Article

Intersectionality and Health: An Introduction

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Abstract

Theoretical and empirical efforts to understand and address disparities in health have emerged in multiple arenas and among scholars and practitioners working within public health, as well as scholars located in the social sciences and humanities. While these scholars all focus on understanding and eliminating health disparities, they bring diverse perspectives and insights to an understanding of the topic and to potential solutions. Yet there are relatively few opportunities for dialogue and mutual exchange across the disciplines and paradigms that inform this work. In this book, we have brought together an interdisciplinary group of scholars from the social sciences and public health to examine the ways that gender, race, and class are mutually constituted and interconnected. Our goal is to inform theory, research, and practice focused on the elimination of health disparities. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

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... Although most often talked about in relation to the oppressed (such as women, the poor, and people of color), race, class, and gender are part of the whole fabric of experience for all groups. These variables exist within interlocking hierarchies that create systems of privilege as well as of disadvantage (Andersen & Collins, 1995;Mullings & Schulz, 2006). The complexity of social relations, social issues, and social justice is infused with race, class, and gender (Andersen & Collins, 1995;Mullings & Schulz, 2006). ...
... These variables exist within interlocking hierarchies that create systems of privilege as well as of disadvantage (Andersen & Collins, 1995;Mullings & Schulz, 2006). The complexity of social relations, social issues, and social justice is infused with race, class, and gender (Andersen & Collins, 1995;Mullings & Schulz, 2006). These processes are dynamic and change by time and place, with individual vulnerability to oppression increasing to the degree that the interlocking systems of oppression increase. ...
... In addition to the suggestions implicit in the basic principles of CBPR, such as having community partners involved in all phases of the research process, the following set of recommendations, drawn from a variety of sources (Chávez et al., 2004;Duran & Duran, 1999;Jones, 2001;Omi, 2000;Mullings & Schulz, 2006;Spigner, 2000;Themba, 1999;Wallerstein, 1999), puts special emphasis on reducing racism and privilege in CBPR. ...
Chapter
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DANCING PROVIDES a provocative analogy for exploring the interplay of race and ethnicity, racism, and privilege that often goes unacknowledged in community-based participatory research (CBPR). Like dancing, CBPR has the potential for making research partners feel exhilarated, awkward, controlled, and free. The dance involves being aware of differences and respecting that although some people appear to be " natural " dancers, others need more time and instruction as they experiment with movement.
... This framework invites public health researchers to consider the health implications of overlapping social systems. Mullings and Schulz (2006) also describe how the implications of categories such as race, gender, and immigration status may vary with respect to one another. ...
... Instead, it suggests that there may be unique, emergent experiences at the intersection of multiple identities (Crenshaw, 1989;Mullings, 1997Mullings, , 2002Weber, 2006). Mullings and Schulz (2006) also describe how the interrelatedness of categories such as race, gender, and immigration status contributes to the production of inequalities in health outcomes. ...
Thesis
This dissertation investigates ways that racism, a system that oppresses some racial groups while privileging others, may shape relationships between education, citizenship, and health outcomes of migrants to France by comparing these relationships among groups of migrants likely to be racialized as white and as non-white. What makes this investigation both challenging and unique is its focus on France, which espouses a set of colorblind national policies, including the exclusion of racial identifiers from most datasets. This poses a methodological challenge for efforts to understand implications of racialization in the French context. It also presents an opportunity to investigate the relationship between racism and health in a context that explicitly aims to “not see race.” To manage this data environment, I used region of origin as a proxy to estimate migrants’ likelihood of being racialized as white or non-white. I explored whether racism weakened the education-health gradient and whether racism diminished the health benefit individuals received from their citizenship status. I developed a quantitative tool for measuring self-reported experiences of discrimination and explored the extent to which discrimination experiences play a role in the education-health relationship. Results are consistent with previously reported findings that educational attainment is associated with improved health status. They are consistent with the positive relationship that Fundamental Cause Theory posits between increased socioeconomic status and better health for all groups. However, the analysis also found evidence that migrants who are likely to be racialized as non-white may experience less health benefit from their educational attainment compared with migrants who are likely to be racialized as white. Analyses showed evidence that citizenship has a positive association with the self-rated health of migrants. Results from analyses assessing whether the association between citizenship and self-rated health were modified by racialization were not statistically significant. Nonetheless, a significant health disadvantage associated with racialization as nonwhite remained robust in these models after accounting for citizenship status. The positive relationship between citizenship and self-rated health was attenuated by the addition of a measure controlling for French language proficiency, suggesting that language proficiency may explain part of the relationship between citizenship and self-rated health. Finally, I psychometrically validated a discrimination experiences scale among migrants in France, showing that it was reliable and associated with self-rated health in the expected direction. Analysis found evidence that nonwhite migrants and men migrants report higher levels of discrimination experiences compared to their white and women counterparts, respectively. Analyses examined whether discrimination experiences play a role in relationships between racialization, educational attainment, and self-rated health. Findings indicated that higher educational attainment was associated with higher levels of discrimination experiences, the relationship between educational attainment and discrimination was stronger for nonwhites, and discrimination was associated with worse self-rated health. Associations between educational attainment and health remained robust after accounting for discrimination: Discrimination, as measured, influences health but does not explain diminished health benefits of education observed for migrants racialized as non-white in France. Findings presented in this dissertation are inconsistent with the idea that “colorblind” policies prohibiting the collection of data on racial identifiers can eradicate adverse health effects of social processes that racialize migrants. They are consistent with the idea that the eradication of racial health inequities will likely require action beyond eliminating state-defined racial identifiers, to encompass proactive intervention counteracting the social devaluation of nonwhite people.
... A teoria da interseccionalidade foi desenvolvida proeminentemente por investigadoras negras das ciências sociais, que enfatizaram a produção simultânea de desigualdades de raça, classe e género de tal forma que a medição da contribuição de apenas um fator seria difícil (Mullings & Schulz, 2006 (Mullings & Schulz, 2006). Por este motivo, decidiu-se estudar a influência do estatuto socioeconómico (ESE) nas expectativas de papel de género no contexto da dor, pois, para além das mulheres, outro grupo populacional que se encontra em risco são indivíduos de baixo estatuto socioeconómico (Azevedo et al., 2012). ...
... A teoria da interseccionalidade foi desenvolvida proeminentemente por investigadoras negras das ciências sociais, que enfatizaram a produção simultânea de desigualdades de raça, classe e género de tal forma que a medição da contribuição de apenas um fator seria difícil (Mullings & Schulz, 2006 (Mullings & Schulz, 2006). Por este motivo, decidiu-se estudar a influência do estatuto socioeconómico (ESE) nas expectativas de papel de género no contexto da dor, pois, para além das mulheres, outro grupo populacional que se encontra em risco são indivíduos de baixo estatuto socioeconómico (Azevedo et al., 2012). ...
Thesis
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Chronic pain affects 37% of the Portuguese population. However, it does not affect the individuals homogeneously and the groups that are most at risk are women and low-educated individuals. Thus, the purpose of this study was to understand how socioeconomic status (SES) influences gender role expectations in the context of pain, i.e., whether gender role expectations are different for women and men from various SES. A total of 227 individuals participated in this study (56.83% women), with an age average of 37.52 years (SD = 14.07). A mixed method approach was used to investigate the influence of SES on gender role expectations on pain (a) sensitivity; (b) tolerance; (c) willingness to express pain; and (d) coping strategies. Analysis of variance (ANOVA) concluded that there was a triple interaction effect between sex and SES of the person with chronic pain and participant’s sex on pain tolerance, but not on sensitivity or willingness to express pain. A content analysis followed by chi-square analyses identified an influence of SES on gender role expectations regarding pain coping strategies: (a) focused on activity, movement or posture; (b) seeking specialized support; (c) focused on environment/context; (d) physical/peripheral pain self-management; and (e) focused on engaging in pleasurable activities. In conclusion, a first step was taken in understanding the influence of SES on gender role expectations in the context of chronic pain, which contributes to a better understanding of the meanings and processes underlying potential social disparities in the pain assessment processes of others.
... These findings highlight the importance of understanding African American men's stress and coping patterns through an intersectional lens (Griffith et al., 2013a,b;Davis, 2008;Mullings and Schulz, 2006;Warner and Brown, 2011). African American men's lives, health, and behaviors are shaped by the intersection of at least two processes: male gender socialization (Courtenay, 2000b), the process by which men learn the gender and culturally ascribed behaviors that characterize masculinity in a particular society, and racial socialization (Stevenson, 1998), the process by which people's sense of racial identity is shaped by families and communities through oppressive and affirming experiences (Griffith, in press; Griffith et al., in press). ...
