Journal of Women & Aging, 27:195–215, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0895-2841 print/1540-7322 online DOI: 10.1080/08952841.2014.933635
Social Integration and Health Insurance Status Among African American Men and Women BEVERLY ROSA WILLIAMS Birmingham Veterans Affairs Medical Center, Birmingham, AL and Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, AL
MIN QI WANG and CHERYL L. HOLT Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD
EMILY SCHULZ Department of Occupational Therapy, School of Health Sciences, A.T. Still University Arizona, Mesa, AZ
EDDIE M. CLARK Department of Psychology, Saint Louis University, St. Louis, MO
Using 2010 national data, we investigate the relationship between social integration and health insurance for African American adults. During the previous year 21.6% of men and 19.8% of women lacked continuous health insurance. The effect of marital status, income, and employment on insurance coverage differed by age and gender. Additionally, frequency of church attendance was positively associated with continuous health insurance for women aged 51–64. Spiritual/religious identity was marginally associated with insurance status for men aged 36–50. As provisions of the Affordable Care Act take effect, implementation programs should expand enrollment efforts to include the conjugal unit and the church. KEYWORDS African Americans, conjugal unit, health insurance, religiosity, spiritual identity
Address correspondence to Beverly Rosa Williams, 700 South 19th Street, 11-G, Birmingham, AL 35233. E-mail: [email protected] 195
196
B. R. Williams et al.
INTRODUCTION From the outset, the Journal of Women & Aging has engaged readers in a discourse on how social, economic, and political policy shapes the life course of women, facilitating or impeding access to social and financial resources and impacting health and well-being in the older adult years in ways that often differ from men (Belgrave, 1994; Caputo, 1997; Feuerbach & Erdwins, 1994; Gottlieb, 1989; Hayes & Parker, 1993; Hibbard, 1995; Jorgensen, 1989, 1994; Kokrda & Cramer, 1996; Rix, 1993; Saxon, 1993; Weitz & Estes, 2001). The impact of social, economic, and political policy on access to health care and health outcomes has long been of interest to readers, particularly as it affects African American women, who have a longer history of workforce participation, higher rates of poverty, a greater risk of serious illness earlier in the life course, and increased likelihood of using a higher proportion of social and financial resources on health care in the preretirement and retirement years compared to their Caucasian counterparts (Goetting, Raiser, Martin, Poon, & Johnson, 1996; Gregoire, Kilty, & Richardson, 2002; McCandless & Conner, 1999; Pearson & Beck, 1989; Wilson-Ford, 1991). Contributors to this journal have described how gender and racial issues produce unique concerns for women of color and differentially affect family structure, workforce participation, and access to health care for African American women (Gottlieb, 1989; Hammond, 1995; Perkins, 1993, 1995; White-Means & Hersch, 1993). African American women have responded to these historical, social, and cultural factors in ways that have produced distinctive patterns of engagement in the personal, interpersonal, and structural aspects of aging across the life course (Conway-Turner, 1999; Daniels, 2004; Trotman, 2002). The issue of health insurance coverage, perhaps more than any other social and economic resource, distinguishes African American women from other race/gender subgroups, reflecting distinctive patterns of social integration that differ from those of Caucasian women and African American men (Anderson & Eamon, 2005; Lieberman, Stoller, & Burg, 1997; Snowden, Libby, Thomas, 1997; Song, Chang, Manheim, & Dunlop, 2006; Taylor, Larson, & Correa-de-Araujo, 2006; Wiltshire, 2011). Using 2010 data from a national telephone survey of African Americans, this article provides an analysis and discussion of the relationship between sociodemographic markers of social integration and continuity of health insurance for African American women and men, identifying commonalities and articulating areas of divergence.
