An intersectionality framework for identifying relevant covariates in health equity research.

Introduction: Health equity research uses impact evaluations to estimate the effectiveness of new interventions that aim to mitigate health inequities. Health inequities are influenced by many experiential factors and failure of research to account for such experiential factors and their potential interactions may jeopardize findings and lead to promoted methods that may unintentionally sustain or even worsen the targeted health inequity. Thus, it is imperative that health equity impact evaluations identify and include variables related to the circumstances, conditions, and experiences of the sample being studied in analyses. In this review, we promote intersectionality as a conceptual framework for brainstorming important yet often overlooked covariates in health equity related impact evaluations. Methods: We briefly review and define concepts and terminology relevant to health equity, then detail four domains of experiential factors that often intersect in ways that may obscure findings: Biological, Social, Environmental, and Economic. Results: We provide examples of the framework's application to lupus-related research and examples of covariates used in our own health equity impact evaluations with minority patients who have lupus. Discussion: Applying an intersectionality framework during covariate selection is an important component to actualizing precision prevention. While we do not provide an exhaustive list, our aim is to provide a springboard for brainstorming meaningful covariates for health equity evaluation that may further help unveil sustainable solutions to persisting health inequities.

Drivers of perceived discrimination among older adults in India: an intersectional analysis.

Discrimination is harmful action taken against individuals or groups to protect customary relations of power and privilege. Older adults are particularly vulnerable to experiences of discrimination that adversely affect their quality of life. We use data from the Longitudinal Ageing Study of India (LASI; Wave 1; 2017-2018) to examine different contextual forces that shape the experiences of discrimination in older adults in India, specifically gender, caste, and economic condition. We used the theory of intersectionality to hypothesize that economic condition, caste, and gender combine uniquely to engender perceived discrimination in older adults. We first used a concentration index to determine the sample's pre-existing inequality levels. The concentration curve evidenced a disproportionate concentration of discrimination among people with low income. Next, we used a three-way ANCOVA to examine the effects of caste, gender, and economic condition on individuals' experiences of discrimination. A significant interaction effect of caste, gender, and economic condition [F(1, 30,394) = 8.91 p = 0.003] evidenced the compounding effects of inequalities on experiences of discrimination. Finally, we ran a moderation model to test the ameliorating effects of education on experiences of discrimination experienced by marginalized castes. The model was significant (ß= -0.192; p < 0.001), thereby supporting the proposition that increased education level can lead to an increased sense of belonging and perceptions of equal treatment, which relate negatively to perceived discrimination. Results are discussed considering intersectionality in peoples' struggles and resilience in India.

Development and validation of the SAFE (Socially Ascribed intersectional identities For Equity) questionnaire.

Traditional questionnaires do not capture the complexity of how people are viewed by others and grouped into categories on the basis of what is inferred (or not) about them. This is critical in applying an intersectionality framework in research because people are negatively impacted because of "who they are" but also based on "how others see them." The purpose of this project was to develop and validate a questionnaire, grounded in intersectionality theory and a nuanced understanding of social position, that can be applied in large-scale, population-based surveys and studies. Drawing on 61 existing quantitative surveys collecting identity-based information and 197 qualitative studies on intersectionality describing the complex ways in which people's social positions are constructed and experienced, we created a draft questionnaire comprising five parts: 1) Sex and Gender, 2) Sexuality and Sexual Orientation, 3) Cultural Context, 4) Disability, Health, and Physical Characteristics, and 5) Socioeconomic Status. A draft of the questionnaire was then reviewed by experts via the Delphi process, which gauged the accessibility of the questionnaire (e.g., language used, length) and the relevance of its content using a 5-point scale and open-ended questions. These responses were ranked, analyzed, and synthesized to refine the questionnaire and, ultimately, to obtain ≥75 % consensus on each questionnaire item and response option. The SAFE questionnaire provides an opportunity to take a significant step forward in advancing our understanding of the complex, intersectional nature of social participation and marginalization.

Redefining global cardiac surgery through an intersectionality lens.