... Gathering information on African American women's perceptions about African American men's stress and coping in relation to their health is useful because, as a key member of their social network, these women often observe and support men under stress, influence men's perceptions about the acceptability of coping responses, and bring health issues to men's attention. Collecting this "shadowed data" from women adds to the richness of the narratives (Morse, 2001) and helps draw attention to the social contexts in which stress and coping occur. ...
... Yet most policy-makers, practitioners, and researchers tend to examine peoples' experiences through narrowly-defined lenses. For example, experiences of new immigrant women are often analysed through one-dimensional categories of race or gender (Mullings & Schulz, 2006). Such strategies simplify individual's realities and often are applied without critical analysis of power. ...
... When used as the only category of analysis, race is often simplified to mean individual characteristics and associated only with people who are racialised, both of which have the effect of masking the relational nature of systemic racism including white compliancy (Frankenberg, 1993;Mohanty, 2004;Mullings & Schulz, 2006). The implication for studying discrimination is that any one form of discrimination cannot be understood in isolation from other simultaneous and intersecting forms; in particular, racial discrimination should not be measured in a way that reduces discrimination to only individual characteristics or in ways that mask systemic and structural dynamics. ...
Article
Racial discrimination is primarily conceptualised and dealt with at the individual level in health research and practice. Most conceptualisations, and the measures which follow, are grounded in stress-coping theories thus reinforcing individual level understandings. This draws attention away from how structures and systems reproduce racial discrimination, and further supports the very racial categorisations upon which racism depends. The purpose of this paper is to discuss the relevance of critical theoretical perspectives in conceptualising racial discrimination and how it is taken-up and measured in health research. Drawing on Indigenous, Black and material feminist, intersectional, critical race, postcolonial and political economy perspectives, we propose that racial discrimination can most usefully be understood as a relational socio-historical concept. Racial discrimination understood at the systemic level in research and measurement will support more effective policies and practices to mitigate intersecting forms of discrimination in healthcare. Critical theoretical approaches to studying racial discrimination in health research could inform future analyses needed to address and limit the harms perpetuated through individual and structural forms of discrimination.
... Tout comme le fait le champ de recherche sur les déterminants de la santé, la perspective intersectionnelle tente de comprendre comment différents déterminants (le revenu et la situation sociale, l'emploi, les conditions de travail et le niveau d'instruction, par exemple) se croisent pour produire des effets atténuants ou aggravants pour la santé. Autrement dit, les études intersectionnelles en santé tentent de comprendre la façon dont la santé des individus est constituée par des forces structurelles (Mullings et Schulz, 2006). L'intersectionnalité peut venir combler des lacunes sur les connaissances de la santé des groupes marginalisés et de la population en général. ...
Article
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L’intersectionnalité renvoie à des expériences différenciées en fonction de l’articulation de multiples formes d’oppressions ou de privilèges. Le concept est également repris aujourd’hui pour l’étude des inégalités en santé, le plus souvent en se basant sur l’intersection de différents déterminants de la santé. Dans ce texte, l’auteure présente tout d’abord brièvement le concept d’intersectionnalité, puis fait le lien avec les déterminants de la santé. Pour ce faire, l’auteure aborde les raisons qui poussent les chercheur(e)s à se concentrer sur l’intersectionnalité dans le domaine des déterminants de la santé. L’article explique comment le fait de considérer l’articulation des inégalités en termes de « déterminants multiples » affecte la santé; ainsi que comment l’intersectionnalité peut combler des lacunes sur les connaissances de la santé des groupes marginalisés et de la population en général. De plus, l’auteure utilise l’exemple de l’allaitement maternel pour montrer de quelles manières le cadre d’analyse intersectionnelle pourrait être bénéfique pour l’avancement des connaissances sur un sujet précis. Pour conclure, l’auteure aborde les défis méthodologiques qu’ils restent à relever pour faire avancer les connaissances dans ce domaine.
... Central to these assertions was the dismissal of an essential or stable identity of Black, nor was there one of woman or lesbian; hence people's experiences cannot be separated and treated independently for each identity (Bowleg, 2008;Hankivsky, 2014). Instead, within an intersectionality framework, identities are understood as complex interweavings of positions of privilege and oppression, influenced by social structures and dominant public discourses (Bowleg, 2008;Collins, 1991;Mullings & Schulz, 2006). Intersectionality draws attention to the social structures that create inequality. ...
Article
While a significant health concern for sexual minority women, there is little qualitative research investigating their experiences of childhood trauma and suicidality. In this study, we used photovoice methods and an intersectionality framework. Drawing on qualitative interviews, we inductively derived three themes (a) Traumatized and discredited, (b) Cascading marginality, estrangement, and suicidality, (c) Reconstruction and reclaiming resilience. In Traumatized and discredited, we describe the sense of abandonment flowing from childhood trauma heightened by a lack of protection and neglect on the part of parents/guardians. The lack of support to deal with childhood trauma and the layering effects of marginality characterizes the theme Cascading marginality, estrangement, and suicidality. In the third theme, we discuss strategies for reconstruction and reclaiming resilience as participants worked to overcome these challenging experiences. Our study findings offer guidance to suicide prevention counseling programs for sexual minority women and affirm actions to address health inequities.
... Our results suggest that GRMs, the microaggressions BWLWH experience due to racism and sexism emerge as the most central factors that impact mental health outcomes both in the network analysis and follow up regressions. Poverty also intersects with racism and sexism and impact access to health care and health outcomes [93]. A comprehensive report by the Institute of Medicine showed that racially and ethnically minoritized groups have lower access to healthcare [94], and factors indicative of racism, sexism, poverty, and barriers to gainful employment significantly impact health outcomes creating hierarchies of health and illness [94,95]. ...
Article
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Black women living with HIV (BWLWH) face intersectional adversities impacting their wellbeing. This study utilized network analysis to assess the associations among adversities linked to racism, sexism, HIV stigma, and socioeconomic status (income, housing, education) and determine which adversities predict mental health outcomes, HIV viral load, and medication adherence more consistently among BWLWH. 119 BWLWH aged 18 years or older completed self-report measures on sociodemographics, adversity factors, and mental health outcomes. Viral load count was obtained through blood draws, and medication adherence was measured via Wisepill adherence monitoring device. Multiple regression analysis was used to assess if the more central factors in the network also predicted health outcomes more consistently than the less central factors. The four most central factors in the network were income, housing, gendered racial microaggression (GRM) frequency, and GRM appraisal. Multiple regression analysis revealed that GRM frequency, GRM appraisal, and the number of traumas contributed uniquely and were positively associated with both depressive symptoms and posttraumatic stress disorder symptoms. HIV-related discrimination contributed uniquely and was positively associated with HIV viral load.
... Intersectionality, as a theoretical and empirical framework (Collins & Bilge, 2016;Crenshaw, 1991;Hancock, 2007;McCall, 2005), has challenged public health researchers to consider how social determinants operate in terms of multiple interacting factors shaping health behaviors and outcomes. Public health scholars have argued (Bowleg, 2012;Hankivsky, 2012;Mullings & Schulz, 2006), and empirically demonstrated (Jackson, 2017;Jackson et al., 2016;Ray, 2017;Wemrell, Mulinari, & Merlo, 2017), that evaluation of health disparities along a single axis of inequality (i.e., gender or SES) can obscure important within-group variation; which could ultimately drive between-group disparities. Most public health research to date, drawing upon intersectionality, has examined disparities in terms of between-group variations (e.g., race/ethnicity, gender, sexuality, SES). ...
Article
Background and objectives: This study examined differences in waterpipe smoking (both lifetime and current) by race and ethnicity. More specifically, we evaluated intra-ethnic racial differences among Latinos using a nationally representative sample. Methods: Pooled data from the National Adult Tobacco Survey (NATS) [2012-2014] was used, in which Log-Poisson multivariable regression models were deployed to determine the prevalence of waterpipe smoking behavior. Models were stratified by gender and we further investigated acculturation, controlling for relevant sociodemographic characteristics. Results: In fully-adjusted models assessing lifetime WTS, Black Latinos and White Latinos exhibited an increase prevalence of lifetime WTS compared to their non-Hispanic white counterparts. Once stratifying by gender, Black Latino men (PR = 1.49; 95% CI = 1.16, 1.90) exhibited increased prevalence of lifetime WTS compared to their non-Hispanic white men counterparts; although white Latino men (PR = 0.88; 95% CI = 0.80, 0.98) exhibited decreased prevalence compared to their non-Hispanic white male counterparts. Similar trends were found for current WTS among men. In fully adjusted models assessing lifetime WTS, among women, only white Latina's (PR = 1.23; 95% CI = 1.04, 1.46) exhibited increased prevalence compared to their non-Hispanic white women counterparts. When evaluating current WTS, Black Latina's (PR = 2.19; 95% CI = 1.32, 3.65) and white Latinas (PR = 1.28; 95% CI = 1.00, 1.63) exhibited increased prevalence of WTS compared to their non-Hispanic white women counterparts. Conclusions/Importance: Among the U.S. general adult population, intra-ethnic racial differences in WTS behaviors exist among Latinos; and is shaped by gender. Future efforts to eliminate racial disparities in WTS should be attentive intra-ethnic racial differences among Latinos.
