I. Case Study & Problem Statement

The life of Kimberly Williams, a 46 year-old black woman and mother of two, was changed forever after being diagnosed with cervical cancer. Four years ago, Mrs. Williams went to her doctor's office nervously and apprehensively after receiving her doctor's call to come in. After being told she had cancer, she experienced overwhelming fear. A series of worries and concerns suddenly emerged to her mind: how long has it lived in her body? Will she die? Who is going to be able to raise her children? At that moment, she knew nothing about the virus that was in her body named the human papillomavirus that brought her cervical cancer. No one had ever tested her for her HPV status or told her that she should be checked to ensure early prevention. In addition to her upcoming battle with cancer, there were more challenges that she had to confront: her family, life routine, diet, and financial costs (Wise, 2022).

Women of color, just like Mrs. Willams, have higher cervical cancer mortality compared to white women. In fact, research has shown a widespread disparity and inequity in rates of cervical cancer affecting women of color, especially for those that have economic difficulties at the same time.

The reproductive organs between men and women are completely distinct. The cervix is a female reproductive organ that men do not biologically have. It is vital to a woman as it represents femininity and enables her to be pregnant, to give birth and to menstruate. It also helps prevent and protect a woman's uterus from bacteria invasion. Although men also face reproductive health problems, only women face gynecological health problems. Among them, cervical cancer is one of the most frequent. Cervical cancer is most commonly developed in women between the ages of 35 and 44 with the average age at diagnosis being 50 (The American Cancer Society, 2023). HPV, the human papillomavirus, is a group of more than 200 related viruses, some of which are spread through vaginal, anal, or oral sex. Sexually transmitted HPV types fall into two groups, low risk and high risk (National Cancer Institute, 2022). Cervical cancers are cancers caused by HPV that start in the cells of the cervix and usually develop slowly over time. Before cancer appears in the cervix, the cells of the cervix go through changes known as dysplasia, in which abnormal cells begin to appear in the cervical tissue. Over time, if not destroyed or removed, the abnormal cells may become cancer cells and start to grow and spread more deeply into the cervix and to surrounding areas (National Cancer Institute, 2022). Nearly all people who are sexually active will become infected with HPV at some point in their lives. Around half of HPV infections are with a high-risk HPV type. High-risk HPV can cause several other types of cancer as well as cervical cancer. HPV16 and HPV18 are the high-risk types that cause most cases of cervical cancer. However, cervical cancer is highly preventable and curable if caught early (National Cancer Institute, 2022). In other words, the most important aspect of treatment is early detection. Most cervical cancers could be prevented by certain treatments including HPV vaccination, routine cancer screenings, and appropriate follow-up treatment. If it is caught early, there is a five-year survival rate of over 90% (Wise, 2022). 

Despite the importance of prevention, women’s access to cervical cancer preventative care like vaccination and screenings, depends on their race and economic status. Women require more health care; however, they are also more likely to be poor. According to U.S. Census Bureau data, 56% of people living in poverty were women in 2018 (The Center for American Progress, 2020).  Given the racial disparities in cervical cancer detection and screening, low-income women of color are less likely to receive certain related health care or screenings for cervical cancer. However, another huge barrier that blocks women’s access to certain healthcare is poverty. It has made many low-income women forgo the chance to receive health services, pap tests and screenings that help early detection.

Asians, Native Hawaiians/other Pacific Islanders, American Indians or Alaskan Natives, Hispanics, and other minorities were significantly less likely to receive Pap tests compared to white women (McDaniel, Hallam, Cadwallader, Lee & Chou, 2021). This means that women of color have less of a chance to confront and treat their possible cervical cancer as Pap tests are essential for early prevention. 

Women younger than 65 who are enrolled in Medicaid, a public insurance program that provides health coverage to low-income populations, are more likely to die from cervical cancer than privately insured women (Bradley, Given & Roberts, 2004). This proves that quality health insurance is crucial for preventing female related health problems among low-income women. Below is a graph showing the rate of cervical cancer mortality by race and ethnicity per 100,000 women (U.S. Cancer Statistics, 2022).

