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Income Disparity Tied to Differences in Behavioral, Psychological Health of Midlife Women

Key findings

  • This analysis, intended to be preliminary and hypothesis-generating, compared 14 publicly insured perimenopausal women with 19 women of similar age, race/ethnicity, education, marital status and menstrual patterns
  • Considerably higher percentages of publicly insured women were current cigarette smokers, reported former illicit substance use, reported not exercising and were obese
  • Publicly insured women also fared significantly worse on measures of mood and sleep quality
  • Stratifying differences in behavioral and psychological characteristics by income may help tailor preventive screenings and health care interventions for vulnerable populations of perimenopausal women

The changes that women experience at midlife can negatively affect quality of life and overall functioning well into the postmenopausal years. These include not just shifts in sex hormones and reproductive functioning, but also changes in personal, family and professional responsibilities.

Nurse-researchers Kirsten A. Dickins, PhD, FNP-C, and Sara E. Looby, PhD, ANP-BC, of the Munn Center for Nursing Research at Massachusetts General Hospital, have found that socioeconomic status may relate to behavioral and psychological health characteristics commonly observed during perimenopause. In Menopause, they note that a better understanding of these relationships may give insight into which women are at high risk of adverse health outcomes.

Study Methods

This preliminary study was intended to be hypothesis-generating. It was a secondary analysis of a study by the authors, also published in Menopause, that compared menopause symptoms and psychological health in 66 perimenopausal women (45–52 years old) with and without HIV. The subjects in the current analysis were 33 women without HIV.

Cohort Characteristics

14 women (42%) were enrolled in public health insurance, which was used as a proxy for low income. Those enrolled in public health insurance were similar to the comparison group with regard to age, race, ethnicity, education, marital status, number of menstrual periods in the previous year, and use of antidepressant and antianxiety medications. Body mass index (BMI) was significantly higher in low-income women.

Behavioral Health

Low-income women were significantly more likely than the comparison group to:

  • Be current cigarette smokers—71% vs. 21%; P = 0.004
  • Have a history of substance abuse—79% vs. 5%; P < 0.0001
  • Have BMI ≥30—50% vs. 11%, P = 0.01

Low-income women were less like to be current exercisers (57% vs. 89%; P = 0.03).

Psychological Health and Sleep

Low-income women had significantly worse mood and sleep scores than the comparison group:

  • Depressive symptoms—Score on the Center for Epidemiologic Studies Depression scale (CES-D), 13.5 vs. 6 (P < 0.0001)
  • Anxiety—Score on the Generalized Anxiety Disorder 7-item scale (GAD-7), 5.5 vs. 2 (P = 0.04)
  • Sleep—Score on the Insomnia Severity Index (ISI), 11 vs. 5 (P = 0.004)

CES-D scores were just below the cutoff for clinical depression, GAD-7 scores indicated mild anxiety (versus minimal anxiety in the comparison group), and ISI scores suggested subthreshold insomnia (versus no clinically significant insomnia in the comparison group).

Understanding the Link Between Economic Inequality and Disparate Health Outcomes

Early detection and intervention of suboptimal lifestyle behaviors might serve as an opportunity to support low-income women to engage in health-promoting behaviors, facilitating improved health into post-menopause and throughout aging.

Scores on the mood and sleep measures were marginally abnormal, but they could progressively worsen in response to hormonal changes throughout and beyond the menopause transition. Those findings suggest two strategies:

  • Provide training opportunities for women's health clinicians on how to screen and address psychological health inequities in socioeconomically vulnerable perimenopausal women
  • Create collaborative opportunities with low-income women designed to raise awareness of the adverse impact that hormone changes can have on mood and sleep, promote care engagement, and enhance self-monitoring and reporting of any health concerns

The authors plan further research to understand the ways in which socioeconomic status influences health outcomes in midlife women and how disparities can be effectively and sustainably addressed.

of low-income perimenopausal women were current cigarette smokers

of low-income perimenopausal women had a history of substance abuse

of low-income perimenopausal women were classified as obese, while 57% of low-income perimenopausal women reported current exercise

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