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Research Agenda for Psychosocial and Behavioral Factors in Womens Health: Chronic Diseases

Arthritis and Rheumatic Diseases
Cancer
Cardiovascular Disease
Depression
Eating Disorders
HIV and AIDS

Arthritis and Rheumatic Diseases

Arthritis and rheumatic disease include more than 100 different illnesses and conditions (Schumacher, Klippel, & Koopman, 1993). Arthritis is the most common self-reported chronic condition affecting women (CDC, 1995), and many of the more common and more serious forms of arthritis and rheumatic disease (e.g., osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, fibromyalgia) affect two to five times more women than men. Hence, arthritis and rheumatic diseases, which significantly affect functioning, represent a significant health problem for women. For example, among women age 15 and older, arthritis is the most frequently cited reason for activity limitations, and people with arthritis experience a disproportionately greater amount of work disability compared with people with other chronic conditions (CDC, 1995; Yelin, 1992).

Research Priorities for Arthritis and Rheumatic Diseases

  • Conduct research to help identify the underlying mechanisms that account for the discrepancies among ethnic groups and social classes in the health outcomes among women with arthritis and rheumatic diseases.

    Epidemiological studies have consistently demonstrated worse health outcomes among women with arthritis and rheumatic diseases who are members of ethnic minority and lower socioeconomic groups (CDC, 1994). Unfortunately, the underlying mechanisms that could account for these differences are poorly understood. Potential constructs that could explain these relationships include cultural differences in health beliefs, stress, social support and coping mechanisms, access to health care, and differential treatment patterns.

  • Initiate studies to describe the complex causal connections between psychological and physical processes in arthritis and rheumatic diseases.

    Current research suggests that complex, reciprocal relationships may exist between physical and cognitive and emotional processes in arthritis and rheumatic diseases. Investigations using a variety of methodological approaches are needed to unravel the causal mechanisms linking cognitions, emotions, arthritis symptoms, physiological processes, and behavior.

  • Expand research on the causes and treatment of pain in patients with arthritis and rheumatic diseases.

    Patients identify pain as the most serious consequence of arthritis and rheumatic diseases (Skevington, 1993). Although a great deal of pain research has been performed regarding inflammation, little is known about other pain mechanisms in patients with inflammatory and non-inflammatory arthritis and rheumatic disease. In addition, little is known about interactions between the brain and endocrine and immune systems that are involved in arthritis pain. Currently, no treatment interventions are available that completely alleviate pain in arthritis and rheumatic diseases. The development of more effective pain treatments would reduce suffering and health care costs for millions of women.

  • Expand research on the epidemiology, identification, treatment, and prevention of depression in people with arthritis and rheumatic diseases.

    Research suggests that people with serious chronic diseases are at greater risk for developing depressive disorders and symptoms (Wells, Golding, & Burnam, 1988). Depression alone is a devastating condition that, in the absence of other health problems, is associated with severe functional limitations. When depressive symptoms occur in combination with other chronic diseases, however, functioning levels decrease (Wells et al., 1989). Because women are at greater risk for depression as well as at greater risk for some of the more serious and more common forms of arthritis and rheumatic disease, they bear a double burden of potential disability (DeVellis, 1993). We need a better understanding of the scope and impact of depression in arthritic and rheumatic diseases as well as research on how to prevent and treat depression in this population.

  • Expand research on the causes and treatment of fatigue in people with arthritis and rheumatic diseases.

    Fatigue is commonly associated with many forms of rheumatic disease such as rheumatoid arthritis (RA) and fibromyalgia syndrome, yet has received little study. Research by Belza and colleagues (Belza, 1995; Belza, Henke, Epstein, & Gilliss, 1993) has found a high degree of fatigue among people with RA that interferes with discretionary and nondiscretionary activities of daily living and causes distress. Among people with RA a number of disease-related characteristics (e.g., pain, disease duration, sleep quality) place them at greater risk for experiencing fatigue. Being female, however, places one at additional risk for fatigue in RA. The causes of fatigue in both health and illness are poorly understood and need further study.

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    Cancer

    Cancer is the second leading cause of death for women in the United States. Approximately one in three Americans will have cancer at some point during their lives. Breast, lung, and colorectal cancers have the highest incidence rates and are most likely to be causes of cancer deaths among women (Meyerowitz & Hart, 1995). The high prevalence of cancers makes it likely that all women will face the disease either in themselves or in family members. Furthermore, the availability of effective early diagnostic procedures means that cancer-related health care behaviors should be a part of every woman’s life.

