Presentation of study findings at the annual meeting of the American Public Health Association, Boston, 2013 (Haji-Jama et al. SpringerPlus, 2013)

1. Breast Cancer Care of Mexican American Women in High Poverty California Neighborhoods:Breast Cancer Care of Mexican American Women in High Poverty California Neighborhoods:
Protective Effects of Social and Financial Capital, Including Health Insurance, in BarriosProtective Effects of Social and Financial Capital, Including Health Insurance, in Barrios
Sundus Haji-Jama,Sundus Haji-Jama,aa
Nancy L. Richter,Nancy L. Richter,aa
Kevin M. Gorey,Kevin M. Gorey,aa
Isaac N. Luginaah,Isaac N. Luginaah,bb
GuangYong Zou,GuangYong Zou,bcbc
Eric J. Holowaty,Eric J. Holowaty,dd
Madhan K. Balagurusamy,Madhan K. Balagurusamy,aa
& Caroline Hamm& Caroline Hammbebe
aa
University of Windsor,University of Windsor, bb
University of Western Ontario,University of Western Ontario, cc
Robarts Research Institute,Robarts Research Institute, dd
University of Toronto,University of Toronto, ee
Windsor Regional Cancer CenterWindsor Regional Cancer Center
AbstractAbstract
IntroductionIntroduction
ResultsResultsMethodMethod
SummarySummary: Seemingly paradoxically, a very strong: Seemingly paradoxically, a very strong
advantaging effect of having health insurance wasadvantaging effect of having health insurance was
observed among MA women who lived in MA barrios,observed among MA women who lived in MA barrios,
neighborhoods that were also very poor. In fact, the ratesneighborhoods that were also very poor. In fact, the rates
of early breast cancer diagnoses, receipt of optimumof early breast cancer diagnoses, receipt of optimum
treatments and survival among MA barrio residents weretreatments and survival among MA barrio residents were
on par with those of NHW women who lived in the loweston par with those of NHW women who lived in the lowest
poverty neighborhoods.poverty neighborhoods.
This study’s barrios were consistent with Maas’ (2011)This study’s barrios were consistent with Maas’ (2011)
“gateway MA neighborhoods:” prevalent low-income &“gateway MA neighborhoods:” prevalent low-income &
high-immigrant populations—places where social capitalhigh-immigrant populations—places where social capital
seems strongest & most supportive.seems strongest & most supportive.
ConclusionConclusion: Findings are consistent with the theory that: Findings are consistent with the theory that
more facilitative social and economic capital is availablemore facilitative social and economic capital is available
to MA women in barrios and to NHW women in moreto MA women in barrios and to NHW women in more
affluent neighborhoods. It is there that each respectiveaffluent neighborhoods. It is there that each respective
group of women is probably best able to absorb thegroup of women is probably best able to absorb the
uncovered costs of breast cancer care.uncovered costs of breast cancer care.
Synchrony (IS) Shared Positive Affect Shared Negative
Affect
Cooperation .440* .440* -.065
Assertion .458* .540** -.560**
Responsibility .368 .488* -.233
Self Control .451* .469* -.220
TOTAL .535** .586** -.325
HYPOTHESIS
SUPPORTED
HYPOTHESIS
REJECTED
* Significant at p < .05 ** Significant at p < .01
1. During the Great Recession prevalent poor, uninsured and
underinsured populations in the United States grew to 46,
50 & 100 million people.
2. The incidence of all such risks were substantially greater
among MAs than NHWs (Jargowsky, 2005).
3. Yet diverse health benefits seem to be enjoyed by
those who live in Hispanic enclaves, especially in
MA barrios populated by 1st
generation immigrants
(Osypuk et al., 2010; Portes & Bach, 1985).
4. Though prevalently poor, MA barrios may provide
relatively more instrumental social & economic
supports (Markides & Coreil, 1986).
5.5. Studies of NHW people suggest adequate healthStudies of NHW people suggest adequate health
insurance (private or Medicare) is most effectiveinsurance (private or Medicare) is most effective
in low poverty neighborhoods, where social andin low poverty neighborhoods, where social and
economic capital abounds.economic capital abounds.
