Back to Political Leadership and the Progress of WomenBy Michal Smith-Mello, Caroline Pogge, Joyce Beaulieu, and Kevin Lomax
From The Future Well-Being of Women in Kentucky
pp. 87-105, published 1999
The realization of any future goal for women in Kentucky will be contingent upon a good health status. The aging of the population and the shift to preventive care it is compelling are profoundly influencing the future of health care. In Kentucky, dramatic breakthroughs in health and medical research may be circumscribed by poverty and undereducation, which are strongly associated with poor health outcomes.
The health status of women in Kentucky has an immeasurable impact on the roles they play in the social and economic life of the Commonwealth. From the quality of family and community life women enjoy, to the ability to realize their full earnings potential, to overall life expectancy, good health is, as those who are without it so quickly remind us, everything. Consequently, a continuously improving health status is key to the realization of any long-term goal for women of the Commonwealth. Without it, all goals will be compromised.
The health future before women—and men—is being redefined at an astonishing pace by breakthroughs in medical research. Our understanding of health and our ability to control and manage the diseases and conditions that end and abbreviate life are growing rapidly. This knowledge will almost certainly extend life expectancy and improve quality of life. At the same time, policymakers continue to grapple with the seemingly insoluble dilemma of how to construct a health care delivery system that expands access, controls costs, and assures quality of care. This unresolved dilemma has a profound influence on the lives of many Kentucky women who, for a variety of reasons, do not have health insurance. Indeed, trends suggest that a growing number of Kentucky women may have limited or little access to the mainstream of health care and are thus excluded from the benefits of medical advances.
Even as we struggle to establish a system of care that is more inclusive, new and unprecedented attention is being brought to the health needs of women. Advances in reproductive health, expanding knowledge of health risks, disease, and treatment in women, and the arrival of the largest female generation in U.S. history at a life stage previously discussed only in whispers have combined to bring new attention to women’s health. This intensified focus has buoyed a somewhat controversial movement to make women’s health a medical specialty in its own right.(1) And it has fostered the development of women’s health centers in medical centers around the nation. At their best, these centers are dedicated to the understanding and advancement of women’s health. As entrepreneurial ventures, they are designed to attract health care’s best customers.
The movement has arrived in Kentucky. Health care institutions around the state are marketing a range of services to women, from delivery rooms that mimic the comforts of home to lectures on hormone replacement therapy. The University of Kentucky Medical Center has sought official recognition as a national center of excellence in women’s health that will address the unique health care needs of Kentucky’s rural and disproportionately poor female population. Moreover, the General Assembly has mandated the creation of an Office of Women’s Health though it remains unfunded.
Unfortunately, the promising future that the movement in women’s health portends could be circumscribed for women in Kentucky. Demographic and lifestyle trends, coupled with historically high rates of poverty and undereducation that have yielded little ground in the present buoyant economy, suggest that women in Kentucky will continue to face many obstacles to optimum health in the years ahead.
Across every age group, the same issues that underpin virtually every public policy dilemma in the state will continue to affect the future health status of women. Disproportionate poverty not only limits women’s access to health care, it is also linked to behaviors and lifestyle choices that exacerbate health risks. Socioeconomic status, research consistently shows, has everything to do with the quality of one’s health. Quite simply, the poor, who are typically undereducated, are more likely to suffer from chronic disease, to die prematurely, and to make the very choices that increase the likelihood of these outcomes. And women of all races, particularly single mothers, are far more likely to be poor than men. As a consequence, the future health status of women in Kentucky remains inextricably linked to how we reckon with the awful legacy of poverty and undereducation, which virtually predetermines impoverishment.
Increasingly, the health of women will be linked to the aging of our population. Demographic trends suggest that the population of older citizens will continue to be predominantly female for some time and, in Kentucky, disproportionately poor. Already, the public health emphasis is shifting to the chronic diseases that afflict and ultimately kill older women. At the same time, our patchwork health care system confronts the costs of caring for an aging population that, some predict, will escalate out of control as Baby Boomers age. Expanding female longevity, the inappropriateness of a health care delivery system focused on disease treatment rather than prevention, and costs that are already pushing the envelope of affordability will help shape a new frontier in women’s health. Preventive care, suggests Dr. Deborah Gomez Kwolek, Medical Director of the Chandler Medical Center’s Women’s Health Center, must become its primary focus.
Epidemiologists and public health experts who seek ways to improve and extend life routinely examine the circumstances that cause death. In addition to the clues to life that they offer, today’s leading causes of death are emblematic of dramatic advances in women’s reproductive health over the past century. In contrast to the turn of the century when women died at an average age of 47, most often from infectious diseases or complications associated with pregnancy or childbirth,(2) diseases generally associated with advanced age are now the leading causes of death among women. Today, the same chronic conditions that afflict and kill most men—heart disease, cancer, and stroke—account for 65 percent of U.S. women’s deaths.(3) In 1996, 64.1 percent of women’s deaths in Kentucky were attributed to these causes.(4) As shown in Figure 1, women and men in the Commonwealth have mortality rates for the leading causes of death that exceed the nation’s as a whole.
On average, white women in the United States lived 79.6 years in 1994-95 while black women lived 74.0 years, compared to 73.4 years for white men and 65.4 years for black men.(5) Today, women in Kentucky enjoy longevity that parallels the national average while men’s lives are more abbreviated here. Over the course of the 1986-1996 decade, the median age at death for women in Kentucky increased two years from 77 in 1986 to the national average of 79 in 1996 while the median age at death for men increased one year from 71 to 72.(6)
Figure 1: Leading Causes of Death, Kentucky, United States, 1995
While women of all races usually live longer than men in the United States, as the federal Agency for Health Care Policy and Research notes, "They do not necessarily live those extra years in good physical and mental health."(7) Consequently, a central public health challenge is that of empowering women with the information they need to prevent and control health risks, as well as the conditions and diseases that accompany aging. In Kentucky, reducing risk factors that contribute to leading causes of death and illness will be critically important to the future health status of women.
Chronic diseases of the cardiovascular system now figure prominently in the mortality of women. Indeed, largely due to the aging of the population, one in two women will eventually die as a result of heart disease or stroke.(8) While mortality attributed to these diseases increases dramatically as women age, an estimated one quarter of strokes occur in women under the age of 65.(9) The ascendance of these chronic illnesses in the mortality of women has effectively rendered the infectious disease treatment models around which our health care system is oriented inappropriate. If their devastating effects on women’s health and longevity are to be alleviated, health/wellness education and counseling and lifelong preventive care will need to become the operative models for caregiving.
