HANDBOOK OF PSYCHOLOGY - PART 9 pps

530 Women’s Health Psychology contradictory “ndings, likely representing the current clash between more traditional views that multiple roles have a negative impact on a woman•s health and relatively recent “ndings that suggest multiple roles can result in positive health effects. The two primary theories that serve as a basis for a great majority of the research examining multiple roles are the scarcity hypothesis (Goode, 1960) and the enhancement or expansion hypothesis (Marks, 1977; Sieber, 1974). Whereas the scarcity hypothesis suggests that the more roles occupied by a woman, the more likely she is to deplete her limited resources, resulting in negative consequences for her health and well-being (Goode, 1960), the enhancement hypothesis suggests that multiple roles result in greater access to resources (i.e., social support, “nancial rewards) and increased likelihood for role balance (Marks, 1977; Sieber, 1974). These two main theories differ in their perspective on the relationship between multiple roles and women•s health: The scarcity hypothesis portends that multiple roles produce deleterious mental and physical health effects, stress, and cause con”ict in balancing roles related to work and family, while the enhancement hypothesis suggests that engaging in multiple roles is protective and provides positive physical and psychological health bene“ts for many women. To illustrate the opposing views offered by these two theories, we present a summary of empirical research relevant to women•s roles as employee and caregiver, and the respec- tive health advantages and disadvantages associated with each. The Employment Role Approximately half of the current U.S. labor force consists of women, and although not equally represented in top-level and more traditional male positions, women hold a wide range of jobs that expose them to stress and health risks (Bond, Galinsky, & Swanberg, 1998). Burke (1988) identi- “ed long work hours, stressful job conditions, high work demands, the number and ages of children at home, and lack of social support as factors that contribute to the strain women experience with work-family con”icts. Likely the most researched and notable cause of this strain is that women continue to take on the primary responsibilities for household chores and childcare, even though the majority also are employed outside the home (Marshall & Barnett, 1995). Furthermore, the contributions of men tend to include tasks such as playing with the children while women tend to as- sume more time-pressured tasks, such as housecleaning, preparing meals, and driving children to appointments (Thompson & Walker, 1989). Women seem to experience work-family con”ict differ- ently than men do, not only because of the nature of women•s roles, but also because of the attitude with which they view the roles. Gunter and Gunter (1990) examined gender differences in perceptions of domestic, household chores (i.e., cleaning, cooking, taking care of children) and found that women view these chores as a personal responsibility, whereas men tend to view such tasks as •helping out.Ž Along these lines, men and women have different attitudes regarding what is the most important resource to provide to the family. Men feel that providing “nancially for their family is the single most important responsibility, while women feel it is equally important to provide childcare and complete household-related chores in addition to contributing to family “nancial resources (Perry-Jenkins, 1993; Perry-Jenkins & Crouter, 1990). Women, therefore, have added pressure and time constraints because of a sense of personal responsibility to complete the bulk of household chores and childcare, in addition to attending to their role as a caregiver, spouse, or partner, and meeting the actual and self-imposed demands of their role as an employee. Work-related challenges, such as work-family con”ict, limited coworker support, gender bias, and restricted opportunity for career advancement, have not only direct “nancial and occupational consequences for women, but also impact on women•s stress levels. In a study by Northwestern National Life (1992), employed women reported nearly double the levels of stress-related illnesses and job burnout than employed men. Another study found 60% of female workers reported job stress as their primary problem (Reich & Nussbaum, 1994). Although women are gaining representation in all “elds, the majority of female-dominated occupations (e.g., those involving customer service and the provision of care) are associated with such common stressors as lack of job security, poor relationships with co-workers and supervisors, and monotonous tasks (Hurrell & Murphy, 1992). Stressors are not limited to women working in less prestigious, lower paying jobs. Women in professional occupations also combat stress as their competency may pose a threat to men„both in the professional and personal environment. For example, single women may feel that a suc- cessful career may jeopardize their prospects for marriage (Post, 1987). Professional women in particular may experience dif“culty forming interdependent, intimate relationships because reliance on independence and self-suf“ciency serve as key components in their achievement of professional