Intersectionality in quantitative health disparities research: A systematic review of challenges and limitations in empirical studies

Who is Anaemic in India? Intersections of class, caste, and gender

Anaemia severely impacts physical and mental abilities, raises health risks, and diminishes the quality of life and work capacity. It is a leading cause of adverse pregnancy outcomes and maternal mortality, especially in developing nations like India, where recent data on anaemia from National Family and Health Survey (NFHS-4) (2015-16) and NFHS-5 (2019-21) indicate a tremendous rise. Anaemia is a marker of poor nutrition and health, and socio-economic factors such as gender norms, race, income, and living conditions influence its impact. As a result, there are disparities in how anaemia affects different segments of society. However, existing research on health inequity and anaemia often employs a single-axis analytical framework of social power. These studies operate under the assumption that gender, economic class, ethnicity, and caste are inherently distinct and mutually exclusive categories and fail to provide a comprehensive understanding of anaemia prevalence. Therefore, the study has adopted the theoretical framework of intersectionality and analysed the NFHS-5 (2019-21) data using bivariate cross-tabulations and binary logistic regression models to understand how gender, class, caste, and place of residence are associated with the prevalence of anaemia. The results suggest that the women of Scheduled Tribes (ST) and Scheduled Castes (SC) share a disproportionate burden of anaemia. This study confirms that economic class and gender, geographical location, level of education, and body mass index significantly determine the prevalence of anaemia. The ST and SC women who are economically marginalised and reside in rural areas with high levels of poverty, exclusion, and poor nutritional status have a higher prevalence of anaemia than other population groups. Thus, the study suggests that intersections of multiple factors such as caste, class, gender, and place of residence significantly determine 'who is anaemic in India'.

Opportunities for incorporating intersectionality into biomedical informatics

Many approaches in biomedical informatics (BMI) rely on the ability to define, gather, and manipulate biomedical data to support health through a cyclical research-practice lifecycle. Researchers within this field are often fortunate to work closely with healthcare and public health systems to influence data generation and capture and have access to a vast amount of biomedical data. Many informaticists also have the expertise to engage with stakeholders, develop new methods and applications, and influence policy. However, research and policy that explicitly seeks to address the systemic drivers of health would more effectively support health. Intersectionality is a theoretical framework that can facilitate such research. It holds that individual human experiences reflect larger socio-structural level systems of privilege and oppression, and cannot be truly understood if these systems are examined in isolation. Intersectionality explicitly accounts for the interrelated nature of systems of privilege and oppression, providing a lens through which to examine and challenge inequities. In this paper, we propose intersectionality as an intervention into how we conduct BMI research. We begin by discussing intersectionality's history and core principles as they apply to BMI. We then elaborate on the potential for intersectionality to stimulate BMI research. Specifically, we posit that our efforts in BMI to improve health should address intersectionality's five key considerations: (1) systems of privilege and oppression that shape health; (2) the interrelated nature of upstream health drivers; (3) the nuances of health outcomes within groups; (4) the problematic and power-laden nature of categories that we assign to people in research and in society; and (5) research to inform and support social change.

Identity Matters: Religious Experiences of US based Transgender Young People

Research centered on the socioemotional benefits of religion and religious congregations for young people has highlighted largely positive outcomes for both young people and religious congregations. However, fewer studies have explored whether transgender young people receive those same socioemotional benefits from being religiously affiliated. Using secondary quantitative data from the 2015 US Transgender Survey, this study examined the religious experiences of transgender young people (aged 18-24). The data indicate that individual demographics (e.g., race, gender identity, sexual orientation, religious affiliation) affected the religious experiences of transgender young people, including leaving their congregations due to the fear of being rejected. More research is needed on the socioemotional benefits of religious affiliation for transgender young people.

Methods for structural sexism and population health research: Introducing a novel analytic framework to capture life-course and intersectional effects