That heart disease is the leading cause of death among women seemed, until recent years, to be a well-kept public health secret. A reflection of the expansion of our older population and the feminization of aging, the raw number of deaths attributed to heart disease has actually increased slightly (1.5 percent) even as the female death rate for cardiovascular disease has declined (18.8 percent between 1985 and 1995).(10) In raw numbers, deaths among U.S. women have actually exceeded those among men since 1984, according to the American Heart Association.(11) But awareness of heart disease among women, which causes more than one third of all female deaths in the United States,(12) is growing as new research emerges. In general, long-lived U.S. women tend to confront heart disease some 10 years after men,(13) but for a variety of reasons, 44 percent of women face mortality within a year of a heart attack compared to 27 percent of men.(14) Nationally, African-American women are at especially high risk; coronary heart disease death rates among black women are 35 percent higher than among white women, while stroke mortality runs 71 percent higher.(15)
In spite of its prominent role in the mortality of women, heart disease in women is not well understood. Because women have been 25 percent less likely to be included in clinical trials for heart attack treatments,(16) the very foundation of knowledge on which treatment protocols for women are based is, in all likelihood, fundamentally flawed. Moreover, research shows that women are treated less aggressively than men are after a heart attack, are more likely to die in the hospital after a heart attack or after bypass surgery or angioplasty, and are less likely to receive life-saving drugs for heart attacks.(17) As Dr. Kwolek notes, our knowledge about how diseases present and therapies work differently in women must be expanded if we are to achieve more effective health caregiving.
And advanced age cannot be blamed solely for the higher risk that female heart patients face. Research reported in The Annals of Thoracic Surgery in July 1998 found that among men and women with identical risk factors, women still fared more poorly after bypass surgery. When outcomes from a massive national database of 1996-1997 heart surgery medical records were examined by risk factors, it was found that even among those candidates with the lowest risk factors, people under age 70, 2.2 percent of women died compared to 1 percent of men. Even relative youth was no assurance of similar outcomes for men and women; 2.4 percent of women under 50 died compared to 1.1 percent of men.(18)
Research also suggests that women’s coronary symptoms often go unacknowledged or untreated due to low levels of awareness among women and their doctors. For example, a recent study published in the Journal of the American College of Cardiology found that women are 50 percent more likely to die from their heart attacks than men. While much of the difference is attributable to age and illness, women are still 13 percent more likely than men to die of a heart attack. The study found a significant difference between men and women in the lapse of time between the onset of symptoms and arrival for treatment at a hospital. On average, men are likely to arrive at the hospital almost an hour before women, within 5.3 hours compared to 6.2 hours, creating potentially critical delays in diagnosis and treatment. Women also are 31 percent less likely to receive clot-dissolving drugs that must be administered within six hours of a heart attack to be effective.(19)
In Kentucky, heart disease is the leading cause of death among men and women, black and white. Moreover, the rate of death due to heart disease has exceeded the national average for many years. In spite of above-average death rates, new, more effective treatment regimens and more healthy lifestyles have helped diminish the toll of heart disease in Kentucky. Overall, the percentage of deaths in Kentucky attributable to heart disease has declined significantly from 39.2 percent in 1970 to 31.7 percent in 1996 while the percentage of deaths attributable to cancer has risen sharply.(20) As shown in Figure 1, all cancers combined cause a higher number of deaths per 100,000 population than heart disease alone. As shown in Figure 2, the heart disease death rate, the number of deaths per 100,000 population, has remained higher among men and higher among both white men and women than among black men and women in Kentucky.(21)
Figure 2: Kentucky Deaths Attributed to Heart Disease, by Gender and Race, 1996
Nationally, the overall incidence of cancer and cancer death rates has declined in recent years, but this overall decline offers small comfort in the Commonwealth where cancer mortality rates are among the highest in the nation. After a decade (1970-1980) of little change, Kentucky deaths due to heart disease dropped almost 8 percentage points between 1980 and 1996 while cancer figured in a steadily increasing portion of deaths in the Commonwealth, up from 16.1 percent of all deaths in 1970 to 24.4 percent of all deaths in 1996.(22) Between 1971 and 1996, the rate of cancer deaths in Kentucky increased 42.3 percent, from 164.0 to 233.3 per 100,000 population.(23) While higher cancer death rates are clearly related to the aging of the population, only Delaware and the District of Columbia are predicted to have higher 1998 cancer death rates than Kentucky.(24)
The story of cancer in the lives and deaths of women is also changing. Important and significant attention has been focused on cervical cancer and breast cancer, which is the most commonly occurring cancer among women of virtually every race and ethnicity(25) and was the major cause of death among women for over 40 years.(26) However, lung cancer deaths among women in the United States have exceeded breast cancer deaths every year since 1987.(27) Between 1973 and 1991, lung cancer mortality rates among women under the age of 65 increased 73.7 percent and 212.5 percent among women over age 65.(28) U.S. women rank fourth among 50 other nations in lung cancer mortality rates.(29) In spite of improved early detection and new treatments, lung cancer remains difficult to detect in its early stages. As a consequence, only 14 percent of white women and 11 percent of black women survive with it for 5 years, compared to 66 percent of black women and 82 percent of white women with breast cancer.(30)
Figure 3: All Cancer Death Rates, by Gender and Race, Kentucky, 1995
This year, the trend of rising lung cancer rates among women is expected to continue on its upward trajectory, further narrowing the gap between lung cancer incidence and mortality among men and women. In 1998, an estimated 80,100 U.S. women were predicted to be diagnosed with lung cancer compared to 91,400 men; 93,000 men and 67,000 women were expected to die from lung cancer.(31) In Kentucky, an estimated 3,600 new cases of lung cancer and 3,300 deaths due to lung cancer are anticipated in 1998.(32) As shown in Figure 4, lung cancer death rates were considerably higher among men in Kentucky and among black Kentuckians in 1995, according to the Centers for Disease Control and Prevention.
