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When asked to capture images of the social and economic factors impacting their health in a qualitative descriptive study using photo elicitation, two women living with HIV produced strikingly similar images, but reflected on their meaning in profoundly different ways (Fig. 1).
Participant A reflected on the image she captured by saying, “I see the mirror…and I have to look into that everyday knowing that I am carrying a virus and it is hard to deal with…. I don't know what I can do about it because every time I look, that is what I see. So, a lot of times I put on extra make-up and try to hide it. I hide behind stuff.”
Conversely, Participant B reflected, “It's the bathroom, the mirror in the bathroom…. I like looking in the mirror…I like looking at myself, it makes me feel good. Like, okay, I'm here. I look at my face, my skin everyday. I am like WOW, you know. I am making it through another year. I still look healthy…it is a strength…it is my go-to place.”
For all intents and purposes, these women represent the same demographic profile. They both self-identify as African American women living with HIV and they are both mothers living in poverty in the southeastern region of the United States. Both women acquired HIV through heterosexual relationships approximately 7 years ago and both completed high school. If viewed through the lens of the traditional biomedical paradigm, these two women would likely be grouped into a single demographic category—African American, female, and low socioeconomic status. Yet, their perceptions of self, health, and living with HIV differ significantly. As clinicians, we understand these differences and regularly observe the spectrum of individual responses to health and illness as well as the social factors that shape those responses. As researchers, however, we often struggle to move beyond the simple documentation of health inequities between broad categories of the population and rather capture the heterogeneity of study participant's responses to illness and social processes.1 The assumption that homogeneity is implicit in demographically similar social groups of people is not only false,2,3 but is potentially harmful in that it can perpetuate the notion that disparate health outcomes for highly affected communities are intractable and push those communities further to the margins.1
Intersectional scholars recognize heterogeneity in illness response, emphasize social context and the power differentials inherent within those contexts, and employ multiaxis analyses needed to expand our understanding of health inequities and identify factors amenable to intervention.1,4 Intersectional approaches are not tied to specific research methodologies, but require an approach to research that acknowledges the social construction of categories of difference such as race, gender, and class.3,4
The images presented by these two women exemplify the complexity and diversity of individual responses to illness and demonstrate how social forces shape the health outcomes of patients living with HIV infection. Asking the right questions in the right way and listening closely to the answers can increase the likelihood of identifying solutions that ameliorate disparate health outcomes in communities affected by HIV.1
We thank the study participants who have helped us to understand their social determinants of health while living with HIV infection and Jeff Poe for his technical assistance. This work is supported by the Jonas Center for Nursing Excellence, Duke University Center for AIDS Research (CFAR) and National Institute of Nursing Research/National Institute of Health: National Research Service Award 1F31NR014628-01.
No competing financial interests exist.