The Social Determinants of Health Disparities: The Role of Social and Temporal Contexts.

Abstract

The goal of this dissertation is to examine contextual determinants of racial disparities in health across the life course. I progress from “downstream” to “upstream” processes by focusing in one chapter on the prenatal context, in another on health behaviors and family context, and in the third, on the neighborhood context.

Chapter 2 examines the relationship between lifetime exposure to abuse among pregnant women in the Boston area and elevated cord blood IgE. Results demonstrate that greater exposure to violence throughout the mother’s life course is associated with increased risk of offspring elevated IgE at birth, after adjusting for maternal and family-level confounders. Abuse occurring more proximate to pregnancy is not correlated with elevated cord blood IgE, suggesting that the cumulative exposure to violence (i.e., chronic abuse) may have the most salient fetal effects. The results indicate that the detrimental effects of violence may a) accumulate over the life course and b) transmit across generations through the fetal environment.

Chapter 3 explores the intergenerational transmission of disadvantage by examining the relationship between teen childbearing and offspring health among a nationally representative sample of children ages 5-19. Logistic regressions reveal no increased risk of low birthweight, chronic illness, obesity or asthma among offspring of teens versus non-teens and a slight decrease in obesity among offspring of teens, suggesting that the timing of one’s pregnancy may matter less than other contextual factors in influence offspring health.

Chapter 4 uses multilevel methods to investigate the extent to which one’s residential environment is linked to currently active asthma. No association is found between neighborhood sociodemographic factors and asthma. Random-slope models demonstrate significant effects of affluence and immigrant concentration for non-blacks; however, the unexpected direction of the coefficients and the small sample size call into question the reliability and validity of these findings.

Emerging from these three studies is a complex picture of how contextual factors may affect health disparities. The findings confirm the value of incorporating social contexts in studying health disparities, while underscoring the pitfalls in overlooking the diversity in age, ethnicity, life stage, and health outcomes within such research.