Figure 4: Lung Cancer Death Rates, by Gender and Race, Kentucky, 1995
As with heart and cardiovascular disease, African-American women are more likely to be stricken with lung cancer, but the black-white gap is closing. Over the most recent decades, the average rate of lung cancer incidence has increased more among white women, 136 percent compared to 116 percent between 1973 and 1995, narrowing the historically higher incidence rate among black women. According to National Cancer Institute data, the 1973-1974 average incidence rate among black women was 21.3 compared to 18.8 for white women. The 1994-1995 age-adjusted, average incidence rate among U.S. black women was 46.1 cases per 100,000 population compared to 44.4 among white women.(33)
Importantly, breast cancer, which affects one in eight women in the United States and is, as shown in Table 1, the leading site of cancer among women in Kentucky, is the leading cause of death in women aged 40 to 55.(34) Most women (77 percent) are over the age 50 when first diagnosed with breast cancer.(35) While lung cancer is more deadly, more than one in every four women who are diagnosed with breast cancer die from what is the most common form of malignancy in U.S. women.(36) This year, the American Cancer Society estimates that 2,900 new cases of breast cancer will occur in Kentucky and 700 of women’s deaths will be attributed to the disease.(37) While some mistakenly believe that breast cancer is largely a hereditary disease, recent studies suggest that genetic defects may account for only about 5 percent to 10 percent of cases.(38) The remaining cases have unknown origins, but some researchers believe environmental and behavioral factors, such as exposure to estrogen-like chemicals, smoking, or high-fat diets may be important causal factors.(39)
Table 1: Leading Sites of Cancer Incidence, by Gender, Kentucky, 1996
Daunting as national statistics are, cancer incidence and mortality rates in Kentucky consistently exceed national rates. Among those sites that are most likely to affect and kill women—breast, lung, and colorectal cancers—women in Kentucky are at significantly higher risk than the average U.S. woman. As Janet Larson Braun, coordinator of the Women’s Health Center at the University of Kentucky observes, "Kentucky lights up like a Christmas tree," on maps of disease incidence. Cancer is prominent. This year, the American Cancer Society estimates that the overall rate of new cancer cases in Kentucky will rank sixth nationally with a rate of 527.1 per 100,000 population, compared to a national rate of 459.(40)
Similar patterns in mortality are also evident in Kentucky. According to the National Cancer Institute, lung cancer mortality rates among women in Kentucky between 1991-1995 ranked behind only those of Nevada.(41) Kentucky’s female rate of death from cancers of the lung and bronchus for 1991-1995 stood at 41.8 deaths per 100,000 population compared to a national rate of 33.3.(42) During the same time period, lung cancer death rates among men in Kentucky led the nation at a rate of 104 per 100,000 population compared to a national rate of 72.(43) As illustrated in Table 2, similarly high mortality rates were also evident in colorectal cancer and cancer of the cervix or uterus, for which Kentucky has the second highest rate of death in the nation. Female breast cancer mortality rates, however, were slightly lower for the period than the national rate.
Table 2: Average Annual Age-Adjusted Cancer Mortality Rates, by Gender, Kentucky, U.S., 1991-1995
The third leading cause of death among women in the United States and in Kentucky is cerebrovascular disease or strokes. Every year, according to the American Heart Association, about 8 percent of U.S. women’s deaths are attributable to stroke.(44) Here in Kentucky, 9.5 percent of 1996 female deaths were caused by these devastating cerebrovascular accidents.(45) Though cerebrovascular disease has caused a declining portion of deaths in the Commonwealth, 7.6 percent in 1996 compared to 11.8 percent in 1970,(46) strokes remain a serious threat to women’s health. Mortality rates are significantly higher among women than men; more than three of five stroke deaths occur in women and those numbers are increasing.(47) And, among African-American women, the U.S. death rate is 71 percent higher than among white women.(48) Stroke mortality rates among black women here in Kentucky, however, have been lower than among white women in recent years.(49)
Importantly, strokes are also the leading cause of serious, long-term disability,(50) which not only exacts an immeasurable human toll but a societal one as well. The estimated direct and indirect costs of strokes were placed at $250 billion in 1997 alone.(51) An estimated 2 million U.S. women are living with the consequences of strokes.(52) Consequently, prevention of this often catastrophic disease is key to the future of women’s health. While we have made great strides in treating high blood pressure, the most significant risk factor for strokes, we appear to be losing ground in many behavioral risk categories that could help prevent strokes and heart disease, two principal killers of women.
Clearly, early detection and treatment of diseases that have a dramatic impact on female longevity is key to extending life and improving the health of women. While Kentucky has made great strides toward ensuring broad access to mammography and Pap smears, obstacles remain. Poverty, inadequate or no health insurance coverage, fear, isolation, lack of knowledge, and cultural norms all play roles of varying importance in keeping women from getting the very tests that could detect breast and cervical cancers at their earliest and most treatable stages and enable proper management of conditions that lead to more serious health consequences.
In spite of the obstacles that remain, concerted attention to reproductive health has dramatically expanded the ranks of women who have had Pap smears and mammograms to screen for cervical and breast cancers. The American Cancer Society recommends annual mammograms for women over age 40, and the importance of these routine exams increases with age. An estimated 77 percent of women with breast cancer are over the age of 50 when diagnosed, according to the American Cancer Society. Annual Pap smears are also recommended by the American Cancer Society for all sexually active women age 18 years or older.
The percentage of women in Kentucky who have had Pap smears and mammograms has increased steadily over the years. Between 1994 and 1996, state health behavior surveys found that the percentage of women who reported not having had a Pap test in the past three years declined slightly to an estimated 25 percent of women 18 and older.(53) About 8 percent of women in Kentucky report never having had a Pap test.(54) The Centers for Disease Control and Prevention report that 35.7 percent of Kentucky women age 50 and older have not had a mammogram in the past two years.(55) African-American women age 50 and older in the Commonwealth were considerably more likely to have had a mammogram. Only 21 percent of those interviewed reported not having had a mammogram in the past two years.(56)
As illustrated in Table 3, the most recent Behavior Risk Factor Survey found that women in the state who are lower income, older, unemployed, undereducated, widowed or separated, or African-American are the least likely to have had a mammogram.(57) Access to health care appears a strong predictor of whether women get recommended mammograms, as the lowest rates of mammogram screening are seen among women who are unemployed or, income levels suggest, working but poor. Women in households with incomes below $24,000 were far less likely to have had mammograms than those in households with higher incomes.
