The Social Determinants of Health for African American Mothers Living with HIV by Courtn

346 Pages·2015·24.91 MB·English

by  Courtney Caiola

The Social Determinants of Health for African American Mothers Living with HIV
by
Courtney Ellis Caiola
Nursing
Duke University

Date:_______________________
Approved:

___________________________
Sharron L. Docherty, Supervisor

___________________________
Julie Barroso

___________________________
Ursula A. Kelly

___________________________
Michael V. Relf

___________________________
Anh Nhat Tran

Dissertation submitted in partial fulfillment of
the requirements for the degree of Doctor
of Philosophy in Nursing in the Graduate School
of Duke University

2015
ABSTRACT
The Social Determinants of Health for African American Mothers Living with HIV
by
Courtney Ellis Caiola
Nursing
Duke University

Date:_______________________
Approved:

___________________________
Sharron L. Docherty, Supervisor

___________________________
Julie Barroso

___________________________
Ursula A. Kelly

___________________________
Michael V. Relf

___________________________
Anh Nhat Tran

An abstract of a dissertation submitted in partial
fulfillment of the requirements for the degree
of Doctor of Philosophy in Nursing in the
Graduate School of Duke University

2015
Copyright by
Courtney Ellis Caiola
2015
Abstract
Problem: The disparate health outcomes of African American mothers living
with HIV functions at the intersection of gender-, race-, and class-inequality; HIV-
related stigma; and motherhood, requiring multidimensional approaches to address the
complex social and economic conditions of their lives, collectively known as the social
determinants of health. African American women suffer significantly higher HIV
infection rates and tend to die earlier from their infection than their White counterparts.
Poverty is a significant precipitating factor for HIV infection and African American
women are disproportionately poorer than other subpopulations in the United States.
HIV-related stigma is linked to poorer mental and physical health outcomes across a
broad range of demographic profiles. Being a mother adds an extra layer of social
complexity to the lives of women living with HIV. This dissertation was designed to
develop knowledge on the social determinants of health for African American mothers
living with HIV by describing their social location at the intersection of gender-, race-
and class – inequality; HIV-related stigma; and motherhood and exploring how their
unique social identity influences their health-related experiences.
Methods: Using data from a literature review on intersectional approaches and
other frameworks for examining vulnerable populations, an intersectional model for the
study of the social determinants of health for African American mothers living with HIV

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was constructed. A pilot study exploring the methodological issues and ethical
challenges of using photo elicitation with a highly stigmatized social group of women
was conducted. The intersectional model and pilot study findings were then used to
guide a qualitative descriptive study using storyline graphs, photo elicitation and in-
depth qualitative interviewing as methods for exploring the intersection of the social
determinants of health for eighteen (18) African American mothers living with HIV.
Content, vector and frame analyses were used to describe the intersection of social
determinants and identify potential process and structural level interventions.
Results: Findings from the pilot study include best practices for using visual
methods with a highly stigmatized and potentially vulnerable group of women.
Findings from the qualitative descriptive study include six additional social
determinants of health - social support, religiosity, animal companions, physical
environment, transportation and housing - not initially included in the conceptual
model, a case for strength-based approaches, intersecting social determinants
functioning as systems of oppression and the heterogeneous and fluid social locations as
framed from the mother’s perspective. Three frames of social location for African
American mothers living with HIV were proposed – emancipatory, situational, and
internalized – as well as potential health implications and interventions. Each of the
findings add to the literature on the configuration of intersecting social determinants

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health relevant to African American mothers living with HIV, expand the proposed
intersectional model and help to generate hypotheses needed for intervention studies.

vi
Contents
Abstract .......................................................................................................................................... iv
List of Tables ............................................................................................................................... xiv
List of Figures ............................................................................................................................. xvi
Acknowledgements ................................................................................................................... xix
1. Introduction ............................................................................................................................... 1
1.1 Problem .............................................................................................................................. 1
1.2 Background ....................................................................................................................... 6
1.2.1 Complexity of the Intersection .................................................................................. 6
1.2.2 Conceptual Framework .............................................................................................. 7
1.3 Approach ........................................................................................................................... 9
1.4 Purpose Statement and Aims ....................................................................................... 11
1.4.1 Chapter 1 Aim ............................................................................................................ 11
1.4.2 Chapter 2 Aims .......................................................................................................... 11
1.4.2.1 Chapter 2 Aim 1 ................................................................................................. 11
1.4.2.2 Chapter 2 Aim 2 ................................................................................................. 11
1.4.2.3 Chapter 2 Aim 3 ................................................................................................. 12
1.4.3 Chapter 3 Aim ............................................................................................................ 12
1.4.4 Chapter 4 Aims .......................................................................................................... 12
1.4.4.1 Chapter 4 Aim 1 ................................................................................................. 12
1.4.4.2 Chapter 4 Aim 2 ................................................................................................. 12

