Precarity and health: Theorizing the intersection of multiple material-need insecurities, stigma, and illness among women in the United States

Highlights

• Investigates the intersection of multiple material-need insecurities among US women.

• Explores the experience of insecurities in finances, food, housing, and healthcare.

• Shows how these insecurities are stigmatizing and widely detrimental to health.

• Analyzes data through lenses of precarity and structural vulnerability.

• Organizes findings into a conceptual framework for research on precarity and health.

Abstract

Material-need insecurities (including insecurities in basic resources such as income, food, housing, and healthcare) are widespread in the United States (US) and may be important predictors of poor health outcomes. How material-need insecurities besides food insecurity are experienced, however, remains under-researched, including how multiple material-need insecurities might intersect and converge on the individual. Here we used qualitative methods to investigate experiences with multiple material-need insecurities among 38 food-insecure women aged over 50 years living with or at risk for HIV in the US. Our aims were: (1) to understand the co-experience of material-need insecurities beyond food insecurity; (2) to elucidate how multiple material-need insecurities might intersect; and (3) to discover how this intersection might be detrimental to health. During November 2017–July 2018, we conducted semi-structured interviews at three sites across the US (Northern California, Georgia, North Carolina) and analyzed the data using an inductive-deductive approach. We identified a common and complex picture of multiple material-need insecurities, stigma, and illness among participants across all three sites. There were five primary themes: (1) insecure income arising from a combination of precarious wage labor and federal disability benefits; (2) resultant experiences of uncertainty, compromised quality, insufficiency, and having to use socially unacceptable coping strategies across finances, food, housing, and healthcare; (3) participants’ disempowerment arising from their engagement with social safety net institutions; (4) closely related experiences of intersectional stigma and discrimination; and (5) negative implications for health across a wide range of illnesses. By employing the sociological concept of precarity—a term denoting the contemporary convergence of insecure wage labor and retraction of the welfare state—we combine these themes into a unifying framework of precarity and health. This framework may prove useful for testing how the widespread intersection of multiple material-need insecurities interacts with stigma and discrimination to negatively impact physical and mental health.

Introduction

Current indicators in the United States (US) show that a substantial proportion of the population lives in conditions either characterized by or bordering on material deprivation. During 2000–2015 the population living below 200% of the Federal Poverty Line grew by 25 million to total 106 million people, at over twice the rate of the nation's population growth (PolicyLink & USC PERE, 2018). In 2017, the US Department of Agriculture, which annually measures food insecurity (a term that denotes a spectrum of poverty-related problems with disrupted food intake and eating patterns) (Weiser et al., 2015), counted 40 million food-insecure people in the US (12.5% of the population) (Coleman-Jensen et al., 2018). In 2018, 38 million households paid over 30% of their income on housing costs (a standardized definition of poor affordability), representing 30% of all US households (Joint Center for Housing Studies, 2018). This percentage of households experiencing some kind of housing need rises to 35% if homeless individuals and overcrowded households are additionally taken into account, and even higher if those with poor housing/neighborhood quality or safety are included (Cox et al., 2017). In 2018, there was not a single US state, metropolitan area, or county where a worker earning the prevailing federal or state minimum wage for a 40-h week could afford a two-bedroom rental home at market rent (National Low Income Housing Coalition, 2018). Furthermore, 28.5 million people in the US (8.8% of the population) lack health insurance (Berchick et al., 2018), and double this number report not being able to afford the healthcare or medications they or their family need (Jones and Nekvasil, 2016).

The impacts that material deprivation has on health have long been studied in the socio-medical sciences. In medical anthropology and sociology in particular, the intersection of multiple vulnerabilities has been a prominent focus of recent research, theorized under such terms as “structural vulnerability” (Quesada et al., 2011), “precarity” (Lopez et al., 2018), “hypermarginality” (Comfort et al., 2015), “severe deprivation” (Desmond, 2015), and the “risk environment” (Rhodes, 2002), among others. Using primarily ethnographic research methods, these studies have illuminated the intersection of multiple harmful experiences that constrain the life-worlds of marginalized populations in the US, including extreme poverty, racism, poor access to health and social services, stigmatization, addiction, repeated incarceration, housing instability, and interpersonal violence. The strength of these studies lies in their ability to analyze, in granular detail, how complex networks of structures and institutions position groups of individuals to be at disproportionate risk for poor health and harm via these intersecting experiences.

