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Factors Influencing Health

Behaviors and Drug Abuse

Among Low-Income Black

and Latino Women

Kathy Sanders-Phillips, Ph.D.

INTRODUCTION

In the past decade, significant increases have occurred in our knowledge of factors that influence women’s health decisions and behaviors,

as well as barriers to healthy behaviors among women (Brown-Bryant

1985; Makuc et al. 1989; Calnan and Johnson 1985; Baum and Grunberg

1991). There is also growing awareness of factors that influence the

health behaviors of ethnic minority women (Sanders-Phillips 1994a,

1994b, 1996a; Cope and Hall 1985; Leigh 1994). In addition, strategies

that can be effective in promoting healthier behaviors among the general

population of women and among ethnic minority women have been

identified (Eng 1993; Levine et al. 1992; Schaefer et al. 1990; Eng et al.

1985).

Despite these findings, efforts to understand and address drug abuse

among women often fail to examine drug abuse in the larger context of a

woman’s health decisions and health behaviors or to incorporate previous

findings regarding successful health promotion interventions for women

into programs developed for drug-abusing women. Both the magnitude

of women’s drug abuse and its repercussions for their health and that of

their children indicate that drug abuse among women is a significant

public health problem (Carr 1975). More than 4.4 million women

currently use illicit drugs, and women constitute more than 37 percent

of the illicit-drug-using population in the United States (Leshner 1995).

Women who abuse drugs also engage in other risk behaviors and tend to

have other health problems (Curtiss et al. 1993). Thus, women’s drug

use may reflect a broader spectrum of unhealthy behaviors.

Current data and approaches from the field of public health and

results from previous studies of women’s health behaviors should be

incorporated into efforts to understand drug abuse by women and develop
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effective programs of intervention. Data from this literature indicate

that health behaviors occur on a continuum from healthy to unhealthy

behaviors (Berkanovic 1981-1982; Weinstein 1993; McLeroy et al.

1992) and that there is consistency in personal health habits over time

(Rakowski 1987). In addition, health behaviors are multiply determined,

and a primary goal must be to understand how health problems are

created and maintained in society (McLeroy et al. 1992). The social

processes through which the health problem or behavior is produced,

the potential points of intervention, and what types of interventions

are successful with which populations and under what social conditions

must be assessed (McLeroy et al. 1992). After these conditions are met,

programs of intervention can be established.

Within this context, drug abuse can be viewed as a health behavior

or, more specifically, a risk behavior that may represent an end point

of a series of risk behaviors in which a women may engage. To effect

change in the health outcomes of drug-abusing women, researchers must

begin to identify and examine the factors that promote risk behaviors,

including drug use, and, conversely, encourage healthier behaviors.

Previous findings from the public health literature regarding the evolution and predictors of healthy behaviors among women may be helpful

in identifying factors that promote such behaviors. Public health theory

and research have identified many of the factors and mechanisms by

which healthy behavior is initiated and maintained (Berkanovic 1981-

1982; DiClemente et al. 1991; Weinstein 1993). It is also important

to identify barriers that prevent women from making decisions to engage

in healthy behaviors or that encourage them to engage in unhealthy

behaviors. Information on variables that promote risk behaviors and the

mechanisms by which risk behaviors are maintained is scant. Identifying

and examining those factors may be critical to the study of drug abuse

among women.

Placing drug abuse on the continuum of women’s health decisions,

health behaviors, and risk behaviors allows for examining the relationships between drug abuse and other health behaviors, identifying the

barriers and correlates of each, and determining common etiologies.

The extent to which drug abuse by women is related to a more general

constellation of unhealthy lifestyle behaviors or whether it represents

a separate category of unhealthy behaviors that may be governed by

different and unrelated factors should be examined. Variables that
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distinguish drug-abusing women from women who engage in other

unhealthy behaviors and factors that increase the probability that a

woman will go from healthy behaviors to unhealthy behaviors to drug

abuse should also be identified. For example, by examining drug use in

the larger context of women’s health behaviors, researchers can begin

to identify and understand factors that may place a woman at risk for

abuse of alcohol or tobacco and, subsequently, illicit drugs.

Finally, examining drug abuse in the context of women's other health

decisions and behaviors may also focus attention on the social and

cultural variables that influence risk behaviors for women as a whole and

for ethnic minority subgroups. Factors that are related to healthy and

unhealthy behaviors and are specific to drug abuse among ethnic minority women remain largely unidentified. Identification of these factors

would increase knowledge regarding ethnic differences in drug abuse, as

well as social and cultural influences on women’s drug abuse, and would

enhance the development of intervention programs targeted to ethnic

minority women. The purpose of this chapter is twofold: First, it examines factors influencing health and risk behaviors among ethnic minority

women, with particular emphasis on individual, social, and cultural

factors related to risk behaviors. Second, factors related to alcohol and

tobacco use among women are identified on the basis of previous literature, and relationships between these factors and factors associated with

the abuse of illicit drugs are discussed. Approaches to health promotion

intervention, particularly with ethnic minority women, also are reviewed.