    Research Priorities for Cancer

  • Continue intensive investigation of methods to promote cancer screening among women and of women’s reactions to such screening, particularly in groups where screening is underutilized (e.g., women who are older, poorer, or of ethnic minority status), and groups at risk for specific cancers (e.g., higher cervical cancer risk in Latina women).

    Early detection of cancer leads to substantial reductions in cancer mortality. Intervention efforts directed toward health care providers should be increased because physicians’ recommendation for screening appears to be the most consistent predictor of mammography use. Further, in light of the national research focus on genetic susceptibility to cancer and the growing consumer demand for genetic screening, we need to know more about the psychological, social, and economic sequelae of being diagnosed with genetic mutations that increase breast cancer risk. It is critical to develop effective methods for delivering information to women about their personal risk and promoting accurate understanding of this risk. Interventions must be developed for women of diverse socioeconomic and ethnic backgrounds that address these special concerns and facilitate the process of making informed screening decisions.

  • Expand research about the impact of cancer, particularly some common sites of cancer about which we have relatively little information (such as colorectal cancers, head and neck cancers, and lung cancers), and about the mechanisms that promote positive adjustment to cancer and its treatments within the context of women’s lives.

    Research suggests that, on average, women remain psychologically resilient after being diagnosed with cancer. However, there are stressful periods during which women with particular characteristics are vulnerable to marked distress and life disruption. Continued investigation of areas of ongoing distress and factors that place women at risk for compromised adjustment is necessary. Additionally, studies of women who do well over time may further our understanding of mechanisms that promote positive adjustment. Data on psychosocial recovery following the diagnosis and initial treatment for cancer, and the areas in which problems are common or persistent, may vary by site of disease and treatment protocol. Data on quality of life and predictors of adjustment at the time of disease recurrence and throughout the period of advanced disease also are needed.

  • Develop methods for improving efficiency and efficacy of psychosocial interventions for particular groups of women and identify mechanisms by which these interventions have positive psychosocial and medical effects.

    Early interventions are necessary to improve psychosocial functioning and quality of life for women at risk for adverse outcomes as a result of receiving a cancer diagnosis. Research on psychosocial interventions for women with cancer has focused on testing the efficacy of supportive and educative interventions conducted in a group context. Results are promising and positive benefit has been documented on both psychological domains and mortality. Effective interventions for women who do not elect a group approach are also needed. In addition, greater attention to study of interventions for the broader family system, as well as for women who serve as caretakers for others who have cancer, is warranted. Further investigation also is needed regarding the psychological, behavioral, and immunological mechanisms through which interventions have their impact.

  • Examine identified causal and protective factors that may decrease cancer incidence and mortality and the potentially complex interactions among biological, psychological, and social factors (e.g., social support, coping strategies, immunological function) that may promote or hinder survival and psychosocial adjustment.

    Researchers have identified possible predictors of cancer incidence and course that require careful examination, including exogenous hormones, environmental and workplace toxins, and regular physical activity.

    Psychoneuroimmunological variables also have shown great promise as predictors of cancer onset and progression. We must understand the role that these factors may play and the mechanisms that underlie their impact on cancers.

  • Examine impediments to receiving medical care, effects on quality of life, optimal coping, and effective psychosocial interventions for poor women and women of color.

    Cancer research has heavily focused on middle-class, non-Hispanic white women who live in urban and suburban areas. It is essential to include research with women who traditionally have not been studied. Future research will require the development of reliable and valid assessment tools specifically designed to address issues of particular relevance to these women.

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    Cardiovascular Disease

    Despite a steadily declining rate of cardiovascular disease mortality in the United States, heart disease is still the number one cause of death in American women. More women die of heart disease than of all malignant neoplasms combined. Women also have a worse prognosis for survival after myocardial infarction (MI) than men, and African American women have the worst prognosis of all.

    Research Priorities for Cardiovascular Disease

  • Examine neurophysiological and neuroendocrine mechanisms unique to cardiovascular changes in women, including the effect of chronic stress on gonadal hormones and the unique neurohormonal and neurophysiological (vagal) mechanisms for stress buffering.

