Can this be done 8 pm 4/22

Using an Intersectional Approach To Study the Impact of Social Determinants of Health for African-American Mothers Living with HIV

Courtney Caiola, MSN, MPH, RN, Duke University School of Nursing

Sharron Docherty, PhD, PNP-BC, FAAN, Duke University School of Nursing

Michael Relf, PhD, RN, ACNS-BC, AACRN, CNE, FAAN, and Duke University School of Nursing

Julie Barroso, PhD, ANP-BC, APRN, FAAN University of Miami School of Nursing and Health Studies

Introduction

This paper outlines an approach to conceptualizing social determinants of health and their

role in producing health inequities. Health scientists and clinicians are increasingly

recognizing that health care systems and the conditions in which people are born, grow up,

live, work, and age -- collectively known as the social determinants --profoundly influence

the health of individuals and subsequently impact the health of populations at large.1-3 Since

the turn of the 21st century, a number of important publications illuminate the significant

role social determinants play in producing health inequities. For instance, in 2003, the

Institute of Medicine produced the first comprehensive report demonstrating that racial and

ethnic minorities have less access to quality healthcare.4 In 2008, the World Health

Organization announced a new global agenda for health equity, clearly asserting and

substantiating that the social determinants of health, fashioned by the distribution of power

and material resources, function to produce many avoidable health inequities.1,3 In 2010, the

Centers for Disease Control and Prevention produced a white paper calling for new

approaches, beyond individual interventions, to reduce health inequities in HIV, viral

hepatitis, STDs, and tuberculosis in the United States.5 Within-country and between-country

analyses show that social determinants such as gender, occupation, income, and race/

ethnicity can radically influence health outcomes to create hierarchies of health and

illness.3,4 In conjunction with these publications, Presidential communications and working

groups,6 a national HIV/AIDS health strategy,7 legislation such as the Patient Protection and

Affordable Care Act, and federally funded research efforts to promote the investigation of

multifactorial, nonbiological factors of health disparities8 have heightened awareness of the

role of social determinants in producing health outcomes.9,10

Correspondence: Courtney Caiola DUMC 3322 307 Trent Drive, Room 3080 Durham, NC 27710 Phone: 919.265.4647 Fax: 919.684.9350 [email protected].

NIH Public Access Author Manuscript ANS Adv Nurs Sci. Author manuscript; available in PMC 2015 October 01.

Published in final edited form as: ANS Adv Nurs Sci. 2014 ; 37(4): 287–298. doi:10.1097/ANS.0000000000000046.

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Despite increased efforts and heightened awareness of social determinants of health, little to

no progress has been made in the amelioration of those social determinants contributing to

health inequities. In fact, a review of Healthy People 2010 reveals that during the decade

between 2000 and 2010, the disparity gap for many of leading health indicators by race and

ethnicity have actually worsened, rather than improved; a disappointing 70% of the

objectives saw no change in disparity.11 We argue, along with a growing number of health

scientists, that reliance on traditional biomedical research paradigms, which reflect a

positivist epistemology, serves to perpetuate these trends by failing to adequately consider

the social and economic context of health, preserving the hegemony of the Euro- and

androcentric perspectives often driving research, and ignoring the unequal power

distributions contributing to health inequities.2,9,10

In contrast to traditional biomedical research paradigms, many feminist and sociology

scholars focus on the influence of unequal power distribution and social and economic

situations in positioning people in the social world.12-15 Over the past three decades, these

scholars have developed a conceptual framework called intersectionality or an intersectional

approach when applied in research,16 aimed at understanding these complexities.2,10,16

Research endeavors using the intersectional framework generally manifest as

multidisciplinary scholarship examining how the hierarchies of race, gender, and class

mutually create structures of oppression and meaning.16 More recently, scholars began using

intersectional approaches to examine the complex configurations of social determinants of

health and how those social constructs interact to produce health inequities.2,9,10

Nevertheless, the utilization of intersectionality to aid nurse scientists in knowledge

development and inform nursing practice regarding issues of social injustice and health

inequities is only just evolving.9

The purpose of this paper is thus threefold. First, we will describe and analyze

intersectionality as a conceptual framework and a means of understanding and addressing

health and health care inequities. Second, we will apply the intersectional approach to the

study of the social determinants of health for African-American mothers living with HIV

and through this application explore the utility of an intersectional approach to generate

knowledge in nursing. Lastly, we will discuss some potential methodological implications of

using an intersectional framework in research.