Although cardiovascular diseases are the leading cause of morbidity and mortality worldwide, six billion people lack access to safe, timely and affordable cardiac surgical care when needed. The burden of cardiovascular disease and disparities in access to care vary widely based on sociodemographic characteristics, including but not limited to geography, sex, gender, race, ethnicity, indigeneity, socioeconomic status and age. To date, the majority of cardiovascular, global health and global surgical research has lacked intersectionality lenses and methodologies to better understand access to care at the intersection of multiple identities and traditions. As such, global (cardiac) surgical definitions and health system interventions have been rooted in reductionism, focusing, at most, on singular sociodemographic characteristics. In this article, we evaluate barriers in global access to cardiac surgery based on existing intersectionality themes and literature. We further examine intersectionality methodologies to study access to cardiovascular care and cardiac surgery and seek to redefine the definition of 'global cardiac surgery' through an intersectionality lens.

Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality.

Patients from minoritized backgrounds based on race/ethnicity, gender, sexuality, and other social identities are more likely to experience inequities in access in kidney transplantation. Although these inequities have been reported over the decades, limited research focuses on the experiences of patients with intersecting minoritized social statuses and the mechanisms that contribute to their reduced access to transplantation. Intersectionality, a framework for understanding the ways in which multiple social identities represent interacting systems of oppression and privilege, offers a nuanced approach for understanding the experiences of patients diagnosed with end-stage organ disease with intersecting social identities. This article outlines complex systems that perpetuate inequities by highlighting the value of intersectionality in studying disparate outcomes to transplant and providing recommendations for the transplant community. This article aligns with the ESOT call for action to promote equity in transplantation worldwide.

A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population.

Primary health care (PHC) systems are a crucial instrument for achieving equitable population health, but there is little evidence of how PHC reforms impact equities in population health. In 2010, Sweden implemented a reform that promoted marketization and privatization of PHC. The present study uses a novel integration of intersectionality-informed and evaluative epidemiological analytical frameworks to disentangle the impact of the 2010 Swedish PHC reform on intersectional inequities in avoidable hospitalizations. The study population comprised the total Swedish population aged 18-85 years across 2001-2017, in total 129 million annual observations, for whom register data on sociodemographics and hospitalizations due to ambulatory care sensitive conditions were retrieved. Multilevel Analysis of Individual Heterogeneity and Discriminatory Analyses (MAIHDA) were run for the pre-reform (2001-2009) and post-reform (2010-2017) periods to provide a mapping of inequities. In addition, random effects estimates reflecting the discriminatory accuracy of intersectional strata were extracted from a series MAIHDAs run per year 2001-2017. The estimates were re-analyzed by Interrupted Time Series Analysis (ITSA), in order to identify the impact of the reform on measures of intersectional inequity in avoidable hospitalizations. The results point to a complex reconfiguration of social inequities following the reform. While the post-reform period showed a reduction in overall rates of avoidable hospitalizations and in age disparities, socioeconomic inequities in avoidable hospitalizations, as well as the importance of interactions between complex social positions, both increased. Socioeconomically disadvantaged groups born in the Nordic countries seem to have benefited the least from the reform. The study supports a greater attention to the potentially complex consequences that health reforms can have on inequities in health and health care, which may not be immediate apparent in conventional evaluations of either population-average outcomes, or by simple evaluations of equity impacts. Methodological approaches for evaluation of complex inequity impacts need further development.

Mechanisms underlying the relationship between the intersectionality of multiple social identities with depression among US adults: A population-based study on the mediating roles of lifestyle behaviors.

