The American Psychological Association (APA) is the largest scientific and professional organization representing psychology in the United States. APA's membership includes more than 151,000 researchers, educators, clinicians, consultants, and students. APA's mission is to advance psychology as a means of promoting human welfare, as a science, and as a profession. APA has a long history of involvement in women's issues, in particular to support and encourage behavioral and social science research to address women's health issues. APA members conduct research on women's health issues such as sexually transmitted infections (including HIV/AIDS), family planning, domestic and family violence, mental and behavioral health, and minority health.

Despite the increased focus on medical and epidemiological aspects of women's health, psychosocial and behavioral factors that contribute to health status have not received much attention. Gender-related psychosocial and behavioral factors and their interrelationships with biomedical factors are important to consider in determining the effectiveness of education and prevention strategies. Women are a heterogeneous group whose experiences may vary with ethnicity and race, marital status, parental status, education, income, occupation, sexual orientation, labor force participation, and geographic location (e.g., rural vs. urban). Therefore, health needs (e.g., services and education), barriers to obtaining services, styles of coping, or bases for well-being may vary among cultural and socioeconomic groups.

In its early stages, CVD is usually covert. For this reason, it is important to track risk factors such as plasma or serum lipid concentrations, adiposity, blood pressure, and diabetes, which are known to be associated with increased risk. In this respect, behavioral and psychosocial factors also play a crucial role. It is well known that genetic predisposition contributes to many components of cardiovascular health, explaining a significant amount of the variance in major CVD risk factors such as high blood lipids, hypertension, obesity, and diabetes. However, the interaction of these predispositions with the environment determines the extent to which they are expressed. Behavioral and psychosocial factors are important triggers in the gene-environment interaction and may be critical in prolonging life when fully addressed in primary and secondary prevention.

A healthy lifestyle and feelings of psychological well-being can contribute greatly to the enhancement of cardiovascular health. Both our general state of well-being and the lifestyle we choose to adopt are influenced by our psychosocial environment. Chronic stressors, social contacts, and coping mechanisms are examples of factors that affect both lifestyle and psychosocial well-being. The two primary pathways through which psychological factors can influence the cardiovascular system involve health behaviors and neuroendocrine mechanisms. Health behaviors such as diet, smoking, alcohol consumption, and physical activity are extremely important factors in cardiovascular health that can prevent or promote the onset of disease. However, chronic psychological strain and its opposite, psychological well-being, can also have effects on cardiovascular physiology through changes that occur in the brain and are transmitted through the vagal, sympathetic, and hormonal systems to the rest of the body.

Psychosocial factors influence health behaviors, which interact with atherogenic and hemostatic metabolic processes, and coupled with genetic predisposition, can promote or reduce the progression of CVD. Psychological factors can also influence the cardiovascular system through neuroendocrine effects triggered by positive or negative emotions. Emotions influence cardiovascular risk through processes initiated in the neurochemical substrate of emotion located in the limbic system, the components of which are closely interconnected through neurotransmitter systems, and communicate with the rest of the body through vagal, sympathetic-adrenal-medullary, and hypothalamic-adrenal-cortical pathways. These pathways can be influenced both positively, through regenerative processes that strengthen and buffer the system against stress, and negatively through pathological processes that weaken it and increase risk.

Social isolation and social support. Social isolation, which is variously defined as lacking an intimate confidant, having few friends or social activities, or not having access to practical assistance when needed in everyday situations, has been associated with cardiovascular mortality in several epidemiological studies and in studies of coronary heart disease (CAD) and post-MI patients. In addition, social isolation has been associated with higher blood pressure, a major risk factor for coronary end points. Social support, in conjunction with adaptive coping strategies, has also predicted fewer depressive systems after an MI. It would seem that social support and social isolation influence the cardiovascular system through multiple mechanisms. The first involves improving compliance with treatment and supporting good health behaviors. The second is hypothesized to occur as a result of neurophysiology changes (i.e., through the limbic system in conjunction with hypothalamic,sympathetic-adrenal-medullary, and possible vagal pathways) accompanying positive and negative emotional states. Because there is now overwhelming evidence of a relationship between social isolation and CVD, it is important that health care providers emphasize the importance of social networks and that methods for helping people enhance them be integrated into primary and secondary prevention programs.