An Intersectional Approach: Conceptualizing Health and Healthcare Inequities

Beginning roughly in the late 1980s and early 1990s, intersectionality developed through

both scholarly endeavors and activist engagement.15 Kimberle Crenshaw, a lawyer and

African-American feminist scholar, is most frequently cited as coining the term

“intersectionality” in her early scholarly work,13,16,17 which was inspired by her activism in

Harvard Law School's faculty integration of both women and people of color.15 Crenshaw

emphasizes that intersectionality is not merely a multiplying of identity categories such as

gender and race; rather, it is meant to provide a means of analysis for how particular

identities and conditions are located within structures of power.15 Patricia Hill Collins,

African-American sociologist and feminist scholar, began publishing extensively on

intersectionality in 1990 with her work entitled Black Feminist Thought: Knowledge,

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Consciousness and the Politics of Empowerment.14 Collins critiques the essentialism of

feminist scholarship of that time and suggests that social theory that fails to acknowledge

social context produces theories that appear to be universal but in reality reflect only the

thought-models of the scholars located in their specific social context.12 Intersectionality is a

way of understanding social location in terms of the way systems of race, social class, and

gender overlap with no one social category taking primacy.2

Orientation and Purpose of Intersectionality

Said by some scholars to be a transformative paradigm, intersectionality's philosophical

underpinnings are largely rooted in critical theory and feminism and no single theorist or

discipline can be credited with its development.15,16 A core epistemological assumption of

intersectionality is that knowledge development is from the perspective of the oppressed, not

the dominant social group.9 Intersectional scholarship was developed from the unique

position of women of color with the purposes of seeking social justice and framing social

inequities as products of differences such as race, class, and gender.9,10 In other words,

intersectionality is both an explanatory conceptual framework and an effort to address social

inequality based on intersecting social constructions (such as race, class, and gender)

manifested at both the individual and population level.18 Intersectional scholars consider the

social constructions of gender, race, and class to be unequal social relationships between

groups of people, rather than biological or genetic attributes of individuals, and they are

concerned with how those relationships act as social determinants of health disparities.18

Central Theoretical Tenets of Intersectionality

We recognize that there are a multitude of conceptualizations of intersectionality and

contradictions in the literature about intersectionality;2,9 it is simultaneously characterized it

as a paradigmatic view, a theoretical framework, and a methodological approach.16,19

However, some basic theoretical tenets characterize much of the literature on

intersectionality. Weber's work identifying the central theoretical tenets of intersectionality

serves as a useful framework of the approach's central constructs: contextually specific

social constructions, multilevel power relations and simultaneity.10

Contextually specific social constructions—Intersectionality describes broad social categories such as race, gender, and class, along with more specific social categories such as

motherhood, as socially constructed phenomena that are fluid, flexible, and contextually

grounded in history and geographical location.2,10 For example, social constructions of race

are not based on the assumption that discrete, biological races exist; rather, they are

concerned with how race is constructed by historical conditions such as slavery and

segregation and leads to inequity based on hierarchies and systems of oppression.18

Social roles such as motherhood are also considered social constructions in intersectionality.