success (Post, 1982). Although employment for women has been seen as imposing demands on personal and social resources contributing to the challenge of balancing work and family life, Social and Cultural Influences on Women’s Health 531 employment has also been found to have positive effects on both the psychological and physical health of a woman. For example, Lennon (1998) examined the relationship between housework and depressive symptoms in employed women and homemakers. Differences were found in the amount of time these two groups devoted to housework, with employed women averaging 25 hours per week and homemakers averaging 38.5 hours. When employment hours outside the home are added to housework hours, employed women averaged 64.7 hours per week. Without accounting for speci“c work conditions, hours, and fairness, there were no signi“cant differences in reports of depressive symptoms between employed wives and homemakers. However, when hours, work conditions, and fairness were taken into account, employed wives averaged signi“cantly fewer depressive symptoms than homemakers. These results suggest that employment may balance the negative aspects of housework, resulting in improved mental health. To challenge the hypothesis that employment is the cata- lyst that causes role overload, role con”ict, and distress, Barnett, Davidson, and Marshall (1991) examined the interplay of women•s work and family roles and the effect the employment role has on the family role. Among employed women, they found that helping others buffered the negative effects of concern about role overload resulting in reduced health problems (e.g., fatigue, headache, stomach, and back pain), and that salary satisfaction also buffered negative health effects for employed mothers. The “nding that employment offering women the chance to help others served as a buffer against role overload distress and poor physical health symptoms is especially relevant because a high percentage of women•s employment involves service provision and caregiving. No evidence was found that work overload caused con”ict in the family role or increased physical health risks. Furthermore, in a review of positive aspects of multiple roles, Barnett and Hyde (2001) indicated the work-related factors of added income, social support, opportunity to experience success, and increased self-complexity all contribute to improved mental and physical health. These results suggest that the employment role does not always result in negative health effects for women. In addition to the social systems of family, friends, and community, women also belong to social systems in the workplace. Given the increased number of women who work outside the home, workplace stress and support are issues of increasing importance to women. These issues appear to in- ”uence physical health directly. For example, Hibbard and Pope (1985) reported that women who felt more supported by their coworkers and more included in their workplace spent fewer days in the hospital over the course of one year. Repetti (1993) concluded that individuals who perceive work relationships with supervisors and coworkers as nonsupportive and high in con”ict appear to be at increased risk for minor illnesses and physical symptoms (e.g., headache, fatigue). Therefore, the quality and function of work relationships appear to play a role in women•s health. Still, gender differences have been reported in the effect of workplace support on health and well-being. In an investiga- tion of the amount and effects of social support, job stress, and tedium experienced by men and women (Geller & Hobfoll, 1994), women reported greater life tedium than men, and men reported the receipt of more household assis- tance than women. Despite the fact that the men and women in this study reported receiving similar amounts of support from their coworkers and supervisors, men bene“ted more from these support sources, particularly coworker support. The researchers offer the possibility that men bene“t more from their work relationships because they may interact with their colleagues on a more informal level, which House (1981) suggests may be most effective in the prevention of work stress and its negative consequences. Because individualistic characteristics are so highly valued in the workplace, and because men are more inclined to engage in this individualistic orientation, support may be provided more genuinely among men and may be more effective since it can involve mutual exchange and spontaneous acts, rather than role- required behavior (House, 1981). Men, therefore, may bene“t more than women in terms of workplace health consequences. Another potential factor serving as a key obstacle in women•s obtainment of the necessary social support in the workplace may be subtle gender bias, which can result in overt stereotyping and sexual harrassment (Gutek, 2001). If women want to retain people•s approval, they must demon- strate qualities of female gender role (i.e., warmth, expres- siveness), whereas if they want to succeed professionally in a traditional work setting, they must act according to the male model of managerial success, by being assertive and compet- itive (Bhatnagar, 1988; J. Grant, 1987). These con”icting expectations may contribute to women•s lack of work