Social Work

Abstract
Background: Many Americans diagnosed with colon cancer do not receive indicated chemotherapy. Certain
unmarried women may be particularly disadvantaged. A 3-way interaction of the multiplicative disadvantages of
being an unmarried and inadequately insured woman living in poverty was explored.
Methods: California registry data were analyzed for 2,319 women diagnosed with stage II to IV colon cancer
between 1996 and 2000 and followed until 2014. Socioeconomic data from the 2000 census classified neighborhoods
as high poverty (≥30% of households poor), middle (5–29%) or low poverty (<5% poor). Primary health insurance was
private, Medicare, Medicaid or none. Comparisons of chemotherapy rates used standardized rate ratios (RR).
We respectively used logistic and Cox regression models to assess chemotherapy and survival.
Results: A statistically significant 3-way marital status by health insurance by poverty interaction effect on chemotherapy
receipt was observed. Chemotherapy rates did not differ between unmarried (39.0%) and married (39.7%) women who
lived in lower poverty neighborhoods and were privately insured. But unmarried women (27.3%) were 26% less likely to
receive chemotherapy than were married women (37.1%, RR = 0.74, 95% CI 0.58, 0.95) who lived in high poverty
neighborhoods and were publicly insured or uninsured. When this interaction and the main effects of health
insurance, poverty and chemotherapy were accounted for, survival did not differ by marital status.
Conclusions: The multiplicative barrier to colon cancer care that results from being inadequately insured and living in
poverty is worse for unmarried than married women. Poverty is more prevalent among unmarried women and they
have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer
care. There seem to be structural inequities related to the institutions of marriage, work and health care that particularly
disadvantage unmarried women that policy makers ought to be cognizant of as future reforms of the American health
care system are considered.
Keywords: Health insurance, Poverty, Colon cancer, Chemotherapy, Marital status, Unmarried, Women, California,
United States

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