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Public Health


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Public health, epidemiology, structural inequalities, complex interactions, gender, poverty, health insurance, marriage, colon cancer, survival, health care reform, social policy


Objectives. Long-term colon cancer survival is not well explained by main effects. We explored the interaction of age, gender, marital status, health insurance and poverty on 10-year colon cancer survival.

Methods. California registry data were analyzed for 5,776 people diagnosed from 1995 to 2000; followed until 2014. Census data classified neighborhood poverty. We tested interactions with regressions and described them with standardized rates and rate ratios (RR).

Results. The 5-way interaction was significant, suggesting larger 4-way disadvantages among non-Medicare-eligible people. A significant 4-way interaction was a 3-way interaction in non-high poverty neighborhoods only. Private insurance was protective for unmarried men (RR = 1.60) but not women, while it was protective for married women (RR = 1.22) but not men. This pattern seemed explained by lower-incomes of certain groups of unmarried women and married men and more prevalent underinsuring of unmarried men.

Conclusions. Structural inequities related to the institutions of marriage and health care seem to affect women and men quite differently. Policy makers ought to be cognizant of such structural imbalances as future reforms of American health care are considered.



Funding Reference Number

CIHR grant no. 67161-2


First published in Public Health,

Copyright The Royal Society for Public Health