support, as behaving aggressively may alienate and anger potential supporters (Lane & Hobfoll, 1992). Examining existing gender bias in the workplace, Geller and Hobfoll (1993) found that each gender preferred to mentor and offer support to his or her own gender, a seeming historical change in women•s socialization. Because of increased awareness and sensitivity to problems such as work-family con”ict and the glass ceil- ing, women may be recognizing a need for increased cama- raderie, consequently, developing increased understanding and acceptance of women adopting a more individualistic 532 Women’s Health Psychology orientation. Such support may offset negative health consequences. However, since males maintain the majority of key supervisor positions at this time, these “ndings indicate that women continue to be at a disadvantage in terms of organiza- tional advancement. Women’s Role as Spouse and as Caregiver Although most women ultimately marry, age at “rst marriage is increasing (Barnett & Hyde, 2001), divorce remains a stable entity, and many individuals choose to cohabitate with an intimate partner. As a result, there are a large number of unmarried, as well as married, individuals in the workforce. The research literature addressing multiple roles, however, has tended to focus on women in traditional heterosexual marriages. When examining women•s role as support provider to their husbands, Waldron and Jacobs (1989) found European American women who were married or employed, or both married and employed, had favorable health trends, as op- posed to European American women who were not married or employed. Interestingly, for European American women, marriage had bene“cial effects for those who were not working, while employment had signi“cant health bene“ts for those who were not married. For African American women, it was found that employment had positive effects on health, but only for those with children at home. Furthermore, Afri- can American women who did not work and stayed home with their children showed negative health trends. While research has demonstrated positive health outcomes related to the marriage (i.e., wife) role, Preston (1995) studied married and unmarried individuals and found married women to be in the poorest physical and mental health and the most vulnerable to stress. A signi“cant main effect of social support on health also was reported, with a positive correlation between social support and health for married men, and a negative correlation for married women. In other words, married men bene“ted, in terms of health, from social support while married women who received more social support indicated poorer health. Women•s role as caregiver, both lay and professional, has been a primary focus in the research examining multiple roles because the caregiving role is held by the great majority of women. Multiple roles do not merely imply juggling work and household tasks, because women are also the predomi- nant caregivers and support providers to elderly parents, in- laws, husbands, and other family members (Preston, 1995; Walker, Pratt, & Eddy, 1995). Women with this additional role constitute the •sandwich generation.Ž Such women are at increased risk for health problems as they experience the stress and time constraint of providing care to elderly friends, parents, or other family members while simultaneously providing care to their own children, supporting their partners, and functioning as employees in the workplace. In comparison with population norms and noncaregiver controls, caregivers reported higher levels of both depressive symptoms and clinical depression and anxiety (Schulz, O•Brien, Bookwala, & Fleissner, 1995; Schulz, Visintainer, & Williamson, 1990). In a review of the empirical research on psychiatric morbidity and gender differences in caregivers, Yee and Schulz (2000) found that female caregivers tended to report higher rates of depression and anxiety and lower levels of life satisfaction than male caregivers. The authors suggest these increased rates of depression are largely attributable to the caregiver role because the rates reported by female caregivers were higher than female non- caregivers in the community. This is supported by results “nding signi“cant increases in psychological distress as women adjust to the caregiver role, as well as in women who are continuing to provide care to a disabled or ill person (Pavalko & Woodbury, 2000). In addition to psychiatric morbidity, women may also be at increased risk for physical illness because of caregiving, as women caregivers were less likely than men to engage in preventative health behaviors, such as exercise, rest, taking time off when sick, and remem- bering to take medications (Burton, Newsom, Schulz, Hirsch, & German, 1997). It may be that having a few roles serves as a buffer against such mental health outcomes as depression, but occupying additional roles„particularly in combination with the caregiver role„counterbalances the positive ef fects reaped from other roles (e.g., employment), further contributing to role strain (Cleary & Mechanic, 1983). The effects of caregiving on women are not limited to lay caregivers; over 90% of paid caregivers are also women (Leutz, Capitman, MacAdam, & Abrahams, 1992). Women Occupying Multiple