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Research Agenda for Psychosocial and Behavioral Factors in Womens Health: Health Behaviors
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Alcohol
and Other Substance Abuse
Cigarette Smoking
Diet and Obesity
Physical Activity and Exercise
If we are to have an impact
on women’s risk of chronic disease, we must intervene in the four prominent
health behaviors influencing chronic disease: alcohol and other substance abuse,
cigarette smoking, dietary patterns, and physical activity patterns. Although
we discuss these behaviors in separate sections, we recognize that controlled
investigation of combinations of the behaviors is critical and to date has received
little systematic attention.
Alcohol and Other Substance
Abuse
Preliminary estimates from
the 1994 National Household Survey on Drug Abuse (Substance Abuse and Mental
Health Services Administration [SAMSHA], 1995) indicate that almost half (46.8%)
of all women in the age range of 15 to 44 years have used an illicit drug at
least once in their lives, 4.7 million women currently use illicit drugs, and
women now constitute more than 37% of the illicit-drug-using population in the
United States. Six percent of women 15 to 54 years of age have met the criteria
for lifetime drug dependence (Kessler et al., 1994). Recent epidemiological
research suggests that between 10% and 15% of U.S. women experience at least
some drinking-related problems (Wilsnack, Wilsnack, & Hiller-Sturmhöfel,
1994) and that approximately 4% (or 4 million) of American women meet diagnostic
criteria for alcohol abuse or dependence (Grant et al., 1994). Finally, more
women than men are at risk for becoming dependent on the non-medical use of
psychotherapeutic drugs. During 1994, 1.2 million women reported having taken
prescription drugs for non-medical purposes during the past month (SAMHSA, 1995).
Although more men than
women use drugs, the consequences of drug use by women are often more severe,
and after initial use, women may proceed more rapidly to drug abuse than men
(Griffin, Weiss, Mirin, & Lange, 1989). A national survey on pregnancy and
health reported that in 1992 among women who gave birth in the United States,
an estimated 221,000 used illicit drugs while they were pregnant (National Institute
on Drug Abuse, in press). Pregnant drug abusers are at increased risk for miscarriage,
stillbirth, low weight gain, anemia, hypertension and other medical problems
(Finnegan, 1994). Their newborns may have lower birth weight and smaller head
size than babies born to healthy mothers (Mayes & Granger, in press). One
of the most devastating consequences of drug use for females is the risk of
HIV/AIDS. AIDS is now the fourth leading cause of death among women 15 to 44
years, and nearly 70% of the AIDS cases among women are drug related (Centers
for Disease Control and Prevention [CDC], 1995a). In addition, heavy alcohol
use and other drug use are risk factors for a wide range of other physical and
mental health disorders in women.
In past research on drug
abuse, research subjects, both humans and animals, have been almost exclusively
male; as a result little data has been available on women. Recently, however,
gender differences have gained attention in the field of drug abuse research,
and preliminary data indicate that the biological mechanisms involved in drug
abuse and addiction, the progression and initiation to drug use and abuse, the
antecedents and consequences of drug use and abuse, and prevention interventions
and treatment for drug abuse vary considerably between men and women. Thus,
more research is needed to understand these differences.
Research Priorities
for Alcohol and Other Substance Abuse
Conduct basic behavioral
research (both human and animal) directed at identifying sex and gender differences
in the etiology and consequences of drug use, abuse, and addiction.
Animal studies have shown
that fundamental gender differences may exist in the reinforcing and stimulus
properties of abused drugs. On several measures of stimulant-induced activity,
females exhibited more responsiveness than males; moreover, this responsiveness
varied with the estrus cycle (see Roberts, Bennett, & Vickers, 1989). Gender
differences have also been reported in self-administration of cocaine. When
cocaine infusions were made contingent upon increasingly higher numbers of bar
presses, female rats made substantially more presses than males, and their level
of cocaine self-administration varied as a function of the estrus cycle (Roberts
et al., 1989).
The results of a study
in humans examining gender and menstrual cycle differences in response to acute
intranasal cocaine showed that mean cocaine plasma levels in women were higher
in the follicular phase than in the luteal (Lukas et al., in press). Thus, studies
are needed that examine the role of the menstrual cycle in modulating drug use
and drug effects; gender-specific behavioral, biological, and medical effects
of drug abuse; and, gender specific biological and behavioral mechanisms that
underlie drug abuse and addiction.
In epidemiological, clinical,
experimental, and longitudinal studies of women’s alcohol and other drug use,
examine variations within groups of women based on such characteristics as age,
ethnicity, employment, marital and family status, and sexual orientation.
