Given that half of all deaths in the United States are caused by modifiable health behaviors, improving use of preventive care could save more than 2 million life years annually. Women are more likely than men to forego care -including preventive care, with 60% of women foregoing care compared to 50% of men. In 2014, only 30% of women in the US were up to date on preventive screenings; this rate was even lower among women living in Illinois (21.8%). Understanding which factors influence women’s preventive care use has the potential to improve women’s health. Much of the literature on barriers to preventive care has focused on demographic and practical barriers to preventive care use. In particular, race/ethnicity, low SES, lower levels of education, not having insurance, and transportation barriers have been identified as significant barriers to preventive care use. However, these factors do not explain all of the variance in preventive care use, and little is known about the psychological and contextual factors that may be barriers to women’s use of preventive care.
One potential psychological barrier to preventive care use may be depression. Depression affects 9% of the US population, and women are almost twice as likely to be diagnosed with depression as men. People with depression use more healthcare, are 2.5 times more likely to visit the emergency department, and have double the healthcare costs compared to non-depressed people. Yet, individuals with depression are also significantly less likely to have insurance, more likely to live in poverty, less likely to have a primary care physician, and have higher rates of chronic health conditions. Although people who are depressed are more likely to seek care from their primary care physician than from a mental health professional, actual utilization of preventive care by people with depression is not well-understood. Further, much of the focus on preventive care use has been on the individual, yet both individual processes and the social context in which these individual processes occur affect health behaviors and disparities in health care. One contextual factor that is associated with health and is implicated in health disparities is the neighborhood in which individuals live. Neighborhood factors are strongly associated with health and healthcare use, especially among women. The focus of this dissertation is the largely understudied areas of psychological barriers (depression) and neighborhood factors (support and stressors) that may be associated with women’s preventive care use through a secondary analysis of the Chicago Community Adult Health Study (CCAHS; N = 3,105). The dataset combines biomedical data, interview data, and objective community-level data and is the most comprehensive existing secondary dataset on Chicagoans’ health; women comprise 60% (n = 1,870) of the total sample.
Hierarchical logistic regressions were used to test the hypothesis that depression and neighborhood factors (stress and support) are associated with lower adherence to both sex-specific (pap tests, mammograms, and breast exams) and general preventive care (checkups, blood pressure and cholesterol checks) and further that neighborhood factors will moderate the relationship between depression and adherence to preventive care. Results showed that overall, the rates of depression in this sample were high, and varied by race/ethnicity. Almost 25% of the sample had probable depression, which is more than triple the rate of current depression (8.2%) among women in the National Comorbidity Study (NCS). The rates were significantly higher among Latinas and African American women. In unadjusted analyses, women with higher levels of depressive symptoms had significantly lower likelihood of being adherent to sex-specific preventive care (pap smears, mammograms, and breast exams), and this was particularly true among African American women. However, when demographic factors were included in the model, the association between depression and sex-specific preventive care disappeared. Counter to expectations, depressive symptoms were not associated with adherence to general preventive care in analyses with all race/ethnic groups combined. Among Latinas, higher levels of perceived neighborhood support were associated with increased likelihood of adherence to sex-specific preventive care. Among African American women, depression was significantly associated with lower likelihood of adherence to sex-specific care, however this association disappeared when demographic factors were added into the model