    Research on nonhuman primates has shown that chronic social stress is related to a significant increase in coronary artery atherosclerosis, anovulatory menstrual cycles, a decrease in estrogen levels, and high central serotonergic responsivity in females. Despite the strong evidence of these associations in primates whose cardiovascular systems strongly resemble our own, the effect of chronic stress on gonadal hormones and atherosclerosis has not been investigated in women.

    Another pathway that needs to be explored is that of oxytocin, a hormone secreted in pregnant and lactating women. This hormone, which differs by only two amino acids from the vasoconstrictor, vasopressin, seems to be associated with blood pressure reduction. As a rule, blood pressure decreases during pregnancy and recent research has demonstrated that exogenously administered oxytocin causes sustained reduction of blood pressure in both male and female hypertensive rats. But oxytocin release also can be stimulated behaviorally by sensory stimuli such as massage. There is a dearth of research on the unique neurohormonal and neurophysiological (vagal) mechanisms for stress buffering in women, and such research should be a priority.

  • Initiate studies to determine the impact of psychosocial factors (e.g., social support, socioeconomic status, and environmental stress) on primary prevention of cardiovascular disease in African American women.

    In Africa, women with large, socially integrated families have the lowest blood pressure. However, in the United States, African Americans have higher rates of hypertension than do whites of similar age. African American women also have the worst prognosis after myocardial infarction. The fact that blood pressure in Africans is much lower than in Americans of African ancestry suggests that sociocultural rather than genetic factors explain a large part of the variance in these differences. Research in black and white differences in recent years has begun to examine gender differences in cardio-vascular and hemodynamic responses to stress. But research on the chronic social psychological stressors specific to the lives of black women is almost nonexistent. Research on such factors as social support, socioeconomic status, and other psycho-social factors should be directed toward identifying patterns of high risk stressors and the mechanisms that mediate their effect on the cardiovascular system.

  • Examine factors that influence adherence and behavioral change in the secondary prevention of coronary heart disease (CHD) in women.

    Women are usually supportive in helping implement lifestyle changes for their husbands and other family members (e.g., dietary changes, exercise, and stress reduction) that are necessary for increasing the probability of survival. However, the lifestyle changes that are important for women’s own rehabilitation of CHD may engender negative responses from immediate family members because these changes may conflict with gender role expectations of women (e.g., traditional caretaker and nurturer). Research is needed that examines the effect of these gender role expectations on the ability of women to effect and maintain health-related lifestyle changes and the subsequent effect on quality of life, depression, and disease course.

  • Expand research to clarify which psychosocial factors (or pattern of factors) increase vulnerability to cardiovascular disease and the neuroendocrine pathways that mediate them.

    Epidemiological studies have repeatedly shown a significant linear association between socioeconomic status (SES) and coronary heart disease (CHD): the lower the SES, the higher the prevalence of CHD. Previous research in this field has focused on the association between low SES and poor health behaviors such as higher smoking rates, unhealthy diets, and higher rates of obesity. More recent research shows a larger proportion of chronic physical and psychosocial stressors such as jobs with high demand and low decision latitude, low social support, high job dissatisfaction, unemployment, residential areas with high crime rates, and poor access to medical treatment among people with low socioeconomic status. Many of these psychosocial factors are related to cardiovascular risk. Women with low SES are particularly vulnerable.

  • Investigate the interactions among genetics, behavior, and environment in the development of coronary heart disease.

    Many different physiological factors predispose an individual to increased risk of coronary events. High blood pressure, high total and LDL cholesterol, low HDL cholesterol, obesity, and diabetes are prime examples. All of these show evidence of genetic influence. Therefore, many genetic variations can predispose one to increased risk. Behavioral and environmental factors interact with underlying genetic predisposition to trigger, to enhance, or to buffer against risk. Although there is general agreement about the interaction, the quantitative and qualitative gene and environment interactions in coronary heart disease have not been well investigated and should be a target of future genetic research.

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    Depression

    Major depression is a common and recurrent disorder. According to Epidemiological Catchment Area (ECA) data (Robins & Regier, 1991), at least 5 percent of the United States population (over 12 million Americans) will experience major depression over the course of a lifetime. Al-though this estimate is substantial, it is thought to be conservative. Longitudinal data have confirmed the recurrent nature of depressive episodes and suggests that recurrence (i.e., appearance of a new episode) occurs in greater than 50 percent of patients who recover from an initial episode (Frank et al., 1990).