A single behavioral risk factor—smoking—is linked to the major causes of female mortality, as well as to a range of illnesses that have ruinous effects on women’s health and cut their lives short. Though smoking-attributable diseases are the most important single preventable cause of death in the United States(58) and smoking is the most significant risk factor for heart attacks and the cause of nearly one third (30 percent) of all cancer deaths,(59) the veracity of this message has failed to resonate in Kentucky. Instead, as illustrated in Table 4, Kentucky had the highest 1996 population of female—and male—smokers in the United States,(60) a predictor of costly and devastating health outcomes. Only Nevada had higher death rates from lung cancer among women between 1991 and 1995. And smoking rates appear to be rising here among both women and adolescent girls, according to Behavioral Risk Factor Surveys conducted by the Kentucky Department for Public Health and the Kentucky Department of Education. Further, if national smoking trends are followed in the Commonwealth, more women than men are expected to become smokers by the year 2000.(61) Though more men than women in Kentucky now report being smokers, youth smoking rates suggest the difference could soon be erased.
Table 4: State Rankings of Smoking Rates and Lung & Bronchus Cancer Mortality Rates Among Women
High rates of smoking portend a future of disease and premature death. In the case of lung cancer, the majority of deaths are attributable to smoking(62) while smoking is linked to nearly a fifth of all deaths from cardiovascular disease.(63) Studies also show that female smokers who use birth control pills are more likely to have a heart attack or a stroke than women who neither smoke nor use oral contraceptives.(64) Indeed, almost half of continuing smokers die prematurely, according to the American Cancer Society, and about half of them die in middle age (35-69 years), losing an average of 20 to 25 years of life.(65)
In addition to its role in heart disease and lung cancer, smoking has also been linked to numerous other cancers, including cancers of the uterus and cervix, for which Kentucky had the second highest rate of cancer mortality of any state in the nation between 1991-95.(66) Only the District of Columbia had higher rates. Moreover, some research suggests links between smoking and colorectal cancers,(67) for which female mortality rates in Kentucky are well above the national average.(68) According to reports from the U.S. Public Health Service, smoking also "substantially elevates the death rates for cancers of the bladder, kidney and pancreas in both men and women."(69) And research now suggests that in addition to its contributions to low-birth weights and other infant disorders, prenatal maternal smoking may affect the likelihood that adolescent daughters will smoke, thus passing high-risk behavior and its attendant long-term health consequences on to the next generation.(70) Moreover, results of a recent study at the University of Minnesota Cancer Center found that a known carcinogen found only in tobacco and nicotine was present in the urine of newborns whose mothers smoked during pregnancy.(71)
Among the most alarming implications for the future health status of women are rising rates of smoking among female adults and teens. Among all racial, ethnic and gender groups, the number of U.S. high school students who were frequent smokers increased between 3 percent and 5 percent a year between 1991 and 1995.(72) In Kentucky, Behavioral Risk Factor Surveys of adults and youth conducted by the Division of Epidemiology and Health Planning in the Department for Public Health show a rising prevalence of smoking. As illustrated in Table 5, smoking rates for the total population rose nearly three percentage points between 1994 and 1996. Among nonwhite Kentuckians, however, smoking rates declined between 1994 and 1996.
Table 5: Prevalence of Current Smokers, by Gender and Race, Kentucky, 1994-1996
Because more than 80 percent of adults who have ever smoked started by age 18,(73) youth smoking patterns are key indicators of future outcomes for women in Kentucky. In its June 1996 report, Healthy Kentuckians 2000 Mid-Decade Review, the Cabinet for Health Services concluded based on 1993 data that Kentucky youth cigarette smoking had become "epidemic and significantly above national rates."(74) If so, 1997 data from the youth survey should signal a health crisis in the making. As illustrated in Table 6, the total 1993 percentage of Kentucky teens (grades 9-12) who were "frequent" smokers (smoked cigarettes on 20 or more days in the past month) was 19.7 percent. Nationally, 13.8 percent of teens reported being frequent smokers during the same time period. Just four years later in 1997, 27.6 percent of Kentucky teens reported being frequent smokers. While comparable national data are not yet available for 1997, the 1995 Youth Risk Factor Behavior Survey found that just over half as many (16 percent) U.S. high school students identified themselves as frequent smokers.(75)
Table 6: Prevalence of Youth Smoking in Kentucky, Grades 9-12, by Gender, 1993, 1997
In Kentucky, the male-female gap among teen smokers also narrowed somewhat between 1993 and 1997. In 1993, boys reported significantly higher rates of current smoking, 36.6 percent compared to 22.8 percent for girls.(76) By 1997, however, the difference between male and female current smokers had narrowed by nearly 2 percentage points. These findings are particularly alarming in light of a recent study from the Centers for Disease Control and Prevention which found that more than a third (36 percent) of teens who try cigarettes develop daily smoking habits before they graduate from high school.(77) Indeed, the majority of U.S. teen smokers with a daily habit (73 percent) report trying to quit smoking though only 13.5 percent succeed.(78)
Diet, Exercise, and Overweight. While the modern female obsession with weight has taken its own toll on women’s psychological and physical well-being, good health is clearly compromised by the condition of being overweight or obese. Poor diets, sedentary lifestyles, lack of exercise, and the excess weight that often results are linked to major causes of disease and death among women. The links between obesity and heart disease and two important risk factors for stroke—high blood pressure and noninsulin-dependent diabetes—are long established. Indeed, nearly 70 percent of diagnosed cases of cardiovascular disease are related to obesity, according to the National Institutes of Health (NIH).(79) Moreover, almost half of breast cancer cases and 42 percent of colon cancer cases are diagnosed in obese individuals.(80) Women who have poor diets also may be at increased risk of cervical cancer.(81)
The percentage of Kentuckians who are overweight has increased considerably, according to Behavioral Risk Factor Surveillance data. While only 22.6 percent of Kentucky adults were overweight in 1989, nearly a third (31.8 percent) of adults were overweight in 1996 and 30.3 percent of women were considered overweight.(82) The sedentary lifestyles or lack of regular physical activity reported by 70.7 percent of Kentucky women in 1996 and the failure of nearly 80 percent (78.7 percent) of women to eat the recommended daily five or more fruits and vegetables are well-established causal factors.(83)
Clearly, the nutritious, low-fat diets and regular exercise urged by the health care community are not only essential to women’s well-being, they are public health imperatives. It is gradually becoming an integral part of an emerging preventive health model aimed at promoting wellness and preventing rather than treating disease. As Dr. Kwolek observes, "For so long, women’s health was considered to be OB/GYN (obstetrics and gynecology), but, if we put half the emphasis on getting people to stop smoking, to exercise, as we put on trying to get them in for Pap smears, it could make a huge difference."