As shown in the table above, Hispanic women have 1.4 times higher incidence of mortality (9.7/100K) from cervical cancer vs white non-hispanic women (7.0/100K). This shows that besides having less access to early detection, women of color also have higher rates of death from cervical cancer compared to white women.

The key to lower the negative outcomes of cervical cancer, and stop racial and economic disparities in cervical cancer deaths is bringing up an equity for all women of earlier prevention and detection. When cervical cancer is diagnosed at an early stage, the 5-year relative survival rate is 92%. When cervical cancer is diagnosed after it has spread to nearby tissues, organs, or regional lymph nodes, the 5-year relative survival rate drops to only 59%. When cervical cancer is diagnosed after it has spread to a distant part of the body, the 5-year relative survival rate drops even further to 17% (National Cancer Institute, 2022). These statistics go to show that earlier the detection and diagnosis, the higher the chance of survival. Several measures can be taken to reduce disparities in cervical cancer. Special attention should be given to different racial groups to promote health equity in cervical cancer screening and subsequent cervical cancer incidence and survival outcomes as the implementation of the HPV test continues to progress. One of them is routine screening that can prevent most cervical cancers, allowing health care providers to find and remove precancerous cells before they develop into cancer. In this case, the education and encouragement for women making routine screening is needed. The government may implement more detections and screening services for low-income women of color and put more efforts to increase insurance coverage.

II. Causal Analysis Literature Review

Various factors have contributed to the racial and economic disparities observed in cervical cancer, including financial struggles that can limit a person's ability to access preventative care or treatment; inadequate health insurance that can result in delays or gaps in necessary medical care; single parenthood that can make it more difficult to balance caregiving responsibilities with work or healthcare; physicians’ bias and stereotypes that can negatively impact the quality of care that certain patients receive, and more.

Firstly, financial issues can give rise to economic disparities for women with lower incomes and those without health insurance. Being low-income, women of color face excessive life and medical expenses that may lead them to forgo health care for themself. Therefore, health insurance is a key and need that assures low-income women health coverage. Cervical cancer screening coverage is mandated by the Affordable Care Act (ACA). However, because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage and in the 12 states that have not adopted the Medicaid expansion as of January 2021, Medicaid eligibility for adults remains limited (Garfield, Orgera & Damico, 2021). Furthermore, the South has higher numbers of poor uninsured rates and more limited eligibility for Medicaid than in other regions that accounts for the majority (8 out of 12) of states that opted not to expand (Garfield, Orgera & Damico, 2021). Compared to other prosperous regions, there is economic stagnation and inequality in the South. There are thriving economies at the local level in the South and economic stagnation and inequality within more prosperous regions. Workers of color have higher rates of unemployment; for example, the black unemployment rate has held at roughly double the rate for white Americans, and Hispanic or Latino Americans have experienced unemployment rates that are typically about 40% to 80% higher than the white unemployment rate (Gaines, Hardy & Schweitzer, 2021). These demonstrate the 12 states that opted not to expand Medicaid are the very same states that have a higher proportion of low income women of color, and have the lowest support for single mothers. Also, indicate that the lack of access to Medicaid due in states that didn’t offer Medicaid expansion may have contributed to the increase in uninsured rates and the decrease in quality health insurance for low-income women. This will forbid low-income women receiving preventative treatment and healthcare for cervical cancer. 

On the other hand, there is a higher rate of single parent families with low income women of color. Among solo parents, 42% are white and 58% are women of color. Compared with cohabiting parents, solo parents are more likely to be female and black. Among solo parents, 81% are mothers and only 19% are fathers. This gender difference is even more pronounced among black solo parents that 89% are mothers and just 11% are fathers (Pew Research Center, 2018). Moreover, single mothers are much more likely to be poor. The poverty rate for single-mother families in 2020 was 23.4%, nearly five times more than the rate (4.7%) for married-couple families (U.S. Census Bureau, 2021). Single motherhoods comprehend more caretaking, family and work responsibilities; therefore, they might not have enough time to take off for work and cover child care and transportations to get to healthcare. It is also a need to consider that low income women are least likely to have paid time off which would make it even less likely they could afford a non emergency health care. The primary cause of low-income individuals not availing of family or medical leave when required or desired is the apprehension of a decrease in their wages or salary. More than half of employees (54%) expressed their fear of losing their jobs, while around 42% felt guilty about burdening their co-workers with additional work. Additionally, 40% were concerned that taking time off might negatively affect their prospects for job advancement (Graf, 2017)

