The month of October is home to two important observances, both of which disproportionately affect women: Breast Cancer Awareness Month and National Domestic Violence Awareness Month. Both breast cancer and domestic violence have incidences or outcomes that are functions of or are influenced by social determinants of health (SDoH). In fact, outcomes for each of these can be exacerbated by challenges with social determinants of health.
Awareness of and responses to these health issues has evolved over time. Breast cancer screening is widespread, and most every woman is familiar with the question that is now asked at virtually every medical appointment as part of routine screening: “Do you feel safe at home?”
Our DSH and Consulting teams regularly work with clients on the forefront of helping women in underserved communities, women who are often economically disadvantaged, with these and other kinds of health challenges.
As Julia Kotchevar (director, Atlanta, remote in Nevada) from the Consulting team notes, access is a critical component to closing the health care gap experienced by women. Kaiser Family Foundation issued a Women’s Health Survey and found that, “Women’s health outcomes are shaped not only by access to care, health insurance, and affordability, but also by the social and economic factors that drive health, discrimination, and experiences within the health care system, which have become a larger focus in providing equitable health care in recent years.”
“Healthy communication with your provider is critical when considering lifesaving preventative health care such as screenings that reduce the mortality rate of breast cancer,” says Julia. “Even more so when considering the impact of domestic or intimate partner violence.”
Breast Cancer Awareness Month
The first-ever observance of breast cancer awareness came in 1985 and arose from a partnership between pharmaceutical division of Imperial Chemical Industries and the American Cancer Society. Betty Ford, herself a breast cancer survivor, participated in the inaugural event. Cosmetics company Estée Lauder, in the first nationwide marketing campaign for the event, gave out 1.5 million pink ribbons, giving the observance its iconic visual aid. The goal of the observance is continued education and awareness, alongside promoting early detection, the importance of mammograms, and the recognition of those dealing with the disease and those who have survived.1
Framing the Issues
Breast cancer is a significant health care issue for all women. It crosses boundaries of age, ethnicity, and income. According to the American Cancer Society, roughly 1 in 3 of all new female cancers each year are breast cancer, with estimates for 2023 that nearly 300,000 new cases of invasive breast cancer will be diagnosed in women.
Still, the incidence of breast cancer, and its corresponding outcomes, vary strongly according to characteristics such as ethnicity and socioeconomic status.
Economically disadvantaged women such as those who get care at the disproportionate share hospitals (DSH) we serve, and socioeconomic factors, such as lack of transportation, information, or insurance may contribute to more negative outcomes.
Moreover, as Jerry Dubberly (principal, Atlanta) points out that, although rare, men also are diagnosed with breast cancer and black men have poorer outcomes than white men.
“A number of controllable circumstances contribute to late detection and poorer breast cancer outcomes in the Medicaid eligible population,” says Jerry. “These include factors such as gaps in Medicaid eligibility, access to care, focus on preventive care, health care literacy, and a number of health-related social needs that create health disparities and inequities.”
National Domestic Violence Awareness Month
First observed in 1989, Domestic Violence Awareness Month provides awareness of and advocacy for those dealing with or recovering from domestic or intimate partner violence (IPV). Domestic violence crosses all socioeconomic lines and has physical, emotional, intellectual, and generational dimensions.
Framing the Issues
According to the National Coalition against Domestic Violence (NCADV), “1 in 4 women and 1 in 9 men experience severe intimate partner physical violence, intimate partner contact sexual violence, and/or intimate partner stalking with impacts such as injury, fearfulness, post-traumatic stress disorder, use of victim services, contraction of sexually transmitted diseases, etc.”
Lower-income women experience more domestic violence than other women, and those working in the health care field are increasingly recognizing this as a significant health threat. According to Purdue University in the study Domestic Violence and Poverty by Deborah Satyanathan and Anna Pollack:
“Families who experience domestic violence are often also victims of poverty. Studies examining the association between domestic violence and poverty have found:
- Of current welfare recipients in Michigan, 63% have experienced physical abuse and 51% have experienced severe physical abuse during their lifetimes.
- Physical abuse/being afraid of someone was cited as the primary cause of homelessness (in a survey of homeless adults in Michigan).
- Half of homeless women and children report being victims of domestic violence.”
While we have made progress toward addressing the numerous complex and nuanced factors associated with domestic violence – and we have become better at recognizing and managing the myriad SDoH presented by Medicaid beneficiaries – much work remains to be done. The report goes on to discuss the significance of the waiver programs, delivery system reform incentive payment programs (DSRIP), and behavioral health projects, such as those our consulting team performs. Consider the following from that same study.
“State Medicaid programs, which provide coverage for more than 80 million people nationwide, are uniquely positioned to support the prevention of IPV, much the way Medicaid programs have proactively addressed other social drivers of poor health.
For instance, Washington State’s Medicaid Transformation Project, a Section 1115 demonstration waiver, provides incentive payments to community-based organizations to work with health care partners to address issues such as transportation, housing, and child care in efforts to improve health care for Medicaid enrollees, and North Carolina is piloting Medicaid payment for services related to food, housing, and transportation.”
According to Julia, these types of services are critical for ensuring that women are able to access their health care providers and do the things important for the treatment of health care conditions. Access to health insurance is not enough to move the dial on health outcomes without the support needed to actually utilize services available.
“Our work examines the quality of health care, and that shapes public policies. Incentives directly impacts provider behavior, an important consideration when research indicates that 29% of women report that doctors dismiss their health care concerns,” says Julia. “Quality of care isn’t just about efficiency of payment, but also about patient experience and provider incentives that directly impact that patient experience and outcome.”