Public health and epidemiological research has studied many of these same social phenomena using primarily quantitative methodologies. Within this literature, conditions of material deprivation including poverty, malnutrition, homelessness, and lacking health insurance—often referred to as part of the “social determinants” (Marmot, 2015) or “fundamental causes” (Phelan et al., 2010) of poor health—are understood to drive poor health outcomes. Yet, in social epidemiological studies, the issues listed above are increasingly conceptualized as only the most extreme forms of a wider collection of related challenges. Food insecurity, for example, moves beyond malnutrition to encompass distinct but closely related experiences including inadequate quantity of food, poor diet quality, uncertainty around accessing food, and having to engage in socially unacceptable procurement of food (e.g. stealing or exchanging sex for food) (Weiser et al., 2015). People experiencing food insecurity face any or all of these challenges at different times. Even milder forms of food insecurity (such as persistent uncertainty around food access) are associated with poor health outcomes in quantitative studies, suggesting that just the threat of hunger confers a differential disadvantage to health (Weiser et al., 2015).

Other domains of basic need are beginning to be characterized in analogous fashion in epidemiological studies as “material-need insecurities” (Berkowitz et al., 2015). Ongoing efforts to develop a standardized measure of housing insecurity, for example, identify seven components that might fall under its definition, including homelessness, overcrowding, living in unsafe structures, substandard quality of interiors, living in an unsafe neighborhood, and poor quality of the neighborhood environment (Cox et al., 2017). Other housing research focuses on “energy insecurity”: the inability to adequately meet basic household energy needs (such as gas, electricity, heating, and water) (Hernandez, 2016). Employment insecurity and debt have been implicated as social determinants of health (Sweet et al., 2013; Virtanen et al., 2013), while other studies employ measures of subjective financial insecurity (Niedzwiedz et al., 2017). Few studies, meanwhile, have examined subjective insecurities in access to health insurance.

Several aspects of material-need insecurities have been associated with poor health in quantitative studies. Food insecurity has been associated with poor outcomes in cardiovascular disease (CVD) (Seligman et al., 2010), type 2 diabetes mellitus (T2DM) (Berkowitz et al., 2018), and HIV (Spinelli et al., 2017), as well as substance use (Whittle, Sheira, Frongillo, et al., 2019) and mental health outcomes including depression (Nagata et al., 2019), anxiety (Whittle, Sheira, Wolfe, et al., 2019b), symptoms of post-traumatic stress disorder (Whittle, Sheira, Wolfe, et al., 2019a,b), and suicidality (Nagata et al., 2019). The paths through which these associations arise are multiple and complex, encompassing numerous interacting biological, psychosocial, and behavioral mechanisms that converge on the individual (Weiser et al., 2015). Various aspects of housing need have similarly been associated with poor outcomes in CVD (Vijayaraghavan et al., 2013), T2DM (Vijayaraghavan et al., 2011), HIV (Clemenzi-Allen et al., 2018), substance use (Smith et al., 2017), depression and anxiety (Burgard et al., 2012), and suicidality (Bossarte et al., 2013). Subjective financial insecurity has been associated with systemic cardiometabolic risk factors (Niedzwiedz et al., 2017), while employment insecurity predisposes to CVD (Virtanen et al., 2013), T2DM (Ferrie et al., 2016), and depression (Kim & von dem Knesebeck, 2016).