Perhaps the one recurrent high-risk circumstance about which women can do the least is poverty. Along with its ubiquitous corollary, undereducation, poverty is virtually synonymous with poor health. Importantly for Kentucky where rates of poverty and undereducation have been historically high, research draws a clear link between these demographic circumstances, the prevalence of high-risk behaviors, and the poor health outcomes to which they often lead. Moreover, the health status of disproportionately poor African-American and Hispanic women, a growing Kentucky minority, is consistently worse than that of whites.(84)
Many factors contribute to the relatively poor health status of women who are poor. Not only does the current market-driven health care system exclude many poor and low-income women from the preventive health services and the medical attention they need, they are often isolated or disconnected from the flow of health information that informs and benefits more educated, more affluent women. Moreover, caretaking roles may overwhelm women with limited resources. As Dr. Kwoleck observes, "Women bear the brunt of poverty, especially single mothers. They often can’t take care of themselves because they’re so busy taking care of others."
High-risk behaviors also abound among those with less education and lower incomes. They are, for example, on average, more likely to be overweight and obese,(85) to lead sedentary lifestyles, to have hypertension, to drink heavily, and to smoke. Rates of smoking among the poor and undereducated are significantly higher than among more educated, higher income cohorts. According to the American Cancer Society, 28.2 percent of U.S. women living below the poverty level were smokers in 1993 compared to 21.7 percent of women with incomes at or above the poverty level.(86) Though some more educated cohorts of women have high rates of smoking, women of lower education status are generally more likely to smoke. For example, 32.3 percent of women with 9-11 years of education were smokers in 1993 compared to 11.9 percent of women with 16 years or more of education.(87) In Kentucky, the correlation between undereducation and high rates of smoking is more pronounced than at the national level; among adults age 20 and older with a high school education or less, 38.4 percent of 1993 male and female smokers in Kentucky were of low educational status compared to 29.2 percent nationally.(88)
Not surprisingly, low socioeconomic status is associated with heart disease and lung, breast, and cervical cancers, major killers of women. Appalachian women in particular have especially high rates of cervical cancer.(89) Kentucky is also part of what has come to be called "Coronary Valley," a cluster of states bordering the Ohio and Mississippi rivers where rates of heart disease mortality exceed those among states in the lowest quartile of coronary heart disease mortality by 56 percent.(90) When more than 30 specialists and researchers convened at the University of Kentucky for an April 1998 symposium on the "Coronary Valley" phenomenon, they concluded that a constellation of behavioral factors were at the root of this health problem.(91) All, including cigarette smoking rates, obesity, diet, lack of physical activity, and hypertension have been linked to lower socioeconomic status.
The team of researchers observed, "The Coronary Valley region has a large disadvantaged population with lower socioeconomic status, and there are barriers in the social environment that are associated with increased CHD (coronary heart disease)."(92) The latter include what some anthropologists have concluded are Appalachian propensities for viewing suffering and privation as virtues and for stoically accepting the lot of this life in favor of the rewards of a future afterlife.(93) The vestiges of these cultural norms are readily detectable in many older Kentuckians who are reluctant to seek medical attention for symptoms of disease and illness, much less become active participants in wellness regimens. Women may be particularly vulnerable to such cultural norms.
A 1998 report from the Centers for Disease Control and Prevention documents the demographic tiers of health status in the United States. In short, the more affluent Americans are, the healthier they are. While the tiers exist within every racial or ethnic group, blacks and Hispanics were also found to have generally poorer health than whites.(94) The economic tiers were evident for virtually every health risk factor, every disease, from chronic conditions such as heart disease to communicable diseases such as HIV infection, and every cause of death. For example, the study found that the death rate for poor women with diabetes was three times that of wealthier women.(95) "It’s a sad thought, but maybe we’ve reached a point where health is a luxury," observed Dr. Elsie Pamuk, lead author of the report.(96) For a relatively poor state like Kentucky, findings such as these suggest disturbing losses of future productivity are at stake.
Moreover, the health status of disproportionately poor minority groups will become an issue of increased concern as the state’s Hispanic population grows and African-Americans continue to experience far poorer health outcomes than whites. The disparities between the health status of whites and minorities are so dramatic that President Clinton pledged $400 million this year to an effort aimed at closing them. For example, women are the fastest growing population group to be infected with AIDS,(97) but four times as many Hispanics and eight times as many blacks became infected in 1997.(98) Nationally, AIDS is now the fourth leading cause of death among African-Americans.(99) In Kentucky, one third of AIDS infection, according to Public Health Director, Dr. Rice Leach, is occurring among African-American women who comprised just 4 percent of the 1990 population.
Demographic data from the 1997 state Behavioral Risk Factor Survey, as shown in Table 3, suggest that even in the area of reproductive health, where dramatic strides have been made in recent years, economic status matters. Women with jobs, with higher incomes, and with higher levels of education were more likely to take steps to detect life-threatening diseases such as breast cancer by having regular mammograms. Likewise, data from the 1997 Kentucky Health Survey show a correlation between the frequency of Pap smears and education levels. The 1992 and 1997 surveys also show predictable differences in the prevalence of mammography and insured status. For example, 69.6 percent of insured females age 50-65 reported having ever had a mammogram versus 52.3 percent of women without health insurance.(100)
Interestingly, estrogen deficiency was also cited by the gathering of Coronary Valley researchers as a potential risk factor for coronary heart disease, one about which little is known. However, given the aging of Kentucky’s population, cultural propensities, and the probable role that the absence of health insurance plays in poor women’s lives, it is likely that many women in the Commonwealth who would possibly benefit from estrogen replacement therapy are not receiving it. Clearly, in addition to research on medical outcomes, more needs to be learned about the roles that income, education, and health insurance status play in access to a therapy that is now being prescribed to millions of women. If estrogen replacement therapy proves to be effective in disease prevention over the long term, exclusion from access to it could become yet another measure of poverty’s toll on longevity.