... In recent years, however, the limitations of this approach have been identified and analyzed from a number of different approaches. For example, Mullings and Schulz (2006) focused on issues of intersectionality and health. In 2012, Social Science and Medicine published a special issue on gender and health that included intersectional approaches. ...
... In this approach, I rely on a theory in which racial experience is thought of as bioculturally embodied differences. As discussed in the work of Benn Torres and Torres Colón (2021), racial experience conceptually draws on the work of Leith Mullins, who wrote about black feminist theories on intersectionality (Schulz & Mullings 2006), and borrows from philosophical theories on pragmatism (Torres Colόn & Hobbs, 2016). The general idea of using racial experience in this way is to incorporate and emphasize the fact that our understanding of race must extend beyond social constructivist perspectives, while acknowledging the complex dynamics between human biological variation and social identity. ...
... The research examining gender by race and class underscores the importance of intersectionality for understanding the impact of gender on mental health (Kohn & Hudson, 2002 ) . Intersectional approaches hold that different combinations of statuses have unique effects on outcomes (Jackson, 2005 ;Salazar & Abrams, 2005 ;Mullings & Schulz, 2006 ;Shields, 2008 ) . Analyses of race, class, or gender separately cannot fully describe individuals' experiences (Choo & Ferree, 2010 ;Constantine, Alleyne, Wallace, & Franklin-Jackson, 2006 ;Salazar & Abrams, 2005 ;Shields, 2008 ;Syed, 2010 ) . ...
Book
This second edition of the Handbook of the Sociology of Mental Health features theory-driven reviews of recent research with a comprehensive approach to the investigation of the ways in which society shapes the mental health of its members and the lives of those who have been diagnosed as having a mental illness The award-winning Handbook is distinctive in its focus on how the organization and functioning of society influences the occurrence of mental disorder and its consequences. A core issue that runs throughout the text concerns the differential distribution of mental illness across various social strata, defined by status characteristics such as gender, race/ethnicity, socioeconomic status, and age. The contributions to this volume shed light on the social, cultural, and economic factors that explain why some social groups have an elevated risk of disorder. They also address the social repercussions of mental disorder for individuals, including stigmatization within the larger society, and for their families and social networks. The second edition of this seminal volume includes substantial updates to previous chapters, as well as seven new chapters on: -The Individual’s Experience of Mental Illness.--The Medicalization of Mental Illness.---Age, Aging, and Mental Health.- -Religion and Mental Health.- -Neighborhoods and Mental Health.- -Mental Health and the Law—and Public Beliefs about Mental Illness.
... Therefore, in addition to Experiential Avoidance, we situate our research within the context of intersectionality, the point at which multiple social identities or social categories meet and interact with another social category 16-18for example, gender, race, age, and class. 19 One aspect of intersectionality, the intracategorical complexity approach, focuses on a disadvantaged or invisible group, that is "typically either a single category at a neglected point of an intersection of multiple master categories or a particular social setting or ideological construction or both." 16(p10) In this study, gender norms render male victims of sexual assault by female perpetrators invisible. ...
Article
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Objectives: To investigate whether forced sex of men by women was associated with sexual risk behaviors, and whether this association was mediated by substance use. Methods: Data from US men aged 18 years or older at interview in the National Survey of Family Growth 2006-2010 (n = 8108) who reported sexual behavior history. Outcome variables were condom use at most recent sex and number of lifetime sexual partners. Sexual activity covariates included age at first consensual sex and treatment of sexually transmitted infections. Alcohol and drug use were the mediating factors. Results: Six percent of men reported forced sex by a woman at a mean age of 18 years. On average, victimized men had 3 more lifetime sexual partners than nonvictimized men (P < .01). Furthermore, victimized men who reported drug use had, on average, 4 more female sexual partners (P < .01) than nonvictimized men. Marijuana (P < .05) and crack cocaine use (P < .05) partially mediated the association between forced sex and number of female partners. Neither condom use nor number of male partners differed between victimized and nonvictimized men. Conclusions: A nontrivial fraction of men experience forced sex by women; some of them have elevated sexual risk behaviors. (Am J Public Health. Published online ahead of print April 14, 2016: e1-e7. doi:10.2105/AJPH.2016.303136).
... Many scholars have called for the application of intersectionality theory to health inequalities in particular (Weber and Parra-Medina, 2003;Schulz and Mullings, 2006;Hankivsky and Christoffersen, 2008;Hankivsky et al., 2011). For instance, Weber and Parra-Medina (Weber and Parra-Medina, 2003) argue that intersectionality 'provides promising avenues for expanding our knowledge of health disparities and of identifying new ways of going about eliminating the persistent and pervasive social inequalities [. . ...
Article
Leisure-based physical activity is socially stratified in Canada. To date, inequalities in physical activity by race or ethnicity, gender, class or sexual orientation, in Canada and elsewhere, have largely been investigated as distinct, additive phenomena. Informed by intersectionality theory, this paper examines whether racial identity, gender, class and sexuality ‘intersect’ with one another to predict physical activity in data from Cycles 2.1 and 3.1 of the Canadian Community Health Survey (n= 149 574). In particular, we apply the intersectional principle of multiplicativity which suggests that people's experiences of their gender identities are raced, classed and sexualized; their racial experiences are gendered, classed and sexualized, and so forth. We find that the positive effect of income on being physically active is strong among visible minority men, of moderate strength among White men and women and weak to non-existent among visible minority women. We also find that a lesbian, gay or bisexual orientation corresponds with a higher likelihood of being physically active among women (especially among less educated women) but not among men. These multiplicative findings undermine additive approaches to investigating social inequalities in leisure-based physical activity and pave the way for future intersectional analyses of axes of inequality and their diverse, intersecting effects.
... Although stated before, it is important to underscore that people can and often do encounter different gender regimes as well as their intersectional constellations without moving abroad. For example and as Mullings and Schulz (2006, p. 5, emphasis in the original) have argued, Bthe very meaning of manhood may vary when applied to one's own racial group as compared to another group; similarly the meaning of a given racial category may vary for men and women.^ In short, social life is very contextual. ...
Article
Full-text available
Intersectional analyses represent an enormously important advance in understanding how people identify whether as individuals, families or other social groups. However, the overwhelming majority of research taking an intersectional approach to date is hampered by limiting its analysis to the confines of any given country. Such “domestic intersectionality” does not reflect the growing transnationalization of people’s lives and family matters given that over 200 million people now live outside the nation where they were born. A key objective of this article is to make a case explicitly for broadening intersectional analyses to the transnational scale. Moreover, the article argues that feminist analysis of families is greatly enhanced when their standpoints are examined simultaneously at multiple social scales including the intimate, local, national and transnational scales. Intersections of gender, class, ethnicity, race, nation, etc. can and typically do shift as we move across scales of analysis. Thus, a family who enjoys a privileged standpoint in their homeland community can, and often does, occupy a marginalized standpoint abroad, albeit marginalization vis-à-vis the society in the country of relocation and enhanced privilege concurrently in the home community. Within the same transnational family—indeed within any family—there will be variability in individuals’ standpoints as well. This article provides a blueprint for how such multi-scalar intersectional analyses can be accomplished and then executes it for one set of transnational families—Hindu Bengalis who conduct their family life between India and South Florida.
... Also, the Romani interviewers felt that the respondents could not distinguish easily between the items on the list of reasons due to a lack of distinct identities based on ethnicity, gender and religion. This is coherent with the theory of intersectionality, which suggests that the gender, ethnicity and poverty status of Romani women together form an identity making them vulnerable to discrimination (Mullings and Schulz 2005). ...
Article
Full-text available
Scales used to assess discrimination in public health research have rarely been validated outside of high income countries. Our objective was to validate the Experiences of Discrimination (EOD) scale and the Everyday Discrimination Scale (EDS) among 410 Romani women in Macedonia and Serbia. Romani female interviewers conducted interviews in 2012-2013. We used a multiple indicator multiple cause approach to test a one-factor model for each scale and to assess differential item functioning (DIF) by age, wealth, country, and education. We also measured associations between the EOD and EDS with smoking in the past year and psychological distress. Three items of the EOD were conceptually irrelevant. Two items of the EDS were not conditionally independent. DIF was found by country for one item in each scale. After excluding these items, all scales exhibited good model fit and were associated with smoking (EOD beta = 0.40, 95 % CI = 0.18, 0.63; EDS beta = 0.33, 95 % CI = 0.12, 0.54) and psychological distress (EOD beta = 0.26, 95 % CI = 0.15, 0.37; EDS beta = 0.26, 95 % CI = 0.04, 0.47). Discrimination scales can be adapted for use among Romani women and are associated with both smoking and psychological distress.