Because women have been
greatly underrepresented in past substance abuse research, the recent shift
in attention to women as a special population in substance abuse research has
often failed to examine differences within the very heterogeneous group of women
who report substance abuse. Based on the few studies that have examined subgroup
differences among women substance abusers, we now know that certain demographic
variables (e.g., age or relationship status) may be powerful predictors of women’s
substance use and abuse. For example, several studies have found a correlation
between women's problem drinking and the presence of a problem-drinking spouse
or partner (Jacob & Bremer, 1986). Women who inject drugs are more at risk
for HIV infection than men, because they are more likely to share needles with
their injection-using partner and to have sex with an injection-using male partner
(see Morokoff, Harlow, & Quina, 1995). Regardless of whether researchers
are examining etiology, consequences, prevention or treatment, studies are needed
that examine drug abuse in women of all ages, ethnic backgrounds, socioeconomic
(SES) groups, and sexual orientations.
Increase attention to
patterns of multiple substance abuse in women rather than a narrower focus on
either alcohol or other drugs in research on etiology, consequences, prevention,
and treatment.
Despite high rates of combined
use of alcohol and other drugs by substance-abusing women, much of the available
research focuses on either alcohol use or the use of other drugs. Increased
knowledge about the antecedents and consequences of various combinations of
alcohol and other drugs could suggest more differentiated approaches to treatment
and prevention of substance abuse in women. Needed research includes (a) improved
measurement of simultaneous, concurrent, and alternating use of alcohol and
other drugs, in both "alcohol" and "drug" research; (b) analysis of antecedents,
correlates, and consequences of specific combinations of alcohol and other drugs;
and (c) increased collaboration between researchers concerned with treatment
and prevention of alcohol disorders and their counterparts studying other substance
use disorders, including nicotine dependence.
Evaluate the effectiveness
of early identification strategies and brief interventions provided to substance-abusing
women by health care professionals in medical and mental health care settings.
Evidence suggests that
health care professionals may serve as a front-line for identifying women with
drinking problems because such women are more likely than men to seek help for
problems other than drinking and to seek help in mental health and medical settings.
Unfortunately, women’s substance abuse problems tend to be under-recognized
in these settings, and physicians are less likely to refer women for alcohol
treatment compared with their referral rates for men (Vogeltanz & Wilsnack,
in press). Moreover, recent evidence suggests that brief interventions can be
as effective as longer-term treatment for some problem drinkers (Babor, 1990;
Bien, Miller, & Tonigan, 1993). The effectiveness and cost-effectiveness
of brief interventions by health care professionals with substance abusing women
needs to be evaluated and established.
Conduct research on antecedents,
pathways, risk and protective factors involved in drug abuse by girls and women
with emphasis on early identification and the full spectrum of prevention interventions.
The progression or developmental
stages of drug involvement appear to differ according to gender. In the progression
from legal drug use to illicit drug use, for example, cigarettes seem to play
a major role for women; for men alcohol alone is sufficient (Kandel, Yamaguchi,
& Chen, 1992). With regard to initiation into illicit drugs, data suggest
that women are more likely to begin or maintain cocaine use in order to develop
more intimate relationships, whereas men are more likely to use the drug with
male friends and in relation to the drug trade (Boyd, Blow, & Orgain, 1993).
The onset of drug abuse is later for females and the paths are more complex
than for males. For females there is typically a pattern of breakdown of individual,
familial, and environmental protective factors and an increase in childhood
fears, anxieties, phobias, and failed relationships; the etiology of female
drug abuse often lies in predisposing psychiatric disorders prior to abusing
drugs (Brooks, Whiteman, Cohen, & Tanaka, 1992). Prevention research expanded
to include interventions based on female-specific antecedents, pathways, and
risk and protective factors is needed.
Conduct research on the
impact of violence and victimization on the psychosocial development and psychosocial
functioning of girls and women as it relates to drug abuse and addiction.
Childhood sexual abuse
has been associated with alcohol and other drug abuse in women in several clinical
and non-clinical studies (e.g., Boyd, Guthrie, Pohl, Whitmarsh, & Henderson,
1994; Miller, Downs, & Testa, 1993; Teets, 1995; Wilsnack, Vogeltanz, Klassen,
& Harris, 1995). For example, research findings indicate that up to 70%
of women in drug abuse treatment report histories of physical and sexual abuse
with victimization beginning before 11 years of age and continuing on a serial
basis (Miller et al., 1993). A study of drug use among young women who became
pregnant before reaching 18 years of age reported that 32% had a history of
early forced sexual intercourse (rape or incest). These adolescents, compared
with non-victims, used more crack, cocaine, and other drugs (except marijuana),
had lower self-esteem, and engaged in a higher number of delinquent activities
(Lanz, 1995). The path by which substance abuse develops following childhood
sexual abuse experiences in women is unclear, and further research is needed
to understand the etiology of this strong correlational finding. Well-designed
and carefully evaluated prevention and intervention efforts with young childhood
sexual abuse victims may help reduce subsequent substance abuse and other physical
and mental disorders in women.