Nationally, according to the Agency for Health Care Policy and Research, most (60 percent) who experience difficulties or delays in getting health care cite their inability to afford it as their main obstacle.(101) In Kentucky, a significant portion of the population is without health insurance and the access to care it enables. The Census Bureau’s most recent three-year, 1994-1996 estimate placed Kentucky’s uninsured population at 15.1 percent or 586,442 people in 1996,(102) compared to a somewhat higher national average of 15.6 percent.(103) Importantly, the Bureau estimated Kentucky’s 1993-1995, three-year average of the population of uninsured Kentuckians at 14.6 percent, indicating that during this period of population growth the number of people in Kentucky who do not have health insurance may have grown.(104)
Not unexpectedly, the working-age, adult population of uninsured is somewhat higher. The University of Kentucky’s 1997 Kentucky Health Survey estimated that 16.1 percent or nearly 400,000 Kentuckians age 18 to 64 were without health insurance.(105) About 15 percent of women who were surveyed reported having no insurance. The uninsured in Kentucky, like most around the nation, are more likely to be poor, usually working poor whose jobs do not provide benefits or pay wages sufficient to cover the cost of private market insurance. For example, 46 percent of those with annual incomes between $14,000 and $24,999 had no health insurance in 1997 compared to 3 percent of those with incomes in excess of $50,000, according to the Kentucky Health Survey.(106) Among women, those living in households with incomes of less than $14,000 were the most likely to be uninsured.(107) Overall, the uninsured in Kentucky are also more likely to live in rural areas, to have less than a college education, and more likely than the insured to report poor health and less likely to report excellent health.(108) Moreover, a University of Kentucky Center for Health Services Management and Research analysis of the 1997 Kentucky Health Survey concluded that being uninsured affected receipt of preventive services, specifically mammograms and Pap smears.(109)
Because of their relative poverty and their higher rates of eligibility for public insurance, nonelderly women are more likely to be insured than nonelderly men. Nationally, 15.1 percent of women under the age of 65 had no health care coverage in 1996 compared to 17.2 percent of men while 13.3 percent of women were covered by Medicaid or other public assistance compared to 10.1 percent of men.(110) Based on two-year averages from the Census Bureau’s 1994 and 1995 Current Population Surveys, Urban Institute researchers found that Kentucky’s nonelderly uninsured population was 53.6 percent male and 46.4 percent female.(111) Among the nonelderly uninsured in Kentucky, married-couple families represented the largest group of uninsured (40.5 percent) while single-parent families, which are typically poor, headed by women, and often Medicaid eligible, were the smallest group of uninsured families (8.8 percent).(112) Most of the nonelderly uninsured (57.3 percent) are in households with only one adult full-time wage earner.(113)
Among those poor enough to qualify for Medicaid in Kentucky, women, most of whom head households that receive welfare, dominate recipient profiles in every age group. In January 1998, Medicaid recipients of all ages were predominantly female, 59 percent compared to 41 percent male.(114) Among the oldest recipients, those ages 65 and older, 73 percent were female. Among the nearly 200,000 adult, working-age (age 18 to 64) recipients, women were again overrepresented, comprising 62.2 percent of this population.(115)
Welfare reform may have a significant impact on the insured status of women as many move from public insurance and welfare rolls into low-wage jobs that typically offer few, if any, benefits. Because women comprise the overwhelming majority of the nearly 15,000 (14,948) adults who left Aid to Families with Dependent Children (AFDC) rolls between April 1996 and April 1998 when Temporary Assistance to Needy Families went into effect, a substantial portion either are or soon will be without health insurance. Though Medicaid coverage has helped many make the transition from welfare dependency to employment, an as-yet undetermined population of women—and men—will no longer have health insurance as a consequence of welfare reform.
Because they are poorer and more dependent upon public insurance, cost-driven changes in the scope and delivery of Medicaid services will disproportionately affect women, as well as sweeping changes in Medicare, which more women receive by virtue of their relative longevity. Changes in service delivery as Medicaid shifts to a managed care model, anticipated reductions in coverage, and increases in costs to the individual under both programs will clearly affect more women than men. Some women may be discouraged from seeking medical care by the challenge of negotiating a system that often befuddles more educated women. From single mothers to nursing home residents, sweeping changes in access to and provisions under public insurance will principally affect women.
The psychological well-being of women is influenced by a range of factors, from biological events that exacerbate depression, which women are almost twice as likely to suffer from than men,(116) to demographics and social problems. Today, women’s lives are more complex and stressful than ever before. They are not only more likely to be poor, to be single parents, and to be principal caregivers regardless of family structure, the majority of women with children face dual and often conflicting roles as caregivers and breadwinners. Many single-handedly manage work and home, juggling child care and, in some cases, elder care arrangements, which are often sources of stress in themselves.
In the workplace, women are shouldering levels of responsibility equal to those borne by men, and, in the process, Columbia University’s Center on Addiction and Substance Abuse (CASA) asserts, they have become more like men "in the extent to which they abuse alcohol, tobacco, illegal drugs, and prescription medication, and in the high price they pay for it."(117) While more adult men abuse more drugs than women, the gap is fast narrowing. If trends persist, as previously noted, more U.S. women will be smokers than men by the year 2000, a dubious international first.(118) Already, the percentage of women and men who abuse prescription drugs is equal, and among adolescents differences in patterns of use have disappeared. Young girls are just as likely to drink, smoke, and use illicit drugs.(119)
According to the University of Kentucky Institute on Women and Substance Abuse, an estimated 112,000 women in the Commonwealth abuse drugs or alcohol(120) and thus experience a range of physical, emotional, economic, and social problems that research suggests are far more prevalent among abusers.(121) The future health consequences of this unfortunate manifestation of equality hold disturbing implications beyond their face value. Women are more susceptible than men to addiction, to poor health outcomes, and to premature death as a result of substance abuse.(122)
Substance abuse among women, especially pregnant women, also poses a threat to the physical and psychological well-being of children. Nevertheless, an estimated one in five pregnant women smokes, drinks, or uses illicit drugs during pregnancy.(123) Recent results from Centers for Disease Control and Prevention surveys show that the number of women who drink alcohol during pregnancy increased from 10 percent in 1992 to 15 percent in 1995; frequent alcohol use among pregnant women also rose.(124)
In Kentucky, nearly 70 percent of the 112,000 women who report needing substance treatment are of childbearing age, according to Alayne L. White, Director of the University of Kentucky Institute on Women and Substance Abuse. Further, research conducted in Kentucky hospitals suggests that as many as one in ten women in Kentucky delivers a chemically affected baby.(125) Moreover, maternal smoking during pregnancy is the number one cause of low-birthweight babies,(126) infants who begin life with a diminished capacity for survival. In a state where smoking is epidemic, the implications of such behaviors are significant.