6.6. Research questionsResearch questions : Using breast cancer care as: Using breast cancer care as
a sentinel health indicator: (1) Is health insurancea sentinel health indicator: (1) Is health insurance
less effective in high poverty neighborhoods forless effective in high poverty neighborhoods for
NHW women? And (2) Is it more effective in highNHW women? And (2) Is it more effective in high
poverty, barrio neighborhoods for MA women.poverty, barrio neighborhoods for MA women.
We examined health insurance mediation of Mexican
American (MA) non-Hispanic white (NHW) disparities
on breast cancer care. And we hypothesized a 3-way
ethnicity by poverty by health insurance interaction;
2-way poverty by health insurance interactions would
differ between ethnic groups. We analyzed California
registry data for 303 MA and 3,611 NHW women
diagnosed between 1996 & 2000, followed until 2011.
Census data categorized neighborhood poverty: high
(> 30% poor) to low (< 5% poor). Barrios where 50% or
more MA. MA-NHW diagnostic, treatment & survival
disparities were mediated by health insurance.
Advantages of health insurance were largest in low
poverty neighborhoods among NHW women while
among MA women they were, paradoxically, largest in
high poverty, MA barrios. These findings are
consistent with the theory that more facilitative social
& financial capital is available to MA women in barrios
and to NHW women in more affluent neighborhoods. It
is there that each respective group of women is
probably best able to absorb the indirect and direct,
but uncovered, costs of breast cancer care.
SamplesSamples
AnalysesAnalyses
For more information please contact:For more information please contact:
gorey@uwindsor.cagorey@uwindsor.ca
HypothesesHypotheses
DiscussionDiscussion
Associations of Adequate Health Insurance with
Breast Cancer Care & Survival : RR (95% CI)
Early Diagnosis of NN Disease
Mexican American women:
Barrios (hi pov): RR = 1.45 (1.11, 1.90)
Non-barrios: RR = 1.04 (0.91, 1.19)
Non-Hispanic white women:
High-poverty: RR = 1.12 (1.02, 1.23)
Low-poverty: RR = 1.20 (1.06, 1.36)
Received Timely RT after BCS†
Mexican American women:
Barrios (hi pov): RR = 1.88 (1.11, 3.10)
Non-barrios: RR = 1.09 (0.87, 1.37)
Non-Hispanic white women:
High-poverty: RR = 1.05 (0.69, 1.60)
Low-poverty: RR = 1.15 (1.07, 1.23)
8-Year Survival of Those with NN Disease
Mexican American women:
Barrios (hi pov): RR = 1.67 (1.13, 2.48)
Non-barrios: RR = 1.38 (0.97, 1.97)
Non-Hispanic white women:
High poverty: RR = 1.06 (1.00, 1.13)
Low poverty: RR = 1.19 (1.05, 1.34)
†
Radiation therapy within 6 months of breast conserving surgery.
Sampling Frames:
California Cancer Registry, breast cancer diagnosed 1996 to
2000, followed until 2011
High Poverty Neighborhoods Oversampled:
Cases joined to census tracts (2000)
High poverty tracts (> 30% poor) were oversampled
So MAs & MA barrios (> 50% MA) were oversampled
MA & NHW Samples:
All breast cancers: 303†
& 3,611 cases
Node negative breast cancer: 194†
& 2,846 cases
†
90% were first generation immigrants born in Mexico
Breast Cancer Care & Outcome Measures:
Stage at diagnosis: node –ve (NN) or node +ve (NP)
Surgical & adjuvant therapies & wait times
Overall & cancer-specific survival to 10 years
NHW Women: Those with adequate health insurance
will be diagnosed earlier, treated more effectively
and survive longer in low poverty neighborhoods.
MA Women: Those with adequate health insurance will
be diagnosed earlier, treated more effectively and
survive longer in high poverty, barrio neighborhoods.
Statistical Analyses: Logistic & Cox Regression Models
Odds ratios (OR), Hazard ratios (HR) & 95%
confidence intervals (CI) were estimated
Modest missing data were imputed from full models
Practical Analyses:
Age- and grade-adjusted rates per 100 reported as %
Standardized rate ratios (RR) were internally adjusted
Other Key Variables such as Birthplace Accounted for
Through Sample Restriction or Mathematical Modeling