Furthermore, women drug
abusers may have greater vulnerability to victimization than men. In a recent
study of homicide in New York City, 59% of white women and 72% of African American
women had been using cocaine prior to their death compared with 38% of white
males and 44% of African American males. Thus, while cocaine is used by more
men than women, its use is a far greater risk factor for victimization for women
than for men (Tardiff et al., 1994). It is, therefore, critical that the factors
involved in the relationship between drug abuse and addiction among females,
and physical and sexual victimization (including partner violence) be identified
and understood.
Investigate the co-occurrence
of psychiatric and substance use disorders with attention to the temporal ordering
of substance use, depression, anxiety (including post-traumatic stress disorder),
and eating disorders.
Studies of substance abusers
in both community and treatment samples have shown high rates of coexisting
psychiatric disorders, although whether psychiatric disorders antedate drug
use has not been well established. Comorbidity rates between substance abuse
and depression/anxiety have been reported to be as high as 80% (Christie, Burke,
Reiger, Boyd, & Locke, 1988). Post-traumatic stress disorder was found to
occur in about 20% of women substance abusers (Villagomez, Thomas, Lin, &
Brown, 1995), and the link between eating disorders, particularly bulimia, and
substance abuse has been established (e.g., Holderness, Brooks-Gunn, & Warren,
1994). For example, as many as 55% of bulimic patients are reported to have
drug abuse or alcohol use problems. Conversely, 15%-40% of females with drug
abuse or alcohol abuse problems have been reported to have eating disorder syndromes,
usually involving binge eating (Beary, Lacey, & Merry, 1986; Hudson, Weiss,
Pope, & McElroy, & Mirin, 1992; Jonas, Gold, Sweeney, & Pottash,
1987; Mitchell, Hatsukami, Echert, & Pyle, 1985; Mitchell, Pyle, Echert,
& Hatsukami, 1990; Weiss & Ebert, 1983).
Further research is needed
on the role of dieting and eating disorders in drug abuse etiology and on the
relationship between affective and anxiety disorders and drug abuse and addiction
in women. Additionally, research is needed on the examination of factors that
may result in overprescription and abuse of psychotherapeutic agents.
Studies that have examined
the temporal sequencing of mood disorders and substance abuse have found that
depression both precedes and follows substance abuse (Schottenfeld, Carroll,
& Rounsaville, 1993). Better understanding of these temporal sequences is
also critical for future theory development, prevention, and treatment.
Expand research examining
the development and effectiveness of drug abuse treatment models that are specific
to the unique needs of women. Such models should include treatment for addiction
as well as any coexisting psychiatric disorder (e.g., depression, anxiety, post-traumatic
stress disorder, eating disorder), and they must be culturally relevant.
It is widely acknowledged
by drug abuse treatment researchers and providers that women who abuse drugs
face a variety of barriers, including barriers to treatment entry, to engagement
in treatment, and to long-term recovery. Barriers to entry include a lack of
economic resources, referral networks, women-oriented services, and conflicting
child-related responsibilities. Engagement in treatment and consequent long-term
recovery are hampered by the primarily male orientation of traditional models
of drug treatment and the lack of treatment modalities that address the specific
treatment needs of women. The development of well-designed
theoretically based treatment models that address these and other female-specific
issues is necessary if treatment is to be effective. These models must also
address such needs as child care, transportation, assertiveness training, and
vocational training. Such services and training in and of themselves do not
constitute treatment, but if not provided, could result in barriers to accessing
treatment and/or an inability to remain drug free. Within the context of treatment,
there is also a need to examine, from the perspective of gender, the complex
issues involved in relapse.
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Cigarette Smoking
Use of tobacco increases
the risk of death from cancer, cardiovascular diseases, and lung diseases. In
women, smoking increases the likelihood of developing osteoporosis, early menopause,
and decreased fertility. Since 1988 at least 147,000 women in the United States
have died each year from tobacco-related illnesses. Historically, more men than
women smoked cigarettes, but this gap has narrowed, and currently almost as
many women (23 percent) as men (28 percent) smoke. Women currently have lower
quitting rates than men, and the number of adolescent girls beginning smoking
is higher than that of adolescent boys (CDC, 1993). Unmarried women are more
likely to smoke during pregnancy, but women with partners who smoke are more
at risk for smoking relapse after pregnancy (Mermelstein & Borrelli, 1995).