The youngest of Kentucky women also appear to be at highest risk for maternal substance abuse. In a study of women seeking pregnancy tests at local health clinics in Kentucky, researchers found that 10 percent of the subjects needed substance abuse treatment.(127) Those most in need were adolescent females under age 18, 18 percent of whom needed treatment. Nearly one third (31.3 percent) of adolescents in the study group reported using illicit drugs in the past month, compared to 17.8 percent of the total group.(128)
Women are also far more likely to be the targets of what Dr. Rice Leach, Commissioner of the Kentucky Department for Public Health, cites as our most troubling health problem—violence. That murder has been a leading cause of workplace fatalities for women attests to the extent of the threat of violence against women.(129) During 1997 alone, seven women were murdered on the job in Kentucky.(130) Whether the subtle psychological violence of sexual harassment or the physical brutality of domestic or childhood violence, women are more vulnerable to a range of acute and traumatic stresses that may trigger mental illness or substance abuse. As substance abusers, they become even more vulnerable to a range of violent consequences. According to White, an estimated 50 percent of women who enter domestic abuse shelters are substance abusers.
The psychological consequences of the stresses women encounter are as manifold as the sources from which they issue. Studies have shown that the overwhelming majority of women who are substance abusers, as many as seven in ten, were physically or sexually abused as children.(131) Many more became victims of violence as adults. And the scars of these events can be passed on to subsequent generations. Studies have found that maternal depression, for example, increases the risk of a range of psychological problems, including depression and substance abuse among adult children, particularly daughters.(132) Moreover, substance dependence is associated with other risk factors, including increased likelihood of dropping out of high school, exposure to sexually transmitted diseases, and involvement in criminal activity.(133) Researchers from the National Institute of Mental Health enumerate the potential consequences, any one of which can, in turn, foster yet another legacy of diminished outcomes.
Negative outcomes that stem from substance use and its concomitant behaviors range from poor physical and mental health to instability in family and marital relationships, unwanted or early pregnancy, truncated educational pursuits, diminished educational achievement, impoverished occupational role performance, jeopardized access to employment opportunities and restricted social integration.(134)
Ironically, increased female longevity brings with it a bevy of new stresses, including loneliness, isolation, and disability. Not surprisingly, the incidence of depression and substance abuse are believed to be higher among older women than older men, creating circumstances that may actually exacerbate illness and hasten death. Though depressive symptoms are usually regarded as an indication of poor health or illness, some studies suggest that depression may actually precipitate illness.(135)
In June 1998, CASA released a report on what it called "America’s hidden epidemic," substance abuse among older women. The two-year study, Under the Rug: Substance Abuse and the Mature Women, found that substance abuse and addiction to cigarettes, alcohol and psychoactive prescription drugs are at epidemic levels in the United States. Alcohol abuse and alcoholism alone affect 1.8 million women age 60 and older, but fewer than 1 percent receive treatment, the study found. Further, the study found that another 2.8 million older women abuse psychoactive prescription drugs, tranquilizers, and sleeping pills, and 4.4 million smoke cigarettes.(136)
While only 2 percent of hospital costs go to treat substance abuse, CASA concluded, 98 percent goes to treat a range of costly consequences, from heart disease, lung cancer, and cirrhosis to fractures and injuries. The health consequences of substance abuse enumerated by CASA include:
Women over 65 who commit suicide are nine times more likely to consume at least three drinks a day than those dying of natural causes.
Mature women who drink are more likely than men to develop liver cirrhosis, to develop it sooner and from drinking less.
Women age 65 to 74 who smoke are more than twice as likely to die as women who don’t.
Women who smoke are more likely to get osteoporosis and macular degeneration.(137)
The CASA report illuminates the importance of a movement within medicine toward more holistic care that looks beyond the physical to underlying problems that may aggravate and even cause disease. "A lot of times when a woman goes in to a doctor, they just look at the body," observes Dr. Kwolek. "Medicine is trying to take a more integrated approach, to look at psychosocial and socioeconomic factors." Beyond diagnosis, White urges expansion of treatment options for women and gender-sensitive approaches to treatment that accommodate children and recognize the unique circumstances of women’s lives.
In Kentucky, the underlying factors in women’s health are particularly important given the relative poverty and undereducation of the population and the cultural characteristics of large segments of it. Though an estimated 15 percent of the adult population in Kentucky has some form of mental disorder, only about a third seek treatment for it.(138) Women in the state are more likely than men to report poor emotional health. Based on results from the 1997 Kentucky Health Survey, the Center for Health Services Management and Research found that Kentucky women reported being "calm and peaceful" less of the time than men (79 percent compared to 89 percent), were more likely to report feeling "nervous" (63 percent compared to 53 percent), "downhearted and blue" (70 percent versus 60 percent), and "down in the dumps" (34 percent compared to 24 percent).(139) While women are more likely than men to seek treatment for mental health problems, those with problems related to substance abuse, according to White, are far less likely to be identified as needing treatment and less likely to seek treatment.
The future of women’s health in Kentucky will depend in large part on the same array of demographic, economic, social, and, ultimately, political trends that subtly and not so subtly affect women’s lives. Indeed, whether we confront and alter the present system of rationing health care by economic status will have a profound impact on women’s future health and well-being. After all, far more women than men number among the poor of this state and this nation. In the meantime, the extent of disadvantage women experience, from disproportionately low wages and salaries to insufficient societal responses to increased violence, will continue to correlate with their health status.
Undoubtedly, one of the most significant trends influencing the future health of women is the aging of the population. In the coming years, this revolutionary demographic change will shape a new health care model, one that is more attuned to the life cycles of men and women. It will be informed by a continuously renewed understanding of how to prevent disease and disability through lifestyle and behavior choices. Breakthroughs in treatments will further extend life and enhance quality of life. Already, new treatments for breast and other cancers, for crippling osteoporosis and for once deadly fractures among the elderly, are increasing longevity and functional capacity.
As the Baby Boomer generation moves into its senior years, the care of older citizens, particularly long-lived older women, will become a central public health focus. As a more educated and more affluent cohort of aging women exerts new pressures on the medical and political establishment, the health concerns of older women will likely rise in priority. Already, a very public dialogue about the previously undiscussed but inevitable life stage of menopause has ensued with the arrival of Baby Boomers, the most educated generation in the nation’s history, at this milestone for women. The demands this generation places on the system could ultimately help improve the quality and the reach of preventive care.
Though the ordinary increases in illness and disability associated with advancing age will likely be mitigated by a rising health consciousness, questions about the capacity of an already cost-stressed health care system to manage these increasing demands remain unanswered. Due to the feminization of aging, however, any system failure will disproportionately affect women. Already, an estimated 70 percent of Kentucky’s nursing home population is female, according to the Office of Aging Services. A significant portion of these women depends on financially strained Medicaid for support of their care. Likewise, the outcomes of added stresses on Medicare and private insurers of the elderly will be felt more sharply by women.