... In addition, these nine NHs tended to be located in poorer communities within metro areas, where non-White individuals are more likely to live. This finding provides some support to the role of geographical segregation as the reason for racial differences, claimed by some as the driver of racial inequality in NH care (Smith et al., 2008), although it may also reflect institutional and interpersonal bias not captured by our data (Mullings & Schulz, 2006). ...
Article
The aim of this study is to investigate racial differences in nursing home (NH) residents' quality of life (QOL) at the resident and facility levels. We used hierarchical linear modeling to identify significant resident- and facility-level predictors for racial differences in six resident-reported QOL domains. Data came from the following: (a) resident-reported QOL (n = 10,929), (b) the Minimum Data Set, and (c) facility-level characteristics from the Minnesota Department of Human Services (n = 376). White residents reported higher QOL in five of six domains, but in full models, individual-level racial differences remained only for food enjoyment. On the facility level, higher percentage of White residents was associated with better scores in three domains, even after adjusting for all characteristics. Racial differences in QOL exist on individual and aggregate levels. Individual differences are mainly explained by health status. The finding that facility racial composition predicts QOL more than individual race underscores the importance of examining NH structural characteristics and practices. © The Author(s) 2015.
... The research examining gender by race and class underscores the importance of intersectionality for understanding the impact of gender on mental health (Kohn & Hudson, 2002 ) . Intersectional approaches hold that different combinations of statuses have unique effects on outcomes (Jackson, 2005 ;Salazar & Abrams, 2005 ;Mullings & Schulz, 2006 ;Shields, 2008 ) . Analyses of race, class, or gender separately cannot fully describe individuals' experiences (Choo & Ferree, 2010 ;Constantine, Alleyne, Wallace, & Franklin-Jackson, 2006 ;Salazar & Abrams, 2005 ;Shields, 2008 ;Syed, 2010 ) . ...
Chapter
Men and women experience different kinds of mental health problems. While women exceed men in internalizing disorders such as depression and anxiety, men exhibit more externalizing disorders such as substance abuse and antisocial behavior, which are problematic for others. These differences also vary by race and social class: for example, African Americans possess better mental health and, thus, a smaller gender gap in psychiatric problems. What explains these differences? We concentrate on conceptions of gender and gender practices. Research on gender and mental health suggests that conceptions of masculinity and femininity affect major risk factors for internalizing and externalizing problems, including the stressors men and women are exposed to, the coping strategies they use, the social relationships they engage in, and the personal resources and vulnerabilities they develop. This chapter investigates explanations in these areas for gender differences both in general and by race and class.
... In this special issue, rather than comparing cases across the continent, we focus on one country: Ghana. In line with intersectional approaches (Mullings and Schulz 2006), this allows us to consider differences that are constructed less along the lines of national borders or culture than through the intersection of structures of inequality, such as gender, age, socioeconomic circumstances, and access to social networks and healthcare. Our focus on Ghana enables us to show how social and economic changes occurring on a global scale are played out on the ground for a variety of conditions requiring care at different stages of the life course within particular urban and rural locales, while allowing for comparison and contrast with other settings. ...
Article
With the rise of noncommunicable diseases such as diabetes and cancer, as well as increased longevity, the role of the family in care has increasing importance in health policy and interventions globally. In low-income settings in sub-Saharan Africa, where health and welfare systems are under-resourced, task shifting to community health workers, volunteers, and family members is sometimes proposed to fill the gaps; however migration, urbanization, and widening social inequality have had profound effects on household structure and the capacity for care. This special issue focuses on Ghana, a country that exemplifies these processes. The contributing articles examine the impact of social, structural, and economic changes on practices of family care for a variety of conditions across the life course in urban and rural locations.
... In its 2003 report titled Unequal Treatment, the US Institute of Medicine (IOM, now the National Academy of Medicine) concluded that implicit bias against members of a social group may negatively affect communication or the care offered to those individuals (IOM, 2003). Structural bias, which is defined by Schulz and Mullings (2006) as the "privileging [of] some groups and denying others access to the resources of society," can also result in significant health disparities (quoted in Yearby, 2011, 87). ...
Chapter
This chapter draws on medical, social, and legal perspectives to identify and highlight ethical issues pertaining to the treatment, representation, and inclusion of persons with disabilities in public health policy and practice. A brief history of disability in the United States is provided as a context for examining the key ethical issues related to public health policy and practice. Conceptual frameworks and approaches to disability are then described and applied. The chapter then discusses the imperativeness of expanding access to public health programs by persons with disabilities, the need to address implicit and structural biases, and the importance of including persons with disabilities in public health decision-making.
... Thus, the notion of 'underclassism' does not imply that oppressive social relations are created or sustained along singular axes. From an intersectional perspective, multiple forms of vulnerability stemming from material conditions, racialisation, or gendered inequities (among others) are experienced simultaneously, in ways that are mutually reinforcing and continually shifting depending on context (Mullings and Schulz 2006;Weber 2006;Hulko 2009;Browne et al. 2011b;Hankisvky 2011). Similarly, the notion of 'underclassism' cannot be understood in isolation from other simultaneous and intersecting forms of social position and locations, which converge to fundamentally structure and sustain complex power relations and unjust social hierarchies. ...
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In this article, we draw on findings from an ethnographic study that explored experiences of healthcare access from the perspectives of Indigenous and non-Indigenous patients seeking services at the non-urgent division of an urban emergency department (ED) in Canada. Our aim is to critically examine the notion of 'underclassism' within the context of healthcare in urban centres. Specifically, we discuss some of the processes by which patients experiencing poverty and racialisation are constructed as 'underclass' patients, and how assumptions of those patients as social and economic Other (including being seen as 'drug users' and 'welfare dependents') subject them to marginalisation, discrimination, and inequitable treatment within the healthcare system. We contend that healthcare is not only a clinical space; it is also a social space in which unequal power relations along the intersecting axes of 'race' and class are negotiated. Given the largely invisible roles that healthcare plays in controlling access to resources and power for people who are marginalised, we argue that there is an urgent need to improve healthcare inequities by challenging the taken-for-granted assumption that healthcare is equally accessible for all Canadians irrespective of differences in social and economic positioning. © 2015 The Authors. Sociology of Health & Illness © 2015 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd.
... Specifically, the ways in which race, social class, and sexual identity are gendered operate to produce a unique social location and differential health outcomes (Collins, 2019). The combinations of these social locations are innumerable depending on the social determinants of concern as race and gender could be 'classed' or gender and class could be 'raced' (Mullings & Schulz, 2006). ...
Article
Contemporary scholars have applied intersectionality as a means of capturing the complex ways in which identity, inequality, and social justice converge to manifest unique sources of strength and vulnerability. Given the increase in the use of this term, the aim of this study was to systematically and comprehensively examine the application of intersectionality in the fields of family science and family therapy from 2010 to 2020. Through the use of content and thematic analysis, we examined trends and variations in how scholars operationalized and applied the principles of intersectionality. Findings suggest that intersectionality remains underutilized and underdefined. Moreover, intersectionality was primarily concentrated in theoretically driven articles and was least prevalent in articles focused on addressing a specific clinical topic or need or research methods. These findings suggest that, although the use of intersectionality is expanding, its applicability in empirical, and especially clinically focused, scholarship remains an area of growth and opportunity.
... Much of the research on racial and ethnic disparities in BF foci is from the perspective of medical, academic, and other professionals and rarely reflects thoughts, attitudes, or ideas from African American women about what they feel might best support BF. Because African American women experience significant barriers to BF such as an unequal elevated burden of disease and illness (Mullings, 2006; Williams, 2000), occupational segregation with inflexible work environments (Smith-Gagen, Hollen, Walker, Cook, & Yang, 2014), shorter maternity leave (Spencer & Grassley, 2013), and less social support, our research practices were designed to highlight these unique challenges facing African American pregnant and postpartum women and to understand what psychosocial strategies and resources are needed to increase BF initiation and duration. ...
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This case study details one aspect of a qualitative research program developed as part of a 2-year postdoctoral translational research program designed to inform readers of socially contextualized issues associated with disparate breastfeeding outcomes. The case sheds light on unique challenges in using focus group study design particularly in the context of a community environment and with a population whose unique socio-historical experiences oftentimes negatively affect the ability to engage them successfully in research protocols. The research goal was to identify potential strategies for an intervention that support breastfeeding behavior in African American women and infants. Focus groups are considered an effective approach to achieve these goals for its power to help design interventions that address social and health needs of African American women and children. African American women experience the lowest rates of breastfeeding compared with other groups and yet represent little of the current perspective or “voice” that espouses breastfeeding recommendations for engaging them. Earlier work applies a social ecological framework to characterize African American mothers’ breastfeeding challenges as a result of intersections between macro-level factors (media, public policy, and legislation) and micro-level factors (community, neighborhood, and workplace). This work often fails, however, to engage with African American women about their contextualized life challenges and to shed light on what these women think about designing culturally appropriate research and intervention programs that enhance breastfeeding among African American women.
