Social and Cultural Influences on Women’s Health 529those with less education (used as proxy measure of social
class), had more risk factors for CHD (e.g., cigarette
smoking, hypertension, body mass index [BMI], and total
cholesterol level). Lower SES not only serves as a risk factor
for incidence of CHD in women, but also for mortality
(Brezinka & Kittel, 1996). Lung cancer has the highest can-
cer mortality rate in women in the United States and has the
third highest incidence rate for women (after breast and colon
cancers; Anderson et al., 2001). This has been attributed to
cigarette smoking; prevalence of smoking is highest among
those women who are less educated and who live in poverty
(Adler & Coriell, 1997). Environmental hazards such as air
pollution, asbestos, and radon, which are found more in
urban areas and lower status occupations, also are risk factors
for lung cancer (Moy & Christiani, 2000). Although Euro-
pean American women have a higher incidence of breast
cancer than African American women, black women have a
17% lower “ve-year survival rate (National Cancer Institute,
1995). These ethnic-racial differences have been explained in
part by the confound of ethnic-racial status and SES in the
United States, such that women of lower SES have lower
mammography utilization rates (Champion, 1992) and report
less knowledge about breast cancer (A. Miller & Champion,
1997). Gay and Underwood (1991) reported that the women
at highest risk for contracting HIV are those with lower edu-
cation levels, lack of employment opportunities (sometimes
resulting in sex industry work such as prostitution), and dif“-
culty receiving adequate health care services„factors all
associated with poverty.
Mental Health and SES
Lower SES has been linked not only to physical health prob-
lems, but also to increased rates of psychopathology and
mental disorders. In a review of 20 prevalence studies,
Neugebauer et al. (1980) found that 17 of these studies re-
ported higher rates of psychopathology in the lowest socio-
economic class than in the highest class. These “ndings were
supported by multiple studies using data from the ECA study
(Holzer et al., 1986; Regier et al., 1993; Robins et al., 1991).
Regier et al. found individuals from the lowest SES level to
have a 2.6 greater relative risk for overall psychopathology
than those in the highest SES level in terms of one-month
prevalence rates. In comparing rates of speci“c disorders be-
tween the lowest and highest social levels, there is an 8.1
greater risk for schizophrenia, 2.9 for obsessive-compulsive
disorder, and 2.5 for alcoholism in those from lower SES lev-
els, indicating signi“cantly higher rates of overall psy-
chopathology, as well as increased risk for speci“c psycho-
logical disorders in low socioeconomic groups. In support of
these results, Holzer et al. examined six-month prevalence
rates and found similar results, again revealing higher rates of
psychological disorders in low compared to high socioeco-
nomic levels.
In examination of gender differences and psychopathol-
ogy, women from lower socioeconomic backgrounds re-
ported higher levels of depressive symptoms (Hirschfeld &
Cross, 1982), with a review by Neugebauer et al. (1980) re-
porting an average female-to-male depression ratio of 3.0.
This suggests women are at increased risk for depression,
with augmented risk for women from lower socioeconomic
backgrounds. As discussed earlier, women also have in-
creased rates of anxiety disorders relative to men (Kessler
et al., 1994, 1995; Neugebauer et al., 1980). In summary, the
results of these epidemiological studies suggest that women
and individuals from low socioeconomic backgrounds are at
increased risk for major depression, anxiety, and other psy-
chiatric disorders (Kohn, Dohrenwend, & Mirotznik, 1998).Multiple Roles: Risk or Protective Factor?Theories regarding women in the workplace began to emerge
in the 1950s with the growing numbers of women entering
the workforce. Since then, there continue to be changes and
developments in the quantity and quality of women•s in-
volvement in the workplace and at home, which makes the
modi“cation of these initial theories necessary although
the underlying issues may be similar (Barnett & Hyde, 2001).
Although women have always been responsible for a variety
of tasks (e.g., managing household chores; providing care
to their children, elderly parents, or relatives), entering the
workforce initiated signi“cant changes in women•s life roles.
Employed women now constitute 48% of the U.S. labor force
(Bond, Galinsky, & Swanberg, 1998), with 54% of women
with children under the age of one year and 70.8% of women
with children under the age of 18 years working outside the
home (U.S. Department of Labor, 1997b). As the number of
working mothers in the work force, and the number of hours
women work outside the home, continue to rise, the num-
ber of women who occupy multiple roles, as well as the
number of roles held by women, will increase.
Society places unique demands on women to “nd a bal-
ance between meeting the role expectations of an employee,
earning an income to support their family, and pursuing a ca-
reer on the one hand, and juggling the social roles of being a
wife, mother, caretaker, and supportive friend, on the other.
The debate as to whether occupying multiple roles serves as
a risk or protective factor in the physical and psychological
health of women continues to be a widely researched and
important issue. The research on multiple roles presents