SSM -Population Health ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 1 Contents lists available at ScienceDirect 2 3 4 SSM -Population Health 5 6 journal homepage: www.elsevier.com/locate/ssmph 7 8 9 Article 10 11 12 (En)gendering racial disparities in health trajectories: A life course and 13 Q2 intersectional analysis 14 a,b,n c 15 Q1 Liana J. Richardson , Tyson H. Brown 16 a 17 Department of Sociology, University of North Carolina at Chapel Hill, 155 Hamilton Hall, CB #3210, Chapel Hill, NC 27599-3210, USA b 18 Carolina Population Center, 206 W. Franklin Street, CB #8120, Chapel Hill, NC 27516-2524, USA c Department of Sociology, Vanderbilt University, 315 Garland Hall, PMB 351811, Nashville, TN 37235-1811, USA 19 20 21 article info abstract 22 23 Article history: Historically, intersectionality has been an underutilized framework in sociological research on racial/ 24 Received 28 September 2015 ethnic and gender inequalities in health. To demonstrate its utility and importance, we conduct an in- 25 Received in revised form tersectional analysis of the social stratification of health using the exemplar of hypertension—a health 26 28 April 2016 condition in which racial/ethnic and gender differences have been well-documented. Previous research Accepted 29 April 2016 27 has tended to examine these differences separately and ignore how the interaction of social status di- 28 mensions may influence health over time. Using seven waves of data from the Health and Retirement 29 Keywords: Study and multilevel logistic regression models, we found a multiplicative effect of race/ethnicity and 30 Race gender on hypertension risk trajectories, consistent with both an intersectionality perspective and per- Gender sistent inequality hypothesis. Group differences in past and contemporaneous socioeconomic and be- 31 Health inequalities havioral factors did not explain this effect. 32 Intersectionality & 33 Life course 2016 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 34 35 67 68 36 37 Introduction To demonstrate the utility and importance of an intersectional 69 70 38 approach to longitudinal research on health disparities, we use the 39 Q5 Stratification scholars widely acknowledge that social status exemplar of hypertension. In the U.S., hypertension is the leading 71 72 40 dimensions, such as race/ethnicity, gender, and socioeconomic cause of cardiovascular disease and a major contributor to high 41 status (SES), structure lived experience by constraining or bol- medical and work productivity loss costs, home productivity loss, 73 fi 74 42 stering resources, opportunities, and life chances. If we view and consequent family nancial and caregiving burdens (Druss 43 health as a life chance (Haas, 2006), then it becomes clear that et al., 2001; Heidenreich et al., 2011; Kessler, Ormel, Demier, & 75 76 44 these dimensions also structure susceptibility and resilience to Stang, 2003; Merikangas et al., 2007). Racial/ethnic and gender 45 illness. As a result, racial/ethnic, gender, and socioeconomic dis- disparities in hypertension prevalence have been well-docu- 77 78 46 parities in health have been increasingly recognized as both con- mented, suggesting that it is a key contributor to inequalities in life 47 sequences of and contributors to social stratification processes chances. Although many studies have been conducted to identify 79 80 48 across the life course (Haas, 2006; House et al., 1994). What is less determinants of hypertension, our understanding of the determi- 49 well acknowledged is the need for a multidimensional—or inter- nants of hypertension disparities remains incomplete (Flack, Fer- 81 82 50 sectional—approach to understanding social stratification gen- dinand, & Nasser, 2003; Minor, Wofford, & Jones, 2008; Rieker, 51 erally and the social stratification of health in particular. Instead, it Bird, & Lang, 2010). Not only have previous studies frequently 83 84 52 is more common for race/ethnicity, gender, and other dimensions considered race/ethnicity and gender as separate (rather than in- 53 of inequality to be treated as separate categories of analysis or, tersecting) categories of analysis (see the Canadian study by 85 86 54 when examined together, viewed as additive rather than mutually Veenstra (2013) for an exception), but they also have focused 55 reinforcing and inseparable. Likewise, considering the inextricable primarily on contemporaneous risk factors rather than risk his- 87 88 56 linkages among social status dimensions is an uncommonly pur- tories. Moreover, much of what we know about gender and racial/ 57 sued approach to health disparities research. This neglect may ethnic differences in hypertension—and their age patterns— 