    Major depression can cause severe impairment in social and physical functioning and is a major precipitating factor in suicide. It has been associated with higher medical costs, greater disability, poor self-care and adherence to medical regimens, and increased morbidity and mortality from medical illness (Katon & Sullivan, 1990).

    Women are approximately two times more likely than men to suffer from major depression (McGrath, Keith, Strickland, & Russo, 1990), and dysthymia (Robins & Regier, 1991). Thus, empirical investigations of depression should be a major focus of a women's health research initiative.

    Research Priorities for Depression

  • Conduct research to determine gender-related risk factors for depression.

    Considerable research effort has contributed to advancements in the diagnosis and treatment of major depression. However, the etiology of depression and why depression is twice as likely in women as in men is not well understood. Understanding risk factors for onset, severity, and relapse of depression should be a target of future research. Models for understanding the etiology of major depression and subtypes of depression should consider direct and indirect effects of study variables as well as interactions.

  • Expand research on differential treatment response by women and men.

    Little is known about differential treatment response patterns for major depression in women and men. This is true for established and new, psychopharmacological and psychosocial treatments, and should be a focus of research. Outcome measures should be expanded to include various measures of cognitive and psychosocial functioning as well as symptom assessments. Response to psychopharmacological treatments can be considerably affected by psychosocial experience, and consequently, somatic treatments also should be included in (a) investigations of differential treatment response patterns for women and men and (b) the larger research agenda for women's health.

    Although effective interventions often are available, the majority of people with psychological disorders do not obtain professional treatment. Even among people with a history of three or more comorbid disorders, less than 50 percent ever obtain specialty sector mental health treatment (Kessler et al., 1994). Data are needed on barriers to treatment and on how to facilitate (a) entry into treatment and (b) treatment compliance and retention, particularly for high prevalence disorders for women such as depression.

  • Expand research on risk factors for depression among different populations of women.

    Data are limited on risk factors for depression in various subgroups of women including lesbians, ethnic minority women, rural women, and older women. For example, although little research has been conducted on depression among lesbians, available information indicates that lesbians may be at higher risk for depression than heterosexual women. Moreover, the rate of suicide attempts by lesbians, particularly African American and Latina lesbians, appears higher than among heterosexual women (National Institute of Mental Health, 1987). Additionally, risk factors for conditions unique to women, specifically postpartum depression, also should be identified.

  • Expand research and therapeutic attention to women with depressive symptoms who do not meet criteria for major depression.

    High utilization of medical services and social impairment are associated with presence of depressive symptoms as well as with diagnosed depression. Individuals with depressive symptoms have comparable, or higher, rates of emergency department use, use of medications, medical consultations for emotional problems, attempted suicide, and days lost from work as individuals with diagnosable depression (Glied & Kofman, 1995; Johnson, Weissman, & Klerman, 1992). Understanding subacute depressive syndromes, and their relationship to psychosocial functioning, should also be a research target.

  • Expand research examining the effects of treating depression on recovery and survival in women with medical conditions.

    More than 60 percent of office visits to physicians are made by women, and women have higher morbidity rates. In addition, the "mortality advantage" over men has been decreasing, that is, the ratio of male to female deaths has been declining (Rodin & Ickovics, 1990). Major depression is a source of increased morbidity and an independent risk factor for mortality in patients with medical conditions (Frasure-Smith, Lesperance, & Talajic, 1993). Identification and treatment of depression in women with medical disorders, and in aging women who tend to have higher rates of medical illness, should be a focus of research.

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    Eating Disorders

    Approximately 2% of adult women meet current diagnostic criteria for anorexia nervosa or bulimia nervosa (Fairburn & Beglin, 1990; Hall & Hay, 1991), and even greater prevalence rates have been found among adolescent girls (Lucas, Beard, O’Fallon, & Kurland, 1991; Whitaker et al., 1990). In addition, an estimated 2 to 4 percent of women experience a clinically significant syndrome of disordered eating that does not fit current criteria for any of the major eating disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 3rd ed., 1980; Striegel-Moore & Marcus, 1995). Eating disorders have a profoundly negative effect on physical and psychological health and on social and vocational adjustment. In many cases, these disturbances in health and adjustment are long lasting or even irreversible. Eating disorders are significantly associated with a variety of psychiatric disorders, including depression, anxiety disorders, personality disorders, and substance abuse (Striegel-Moore & Marcus, 1995).