BACKGROUND Health insurance for underserved populations is a salient issue in the United States (Wright, 2010). Since 2001, the Institute of Medicine has issued a series
Social Integration and Health Insurance Status
197
of reports articulating the health risks and economic costs of uninsurance in the United States, asserting “health insurance matters,” and being uninsured is “hazardous to health” (Institute for Medicine, 2009, p. 1). The 2009 United Status Census found over 16.7% of the population was without health insurance (U.S. Census Bureau, 2009). Health insurance status is an important determinant of health-care-seeking behaviors and health outcomes Hogben & Leichliter, 2008). Continuity of health insurance coverage impacts perceived health status (Probst, Wang, Moore, Powell, & Martin, 2008). Absence of health insurance coverage is associated with lack of a usual source of care even when adjusted for perceived health, chronic health conditions, and a history of serious medical illness (Choi, 2011; Hsia et al., 2000). Lack of adequate health insurance coverage produces “reverse targeting” of preventive care, such that those at highest risk such as socially disadvantaged women are least likely to receive screening services (Woolhandler & Himmelstein, 1988, p. 2872). Universal health-care coverage remains a social and political issue in the United States, drawing attention to the medically uninsured and underserved within our midst. Even before the March 23, 2010, signing of the Affordable Care Act (ACA), inequalities in health and health care among the uninsured were a recurring issue, generating policy recommendations for identifying and reducing disparities (Institute of Medicine, 2002). In March 2012, an ACA provision went into effect mandating federal health programs to collect and report data on health disparities due to race and other demographics (Government Printing Office [GPO], 2010). Difficulty accessing health insurance coverage is a burden historically borne by racial and ethnic minority populations and characterized by persistent racial and ethnic health disparities (Agency for Healthcare Research and Quality, 2011; Hargraves, 2004; Kirby & Kaneda, 2010; Monheit & Vistnes, 2000; D. R. Williams, 2012). Higher rates of morbidity and mortality persist among minority populations, with the death rate for many major causes of death 30% higher for African Americans compared to Caucasians, signifying a link between health insurance inequality, health disparities, and mortality rates (Xu, Kochanek, Murphy, & Tejada-Vera, 2008). Historically, African Americans have been disadvantaged in accessing job-based and private health insurance. They continue to suffer from lower than average rates of health insurance coverage even when employed (Brown, Ojeda, Wyn, & Levan, 2000; Roberts, 2002). The 2009 U.S. Census data indicated African Americans have an uninsurance rate of 21.0%, compared to 12.0% for non-Hispanic Whites (United States Census Bureau, 2010). Research has addressed the negative consequences of being medically uninsured and has documented how health inequalities are related to ethnic and racial disparities in health insurance (Kirby & Kaneda, 2010). Impediments to insurance coverage, accessibility, stability, and options make it difficult for poor and medically underserved African American adults to
198
B. R. Williams et al.
utilize the health-care system (Bade, Evertsen, Smiley, & Banerjee, 2008). African American men, in particular, face social, economic, and cultural issues related socioeconomic status, racism, and peer pressure which, when taken together, can engender a seemingly insurmountable impediment to health insurance access and health-care utilization (Cheatham, Barksdale, & Rodgers, 2008). Health-care coverage is at the forefront of the national consciousness, generating a renewed awareness of the need for modifying current programs and implementing innovative ways for providing access to health insurance for individuals regardless of their race, sex, age, and economic circumstances. Previous research indicates health insurance coverage is tied closely to social and structural factors such as race, age, gender, income, education, residence, employment, marital status, and religious affiliation (Bernstein, Cohen, Brett, & Bush, 2008; Carson, Cook, & Alegria, 2010; Gillum, Jarrett, & Obisesan, 2009; Hogben & Leichliter, 2008; Salim et al., 2010); however, further research is needed to understand the differential effect of sociodemographic characteristics on individuals at different stages in the life course. Indeed, there is a renewed interest in identifying specific gender- and age-related correlates of continuity of health insurance coverage among racial subgroups and in articulating the role of social integration in promoting continuity of coverage (Angel, Montez, & Angel, 2011; August & Sorkin, 2010; Becker, Gates, & Newsom, 2004; Cheatham et al., 2008; Walker et al., 2010).