Accumulating evidence links structural sexism to gendered health inequities, yet methodological challenges have precluded comprehensive examinations into life-course and/or intersectional effects. To help address this gap, we introduce an analytic framework that uses sequential conditional mean models (SCMMs) to jointly account for longitudinal exposure trajectories and moderation by multiple dimensions of social identity/position, which we then apply to study how early life-course exposure to U.S. state-level structural sexism shapes mental health outcomes within and between gender groups. Data came from the Growing Up Today Study, a cohort of 16,875 children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant public policies and societal conditions (e.g., abortion bans, wage gaps), we assigned each U.S. state a year-specific structural sexism score and calculated participants' cumulative exposure by averaging the scores associated with states they had lived in during the study period, weighted according to duration of time spent in each. We then fit a series of SCMMs to estimate overall and group-specific associations between cumulative exposure from baseline through a given study wave and subsequent depressive symptomology; we also fit models using simplified (i.e., non-cumulative) exposure variables for comparison purposes. Analyses revealed that cumulative exposure to structural sexism: (1) was associated with significantly increased odds of experiencing depressive symptoms by the subsequent wave; (2) disproportionately impacted multiply marginalized groups (e.g., sexual minority girls/women); and (3) was more strongly associated with depressive symptomology compared to static or point-in-time exposure operationalizations (e.g., exposure in a single year). Substantively, these findings suggest that long-term exposure to structural sexism may contribute to the inequitable social patterning of mental distress among young people living in the U.S. More broadly, the proposed analytic framework represents a promising approach to examining the complex links between structural sexism and health across the life course and for diverse social groups.

Differences in Cardiovascular Health at the Intersection of Race, Ethnicity, and Sexual Identity

Importance

An understanding of the intersectional effect of sexual identity, race, and ethnicity on disparities in cardiovascular health (CVH) has been limited.

Objective

To evaluate differences in CVH at the intersection of race, ethnicity, and sexual identity using the American Heart Association's Life's Essential 8 measure.

Design, Setting, and Participants

This cross-sectional study was conducted from July 27 to September 6, 2023, using National Health and Nutrition Examination Survey data from 2007 to 2016. Participants were noninstitutionalized, nonpregnant adults (aged 18-59 years) without cardiovascular disease or stroke.

Exposures

Self-reported sexual identity, categorized as heterosexual or sexual minority (SM; lesbian, gay, bisexual, or "something else"), and self-reported race and ethnicity, categorized as non-Hispanic Black (hereafter, Black), Hispanic, non-Hispanic White (hereafter, White), and other (Asian, multiracial, or any other race and ethnicity).

Main Outcome and Measures

The primary outcome was overall CVH score, which is the unweighted mean of 8 CVH metrics, assessed from questionnaire, dietary, and physical examination data. Regression models stratified by sex, race, and ethnicity were developed for the overall CVH score and individual CVH metrics, adjusting for age, survey year, and socioeconomic status (SES) factors.

Results

The sample included 12 180 adults (mean [SD] age, 39.6 [11.7] years; 6147 [50.5%] male, 2464 [20.2%] Black, 3288 [27.0%] Hispanic, 5122 [42.1%] White, and 1306 [10.7%] other race and ethnicity). After adjusting for age, survey year, and SES, Black (β, -3.2; 95% CI, -5.8 to -0.6), Hispanic (β, -5.9; 95% CI, -10.3 to -1.5), and White (β, -3.3; 95% CI, -6.2 to -0.4) SM female adults had lower overall CVH scores compared with their heterosexual counterparts. There were no statistically significant differences for female adults of other race and ethnicity (β, -2.8; 95% CI, -9.3 to 3.7) and for SM male adults of any race and ethnicity compared with their heterosexual counterparts (Black: β, 2.2 [95% CI, -1.2 to 5.7]; Hispanic: β, -0.9 [95% CI, -6.3 to 4.6]; White: β, 1.5 [95% CI, -2.2 to 5.2]; other race and ethnicity: β, -2.2 [95% CI, -8.2 to 3.8]).

Conclusions and Relevance

In this cross-sectional study, CVH differed across race and ethnicity categories in SM females, suggesting that different communities within the larger SM population require tailored interventions to improve CVH. Longitudinal studies are needed to identify the causes of CVH disparities, particularly in Black and Hispanic SM females and inclusive of other racial and ethnic identities.

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.

The Threefold Path to Equity: Approaches for Health and Aging Researchers

The authors present a model for pursuing equity in research on health and aging, in terms of: (a) community-driven research governance, with reference to examples inside and outside of the United States, (b) a focus on policy change, where policy is defined broadly in terms of all legislative and regulatory change, and (c) equity-focused research practices, at the level of measurement, analysis, and study design. The model is visualized as a "threefold path" that researchers may walk, to achieve changes within our field, and changes in how we interface with other fields, and communities.