For example, within an intersectional framework, motherhood is not assumed to be a

universal phenomenon with a single, objective definition of mothering. Rather, mothering is

thought of as a relationship in which a person's actions to nurture and care for another is

based in a historical and cultural context.12,20 Collins’ theorizing about motherhood

explicitly challenges universalism, acknowledges inherent diversity in motherhood, and

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suggests a shift to a concept that accommodates the diversity of race, ethnicity, and social

class.12 Her work on motherhood is firmly grounded in an intersectional approach - an

approach she is credited with helping to shape.16 From an intersectional approach, there is

no one meaning of motherhood, manhood, womanhood or the like; they are deeply

embedded in the social context from which they arise.12,18

Multilevel power relations—The exploration of social relationships marked by a power differential--in which one group is subordinate and another is dominant--as well as how

those relationships persist is a central focus of intersectionality.10 Social relationships are

interactions between the people assigned to socially constructed categories of difference

noted above such as race, gender, and class; the persistence of power in such relationships is

fashioned by the dominant group's access to greater material and social resources.10 As

power relationships persist and hierarchies are perpetuated, the dominant social groups

become the standard from which all group comparisons are made, and subordinate social

groups are subsequently marginalized.10 Macrolevel power differentials manifest

structurally in the form of policies, rules, or laws benefiting only certain groups; while

microlevel power differentials present in individual relationships in which one individual

exerts power over another.10

Simultaneity—Socially constructed differences in gender, race, and class do not simply intersect in an intersectional approach as an inequity that is additive or multiplicative.18

Rather, the constructs exist simultaneously and vary as a function of one another depending

on the particular gender, race, and class to which an individual belongs.18 The ability of the

constructs to vary as a function of one another is described as “mutually constituted,”

creating a specific social location for individuals.10,16,21 An individual's social location

based on mutually constituted social inequities is an important concept in intersectionality

and is often best explicated by example. Using health as an example, the intersection of

social determinants of health for an African-American (race) mother (gender) living in

poverty (class) and with HIV may function quite differently than that of an African-

American (race) father (gender) living in poverty (class) and with HIV. That is, race and

class are gendered and may operate to produce different health outcomes18 as well as a

unique social location for those individuals. Indeed, the combinations are innumerable

depending on the social determinants of concern, as race and gender could just as

conceivably be “classed” or gender and class could be “raced.”18 Finally, but very

importantly, intersectionality challenges the idea of gender as the primary dimension of

inequity; rather, it asserts that multiple dimensions can and do shape social inequality.2

Analysis of Intersectionality

We assert that the strengths of intersectionality as an approach for investigating health

disparities are clear; namely, it provides insights into the nature of social inequality, social

determinants of health, and power structure. Indeed, it provides some clear advantages over

the biomedical paradigm. First, acknowledgement of social constructions of difference

requires the researcher(s) to develop a specific awareness of the community of interest,

including nuances of community strengths, weaknesses, historical context, political context,

and more.10 This awareness, long advocated for by feminist and critical scholars, fosters

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researcher and participant engagement, self-reflection, and involvement10 such that

participants are no longer subjects to the research process but involved at a level in which a

process of conscientisation may occur.22 Conscientisation, a concept originally developed

by Paulo Freire, is a process of consciousness raising and critical awareness through practice

and participation.22 Such participant involvement and conscientisation is in itself a

community intervention and may lead to more appropriate community-based interventions

where biomedical approaches have failed.

Second, the acknowledgement of power relations in intersectionality has three important

consequences. One, as discussed earlier, the intentional privileging of the perspectives of

groups traditionally subordinated means that dominant groups are no longer considered the

standard from which all group comparisons are made and moves health research away from

a traditional Euro- and androcentric perspective.9,10 Two, comprehensive examination of

power structures leaves room for the study of privilege and how the process of whiteness is

central to producing health inequities.2,23 Whiteness is not only a social location of

structural privilege by white people, but also the unmarked and seemingly transparent

practices and discourse that perpetuate racial domination and reproduce social inequality in

society.23 A worthy endeavor and example of research investigating the role of whiteness

might be using an intersectional approach to examine of the discourse between elite, white

politicians who are largely responsible for brokering health policy in the US. Three,

exploration and disclosure of power differentials at the macrolevel requires health scientists

to consider health interventions aimed at balancing power at the structural or institutional

level rather than the microlevel interventions, such as individual behavior change,

traditionally targeted by biomedical research.10

Third, by stressing simultaneity, intersectionality moves beyond the single-axis analysis

centered on dichotomies such a man/woman, African-American/White, and wealthy/poor

and provides a means for multi-axis analyses in which heterogeneity is implicit2 and no

social group is considered homogeneous.9 In doing so, intersectionality creates a more

empirically sound model of diversity and challenges the “binary thinking which tends to

place certain groups in opposition to one another” in the biomedical paradigm.2 (p.1713)