Hostility. Much has been published concerning Type A behavior, anger, coping styles, and hostility as they relate to CVD. The findings concerning Type A behavior have been contradictory, and the majority of the researchers in this field now believe that hostility is a more important variable. Results of two prospective studies have shown an association between hostility and increased incidence of coronary heart disease (CHD) after 20 and 25 years of follow-up, respectively. Also, the negative effects of hostility seem to be mediated through health behaviors as well as neuroendocrine pathways. Research on the effects of hostility on health behaviors have demonstrated that high hostility has been associated with higher caffeine consumption; more smoking; more marijuana use, increased alcohol intake, greater caloric intake; and higher cholesterol consumption and (only in women) higher animal fat intake and lower fiber intake.

In conclusion, hostile personality characteristics can negatively affect cardiovascular health through multiple paths. Behavioral treatments to reduce hostility have been developed and should be seriously considered in cardiac rehabilitation programs for use with people measuring high on this trait. Health care practitioners should be aware of the effects of hostility on preventive health behaviors and integrate this awareness into treatment strategies.

Depression. Recently depression has been identified as a possible risk factor for CHD mortality. A number of studies have found that depression was strongly and significantly associated with CHD for both men and women; depression and other negative affects have been found to be related to both all-cause mortality and sudden cardiac death in women; and that the severity of depression predicted angina pectoris at 12-year follow-up. Studies have also shown women to be more depressed than men after an MI, and several studies have linked depression with cardiac mortality after an MI in men and women. Therefore patients with pronounced depressive symptoms should be referred for psychological evaluation and possible treatment.

Socioeconomic status and racial differences in cardiovascular risk. A consistent pattern of inverse association between CHD and socioeconomic status (SES) has been established cross-culturally. People with low SES not only have higher mortality but are also less likely to survive out-of-hospital cardiac arrest and have a worse prognosis among medically treated patients with CAD. Even the decline in CHD is greatest in higher SES areas.

Within the United States, improvement in life expectancy and rates of illness and death from CHD has not been as great for African Americans as for Whites. The report of the Secretary's Task Force on Black and Minority Health (Heckler, 1985) suggests that 'it is not minority status, itself which leads to poorer health...Rather, it is the association of low SES with minority group membership which has consequences for health.' The social class differences in mortality for heart disease are larger than those for race. When income is used as the definition of SES, African Americans are reported to have higher mortality at each level than Whites; however, when education is used to define SES, racial differences are no longer significant. In the United States, the prevalence of hypertension is greater among African Americans than Whites at all ages. However, the prevalence of hypertension in Blacks in Sub-Saharan African is substantially lower than that of African Americans. Although research has made it clear that there is a genetic component to hypertension and that hypertension and CHD aggregate in families of African American people, the discrepancy between American and African Black people indicates that a genetic explanation is inadequate and that nongenetic (environmental) factors may play an important role. In comparison to White Americans, a disproportionately large number of Black Americans belong to a poorly educated working class with low pay.

Education is the most frequently used measure of SES, and it assumed that higher education increases knowledge about the consequences of proper diet, the hazards of smoking, insufficient exercise, and so on. However, health behavior is not the only aspect of SES that influences morbidity and mortality outcomes. Access to adequate health care also is important. Lack of health care coverage, not surprisingly, is associated with low income. In people who are not covered by health insurance, preventive care such as regular physical checkups are less likely to occur. People with low SES also have a greater risk for suffering medical injury due to substandard medical care. Low SES is also characterized by jobs that have low decision latitude and are highly demanding, such as factory and clerical work. Social inequality for people at the lower end of the socioeconomic gradient involves the simultaneous presence of multiple chronic stressors. These include less social support, as defined by stability of the family, size of network, diversity of relations or closeness of marital bonds, as well as more unemployment, dilapidated housing units, and housing units with a shared bathroom or no bathroom. A recent study found that low-SES people are more likely to experience stress and to have stressful life events beyond their control than those higher on the gradient. These negative psychosocial stressors are hypothesized to influence CHD end points through neuroendocrine influences on endothelial injury and platelet function.

