Daily hassles' role in health seeking behavior among low-income populations.

Several hazardous health behaviors such as smoking, unhealthy diet, and physical inactivity are associated with negative health outcomes and are disproportionately prevalent among low income or other traditionally underserved pop-ulations.1-4 Among these same populations, performance of preventive health behaviors is low and delay in seeking medical care is not uncommon.5-8 This contributes to poorer self-rated health, less frequent healthcare utilization, and poorer health outcomes in low-income populations.4 A large body of literature exists that highlights low income or low socioeconomic status (SES) as the “fundamental” contributor to health inequalities.9,10 Often, low-income, underinsured, and uninsured patients can find lower-cost care in a “safety-net” healthcare setting, health centers that primarily serve underinsured, Medicaid, and uninsured patients. However, whereas financial access to preventive health services may alleviate some of the barriers for low-income populations, studies in other countries show that even with universal health services free of charge, inequalities along the socioeconomic gradient persist in preventive health seeking behaviors and health outcomes.11,12 This adds to the complexity of determinants of health in low-income populations. Although there are a number of factors related to screening behaviors in low socioeconomic status populations, stress, particularly that associated with SES, has been poorly studied in relation to preventive care. Literature has postulated that consideration of stressors and strains provides a contextual link among socioeconomic disadvantage, low levels of preventive health behaviors, and negative health outcomes. This literature6,13-16 suggests that people who experience socioeconomic disadvantage also experience higher frequencies of stressful events and have fewer resources to ameliorate this stress. This may include large-scale life events but also daily events that contribute to overall stress levels. Measuring daily stress, or daily hassles, and understanding their impact on health is challenging, and many measures of hassles were developed in more economically advantaged populations. For example, the Daily Inventory of Stressful Events was initially introduced during the National Study of Daily Experiences in a population that was mostly white and had completed some college or higher education.17 Also, while shown to be a valid measure of daily stressors, the Daily Hassles scale was similarly developed and introduced in relatively advantaged populations with high education and income levels. Such measures may not capture hassles that are more commonly experienced by socioeconomically disadvantaged populations, such as finding resources for basic daily needs. Time and resources dedicated to struggling to meet basic needs may compete against those needed for things like preventive care. Thus, there is a need to examine these measures in socioeconomically disadvantaged populations to maximize their utility in understanding the association between hassles and health. Finding appropriate measures of hassles will be important in understanding how they interfere with preventive care and health maintenance and will help researchers identify strategies and targets for successful interventions, or to understand why previous interventions may have been less successful. There are several potential explanations for how daily hassles can affect preventive health care. Some research suggests that individuals who continually face daily hassles or stress react more rapidly to situations (“reactive responding”), thus, reducing resources available for planning for the future or scheduling health activities such as cancer screening or seeking other preventive health care.13 Others suggest that as SES decreases, stressors and demands (to meet basic needs) increase, creating a cycle of lacking adequate resources to deal with such life obstacles.14 Both of these propose that while individuals are busy attending to stressors or hassles, they are less likely to actively promote their own health. This concept is especially relevant to preventive health behavior performance, as there may not be acute “cues” (ie, symptoms) to place it higher than other priorities. The consequence is that after delay, services like screening may detect health issues at later, more advanced stages, which then require more personal time and resources to be addressed. Accordingly, identifying the hassles that impede timely screening, and helping individuals access care despite those hassles could lead to opportunities for prevention, earlier detection, and reduced burden from cancer. In this formative mixed-methods multi-phase study, we sought to: (1) examine common daily hassles in a low income population to inform an adapted hassles scale measure and then (2) measure the relationship between common daily hassles and preventive health behavior performance as well as health status.