Policy, rural care gaps hurt Alabama women’s access to health care

For many women in Alabama, systemic problems and state policies make access to affordable quality health care a challenge. 

America’s Health Rankings, an annual assessment of the nation’s health, ranked Alabama 46th in the 2022 report on the health of women and children. Only Oklahoma, Mississippi, Arkansas and Louisiana came behind Alabama in the latest ranking.

Much of the low ranking is due to the state ranking low for infant mortality (47th), high teen birth rate (46th), and high prevalence of illicit drug use (47th).

For cancers that are specific to women, incidence is on par with the national rate, but mortality rates in Alabama tend to be higher.

According to the State Cancer Profiles, a project by the National Cancer Institute and Centers for Disease Control and Prevention (CDC), the overall mortality rate from cancer in women is far higher than the national average, and all but one women’s cancer, uterine cancer, had a higher mortality rate than the national average.

Wendy Demark-Wahnefried, a cancer researcher at UAB with a focus on nutrition, said that while ovarian cancer is rarer, as women are postponing their pregnancies, those cancers are on the rise.

“They’re much lower than breast cancer, but the rates are climbing,” she said.

She said that weight can be a risk factor in getting cancer, but it is also a risk factor for “promoting the cancer” as well.

“A large portion of the cancers that we get may be attributed to lifestyle – obesity, poor diet, insufficient physical activity, can contribute to getting the cancer as well as cancer progression,” she said.

Dr. Elizabeth Jackson, a preventative cardiologist at the University of Alabama in Birmingham (UAB) and director at the medical school’s Cardiovascular Outcomes and Effectiveness Research Program, said that women face unique aspects of health as they go through the “continuum of life.” Because of the lack of health care access in Alabama, especially in rural areas, health issues that are specific to women may go untreated or even undiagnosed.

Alabama has a higher-than-average number of women without insurance. KFF reports 13.6% of Alabama women aged 19 to 64 — about 202,000 people — lacked health coverage in 2021, higher than the national average of 10.5% and seventh among all the states. (About 16.9% of men in the state were uninsured that year, 10th in the nation.)

KFF reported that in 2021, 23% of Alabama women reported being in fair or poor health, compared to 17% in the nation. For white women, the number was 21%; for Black women, it was 27%. 9% of Alabama women — and 11% of Black women in Alabama — reported not seeing a doctor in the previous year due to costs.

Disparities

Jackson said women can develop conditions related to their reproductive systems, such as gestational diabetes, hypertension or preeclampsia, aside from other reproductive complications.

“For women going through menopausal transition, as they’re getting into their 50s and 60s, we really want women to understand what the risk factors are for cardiovascular disease, and this is tremendously important for women,” she said.

Men and women face similar health risks, Jackson said, such as high cholesterol, hypertension and rates of smoking. But the rates of some of these are higher in different groups of women. For instance, the incidence of hypertension is particularly high among Black women in the U.S.

“There are concerning rates of smoking in younger women that need to be addressed. Smoking at any age is not good, and there’s huge benefits for women who quit smoking no matter what age,” she said.

Jackson said that women also have higher rates of strokes throughout their lifespan, and while those rates tend to level off as both sexes get older, young women are more at risk for strokes than young men. This is particularly true in the South, which has reported higher mortality rates from stroke for decades.

“It’s not completely clear – there could be a lot more research done on rates of different strokes, but really for the underlying mechanisms for those. And again, when you look back to gestational diabetes, hypertension, those are probably factors that are unique to women, that come up to create a higher risk for things like stroke,” Jackson said.

Jackson also said that there are social determinants of health that also affect women’s health in Alabama. Stress due to structural racism, for example, affects women across that lifespan. Medical professionals are only beginning to look at those issues, she said. 

“Having more stress, having less rewarding social roles – the burdens of life that we traditionally hadn’t measured – really do have an increased risk of making it harder to have a healthy lifestyle. Not smoking, having regular physical activity, all the things that actually are tremendously important in terms of cardiovascular health throughout your lifespan,” she said.

Lack of access

In Alabama specifically, Jackson said, a lack of access to preventative services in rural areas contribute to the state’s challenges in addressing women’s health. She said that rural areas have less access to healthy foods and higher rates of smoking. The average price of a pack of cigarettes in Alabama is some of the lowest across the country. Only four states have cheaper cigarettes than Alabama.

“There’s a lot of poverty in rural areas. That can create different stress points and different stresses around your day-to-day activities, that make it harder to do everything from having time and money and transportation to get preventative services, to having access to places where you can walk or be physically active or even have the time to do that,” she said.

Access to health care in Alabama contributes to challenges in combating health issues such as breast and cervical cancer. Many Alabama women, particularly those in rural and low-income communities, find these essential services out of reach due to logistical and financial constraints. As such, the opportunity for early detection and treatment of potential health issues is missed, often leading to dire consequences.

Demark-Wahnefried said Alabama’s rural landscape is a predictor for cancer. She said that if there’s a delay in treatment or in diagnosis, that can adversely affect prognosis for those women, especially those living in rural and impoverished areas, have the “double whammy” in being physically at a disadvantage for access to care, but then also financially disadvantaged.

“We have a large rural population, and we know that people who live in rural places have access to care issues, travel and just general access issues that can delay diagnosis,” she said. “And with cancer, that can be particularly deadly.”

Looking forward

UAB is currently recruiting for a study looking at how survivors of obesity-related cancer respond to web-based interventions. Demark-Wahnefried, one of the researchers on the team, said they are targeting people in rural areas, who may not have access to a dietician or a personal trainer.

While the study does not specifically target women, it will also analyze obesity-related cancers specific to women, such as breast, ovarian and endometrial cancer.

“This is a study that’s aimed at cancer survivors for whom weight management is important, so those who need to lose some weight and get more active and eat better,” Demark-Wahnefried said.

The study’s aim is for rural Alabamians to benefit from diet and exercise education in their own homes, but the researchers will then analyze health indicators for cancer survivors, such as blood pressure, to determine the benefits of web-based interventions for diet and exercise.

“What we really hope to do with that study, first of all, we want to see how people change their diets, their exercise and their weight status. But then we’re looking at these downstream health benefits,” she said.