In conclusion, low SES affects cardiac end points through multiple mechanisms: health behaviors, access to adequate health care, and psychosocial stress. Differences in CHD mortality are higher for social class than they are for race. A majority of Blacks in the United States are clustered at the lower end of the socioeconomic gradient, and thus associations between race and CHD mortality are inextricably intertwined with SES. Awareness on the part of the treating physician of the potent stress associated with low SES may help in structuring interventions to meet the needs of individual patients.

Additionally, concerns have been raised that women with CHD are managed less aggressively than men. It is not clear from the data whether procedures, such as angiography, are underutilized in women or overutilized in men. However, evidence suggests that the perception of cardiac symptoms by women and their physicians has a significant impact on diagnostic and treatment strategies. For example, women with coronary disease who experience chest pain may not seek care as frequently as men, and women with severe chest pain wait longer than men before seeking emergency care. Physicians may refer women less often for invasive interventions because of beliefs about the relative ineffectiveness of some procedures in women; because they believe some diagnostic procedures are less reliable in women; or because women's symptoms are not interpreted by physicians as cardiac symptoms as early in the disease process as men.

More studies are needed to determine the extent to which psychosocial factors (e.g., misinterpretation of symptoms and delayed care seeking in women, physician beliefs and attitudes about heart disease in women) play a role in the clinical management, and ultimately the poorer prognosis, of women following CHD events and treatments. These studies should include research on the decision-making process used by women in seeking care and by their physicians in ordering diagnostic tests and referring women for invasive procedures.

Given the benefits derived from appropriate identification and treatment, early detection of CHD should become a priority for women and their health care providers. Unfortunately, women are often unaware of the threat posed by CHD to their lives and health. One study found that when asked to identify the most serious health problem faced by women, 76% of the women surveyed said cancer, whereas only 6% identified diseases of the heart, blood vessels, diabetes, and arthritis. Because CVD is by far the leading cause of death in women, these results reveal a lack of concern on the part of women about the real risk imposed by CVD. This lack of awareness of how common CVD is in women may contribute to a lack of recognition of its symptoms and the failure to seek treatment when symptoms occur.

These differences appear to be related to socioeconomic factors. Minority low-income women are less likely to recognize breast cancer risk factors and the need for early detection than White women with higher incomes. Women with lower-than-median education and incomes are less likely to be screened for breast cancer, delay seeking care in the presence of symptoms, are diagnosed in later disease stages, and have 25% higher death rates from breast cancer than those of higher education and incomes. They are also less likely to participate in psychosocial interventions demonstrated to improve psychological and physical well-being among cancer patients.

It is critical to educate women about breast cancer risk factors, early detection, prompt symptom care, treatment options, and effective intervention programs for dealing with the psychosocial consequences of breast cancer. Primary care providers are critical agents in communicating this information to women. Part of the process involves acquiring skills to educate women with information that promotes informed screening decisions and strategies to translate these decisions into action. This can be accomplished by a) using culturally specific strategies to promote screening for early detection; b) recommending mammograms to all women meeting the risk and age requirements; c)providing information about low-cost mammography facilities that meet federal quality standards; and d) promoting national insurance coverage for both mammograms and clinical breast examinations (CBEs).

Facilitating Early Detection Practices. Psychosocial factors that are linked to women participating in CBE and mammography screening include women s perceptions of need; health care providers perceptions, practices, and recommendations; and social and demographic factors. The mammography screening barriers most frequently cited by women include cost, lack of insurance coverage, not having any problems with their breasts, and no physician recommendation. Data from the 1990 National Health Interview Survey indicated that the most frequently reported reason for not having a mammogram was no awareness of need or no breast problems. Forty-one percent lacked knowledge about the need for breast cancer screening, and 31% reported that physicians had not recommended mammography. Cost was cited by 7% of women as a reason for not having mammograms.