Social Integration Social integration is a concept incorporating an individual’s relational and normative ties to society, as well as the structural and moral solidarity such ties represent. Durkheim first articulated the relationship between religion and social integration, describing how religious beliefs and rituals create a sense of social cohesion by representing the social order within its members and exerting pressure for conformity to social norms and values (Durkheim, 1912). Although there is no one definitive measure of social integration, typically it is operationalized on a scale with individual scores calculated from the sum of the regularity and extent of different types of social roles or social participation networks. In social integration research, the most widely used surrogates for social integration are marital status, employment status, secular community ties, and religious organizational membership and participation (Green, Doherty, Reisinger, Chilcoat, & Ensminger, 2010). Previous research suggests that religious institutions can function as mechanisms of social integration in the African American community, impacting health-care behaviors. Social integration has been shown to
Social Integration and Health Insurance Status
199
be associated with a wide array of health-related social and behavioral outcomes (Gracia & Herrero, 2004). For example, in research on low-SES African Americans, Aaron and colleagues (Aaron, Levine, & Burstin, 2003; Felix-Aaron, Weinick, & Levine et al., 2001) found that church attendance significantly improved health-care-seeking behavior among low-income African Americans. In recent research, social integration in the form of community engagement has been linked to health outcomes in African American women (Fothergill et al., 2011). While there is a growing literature examining the relationship between religious involvement and health among African Americans (Levin, Chatters, & Taylor, 2005), to the best of our knowledge, there is not a substantial body of research on the sociodemographic correlates of health insurance status that considers religion and spirituality or incorporates religious participation as predictors of health insurance status among African American adults. This analysis will describe the landscape of health insurance status across the life course, characterizing its relationship to key sociodemographic components of social integration, and highlighting its relationship with religious and spiritual involvement. Based on prior research exploring the religion-health connection among African Americans (Holt et al., 2009; Holt, Lewellyn, & Rathweg, 2005; Holt & McClure, 2006; Musgrave, Allen, & Allen, 2002), we explore if religious participation and religious/spiritual identity will emerge alongside other sociodemographic elements of social integration in shaping the health insurance status of African Americans.
METHODS We use data from Religion and Health in African Americans II (RHIAA-II) study, a 2010 national telephone survey of African Americans to examine sociodemographic, health and function, and spiritual/religious correlates of health insurance status. Telephone survey methods were used to gather standard sociodemographic information and to query participants about religious/spiritual preferences, beliefs, and practices. Using probability-based methods, a professional sampling company (Genesys) developed a call list of households from the 50 United States. The list of names, addresses, and telephone numbers was generated from publicly available sources. Professional interviewers dialed telephone numbers randomly from this list. Interviewers described the project to the adult living at the household being contacted. If that adult indicated interest, they were screened for eligibility. Eligibility criterion included being an African American age 21 or older. Interested and eligible persons were asked to provide verbal assent to participate. The study had an overall response rate of 27%, calculated as the proportion of complete interviews to the total number of eligible individuals (803/2,998). A total of
200
B. R. Williams et al.
803 interviews took an average of 30 minutes each to complete. Participants were mailed a $25 gift card upon completion of the survey.
Measures Demographic items included age, sex, marital status (married/not married), educational attainment level, current employment status (full-time, part-time, unemployed), household income before taxes, and uninterrupted health insurance coverage during the previous year (yes/no). General health and physical functioning were assessed using the Medical Outcomes Survey Short Form SF-12, which measures eight domains of health and provides two summary measures of physical and mental health. Widely used in large population health surveys, this brief, 12-item form has provided reliability and validity data similar to the longer versions, and acceptable test-retest reliability for both the physical (.89) and emotional (.76) subscales (Ware, Kosinski, & Keller, 1996). Internal reliability estimates in the present sample were acceptable (α = .85 for physical functioning; α = .83 for emotional functioning) (Ware et al., 1996). An established Religiosity Scale was used to assess religious involvement, which was previously validated in an African American population (Lukwago, Kreuter, Bucholtz, Holt, & Clark, 2001). A number of religious behaviors were assessed (e.g., “About how many times a month do you usually attend religious services?”; “Besides attending services, about how many times a month do you take part in other religious activities like Bible study, choir rehearsal, or ministry meetings?”; α = .88 in present sample). Religious/spiritual identity was ascertained by asking participants the following: “Do you consider yourself religious (1), spiritual (2), both (3), or neither (0)?”