... The copyright holder for this preprint this version posted April 17, 2021. This study leverages an intersectional approach [29,30] to measure disparities in both COVID-19 mortality and excess all-cause mortality. Thus, we stratified our analysis by place and sociodemographics -as reflected across age, sex, race, and ethnicity. ...
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Importance: Tracking the direct and indirect impact of the coronavirus disease 2019 (COVID-19) pandemic on all-cause mortality in the United States has been hindered by the lack of testing and by reporting delays. Evaluating excess mortality, or the number of deaths above what is expected in a given time period, provides critical insights into the true burden of the COVID-19 pandemic caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Stratifying mortality data by demographics such as age, sex, race, ethnicity, and geography helps quantify how subgroups of the population have been differentially affected. Similarly, stratifying mortality data by cause of death reveals the public health effects of the pandemic in terms of other acute and chronic diseases. Objective: To provide stratified estimates of excess mortality in Colorado from March to September 2020. Design, Setting, and Population: This study evaluated the number of excess deaths both directly due to SARS-CoV-2 infection and from all other causes between March and September 2020 at the county level in Colorado. Data were obtained from the Vital Statistics Program at the Colorado Department of Public Health and Environment. These estimates of excess mortality were derived by comparing population- adjusted mortality rates in 2020 with rates in the same months from 2015 to 2019. Results: We found evidence of excess mortality in Colorado between March and September 2020. Two peaks in excess deaths from all causes were recorded in the state, one mid-April and the other at the end of June. Since the first documented SARS-CoV-2 infection on March 5th, we estimated that the excess mortality rate in Colorado was two times higher than the officially reported COVID-19 mortality rate. State-level cumulative excess mortality from all causes reached 71 excess deaths per 100k residents (~4000 excess deaths in the state); in contrast, 35 deaths per 100k directly due to SARS-CoV-2 were recorded in the same period (~1980 deaths. Excess mortality occurred in 52 of 64 counties, accounting for 99% of the state's population. Most excess deaths recorded from March to September 2020 were associated with acute events (estimated at 44 excess deaths per 100k residents and at 9 after excluding deaths directly due to SARS-CoV-2) rather than with chronic conditions (~21 excess deaths per 100k). Among Coloradans aged 14-44, 1.4 times more deaths occurred in those months than during the same period in the five previous years. Hispanic White males died of COVID-19 at the highest rate during this time (~90 deaths from COVID-19 per 100k residents); however, Non-Hispanic Black/African American males were the most affected in terms of overall excess mortality (~204 excess deaths per 100k). Beyond inequalities in COVID-19 mortality per se, these findings signal considerable regional and racial-ethnic disparities in excess all-cause mortality that need to be addressed for a just recovery and in future public health crises.
... Where a person lives, is as important as who they are in terms of health [64][65][66]. Geography, culture, context, health and place [12] especially income, education, relations, beliefs and infrastructure/ attitudes/ leisure have different meanings attached to life and in a given place [20,67]. In Kalangala, Kulya sente kivubi meant living in the moment and for the moment. ...
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Background The study set out to give an in-depth intersection of geo, eco-socio exposition of the factors relating to geography, healthcare supply and utilization in an island setting. This analysis is informed by what has emerged to be known as social epidemiology. We provide in-depth explanation of context to health care access, utilization and outcomes. We argue that health care delivery has multiple intersections that are experientially complex, multi-layered and multi-dimensional to the disadvantage of vulnerable population segments of society in the study area. Methods We used a cross-sectional qualitative exploratory design. Qualitative methods facilitated an in-depth exploration and understanding of this island dispersed and peripheral setting. Data sources included a review of relevant literature and an ethnographic exploration of the lived experiences of community members while seeking and accessing health care. Data collection methods included in-depth interviews (IDI) from selected respondents, observation, focus group discussions (FGDs) and key informant interviews (KII). Results We report based on the health care systems model which posits that, health care activities are diverse but interconnected in a complex way. The identified themes are; the role of geography, access (geographical and financial) to health services, demand and utilization, Supplies, staffing and logistical barriers and a permissive and transient society. When and how to travel for care was beyond a matter of having a health need/ being sick and need arising. A motivated workforce is as critical as health facilities themselves in determining healthcare outcomes. Conclusion Geography doesn’t work and affect health outcomes in isolation. Measures that target only individuals will not be adequate to tackle health inequalities because aspects of the collective social group and physical environment may also need to be changed in order to reduce health variations.
... There are three basic tenets of intersectionality, as explained by Weber (2006): contextually specific social constructions, multi-level power relations, and simultaneity. First, intersectionality is not concerned with biological identities (e.g., race or gender); rather, the construction of such identities through historical and social systems (Mullings & Schulz, 2006). Second, intersectionality explores how social relationships are influenced by power at the macro (i.e., policies and laws) and micro (i.e., individual relationships) levels (Weber, 2006). ...
Article
All individuals deserve an equitable opportunity to achieve a good death. Unfortunately, access to end-of-life care and services is largely unequal on the basis of race, gender, class, and other social identities. We need to understand how individuals with multiple marginalized identities face different access in attaining a good death and use this knowledge to bring equity to end-of- life care. The conceptual framework for this argument derives from intersectionality theory and the existing disparities in end-of-life care. This argument sheds light on the relationship between intersectionality and a good death, demonstrated by a case vignette, and suggests that the more marginalized social identities one has, the more difficult their access to a good death. Because it is particularly important to both recognize and actively combat these inequities, I offer three practical strategies for end-of-life researchers and practitioners. For the sake of our increasingly diverse population, advancements in end-of-life care must be made to facilitate a good death for all.
Article
We examined the association between racial/ethnic minority segregation and low birth weight (LBW) in Chicago and Toronto communities. While previous work has documented the importance of contextual effects on LBW, these studies have usually been conducted within a single city. We used Pearson correlation coefficients and OLS regression models to examine potential variability in the association between racial/ethnic minority segregation and LBW in Chicago (N = 77 communities) and Toronto (N = 140 communities). Results indicate that racial/ethnic minority segregation, unemployment, and low educational attainment are not associated with LBW in Toronto, while these indicators have strong and significant associations with LBW in Chicago. In a combined model with data from both cities, a 10% increase in minority composition is associated with a 0.5% increase in LBW, controlling for the effects of unemployment and low educational attainment. Stratified models show that this effect is only significant in Chicago, and subsequent models revealed opposite effects for percentage non-Hispanic Black and percentage Hispanic. Future research should consider additional cities for comparative analysis. Such work could test the notion that Chicago and Toronto represent opposite sides of a spectrum, reflecting variability in how social determinants map on to public health outcomes. Future research should also examine the significant heterogeneity observed in highly segregated communities, particularly in Chicago.
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Mattering, defined as synergistic experiences of feeling valued and adding value, is a psychosocial construct with underappreciated pragmatic potential. It has explanatory relevance across disciplines, domains of life, and social contexts. It is also both parsimonious and far-reaching in uniting areas of concern relevant to community psychologists and the needs, values, and goals of diverse communities. Nevertheless, it has received limited attention in the community psychology (CP) literature. This dissertation will develop and provide empirical support for an ecological understanding of mattering suited to community research and practice. Empirical support is furnished in three studies using large, representative U.S. samples. The first evaluates a novel multidimensional measure of mattering (MIDLS), providing evidence of MIDLS’ validity as a bifactor measure of general and domain-specific mattering. The second study provides evidence of differences between demographic groups in domain-specific mattering. Finally, covariance-based structural equation modeling (CB-SEM) is used to assess the relationships between multidimensional mattering, fairness, and well-being in six life domains. Findings suggest that mattering fully mediates the relationship between fairness and well-being for all domains investigated except economic well-being. Taken together, these studies show that mattering can be conceived and assessed in multidimensional terms; that doing so can yield novel insights; and that mattering has unique value as an organizing construct which helps map the relationship between key community psychology values and outcomes. The dissertation concludes with a discussion of key limitations and implications as well as next steps for a program of research which can actualize the pragmatic potential of multidimensional mattering for community research and practice.