Although recent legislation in many states mandates coverage of screening mammography by insurers and biennial screening mammography by Medicare, Washington State surveys with women aged 50-75 did not find that improved insurance coverage significantly increased the use of screening mammography. The lack of coverage for preventive office visits, however, limits women s contact with physicians for CBE and mammography referral. Research with low income African American women in North Carolina emphasizes the important role of CBE in mammography referral. Mammography screening was correlated with CBE for 40- to 49-year-old women. Legislation mandating coverage by private insurers and Medicare could significantly affect physician recommendation and create an important standard of care. If all physicians were to refer women for mammography at the same rates as do gynecologists, mammography screening could increase from 59% to 75%.

Social Networks, Breast Cancer Screening, and Cancer Prevention. Social networks are important in encouraging breast cancer screening tests, timely follow up for symptoms, and acceptance of doctors' recommendations. Studies have shown that even after controlling for age, education, health status, type of health insurance, and having a primary care physician, Black women with more social ties are more likely to receive mammograms than those with fewer social ties. Likewise, social networks, specifically the number of close friends and traditional attitudes toward family, are important determinants of mammography screening behavior among older, low-income Mexican American women. The absence of social ties and sources of emotional support are associated with late diagnosis and increased breast cancer death rate among Black women.

Health promotion interventions using social ties in church communities have been successful in cancer prevention and control and may successfully promote early detection. Church-based education programs with African American and Hispanic women have increased the rates of mammography, breast self-examinations (BSEs), and cervical cancer screening. Using African American breast cancer survivors as role models, the witnessing program, promoted breast cancer detection by addressing existing attitudes, norms, and values regarding BSE and mammography. Shared values of participants and Black lay health educators may provide positive experiences with breast cancer survivors, serving to counteract the fatalism, negativism, and low knowledge levels with the African American community regarding cancer.

Breast Cancer Risk: Perceptions, Worry, and Screening Among Women With Family Histories of Breast Cancer. Perceptions of risk for developing breast cancer influence women's screening practices. Accurate knowledge of breast cancer risk, particularly the role of family history, perceptions of personal risk, and beliefs about screening effectiveness, is significantly related to screening behaviors. A study that identified perceptions that promote breast cancer screening in Black women with family histories of breast cancer indicated that the majority of participants had inaccurate knowledge of breast cancer risk factors and that they had not received adequate education about risk by their health care providers. Only 25% identified the risk of family history; one quarter identified factors that have not been demonstrated to increase risk, such as bumping and bruising a breast and smoking. Less than 10% of the women identified other factors known to increase breast cancer risk besides family history, including current age, age at first live birth, age at menarche, and a number of benign breast biopsies.

Although only 25% of this sample reported being told of their higher risk of developing breast cancer because of family history, approximately 50% perceived themselves to be at risk of developing this disease and reported concern and worry about this. Unlike rates of breast cancer concern reported for White middle- and upper-income women with family histories, these low-income Black women did not feel that their concern affected their carrying out daily activities (87%) or their moods (70%). Other researchers, however, have found that anxiety or worry about breast cancer risk interferes with mammography screening among women both with and without family histories of breast cancer , particularly those with limited education.

It is important for providers to acknowledge their influence on the screening practices of women with family histories of breast cancer. Professionals can motivate women to participate in routine screening through office visit discussions that provide accurate information about their risk status and the factors that contribute to personal risk. They can facilitate regular screening by addressing the breast cancer concerns and anxiety of women patients.

Breast Symptoms: Patterns of Seeking Care. Patient delay in seeking help for breast symptoms and provider delay in treating those symptoms combine to decrease breast cancer survival. A meta-analysis of 12 studies on patient delay documented that 34% of women were symptomatic for several months before seeking evaluation and poor women of color were overrepresented in this number. African American women, in particular, have lower survival due to late-stage diagnosis and delay in seeking care.