FACTORS INFLUENCING HEALTH

AND RISK BEHAVIORS AMONG WOMEN

There is considerable evidence that factors related to health and

risk behaviors may be gender-specific (Gottlieb and Green 1984, 1987;

Rakowski 1988; Cohen et al. 1982, 1991; Baum and Grunberg 1991;

Calnan and Johnson 1985). Several factors, including demographic

characteristics, knowledge and attitudes regarding health and healthy

behaviors, locus of control, and degree of participation in religious

groups, have been associated with health behaviors among women.

In general, higher education, income, and employment status; greater

knowledge of health promotion behaviors; positive perceptions of health

status; internal locus of control; higher levels of participation in religious

groups; and more positive attitudes regarding the prevention of disease
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are related to healthier behaviors among women such as eating breakfast,

exercising, moderate use of alcohol and tobacco, and good sleeping habits

(Gottlieb and Green 1984, 1987; Rakowski 1988; Cohen et al. 1982,

1991; Baum and Grunberg 1991).

Both psychological and social variables are also significant correlates

of health and risk behaviors among women. For example, higher levels

of social support, which include emotional support, information sharing,

and the provision of tangible goods and services are generally associated

with healthier lifestyle behaviors (Gottlieb and Green 1984; Neighbors

and Jackson 1984; Shumaker and Hill 1991). Stressful life events such

as marital conflict also appear to be better predictors of involvement in

healthy behaviors for women than for men (Rakowski 1988; Gottlieb and

Green 1984; Cohen et al. 1991). That is, fewer stressful life events are

related to higher levels of healthy behavior among women, especially in

low-income groups. Conversely, both lack of social support and higher

levels of stressful life events are associated with risk behaviors among

women. Since levels of social support and stressful life events can also

be associated with age and income, each of these variables may serve

as mediators in relationships between age, income, and risk behaviors

among women (Gottlieb and Green 1984). Psychological status, which

is related to levels of stressful life events and social support (Cohen et al.

1991; Shumaker and Hill 1991), also influences risk behaviors among

women. Poorer health behaviors are more common among women with

symptoms of depression (Cohen et al. 1991; Leftwich and Collins 1994).

Illness behavior also differs for men and women. Women are more likely

to seek treatment when ill and to recognize the need for professional help

with health problems (Neighbors and Jackson 1984).

Relationships between stressful life events and risk behaviors may be

intensified in low-income, ethnic minority groups. Gottlieb and Green

(1984) noted that poor women reported more stressful life events than

higher income women and practiced fewer health promotion behaviors,

both of which were related to decreased involvement in social networks.

Family and friends are primary sources of health information for lowincome, ethnic minority women, and lack of family or social support for

healthy behaviors deters these behaviors (Neighbors and Jackson 1984;

Gombeski et al. 1982). Social and ecological factors such as community

and interpersonal violence are also related to fewer health promotion

behaviors and poorer perceptions of health (Sanders-Phillips 1994a,
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1994b, 1996a; Cohen et al. 1991). Women who have had a family

member murdered or have experienced domestic violence engage

in fewer healthy behaviors than women not exposed to violence

(Sanders-Phillips 1994b, 1996a). Psychological factors such as alienation from the larger society and powerlessness in controlling life,

which are related to exposure to violence and other stressful events,

are also significant correlates of poor health behaviors for black and

Latino women (Cohen et al. 1982; Bullough 1972; Hibbard 1985;

Seeman and Evans 1962; Seeman and Seeman 1983; Morris et al. 1966).

Perceptions of the health care system and quality of interactions

with health care workers influence health and risk behaviors in these

groups. Lack of trust in the health care system and the perception that

it disrespects them are associated with poorer health behaviors and

fewer health promotion behaviors among ethnic minorities, which may

also be related to delay of treatment (Perez-Stable 1987; Webb 1984;

Freimuth and Mettzger 1990; Harrison and Harrison 1971, pp. 175-199;

James et al. 1984). The quality of interactions with health care providers also influences health behaviors (Sanders-Phillips 1996a; Makuc

et al. 1989). Higher levels of fatalism regarding the ability to affect

health outcomes and low levels of self-efficacy have also been noted

(Farris and Glenn 1976; Balshem 1991).

These data suggest that psychological variables such as stressful life

events, psychological status, social support, and quality of interactions

with the health care system may significantly influence health behaviors

and decisions among women. Although the mechanisms by which

these factors affect health decisions and behaviors have not been fully

explored, these variables may play a more critical role in determining

the health decisions and behaviors of women than those of men.