Data Analysis Data analysis was conducted on responses of 563 participants between the ages of 21 and 64. Based on age-structured life course transitions (Burton, 1996; Gadsden & Trent, 1995; Settersten & Hagestad, 1996; Settersten & Mayer, 1997), the following categories were used for age and sex subgroup analyses: 21–35 years, 36–50 years, and 51–64 years. Frequency distribution and percentages were obtained for sociodemographic variables including age, gender, marital status, education, income, and health insurance. Descriptive statistics were calculated for religious and spiritual variables and health/function scores. Univariate statistical tests were conducted to examine age and sex differences among sociodemographic variables, health/function characteristic, and religiosity/spirituality. Pearson correlation coefficients were used to assess the association between health insurance status and
Social Integration and Health Insurance Status
201
other variables. Analyses were conducted using SAS statistical software with statistical significance indicated by p < .05.
RESULTS Sample Of the 803 individuals who completed the telephone interview, 240 participants were excluded from the analysis because they were ≥65 years of age and eligible for Medicare. Table 1 displays demographic characteristics for the 563 African American adults included in this analysis. Respondents had a mean age of 48.7 years, with over half between 51 and 64 years old. Slightly more women than men were in the study (53.1% vs. 46.9%), and a majority of participants were not currently married (63.4%). Nearly all respondents had a high school education (90.9%), and one-third reported annual incomes of less than $20,000. Slightly more than half were not working full time. Mean scores on self-reported general health were in the good range (3.43 [SD 1.22]) while those for physical function were in the very good to excellent range (4.93 [SD 1.41]). More than half of respondents attended religious services at least three times per month, while 17% of participants indicated they had not attended a religious service in the past year. Onefourth of participants identified themselves as neither spiritual nor religious (Table 1).
Health Insurance Coverage and Its Correlates Overall, 19.7% of the sample reporting interrupted health insurance coverage during the previous 12 months, including 21.6% of men and 19.8% of women. As Tables 2 and 3 illustrate for men and women respectively, while uninterrupted health insurance coverage did not vary by education or self-reported general health or physical function, health insurance status had significant associations with employment, income, marital status, frequency of religious service participation, and religious/spiritual identity.
EMPLOYMENT
AND I NCOME
Among African American women ages 21–34, there were no significant differences in frequency of continuous health insurance based on employment or income, suggesting that younger women access health insurance outside of the work sector. However, as Table 2 illustrates, for African American women between the ages of 36 and 64, the highest frequency of continuous health insurance coverage was reported by those with full-time employment (p < .001) or incomes ≥$20,000 (p < .01).
202
B. R. Williams et al.
TABLE 1 Sociodemographic Characteristics, General Health, Physical Function, Religiosity, and Spirituality N = 563 Characteristic Age General Health Physical Function
Mean (SD) 48.73 3.43 4.93
Category Sex Male Female Relationship Status Married Not Married Education $20,000 Health Insurance Yes No Religious Spiritual Preference Religious Spiritual Neither Both Frequency of worship service attendance per month 0 times 1–2 times 3 or more times Attend worship service in past year? Yes No
11.26 1.22 1.41 % (N )
46.9 53.1
264 299
36.59 63.41
206 357
9.11 90.89
51 509
45.52 11.83 18.64 10.39 13.62
254 66 104 58 58
32.57 67.43
156 323
80.28 19.72
452 111
5.35 20.50 28.52 45.63
30 115 160 256
4.98 40.48 54.55
23 187 252
82.74 17.26
465 97
Note. Numbers may not sum to 563 or 100% due to missing data.