Racial and Socioeconomic Disparities in Preconception Health Risk Factors and Access to Care

Background: Black birthing people have significantly higher risks of maternal mortality and morbidity compared with White people. Preconception chronic conditions increase the risk of adverse pregnancy outcomes, yet little is known about disparities in preconception health. This study applies an intersectional framework to examine the simultaneous contributions of racial marginalization and economic deprivation in determining disparities in preconception risk factors and access to care. Methods: Using data from the Pregnancy Risk Assessment Monitoring System, 2016-2020 (N = 123,697), we evaluated disparities by race and income in self-reported preconception hypertension, diabetes, obesity, depression, and smoking, as well as preconception insurance coverage and utilization of health care. We estimated linear regression models and calculated predicted probabilities. Results: Black respondents experienced higher probabilities of preconception obesity and high blood pressure at every income level compared with White respondents. Higher income did not attenuate the probability of obesity for Black respondents (linear trend p = 0.21), as it did for White respondents (p < 0.001). Conversely, while White respondents with low income were at higher risk of preconception depression and smoking than their Black counterparts, higher income was strongly associated with reduced risk, with significantly steeper reductions for White compared with Black respondents (difference in trends p < 0.001 for both risk factors). White respondents had higher probabilities of utilizing preconception care across all income levels, despite similar probabilities of insurance coverage. Conclusions: Higher income does not protect against the risk of preconception obesity and other preconception risk factors for Black birthing people as it does for White birthing people. Results point to the need to consider multiple forms of intersecting structural factors in policy and intervention research to improve preconception and maternal health.

Social determinants of health and treatment center affiliation: analysis from the sickle cell disease implementation consortium registry

BACKGROUND

Adults with sickle cell disease (SCD) suffer early mortality and high morbidity. Many are not affiliated with SCD centers, defined as no ambulatory visit with a SCD specialist in 2 years. Negative social determinants of health (SDOH) can impair access to care.

HYPOTHESIS

Negative SDOH are more likely to be experienced by unaffiliated adults than adults who regularly receive expert SCD care.

METHODS

Cross-sectional analysis of the SCD Implementation Consortium (SCDIC) Registry, a convenience sample at 8 academic SCD centers in 2017-2019. A Distressed Communities Index (DCI) score was assigned to each registry member's zip code. Insurance status and other barriers to care were self-reported. Most patients were enrolled in the clinic or hospital setting.

RESULTS

The SCDIC Registry enrolled 288 Unaffiliated and 2110 Affiliated SCD patients, ages 15-45y. The highest DCI quintile accounted for 39% of both Unaffiliated and Affiliated patients. Lack of health insurance was reported by 19% of Unaffiliated versus 7% of Affiliated patients. The most frequently selected barriers to care for both groups were "previous bad experience with the healthcare system" (40%) and "Worry about Cost" (17%). SCD co-morbidities had no straightforward trend of association with Unaffiliated status. The 8 sites' results varied.

CONCLUSION

The DCI economic measure of SDOH was not associated with Unaffiliated status of patients recruited in the health care delivery setting. SCDIC Registrants reside in more distressed communities than other Americans. Other SDOH themes of affordability and negative experiences might contribute to Unaffiliated status. Recruiting Unaffiliated SCD patients to care might benefit from systems adopting value-based patient-centered solutions.

Associations of social vulnerability with truncal and extremity melanomas in the United States

BACKGROUND

Prior studies in social determinants (SDoH) of truncal-extremity melanomas (TEM) have analyzed race, income, and environmental factors relative to their effect on health disparities. However, they are limited by the narrow scopes of SDoH and study population, while lacking analyses of interrelational contribution of SDoH on TEM disparities.

METHODS

This retrospective cohort study of adult TEM patients (1975-2017) assessed linear regression trends in months of survival, as well as logistic regression trends in advanced presenting stage, surgery, and chemotherapy receipt across TEM subtypes with increasing overall social vulnerability and vulnerability in 15 SDoH variables grouped into socioeconomic status (SES), minority-language status (ML), household composition (HH), and housing-transportation (HT) themes measured by the SVI. SVI measures are ranked/compared across all US counties for relative vulnerability in a specific SDH and their total composite while accounting for sociodemographic-regional differences.

RESULTS

Across 325 760 TEM patients, increasing overall social vulnerability demonstrated significant decreases in the survival period for 7/13 TEM histology types (p < 0.001), with relative decreases in the survival period as high as 44.0% (67.0-37.5 months) for epithelioid cell. SES and HH were the highest-magnitude contributors to these overall trends. For many patients with TEM, increased odds of advanced presenting stage (highest with acral-lentiginous: odds ratio [OR], -1.18; 95% confidence interval [CI], 1.02-1.36), decreased odds of indicated surgery receipt (lowest with amelanotic, 0.79; 0.71-0.87), and increased odds of indicated chemotherapy (highest with melanoma in giant nevi: 1.50; 1.01-2.44) were observed; SES and ML followed by HH and HT contributed to these trends.

CONCLUSIONS

There were detriments in TEM care & prognosis in the United States with increasing social vulnerability. Identifying which SDH quantifiably are associated more with disparities in interrelational, real-world contexts is important to provide nuance to inform future research and initiatives to address TEM disparity.

