Differences That Matter

Abstract

The practice of stratification based on variables or indicators such as race, ethnicity, gender and socioeconomic position has been integral in the development of a substantial body of the social epidemiologic literature demonstrating significant and persistent inequalities in health outcomes. However, it is time for social epidemiologists to recognize that mere demonstration of gradients is no longer enough. The identification of gaps and gradients based on these variables flags the presence of a potential problem but does not explain the underlying mechanisms. Yet these proxies are often treated as if they are the exposures responsible for the gaps in outcomes. In this chapter, we will explore how the practice of stratification in epidemiologic research can evolve to identify the real causes of the gaps and to inform interventions and evaluations of interventions that target identified health inequities. The key recommendations of this chapter are to:

• 1. Draw from strong theories about causal mechanisms, which must take into ­consideration the relational aspects of the groups we are comparing;

• 2. Undertake measurement of, and stratification by, the modifiable societal and contextual factors that lead to hierarchical power relations between socially defined groups; and

• 3. Undertake measurement of variables that accurately explain the heterogeneity of experiences within socially defined groups to ensure that groups or individuals are not essentialized, with a particular focus on the solution-linked variables responsible for the heterogeneity.