Article
Background Identifying social determinants of health has become a priority for many researchers, health care providers, and payers. The vast amount of patient and population-level data available on social determinants creates, however, both an opportunity and a challenge as these data can be difficult to synthesize and analyze. Methods Medicare beneficiaries who underwent 1 of 4 common operations between 2013 and 2017 were identified. Using a machine learning algorithm, the primary independent variable, surgery social determinants of health index, was derived from 15 common, publicly available social determents of health measures. After development of a surgery social determinants of health index, multivariable logistic regression was used to estimate the association of this index with textbook outcomes, as well as the component metrics of textbook outcomes. Results A novel surgery social determinants of health index was developed with factor component weights that varied relative to their impact on postoperative outcomes. Factors with the highest weight in the algorithm relative to postoperative outcomes were the proportion of noninstitutionalized civilians with a disability and persons without high school diploma, while components with the lowest weights were the proportion of households with more people than rooms and persons below poverty. Overall, an increase in surgery social determinants of health index was associated with 6% decreased odds (95% confidence interval: 0.93–0.94) of achieving a textbook outcome. In addition, an increase in surgery social determinants of health index was associated with increased odds of each of the individual components of textbook outcome; ranging from 3% increased odds (95% confidence interval: 1.03–1.04) for 90-day readmission to 10% increased odds (95% confidence interval: 1.09–1.11) for 90-day mortality. Further, there was 6% increased odds (95% confidence interval: 1.05–1.07) of experiencing a complication and 7% increased odds (95% confidence interval: 1.06–1.07) of having an extended length of stay. Minority patients from a high surgery social determinants of health index had 38% lower odds (95% confidence interval: 0.60–0.65) of achieving a textbook outcome compared with White/non-Hispanic patients from a low surgery social determinants of health index area. Conclusion Using a machine learning approach, we developed a novel social determents of health index to predict the probability of achieving a textbook outcome after surgery.
Article
Background and Objectives This study examined the relationship between number of attributed reasons for everyday discrimination and all-cause mortality risk, developed latent classes of discrimination attribution, and assessed whether these latent classes were related to all-cause mortality risk among US older Black women. Research Design and Method Participants were from the 2006 and 2008 waves of the Health and Retirement Study (N = 1133; 335 deaths). Vital status was collected through the National Death Index through 2013 and key informant reports through 2019. Latent Class Analyses were conducted on discrimination attributions. Weighted Cox proportional hazards model were used to predict all-cause mortality. Analyses controlled for demographic characteristics, socioeconomic status, and health. Results Reporting greater attributions for everyday discrimination was associated with higher mortality risk (HR = 1.117; 95% CI: 1.038 – 1.202; p <.01), controlling for demographic characteristics, socioeconomic status, and health as well as health behaviors. A four-class solution of the Latent Class Analysis specified the following attribution classes: No/Low Attribution; Ancestry/Gender/Race/Age; Age/Physical Disability; High on All Attributions. When compared to the No/Low Attribution class, membership in the High on All Attributions class was associated with greater mortality risk (HR = 2.809; CI: 1.458 – 5.412; p < .01). Discussion and Implications Findings underscore the importance of everyday discrimination experiences from multiple sources in shaping all-cause mortality risk among older Black women. Accordingly, this study problematizes the homogenization of Black women in aging research and suggests the need for health interventions that consider Black women’s multiplicity of social statuses.
Article
Personality science is the study of the individual. It aims to understand what makes people similar to others, different from some, and unique to themselves. However, there is room for research in personality to more thoughtfully consider culture, race, and ethnicity in order to better understand individual differences in people’s patterns of thinking, feeling, and behaving. High impact personality journals rarely include such factors into the interpretation of results, and cross-cultural and ethnic minority publications are limited within the discipline. This article offers a brief, non-exhaustive overview of how culture, race, and ethnicity are examined in relation to personality, showing that: (1) social structures continue to be neglected in the research, (2) we can learn from research being conducted in neighboring areas, and (3) valuable work is already being done within personality psychology. We offer recommendations that emphasize community based participatory research methods, combined etic-emic approaches, and contextualizing research findings to improve the consideration of culture, race, and ethnicity in personality research.
Article
Equity remains poorly conceptualised in current nutrition frameworks and policy approaches. We draw on existing literatures to present a novel Nutrition Equity Framework (NEF) that can be used to identify priorities for nutrition research and action. The framework illustrates how social and political processes structure the food, health and care environments most important to nutrition. Central to the framework are processes of unfairness, injustice and exclusion as the engine of nutrition inequity across place, time and generations, ultimately influencing both nutritional status and people's space to act. The NEF illustrates conceptually how action on the socio-political determinants of nutrition is the most fundamental and sustainable way of improving nutrition equity for everyone everywhere, through ‘equity-sensitive nutrition’. Efforts must ensure, in the words of the Sustainable Development Goals, that not only is “no one left behind” but also that the inequities and injustices we describe do not hold anyone back from realising their right to healthy diets and good nutrition.
Article
This commentary offers additional considerations for better understanding and studying how women of color detect and respond to prejudice in the United States. Building on the thoughts raised by Remedios and Snyder (2015), we highlight the importance of considering the socio-cultural and historic factors that differentially impact how sub-groups of women of color are perceived. Rather than generalizing work on stigma and discrimination across the diverse group of women of color, we discuss the importance and benefits of examining subgroups individually. In this commentary therefore, we pose research questions about three additional bodies of literature that add to Remedios and Snyder’s (2015) ideas regarding experiencing stigma. First, we examine how stereotypes of subgroups of women of color differ. Next, we introduce other work in the field of intersectionality, e.g. gendered race, to argue that differences in the ways women of color are perceived may affect how they experience identity centrality, discrimination, and other identity-related processes. Finally, we provide empirical evidence highlighting the concept of intersectional invisibility as an additional form of felt discrimination.
Article
Purpose – This chapter discusses health disparities among African Americans living in urban spaces within the United States. Approach – This chapter provides an overview of health disparities in morbidity and mortality related to maternal and child health (maternal mortality rate, infant mortality, and low birth weight). Practical implications – This chapter describes research and interventions that strive to increase our ability to understand and reduce health disparities. Eliminating health disparities not only is beneficial to these affected groups but also offers the opportunity to improve the health of the entire U.S. population. Originality/value – This chapter adds to our understanding of the correlates of health disparities for African American women and children as well as successful interventions that have proven effective in ameliorating these disparities.
Article
Our understanding of gender carries significant bioethical implications. An errant account of gender-specific disease can lead to overgeneralizations, undergeneralizations, and misdiagnoses. It can also lead to problems in the structure of health-care delivery, the creation of policy, and the development of clinical curricula. In this volume, Cutter argues that gender-specific disease and related bioethical discourses are philosophically integrative. Gender-specific disease is integrative because the descriptive roles of gender, disease, and their relation are inextricably tied to their prescriptive roles within frames of reference. An integrative account of gender-specific disease carries ethical implications because our understanding of gender-specific disease is evaluative, and our evaluations of gender-specific disease entail judgments concerning the praiseworthiness and blameworthiness of a clinical event. Cutter supports a "both/and" emphasis on context and integration in relation to gender-specific disease and bioethical analyses. While the text mainly focuses on gender-specific diseases that affect women, Cutter also includes examples involving men, children, and members of the LGBT community.
Chapter
Nutritional, hormonal, and other aspects of the gestational and infancy environments have effects on biology and metabolism that persist into adulthood to influence risk for cardiovascular, metabolic and other diseases of aging. These effects are examples of developmental plasticity, which involves modified growth of organs and tissues and durable epigenetic changes that influence gene expression. In this chapter, we first review the evidence linking early environments to adult health, including discussion of underlying developmental and epigenetic mechanisms and their possible evolutionary function. We then explore the applicability of these principles to two public health problems: the rapid rise of chronic diseases in lower and middle income nations, and the persistent health disparities within societies that map onto social categories such as race or class. The developmental processes reviewed here show how buffering infants and pregnant women from social and nutritional stressors could help promote healthy aging in future generations.
Article
Objective: Research on social determinants of health in India has focused largely on the independent influence of education, gender, and region. Using an intersectionality framework in this study, we examine the combined effects of these three key social locators on the critical, yet underexamined outcome of later life functional health. Method: We use data from Wave 1 (2007–2010) of the Study of Global Ageing and Adult Health (SAGE) ( N = 7,150) to examine whether the effects of education on functional limitations differ by gender in six highly heterogenous regions of India. Results: The effects of education on functional limitations were significantly greater (β = .026, p < .001) for men than women. Consistent with established regional differences in economic development, cultural practices, and political context, this relationship varied across locales. Discussion: Our findings highlight the need to move beyond independent sources of heterogeneity in examining later life functional health in the global South.