For African American men between the ages of 21 and 34 years, being unemployed (p = .021), or earning ≥$20,000 (p = 0.01) seemed to be an impediment to uninterrupted health insurance coverage. In contrast, having part-time employment was an obstacle to continuous health insurance coverage for those men age 36–50 years (p = .023) and age 51–64 years (p = .009). While income was not a factor in health insurance status for men between
203
Social Integration and Health Insurance Status TABLE 2 Correlates of Health Insurance Status for Women by Age Group (N = 299) 21–35 years (N = 45) P Value Marital Status Education Level Income Employment Status General Health Physical Function Religious/Spiritual Preference Attend worship service in past year? Frequency of worship service attendance by month
NS NS NS NS NS NS NS NS NS
36–50 years (N = 89) P Value
51–64 years (N = 165) P Value
NS NS 0.003
Social Integration and Health Insurance Status Among African American Men and Women BEVERLY ROSA WILLIAMS Birmingham Veterans Affairs Medical Center, Birmingham, AL and Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, AL
MIN QI WANG and CHERYL L. HOLT Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD
EMILY SCHULZ Department of Occupational Therapy, School of Health Sciences, A.T. Still University Arizona, Mesa, AZ
EDDIE M. CLARK Department of Psychology, Saint Louis University, St. Louis, MO
Using 2010 national data, we investigate the relationship between social integration and health insurance for African American adults. During the previous year 21.6% of men and 19.8% of women lacked continuous health insurance. The effect of marital status, income, and employment on insurance coverage differed by age and gender. Additionally, frequency of church attendance was positively associated with continuous health insurance for women aged 51–64. Spiritual/religious identity was marginally associated with insurance status for men aged 36–50. As provisions of the Affordable Care Act take effect, implementation programs should expand enrollment efforts to include the conjugal unit and the church. KEYWORDS African Americans, conjugal unit, health insurance, religiosity, spiritual identity
Address correspondence to Beverly Rosa Williams, 700 South 19th Street, 11-G, Birmingham, AL 35233. E-mail: [email protected] 195
196
B. R. Williams et al.
INTRODUCTION From the outset, the Journal of Women & Aging has engaged readers in a discourse on how social, economic, and political policy shapes the life course of women, facilitating or impeding access to social and financial resources and impacting health and well-being in the older adult years in ways that often differ from men (Belgrave, 1994; Caputo, 1997; Feuerbach & Erdwins, 1994; Gottlieb, 1989; Hayes & Parker, 1993; Hibbard, 1995; Jorgensen, 1989, 1994; Kokrda & Cramer, 1996; Rix, 1993; Saxon, 1993; Weitz & Estes, 2001). The impact of social, economic, and political policy on access to health care and health outcomes has long been of interest to readers, particularly as it affects African American women, who have a longer history of workforce participation, higher rates of poverty, a greater risk of serious illness earlier in the life course, and increased likelihood of using a higher proportion of social and financial resources on health care in the preretirement and retirement years compared to their Caucasian counterparts (Goetting, Raiser, Martin, Poon, & Johnson, 1996; Gregoire, Kilty, & Richardson, 2002; McCandless & Conner, 1999; Pearson & Beck, 1989; Wilson-Ford, 1991). Contributors to this journal have described how gender and racial issues produce unique concerns for women of color and differentially affect family structure, workforce participation, and access to health care for African American women (Gottlieb, 1989; Hammond, 1995; Perkins, 1993, 1995; White-Means & Hersch, 1993). African American women have responded to these historical, social, and cultural factors in ways that have produced distinctive patterns of engagement in the personal, interpersonal, and structural aspects of aging across the life course (Conway-Turner, 1999; Daniels, 2004; Trotman, 2002). The issue of health insurance coverage, perhaps more than any other social and economic resource, distinguishes African American women from other race/gender subgroups, reflecting distinctive patterns of social integration that differ from those of Caucasian women and African American men (Anderson & Eamon, 2005; Lieberman, Stoller, & Burg, 1997; Snowden, Libby, Thomas, 1997; Song, Chang, Manheim, & Dunlop, 2006; Taylor, Larson, & Correa-de-Araujo, 2006; Wiltshire, 2011). Using 2010 data from a national telephone survey of African Americans, this article provides an analysis and discussion of the relationship between sociodemographic markers of social integration and continuity of health insurance for African American women and men, identifying commonalities and articulating areas of divergence.