Causal relationships between these variables have not been established; however, stressful life events and lack of social support may be

specifically related to the initiation and maintenance of unhealthy or

risky behaviors by women. Stressful life events such as exposure to

violence may result in feelings of powerlessness and alienation, which,

in turn, are related to perceptions of poor health status and decreased

health promotion behaviors (Sanders-Phillips 1996b). Perceptions

of the health care system and quality of interactions with health care

staff members appear to influence the level of healthy behaviors and

compliance with treatment. Thus, ecological variables such as a
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woman’s exposure to violence and the nature of her interactions with

health facilities, as well as individual variables such as psychological

status and perceptions of stress, must be considered in assessment of

health behavior and decisions.

FACTORS RELATED TO ALCOHOL

AND TOBACCO USE AMONG WOMEN

Research on factors related to alcohol and tobacco use among

women provides additional evidence that men and women differ regarding relationships between risk factors and health behaviors and that

factors influencing the use of alcohol and tobacco among women are

similar to those influencing other unhealthy behaviors. For example,

there is a well-documented relationship between stressful life events

and women’s use of tobacco and alcohol. Stressful life events are related

to smoking initiation, smoking cessation, and alcohol use by women

(Gottlieb and Green 1984). Gottlieb and Green have suggested that

the relationship between stressful life events and alcohol consumption

and smoking by women may be strong enough to justify sex-specific

norms for smoking and drinking as coping mechanisms for stress.

Social support, as measured by church attendance and marriage

status, is related to lower levels of smoking and consumption of alcohol

by women. Social network influences, including the availability of

substances, modeling of their use, and attitudes toward their use, are

correlates of substance abuse among women (Gottlieb 1982; Ferguson

et al. 1976). Women’s substance use, particularly alcohol use, is also

related to parental drug abuse and the quality of family relationships

(Beckman 1975; Swinson 1980; Ensminger et al. 1982). Demographic

characteristics such as older age and full-time employment are also

related to higher alcohol consumption among women, but, unlike with

men, older age of women is not related to smoking cessation (Gottlieb

and Green 1984).

Mental health status is also a predictor of women’s smoking and

drinking behavior. A history of marital conflict and depression is associated with higher levels of drinking and smoking (Cohen et al. 1991;

Lex 1991). One study found that among women with depression, the

incidence of smoking was 90 percent greater and the incidence of

moderate or heavy drinking 120 percent greater than among women

without a history of depression (Cohen et al. 1991). There is also a
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relationship among full-time employment, marital conflict, and smoking.

Marital conflict is related to an increased probability of smoking only

among women who are not working full time, which supports the conclusion that relationships between stress and risk behaviors may be more

significant for women of lower income. Data from this study also confirm

that mental health factors may be more relevant to the health behaviors

of women than those of men, particularly for substance abuse (Lex 1991).

Although relationships among stressful life events, depression,

smoking, and drinking also have been found for ethnic minority women,

the sources of stress related to tobacco and alcohol use and factors related

to depression in ethnic minority women may differ, social norms and

support for smoking may vary within groups of ethnic minority women,

and factors such as acculturation may significantly affect depression and

smoking and drinking behaviors.

Among black women, education is negatively related to age of

smoking onset, amount of smoking, and perceived difficulties in quitting

(Manfredi et al. 1992). Education is positively related to plans to quit,

the belief that smoking is related to lung cancer and other serious health

problems, and knowledge of where to go for help. Black women with

more education also are more likely to live in environments that support

smoking cessation and have fewer smokers. Education and level of

acculturation are also important predictors of smoking behavior among

Latino women, but the nature of the relationship differs. More acculturated Latinas tend to smoke more than Latinas with lower levels of

acculturation or less education (Marin et al. 1989a), and MexicanAmerican women have been found to smoke more than Mexican immigrant women (Zambrana et al. 1991). Level of acculturation has also

been shown to influence attitudes, norms, and expectancies about

smoking in Latino groups (Marin et al. 1989b). Higher acculturation

and education among Latinas are also positively related to alcohol

consumption, as are older age and employment; however, drinking

patterns among Latino women are not related to length of residence in

the United States (Black and Markides 1993; Caetano and Mora 1988).

These findings support prior reports that risk behaviors such as smoking

and alcohol consumption tend to increase as Latinos become more

acculturated (Marcus and Crane 1985; Marcus et al. 1986); however,

Zambrana and colleagues (1991) found few differences in the consumption of alcohol between Mexican-American women and recent Mexican
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immigrants. Low income among Latinas also is an important predictor

of alcohol consumption. Among drinkers, poor Latino women tend to

consume more drinks per occasion and are more likely to be heavy

drinkers than Latinas at higher income levels (Black and Markides

1993).

