and that offer both physical and mental health services in one location. Health systems could also be improved by policy changes, including having more flexible hours at health centers/clinics. Increasing the availability of services at the local and neighborhood levels may help improve accessibility of services, as might transportation vouchers or free shuttles.
As health disparities are embedded in larger social, political, and economic contexts, elimination of inequities will require interventions that do more than address health care policies. Effective policies and efforts to eliminate health disparities must also address social inequities and fundamental non-medical determinants of health as well.42–44
Specifically, social polices can help improve the living and working conditions of low-income populations, since our social environment structures our opportunities and chances for being healthy. For example, low-income women are more likely to be part-time employees or unemployed, and therefore inadequately insured; policies must be put in place to provide universal health care coverage to ensure that everyone is adequately covered. Steps to diminish financial barriers to health care have been instituted in Massachusetts though Massachusetts Health Reform, although only time will tell the impact of this legislation. For women who are working, employers can offer flexible work policies to facilitate attendance at medical appointments, though this recommendation may be met with strong reluctance from employers in the service sector where much of this population works. Social policies can also help increase funding to improve the living conditions of lower-income women, devoting money and time towards improving the quality of housing, education, employment opportunities, income support, neighborhood conditions (e.g. safety), and access to resources and facilities (i.e. transportation services, clinics, parks, affordable and healthy supermarkets, job training) in low-income neighborhoods (see Williams et al., 2008) 44
for a review of interventions and policies that have been used to address social determinants of health).
With ethnic and racial diversity growing rapidly within the U.S., eliminating health disparities is imperative and will require a better understanding of the social context in which health behaviors are developed and maintained. This research illuminated numerous life circumstances and social contextual factors -- linked to the status of low-income minority women -- that have important health consequences. Future research is needed to test some of the hypotheses formulated here. Specifically, a greater understanding of the pathways by which these circumstances and stressors interact and impact health behaviors and outcomes is needed in order to develop effective comprehensive multi-level interventions, and to identify resources, supports, services and policies that may help mitigate the potentially negative consequences of these social contextual influences on health.