Identifying Healthcare Priorities of Black Women in a Resource-Poor Neighborhood Using Longitudinal Focus Group Methodology

Thesis (M.S.)--University of Rochester. School of Medicine and Dentistry. Dept. of Community & Preventive Medicine, 2009.Black American women suffer disproportionate morbidity and mortality, as compared with other populations in the United States. Conventional models of health disparities fail to account for these differences. To cultivate greater community engagement in disparities research, we adapted traditional focus group methodology to longitudinal use, with the principles of Freirean dialogics and community-based participatory research. Six focus groups with the same participants were convened over a nine-month period to explore the social determinants of health and illness of black American women from a resource-poor neighborhood in Rochester, New York. Early focus group themes, which related to priorities for and barriers to health care, echoed similar, previous studies with black American women. Later focus groups, in which familiarity and trust had been more developed, explored delicate topics such as abortion, adoption, and menopause. Participants described significance of these events, as well as barriers to discussion with researchers and primary health providers. Keywords: Healthcare disparities, focus groups, attitude to health, African Americans, women, researcher-subject relations Black-white inequalities are not new; disparities in morbidity, mortality, and access to health care have been well documented in the United States.1,2,3 In addition, elimination of these disparities has been a focal point of national health policy for more than two decades. However, there has been no sustained decrease in black-white disparities in either age-adjusted mortality or overall life expectancy at birth at the national level since the end of World War II.1 Considerable racial gaps remain; among older black Americans, these gaps are even increasing in several areas, including prevalence of diabetes, difficulty performing self-care activities, and limitation in major activity because of chronic conditions.2 Conventional models of health inequalities- a racial genetic model, a lifestyle model, and a socioeconomic status model- have failed to account for any of these differences.3 Black women represent a unique population in the United States. Not only do they suffer a disproportionate burden of morbidity and mortality, as compared with whites, but black women also experience higher mortality rates than black men from preventable, or least modifiable disease, including diabetes, heart disease, liver and kidney disease, and AIDS.4,5,6,7 All of these causes may be significantly influenced by external, modifiable factors; one explanation for inequality may be gender differences in lifestyle choices and socioeconomic status. 1,5,8,9 However, in studies that control for income, education, and marital status, gender does not significantly impact healthy lifestyle choices.8,10 A recent study even reported that black women scored higher nutrition scores and higher frequencies of interpersonal relationships and health-responsibility activities as compared with black men, despite their unequal burden of preventable disease.8 Healthy People 2010 prioritizes the “elimination of health disparities,” and proposes that negative health outcomes may be better understood by examining the complex interaction between biologic and behavioral health determinants, as well as the interaction between those individual factors and the social environment.6 Black women have been poorly represented in both clinical prevention studies and sociological literature; the majority of social science literature on black women has concentrated on the poor and troubled. While focus group methodology has been used to explore black American women’s beliefs surrounding specific health concerns, such as HIV,11 diabetes,12 cancer,13,14 menopause,15,16 and domestic abuse,17 relatively few studies have asked black American women to discuss personal health issues of significant relevance to them. We conducted this qualitative study in response to the gap in research on the social determinants of health and illness of black American women. Methods Setting. The city of Rochester in New York State is home to high-tech industries such as Kodak, Xerox, and Bausch & Lomb, as well as other clothing, shoe, brewing, and machine tool manufacturing industries. Despite the prosperity brought by these diverse industries during the 19th and early 20th centuries, today Rochester suffers from a lagging economy, and unexpectedly high rates of unemployment, violence, and drug abuse.18,19 In 2007, the murder rate for the city of Rochester was 24.2 per 100,000 people, which represents 3.49 times the national average.20 Rochester’s urban neighborhoods suffer the brunt of the city’s hardship. More than 90 percent of Rochester’s homicides occur in several central urban neighborhoods, despite the fact that less than 30 percent of Rochester’s population lives here.19,20 One of the most economically underprivileged sections of urban Rochester is Sector 10, which encompasses three neighborhoods in the center of the city. The demographic profile in Table 1, comprised of data from the 2000 U.S. Census Bureau, demonstrates how Sector 10 differs- both economically and ethnically- from the city of Rochester as a whole. When compared to the population citywide, Sector 10 has a larger percentage of black or African-American, as well as Hispanic or Latino residents. Annual household income for those living in Sector 10 is much less- between 50 and 350 percent smaller- than the median income for Rochester city households.21 Over the past 15 years, local community leaders, neighborhood alliances, and even regional initiatives have worked to provide health and social services for Sector 10 residents. Despite the successes of these programs, many have been scaled back, or cut altogether in recent years, due to uncertainty about the continuity of foundation and government funds. 22 Although it seems evident that any remaining community programs would in turn become overburdened, many Sector 10 residents have realized the temporality of such programs and have stopped relying on them to meet their needs. In the words of one resident, “When the money is there, everything is a boom. And when the money is gone, the services in the community is gone. And then we have another boarded up building and a fragmentation of programs of what’s left.