Roles: Who Benefits and Who Suffers? Researchers have attempted to investigate different factors that may increase a woman•s risk for role overload or serve as a buffer for experiencing distress related to multiple roles. A major factor that appears to help limit women•s struggles with “nding a healthy balance between work and home life and enhance the bene“ts of multiple roles involves social support from family and friends (Marshall & Barnett, 1991, 1993). For example, women who do not feel they have their husband•s support or approval concerning their employment role will experience increased role strain (Elman & Gilbert, 1984). Marks (1977) suggested that role commitment is a Social and Cultural Influences on Women’s Health 533 second factor that may increase women•s distress when deal- ing with multiple roles because those individuals who are highly committed to a single role (i.e., job, parenthood) are more likely to experience role strain than individuals who are equally committed to multiple roles. The disparity in research “ndings regarding the health effects of multiple roles highlights the need for clinicians and researchers to further investigate the possible negative effects that can be garnered by women who occupy multiple roles, speci“cally with regard to physical and psychological health. More research addressing additional personal and social resources that can offset negative sequelae, as well as other possible risk and protective factors, is warranted in individuals from diverse social groups (e.g., marital status, sexual preference, SES), occupations, and ethnic-racial back- grounds. Future research on multiple roles needs to focus not only on the individual, but also on the effect socially con- structed gender roles have in shaping society•s perception of different roles, as well as the degree to which these gender roles shape the attitudes and behaviors of women. Sex Roles, Socialization, and Women’s Health This section examines the ways the female sex role and socialization process may contribute directly or indirectly to women•s health. The etiology of the disorders and stressors discussed suggests the role of society largely explains the higher prevalence of these disorders among women. Gender is a salient social category that helps individuals and society understandandperceive the world(Beall, 1993). Unlike biological sex, gender is in”uenced by the society in which the individual lives, as different cultures have different gender stereotypes that in”uence the way men and women are per- ceived. Gender schema theory (Bem, 1981) proposes that society classify the behaviors and attitudes of women and men into •feminineŽand•masculineŽtraits, and thatone•sself-concept is assimilatedto hisorhergenderschema.Inmost cultures,thedis- tinction between male and female is clear, and individuals are expected to behave in a way that is appropriate to their re- spective sex role. In Western cultures, the traditional female sex role has been characterized by traits of warmth and expressive- ness while the traditional male sex role suggests traits of domi- nance and instrumentality. The in”uence of this female sex role has numerous direct and indirect consequences on the psychological and physical health of women. For example, the female sex role and socialization process largely impact women•s de- sire to be thin and may be a contributing factor to high rates of eating disorders.Americansociety tendstoequate thinnesswith attractiveness, especially for individuals in higher socioeconomic brackets (Sokol & Gray, 1998). Women are judged by their physical appearances more often than men (Sobal, 1995), and it has been suggested that body weight and shape are the primary factorsin determiningawoman•sattractiveness andde- sirability (Polivy & McFarlane, 1998). In reality, the average woman is not able to achieve these standards, which results in feelings of low self-esteem, body dissatisfaction, and excessive dieting (Heffernan, 1998). As discussed earlier, the impact of societal expectations on mental and physical health is also evident for women experiencing infertility as well as postpar- tum depression. Coping and Women’s Expression of Illness Several suggestions involving socialization have been offered to explain gender discrepancy in morbidity and mortality. An older idea is that the •sick roleŽ is more in line with women•s sex role stereotype of being a homemaker than to men•s role of provider, and that this allows greater acceptance and opportunity for women to seek medical attention for their illnesses (Nathanson, 1975). It also has been suggested that sickness is a socially acceptable way for women to be relieved of their household, caregiving, and employment responsibilities (Toner, 1994). An alternative explana- tion is that women•s higher morbidity rates result from the stress women experience occupying multiple roles (i.e., wife, mother, paid employee), which in turn leads to higher rates of illness (Reifman, Biernat, & Lang, 1991). Equally important is how women cope with illness. In a study of couples where one partner had been diagnosed with cancer, Baider and colleagues (1996) attempted to further un- derstand gender differences in coping with psychological distress. Their evaluation of 101 couples revealed that the wives of