Multiplicative disadvantage of being an unmarried and inadequately insured woman living in poverty with colon cancer: historical cohort exploration in California

Abstract

BackgroundMany Americans diagnosed with colon cancer do not receive indicated chemotherapy. Certain unmarried women may be particularly disadvantaged. A 3-way interaction of the multiplicative disadvantages of being an unmarried and inadequately insured woman living in poverty was explored.MethodsCalifornia registry data were analyzed for 2,319 women diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2014. Socioeconomic data from the 2000 census classified neighborhoods as high poverty (≥30% of households poor), middle (5–29%) or low poverty (<5% poor). Primary health insurance was private, Medicare, Medicaid or none. Comparisons of chemotherapy rates used standardized rate ratios (RR). We respectively used logistic and Cox regression models to assess chemotherapy and survival.ResultsA statistically significant 3-way marital status by health insurance by poverty interaction effect on chemotherapy receipt was observed. Chemotherapy rates did not differ between unmarried (39.0%) and married (39.7%) women who lived in lower poverty neighborhoods and were privately insured. But unmarried women (27.3%) were 26% less likely to receive chemotherapy than were married women (37.1%, RR = 0.74, 95% CI 0.58, 0.95) who lived in high poverty neighborhoods and were publicly insured or uninsured. When this interaction and the main effects of health insurance, poverty and chemotherapy were accounted for, survival did not differ by marital status.ConclusionsThe multiplicative barrier to colon cancer care that results from being inadequately insured and living in poverty is worse for unmarried than married women. Poverty is more prevalent among unmarried women and they have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. There seem to be structural inequities related to the institutions of marriage, work and health care that particularly disadvantage unmarried women that policy makers ought to be cognizant of as future reforms of the American health care system are considered.

Single Marital Status and Infectious Mortality in Women With Cervical Cancer in the United States

“…Pattern of death was examined in women of single marital status for cervical cancer (Table S3, 32,628 women with cervical cancer remained for analysis. All variables were statistically similar between the 2 groups (all, P 9 0.10).…”

“…A possible explanation for increased infectious mortality despite early stage of diagnosis for single women is underuse of the health care system and the aforementioned effect of inadequate social support on mental wellbeing, immune function, and overall health. 31,32 Strengths of this study include that this is a populationbased study with a large-scale sample size and adjustment for patient clinical demographic characteristics by propensity score matching analysis. The quality of our analysis in this study was greatly enhanced by propensity score matching, which has been argued to be a powerful means of accounting for baseline confounding and selection biases.…”

Chinese enclave protections among married Chinese American women: exploratory secondary analysis of colon cancer survival

“…As with other American women, marriage is positively associated with adequate health insurance coverage among Chinese American women (Levitz et al 2015;Tan 2009). Marriage and/or health insurance have also been significantly associated with a range of behaviors among Chinese Americans that, together, could bode for better colon cancer outcomes.…”

“…Research in the same context as the present study has shown that gender and marital status interact with health insurance adequacy which influences cancer survival. For example, among women with colon cancer, poverty and inadequate health insurance coverage were more prevalent among unmarried women (Levitz et al 2015). Among those living near or below the poverty line with colon cancer, private health insurance was associated with survival among married women, but not men.…”

Profound barriers to basic cancer care most notably experienced by uninsured women: Historical note on the present policy considerations

“…Most people studied received such a colectomy (93% to 98%). Preliminary analyses suggested that the uninsured may be at grave risk of its nonreceipt and that women may be at greater risk than men (Campbell et al, 2016;Levitz et al, 2015). This secondary analysis explored that novel gender by health insurance hypothesis.…”