    Research Priorities for Eating Disorders

  • Improve classification to better characterize the full spectrum of eating disorders, including the range of problems grouped under "eating disorders not otherwise specified" (EDNOS), and to examine the usefulness of binge eating disorder (BED) in particular.

    Currently, diagnostic criteria are based on the clinical picture of individuals presenting for treatment, yet only a fraction of individuals with an eating disorder ever seek therapy for their eating disorder. Important questions remain about the proper classification of eating disorders.

  • Conduct studies to determine incidence and prevalence of eating disorders in a representative sample of adolescent and adult women, including ethnic minority women. Studies should also examine whether the current diagnostic criteria adequately address the spectrum of eating disorders in ethnic minority women.

    The Epidemiological Catchment Area (Robins & Regier, 1991) study included only anorexia nervosa but not bulimia nervosa or "eating disorders not otherwise specified" in its diagnostic interview. Additionally, virtually excluded from major research studies are women of color, women from rural communities, and women representing lower SES groups. Inclusion of a more diverse group of women is critical to developing an empirically based classification of eating disorders, to testing hypotheses regarding differential risk based on membership in a particular subgroup, and to developing therapeutic and preventive interventions that are maximally effective for all women. For example, preliminary studies among women of color suggest that they have higher rates of eating disorder symptoms than had been commonly assumed.

  • Conduct research to identify risk factors (such as dieting) associated with different eating disorders.

    Dieting is generally thought to be a risk factor for the development of an eating disorder. But research that examines the role of dieting in the context of other risk factors would be useful. Given the pervasive negative stereotypes about obesity and a broad-based acceptance of dieting as a weight loss strategy, little research has focused on the potential adverse consequences of dieting. Identifying risk factors for eating disorders is critical to developing effective prevention programs.

  • Test etiological models of eating disorders that encompass both biological and psychosocial pathways and address patterns of comorbidity.

    A range of etiological factors have been hypothesized to contribute to the development of an eating disorder. Twin studies and family genetic studies have found significant familial aggregation of eating disorders; however, whether and to what degree eating disorders are genetically determined is not clear. Recently, experts have proposed that the development of an eating disorder may be best understood by models that encompass both psychosocial and biological pathways.

  • Conduct studies that will lead to the development of effective interventions for the full spectrum of eating disorders.

    Significant advances have been made in the treatment of bulimia nervosa and binge eating disorder. To date, individuals with eating disorders not otherwise specified, who outnumber those with anorexia nervosa or bulimia nervosa, have been excluded from controlled clinical trials. Moreover, in many trials, comorbidity, especially in the form of substance abuse, has been an exclusion criterion. As a consequence, rigorous treatment outcome data are missing for the largest number of individuals in need of treatment. The results of current treatment methods for anorexia nervosa remain disappointing. Relatively little research has been devoted to developing improved methods for its treatment.

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    HIV and AIDS

    Over the last decade, women have accounted for an increasing percentage of people with HIV/AIDS in the United States, rising from 6.6 percent in 1985 to 18 percent in 1994 (CDC, 1994). As of December 1994, 58,428 American women were diagnosed with AIDS. More than half of these women are African American; one quarter, White; one fifth, Hispanic (CDC, 1993a). Although women across the entire life span are living with HIV/AIDS, the majority are of reproductive age and living in poverty. They also are likely to be single parents caring for children, some of whom are infected as well. Furthermore, women with HIV/AIDS may be diagnosed at a later point in the disease course than men, and they are more likely to face barriers to health and mental health care, social services, and community support.

    These alarming epidemiologic trends underscore an urgent need to identify and explain the social and behavioral risk factors for HIV, especially among African American and Hispanic/Latina women, as well as adolescent girls, regardless of ethnic group membership. Further, although effective strategies for HIV prevention across and within ethnic groups are vital, the large number of women already living with HIV/AIDS suggests the need for research on demographic, psychosocial, disease, and treatment factors associated with adaptation, quality of life, and long-term survival.