male spouses with cancer reported signi“cantly higher levels of anxiety thandid female patients or their sickpartners. Interestingly, the distress experienced by female patients was accounted forby degree of dif“culty in the domestic environment, extended family relations, and their husband•s psychological distress, with education having a protective effect. However, distress among male patients primarily was accounted for by the degree of dif“culty in the domestic environment. It is noteworthy that the psychological distress experienced by the male patient contributed to the distress experienced by the female spouse; however, the psychological distress of the female patient did not contribute to the male spouse•s distress. These results suggest that the health behaviors and coping styles usedby women may be explained by the female social role that encourages women to focus on emo- tional support, nurturance, and caring for others, as well as care for oneself, while the male social role encourages concern with instrumentality and problem solving. Nezu and 534 Women’s Health Psychology Nezu (1987) found that level of masculinity, not biological sex, predicted distress levels and effective use of problem- solving coping skills in undergraduate students and that coping skills may mediate the relationship between sex roles and distress. Similarly, Friedman, Nezu, Nezu, Trunzo, & Graf (1999) found problem-solving skills and masculinity, regard- less of biological sex, to be signi“cant predictors of psychological distressin personswith cancer,whereas femininitywas not predictive of these factors. Results such as these suggest that social roles or sex roles may better explain differences in coping style, thoughts, and behaviors because studies examining biological sex differences in coping have been inconclu- sive (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992). These results have implications for women in both research and clinical settings. With respect to social context, women are stereotypically categorized as being high in femi- ninity and expected to model the traditional female sex role. Those in the “eld of medicine and mental health must remain cautious of classifying patients according to their biological sex exclusively. By considering the sex role orientation of the individual (rather than making assumptions based on biological sex), researchers and mental health and health care professionals can reduce clinical biases that can potentially hamper treatment, among other variables. CONCLUSIONS AND FUTURE DIRECTIONS IN WOMEN’S HEALTH This chapter addresses several of the physical and psychological health problems faced by women, as well as social factors that may contribute to women•s health problems. Despite advances in the “eld, women•s health remains an area de- serving increased attention. It is important for clinicians and researchers who work in the “eld of women•s health to continue to serve as ambassadors for increased research funding, health education, and outreach to women from all ethnic- racial and cultural groups, and for the achievement of equal status for women in academia. Those working in the “eld of women•s health must look at past achievements and suc- cesses as a guide for future goals, opportunities, and contin- ued progress. This section provides a summary of the current status of women•s health, as well as some possible challenges and opportunities we may confront in the future. Health Care Historically, health care has been a male-dominated profession, with men serving as the primary providers and adminis- trators in the “eld. This has changed signi“cantly as the 13.4% of women graduating from medical school in 1975 increased to 40% in 1997 (Bertakis, 1998). Despite this signif- icant increase in women•s medical school enrollment, more women drop out of medical school than men, with attrition rates for women steadily increasing over time (Fitzpatrick & Wright, 1995). Future research must examine not only rates of attrition, but also potential factors contributing to higher medical school drop-out for women across the nation (e.g., “nancial burden, role strain) and possible solutions. As a result of women entering and graduating from medical school in greater numbers, more women currently serve as faculty members in academic medicine than ever before. This is positive in terms of the interaction between female physicians and female medical students with respect to mentorship, the availability of female physicians for training both male and female medical students, and possible augmented exposure to women•s health issues, as well as greater research and clinical opportunities available in the area of women•s health because of increased numbers of women in the “eld. However, while great strides have been made in the number of women entering academic medicine, the rate of women faculty who are awarded tenure and achieve senior ranks or high administrative ranks has not advanced at the rate expected given the in”ux of women in academia (Morahan et al., 2001). In a review of the literature, Carnes et al. (2001) reported that lack of role models and mentors, feelings of iso- lation, gender discrimination, and lack of support for family- related responsibilities that most commonly fall on women serve as potential