Research Priorities
for Cigarette Smoking
Conduct research to
identify key factors in smoking initiation by adolescent girls.
Fewer African American
than white teenagers initiate smoking; African American women start smoking
at much older ages than white women (Geronimus, Neidert, & Bound, 1993).
Moreover, there has been a consistent and significant decline in smoking among
African Americans, and virtually no decline among whites (Johnston, O’Malley,&
Bach-man, 1993). Little research is focused on the reasons for these differences
or on differential smoking behavior of racial and ethnic groups of women. Further
research is needed to determine effective methods for reaching adolescent girls
with antismoking messages other than through the schools as well as for reaching
women who initiate smoking at older ages.
Conduct research to determine
factors critical to smoking cessation and maintenance among different populations
of women.
More research is needed
on recruitment strategies for cessation programs that are effective for specific
groups of women (e.g., women of color, blue collar women, women of lower socioeconomic
status, and older women) and adjuncts to traditional cessation intervention
that will be helpful to these specific groups of women. For example, research
indicates that there may be racial differences in reasons for smoking (Camp,
Klesges, & Reylea, 1993) and in success quitting (Windsor et al., 1993).
Conduct research to determine
how the desire to control weight and strive for thinness affects women's smoking
initiation and maintenance, and how this motivation is influenced by ethnicity.
The issue of weight control
for female smokers is complex. Approximately 80 percent of those who stop smoking
will gain weight (average weight gain of 8-10 pounds), and women tend to gain
more weight than men (Nides et al., 1994). Additionally, women smokers who relapse
are likely to report that weight gain was the cause of the relapse (Pirie et
al., 1991). Research is needed to examine these issues and to determine the
efficacy of intensive and minimal interventions that combine smoking cessation
and weight control (Glynn & Mills, 1993).
Conduct research to determine
the relationship between smoking and depressed mood.
In community studies, smoking
and depression rates have been found to correlate, and depressed smokers are
less likely to quit (Anda et al., 1990). The role smoking plays in coping with
depressed mood needs further study.
Conduct studies that will
lead to the development of more effective strategies for motivating women to
stop smoking.
Female smokers are more
likely to be in a pre-contemplation stage of quitting than are male smokers.
In other words, they are more likely to have no intention to stop smoking in
the near future. Effective strategies should be developed to help women consider
smoking cessation and to prepare them to take action. These strategies may need
to be tailored by stage of life.
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Diet and Obesity
Obesity is a well-established
risk factor for many of the leading causes of mortality and morbidity in the
United States. Cardiovascular disease and mortality are increased in women who
are overweight. The lowest rates of coronary heart disease mortality and morbidity
are found in women with a Body Mass Index (BMI) of 21 (equivalent to approximately
95 percent of ideal body weight). The prevalence of hypertension, noninsulin
dependent diabetes, certain types of cancer, osteoarthritis, sleep apnea, and
gallstones are also increased in individuals who are overweight (Manson et al.,
1990).
Obesity has reached epidemic
proportions among women in the United States. Thirty-five percent of women in
the United States are overweight (BMI > 27.3). Obesity increases with age
in American women; 20 percent of women aged 20 to 29 are overweight, compared
with 34 percent of those individuals aged 30 to 39, 38 percent of those aged
40 to 49, and 52 percent of those aged 50 to 59. Obesity is particularly prevalent
among ethnic minority women: 49 percent of African American women are overweight,
47 percent of Mexican Americans, compared with 33 percent of Caucasians. Obesity
also disproportionately affects those of lower socioeconomic status (Kuczmarski,
Fiegel, Campbell, & Johnson, 1994).
Research Priorities
for Diet and Obesity
Conduct studies that will
lead to development of more effective programs for weight loss maintenance.
Because women constitute
the majority of participants in organized weight loss programs, it is important
to develop more effective long-term treatments for these individuals. Current
weight loss programs are successful in producing initial weight loss, but maintenance
of weight loss is poor. Research is needed to determine the most effective weight
management strategies and procedures.
Conduct research to determine
effective approaches to the prevention of weight gain and obesity at different
stages of women’s lives.
Women are likely to gain
excess weight between age 25 and 34 (Williamson, Kahn, Remington, & Anda,
1990), during smoking cessation, and during the menopausal transition, and to
retain excess weight following pregnancy. Research is needed to determine how
best to prevent weight gain at each of these critical time periods.
Conduct studies that will
lead to the development of programs targeting the special needs of different
subgroups of the obese population.