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Background: Racial discrimination may increase the risk of low birthweight (LBW), but has not been studied among Roma, the largest minority population in Europe. Moreover, few studies test both institutional and interpersonal forms of racial discrimination on health. Our objective was to examine associations between institutional and interpersonal racial discrimination with LBW, and to test potential mediation by smoking during pregnancy. Methods: In 2012-2013, Romani women interviewers surveyed 410 Romani women in Serbia and Macedonia. We measured institutional discrimination (neighborhood segregation, legal status of housing and neighborhood socioeconomic status), interpersonal discrimination [Everyday Discrimination Scale (EDS)], birthweight and smoking by self-report or interviewer report. We estimated relative risks for discrimination on LBW and separately on smoking during pregnancy using log-binomial regression, adjusting for age, parity, years at residence and wealth. Results: The indirect effect of high EDS via smoking on LBW was estimated using inverse odds weighting mediation. Living in a low SES neighborhood showed a 2-fold risk of LBW [adjusted risk ratio (aRR) = 2.4, 95% CI = 1.2, 5.0]; aRRs for segregation and illegal housing were weaker (aRR = 1.8, 95% CI = 0.7, 4.3; aRR = 1.3, 95% CI = 0.6, 2.6, respectively). Institutional measures were not associated with smoking. High EDS was associated with LBW (aRR = 2.4, 95% CI = 1.1, 5.2) and smoking during pregnancy (aRR = 1.4, 95% CI = 1.1, 1.8); the indirect effect of EDS on LBW via smoking was not significant. Conclusion: Interpersonal discrimination and living in a low SES neighborhood were associated with LBW among Roma. Interventions to improve Romani health may benefit from a human rights approach.
Chapter
Black men who have sex with men (MSM) have been severely affected by HIV burden in the United States. A multitude of epidemiologic, structural, and psychosocial factors has contributed to the disparate HIV incidence and prevalence rates of black MSM. The objective of this chapter is to better understand the prevention, care, and treatment considerations for black MSM. Thus, this chapter examines (1) theoretical approaches to HIV prevention with a specific focus on the role of stigma, marginalization, and structural inequalities in black MSM communities; (2) factors associated with disproportionate HIV infection rates and HIV sexual behavior in black MSM; (3) the role of primary and secondary prevention in black MSM communities; (4) culturally congruent treatment and care in black MSM communities; and (5) psychosocial support and mental health needs in black MSM communities.
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El presente libro nace con el objetivo de aportar a la discusión sobre los retos que el estudio de la Epidemiología tiene en un contexto global en el que 193 países miembros de la Organización de las Naciones Unidas (ONU), organizaciones de la sociedad civil y otras partes interesadas, acordaron “Transformar nuestro mundo: la Agenda 2030 para el Desarrollo Sostenible" (1), como un plan de acción en favor de las personas, el planeta, la prosperidad, la paz y las alianzas, mismo que entró en vigor el primer día de enero de 2016. La Epidemiología en su origen, se concibió como una rama de las ciencias médicas para tratar epidemias, o controlar enfermedades epidémicas sumamente infecciosas (cólera, peste, viruela, y más) y, con el tiempo, ha contribuido también a controlar enfermedades no transmisibles como el cáncer, las enfermedades cardiovasculares y los trastornos genéticos, entre otras. Su comprensión ha permitido intervenir antes de que se declare la enfermedad, es decir, sonar alarmas previo a que sea demasiado tarde y, ayudar a los altos funcionarios a formular estrategias para su solución (2). No obstante, el avance progresivo del concepto de salud, ha permitido pasar de no sólo la prevención de enfermedades infecciosas y no transmisibles, a considerar a la salud como un estado de bienestar físico, mental y social integro. Más recientemente, la salud se inscribe como un derecho humano, cuyo enfoque implica la no discriminación, la disponibilidad de los bienes y servicios públicos de salud, así como la accesibilidad, calidad, universalidad y rendición de cuentas (3), en un medio ambiente sano.
Article
Differences in coping within the African American population are not well understood, yet these differences may be critical to reducing stress, improving health, and reducing racial health disparities. Using a descriptive, exploratory analysis of the Jackson Heart Study (N = 5301), we examine correlations between coping responses and associations between coping and demographic, socioeconomic, psychosocial, and neighborhood factors. Overall, coping responses were not strongly correlated and patterns of associations between covariates and coping responses were largely inconsistent. The results suggest that coping varies substantially within this African American population and is driven mainly by psychosocial factors such as spirituality and interpersonal support. Understanding these complex relationships may inform strategies by which to intervene in the stress process to mitigate the effects of stress on health and to identify vulnerable subgroups of African Americans that might need targeted interventions to reduce exposure to stressors and improve coping capacities.
Article
Black women have elevated rates of multiple physical illnesses and conditions when compared to White women – disparities that are only partially explained by socioeconomic status (SES). Consequently, scholars have called for renewed attention to the significance of racism-related stress in explaining Black-White disparities in women's physical health. Drawing on the biopsychosocial model of racism as a stressor and the intersectionality perspective, this study examines the extent to which SES and racism-related stressors – i.e., discrimination, criminalization, and adverse neighborhood conditions – account for disparities in self-rated physical health and chronic health conditions between Black and White women. Results indicate that Black women have lower SES and report greater exposure to racism-related stressors across all domains. Moreover, I find that SES and racism-related stressors jointly account for more than 90% of the Black-White disparity in women's self-rated physical health and almost 50% of the Black-White disparity in chronic health conditions. Theoretical and policy implications of these findings are discussed.
Article
Compared to their HIV-seropositive male counterparts, HIV-seropositive women are less likely to achieve and retain viral suppression (VS). Data regarding the social, behavioral, clinical, and structural factors that facilitate or impede viral suppression among HIV-seropositive women is needed. This study aims to examine HIV-seropositive women's perceptions regarding factors that contribute to their HIV treatment decisions. Two case studies describe the HIV treatment decision-making of two never suppressed, HIV-seropositive women aged 65 and 54. The framework method of analysis was employed to obtain a descriptive overview of three interrelated areas of inquiry: (1) the meanings women give to VS; (2) social, behavioral, clinical, and structural obstacles related to HIV medication adherence; and (3) women's perceptions of what they need to achieve and sustain (VS). The meaning of VS for both women is influenced by how they currently feel. Women's general feeling of wellness detracts from any sense of urgency that may be associated with engaging in HIV treatment. Mistrust of medical providers and unstable housing/unemployment pose as obstacles to medication adherence. Finally, women's accounts of what they need to achieve and remain virally suppressed are influenced by a gap in understanding related to HIV treatment. HIV clinicians should routinely measure their patients' HIV health literacy to ensure patients understand when to begin and why they should continue an HIV treatment regimen. To increase their capacity to provide appropriate HIV care, providers should take into consideration how patients' life experiences and social locations influence their HIV treatment decision-making.
Article
During the Jim Crow era of 1877 to 1954, the federal government sponsored and supported the racially separate and unequal distribution of resources, including, but not limited to, education, housing, employment, and healthcare. On May 14, 1954, the Supreme Court ruled in Brown v. Board of Education that separate and unequal education violated the Constitution because separate is inherently unequal. Many believed that this ruling, the Civil Rights Acts of 1957, 1960, 1964, 1968, and the Voting Rights Act of 1965 would put an end to the unequal treatment of African Americans in the United States. However, inequalities still exist today because the ruling and the laws did not change the structures of the United States. Specifically, structural racism prevents African Americans from obtaining equal access to resources such as wealth, employment, income, and healthcare, resulting in racial disparities in health. Because racial disparities between African Americans and Caucasians are the most studied in the United States, this article will focus exclusively on how structural racism continues and causes racial inequalities between African Americans and Caucasians in wealth, employment, income, and healthcare, which lead to racial disparities in access to healthcare and health status.
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Many studies have demonstrated the existence of simple, unidimensional socioeconomic gradients in body mass index (BMI). However, in the present paper we move beyond such traditional analyses by simultaneously considering multiple demographic and socioeconomic dimensions. Using the Spanish National Health Survey 2011–2012, we apply intersectionality theory and multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to analyze 14,190 adults nested within 108 intersectional strata defined by combining categories of gender, age, income, educational achievement and living situation. We develop two multilevel models to obtain information on stratum-specific BMI averages and the degree of clustering of BMI within strata expressed by the intra-class correlation coefficient (ICC). The first model is a simple variance components analysis that provides a detailed mapping of the BMI disparities in the population and measures the accuracy of stratum membership to predict individual BMI. The second model includes the variables used to define the intersectional strata as a way to identify stratum-specific interactions. The first model suggests moderate but meaningful clustering of individual BMI within the intersectional strata (ICC = 12.4%). Compared with the population average (BMI = 26.07 Kg/m2), the stratum of cohabiting 18-35-year-old females with medium income and high education presents the lowest BMI (-3.7 Kg/m2), while cohabiting 36-64-year-old females with low income and low education show the highest BMI (+2.6 Kg/m2). In the second model, the ICC falls to 1.9%, suggesting the existence of only very small stratum specific interaction effects. We confirm the existence of a socioeconomic gradient in BMI. Compared with traditional analyses, the intersectional MAIHDA approach provides a better mapping of socioeconomic and demographic inequalities in BMI. Because of the moderate clustering, public health policies aiming to reduce BMI in Spain should not solely focus on the intersectional strata with the highest BMI, but should also consider whole population polices.