reasons women do not achieve academic leadership positions. Traditionally, such positions are ob- tained through research and the acquisition of grant funding, areas in which improvement for women is needed. In the future, women•s health is an area of research that may allow female psychologists, physicians, and scientists to advance to academic positions, at the same time promoting the clinical and research knowledge of women•s health. Psychology The entrance and advancement of women in the “eld of psychology has been dramatic as women earned 66% of the PhD degrees in psychology awarded in 1999. The rate of women earning PhD degrees has increased 8% since 1990, at which time 58% of new PhD degrees were awarded to women. The majority of these degrees were awarded to European American women (84%), followed by Hispanic women (6%), African American women (5%), Asian women (4%), and women of Native American descent (1%). Over the past decade, the percentage of PhD degrees awarded to women of color increased from 12% to 17%, indicating increasing Conclusions and Future Directions in Women’s Health 535 diversity among women in the profession of psychology (Kohout, 2001). The growing number of women entering psychology overall, in addition to increases in women of color, no doubt will in”uence research agendas and clinical attention in the area of women•s health. The growing number of women earning PhDs in psychology has coincided with a 49% increase in the number of grants submitted by women and a 92% increase in the number of grants awarded to women in psychology from 1988 to 1997. Since the 1970s, the percentage of articles with female “rst authors published in psychology journals, including top- tiered journals, has dramatically increased. In the “eld of health psychology, for example, 19% of the articles published in the Journal of Behavioral Medicine were “rst authored by women when the journal was “rst published in 1978, compared to 48% in 1990. Women also are becoming increasingly represented in editorial roles, with a female currently serving as editor for 32% of the APA•s journals as compared to 5% in the early 1980s. There is a similar trend for associate editor positions (currently 37% female) as well as consulting editor and reviewer positions (currently 34% female) in APA journals (Kite et al., 2001). Despite these advances, women in psychology face many of the same challenges as women employed in health care. One primary challenge that exists is the obtainment of senior faculty positions in academia. While women constitute 39% of the full-time faculty at four-year academic institutions, 30% of women achieve tenure compared to 53% of men (American Psychological Association, 2000). The reasons for this discrepancy must be evaluated and remediated. Mentorship The increasing number of women in health care and psychology has a direct impact on the personal and professional development of women pursuing undergraduate and advanced degrees. While female mentors at senior levels may be dif“- cult to “nd in academia, those female graduate students who have the opportunity to work with female mentors bene“t professionally as well as personally (Schlegel, 2000). As discussed throughout this chapter, women experience stressors that are unique to those experienced by men. Having a female mentor can help the female student navigate these stressors and “nd an adaptive balance between her role as a professional and being a woman with many other life roles. Research Scant research prior to the 1990s included female samples exclusively. This approach failed women because it was assumed that either women•s physiological systems were the same as males, or female hormones would confound research, resulting in a strictly male sample. Despite the development of organizations, such as the Of“ce of Research on Women•s Health in 1990 and the NIH Revitalization Act of 1993 that required research supported by federal funds to include women and individuals from diverse ethnic-racial groups, advancements still are needed in women•s health research. Future research must strive to increase the inclusion of women in clinical research trials and to focus on female samples when appropriate. Studies designed to further assess risk factors and disease symptoms that may differ signi“cantly from those of men, or those factors and symptoms that may be exclusively found in women, must be conducted. For example, as discussed earlier in this chapter, women continue to be assessed for and diagnosed with heart disease based on criteria researched on men. This has drawbacks in that symptoms considered atypical for men may be what are typical for women, and without this knowledge, appropriate care for women may be limited. In addition to further research focusing on gender differences in risk factors, illness presentation and course, and pharmacology and other treatments, more attention and increased funding must be dedicated to disorders that occur primarily in women, such as lupus and rheumatoid arthritis. Furthermore, women cannot be categorized as a homogenous population. For example, although morbidity and mortality statistics provide evidence for ethnic-racial disparity for various health conditions, adequate research illuminating risk and other relevant factors is