BACKGROUND: Despite substantial efforts to investigate the inequalities in mental health among people with marginalized identities, most research has concentrated on single social identities rather than complete persons. The current study aimed to explore the mechanisms underlying the relationship between the intersectionality of multiple social identities with depression among US adults. METHODS: Data for this study came from the National Health and Nutrition Examination Survey waves between 2015 and 2018, including a total of 11,268 US adults. A latent class analysis (LCA) was conducted to identify latent subpopulations based on sex, race/ethnicity, immigrant status, disability, household income, employment status, and education level. Interclass differences in lifestyle factors and depression were examined. Multiple mediation analysis was used to examine the mediating roles of lifestyle behaviors. RESULTS: LCA identified four potential subpopulations: "least marginalized", "immigrant minorities", "disabled, less-educated non-workers", and "low-income minorities" groups. There was enormous heterogeneity in mental health among immigrant minority individuals. The "disabled, less-educated non-workers" group had the highest rates of depression; in contrast, the "immigrant minorities" group had the best mental health, even better than that of the "least marginalized" group. Distributions of lifestyle factors followed a similar pattern. In addition, lifestyle behaviors significantly mediated the relationship between intersectional social identities and depression. LIMITATIONS: The cross-sectional design prevented establishment of the causality of relationships. CONCLUSIONS: This study suggests that applying a person-centered approach is important when examining intersectional inequalities in mental health and highlights the effects of structural social hierarchies on individuals' health behaviors and mental health.

Understanding intersectional inequality in access to primary care providers using multilevel analysis of individual heterogeneity and discriminatory accuracy.

BACKGROUND: Despite the Canadian healthcare system's commitment to equity, evidence for disparate access to primary care (PC) providers exists across individual social identities/positions. Intersectionality allows us to reflect the realities of how social power shapes healthcare experiences at an individual's interdependent and intersecting social identities/positions. The objectives of this study were to determine: (1) the extent to which intersections can be used classify those who had/did not have a PC provider; (2) the degree to which each social identity/position contributes to the ability to classify individuals as having a PC provider; and (3) predicted probabilities of having a PC provider for each intersection. METHODS AND FINDINGS: Using national cross-sectional data from 241,445 individuals in Canada aged ≥18, we constructed 320 intersections along the dimensions of gender, age, immigration status, race, and income to examine the outcome of whether one had a PC provider. Multilevel analysis of individual heterogeneity and discriminatory accuracy, a multi-level model using individual-level data, was employed to address intersectional objectives. An intra-class correlation coefficient (ICC) of 23% (95%CI: 21-26%) suggests that these intersections could, to a very good extent, explain individual variation in the outcome, with age playing the largest role. Not all between-intersection variance in this outcome could be explained by additive effects of dimensions (remaining ICC: 6%; 95%CI: 2-16%). The highest intersectional predicted probability existed for established immigrant, older South Asian women with high income. The lowest intersectional predicted probability existed for recently immigrated, young, Black men with low income. CONCLUSIONS: Despite a "universal" healthcare system, our analysis demonstrated a substantial amount of inequity in primary care across intersections of gender, age, immigration status, race, and income.

We are complex beings: comparison of statistical methods to capture and account for intersectionality.

OBJECTIVES: Intersectionality conceptualises how different parts of our identity compound, creating unique and multifaceted experiences of oppression. Our objective was to explore and compare several quantitative analytical approaches to measure interactions among four sociodemographic variables and interpret the relative impact of axes of marginalisation on self-reported health, to visualise the potential elevated impact of intersectionality on health outcomes. DESIGN: Secondary analysis of National Epidemiologic Survey on Alcohol and Related Conditions-III, a nationally representative cross-sectional study of 36 309 non-institutionalised US citizens aged 18 years or older. PRIMARY OUTCOME MEASURES: We assessed the effect of interactions among race/ethnicity, disability status, sexual orientation and income level on a self-reported health outcome with three approaches: non-intersectional multivariate regression, intersectional multivariate regression with a single multicategorical predictor variable and intersectional multivariate regression with two-way interactions. RESULTS: Multivariate regression with a single multicategorical predictor variable allows for more flexibility in a logistic regression problem. In the fully fitted model, compared with individuals who were white, above the poverty level, had no disability and were heterosexual (referent), only those who were white, above the poverty level, had no disability and were gay/lesbian/bisexual/not sure (LGBQ+) demonstrated no significant difference in the odds of reporting excellent/very good health (aOR=0.90, 95% CI=0.71 to 1.13, p=0.36). Multivariate regression with two-way interactions modelled the extent that the relationship between each predictor and outcome depended on the value of a third predictor variable, allowing social position variation at several intersections. For example, compared with heterosexual individuals, LGBQ+ individuals had lower odds of reporting better health among whites (aOR=0.94, 95% CI=0.93 to 0.95) but higher odds of reporting better health among Black Indigenous People of Color (BIPOC) individuals (aOR=1.13, 95% CI=1.11 to 1.15). CONCLUSION: These quantitative approaches help us to understand compounding intersectional experiences within healthcare, to plan interventions and policies that address multiple needs simultaneously.