In addition, physicians' bias may have been an important factor that brought about health care disparities for women of color. According to Chapman et al. (2013), implicit bias occurs when cultural stereotypes impact how an individual’s information is processed and leads to unintended biases in decision-making. Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics (Chapman et al. 2013). The racial bias can result in women of color being treated differently and even unequally. In fact, a real clinical scenario where bias is suggested is that nurses asked to take the patient’s perspective offered equal pain treatment, regardless of patient race, whereas those not asked to do so recommended more pain medication for White patients (Drwekci, 2011). The implicit biases may guide providers’ communication and medical judgments that may influence the patient’s satisfaction with and trust in the provider (Torres et al., 2022). Some evidence shows that the quality of communication and cancer screening decisions may be influenced by physicians’ own biases and expectations about a patient’s likely adherence (Peterson et al., 2016). Moreover, there are fewer provider recommendations for follow-up treatment reported by Black women (Ford et al., 2021). Based on the above-mentioned, physicians’ bias may hinder women of color from receiving preventive screening, healthcare and treatment for cervical cancer.

III. Policy Advocacy & Conclusion

Cervical cancer disparities are a complex issue that involves a multitude of factors. Addressing these factors will require multi-faced approaches, including systemic changes in healthcare policies, increased access to resources and education, and targeted efforts for the healthcare system. Therefore, it is important and necessary to recognize that the solutions to cervical cancer disparities must address the root causes of the problem to be effective. Systemic changes in healthcare policies can ensure that preventative screenings and follow-up healthcare are accessible to all individuals, regardless of their economic or racial background. This can include initiatives such as expanding insurance coverage for cervical cancer screenings and reducing out-of-pocket costs. In advance, to implement programs such as medicare for all or universal health insurance. In addition, targeted efforts are needed to address the specific needs of low income women of color, including programs that focus on increasing access to healthcare in low-income areas and addressing the issue of physicians' bias through cultural sensitivity training for healthcare providers. Further through monitoring and assessing the impact of these different approaches, healthcare systems can ensure that they are effectively addressing cervical cancer disparities and working towards providing equitable healthcare for all individuals.

Medicare for all is one of the programs that seems promising to address the economic disparities for low income women and the factor of lack of insurance. In fact, there is the Medicare for All Act that has been introduced in the senate by Mr. Sanders on April 10, 2019 which establishes a national health insurance program that is administered by the Department of Health and Human Services (U.S. Congress, 2019). According to the introduced act (2019), the program has formulated certain requirements including that it must cover and encompass all U.S. residents, with a provision for automatic enrollment upon birth or residency in the United States; it must also cover all necessary medical items and services to maintain or improve health, including hospital services, prescription drugs, mental health and substance abuse treatment, dental and vision services, as well as home- and community-based long-term care. In accordance with the presented bill (2019), the Secretary shall establish an overall national health budget that outlines the total expenses for healthcare services covered by this Act. The budget will be divided and contributed for quality assessment activities, health professional education expenditures, administrative costs, innovation, operating, capital expenditures, and prevention and public health activities. Some benefits for people who are enrolled under this Act are receiving payment from the Secretary for eligible healthcare items and services, provided that they are medically necessary or appropriate for maintaining or improving health or for treating a health condition. These covered services include hospital services such as inpatient and outpatient care, emergency services, and prescription drugs. Ambulatory patient services, primary and preventative care, mental health and substance abuse treatment, laboratory and diagnostic services, reproductive and newborn care, pediatric care, oral health, audiology, and vision services are also covered. Short-term rehabilitative and habilitative services and devices, emergency services and transportation, and necessary transportation for individuals with disabilities and low-income individuals to receive healthcare services are also included. Finally, home and community-based long-term services and support will be provided according to the requirements for home and community-based settings (U. S. Congress, 2019).