Health inequalities at the intersection of multiple social determinants among under five children residing Nairobi urban slums: An application of multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

In this analysis we examine through an intersectionality lens how key social determinants of health (SDOH) are associated with health conditions among under-five children (<5y) residing in Nairobi slums, Kenya. We used cross-sectional data collected from Nairobi slums between June and November 2012 to explore how multiple interactions of SDoH shape health inequalities in slums. We applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) approach. We constructed intersectional strata for each health condition from combinations of significant SDoH obtained using univariate analyses. We then estimated the intersectional effects of health condition in a series of MAIHDA logistic regression models distinguishing between additive and interaction effects. We quantified discriminatory accuracy (DA) of the intersectional strata by means of the variance partitioning coefficient (VPC) and the area under the receiver operating characteristic curve (AUC-ROC). The total participants were 2,199 <5y, with 120 records (5.5%) dropped because health conditions were recorded as "not applicable". The main outcome variables were three health conditions: 1) whether a child had diarrhea or not, 2) whether a child had fever or not, and 3) whether a child had cough or not in the previous two weeks. We found non-significant intersectional effects for each health condition. The head of household ethnic group was significantly associated with each health condition. We found good DA for diarrhea (VPC = 9.0%, AUC-ROC = 76.6%) an indication of large intersectional effects. However, fever (VPC = 1.9%, AUC-ROC = 66.3%) and cough (VPC = 0.5%, AUC-ROC = 61.8%) had weak DA indicating existence of small intersectional effects. Our study shows pathways for SDoH that affect diarrhea, cough, and fever for <5y living in slums are multiplicative and shared. The findings show that <5y from Luo and Luhya ethnic groups, recent migrants (less than 2 years), and households experiencing CHE are more likely to face worse health outcomes. We recommend relevant stakeholders to develop strategies aimed at identifying these groups for targeted proportionate universalism based on the level of their need.

Sexual Orientation and Racial Bias in Relation to Medical Specialty

Physician explicit and implicit biases involving race and sexual orientation (SO) affect patient and provider experiences in healthcare settings. An anonymous survey was disseminated nationally to graduating medical students, residents, and practicing physicians to evaluate SO and racial biases across medical specialties. SO explicit and implicit bias were measured with the Attitudes toward Lesbians and Gay Men Scale, short form (ATLG-S) and Gay-Straight Implicit Association Test (IAT). Racial explicit and implicit bias were measured with the Quick Discrimination Index (QDI) and the Black-White IAT. Medical specialty was associated with racial explicit bias and specialty prestige with Black-White IAT score. Medical specialty and specialty prestige were not associated with SO bias. Female sex, sexual and gender minority (SGM) identity, and decreased religiosity were associated with reduced SO and racial bias. Provider race was associated with racial implicit and explicit bias.

An Introduction to Health Literacy and Social Contexts with Recommendations for Health Professionals and Researchers

Rarely do individuals seek, obtain, and understand health information in a solitary void [...].

Causal Inference Challenges in the Relationship Between Social Determinants and Cardiovascular Outcomes

The effects of social determinants on cardiovascular outcomes are frequently estimated in epidemiologic analyses, but the profound causal and statistical challenges of this research program are not widely discussed. Here, we carefully review definitions and measures for social determinants of cardiovascular health and then examine the various assumptions required for valid causal inference in multivariable analyses of observational data, such as what one would typically encounter in cohorts, population surveys, health care databases, and vital statistics databases. We explain the necessity of the "well-defined exposure" and show how this goal relates to the "consistency assumption" that is necessary for valid causal inference. Well-defined exposure is especially challenging for social determinants of health because they are seldom simple atomistic interventions that are easily conceptualized and measured. We then review threats to valid inference that arise from confounding, selection bias, information bias, and positivity violations. Other causal considerations are reviewed and explained, such as correct model specification, absence of immortal time, and avoidance of the "Table 2 Fallacy," and their application to social determinants of cardiovascular outcomes are discussed. Fruitful approaches, including focusing on policy interventions and the "target trial" frameworks are proposed and provide a pathway for a more efficacious research program that can more reliably improve population health. Valid causal inference in this setting is quite challenging, but-with clever design and thoughtful analysis-the important role of social factors in patterning cardiovascular outcomes can be quantified and reported.

More than just double discrimination: a scoping review of the experiences and impact of ableism and racism in employment

PURPOSE

Research has shed light on the employment barriers faced by individuals with disabilities, and by racialized people. The challenges faced by people belonging to both marginalized groups are less well-understood. The purpose of this scoping review was to examine existing research on labour market and workplace experiences of racialized people with disabilities, and to identify how ableism and racism intersect to shape employment experiences and outcomes.