Intersecting gender identity and racial/ethnic inequities in eating disorder risk factors, symptoms, and diagnosis among U.S. college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy.

INTRODUCTION: There are documented inequities in eating disorders (EDs) by gender and race/ethnicity, yet, little is known about population-level prevalence of ED risk factors, symptoms, and diagnosis at the intersection of diverse gender and racial/ethnic identities. METHODS: Data from the Healthy Minds Study 2015-2019 (N = 251,310 U.S. university students) were used in a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Participants were nested in 35 intersectional strata given by all combinations of 5 gender and 7 racial/ethnic categories. Multilevel logistic models with participants at level 1 and intersectional strata at level 2 were used to estimate stratum-specific predicted prevalence estimates for self-reported thin-ideal internalization, ED symptoms, and ED diagnosis. The variance partition coefficient (VPC) was calculated to quantify the contextual effect of the strata. RESULTS: There was considerable heterogeneity in the predicted prevalence of our ED outcomes across the strata (e.g., .3%-18.3% for ED diagnoses). There were large disparities in all three outcomes, with transgender participants of color having a higher predicted prevalence than expected based on the additive effects of gender and race/ethnicity. Moderation by race/ethnicity was also apparent, such that racial/ethnic disparities were wider within the cisgender groups relative to the transgender groups. VPCs indicated that ~10% of the total variance in ED outcomes was due to intersectionality between gender and race/ethnicity, over and above variance due to individual-level differences. CONCLUSION: Findings suggest that gender and racial/ethnic disparities in EDs are interrelated, underscoring the need to develop preventive interventions centering health equity. PUBLIC SIGNIFICANCE: Despite evidence that sexism, racism, and cissexism (i.e., anti-transgender prejudice) can impact EDs risk, little research examines the social patterning of EDs at the intersection of diverse gender and racial/ethnic identities. Using data from a sample of 250,000 U.S. university students, this study found that gender and racial/ethnic disparities in eating disorder risk are interrelated, highlighting the need to develop health equity centered preventive interventions.

Intersectionality of demographic characteristics in self-reported anorexia nervosa, bulimia nervosa, and probable eating disorders among college students.

OBJECTIVE: To investigate associations between identity intersectionality, with a primary focus on minority identity, and probable eating disorders (EDs) within the US college student population. METHOD: Data consisting of n = 414,299 college students' responses to the American College Health Association's National College Health Assessment between fall 2015 and spring 2019 were utilized for this study. Overall and stratified adjusted odds ratios (aORs) were used to assess the association between different facets of identity (i.e., race/ethnicity, gender identity, and sexual orientation) and probable EDs. RESULTS: Among all, in our analytic sample, 7.15% reported a probable ED. Interactions between all three identity variables were significant, and thus stratified odds ratios were evaluated. Transgender men were significantly more likely to report probable ED than cisgender male peers within the following racial/ethnic groups: non-Hispanic White (aOR: 3.33; 95% CI: 2.79, 3.96; p < .0001), non-Hispanic Black (aOR: 3.29; 95% CI: 1.72, 6.28; p = .0003), Hispanic (aOR: 2.31; 95% CI: 1.55, 3.43; p < .0001), Asian or Pacific Islander (aOR: 2.19; 95% CI: 1.45, 3.30; p = .0002), Biracial or Multicultural (aOR: 3.36; 95% CI: 2.17, 5.22; p < .0001), and other (aOR: 4.19; 95% CI: 2.25, 7.79; p < .0001). CONCLUSIONS: This study underscores the importance of increasing our understanding of interactions between marginalized identities and the ways in which minority identity informs ED risk. PUBLIC SIGNIFICANCE: The impact of multiple marginalized identities on ED outcomes is not well understood. Our study expands on previous ACHA-NCHA studies by addressing identity intersectionality, looking at more than one identity at a time (i.e., specifically race/ethnicity, gender identity, and sexual orientation). Our results contribute unique risk profiles for students who identify with multiple marginalized groups. Further, they indicate that that these associations vary based on the compounded effect of the demographic factors considered.