lacking. De- spite statistics that show African American women living in the United States have the fastest growing rates of HIV in- fection, as well as poorer cancer-related health outcomes rel- ative to European American women, research has failed to reach out to women of color and gain their participation in clinical trials (Killien et al., 2000). Women•s health research must include representative samples of all women, including neglected or hard-to-reach populations, such as women of color, lesbians, women from lower socioeconomic back- grounds, and the elderly. Cross-cultural investigations that include women from various countries also are warranted. Why Women’s Health? Why Now? The need for research and clinical attention to women•s health issues has always been present. However, only in the past few decades have women•s health care needs, research, and social and cultural issues been deemed important health topics in both the clinical and research setting. Because women are living longer than ever, the need for empirically 536 Women’s Health Psychology based research “ndings, clinical care, and a more comprehensive understanding of women•s health is greater than ever. In 1940, there were 211,000 women over the age of 85 living in the United States. Today, in the United States alone, there are over 2.9 million women over the age of 85„many of whom have multiple chronic diseases that impact the physical and psychological health (Guralnik, 2000). Earlier in this chapter, we discussed the three leading causes of death for American women: CHD, cancer, and stroke. With respect to elderly women, nearly 70% of total deaths can be attributed to these three conditions (Guralnik, 2000). Research focusing on health behaviors and lifestyle factors relevant to disease development, course, outcome, and quality of life is necessary to develop and disseminate prevention programs, pro- mote psychosocial intervention, and facilitate coping efforts. Attention to such behaviors as cigarette smoking, alcohol consumption, exercise, diet, and seeking routine Pap smears and mammograms can in”uence not only illness prevention, but also outcome. Prevention and treatment issues are equally important for psychological health, as well as physical health. Elderly women commonly experience the death of spouses and friends, the diagnosis of medical conditions, and the social stereotypes of growing old in a society that glori“es youth, all of which contribute to health and well-being. Problems experienced by the elderly in”uence women of all ages because 72% of care given to the elderly is provided by women, including daughters (29%), wives (23%), and other women who serve as lay or professional caregivers (20%; Siegler, 1998), placing the female caregiver at risk for both physical and psychological health concerns as reviewed earlier in this chapter. Because women live longer than men, with a great majority of elderly women living alone, health education must cre- ate interventions and outreach programs that accommodate elderly women who serve as their own primary caretakers, as well as younger caretakers who may have a dif“cult time leaving the house because of child care or household responsibilities. In addressing this concern, the Centers of Excel- lence in Women•s Health (CoE) have turned to the World Wide Web as a way to reach women. The CoE have adopted online health information sites relevant to women patient support groups and is developing other plans to expand these Internet services (Crandall, Zitzelberger, Rosenberg, Winner, & Holaday, 2001). Because women continue to make the majority of the family health care decisions, the Internet serves as a convenient and informative way for women to access resources and acquire education related to women•s health. Caution is warranted, of course, as not all Internet sites relevant to women•s health issues provide comprehensive or accurate information. Several U.S based programs and organizations are cornerstones in the “eld of women•s health, including the American Medical Women•s Association, Division 35 of the American Psychological Association (i.e., Society for the Psychology of Women), the Of“ce of Research on Women•s Health, the Society for Women•s Health Research, and the Women•s Health Initiative (WHI). In an effort to unite the multiple aspects and professions included in the “eld of women•s health, the National Centers of Excellence in Women•s Health (CoE) were developed in 1996 with the goal of promoting women•s health by bringing together those associated with research, clinical care, health education and outreach, and medical training, and increasing the number of women in academic medicine (Morahan et al., 2001). There are currently 15 CoE in academic health centers (Gwinner, Strauss, Milliken, & Donoghue, 2000), with women serving as directors for 13 of these centers (Carnes et al., 2001). It is programs such as these that allow both the physical and psychological care of women to transcend the standards and practices of the past. The future of the “eld of women•s health largely depends on organizations such as these not only to further the advancement of knowledge in women•s health issues, but also to offer interdisciplinary support to women across the applied “elds of medicine, health care, and psychology, and their corresponding academic departments. The “eld of women•s health holds many exciting opportunities and potential advancements for all women. REFERENCES Adler, N. E., Boyce, T., Chesney, M. A., Folkman, S., & Syme, S. L. (1993). Socioeconomic inequalities in health: No easy solution. Journal of the American Medical Association, 269, 3140…3145. Adler, N. E., & Coriell, M. (1997). 