Programs are needed that
target the special needs of different sociodemographic groups such as different
ethnic minority, age, and rural/urban populations. Likewise, programs are needed
that target women with specific behavioral problems related to their being overweight
(e.g., obese binge eaters). Although more than 50 percent of middle-aged African
American women are overweight, the majority of participants in university-based
research studies on weight control are white. African Americans also tend to
lose less weight than whites (Kumanyika, Obarzanek, Stevens, Herbert, &
Whelton, 1991). It is unclear whether this difference in weight loss reflects
differences in adherence to programs or differences in physiological or metabolic
parameters (Wing, 1995).
Conduct research on the
relationship between psychological factors and obesity.
Although many people assume
that stress leads to weight gain, little research supports this assumption,
and there is little research on how other psychological factors (such as depression)
influence weight and/or body fat distribution. The effects of obesity and efforts
at weight loss on psychological variables and the role of psychological variables
in the efficacy of weight loss attempts need further study.
Conduct research that
will provide a better understanding of the way in which behavior interacts with
genetics in the development and maintenance of obesity.
Twin studies, adoption
studies, and family studies show clearly that both genetics and environment
play a major role in determining body weight. Research is needed to better understand
the interaction between these two sources of influence. With the recent identification
of genes related to obesity, there is tremendous potential for interaction between
geneticists and psychologists. Identification of behavioral phenotypes related
to obesity would greatly facilitate such interaction.
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Physical
Activity and Exercise
Physical activity holds
the promise of improved physical and mental health for women. Risks of chronic
disease, especially those related to aging such as cardiovascular disease, osteoporosis
and diabetes, may be significantly ameliorated or, in some cases, eliminated
by moderate increases in physical activity. Risk of certain cancers, stress
reactivity, and depression may be reduced with physical activity, whereas immune
function and well-being may be improved. However, almost 60 percent of American
women, and almost 65 percent of ethnic minority women, remain sedentary (Marcus,
Dubbert, King, & Pinto, 1995). Little is known about the physical and mental
health consequences of physical activity or inactivity for women or the most
effective methods of reliably increasing regular physical activity among women.
Research could have a substantial impact on reversing the inactivity of women
in this country, with potential health, economic, and quality of life benefits.
Specific knowledge of the
similarities and differences across cultural, ethnic, and racial subgroups of
women is minimal. Further, there is limited understanding of the factors associated
with disease or disability in women who already are ill.
Research Priorities for
Physical Activity and Exercise
Conduct studies to
identify the factors contributing to both the initiation and ongoing maintenance
of alternative forms of physical activity that can reduce risk of cardiovascular
heart disease and other chronic diseases.
Examples of ways to help
women begin and maintain physical activity include moving physical activity
outside of gyms and aerobics classes and integrating it into the individual’s
home and work environments, or otherwise natural environments, for example,
walking or taking the stairs (King, Taylor, Haskell, & DeBusk, 1990), and
building physical activity into people’s lifestyles (DeBusk, Hakansson, Sheehan,
& Haskell, 1990).
Investigate factors that
set the stage for either increased or decreased activity at different stages
in a woman's life.
Developmental milestones
such as puberty have been associated with changes in physical activity levels
among women. Other important transitional stages such as entry into college
or the workforce, pregnancy, parenthood, menopause, and family care giving need
further study.
Evaluate the behavioral
and physiological synergy between physical activity and other health behaviors
such as dietary patterns, cigarette smoking, and alcohol and other drug use.
To have the greatest impact
on chronic disease risk, interventions are needed on the four prominent health
behaviors influencing chronic disease: cigarette smoking, dietary patterns,
physical activity patterns, and alcohol and other drug use. Typically, these
four have been studied in isolation. However, physiological and behavioral synergy
may occur when changes in several of these health behaviors occur simultaneously.
Therefore, the controlled investigation of such health behaviors in combination
is critical, and to date has received little systematic attention.
Conduct studies to determine
how work, family life, community participation, mass media and other social
factors influence women's physical activity patterns.
Little is known about how
the social forces in the family, the worksite, the medical setting, and other
community settings may influence women at different phases of readiness and
at different stages of their lives. In addition, there is virtually no research
about the potentially powerful influences of the media and other environmental
influences on women’s physical activity patterns.
Expand the study of the
effects of physical activity on depression, anxiety, and physiological and psychological
responses to stress.
There is evidence indicating
the potential role of regular physical activity in diminishing negative affective
states such as depression and anxiety as well as attenuating physiological and
psychological responses to stress. Yet, few studies in this area have focused
specifically on women, and the mechanisms mediating this relationship need to
be clarified.
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