METHODS

Seven international databases were searched, covering the period from 2000 to April 2022. Four reviewers independently conducted the screening, and data extraction and analysis were performed on 44 articles that met our inclusion criteria.

RESULTS

The findings highlighted rates of workplace ableism and racism (including discrimination allegations and perceived discrimination); types and forms of experiences arising from the intersection of ableism and racism (including unique individual stereotyping and systemic and institutional discrimination); and the role of other demographic variables. The intersection of ableism and racism impacted labour market outcomes, well-being in the workplace, and career/professional advancement.

CONCLUSIONS

Our review highlights the need for greater in-depth research focusing explicitly on the intersection of ableism and racism (and of other forms of discrimination), to better understand and address the barriers that racialized people with disabilities face in employment.IMPLICATIONS FOR REHABILITATIONThe experiences of racialized people with disabilities have been under explored, and clinicians and rehabilitation specialists should consider incorporating intersectionality into their practices to better understand and serve these populations.Ableism and racism do not operate in isolation, and clinicians and other professionals need to be aware that racialized people with disabilities may face unique challenges and barriers as a result.Service providers should aim to address gaps and inequities in services faced by racialized people with disabilities which may prevent them from finding and/or maintaining meaningful employment.

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.

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.

Impact of Patient Factors on Attendance at Remote Telehealth Swallow Therapy

In-person swallow therapy is a primary and effective treatment for dysphagia. However, remote telehealth is now a widely utilized component of healthcare delivery for therapeutic interventions. This study evaluates potential factors influencing attendance at telehealth swallow therapy. Retrospective review of 308 patients referred for telehealth swallow therapy from April 2020-November 2021 included patient referral diagnosis, diagnostic swallowing evaluations, and sociodemographic information including age, race, health insurance, interpreter use, and socioeconomic status. Univariable and multivariable analyses compared patient and appointment factors for those who attended telehealth swallow therapy with those who did not attend. Overall, 71.8% of patients attended at least one telehealth swallow therapy appointment while 28.2% did not attend any. The most common referral diagnoses were "Cancer" (19.2%) and "Dysphagia Unspecified" (19.2%). Patients diagnosed with "Cancer" and "Muscle Tension" were significantly less likely to attend telehealth swallow therapy compared to those with "Dysphagia Unspecified," "Globus," and "Gastroesophageal Reflux Disease/Laryngopharyngeal Reflux" after adjusting for covariates. Lower socioeconomic status (p = 0.023), no interpreter use (p < 0.001), and more diagnostic evaluations (p = 0.001) correlated with higher telehealth swallow therapy attendance. Race and sex did not correlate with attendance. Most patients referred to telehealth swallow therapy attended at least one appointment. Patients with dysphagia associated with cancer and muscle tension, those with higher socioeconomic status, interpreter use, and fewer diagnostic swallowing evaluations were less likely to attend telehealth swallow therapy. Future research should investigate and compare attendance and efficacy of telehealth swallow therapy with in-person therapy.

A qualitative study on opportunities to improve research engagement and inclusion of Black adults with systemic lupus erythematosus

In response to racial inequities in systemic lupus erythematosus (SLE), we aimed to identify practical recommendations for increasing engagement and inclusion of Black adults in SLE research. We used a qualitative, interpretive description approach and recruited 30 Black adults diagnosed with SLE in Michigan to participate in semi-structured interviews. Theme development focused on what factors influenced research perceptions and how research did not meet participant needs and expectations. We developed five main themes: (1) Ethical and equitable research. Participants shared how the impacts of past and present-day racism impacted their willingness to participate in research. (2) Trusting researchers to conduct studies and translate findings to health care. Participants had concerns related to researcher intentions and expressed the importance of communicating research outcomes to participants and translating findings to health care. (3) Drug trial beneficence. When considering drug trials, several people did not consider the potential benefits worth the risk of side effects, and some said they would need to consult with their doctor before agreeing to participate. (4) Altruism. Participants explained how the desire to help others was a motivating factor for participating in research and donating biological samples. (5) Research priorities. Participants described a need for better treatments that value their overall health and well-being. Findings indicate that researchers can center the perspectives of Black people with SLE across the research life cycle-beyond a focus on adequate racial diversity among study participants.

At the Intersection of Intersectionality: Race and Gender Diversity Among Surgical Faculty and Trainees

OBJECTIVE

To compare the representation of intersectional (ie, racial/ethnic and gender) identities among surgical faculty versus medical students.