So long as health care and good health remain linked to economic status, more women, young and old, are likely to be without them. And changes underway may exacerbate the inequities women experience. Changes in welfare law, for example, may block access to health care for thousands of poor Kentucky women who lack the requisite skills and earnings capabilities needed to purchase or to gain access to health care benefits through employers. Indeed, the concentration of women in low-paying jobs in the Commonwealth virtually assures a future of limited access to health care for a substantial portion of the female population.
Today, the body of information about the causes and the prevention of illness and disease is expanding exponentially due largely to advances in information and communications technology. Scientific breakthroughs are ensuing at a dizzying pace, pushing the boundaries of life expectancy. But, as the current health status of women in Kentucky so clearly illustrates, any successful effort to improve health and well-being depends upon the empowerment of individuals with information that will permit them to make informed choices that increase the likelihood of wellness. In Kentucky, achieving this goal will require sensitivity to cultural norms that may subtly encourage women to forego their own health concerns in the interest of others.
The outlook for women’s health in Kentucky is mixed. On the one hand, rapid advances in medical and health research herald a future of continuously improving outcomes. On the other, the health status of women in Kentucky will almost certainly be circumscribed by high rates of poverty and undereducation that are associated with behavioral risk and poor health outcomes. In addition to the central and as yet unanswered questions around access to care, the future health of women in Kentucky is inextricably linked to how rapidly, how successfully, and how equitably we improve the educational and economic status of our citizens, and to how we respond to the health priorities the circumstances of women’s lives compel.
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National Center for Health Statistics, Centers for Disease Control and Prevention, "Births and Deaths for 1995," Hyattsville, Maryland, Oct. 1996 online, Internet at: http://www.hhs.gov/cgi—bin/waisgat. Return to text.
The Kentucky State Center for Health Statistics provided these data. Return to text.
Lori Mosca, JoAnn F. Manson, Susan E. Sutherland, Robert D. Langer, Teri Manolio and Elizabeth Barrett-Conner, "Cardiovascular Disease in Women: A Statement for Healthcare Professionals from the American Heart Association," online, Internet, 17 July 1998 at: http://www.americanheart.org/Scientific/statements/1997/109701.html. Return to text.
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KY Center for Health Statistics, 1996. Return to text.
AHA, "Brain . . ." Return to text.
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KY Div. of Epidemiology, Health Behavior Trends 15. Return to text.
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ACS, "Facts and Figures 1998: Tobacco." Return to text.
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KY Div. of Epidemiology, Healthy Kentuckians 2000. Return to text.
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ACS, "What Are the Risk Factors for Cancer of the Cervix?" online, Internet, 21 July 1998 at: http://www.cancer.org/cidSpecificCancers/cervical/cervixrisk.htm. Return to text.
KY Div. of Epidemiology, Healthy Kentuckians 2000 10. Return to text.
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ACS, "Cancer Risk Report, 1995." Return to text.
NCI, "Risk Factors: Uterine Cervix," online, Internet, 3 Aug 1998 at: http://rex.nci.nih.gov/NCI_Pub_Interface/raterisk/risks200.html. Return to text.
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"Consensus Statement . . ." Return to text.
"Consensus Statement . . ." Return to text.
John Friedl, "Health Care Services and the Appalachian Migrant," prepared for the National Center for Health Services Research, 1978. Return to text.
Brigid Schulte, "Study’s Lesson: ‘Prosper and You’ll Live Long’" Lexington Herald-Leader 30 July 1998: C9. Return to text.
Brigid Schulte, "Minorities’ Access Separate, Unequal," Lexington Herald-Leader 8 Aug. 1998: A1. Return to text.
Schulte, "Study’s Lesson . . ." Return to text.
Susan J. Blumenthal, "Women and Substance Abuse: A New National Focus," National Institute of Mental Health, Bethesda, Maryland. Return to text.
Schulte, "Study’s Lesson . . ." Return to text.
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F. Douglas Scutchfield, Joyce Beaulieu and Kevin C. Lomax, "Who Are Kentucky’s Adult Uninsured and What Impact Does Being Uninsured Have on Those Individuals?" Policy Brief, Center for Health Services Management & Research, University of Kentucky, Lexington, July 1998. Return to text.
Shelly Reese, "Access to Care," American Demographics Aug. 1998: 57. Return to text.
Based on U.S. Census Bureau population estimates for 1996 as reported by the State Data Center, Louisville, Kentucky. Return to text.
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James Wolf, Deena Watson and Carl Leukefeld, "Substance Abuse Prevalence and Need for Substance Abuse Treatment in Kentucky: Adult Household Survey," Center on Drug and Alcohol Research Technical Report 96104, prepared by the University of Kentucky Center on Drug and Alcohol Abuse for the Kentucky Division of Substance Abuse, 1995. Return to text.
Alayne L. White, "Alcohol and Drug Abuse: An Unrecognized Women’s Health Issue," Women’s Health in Kentucky: Setting the Agenda Conference, Center for Rural Development, Somerset, Kentucky, 26 Sept. 1998. Return to text.
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Damaris Christensen, "Number of Pregnant Women Who Drink Has Climbed," Medical Tribune News Service, 1998, online, Internet, 20 Aug. 1998. Return to text.
James Wolf, Deena Watson, Carl G. Leukefeld, Hugh Spalding, Carol Sauers and Michael Townsend, "Substance Use and Need for Treatment Among Women of Childbearing Age," University of Kentucky Center on Drug and Alcohol Research and Kentucky Division of Substance Abuse, 1998. Return to text.
Wolf et al. Return to text.
Bureau of Labor Statistics, "National Census of Fatal Occupational Injuries, 1997," News Release, U.S. Department of Labor, Washington, DC, 21 Aug. 1998. Return to text.
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Kandel et al. Return to text.
Judith D. Kasper and Eleanor M. Simonsick, "Mental Health and General Well-Being" in The Women’s Health and Aging Study (Baltimore, MD: National Institutes of Health) online, Internet, at: http://www.nih.gov/nia/edb/whasbook/chap8/chap8.htm. Return to text.
CASA, "First Lady Betty Ford and Former HEW Secretary Joseph Califano Release CASA Study: Under the Rug: Substance Abuse and the Mature Woman," News Release, National Center on Addiction and Substance Abuse, Columbia University, 4 June 1998. Return to text.
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Beaulieu et al. Return to text.