89 90 58 obscure the social processes underlying these disparities. comes from cross-sectional data (e.g., Cutler et al., 2008; Ger- 59 onimus, Bound, Keene, & Hicken, 2007), which are not well-suited 91 92 60 n for testing hypotheses about group differences in intra-individual Q4 Q3 Corresponding author at: Department of Sociology, University of North Carolina change with age. 93 61 at Chapel Hill, 155 Hamilton Hall, CB #3210, Chapel Hill, NC 27599-3210, USA. 94 62 E-mail addresses: [email protected] (L.J. Richardson), Thus, we extended previous research by using panel data and 63 [email protected] (T.H. Brown). integrating intersectionality and life course perspectives to 95 64 96 http://dx.doi.org/10.1016/j.ssmph.2016.04.011 97 65 2352-8273/& 2016 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 66 98 Please cite this article as: Richardson, L. J., & Brown, T. H. (En)gendering racial disparities in health trajectories: A life course and intersectional analysis. SSM - Population Health (2016), http://dx.doi.org/10.1016/j.ssmph.2016.04.011i 2 L.J. Richardson, T.H. Brown / SSM -Population Health ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 1 examine how race/ethnicity, gender, and age combine to shape popular notions about the low social status of Black men. Indeed, 67 2 hypertension risk trajectories between mid- and late-life among Black women experience the greatest disadvantages of all racial/ 68 3 Black, White, and Mexican Americans. Specifically, we sought to ethnic-gender groups across multiple indicators of life chances, 69 4 determine whether and how racial/ethnic disparities in hy- including poverty rates (Elemelech & Lu, 2004), income (U.S. 70 5 pertension trajectories are (en)gendered. Using seven waves of Census Bureau 2012), wealth (Chang, 2006), and marriage (Warner 71 6 data from the Health and Retirement Study (1992–2004) and & Brown, 2011). This relative disadvantage is posited to result from 72 7 multilevel logistic regression models, we investigated whether Black women’s experiences of “a double [or triple] load of dis- 73 8 race/ethnicity and gender combine in a multiplicative fashion— crimination” (Borrell, Kiefe, Williams, Diez-Roux, & Gordon-Larsen, 74 9 i.e., the intersectionality hypothesis—to produce disparate trajec- 2006), and/or “gendered racism” (Essed, 1991), as well as addi- 75 10 tories of hypertension risk net of early life and contemporaneous tional burdens stemming from the plight of their male counter- 76 11 social, economic, and behavioral factors. We also tested the alter- parts, who suffer disproportionate incarceration, unemployment, 77 12 nate hypothesis—i.e., the double jeopardy hypothesis—that the and premature mortality (U.S. Bureau of Labor Statistics 2011; 78 13 relationships among race/ethnicity and gender are additive. In Guerino, Harrison, & Sabol, 2011; Xu, Kochanek, Murphy & Tejada- 79 14 addition, we tested whether group differences in hypertension risk Vera, 2010) (2001: 164). 80 15 trajectories are consistent with cumulative advantage/dis- These chronic stressors, together with Black women’s perpetual 81 16 advantage, aging-as-leveler, or persistent inequality hypotheses. and often unsuccessful attempts to cope with them, could pre- 82 17 cipitate poor health (Geronimus, 1992; Mullings & Wali, 2001; 83 18 Racial/ethnic, gender, and age disparities in hypertension prevalence Thomas, Witherspoon & Speight, 2008). In fact, studies have found 84 19 that Black women experience multiple chronic stress-related 85 20 Racial/ethnic disparities in hypertension prevalence in the U.S. morbidities at a higher rate than other racial/ethnic-gender 86 21 are well-documented. Non-Hispanic Blacks have had consistently groups, including Black males (e.g., Bird et al., 2010; Brown & 87 22 higher rates of hypertension than Whites (Minor et al., 2008; Ong Hargrove, 2013; Geronimus et al., 2007; Geronimus, Hicken, Keene 88 23 et al., 2007). Conversely, although the prevalence of hypertension & Bound, 2006b; Read & Gorman, 2006; Warner & Brown 2011). 89 24 has been rising among Mexican Americans (Ghatrif et al., 2011), Thus, while Black men live shorter lives than their female coun- 90 25 they typically have rates of hypertension similar to or lower than terparts on average, Black women have the shortest healthy life 91 26 those of Whites (Gillespie & Hurvitz, 2013). Age-related increases expectancy of all racial/ethnic gender groups. 92 27 in hypertension prevalence also differ by race/ethnicity, as well as While there is growing interest in bringing intersectionality to 93 28 gender. Blacks have an earlier average age of hypertension onset bear on health disparities research (Schulz & Mullings, 2006), few 94