We do acknowledge that the methodological complexities of executing an intersectional

approach can be daunting and might be considered a potential weakness of the

framework.16,19 These complexities have likely evolved because intersectionality grew out

of multiple disciplines, and the methodological boundaries of various disciplines can vary

significantly.10 We suggest the lack of clarity as to the nature of intersectionality as a

paradigm or theory and the methodological complexities associated with intersectionality

are not weaknesses, but opportunities for creating new ways of knowing. In the following

section we will address some of these issues through application of an intersectional

approach to research involving African-American mothers living with HIV and suggest a

model of the theoretical relationships within the framework.

Exemplar: The Practical Application of an Intersectional Approach

As a means of evaluating intersectionality, we will discuss the applicability and limitations

of the conceptual framework for investigating the health inequities and social determinants

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of African-American mothers living with HIV. To begin, it is important to explain the

rationale for the population and disease process chosen, as the choices have distinct

methodological implications in an intersectional framework.

Population and disease process rationale—The rationale for choosing one socially constructed group (African-American women) at the intersection of multiple social identities

(female, African-American, mothers, living in poverty) is driven by the intersectional

framework itself. Managing the complexity of multiple categories simultaneously has

proven to be challenging for intersectional scholars.19 Efforts to manage complexity and still

produce findings led to three primary methodological approaches – anticategorical,

intracategorical, and intercategorical.19 These approaches fall on a continuum, with

anticategorical and intercategorical landing on the extremes of the spectrum.19 Simply

stated, anticategorical approaches deny any fixed categories, and intercategorical

approaches, similar to traditional biomedical approaches, analyze multiple social groups

within and across categories.9,19 The approach chosen for this discussion, intracategorical,

focuses on one social group at the intersection of multiple social identities so that within-

group differences and larger social structures influencing their lives can be explicated.9,19

The rationale for choosing African-American mothers living with HIV is twofold. One, this

choice is in keeping with the premise that intersectional approaches focus on knowledge

development via non-dominant, minority, and frequently marginalized groups. Two, this

choice is based on magnitude of disease burden and disparity in health outcomes. Indeed,

disparities in the health outcomes for African-American mothers living with HIV are clear

across racial, gender, and socioeconomic groups. Women now represent 25% of all HIV

infections in the US.24 African-American women are 20 times more likely than White

women to be newly infected with HIV,24 and once infected, they are likely to die from

AIDS earlier than their White counterparts.25 Moreover, African-American women are

disproportionately poorer than other subpopulations in the US,26 and at least twice as likely

as White women to be living in poverty, a significant precipitating factor for HIV

infection.27 Being a mother adds an extra layer of complexity to the lives of women living

with HIV. Studies show that the primary goals of mothers living with HIV are to protect

their children from HIV infection and HIV-related stigma;28 these mothers describe higher

levels of stress than non-mothers as they manage their own needs and the needs of their

children in circumstances such as poverty.29 HIV-related stigma brings poorer mental and

physical health outcomes across a broad range of demographic profiles.30 If vulnerability is

defined as the “susceptibility to poor health,”31 (p.2) then the vulnerability of African-

American mothers living with HIV functions at the intersection of gender,32 race,33 class,27

HIV-related stigma,28 and motherhood,28,29 and necessitates multidimensional and

transdisciplinary approaches to address the complex social and economic conditions of these

mother's lives, collectively known as social determinants of health.

