Effects of social injustice on breast health-seeking behaviors of low-income women.

PURPOSE: The study uses qualitative research to gain a better understanding of what occurs after low-income women receive an abnormal breast screening and the factors that influence their decisions and behavior. A heuristic model is presented for understanding this complexity. DESIGN: Qualitative research methods used to elicited social and cultural themes related to breast cancer screening follow-up. SETTING: Individual telephone interviews were conducted with 16 women with confirmed breast anomaly. PARTICIPANTS: Low-income women screened through a national breast cancer early detection program. METHOD: Grounded theory using selective coding was employed to elicit factors that influenced the understanding and follow-up of an abnormal breast screening result. Interviews were digitally recorded, transcribed, and uploaded into NVivo 8, a qualitative management and analysis software package. RESULTS: For women (16, or 72% of case management referrals) below 250% of the poverty level, the impact of social and economic inequities creates a psychosocial context underlined by structural and cultural barriers to treatment that forecasts the mechanism that generates differences in health outcomes. The absence of insurance due to underemployment and unemployment and inadequate public infrastructure intensified emotional stress impacting participants' health decisions. CONCLUSION: The findings that emerged offer explanations of how consistent patterns of social injustice impact treatment decisions in a high-risk vulnerable population that have implications for health promotion research and systems-level program improvement and development.

HIV testing in women: missed opportunities.

OBJECTIVE: To investigate opportunities for early human immunodeficiency virus (HIV) testing of women. METHODS: A retrospective cohort study design linked case reports from HIV surveillance to several statewide health-care databases. Medical encounters occurring before the first positive HIV test (missed opportunities) were categorized by diagnosis/procedure codes to distinguish visits that were likely to have prompted an HIV test. Women were categorized as late testers (AIDS diagnosis <12 months from first HIV test date), non-late testers (no AIDS diagnosis during study period or diagnosis of AIDS >12 months of HIV diagnosis), of reproductive age (13-44 years old), and not of reproductive age (>44 years old). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used to estimate risk and its statistical significance. RESULTS: Of 3303 HIV-infected women diagnosed during the study period, 2408 (73%) had missed opportunity visits. Late testers (39%) were more likely to be black than white (aOR 1.48, 95% CI 1.12-1.95), be older (>44 years old; aOR 7.85, 95% CI 4.49-13.7), and have >10 missed opportunity visits (aOR 2.17, 95% CI 1.62-2.91). Fifty-four percent of women >44 years old were also late testers. Women >44 years old had lower median initial CD4 counts (p<0.001). The top two procedures were the same for all groups of women but mammography was ranked fourth for women >44 years old and Papanicolau smear was ranked fourth for late testers. CONCLUSIONS: Feasibility and acceptability of routine HIV testing in nontraditional health-care settings, such as mammography and Papanicolau screenings, should be explored to identify late testers and older (not of reproductive age) HIV-infected women.