1. Women’s Health Disparities Among Border Populations Francisco A. R. García, MD, MPH, FACOG Distinguished Outreach Professor Public Health Obstetrics & Gynecology Mexican-American Studies Pharmacy

2. US-Mexico Border 2000 miles2000 miles 100 km strip on either side of international boundary100 km strip on either side of international boundary 4 US and 6 Mexican states4 US and 6 Mexican states 44 US counties & 80 Mexican municipios44 US counties & 80 Mexican municipios 12.2 M people border region12.2 M people border region 800,000-1.1M legal border crossing every day800,000-1.1M legal border crossing every day

3. US-Mexico Border

4. US Border Communities 7.2 M individuals (3.1M in 1970) 44 US counties 3 of 10 poorest counties 2 of 10 fastest growing metro areas 5 of 7 poorest metro areas 25 tribal communities

5. Hispanic Immigrants in the US Hispanics make up 15 percent of total US population (64% of Mexican descent). Foreign-born Mexicans are the largest immigrant group in the US. >11.5 million Mexican immigrants in the US (30.7%) of all US immigrants. Immigrants beginning to settle in non-traditional areas.

6. Women in Border Communities Mexican origin 51% population < 15y ( 23% v 19%) > 45y (36% v 40%)

7. Women in Border Communities 18% below FPL (9% US) More likely to live in poverty compared to men (18 v 14%) 27% uninsured (17%)* 29% women v 33% men 1 of 3 reside in HPSAs * National comparison www.borderhealth.org

8. Women in Border Communities; 2009 BRFSS AllWhite, NHHispanics (non-border) Hispanics (border) Insured86%91%68%61% Did not see clinician due to cost 16%13%29%30% Routine Check-up Last Year 73%74%68%59% Poor Health5%4%6%8%

11. Adults with Diabetes in Border Communities by Race/Ethnicity, 2007

12. Reproductive Health 41% reproductive age Fertility rate 2.5 (2.1*) 123k births/year Adolescent preg 5% (3.4) Lower LBW and VLBW

13. Cancer Among Women in Border Communities

14. Age Adjusted Cervical Ca Mortality, 2003-2005

15. Invasive, age-specific cervical cancer incidence (per 100,000 women) Coughlin. Cancer 2008.

16. AZ Cervix Cancer Mortality 2001-2004 Courtesy of T Flood, AZ DHS

17. Hispanic Cervical Cancer Mortality 1990-2006 (SEER) Rate per 100,000 Hispanic Females Counties are not shown if < 5 cases

18. Women in Border Communities; 2009 BRFSS AllWhite, NHHispanics (non-border) Hispanics (border) Mammo, ever65%68%51% Mammo, 24 mo82%81%83%78% Pap, ever93%94%89%90% Pap, 24 mo83%82%88%83%

19. Cancer Screening in Border Communities:BRFSS1999-2000 Never PapPap >3 years HispanicNon-HispanicHispanicNon-Hispanic Border Counties14.9%3.8%26.4%11.7% Non-Border Counties8.7%5.4%16.7%15.4% US8.7%5.3%15.9%15.0% S. Coughlin. Fam Community Health 2003 Factors Positively Associated with Pap <3 years: Younger age, non- Hispanic ethnicity, lower parity, non-rural residence, physician visit past year & insurance.

20. Yuma Project Cross-sectional population based study (n=504) Post menopausal (>50) women in Yuma County Mexican-born, US-born Hisp, White/Non-Hisp Cancer screening & utilization Garcia & Nuno Pap <1 year a Pap <3 years a n=504 N%OR95%CIOR95%CI Visited Provider Last 12 Months No (ref)7415%1.0 Yes42585%5.82.3-14.94.31.9-9.6 Provider Recommendation Neither (ref)13527%1.0 Pap smear7415%3.31.9-5.76.03.4-10.6 Both29258%3.72.0-6.87.63.8-15.1

21. Behavioral Risk Factors

22. Adult Current Tobacco Use in Border Communities BRFSSUSWhiteHisp(Exc) Hisp (Border) Ever Smoke37%42%22%18%

23. Adult Alcohol Consumption in Border Communities, 2007

24. Women in Border Communities; 2009 BRFSS AllWhite, NHHispanics (non-border) Hispanics (border) Fruit (3+/d)15%14%18%21% Veg (3+/d)18% 15%13%

26. Mortality Among Women in Border Communities, 2005

27. Leading Causes of Death in Border Communities, 2005

28. Positive Variance WhiteUS-HispMex-Born Hysterectomy63%44%39% Fam h/o breast cancer24%14%12%

29. Considerations for Future Research in Border “Disparities” Disparities provide opportunities to improve biological/behavioral insight into health and disease Focus on “positive outliers” & strengthening protective factors in communities Access though the major contributor to disparities, will not solve the problem Solutions to be sustainable and realistic must be “native” and arise organically from communities Disease and health are not bounded by international borders

30. Reducing Women’s Health Disparities in Border Communities Informed women Access to health care Aware providers Good data Enlightened policy makers

31. Francisco Garcia, MD, MPH 520 626 8539 fcisco@u.arizona.edu

32. Hispanics in the US