BACKGROUND Health insurance for underserved populations is a salient issue in the United States (Wright, 2010). Since 2001, the Institute of Medicine has issued a series
Social Integration and Health Insurance Status
197
of reports articulating the health risks and economic costs of uninsurance in the United States, asserting “health insurance matters,” and being uninsured is “hazardous to health” (Institute for Medicine, 2009, p. 1). The 2009 United Status Census found over 16.7% of the population was without health insurance (U.S. Census Bureau, 2009). Health insurance status is an important determinant of health-care-seeking behaviors and health outcomes Hogben & Leichliter, 2008). Continuity of health insurance coverage impacts perceived health status (Probst, Wang, Moore, Powell, & Martin, 2008). Absence of health insurance coverage is associated with lack of a usual source of care even when adjusted for perceived health, chronic health conditions, and a history of serious medical illness (Choi, 2011; Hsia et al., 2000). Lack of adequate health insurance coverage produces “reverse targeting” of preventive care, such that those at highest risk such as socially disadvantaged women are least likely to receive screening services (Woolhandler & Himmelstein, 1988, p. 2872). Universal health-care coverage remains a social and political issue in the United States, drawing attention to the medically uninsured and underserved within our midst. Even before the March 23, 2010, signing of the Affordable Care Act (ACA), inequalities in health and health care among the uninsured were a recurring issue, generating policy recommendations for identifying and reducing disparities (Institute of Medicine, 2002). In March 2012, an ACA provision went into effect mandating federal health programs to collect and report data on health disparities due to race and other demographics (Government Printing Office [GPO], 2010). Difficulty accessing health insurance coverage is a burden historically borne by racial and ethnic minority populations and characterized by persistent racial and ethnic health disparities (Agency for Healthcare Research and Quality, 2011; Hargraves, 2004; Kirby & Kaneda, 2010; Monheit & Vistnes, 2000; D. R. Williams, 2012). Higher rates of morbidity and mortality persist among minority populations, with the death rate for many major causes of death 30% higher for African Americans compared to Caucasians, signifying a link between health insurance inequality, health disparities, and mortality rates (Xu, Kochanek, Murphy, & Tejada-Vera, 2008). Historically, African Americans have been disadvantaged in accessing job-based and private health insurance. They continue to suffer from lower than average rates of health insurance coverage even when employed (Brown, Ojeda, Wyn, & Levan, 2000; Roberts, 2002). The 2009 U.S. Census data indicated African Americans have an uninsurance rate of 21.0%, compared to 12.0% for non-Hispanic Whites (United States Census Bureau, 2010). Research has addressed the negative consequences of being medically uninsured and has documented how health inequalities are related to ethnic and racial disparities in health insurance (Kirby & Kaneda, 2010). Impediments to insurance coverage, accessibility, stability, and options make it difficult for poor and medically underserved African American adults to
198
B. R. Williams et al.
utilize the health-care system (Bade, Evertsen, Smiley, & Banerjee, 2008). African American men, in particular, face social, economic, and cultural issues related socioeconomic status, racism, and peer pressure which, when taken together, can engender a seemingly insurmountable impediment to health insurance access and health-care utilization (Cheatham, Barksdale, & Rodgers, 2008). Health-care coverage is at the forefront of the national consciousness, generating a renewed awareness of the need for modifying current programs and implementing innovative ways for providing access to health insurance for individuals regardless of their race, sex, age, and economic circumstances. Previous research indicates health insurance coverage is tied closely to social and structural factors such as race, age, gender, income, education, residence, employment, marital status, and religious affiliation (Bernstein, Cohen, Brett, & Bush, 2008; Carson, Cook, & Alegria, 2010; Gillum, Jarrett, & Obisesan, 2009; Hogben & Leichliter, 2008; Salim et al., 2010); however, further research is needed to understand the differential effect of sociodemographic characteristics on individuals at different stages in the life course. Indeed, there is a renewed interest in identifying specific gender- and age-related correlates of continuity of health insurance coverage among racial subgroups and in articulating the role of social integration in promoting continuity of coverage (Angel, Montez, & Angel, 2011; August & Sorkin, 2010; Becker, Gates, & Newsom, 2004; Cheatham et al., 2008; Walker et al., 2010).