In a study of factors related to alcohol consumption by black

women, Taylor and colleagues (1991) found that stressful life events

such as exposure to violence and internalized racism accounted for a

significant proportion of the variance in alcohol consumption. Internalized racism was defined as the degree to which black women internalized

negative racial stereotypes from the dominant society. Higher levels

of internalized racism were associated with higher consumption of

alcohol. Greater participation in religious activities was related to

higher alcohol consumption and depression. This finding is consistent

with previous findings that increased religious involvement is associated

with increased depression among blacks who are experiencing chronic

economic strain (Brown et al. 1992). Religious orientation was also

positively correlated with internalized racism.

Singleton and colleagues (1986) have reported that smoking by

black women is related to psychosocial stress and experiences of racism.

They also note that smoking by black women may be related to problems of assertion, independence, rebellion, or identification in their

relationships with males. This conclusion is supported by findings that

women who quit smoking are more likely to be married, have spousal

support, and be employed (U.S. Department of Health and Human

Services 1980). Conversely, black women, who are more likely to be

single and live in environments of high stress, are less likely to quit

smoking than white women (Singleton et al. 1986).

Studies of depression among black and Latino women indicate that

negative life events, internalized racism, and lack of social support are

significant predictors of depression. However, for black women, stressful

life events have a greater effect on depression than lack of social support

(Taylor et al. 1991). Although social support was inversely related to

depressive symptoms, it was unrelated to alcohol consumption. Several

investigators have shown that acculturative stress is related to depression

among Latinos (Salgado de Snyder 1987; Golding and Burnam 1990;

Williams and Berry 1991; Ring and Marquis 1991). As has been found

for black women, experiences of racial discrimination contribute to
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higher rates of acculturative stress and depression among Latinas

(Salgado de Snyder 1987). Among Latino professional women, both

marital conflict and racial discrimination are significant predictors of

depression (Amaro et al. 1987).

The studies cited above document relationships among stressful

life events, depression, alcohol consumption, and tobacco use in black

and Latino women and suggest that experiences of racism, exposure to

violence, and lack of social support may precipitate acculturative stress

and depression. These findings are consistent with Ferrence’s (1988)

observation that women’s risk behaviors, such as smoking and alcohol

use, are related to social status and interactions outside the home and

that experiences of racism affect health outcomes among blacks (Kreiger

1990).

These results also underscore the importance of psychological and

social variables to the use and abuse of tobacco and alcohol by these

groups and support previous findings that psychological and social

factors are significant predictors of risk behaviors among the general

population of women and among ethnic minority women. It is also

clear that ethnic differences, both between ethnic minority women

and nonethnic minority women and among groups of ethnic minority

women, exist in the sources of stress and factors that precipitate stress

and depression.

FACTORS RELATED TO ILLICIT

DRUG USE AMONG WOMEN

Most previous research on factors related to drug abuse has been

conducted with male populations; consequently, there are fewer available data on factors related to illicit drug abuse among women (Hser

et al. 1987). It has been reported that, in general, more white women

(35 percent) and black women (33 percent) than Hispanic women

(25 percent) report using illicit drugs at some point in their lives.

Current use of any illicit drug is slightly higher among black women

(7 percent) than among white women or Hispanic women (Leigh 1994).

Patterns of drug use and factors related to drug use differ for men

and women (Lex 1991). Compared with male drug abusers, women

who use illicit drugs, both during pregnancy and at other points in their

lives, tend to use a number of drugs concurrently, report use of somewhat
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higher amounts of drugs used but less money spent on drugs, are more

likely to be living with a drug-dependent partner, are more likely to show

symptoms of depression and isolation, and report more family and job

pressures (Carr 1975; Streissguth et al. 1991; Frank et al. 1988; Singer et

al. 1992, 1993; Lex 1991). Girls also are more likely to become polydrug

users or to self-medicate for depression than boys (Booth et al. 1991,

pp. 21-43). In addition, women’s initiation into drug use and their

progression through the addiction cycle are significantly influenced

by their male partners (Hser et al. 1987). This is not common among

male addicts.

Compared with women who do not report use of illicit drugs, drugusing women were more likely to be single, separated, or divorced; have

less than a high school education; use alcohol and tobacco in addition

to illicit drugs; and have fewer sources of social support (Streissguth et al.

1991; Singer et al. 1993; Beckwith 1986). Trauma, especially exposure

to violence, may be a particularly important predictor of women’s illicit

drug use. Pregnant victims of abuse were more likely than nonvictims

to use alcohol, marijuana, and cocaine, and women who experienced

maternal battering admitted more alcohol and cocaine use than

nonbattered women (Singer et al. 1993). In addition to histories of

childhood physical and sexual abuse, female drug abusers were more

likely to be physically and sexually abused during the time of their drug

use, as well as exposed to stigmatization from the public and peers

(Fullilove et al. 1992).