It is important for health professionals to address the practices and beliefs of patients and providers that may contribute to delays in seeking help. Both providers and patients have a variety of responses to breast symptoms. Providers should be aware of the possible range of the patients as well as their own responses to symptom discovery. Helping patients identify incorrect beliefs and fears will increase the likelihood that women s decisions to seek help or delay are based on accurate understanding of the consequences associated with the actions. Understanding the anxiety that patients experience about their symptoms, potential diagnoses, and procedures can enhance effective communication in the medical encounter and promote effective decision-making when dealing with breast symptoms.

Breast Cancer Diagnosis: Psychosocial and Behavioral Factors. To provide effective psychosocial intervention to women receiving a diagnosis of breast cancer, health care providers must become knowledgeable about women s experience. For most women with breast cancer, psychological functioning is indistinguishable from that of physically healthy women 12-24 months after diagnosis if the treatment is complete and the cancer controlled. Rather than producing global psychological dysfunction, a cancer diagnosis often produces islands of psychosocial disruption that vary across the course of the experience and as a function of medical, intrapersonal, and social contexts.

Although most women remain psychologically resilient in the face of breast cancer diagnosis, several realms of functioning may be affected at various points during diagnosis and treatment. Unfortunately, little is known about whether psychosocial issues or specific needs for support vary as a function of ethnicity or SES of the affected women. In designing interventions, health care providers need to assess specific areas of psychological impact for particular women. Providers can support women by offering information about psychosocial resources to all women confronting a breast cancer diagnosis. Some women at risk for psychological morbidity (e.g., those at a younger age, or coping through disengagement) may warrant specific psychosocial support referral.

In conclusion, psychosocial and behavioral strategies that target both women and their health care providers can promote accurate risk perception, routine screening, prompt diagnosis and treatment, and recovery in breast cancer. One goal for effective intervention is patient-physician communication that enhances decision making while taking into account the patients' perspectives. Office discussions that provide information, skills necessary for decision making, and emotional support enhance women's perceptions of control in screening and treatment decisions. Eliciting women s risk perceptions and providing accurate feedback can help them weigh the balance between the benefits and costs of screening.

Because risk perception is related directly to screening practices, educating patients about accurate breast cancer risk and their providers about the process of information delivery is critical. Discussions to address socioeconomic barriers and deliver information using tailored, culturally relevant formats are usually the most effective in reaching their target audiences.

Health care professionals can help women diagnosed with breast cancer by providing information about the resources for psychosocial support available in their communities. This type of support and psychosocial interventions promote well-being during breast cancer treatment and the adjustment period afterward must be made available to all women, including those from diverse socioeconomic and ethnic backgrounds. Women who are at risk for psychological morbidity (e.g., young women and those with limited social support) may need specific kinds of psychosocial support, referral, and follow-up. Providers can facilitate this process by establishing patient referral networks with experts in psychosocial oncology and community based organizations to help women and their families cope with diagnosis, treatment, and recovery.

It is critical that education and prevention strategies consider the psychosocial and behavioral factors and their interrelationships with biomedical factors---particularly on this issue. Research has shown that menarche may be the beginning of change in girls' self- and body image and that many adolescent girls develop a negative sense of themselves and their bodies during puberty. This lack of a positive self-image can put them at risk for multiple other problems (e.g., alcohol and other substance abuse, partner abuse, eating disorders, risky sexual behavior, and unwanted pregnancy). As increasing numbers of adolescent women become sexually active and face decisions concerning safe sex, pregnancy, prenatal care, teenage parenting, or abortion, it is important that factors associated with women's sexual decision-making, particularly within a relational context are understood. For example, what factors influence girls' sexual and contraceptive decision making? What is the role of sexual coercion in the process? Most work to date in these areas has focused on intrapersonal characteristics associated with beginning sexual activities and deciding to use contraceptive or sexually transmitted disease prevention mechanisms. Future research needs to adapt a relational goals perspective and study how these factors influence decision making.

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