Integrating Multiple Social Statuses in Health Disparities Research: The Case of Lung Cancer

Socioeconomic status (SES) as measured by income, education, or occupational status, is a robust predictor of variations in health and health service utilization (Braveman et al. 2010). Racial/ethnic differences in health status and health service use have also been well documented (Williams et al. 2001). Although racial/ethnic and SES disparities overlap to some degree, health disparities researchers tend to study them separately. Race/ethnicity is correlated with SES, such that SES differences between racial/ethnic groups account for a substantial part of the observed racial/ethnic differences in health, including cancer (Krieger et al.2008; Howard et al. 2006; Albano et al. 2008). Typically, adjustment for SES substantially reduces but does not eliminate disparities in health risks and outcomes by race/ethnicity. Moreover, large gender differences exist in health and health service use (Williams 2002;Read and Gorman 2007). Importantly, race/ethnicity, SES, and gender converge in complex ways that can enhance or impair health (Weber and Parra-Medina 2008). This article explores how the simultaneous consideration of race/ethnicity, SES, and gender can provide novel insights into disease risks, patterns of health service utilization, and effective interventions to reduce health care disparities. An intersectional approach emphasizes the importance of intersecting inequalities, multiple vulnerabilities, and the need to examine how multiple dimensions of social statuses combine to facilitate or restrict exposure and response to risk factors and resources relevant for a disease and its treatment (Schulz and Mullings 2006; Weber and Fore 2004). Intersectional theory posits that multiple social statuses are experienced simultaneously and dynamic interdependent processes arise when race/ethnicity, SES, and gender (and/or other social statuses) combine to affect patterns of risks and resources, privilege and disadvantage that can affect health risks and health service utilization across different social contexts (Cole 2010). The intersectionality framework emphasizes that social identities and categories should not be viewed as independent variables that capture individual characteristics; instead, they are markers of institutional processes (Cole 2010). Cole 2010) identifies at least three implications for researchers. First, heterogeneity within social categories should be examined, especially attending to categories that have been neglected to facilitate the identification of how the meaning and consequences of one social category depend on other categories. Second, the intersectionality perspective highlights that membership in a social category often embodies institutional policies and practices that structure social inequalities and stigma in ways that shape opportunity and life chances. Third, intersectionality calls for exploring how macro-level social processes create commonalities across different social categories. Thus, an intersectional lens calls for research on health disparities to unpack the lived experiences of social groups at the convergence of multiple identities. It emphasizes that various social inequalities do not act independently but interact in ways that can transform and alter processes and outcomes of inequality from one setting or context to another. This approach can also delineate potential avenues of improving population health and inform targeted interventions to effectively address disparities in health care. Using lung cancer as an exemplar, this conceptual article illustrates the complex patterns that can emerge when race/ethnicity, SES, and gender are considered simultaneously and outlines health services research considerations to understand and address disparities across the continuum of lung cancer.