A study of the personality characteristics of male and female cocaine

and alcohol abusers showed that Minnesota Multiphasic Personality

Inventory profiles could not be distinguished on the basis of whether

the individual abused alcohol or cocaine, although cocaine use was

associated with higher levels of depression, anxiety, and antisocial

behavior (Johnson et al. 1992). Female cocaine abusers are more likely

than male abusers to have an Axis I diagnosis (American Psychiatric

Association 1987). Depression was the most common disorder among

women, whereas only men reported antisocial personality characteristics.

Differences in depression for male and female drug users persisted over

time, and women showed slower recovery from depression regardless of

sociodemographic characteristics (Griffin et al. 1989). These findings

suggest that previous reports of higher rates of antisocial behaviors among
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cocaine users may have been confounded by the combining data from

male and female samples.

Women who abuse illicit drugs also experience a wide range of

health problems and engage in other risk behaviors. As indicated,

marijuana, alcohol, and cigarette use is almost three times higher among

drug-abusing women than among non-drug-abusing women from similar

racial and social class groups (Frank et al. 1988; Singer et al. 1991).

Poor prenatal care is also common among drug-using pregnant women

(Singer et al. 1991). Women who use cocaine during pregnancy also

tend to weigh less during pregnancy and at delivery, which may be

related to anorexia and poor maternal nutrition (Singer et al. 1991;

Frank et al. 1988). Drug-using women are also more likely to have a

high prevalence of lifestyle or behavior-related health problems such as

sexually transmitted diseases, anemia, and dental disease (Curtiss et al.

1993). Significant medical illnesses such as heart disease, surgical

conditions, and breast disease also have been found among drug-abusing

women (Curtiss et al. 1993), and their use of drugs and possible involvement in prostitution increase the risk of HIV (human immunodeficiency

virus) exposure and AIDS (acquired immunodeficiency syndrome)

(Fullilove et al. 1990). Current statistics indicate that approximately

67 percent of AIDS cases among women are related to drug use

(Centers for Disease Control and Prevention 1994).

Since many of the previous studies of women using illicit drugs

have utilized samples from public urban hospitals predominantly serving

low-income, ethnic minority populations, relatively few comparison

studies of factors related to drug use among ethnic and/or economic

subgroups of women have been conducted. In addition, overreporting

of ethnic minority drug-abusing women to public health and/or social

service agencies has also skewed and biased samples on which many

previous studies are based (Chasnoff et al. 1990). Nevertheless, some

studies of ethnic differences among female drug abusers have been

published. Zambrana and colleagues (1991) examined ethnic differences in the use of alcohol, cigarettes, and illicit drugs among MexicanAmerican, Mexican immigrant, and African-American women. Consumption of alcohol was most likely to be reported by black women.

Black women were also more likely to use marijuana, cocaine, PCP

(phencyclidine), and heroin, as well as over-the-counter medications.

Use of illicit drugs was low among both the Mexican-American and
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Mexican immigrant groups; however, Mexican immigrant women were

slightly more likely than Mexican-American women to report use of

illicit drugs. Black women were most likely to be smokers, although

approximately one-third or more of women in each group reported

smoking. Mexican-American women were more likely to be smokers

than were Mexican immigrant women. Women who used alcohol, illicit

drugs, or cigarettes during pregnancy were older, more likely to report

negative life events, less likely to be living with the baby’s father, and

less likely to have planned the pregnancy (Zambrana et al. 1991).

The relationship between planned pregnancy and drug use in this

sample of women is particularly interesting in light of previous data

indicating that planned pregnancy is highly correlated with healthier

behaviors, more positive health attitudes, greater involvement in prenatal care, and higher levels of self-care practices to protect the health

of the baby (Cramer 1987). Conversely, failure to plan pregnancy is

associated with higher levels of depression, alienation, and powerlessness

(Groat and Neal 1967), which, as previously noted, are associated with

poorer health behaviors among women.

De La Rosa and colleagues (1990) reported that the prevalence of

drug use differs among Hispanic subgroups and that degree of acculturation influences rates of drug use in Hispanic populations. Puerto Ricans

and Mexican-Americans who were born in the United States and whose

primary language was English were most vulnerable to the use of illicit

drugs. Greater drug use by these groups may be related to higher rates

of poverty, limited school and employment opportunities, and racial

discrimination (De La Rosa et al. 1990). Drug use among younger

Hispanics is associated with acculturative stress, particularly loss of

identification with Hispanic culture. Historical differences between

Hispanic subgroups also may be related to differences in drug use patterns (De La Rosa et al. 1990).