Social Integration Social integration is a concept incorporating an individual’s relational and normative ties to society, as well as the structural and moral solidarity such ties represent. Durkheim first articulated the relationship between religion and social integration, describing how religious beliefs and rituals create a sense of social cohesion by representing the social order within its members and exerting pressure for conformity to social norms and values (Durkheim, 1912). Although there is no one definitive measure of social integration, typically it is operationalized on a scale with individual scores calculated from the sum of the regularity and extent of different types of social roles or social participation networks. In social integration research, the most widely used surrogates for social integration are marital status, employment status, secular community ties, and religious organizational membership and participation (Green, Doherty, Reisinger, Chilcoat, & Ensminger, 2010). Previous research suggests that religious institutions can function as mechanisms of social integration in the African American community, impacting health-care behaviors. Social integration has been shown to
Social Integration and Health Insurance Status
199
be associated with a wide array of health-related social and behavioral outcomes (Gracia & Herrero, 2004). For example, in research on low-SES African Americans, Aaron and colleagues (Aaron, Levine, & Burstin, 2003; Felix-Aaron, Weinick, & Levine et al., 2001) found that church attendance significantly improved health-care-seeking behavior among low-income African Americans. In recent research, social integration in the form of community engagement has been linked to health outcomes in African American women (Fothergill et al., 2011). While there is a growing literature examining the relationship between religious involvement and health among African Americans (Levin, Chatters, & Taylor, 2005), to the best of our knowledge, there is not a substantial body of research on the sociodemographic correlates of health insurance status that considers religion and spirituality or incorporates religious participation as predictors of health insurance status among African American adults. This analysis will describe the landscape of health insurance status across the life course, characterizing its relationship to key sociodemographic components of social integration, and highlighting its relationship with religious and spiritual involvement. Based on prior research exploring the religion-health connection among African Americans (Holt et al., 2009; Holt, Lewellyn, & Rathweg, 2005; Holt & McClure, 2006; Musgrave, Allen, & Allen, 2002), we explore if religious participation and religious/spiritual identity will emerge alongside other sociodemographic elements of social integration in shaping the health insurance status of African Americans.
METHODS We use data from Religion and Health in African Americans II (RHIAA-II) study, a 2010 national telephone survey of African Americans to examine sociodemographic, health and function, and spiritual/religious correlates of health insurance status. Telephone survey methods were used to gather standard sociodemographic information and to query participants about religious/spiritual preferences, beliefs, and practices. Using probability-based methods, a professional sampling company (Genesys) developed a call list of households from the 50 United States. The list of names, addresses, and telephone numbers was generated from publicly available sources. Professional interviewers dialed telephone numbers randomly from this list. Interviewers described the project to the adult living at the household being contacted. If that adult indicated interest, they were screened for eligibility. Eligibility criterion included being an African American age 21 or older. Interested and eligible persons were asked to provide verbal assent to participate. The study had an overall response rate of 27%, calculated as the proportion of complete interviews to the total number of eligible individuals (803/2,998). A total of
200
B. R. Williams et al.
803 interviews took an average of 30 minutes each to complete. Participants were mailed a $25 gift card upon completion of the survey.
Measures Demographic items included age, sex, marital status (married/not married), educational attainment level, current employment status (full-time, part-time, unemployed), household income before taxes, and uninterrupted health insurance coverage during the previous year (yes/no). General health and physical functioning were assessed using the Medical Outcomes Survey Short Form SF-12, which measures eight domains of health and provides two summary measures of physical and mental health. Widely used in large population health surveys, this brief, 12-item form has provided reliability and validity data similar to the longer versions, and acceptable test-retest reliability for both the physical (.89) and emotional (.76) subscales (Ware, Kosinski, & Keller, 1996). Internal reliability estimates in the present sample were acceptable (α = .85 for physical functioning; α = .83 for emotional functioning) (Ware et al., 1996). An established Religiosity Scale was used to assess religious involvement, which was previously validated in an African American population (Lukwago, Kreuter, Bucholtz, Holt, & Clark, 2001). A number of religious behaviors were assessed (e.g., “About how many times a month do you usually attend religious services?”; “Besides attending services, about how many times a month do you take part in other religious activities like Bible study, choir rehearsal, or ministry meetings?”; α = .88 in present sample). Religious/spiritual identity was ascertained by asking participants the following: “Do you consider yourself religious (1), spiritual (2), both (3), or neither (0)?”