The Intersection of Social Determinants of Health and Post-stroke Aphasia Outcomes: A Need for Intersectional Analysis.

Aphasia is a disorder that results from damage to portions of the brain that are responsible for language and can vary significantly by type and severity. Differences in aphasia outcomes are influenced by the social determinants of health (SDOH). The SDOH are structural, environmental, and personal determinants that influence health outcomes. Intersectionality, or how one's social and political identities interact to influence individual life outcomes and/or advantage in our society, provides a way to examine the varying levels of the SDOH. However, intersectionality is complex, difficult to measure, and has not yet been explored in post-stroke aphasia outcomes. This article reviews the relationship of race and aphasia outcomes and the SDOH and aphasia outcomes. Additionally, we provide a novel current approach to examine the SDOH and aphasia outcomes. Lastly, we discuss the need for evaluation of intersectionality in aphasia and aim to provide a leveled social-ecological framework to examine aphasia-related outcomes. With notable individual differences among aphasia outcomes, we present a framework to support optimizing research and clinical aphasia care in speech-language pathology.

An intersectional analysis of long COVID prevalence.

BACKGROUND: Long COVID symptoms - which include brain fog, depression, and fatigue - are mild at best and debilitating at worst. Some U.S. health surveys have found that women, lower income individuals, and those with less education are overrepresented among adults with long COVID, but these studies do not address intersectionality. To fill this gap, we conduct an intersectional analysis of the prevalence and outcomes of long COVID in the U.S. We posit that disparities in long COVID have less to do with the virus itself and more to do with social determinants of health, especially those associated with occupational segregation and the gendered division of household work. METHODS: We use 10 rounds of Household Pulse Survey (HPS) data collected between June 2022 and March 2023 to perform an intersectional analysis using a battery of descriptive statistics that evaluate (1) the prevalence of long COVID and (2) the interference of long COVID symptoms with day-to-day activities. We also use the HPS data to estimate a set of multivariate logistic regressions that relate the odds of having long COVID and activity limitations due to long COVID to a set of individual characteristics as well as intersections by sex, race/ethnicity, education, and sexual orientation and gender identity. RESULTS: Findings indicate that women, some people of color, sexual and gender minorities, and people without college degrees are more likely to have long COVID and to have activity limitations from long COVID. Women have considerably higher odds of developing long COVID compared to men, a disparity exacerbated by having less education. Intersectional analysis by gender, race, ethnicity, and education reveals a striking step-like pattern: college-educated men have the lowest prevalence of long COVID while women without college educations have the highest prevalence. Daily activity limitations are more evenly distributed across demographics, but a different step-like pattern is present: fewer women with degrees have activity limitations while limitations are more widespread among men without degrees. Regression results confirm the negative association of long COVID with being a woman, less educated, Hispanic, and a sexual and gender minority, while results for the intersectional effects are more nuanced. CONCLUSIONS: Results point to systematic disparities in health, highlighting the urgent need for policies that increase access to quality healthcare, strengthen the social safety net, and reduce economic precarity.

Palliative care research utilising intersectionality: a scoping review.