Several studies have documented gender and ethnic differences in

the initiation, addiction, and treatment phases of narcotic drug use, and

findings suggest that male-female differences in drug use behavior are

more pronounced among Latinos than among other ethnic or cultural

groups. Gender differences in demographic and social characteristics

of narcotic users are generally consistent with those reported above;

however, shorter times from initiation of drug use to addiction have

been noted for Latinas, and they were more likely than other groups
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to use heroin (Anglin et al. 1987b). Both illicit and prescription drug use

may serve as forms of self-medication to cope with the stresses of acculturation among Latinas (Booth et al. 1991). Latino women who abuse

drugs have also been found to display lower self-esteem and self-efficacy

than black female drug users and to engage in more risk behaviors (Grella

et al. 1995).

Compared with white female narcotic users, Latinas are less likely

to be employed and more likely to receive welfare or disability payments.

Latinas also are more likely to come from single-parent, low-income

households and to report family dysfunction. These circumstances,

combined with lower educational achievement and a cultural milieu that

disapproves of drug use by women and of women working outside of the

home, encourage greater dependence on an addicted partner or on

welfare and disability payments (Anglin et al. 1988) and suggest that

Latinas who use drugs are significantly influenced by cultural gender

norms (Booth et al. 1991). Cultural differences in expectations regarding

women and their roles may also contribute to drug-dependent Latinas

becoming marginal persons, both to the larger white society and within

the Latino community (Anglin et al. 1988). Anglin and associates

(1987a) have concluded that although sex role conflicts, restricted job

opportunities, and other marginal attributes may influence female addicts

in general, their impact may be more severe on Latino addicts.

Response to drug treatment also differs by gender and ethnicity.

In general, a perceived need for treatment is higher among female drug

abusers, but women are more likely to perceive a need for treatment

on the basis of crisis events rather than degree of drug dependence

(Longshore et al. 1993). Black and Latino drug users are less likely to

report having been in drug treatment, Latino drug users are most likely to

report that they do not seek treatment because they do not need it, and

blacks are more likely to hold unfavorable views of treatment (Longshore

et al. 1992). Both blacks and Latinos may refuse treatment because it

may be viewed as a form of oppression that is associated with racism

(Longshore et al. 1993). Latino women often report pregnancy as a

reason for seeking drug treatment, but they are more likely to indicate

that treatment programs do not help them (Anglin et al. 1987a).

Finally, the importance of community-level social and environmental

risk factors to patterns of drug use has been observed. Community norms

regarding alcohol and other drug use and acceptance of drug use influence
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perceptions of its prevalence (Fitzpatrick and Gerard 1993). In a study

conducted by Lillie-Blanton and colleagues (1993), the availability of

drugs, community contacts with police, premature-death rates, mechanisms for coping with life stressors, distribution of wealth, and access

to social resources were related to drug use patterns. Ethnic differences

in illicit drug use did not persist after differences in these factors were

considered. The investigators concluded that neighborhood-level social

conditions were critical determinants of individual drug use among

ethnic minority groups.

These findings on factors related to drug use for women and ethnic

minority subgroups are important for several reasons. First, there is

consistency in the factors related to unhealthy lifestyle behaviors,

alcohol and tobacco use, and illicit substance abuse among women.

Psychological, ecological, and interpersonal variables are salient factors

related to risk behaviors among women, and relationships between these

variables and drug abuse by ethnic minority women, particularly Latinas,

are pronounced. Second, drug use is associated with involvement in

other unhealthy behaviors, although it is not clear whether they precede, accompany, or occur after drug addiction. Physical disability and

poor health are cited as primary reasons for discontinuing drug use for

some women (Longshore et al. 1993). Third, for some drug-abusing

women, pregnancy is a time of greater motivation to engage in healthier

behaviors, less drug use, and improved self-care practices. Fourth, for

ethnic minority women, the factors related to drug use are complex;

however, it appears that ethnic minority women experience and are

exposed to more of the factors related to unhealthy lifestyle behaviors

and alcohol, tobacco, and other drug use than other female drug users

and that psychological status and functioning may be more marginal

in these groups. Finally, some investigators have reported that trauma

and depression are important etiologic factors in women’s drug abuse

(Fullilove et al. 1992). It has been suggested that female drug users

experience a cycle of initiating drug use to relieve symptoms of depression or trauma, experiencing trauma in their efforts to secure drugs,

and relieving the new trauma by continuing to use drugs.
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STRATEGIES FOR HEALTH PROMOTION

INTERVENTION FOR WOMEN

An ecological approach to health intervention that focuses on

the environmental, cultural, and social correlates of health behaviors;

acknowledges the individual factors that contribute to health behaviors;

and utilizes social networks to effect behavior change has also been

emphasized in health promotion programs developed for women. Effective health promotion programs must identify and address the social,

cultural, psychological, and economic factors that influence women's

health behaviors and the lifestyle and cultural practices specific to the

health behaviors and communities that are targeted (Schorr 1990; Israel

1982, 1985; Thomas 1990). Cognitive approaches to health behavior

change, in the absence of attention to psychological, social, and cultural

determinants of health behaviors, may be ineffective in promoting

behavior change. Self-efficacy is an important predictor of health

behavior change by women; cooperative learning methods may

be highly effective in promoting behavior change, but knowledge is

a relatively poor predictor of behavior change (Hargreaves et al. 1989;

Vega et al. 1988; Amezcua et al. 1990, pp. 145-146; Schaefer et al.