Data Analysis Data analysis was conducted on responses of 563 participants between the ages of 21 and 64. Based on age-structured life course transitions (Burton, 1996; Gadsden & Trent, 1995; Settersten & Hagestad, 1996; Settersten & Mayer, 1997), the following categories were used for age and sex subgroup analyses: 21–35 years, 36–50 years, and 51–64 years. Frequency distribution and percentages were obtained for sociodemographic variables including age, gender, marital status, education, income, and health insurance. Descriptive statistics were calculated for religious and spiritual variables and health/function scores. Univariate statistical tests were conducted to examine age and sex differences among sociodemographic variables, health/function characteristic, and religiosity/spirituality. Pearson correlation coefficients were used to assess the association between health insurance status and
Social Integration and Health Insurance Status
201
other variables. Analyses were conducted using SAS statistical software with statistical significance indicated by p < .05.
RESULTS Sample Of the 803 individuals who completed the telephone interview, 240 participants were excluded from the analysis because they were ≥65 years of age and eligible for Medicare. Table 1 displays demographic characteristics for the 563 African American adults included in this analysis. Respondents had a mean age of 48.7 years, with over half between 51 and 64 years old. Slightly more women than men were in the study (53.1% vs. 46.9%), and a majority of participants were not currently married (63.4%). Nearly all respondents had a high school education (90.9%), and one-third reported annual incomes of less than $20,000. Slightly more than half were not working full time. Mean scores on self-reported general health were in the good range (3.43 [SD 1.22]) while those for physical function were in the very good to excellent range (4.93 [SD 1.41]). More than half of respondents attended religious services at least three times per month, while 17% of participants indicated they had not attended a religious service in the past year. Onefourth of participants identified themselves as neither spiritual nor religious (Table 1).
Health Insurance Coverage and Its Correlates Overall, 19.7% of the sample reporting interrupted health insurance coverage during the previous 12 months, including 21.6% of men and 19.8% of women. As Tables 2 and 3 illustrate for men and women respectively, while uninterrupted health insurance coverage did not vary by education or self-reported general health or physical function, health insurance status had significant associations with employment, income, marital status, frequency of religious service participation, and religious/spiritual identity.
EMPLOYMENT
AND I NCOME
Among African American women ages 21–34, there were no significant differences in frequency of continuous health insurance based on employment or income, suggesting that younger women access health insurance outside of the work sector. However, as Table 2 illustrates, for African American women between the ages of 36 and 64, the highest frequency of continuous health insurance coverage was reported by those with full-time employment (p < .001) or incomes ≥$20,000 (p < .01).
202
B. R. Williams et al.
TABLE 1 Sociodemographic Characteristics, General Health, Physical Function, Religiosity, and Spirituality N = 563 Characteristic Age General Health Physical Function
Mean (SD) 48.73 3.43 4.93
Category Sex Male Female Relationship Status Married Not Married Education $20,000 Health Insurance Yes No Religious Spiritual Preference Religious Spiritual Neither Both Frequency of worship service attendance per month 0 times 1–2 times 3 or more times Attend worship service in past year? Yes No
11.26 1.22 1.41 % (N )
46.9 53.1
264 299
36.59 63.41
206 357
9.11 90.89
51 509
45.52 11.83 18.64 10.39 13.62
254 66 104 58 58
32.57 67.43
156 323
80.28 19.72
452 111
5.35 20.50 28.52 45.63
30 115 160 256
4.98 40.48 54.55
23 187 252
82.74 17.26
465 97
Note. Numbers may not sum to 563 or 100% due to missing data.
For African American men between the ages of 21 and 34 years, being unemployed (p = .021), or earning ≥$20,000 (p = 0.01) seemed to be an impediment to uninterrupted health insurance coverage. In contrast, having part-time employment was an obstacle to continuous health insurance coverage for those men age 36–50 years (p = .023) and age 51–64 years (p = .009). While income was not a factor in health insurance status for men between
203
Social Integration and Health Insurance Status TABLE 2 Correlates of Health Insurance Status for Women by Age Group (N = 299) 21–35 years (N = 45) P Value Marital Status Education Level Income Employment Status General Health Physical Function Religious/Spiritual Preference Attend worship service in past year? Frequency of worship service attendance by month
NS NS NS NS NS NS NS NS NS
36–50 years (N = 89) P Value
51–64 years (N = 165) P Value
NS NS 0.003
