The Rural Household Production of Health Approach: Applying Lessons from Zambia to Rural Cancer Disparities in the U.S.

The recent focus on rural–urban cancer disparities in the United States (U.S.) requires a comprehensive understanding of the processes and relations that influence cancer care seeking and decision making. This is of particular importance for Black, Latino, and Native populations living in rural areas in the U.S., who remain marginalized in health care spaces. In this article, we describe the household production of health approach (HHPH) as a contextually-sensitive approach to examining health care seeking and treatment decisions and actions. The HHPH approach is based on several decades of research and grounded in anthropological theory on the household, gender, and therapy management. This approach directs analytical attention to how time, money, and social resources are secured and allocated within the household, sometimes in highly unequal ways that reflect and refract broader social structures. To demonstrate the benefits of such an approach to the study of cancer in rural populations in the U.S., we take lessons from our extensive HHPH research in Zambia. Using a case study of a rural household, in which household members had to seek care in a distant urban hospital, we map out what we call a rural HHPH approach to bring into focus the relations, negotiations, and interactions that are central to individual and familial health care seeking behaviors and clinical treatment particular to rural regions. Our aim is to show how such an approach might offer alternative interpretations of existing rural cancer research in the U.S. and also present new avenues for questions and for developing interventions that are more sensitive to people’s realities.

Did Medicaid Expansion Mitigate Disparities in Post-mastectomy Reconstruction Rates?

Background Patient and socioeconomic factors both contribute to disparities in post-mastectomy reconstruction (PMR) rates. We sought to explore PMR patterns across the US and to determine if PMR rates were associated with Medicaid expansion. Methods The NCDB was used to identify women who underwent PMR between 2004-2016. The data was stratified by race, state Medicaid expansion status, and region. A multivariate model was fit to determine the association between Medicaid expansion and receipt of PMR. Results In comparison to Caucasian women receiving PMR in Medicaid expansion states, African American (AA) women in Medicaid expansion states were less likely to receive PMR (OR .96 [.92-1.00] P < .001). Patients in the Northeast (NE) had better PMR rates vs any other region in the US, for both Caucasian and AA women (Caucasian NE ref, Caucasian-South .80 [.77-.83] vs AA NE 1.11 [1.04-1.19], AA-South (.60 [.58-.63], P < .001). Interestingly, AA patients residing in the NE had the highest receipt of PMR 1.11 (1.04-1.19), even higher than their Caucasian counterparts residing in the same region (ref). Rural AA women had the lowest rates of PMR vs rural Caucasian women (.40 [.28-.58] vs .79 [.73-.85], P < .001]. Discussion Racial disparities in PMR rates persisted despite Medicaid expansion. When stratified by region, however, AA patients in the NE had higher rates of PMR than AA women in other regions. The largest disparities were seen in AA women in the rural US. Breast cancer disparities continue to be a complex problem that was not entirely mitigated by improved insurance coverage.