Intersectional Approach for Research Involving African-American Mothers Living with HIV

The intersectional approach is based on a model titled Motherhood and HIV: An

Intersectional Approach. In this model (Figure 1), informed by the work of Shi and

Steven's,31 the concept of vulnerability, defined as a “susceptibility to poor health,” 31 (p.2) is

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at the center. The model represents the intersection of specific factors as mutually

constituted2,10,18,21 vulnerability in which these factors jointly determine health status and

access to quality health care.

To illustrate the conceptual relationships in the intersectional model (Figure 1), a mother

living with HIV is standing at a large traffic intersection with her children in tow. Her

challenge is to cross the intersection safely, protecting both herself and her children. In the

model, 1) the social determinants of health (represented by roads) intersect to create a

mutually constituted vulnerability; 2) the larger the intersection (i.e., the more

vulnerabilities), the more difficult the mother's task of managing her condition and accessing

quality health care, leading to a greater likelihood of poor health outcomes; 3) gender, race,

and class are socially constructed categories involving sometimes unequal relationships

between groups of people, rather than biological or genetic attributes of individuals;18 4)

certain factors (represented by bridges) can positively influence the ability of a mother living

with HIV to navigate the intersection and her subsequent health outcomes; and 5) the health

outcomes of the children are at least partially dependent on the health outcomes of the

mother and her ability to navigate the intersection. Definitions of the concepts used in the

model, along with rationale for their inclusion, follow.

Gender/Gender Inequality—Gender is a socially constructed category with differences in how it is enacted and arranged hierarchically in society.18 Gender inequality based on

hierarchical structures can lead to differences in health outcomes between men and women

due to distinctive social roles and expectations.34 Gender inequality35 and gender-based

violence36 increase the risk of HIV infection, and increased violence among women already

living with HIV leads to poorer health outcomes.36

Race/Race Inequality or Racism—Race is a socially constructed group of categories that can lead to inequity based on hierarchies and systems of oppression.18 Health scientists

have found that the social impact of race on daily life experiences, not innate biological

differences or poverty, actually mediates differences in race-associated health outcomes.37

High levels of self-reported experiences of racism have been associated with numerous poor

health outcomes, from cardiovascular disease to certain forms of cancer.33

Class/Class Inequality—Class is a relative position along a socioeconomic gradient and it has been associated with poor health through material deprivation or “the lack of material

resources that enable the protection or promotion of health.”31 (p.66) Epidemiological studies

have found an association between HIV infection risk and poverty27 and have shown that

socioeconomic status is a major determinant of high morbidity among nonwhite women

living with HIV in the Southern region of the United States.38

HIV-related Stigma—In his landmark work, Erving Goffman39 defined stigma as both a discrediting attribute of an individual and a social process in which the discredited

individual is rejected by society.39 A recent meta-analysis concluded that high HIV-related

stigma is correlated with poor physical outcomes such as AIDS symptoms; poor mental

health outcomes such as depression, anxiety, and psychological distress; and low social

support.30 In addition, HIV-related stigma has been identified as a significant barrier to

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initiation of HIV care40 and associated with greater gaps in medical care as measured by

days, ARV non-adherence, low CD4 cell counts (<200) and higher chronic illness

comorbidity.41

Motherhood—Nakano Glenn and colleagues20 reframed “mother” from a biological construct into “mother” as a social construct, by defining mothering as a relationship in

which a person's actions to nurture and care for another are based in a historical and cultural

context.20 Research exploring the experiences of women living with HIV has revealed that

motherhood creates added challenges and higher levels of stress for women who must

manage their own health care needs while simultaneously acting as caregivers to their

children.29 Mothers living with HIV also experience role conflicts as they attempt to carry

out the daily activities of motherhood while experiencing profound fatigue and other

physical limitations imposed by their disease.42 Finally, mothers living with HIV desire to

protect their children from HIV-related stigma and experience stress in regard to disclosure

of their HIV status to their children, significant others, and other family members, fearing

that disclosure will make their children vulnerable to stigma.28 As such, these mothers also

have concerns about the care of their children in case they become ill and die, and

paradoxically they cite motherhood and the desire to protect their children as a source of

strength and a reason to live despite their infection.28 The evidence as to whether

motherhood plays a positive28 or negative28,29,42 role in health outcomes for mothers living

with HIV is conflicting; therefore, motherhood could be explored as both an axis of

vulnerability and as a potential strength in an intersectional framework.