Epidemiological research in this topic has been limited, however, by its separation of concepts shown by social science studies to be inseparably intertwined. Material-need insecurities have largely been studied separately but are likely to be closely related and fluctuate in response to changing resource demands, financial pressures, and local provisions. Exceptions include recent studies on the role of multiple material-need insecurities in T2DM (Berkowitz et al., 2015) and the effects of the “double precarity” of employment and housing insecurity on mental health (Bentley et al., 2019). Previous research on food insecurity specifically has demonstrated the value of mixed methods approaches to studying material-need insecurities. Qualitative insights were used to inform the original concept (Radimer et al., 1992) and have subsequently helped to elucidate the ways in which experiences of food insecurity are detrimental to health (Whittle et al., 2016), contributing in both cases to the development of frameworks for quantitative testing. Few qualitative studies, however, have specifically explored the experience of other material-need insecurities in the US in this manner, or specifically focused on the intersection of multiple material-need insecurities as they are conceptualized in the public health literature. While insights from social science studies have much to contribute in this respect, the complexity of their theoretical models means that further analytic work is needed to distill and translate some of these insights into a conceptual framework of material-need insecurities that can be operationalized and tested in public health and clinical research.

In this study, we draw on the concepts of structural vulnerability and precarity to analyze the experience of multiple material-need insecurities among women in the US, to conceptually clarify (1) our understanding of other material-need insecurities beyond food insecurity, (2) the ways in which multiple material-need insecurities might intersect, and (3) how the intersection of these insecurities may be detrimental to health. Structural vulnerability is a concept developed from earlier theories of “structural violence”, a term that describes how historically embedded social, economic, legal, cultural, and institutional structures converge to place particular groups of individuals at elevated risk for poor health (Quesada et al., 2011). Structural vulnerability builds on this mainly political-economic concept to additionally integrate cultural and idiosyncratic sources of physical and psychological harm, and, crucially, conceptualizes the convergence of these factors as a “positionality” that can be examined from the ground up (Quesada et al., 2011). A key insight of structural vulnerability is that such large-scale, distal forces tend to exert more subtle and insidious everyday effects on affected individuals, slowly altering perceptions, behavior, affect, and cognition in chronically harmful ways.

Within this framework, cognitive processes of internalization, self-blame, and shame play an important role, as they tend to conceal (and therefore perpetuate) the structural causes of poor health (Holmes, 2013). Studies using structural vulnerability tend to employ concepts developed from Bourdieusian sociology—particularly “symbolic violence” (Bourdieu, 2000)—to describe these internalization dynamics. Closely related, however, is the concept of “internalized stigma,” which describes how stigmatized individuals come to accept stigmatizing attitudes as natural and valid, developing negative self-perceptions and feelings of shame (Turan et al., 2017). This is contrasted with “enacted” or “felt” stigma, which refer to actual or anticipated acts of discrimination, respectively (Turan et al., 2017). Here we opt to employ these concepts of stigma due to their frequent use in public health research, where studies have shown that health-related stigmas (such as HIV stigma) are frequently reinforced by other marginalized social identities (e.g. pertaining to gender, race/ethnicity, socioeconomic status, or sexual orientation) to negatively impact health outcomes (Turan et al., 2017). This process of convergence and interaction, termed “intersectional stigma” because of its origins in intersectionality theory (Crenshaw, 1991), has principally been developed through insights from qualitative studies (Logie et al., 2011; Rice et al., 2018; Whittle et al., 2017).

The other concept we employ, precarity, was developed in European labor activist movements before being adopted by various fields of social science (Neilson and Rossiter, 2008). We employ the term here in a sociological sense, using it to refer to contemporary social and economic insecurity in certain nations (principally in Europe and North America) driven specifically by two interlinked phenomena observed during the latter 20th and early 21st centuries: (1) the post-industrial resurgence of insecure and informal labor; and (2) the political retraction of state responsibility for social welfare (Schram, 2015; Wacquant, 2009). The ideal of combining secure wage labor with a comprehensive social safety net dominated the political economy of nations such as the US in the post-war era (Katz, 2013). The well-documented dissolution of this ideal since the 1980's, in turn, has prompted recognition of the widespread economic uncertainty, anxiety, and hardship that result when the responsible institutions are weakened (Harvey, 2005; Katz, 2013; Schram, 2015; Wacquant, 2009). Used in this sense, precarity anchors this study of US women in 2017–2018 to its specific historic and geographic context, and provides an organizing framework for conceptualizing the convergence and intersection of multiple material-need insecurities.