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1.4.5 Chapter 5 Aim ............................................................................................................ 12
2. Using an Intersectional Approach to Study the Impact of Social Determinants of
Health for African American Mothers Living with HIV ....................................................... 14
2.1 Abstract ............................................................................................................................ 14
2.2 Introduction ..................................................................................................................... 14
2.3 An Intersectional Approach: Conceptualizing Health and Health Care Inequities
................................................................................................................................................. 18
2.4 Orientation and Purpose of Intersectionality ............................................................. 19
2.5 Central Theoretical Tenets of Intersectionality .......................................................... 20
2.5.1 Contextually specific social constructions ............................................................. 20
2.5.2 Multilevel power relations ....................................................................................... 21
2.5.3 Simultaneity ............................................................................................................... 22
2.6 Analysis of Intersectionality ......................................................................................... 23
2.7 Exemplar: The Practical Application of an Intersectional Approach ..................... 26
2.7.1 Population and disease process rationale .............................................................. 26
2.7.2 Intersectional Approach for Research Involving African American Mothers
Living with HIV .................................................................................................................. 28
2.7.2.1 Gender/gender inequality ................................................................................. 30
2.7.2.2 Race/race inequality or racism ......................................................................... 31
2.7.2.3 Class/class inequality ......................................................................................... 31
2.7.2.4 HIV-related stigma ............................................................................................ 32
2.7.2.5 Motherhood ........................................................................................................ 32
2.8 Implications of Using an Intersectional Approach .................................................... 35

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2.9 Conclusion ....................................................................................................................... 39
3. One Size Does Not Fit All: Tailoring a Visual Methods Protocol for Mothers Living
with HV in the Deep South ........................................................................................................ 41
3.1 Vulnerability: Why the “Who and Where” Matters .................................................. 42
3.2 The Study ......................................................................................................................... 45
3.2.1 Setting, Sample and Ethical Review ....................................................................... 46
3.2.2 Data Collection ........................................................................................................... 47
3.2.2.1 Outlining the Goals and Use of Photography ............................................... 48
3.2.2.2. Photo Content and Feasibility Interview ....................................................... 50
3.2.2.3 Participants and Photographs .......................................................................... 52
3.2.3 Data Analysis ............................................................................................................. 52
3.3 Results .............................................................................................................................. 53
3.3.1 Feasibility .................................................................................................................... 53
3.3.2 Utility ........................................................................................................................... 55
3.3.3 Ethical Challenges, Tailoring and Best Practices .................................................. 60
3.4 Conclusions ..................................................................................................................... 62
4. The Social Determinants of Health for African American Mothers Living with HIV .. 64
4.1 Introduction ..................................................................................................................... 64
4.2 Specific Aims ................................................................................................................... 68
4.2.1. Specific Aim 1 ............................................................................................................ 68
4.2.2 Specific Aim 2 ............................................................................................................. 68
4.3 Conceptual Framework ................................................................................................. 68

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4.4 Approach ......................................................................................................................... 73
4.4.1 Design .......................................................................................................................... 73
4.4.2 Setting .......................................................................................................................... 75
4.4.3 Sample and Sampling Plan ...................................................................................... 76
4.4.4. Recruitment and Retention ..................................................................................... 76
4.5 Data Collection Instruments and Procedures ............................................................ 78
4.5.1 Demographic Data .................................................................................................... 78
4.5.2 Interviews ................................................................................................................... 79
4.5.2.1 Rapport Building Interview ............................................................................. 80
4.5.2.2 Photo Content Interview ................................................................................... 82
4.5.2.3 Final In-depth Interview ................................................................................... 82
4.5.3 Ethical Conduct ......................................................................................................... 83
4.5.4 Data Preparation ........................................................................................................ 83
4.6 Data Analysis .................................................................................................................. 83
4.6.1 Demographic Data .................................................................................................... 83
4.6.2 Qualitative Data ......................................................................................................... 84
4.6.2.1 Phase One of Qualitative Analysis .................................................................. 84
4.6.2.2 Phase Two of Qualitative Analysis ................................................................. 90
4.6.2.3 Phase Three of Qualitative Analysis ............................................................... 93
4.7 Assuring Trustworthiness of Qualitative Descriptive Study ................................... 94
4.8 Results .............................................................................................................................. 95
4.8.1 Phase One: Content Analysis ................................................................................... 96

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