We argue that an intersectional approach is highly applicable to research on the impact of

social determinants of health for African-American mothers living with HIV and a number

of other populations experiencing disparate health outcomes. Modifiable health status in

chronic illnesses such as HIV is largely determined by environmental, social, and behavioral

factors;43 in 2010, as part of the Patient Protection and Affordable Care Act, Congress

authorized funding of the Patient-Centered Outcomes Research Trust Fund aimed at

producing information from research that is guided by patients and other stakeholders in

order to illuminate these factors. As the US moves toward more patient-centered care,

understanding the role of social determinants in patients’ health will be central to the design

of interventions that will help to ameliorate those social determinants when they do not

promote health.

Unlike a general intersectional approach, our model emphasizes access to quality health

care, health outcomes, and potential health-promoting social determinants.31 It encourages

understanding potential pathways and relationships social determinants have with health

access, health quality, and health outcomes both at the individual and population level.

Additionally, we argue that it is critical to examine health-promoting (or positive) social

determinants of health that will move research from a deficit model to identify and capitalize

on those patient and community attributes that enhance health.43

Using an intersectional approach to investigate disparate health outcomes in HIV and other

chronic illnesses could potentially address important questions such as: What mutually

constituted social determinants contribute to the prevalence of a specified disease? How are

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those social determinants related and how are they embedded in power structures for

specific diseases or populations? What are some of the health-promoting social

determinants, such as motherhood, that can enhance a patient's ability to self-manage a

disease process? Can structural interventions and health policies be developed to improve

the health disparity found in people with specific disease processes across gender, race, and

class groups?

Implications of Using an Intersectional Approach

The methodological implications of using an intersectional approach, such as the one we

have proposed above, are vast, and entire texts have been devoted primarily to this

topic.16,18 Intersectional scholars have asserted that intersectional approaches tend to be less

amenable to traditional biomedical, variable-oriented, or disaggregating methodologies such

as multivariate, predictive models.18 Such methods seek to explain the relationship between

independent, discrete variables but they do not explain why those relationships occur or

illuminate their social and context-dependent constructions or the power structures within

those relationships.18 Others have suggested that intersectional approaches have a closer

alignment with or affinity with traditional qualitative methodological approaches such as

ethnography or case study accounts.18 However, Kelly,9 a nurse scientist, moves the

conversation forward for nursing by discrediting a strictly dichotomous intersectional versus

biomedical paradigm and qualitative versus quantitative view and suggests that “the

integration of feminist intersectionality and biomedical paradigm in research occurs in the

selection of the research problems, design, and methods, as well as in the operationalization

of the assumptions of each paradigm throughout the research process.” (p.E46) In other

words, retreating to comparisons of the biomedical versus intersectional paradigms and their

traditional affiliations with quantitative versus qualitative methods, respectively, simply

reinforces a binary form of thinking that only one philosophical approach can address the

complexity of health inequities and fails to acknowledge that philosophical or theoretical

approaches are in no way tied to specific methodologies.44 Integration of the intersectional

and biomedical paradigm for the purpose of addressing health inequities will require an

orientation toward the data, no matter the methodology with which it is collected, such that

questions related to socially constructed categories of difference, power differentials, and

mutually constituted social identities are considered. Scholars using the intersectional

approach also have a long tradition of combining scholarship and activism in the pursuit of

social justice; therefore, community-based participatory research is uniquely suited to

intersectional approach because of its emphasis on participant-researcher collaboration and

community engagement.9,16 Additionally, intersectional approaches may be served best by

transdisciplinary groups of scholars engaging in collaborative research efforts. As McCall16

asserts, intersectional approaches cross disciplinary borders and such a “border-crossing

concept suggests an interdisciplinary rigor that helps challenge traditional ways of framing

research inquiries, questions and methods.”(p.7)