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Disorganised attachment behaviour among infants born [...]... al., 199 8; Litonjua et al., 199 9) but not all health outcomes (Kington & Smith, 199 7; Lillie-Blanton & Laveist, 199 6; NCHS, 199 8; Schoenbaum & Waidmann, 199 7; Schoendorf, Hogue, Kleinman, & Rowley, 199 2; D Williams, 199 6) A number of hypotheses have been presented to explain the persistence of these between-group disparities (N Anderson & Armstead, 199 5; Kington & Nickens, 199 9; D Williams, 199 6) For... groups for all-cause and diseasespeci“c mortality and an array of chronic diseases, communicable diseases, and injuries (Breen & Figueroa, 199 6; Cantwell, McKenna, McCray, & Onorato, 199 8; Gissler, Rahkonen, Jarvelin, & Hemminki, 199 8; JNC, 199 3; Litonjua, Carey, Weiss, & Gold, 199 9; Liu, Wang, Waterbor, Weiss, & Soong, 199 8; NCHS, 199 8; Ogle, Swanson, Woods, & Azzouz, 2000; Robert & House, 199 6) These... Dietetic Association, 99 (9) , 1084…10 89 Lester, D ( 199 9) Native American suicide rates, acculturation stress and traditional integration Psychological Reports, 84(2), 398 Liao, Y., McGee, D L., Kaufman, J S., Cao, G., & Cooper, R S ( 199 9) Socioeconomic status and morbidity in the last years of life American Journal of Public Health, 89, 5 69 572 Lillie-Blanton, M., & Laveist, T ( 199 6) Race/ethnicity, the... American counterparts at every level of education attainment (NCHS, 199 8) Second, if African Americans Socioeconomic Status disproportionately perceive their environments as threatening, harmful, or challenging as a result of ethnically speci“c stimuli (Clark, Tyroler, & Heiss, 2000; S James, 199 3; Krieger, 199 0; Outlaw, 199 3; Sears, 199 1; Thompson, 199 6; D Williams, Yu, Jackson, & Anderson, 199 7), they... disease (JNC, 199 3; NCHS, 199 8) Research suggests that smoking, obesity, dietary intake, and hypertension are inversely related to SES (Harrell & Gore, 199 8; King, Polednak, Bendel et al., 199 9; Lowry, Kann, Collins, & Kolbe, 199 6; Luepker et al., 199 3; Winkleby, Robinson, Sundquist, & Kraemer, 199 9), and that statistically adjusting for known behavioral risk factors does not eliminate the SES-health gradient... processes (N Anderson, McNeilly, & Myers, 199 1; Barefoot, Dahlstrom, & Williams, 198 3; Burch“eld, 198 5; Cacioppo, 199 4; R Clark et al., 199 9; Everson, Goldberg, Kaplan, Julkunen, & Solonen, 199 8), coupled with the observation that known and measured risk factors do not account for all of the variability in SES-health differentials (Lantz et al., 199 8; D Williams, 199 6), it is possible that psychosocial... influences (pp 97 …14) Washington, DC: 1 American Psychological Association Pinn, V W ( 199 4) The role of the NIH•s Of ce of Research on Women•s Health Academic Medicine, 69( 9), 698 …702 Pi-Sunyer, F X ( 199 5) Medical complications of obesity In K D Brownell & C G Fairburn (Eds.), Eating disorders and obesity: A comprehensive handbook (pp 401…405) New York: Guilford Press Plichta, S ( 199 2) The effects of women... Hemingway & Marmot, 199 9; House et al., 198 8; Miller, Smith, Turner, Guijarro, & Haller, 199 6; Rozanski, Blumenthal, & Kaplan, 199 9; Schnall, Landsbergis, & Baker, 199 4; Shumaker & Czajkowski, 199 4; Uchino, Cacioppo, & Kiecolt-Glaser, 199 6; Weidner & Mueller, 2000) Gender-speci“c associations of personality attributes (Type A behavior, hostility), negative emotions (particularly depression), and social... is measured cross-sectionally This methodological limitation is particularly noteworthy, given that an emerging body of literature suggests that changes in socioeconomic status (Hart, Smith, & Blane, 199 8; Lynch, Kaplan, & Shema, 199 7; McDonough, Duncan, Williams, & House, 199 7) and early life experiences (D Barker, 199 5; Peck, 199 4; Rahkonen, Lahelma, & Huuhka, 199 7) are predictive of health outcomes... Hispanic origin, 199 0 to 199 7 Available from www.census.gov/population/estimates/nation U.S Bureau of Labor Statistics ( 199 1, January) Employment and earnings Washington, DC: U.S Government Printing Of ce Wolf, P A ( 199 0) An overview of the epidemiology of stroke Stroke, 21(Suppl 2), 4…6 U.S Bureau of Labor Statistics ( 199 7a) Employment and earnings Washington, DC: U.S Government Printing Of ce Yanovski, . the Census. ( 199 7). Poverty in the United States: 199 6. Current population reports (Series P-60, 198 ). Washington, DC: U.S. Government Printing Of ce. U.S. Bureau of the Census. ( 199 9). United States. confound research, resulting in a strictly male sample. Despite the development of organizations, such as the Of ce of Research on Women•s Health in 199 0 and the NIH Revitalization Act of 199 3 that. Centers of Excellence in Women•s Health. Journal of Women’s Health and Gender-Based Medicine, 9( 9), 97 9 98 5. Hall, J. A., Irish, J. T., Roter, D. L., Ehrlich, C. M., & Miller, L. H. ( 199 4).

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