BACKGROUND

Health disparities are pervasive in medicine, but diverse physicians may help the medical profession achieve health equity.

METHODS

Data from the Association of American Medical Colleges for 140 programs (2011/2012-2019/2020) were analyzed for students and full-time surgical faculty. Underrepresented in medicine (URiM) was defined as Black/African American, American Indian/Alaskan Native, Hispanic/Latino/Spanish Origin, or Native Hawaiian/Other Pacific Islander. Non-White included URiM plus Asian, multiracial, and non-citizen permanent residents. Linear regression was used to estimate the association of year and proportions of URiM and non-White female and male faculty with proportions of URiM and non-White students.

RESULTS

Medical students were comprised of more White (25.2% vs 14.4%), non-White (18.8% vs 6.6%), and URiM (9.6% vs 2.8%) women and concomitantly fewer men across all groups versus faculty (all P < 0.01). Although the proportion of White and non-White female faculty increased over time (both P ≤ 0.001), there was no significant change among non-White URiM female faculty, nor among non-White male faculty, regardless of whether they were URiM or not. Having more URiM male faculty was associated with having more non-White female students (estimate = +14.5% students/100% increase in faculty, 95% CI: 1.0% to 8.1%, P = 0.04), and this association was especially pronounced for URiM female students (estimate = +46.6% students/100% increase in faculty, 95% CI: 36.9% to 56.3%, P < 0.001).

CONCLUSIONS

URiM faculty representation has not improved despite a positive association between having more URiM male faculty and having more diverse students.

Considerations of Intersectionality for Older Adults with Palliative Care Needs in the Emergency Department: An Integrative Review

Purpose of Review

We sought to identify current interventions, research, or non-research evidence that has direct or indirect consideration of intersectionality in the care of older adults in the emergency department (ED). An integrative review informed by Crenshaw's Theory of Intersectionality was conducted in accordance with Whittemore and Knafl's five-stage methodology. A rigorous review process determined appropriateness for inclusion, and articles were analyzed for areas related to direct or indirect relationship to intersectionality.

Recent Findings

Older adults aged 60 and above in the United States (US) account for more than 20% of ED visits annually, and half of older adults will visit the ED in their last year of life. There has been a growing focus on adapting the ED to meet the palliative care needs of older adults, but relatively little consideration has been given to older adults' intersectional identities.

Summary

Six articles were identified that provided indirect insights into the status of intersectionality in ED-based palliative care for older adults. Two areas of interest were identified: (1) intersectional elements or reference to such elements embedded within the studies; and (2) the challenges of adapting quantitative methodologies to incorporate variables and approaches that would allow for intersectional analysis. This review highlights areas for future research along with recommendations for adopting an intersectional framing into commonly used methodologies.

Racial and Ethnic Differences in Sleep Duration Life Expectancies among Men and Women in Mid-to-Late Life

This analysis documents U.S. racial/ethnic and gender differences in life expectancies with different self-reported sleep durations among adults aged 50 and older. We used self-reported sleep duration and linked mortality information from the 2004-2015 National Health Interview Survey (n = 145,015) to calculate Sullivan Method Lifetables for life expectancies with different self-reported sleep duration states: short (≤6 hours), optimal (seven to 8 hours), and long (≥9 hours) sleep duration per-day by race/ethnicity and gender. Non-Hispanic Black men (35.8%, 95% CI: 34.8%-36.8%) and women (36.5%, 95% CI: 35.7%-37.1%) exhibited the highest proportion of years lived with short sleep duration followed by Hispanic men (31.1%, 95% CI: 29.9%-32.3%) and women (34.1%, 95% CI: 33.1%-35.1%) and Non-Hispanic White men (25.8%, 95% CI: 25.4%-26.2%) and women (27.4%, 95% CI: 27.0%-27.7%). These results highlight how race/ethnic inequality in sleep duration and life expectancy are intertwined among older adults in the U.S.

Racial-ethnic, gender identity, and sexual orientation disparities in COVID-19-related social and health outcomes: A decomposition analysis

