Intersectional Life Course Inequalities in Cardiovascular Health in Post-Apartheid South Africa

Health inequalities research typically employs single measurement modalities, which limit our understanding of how historical structural violence affects different dimensions of health experience across intersectional social positions over the life course.

Using longitudinal data from South Africa's National Income Dynamics Study (2008-2017), we employed dual measurement approaches and intersectional life course analysis to examine cardiovascular health trajectories among 36,814 individuals (92,702 person-years of observation). Random-effects logistic regression modeled measured hypertension, while zero-inflated Poisson regression examined self-reported CVD comorbidity across birth cohorts defined by differential apartheid exposure, testing race × gender interactions explicitly.

Pronounced birth cohort gradients emerged with hypertension prevalence declining from 77.8% (Pre-Apartheid cohort) to 20.3% (Born Free generation), remaining stable across nine study years. Born Free participants showed 46% lower odds of hypertension (OR = 0.54, 95% CI: 0.45-0.64) but 85% lower rates of CVD comorbidity (IRR = 0.15, 95% CI: 0.10-0.22) compared to Apartheid-Era cohorts. Non-additive race × gender interactions varied systematically by measurement domain: among Africans, women exhibited lower hypertension prevalence than men but higher CVD comorbidity reporting, while other racial groups showed minimal gender differences. Intersectional patterns demonstrated remarkable temporal stability, suggesting durable characteristics established during critical periods rather than transient variations.

These findings advance life course epidemiology by demonstrating that historical structural violence creates lasting health consequences through two pathways: biological embedding, which produces stable physiological alterations, and psychosocial adaptation, which affects health perceptions. Intersectionality theory gains empirical support through evidence that multiple disadvantaged systems create qualitatively different health experiences requiring non-additive analytical approaches. The systematic measurement divergences underscore the importance of dual assessment for the comprehensive evaluation of health inequalities. Similar to European post-transition societies, post-conflict health patterns exhibit complex trajectories requiring longitudinal intersectional analysis. Policy interventions must address both biological and psychosocial pathways while accounting for intersectional health vulnerabilities that persist decades after institutional discrimination ends.