1990). Successful intervention should be based in the community and

utilize naturally occurring social networks. Low-income, socially isolated women may profit most from health intervention programs that

address their immediate needs for companionship and mutual support

and provide them with methods of self-improvement (Lacey 1992).

In addition, in light of relationships between exposure to violence and

health behaviors among women (Sanders-Phillips 1994b, 1996a) and

data that show that low-income ethnic minority women are more likely

to experience traumatic events such as violence (Bell and Jenkins 1991),

health promotion programs for women must acknowledge the impact

of trauma and exposure to violence on risk behaviors.

Lay health advisers have been used successfully to promote behavior

change among women, especially ethnic minority women, and address

the social and cultural barriers to healthy behaviors (Amezcua et al.

1990, pp. 145-146; Hargreaves et al. 1989). The effectiveness of lay

health advisers in overcoming the cultural and social barriers to healthy

behaviors, in recruiting women to health promotion interventions,

and in increasing the health promotion behaviors of women has been

well documented (Salber 1979; Levine et al. 1992; Brownstein et al.
454

1992; Warnecke et al. 1975, 1976). The particular effectiveness of using

lay health advisers who are ethnically and demographically similar to

the target population and who conduct interventions in programs where

there is a shared sense of identity has also been stressed (Israel 1982,

1985; Warnecke et al. 1975). The use of indigenous, lay health advisers

operating in close-knit social networks may exert a greater social influence than those functioning in loose-knit programs that lack a common

identity or purpose (Israel 1985; Gottlieb 1981). The use of lay health

advisers in health promotion and intervention programs is also consistent with findings that women tend to turn to informal support systems

and other women for health advice and information (Schaefer et al.

1990; Warnecke et al. 1976; Neighbors and Jackson 1984; Leutz 1976).

For example, among low-income black women, the use of lay health

advisers is related to lower levels of depression, which in turn is related

to healthier behaviors (Rhodes et al. 1992; Cohen et al. 1991; Gottlieb

and Green 1987; Taylor et al. 1991). Lay health advisers may provide a

level of social support for women that is necessary for health behavior

change to occur (Israel 1985). The social support offered by lay health

advisers may reduce stress and increase coping skills (Salber 1979;

Gottlieb 1981; Hirsch 1981) as well as increase self-efficacy and perceived control over health outcomes (Hibbard 1985).

An ecological approach to intervention and treatment of drugabusing women has also been stressed. Longshore and colleagues (1993)

have concluded that special efforts may be needed to engage women,

particularly ethnic minority women, into treatment. This emphasis may

be especially important for clients who seek treatment because of family

pressure, legal coercion, or other external motivators. Engagement of

clients can be facilitated by the design of intake and referral services that

are culturally specific and appropriate and by the provision of staff

members who are ethnically compatible with the targeted group. Staffclient interactions may improve if staff members are bilingual and

trained to adopt interaction styles that are consistent with the cultural

group being served. In addition, closer ties should be established between treatment providers and community caregivers such as neighborhood health clinics, school programs, and churches. Nonprofessional

counselors may be recruited, and community-based resources should be

utilized as adjuncts or alternatives to formal treatment.
455

The development of trauma treatment services may also be an

integral component of drug treatment for women. Fullilove and colleagues (1992) have suggested that peer support to address experiences

of trauma may be a critical element in recovery for female addicts. A

focus on self-affirmation and self-efficacy in overcoming drug abuse

problems also may be needed in drug treatment. In addition, given the

unique influence of a male partner on drug use patterns among women,

intervention programs possibly should provide treatment for or solicit

the support of male partners in the treatment of women (Anglin et al.

1987a). Finally, treatment programs for female drug addicts may be

needed to capitalize on the motivation of pregnant addicts to improve

their health for the well-being of the baby. This may be a critical point

of intervention for effecting health behavior changes among drugabusing women.

SUMMARY AND CONCLUSIONS

Efforts to understand drug abuse by women, particularly women

in ethnic minority subgroups, and to develop successful programs of

intervention should be guided by previous findings regarding women’s

health behaviors and by knowledge of factors related to substance use

by women. In addition, programs of intervention for drug-abusing

women should be based on findings from previously developed health

promotion programs that have been effective in modifying other

health behaviors among women.

Baum and Grunberg (1991) have argued that use of cigarettes, alcohol, and illicit drugs should be viewed as coping behaviors for women.