Finally, this approach is particularly powerful for the design and implementation of

interventions. Structural interventions, which focus on changing the “environment or context

within which people act for the purpose of influencing individual health behaviors,”45 (p.S46)

attempt to target the social determinants associated with negative population health

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outcomes.1 Social determinants include not only socially constructed categories such as

race, gender, and class, 18 but also built environment such as actual neighborhoods and

community spaces or trusted and reciprocal social networks.46 By illuminating the social

determinants negatively and positively impacting health and how those social determinants

interact, we can assess which, if any, of those structural influences may be amenable to

intervention via health policy and advocacy. As related to our example of African-American

mothers living with HIV, inquiry framed with an intersectional approach may produce

evidence substantiating the nuances of how macrolevel power differentials create their

disparate health outcomes. For example, does one social determinant such as class inequality

consistently trump other determinants such as gender or race in producing negative health

outcomes? Can the intersection of the racism, classism, gender inequality, and stigma be

mitigated by motherhood? How does whiteness operate to shape the health experiences of

these mothers? Research using an intersectional approach and our proposed model can

unveil such nuances. The evidence could then be used to advocate for structural

interventions aimed at altering imbalances of power, such as the provision of micro-

financing programs to reduce economic inequality1 or antiracist education to challenge and

change the unmarked white privilege of the US healthcare system.47

Process interventions are nested within structures and aimed at impacting individual health

and health behaviors through specific healthcare processes such as evidence-based care,

behavior change management, and the patient-provider relationship.43,48,49 For example,

exploring the ways in which the unique social identity of African-American mothers living

with HIV influences their health-related experiences and creating empirically-driven

typologies of vulnerability, researchers have a potential means for assessing vulnerability

that may be clinically relevant for clinicians.48 Being able to adequately assess vulnerability

gives clinicians a greater understanding of social forces influencing a patient's health care

decisions and will allow for a greater congruence or shared understanding between the

provider and patient regarding “realistically attainable health care goals.”48 (p.384) Such an

assessment literally gives the provider a sense of what it is like for the mother as she stands

in the middle of the intersection of social determinants and the potential “trade-off”

decisions she must make regarding her health care, such as whether to buy her medications

or clothing for her child.48 This kind of evidence could be used to develop HIV-specific,

evidence-based guidelines for mothers that: 1) consider how a mother's assessed

vulnerability changes certain health care recommendations, 2) provide a patient-provider

decision making tool for trade-off decisions, and 3) suggest ways providers can adapt their

health practice in caring for mothers living with HIV.43,48 Few guidelines such as these

exist, but an excellent example is the guidelines provided by the Health Care for Homeless

Clinicians Network called Adapting Your Practice: Treatment and Recommendations for

Homeless Patients with HIV/AIDS.50

Conclusion

To date, the acknowledgement of the role of social determinants in producing health

inequities by the scientific community has failed to translate into significant progress toward

interventions that ameliorate disparate health outcomes among populations. As healthcare

scientists, we urgently need to expand our understanding of health inequities and the means

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with which we investigate them. An intersectional approach offers a complexity of inquiry

matching the complexity of social forces shaping those inequities. Our model of

Motherhood and HIV: An Intersectional Approach, while specific to African-American

mothers living with HIV, can be modified to reflect the social determinants of health

relevant to a multitude of other populations and offers a framework for this future work.

Supplementary Material

Refer to Web version on PubMed Central for supplementary material.

Acknowledgments

The authors thank Ursula A. Kelly, PhD, ANP-BC, PMHNP-BC, Assistant Professor, Emory University, Nell Hodgson Woodruff School of Nursing

Funding: This work is supported by Duke University School of Nursing and National Institute of Nursing Research/ National Institute of Health: National Research Service Award 1F31NR014628-01.

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FIGURE 1.

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