Despite the growing literature on racial-ethnic disparities during the pandemic, less is known about the explanatory mechanisms of these disparities and inequalities across other axes, such as gender and sexual identities. We studied the levels and sources of racial-ethnic, gender identity, and sexual minority disparities in social (i.e., unmet resource needs) and health (i.e., hospitalization) outcomes among individuals diagnosed with COVID-19, hypothesizing differential age structure, underlying health, and work and living arrangements as contributors to inequalities. Using large-scale administrative data from Chicago and adjusting for covariates, we found substantial racial-ethnic and gender identity disparities in both outcomes, and weak evidence of sexual minority disparities in unmet needs. Subsequent decomposition analyses revealed that living in larger households, having a higher share of non-adult cases, and facing higher burdens of chronic illness, obesity, and unemployment each statistically significantly drove racial-ethnic disparities in unmet needs, but these together explained less than 15% of the disparities. Similarly, about 20% of the Black-White gap in hospitalization resulted from disparities in underlying health and unemployment, whereas a higher proportion of non-adult cases or higher unemployment rates respectively proved the only significant pathways to partially explain transgender individuals' disadvantages in unmet needs (12%) or hospitalization (6%). These findings highlight the importance of considering multiple dimensions of social differences in studying health disparities, the vulnerabilities of transgender and non-adult communities during the pandemic, and the valid yet quite limited roles of previously suggested sociodemographic factors in accounting for COVID-19-related categorical inequalities.

[Intersectionality as a theoretical-analytical tool to study health inequalities in the AmericasA interseccionalidade como ferramenta teórico-analítica para estudo das desigualdades em saúde nas Américas]

Objective

Analyze inequalities in self-perceived health among population groups located at the intersections of gender identity, ethnicity, and education level in countries of the Americas, classified by income level.

Methods

Panel data from the World Values Survey were used for the period 1990-2022. The study sample included 58 790 people between 16 and 65 years of age from 14 countries in the Americas. The dependent variable was poor self-perceived health, and the independent variables were gender, education level, and ethnicity. A multi-categorical variable with 12 strata was created for the intercategorical intersectionality analysis. An analysis of individual heterogeneity and diagnostic accuracy was performed using five logistic regression models, adjusted by age and by survey wave.

Results

A clear and persistent intersectional gradient for poor self-perceived health was observed in all country disaggregations by income. Compared to the category with the most advantage (men of majority ethnicity and higher education), the other groups had increased risk of poor health, with the highest risk among women of minority ethnicity and in Indigenous peoples with less than secondary education (three to four times higher). In addition, women had a higher risk of poor health than men in each pair of intersectional strata.

Conclusions

The intersectional analysis demonstrated a persistent social gradient of self-perceived ill health in the Americas.

Inequities in Mental Health Care Facing Racialized Immigrant Older Adults With Mental Disorders Despite Universal Coverage: A Population-Based Study in Canada

OBJECTIVES

Contemporary immigration scholarship has typically treated immigrants with diverse racial backgrounds as a monolithic population. Knowledge gaps remain in understanding how racial and nativity inequities in mental health care intersect and unfold in midlife and old age. This study aims to examine the joint impact of race, migration, and old age in shaping mental health treatment.

METHODS

Pooled data were obtained from the Canadian Community Health Survey (2015-2018) and restricted to respondents (aged ≥45 years) with mood or anxiety disorders (n = 9,099). Multivariable logistic regression was performed to estimate associations between race-migration nexus and past-year mental health consultations (MHC). Classification and regression tree (CART) analysis was applied to identify intersecting determinants of MHC.

RESULTS

Compared to Canadian-born Whites, racialized immigrants had greater mental health needs: poor/fair self-rated mental health (odds ratio [OR] = 2.23, 99% confidence interval [CI]: 1.67-2.99), perceived life stressful (OR = 1.49, 99% CI: 1.14-1.95), psychiatric comorbidity (OR = 1.42, 99% CI: 1.06-1.89), and unmet needs for care (OR = 2.02, 99% CI: 1.36-3.02); in sharp contrast, they were less likely to access mental health services across most indicators: overall past-year MHC (OR = 0.54, 99% CI: 0.41-0.71) and consultations with family doctors (OR = 0.67, 99% CI: 0.50-0.89), psychologists (OR = 0.54, 99% CI: 0.33-0.87), and social workers (OR = 0.37, 99% CI: 0.21-0.65), with the exception of psychiatrist visits (p = .324). The CART algorithm identifies three groups at risk of MHC service underuse: racialized immigrants aged ≥55 years, immigrants without high school diplomas, and linguistic minorities who were home renters.

DISCUSSION

To safeguard health care equity for medically underserved communities in Canada, multisectoral efforts need to guarantee culturally responsive mental health care, multilingual services, and affordable housing for racialized immigrant older adults with mental disorders.

Vaccination intention and uptake within the Black community in Appalachia

OBJECTIVE

Black communities have disproportionately experienced adverse health effects from the COVID-19 pandemic while simultaneously having less vaccination access and decreased vaccine utilization. As such, predictors of vaccination uptake within Black communities are a public health imperative. Black Americans from socio-geographic regions associated with health inequities (e.g., Appalachia), including vaccination disparities, represent an intersection of racial, economic, and ethnic social identities. To better understand the preventive health needs of Black communities in Appalachia and elsewhere, this study examined psychosocial predictors of vaccination intention or behavior.