Gender-based differences in the use of these substances may be related to

gender differences in perceptions of stress or in motivations to regulate

mood through substance use. Thus, women may be at greater risk for

coping with stress by altering behaviors that affect health (Baum and

Grunberg 1991). Increased understanding of the relationships between

stress and unhealthy behaviors practiced by women may be critical to

understanding the development of risk behaviors among women and

to the consequences of high stress for women.

The similarities in factors related to women’s risk behaviors highlight the common experiences and events that may precipitate risk

behaviors among women. Much of the previous research on drug abuse
456

among women appears to have assumed that women who use illicit drugs

differ considerably from other groups of women and that the factors that

influence drug use differ from factors that influence other risk behaviors.

The findings presented in this chapter contradict these assumptions and

support the conclusion that women’s risk behaviors may have common

etiologies. It is possible that the degree or nature of exposure to critical

events such as violence and trauma may distinguish women who use

illicit drugs from women who do not or that time of exposure to specific

events (e.g., trauma, violence) may contribute to a woman’s decision to

use illicit drugs and encourage a transition from other risk behaviors to

drug abuse. Future research will be needed to clarify the relationships

between these factors and women’s risk behaviors, but it appears that

both the healthy and unhealthy behaviors of women may be precipitated

by similar factors and that women’s drug abuse may be associated with a

pattern of unhealthy behaviors that is established before the onset of

drug abuse. In terms of future research, gender-specific models of health

behavior are needed that include rather than exclude women’s drug

abuse and that conceptualize drug abuse as a risk behavior that is related

to other risk behaviors. In addition, future research should focus on

identifying protective factors that may insulate a woman against progression along the continuum from unhealthy behaviors to drug abuse.

The increased rates of disease and disabilities among drug-abusing

women also suggest that programs of intervention for drug-abusing

women must provide comprehensive medical care and address other risk

behaviors in which drug-abusing women engage. A more comprehensive approach to health for drug-abusing women that does not focus

exclusively on drug abuse behavior but addresses the factors that promote unhealthy lifestyle behaviors, including drug abuse, may result in

better overall health outcomes and changes in drug abuse behavior.

The findings presented in this chapter also reaffirm the conclusion

that health behaviors, particularly for women, do not develop and occur

in a vacuum. Health and risk behaviors are significantly influenced by

the social and cultural environment and context in which they occur.

Efforts to address more global lifestyle behaviors, as well as drug abuse,

and to foster health behavior change should focus on these determinants

of women’s health and risk behaviors and incorporate them into program

planning. Perhaps the most important contribution from the public

health field to the study of drug abuse among women is the ecological
457

approach to health promotion. This approach not only acknowledges

the importance of effecting change in individual health behaviors but

also emphasizes the need to create health-promoting environments as

adjuncts to behaviorally oriented health promotion programs (Stokols

1992). The approach also assumes that individual health and risk

behaviors are influenced by both the physical and social environment

and that efforts to promote well-being should be based on an understanding of the dynamic interplay between environmental and individual factors. Social-ecological approaches to health promotion link

the communitywide, preventive strategies and epidemiologic orientation

of public health with the individual therapeutic and curative strategies

of medicine (Stokols 1992).

Drug abuse behaviors among women, particularly those of ethnic

minority groups, must be understood and addressed in terms of both the

personal characteristics that promote drug use and the ecological factors

such as community characteristics that also contribute to drug use,

regardless of individual characteristics (Lillie-Blanton et al. 1993).

An ecological approach suggests that interventions designed to promote

health behavior change and influence drug abuse behaviors may have to

be implemented at the microsocial, mesosocial, and macrosocial levels

(Taylor et al. 1991). At the microsystem level, the effects of life events,

social support, depressive symptoms, and poor health on women’s risk

behaviors suggest the need for programs to enhance coping skills,

improve social management skills, and encourage health promotion.

At the mesosystem level, the roles of religious orientation, internalized

racism, and socioeconomic status in promoting risk behaviors suggest

the need for church-based support and intervention, cultural programs

to replace negative racial stereotypes, and social-vocational programs

to improve educational and economic status. Macrosystem approaches

should include public and cultural policies that are supportive of the

microsystem and mesosystem interventions (e.g., public policies supporting job development, technical training, and full employment). As

McLeroy and colleagues (1992) have concluded, the goals of health

education should include not only changes in health-related behaviors

and health status but also changes in the capacity of individuals, networks, organizations, communities, and political structures to address

health problems.
458

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AUTHOR

Kathy Sanders-Phillips, Ph.D.

Associate Professor

Department of Pediatrics

School of Medicine

University of California, Los Angeles

5120 Goldleaf Circle, Suite 380

Los Angeles, CA 90056

(310) 216-7469 (Tel)

(310) 216-2773 (Fax)