    There are major gender differences in sexual behavior that are critical in the analysis of HIV transmission in women. Although having multiple partners can be a major risk factor for women, having only one partner who engages in risky behavior places women at increased risk. Women appear to have a greater chance than men of becoming infected per coital act, and younger women may be vulnerable because of their immature cervical tissue. Younger women also are more likely to have an older, more experienced partner who places them at risk for sexually transmitted diseases (STDs) and HIV. Likewise, women may be especially vulnerable to infection as a result of their patterns of sharing drug injection equipment with a sex partner. Women are more likely than men to have an injection-drug using partner (Feucht, Stephens, & Roman, 1990), to have only one needle-sharing partner (Brown & Weissman, 1993), who is typically a sex partner, and to often use drug injection equipment after their male partner (Castro, Valdiserri, & Curran, 1992).

    Research Priorities for HIV and AIDS

  • Conduct studies to identify distinctive patterns of behaviors and social conditions among cultural and age-based subgroups of women that determine their risk of infection and determine how women protect themselves against sex with risky partners.

    The extent to which patterns of sexual behaviors and intravenous drug use are similar among African American, Hispanic, and adolescent women of all backgrounds is not well understood (Amaro, 1995; Cochran & Mays, 1989). Ethnic differences in high-risk sexual activity, substance abuse, and HIV within the context of familial and peer group networks also have yet to be identified.

    Women tend to have substantially fewer sex partners than men. Consequently, it is crucial that prevention efforts help women understand the risk level associated with particular partners. Research needs to explore sexual communication between heterosexual partners within and across different ethnic groups. For example, to what extent and under what conditions do men disclose risk factors for HIV and other STD infection, disclose their intravenous drug use, and/or disclose their serostatus? To what extent and under what conditions do women communicate in a sexually assertive manner to find out sexual history information from potential partners? How are decisions made regarding condom use? How do relationship dynamics influence needle sharing? Additional research on the role of sexual coercion, sexual assault, and domestic violence in the transmission of HIV also is vital to prevention efforts.

  • Increase research on predictors of risky behaviors focusing on issues such as power in various relationships, physical and/or sexual abuse, and alcohol and other drug use; conduct research that will translate identified predictors of risk into effective interventions to reduce risk.

    Several factors have been found to increase women’s vulnerability to HIV infection, including history of sexual abuse, current experience of physical abuse in the primary relationship, sexual assertiveness, and alcohol and other drug use. Research should examine these possible predictors of risk separately for women from different ethnic groups. Moreover, models of behavior change should be developed and evaluated that incorporate issues of reproduction as well as STD prevention for women. These models should be based on issues identified with diverse populations of women across age, educational, and economic backgrounds and should incorporate healthy sexual practices.

  • Evaluate programs designed to decrease women's risk associated with injection drug use (e.g., treatment and needle exchange programs).

    Effective, research-based substance use prevention and drug treatment programs for women are vital. Outcome-based, comprehensive programs that are gender and culture specific and provide training in jobs skills, AIDS awareness, sexual assertiveness, childcare, and sexual abuse survivor issues should be developed. A number of model programs are currently under way that require careful evaluation.

    Needle exchange programs also should be evaluated, especially their effectiveness for women. Some studies indicate that women have less access to needle exchange programs than men (Brown & Weissman, 1993; CDC, 1993a). Increasing women's utilization of such programs is a high priority because it can save lives immediately.

  • Determine the effects of HIV/AIDS on women’s psychological functioning.

    Few studies have investigated the psychological sequelae of HIV and AIDS among women and their families. Longitudinal, comprehensive research needs to address the relationships among sociodemographic factors, disease and treatment factors, drug use, caregiving, sexual abuse, domestic violence, and continued substance abuse or high risk sexual behavior following diagnosis, coping, resilience, adjustment difficulties, isolation, social support, quality of life, immune functioning, and survival among women with HIV/AIDS. In addition, these psychosocial and behavioral factors should be evaluated in women with HIV/AIDS who also are homeless, disabled, have enduring mental illness or are older. This research should assess ethnic and cultural expectations for women such as providing caretaking functions for others and how these roles are carried out over the course of HIV infection. Research in these areas is necessary for the development of outcome-based interventions aimed at enhancing self-care, coping, resilience, and quality of life for the broad range of women and families living with HIV/AIDS.

  • Conduct studies to assess barriers to obtaining medical and psychological treatment for women with HIV infection or AIDS.

    Innovative, outcome-based programs that reduce barriers to health care, mental health care, and social services for women with HIV/AIDS should be developed. Community-based programs targeting women of color and families must address barriers (e.g., poverty, language, child care, transportation, gender and ethnic bias in services, and HIV-related discrimination) to care and service.

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