1. The World Health Organization (WHO) posits that “health inequities flow from patterns of social stratification – that is, from the systematically unequal distribution of power, prestige, and resources among groups in a society.” Where individuals and groups fall within the social hierarchy produced by these distributions is most often governed by structural and intermediary determinants. Structural determinants include social factors that promote and undermine the health of individuals and populations such as income, education, occupation, social class, gender, and race/ethnicity. Intermediary determinants are defined as a set of “individual influences…that determine differences in exposure and vulnerability to health-compromising conditions, and include material circumstances (i.e. living conditions, access to basic necessities such as food, shelter, clothing), social-environmental or psychosocial circumstances (i.e. stressors, access to social support), behavioral and biological factors (i.e. smoking, diet, alcohol consumption, physical mobility, and genetics), and the health system. Of the structural and intermediary determinants listed in the WHO framework on social determinants of health, I elect to focus on race/ethnicity, material circumstances, and social-environmental/psychosocial circumstances because of their respective strength as a predictors of health outcomes.
Race/ethnicity: Race/ethnicity is an important determinant of health because of its role in defining the social position of people within racial/ethnic groups. According to WHO, in societies marked by racial discrimination and exclusion, people belonging to a marginalized racial/ethnic group affects every aspect of their social position, opportunities, and trajectory throughout the life course – including health status and outcomes. In examining factors that contribute to the Black-White disparity in birth outcomes, Alio, et al (2010) demonstrate that risky behaviors (i.e. smoking), educational attainment, and access to prenatal care do not provide a substantive or significant explanation for Black-White disparities in birth outcomes; and that in fact, psychosocial factors such as intimate partner violence, maternal stress, and racial discrimination are more useful predictive measures for explaining disparities in birth outcomes among Black and White women. Despite the commonplace of education, income, and occupation as go-to proxies of socioeconomic predictors of health outcomes (and the strong correlation between each respectively), Braveman et al (2005) explain that income and earnings can vary at similar educational levels, particularly among marginalized racial and gender groups such as Black women. It can be argued that what appears to be a strong correlation between health outcomes and social disadvantage in determinants such as income and education is actually the accumulation and subsequent “biological expression” of racial discrimination.
Material Circumstances: Material circumstances such as an individual’s housing stability and ability to afford basic necessities such as food, housing, and clothing are very strong intermediary determinants of health. As it relates to birth outcomes, material circumstances have the ability to create maternal stress which is a factor that has been consistently linked to Black-White disparities in infant mortality. The negative realities of poverty result in premature aging (Alio 2010) and “weathering” (Hogue 2005) that contribute to a wear and tear on Black women’s bodies. These realities are exacerbated by single motherhood and the related financial and psychosocial stressors which are disproportionately experienced by Black women.
Social-Environmental and Psychosocial Circumstances: According to WHO, a person’s social position is a legitimate source of long-term stress and it impacts their ability to deal with stressful and difficult situations. Individuals and groups that are marginalized are particularly impacted by psychosocial stress linked to social exclusion, poverty, neighborhood conditions, and discrimination. The ecological model presented by Alio et al suggests that birth outcomes are impacted by maternal and family characteristics as well as broader community and societal influences. For example, studies have found links between neighborhood deprivation and pre-term birth among Black women which suggests that the environments occupied and navigated by Black women on a daily basis are a source of gestational poison. The stress associated with living in communities impacted by concentrated levels of violence, trauma, and overall deprivation helps explain some of the disparity in birth outcomes among Black women.
2. Early exposure to poverty, violence in the community, chronic stress, racism and many other experiences linked to socioeconomic status and neighborhood conditions influence future reproductive potential because of their cumulated effects over time on the bodies of Black women. Along with having legitimate biological implications (high blood pressure, diabetes, increases in allostatic load, etc.), these exposures create a level of psychosocial stress among Black women that eventually leads to adverse health conditions in their children. Studies show that maternal health is a strong predictor of health outcomes in the child and often times Black children are disadvantaged years before they are even conceived because of the experiences and health conditions of their mother.