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There has been increasing interest in collaborative approaches between the environmental justice (EJ) and reproductive justice (RJ) movements to address the higher burden of toxic exposures and associated reproductive health outcomes in vulnerable communities. This study examined the collective action frames (CAFs) of advocates at the EJ/RJ nexus. CAFs highlight how advocates identify problems and solutions, and motivate action. The use of intersectionality was identified as a main CAF used in three key ways: breaking free from identity-based, issue-based, and movement-based siloes. First, interviewees described breaking free from identity-based siloes by identifying risks of toxic exposures that result from intersecting social locations (e.g. gender, race/ethnicity, income, immigration status) and by equally prioritizing multiple aspects of their identities as they engage in advocacy. Second, they described breaking free from issue-based siloes by developing multi-issue agendas that address a complex web of interrelated problems impacting health. Third, they described breaking free from movement-based siloes by developing cross-movement collaborations to address issues of mutual concern. Among multiple reasons given for cross-movement collaborations, advocates perceived them as valuable in order to disrupt social, political, and economic power imbalances that shape environmental reproductive health inequities, as well as other health and social inequities. Based on these findings, we suggest that intersectionality is a master frame, and thus may be useful to advocates in other social movements addressing intersectional issues. Understanding an intersectionality frame can help to inform advocacy approaches to promote health and health equity, particularly those focused on policies and structural drivers of health.
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In the United States, nursing is the largest healthcare profession, with over 3.2 million registered nurses (RNs) nationwide and comprised of mostly women. Foreign‐trained RNs make up 15 percent of the RN workforce. For over half a century, the U.S. healthcare industry has recruited these RNs in response to nurse shortages in hospitals and nursing homes. Philippines‐trained RNs make up 1 out of 20 RNs in this country and continue to be the largest group of foreign‐trained nurses today. Recently, the news media has publicized the many deaths of Filipino RNs as a result of the COVID‐19 pandemic in the United States. Given the imperial historical ties between these two countries in the context of the nursing profession and the enduring labor inequities that persist, this nationally representative study is one of the few to our knowledge to not only quantitatively examine the current work differences in characteristics and experiences of Philippines‐trained RNs and U.S.‐trained white RNs practicing in the United States today, but to also do so from an intersectionality lens. The overall aim of this paper is to illuminate how these differences may serve as potential factors contributing to the disproportionate number of Filipino nurses' COVID‐19 related vulnerability and deaths in the workplace. This article is protected by copyright. All rights reserved.
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Purpose of the study: Few existing studies have addressed racial/ethnic differences in the health and quality of life of lesbian, gay, bisexual, and transgender (LGBT) older adults. Guided by the Health Equity Promotion Model, this study examines health-promoting and health risk factors that contribute to racial/ethnic health disparities among LGBT adults aged 50 and older. Design and methods: We utilized weighted survey data from Aging with Pride: National Health, Aging, and Sexuality/Gender Study. By applying multiple mediator models, we analyzed the indirect effects of race/ethnicity on health-related quality of life (HRQOL) via demographics, lifetime LGBT-related discrimination, and victimization, and socioeconomic, identity-related, spiritual, and social resources. Results: Although African Americans and Hispanics, compared with non-Hispanic Whites, reported lower physical HRQOL and comparable psychological HRQOL, indirect pathways between race/ethnicity and HRQOL were observed. African Americans and Hispanics had lower income, educational attainment, identity affirmation, and social support, which were associated with a decrease in physical and psychological HRQOL. African Americans had higher lifetime LGBT-related discrimination, which was linked to a decrease in their physical and psychological HRQOL. African Americans and Hispanics had higher spirituality, which was associated with an increase in psychological HRQOL. Implications: Findings illustrate the importance of identifying both health-promoting and health risk factors to understand ways to maximize the health potential of racially and ethnically diverse LGBT older adults. Interventions aimed at health equity should be tailored to bolster identity affirmation and social networks of LGBT older adults of color and to support strengths, including spiritual resources.
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Drug testing is widely used and employed in diverse contexts, including drug treatment clinics. Building on previous research, this paper aims to (i) compare self-report data and oral fluid (OMT) testing in detecting drug use amongst individuals beginning a new episode of drug treatment and (ii) identify factors that may predict drug users who have discordant self-report and OMT test results. Two hundred and seventy-one new drug treatment clients completed a structured questionnaire that included questions relating to drug use during the preceding 3 days and provided an oral fluid sample that was independently tested for opiates, benzodiazepines, methadone and cannabis. Data were analysed using kappa statistics (Cohen, 1960) and univariate and multivariate logistic regression. Findings indicated a high level of consistency between self-reported drug use and OMT testing. However, agreement varied by drug type and respondents commonly reported consumption that screening failed to identify. Inconsistencies appeared to relate to a number of factors and were not necessarily a function of deliberate distortion by the drug user. Overall, it is concluded that OMT testing is a good indicator of the validity and reliability of drug users' self-report data. Nonetheless, its accuracy might be greater for some drug categories than for others. Equally, further study comparing test results and self-reported drug use amongst different populations and in different contexts is required.
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The present study assessed drug use and the validity of self-reports of drug use among young people seeking treatment. On admission the participants (n = 316), 215 males and 101 females, were interviewed about their drug use. Urine samples were collected to screen for alcohol, amphetamine, benzodiazepines, cannabis, cocaine, methylenedioxymethamphetamine (MDMA) and opiate use. Self-reports of substance use were compared with urinalysis results. Seventy-three percent of the participants reported use of two or more substances. Single substance users were primarily alcohol users. Kappa agreement between self-report and urinalysis results was of acceptable concordance (> or = 0.65) except for alcohol (kappa = 0.19). Conditional kappa values were good (> or = 0.85) with exception of opiates (cond. kappa = 0.57). The self-reports were generally reliable among young people seeking treatment. No significant differences (p > or = 0.54) were found in the validity of self-reports between the genders.
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Understanding the long-term course of problematic drinking is a fundamental concern for health services research in the alcohol field. The stability of, or change in, the course of drinking--especially heavy drinking--has both theoretical and applied relevance to alcohol research. We explore the application of latent class growth modeling to 5 years of survey data collected from dependent and problem drinkers--some not in treatment at baseline--in an attempt to uncover prototypical longitudinal drinking patterns. Results indicated that five profiles of drinkers can be used to represent their longitudinal course of alcohol consumption: early quitters (N = 88), light/non-drinkers (N = 76), gradual improvers (N = 129), moderate drinkers (N = 229), and heavy drinkers (N = 572). Significant baseline factors included ASI drug severity, dependence symptoms, and marital status. Attendance at AA meetings, the size of one's heavy drinking and drug using social network, past treatment, receiving suggestions about one's drinking, and contacts with the medical system were significant influences. The size of heavy drinking and drug using social networks was noticeably larger for the heavy drinkers. Findings also support the usefulness of a semi-parametric latent group-based approach as a tool for analyzing alcohol-related behaviors.
Misuse and abuse of legal and illegal drugs constitute a growing problem among older adults. This article reviews the prevalence, risks and protective factors, and screening and diagnosis of drug abuse in older adults. Treatment concerns and the consequences of drug problems are examined briefly. MEDLINE and PsychInfo were searched using the terms substance-related disorders, drug-use disorders, abuse, dependency, opioid-related disorders, stimulant-related disorders, cocaine-related disorders, marijuana-related disorders, and withdrawal syndrome. The review included articles published in English between January 1, 1990, and May 31, 2006. Despite a wealth of information on the epidemiology and treatment of alcohol abuse in older adults, few comparable data are available on drug abuse in this population. The evidence suggests that although illegal drug use is relatively rare among older adults compared with younger adults and adolescents, there is a growing problem of the misuse and abuse of prescription drugs with abuse potential. It is estimated that up to 11% of older women misuse prescription drugs and that nonmedical use of prescription drugs among all adults aged > or =50 years will increase to 2.7 million by the year 2020. Factors associated with drug abuse in older adults include female sex, social isolation, history of a substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential. No validated screening or assessment instruments are available for identifying or diagnosing drug abuse in the older population. Special approaches may be necessary when treating substance-use disorders in older adults with multiple comorbidities and/or functional impairment, and the least intensive approaches should be considered first. Psychoactive medications with abuse potential are used by at least 1 in 4 older adults, and such use is likely to grow as the population ages. The treatment of disorders of prescription drug use in older adults may involve family and caretakers, and should take into account the unique physical, emotional, and cognitive factors of aging. Further research is needed on the epidemiologic, health services, and treatment aspects of drug abuse in older adults, as well as the development of appropriate screening and diagnostic tools.