Based on the above-mentioned, low income women will be able to be covered and receive financial coverage for preventative cervical cancer healthcare and relevant treatments. This indicates that low income women who may not have been able to afford regular cervical cancer screenings or treatment in the past will now have access to these crucial services if this act passes. With the financial coverage provided, they will be able to receive preventive healthcare services such as regular pap smears, HPV testing, and other screening procedures. Additionally, if any abnormal cells or cancerous growths are detected, they will be able to receive the necessary treatments without worrying about the financial burden. This is an important step towards ensuring that all women, regardless of their income level, have access to the healthcare services they need to maintain their health and well-being.

Besides addressing economic disparities in healthcare, it is also essential to tackle the issue of racial disparities. Studies have shown that racial bias exists within the healthcare system, and this can lead to disparities in the quality of care received by individuals of different races. To address this issue, programs that aim to reduce physicians' bias through cultural sensitivity training for healthcare providers need to be expanded. By providing healthcare providers with the necessary training, they can become more aware of their own biases and learn how to provide culturally sensitive care to their patients. There have been training programs developed to tackle the negative impacts of implicit bias, and in some states like California, Maryland, Michigan, Minnesota, and Washington, there has been the recent passage of laws that require implicit bias training for certain categories of healthcare professionals (Cooper, Saha & Ryn, 2022). Such training programs can help to improve the quality of care received by women from diverse racial backgrounds and help to reduce healthcare racial disparities. There are bills in different stages of the legislative process in other states (Cooper, Saha & Ryn, 2022). Therefore, it is recommended to pass the bills as soon as possible in order to ensure equitable healthcare since there are low income women of color who have been negatively impacted or treated by receiving low quality healthcare.

People may argue that the Medicare for All Act and cultural sensitivity training programs have respective drawbacks such as the potential cost and concerns about the time and resources required for implementing a universal healthcare system and such programs. However, the potential benefits outweigh these concerns. Critics of the Medicare for All Act argue that the high cost of implementing universal healthcare coverage could lead to increased taxes for citizens. Nonetheless, studies have shown that this policy could lead to cost savings for individuals, businesses, and the government. A study conducted by the Political Economy Research Institute estimated that Medicare for All could reduce healthcare spending by $450 billion per year. This could offset the cost of implementing this policy. Similarly, while cultural sensitivity training for healthcare providers may be costly and time-consuming, it has been shown to improve healthcare outcomes for marginalized communities. Patients who receive care from culturally sensitive providers report higher levels of trust, satisfaction, and adherence to medical recommendations. Therefore, the potential benefits of these policies should not be ignored, as they have the potential to improve healthcare access and outcomes for all individuals.

“Cervical cancer prevention should encompass a multidisciplinary, including components from community education, social mobilization, vaccination, screening, treatment and palliative care” (World Health Organization, 2022). Health education is also a vital component of the healthcare system. Educating women on how to maintain a healthy lifestyle and prevent illnesses can help to reduce the overall burden on the healthcare system. This can include educating them on healthy eating habits, exercise, and the importance of regular check-ups and preventative screenings. Health education can also include educating individuals on the proper use of medications and medical devices, as well as providing information about cervical cancer and how to manage it. By improving health education, all women can become more informed about their health and make better decisions about their healthcare needs. 

To sum up, there is a need to care about these disparities as they represent a fundamental matter of social justice and equity in healthcare. Women, especially those from low-income and racial minority communities, are disproportionately affected by cervical cancer disparities who often face significant obstacles to accessing related healthcare, including preventative screening and treatment. These barriers can be due to economic struggles, such as inability to afford high medical expenses and also lack of health insurance, as well as racial biases that exist within the healthcare system. If these disparities are left unaddressed, they can lead to significant health inequities and can have a negative impact on the overall health of affected communities. Addressing these disparities requires a focused effort to eliminate economic and racial barriers to healthcare access and to promote preventative measures like regular cervical cancer screening, vaccination and further treatments. These can help to ensure that all individuals have equal access to the care they need to maintain good health and well-being, regardless of their economic or racial background. Overall, addressing both economic and racial disparities and improving health education are crucial steps towards building a more equitable and effective healthcare system for all women. Because, every individual is important, valuable and deserves respect, care and dignity.

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