BACKGROUND: Access to palliative care is recognised as a human right, yet clear disparities exist. There have been recent appeals to examine people's contexts and interactions with social systems which for many, adversely influence their utilisation of palliative care. Intersectionality provides a way to understand these drivers of inequity and ultimately advocate for change. AIM: To identify and describe published studies utilising intersectionality in relation to need, access and experience of palliative care. DESIGN: A scoping review. DATA SOURCES: Medline, PsycINFO, CINAHL and Google Scholar databases and a manual search were undertaken for studies published up to January 2023. Included studies were evidence based articles where palliative or end of life care was the focus and intersectionality was identified and/or applied to the research that was undertaken. RESULTS: Ten published studies were included. An analytic framework was developed to identify the extent that intersectionality was utilised in each study. A wide range of different groups were researched across the studies, with most focusing on aspects of their participant's identity in relation to palliative care access and experience. Common topics of power, heterogeneity of people within the health system and barriers to palliative care were illuminated across the studies. CONCLUSIONS: Very limited research to date has utilised intersectionality to understand access, utilisation and experience of palliative care. This scoping review demonstrates intersectionality can provide a way to illuminate rich understandings of inequity in palliative care. It is imperative that future palliative research incorporates an intersectionality focus to further clarify the needs and experiences of structurally marginalised groups.

Admitting the heterogeneity of social inequalities: intersectionality as a (self-)critical framework and tool within mental health care.

Inequities shape the everyday experiences and life chances of individuals at the margins of societies and are often associated with lower health and particular challenges in accessing quality treatment and support. This fact is even more dramatic for those individuals who live at the nexus of different marginalized groups and thus may face multiple discrimination, stigma, and oppression. To address these multiple social and structural disadvantages, intersectional approaches have recently gained a foothold, especially in the public health field. This study makes an empirically informed argument for the merits of increasing the use of intersectional frameworks in the mental health field. In the mental health field, the potential for greater attention to multiple unjustified disadvantages appears to be of particular importance, as many mental health service users already face stigma and discrimination because of their mental health issues and thus may benefit particularly frequently and far-reachingly from effective problem awareness about multiple disadvantages. Intersectional approaches may help address the complexity, interdependence, and mutual constitution of social inequalities better than previous approaches that examined only one category of sociostructural stratification. By helping to identify the needs of those at the greatest risk of poor health, intersectional frameworks and tools can contribute not only to better address the needs of multiple disadvantaged individuals with mental health issues but also to the promotion of equity in the field of mental health, contributing to the reduction of health disparities.

Female Latin American migrant workers and violences: towards an intersectional perspective? / Trabalhadoras migrantes latino-americanas e violências: rumo a uma visão interseccional?

The history of Latin American society has been influenced by colonization, which has subjugated non-white women to gender violence, racism and sexism. This article discusses the work of female Latin American migrants through the lens of intersectionality to reflect upon the historical and social realities of Latin women who migrate in search of employment or to escape violence. Drawing upon the contributions of the sociologist Patricia Collins, this article discusses the concept of intersectionality and topics pertaining to intersectional analyses (relationality, power relations, social inequality, social context, complexity and social justice). As a critical social theory that is under construction, intersectionality deepens the analysis of oppressions experienced by female migrant workers, such as xenophobia, racism, slave labor, sexual exploitation and precarious working conditions. Thinking about the violence experienced by female Latin American workers from an intersectional perspective implies listening to these women, understanding their resistance, increasing the visibility of collective actions, and guaranteeing the implementation of public policies considering their experiences and perspectives.

A história da sociedade latino-americana é influenciada pela colonização que subjugou, sobretudo, as mulheres não brancas às violências de gênero, ao racismo e ao sexismo. Este artigo tem por finalidade discutir o trabalho de migrantes latino-americanas a partir da abordagem interseccional, para se pensar nas realidades históricas e sociais de mulheres latinas, que se deslocam para a procura de emprego ou para escapar das violências sofridas no meio social. Mediante as contribuições da socióloga Patrícia Collins, são discutidos o conceito de interseccionalidade e os temas pertinentes às análises interseccionais (relacionalidade, relações de poder, desigualdade social, contexto social, a complexidade e justiça social). A interseccionalidade como teoria social crítica em construção aprofunda as análises das opressões vividas pelas trabalhadoras migrantes, como a xenofobia, o racismo, as inclinações ao trabalho escravizado e/ou à exploração sexual, as condições de trabalho precarizadas etc. Pensar nas violências sofridas pelas trabalhadoras latino-americanas sob a perspectiva interseccional é escutá-las, compreender suas resistências, visibilizar as ações coletivas e garantir que políticas públicas sejam implementadas, considerando as experiências e as perspectivas dessas trabalhadoras.