METHOD

Adults (n = 336) identifying as Black or African American from West Virginia indicated demographics, reported COVID-19 vaccination intention, flu vaccination uptake, and human papillomavirus (HPV) vaccination uptake, and completed assessments of vaccine hesitancy, medical mistrust, and racial discrimination. Hierarchical logistic regression modeling examined potential associations between psychosocial predictors and each vaccine type.

RESULTS

Results showed variation in significant predictors across the vaccines of focus. Racial discrimination (OR = 0.64) and medical mistrust (OR = 0.93) were negatively associated with COVID-19 vaccination intention. Vaccine confidence was positively associated with COVID-19 vaccination intention (OR = 2.17) and HPV vaccination uptake (OR = 1.77). Total household income was the only predictor associated with flu vaccination uptake (OR = 1.12).

CONCLUSIONS

These findings suggest that social interventions targeting racial discrimination in healthcare may significantly help address vaccination disparities in rural Black communities. Moreover, results emphasize unique aspects of vaccination behavior in the Black community within Appalachia that may generalize to other Black communities living in rural regions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The intersections of socioeconomic position, gender, race/ethnicity and nationality in relation to oral conditions among American adults

OBJECTIVE

The objective of the study was to evaluate how gender, socioeconomic position (SEP), race/ethnicity and nationality intersect to structure social inequalities in adult oral health among American adults.

METHODS

Data from adults aged 20 years or over who participated in the National Health and Nutrition Examination Survey (NHANES) 2009-2018 were analysed. The outcomes were poor self-rated oral health and edentulism among all adults (n = 24 541 and 21 446 participants, respectively) and untreated caries and periodontitis among dentate adults (n = 16 483 and 9829 participants, respectively). A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was conducted for each outcome, by nesting individuals within 48 intersectional strata defined as combinations of gender, SEP, race/ethnicity and nationality. Intersectional measures included the variance partition coefficient (VPC), the proportional change in variance (PCV) and predicted excess probability due to interaction.

RESULTS

Substantial social inequalities in the prevalence of oral conditions among adults were found, which were characterized by high between-stratum heterogeneity and outcome specificity. The VPCs of the simple intersectional model showed that 9.4%-12.7% of the total variance in the presentation of oral conditions was attributed to between-stratum differences. In addition, the PCVs from the simple intersectional model to the intersectional interaction model showed that 84.1%-97.1% of the stratum-level variance in the presentation of oral conditions was attributed to the additive effects of gender, SEP, race/ethnicity and nationality. The point estimates of the predictions for some intersectional strata were suggestive of an intersectional interaction effect. However, the 95% credible intervals were very wide and the estimations inconclusive.

CONCLUSIONS

This analysis highlights the value of the intersectionality framework to understand heterogeneity in social inequalities in oral health. These inequalities were mainly due to the additive effect of the social identities defining the intersectional strata, with no evidence of interaction effects.

Intersectionality and adolescent medicine: an overview

PURPOSE OF REVIEW

This review defines intersectionality, discusses recent studies that use an intersectional framework in adolescent health research, and outlines ways where clinicians can use intersectionality to address health disparities in youth of color through clinical practice, research, and advocacy.

RECENT FINDINGS

Research using an intersectional framework can identify populations at risk for certain disorders or behaviors. Recent studies in adolescent health research using an intersectional lens identified lesbian girls of color as an at-risk population for e-cigarette use, demonstrated lower skin color satisfaction among Black girls of all ages predicted greater binge-eating disorder symptoms, and showed that two-thirds of Latine (gender-neutral term that refers to people with Latin American roots) youth who recently immigrated to the United States experienced at least one traumatic event during their migration journey, putting them at risk for PTSD and other mental health disorders.

SUMMARY

Intersectionality refers to how multiple social identities intersect to produce a specific experience that reflects overlapping systems of oppression. Diverse youth contain multiple identities that intersect to produce unique experiences and health inequities. Using an intersectional framework acknowledges that youth of color are not homogenous. Intersectionality becomes an important tool to care for marginalized youth and advance health equity.

[Consequences of the COVID-19 pandemic: Are there risk groups for reduced subjective well-being after the first lockdown?]

BACKGROUND

Measures to contain COVID-19 have created burdens that have widened health inequalities. We examine the extent to which risk groups for reduced subjective well-being can be identified after the 2020 lockdown. In doing so, we also consider possible interactions of different social grouping characteristics as part of an intersectional approach.

METHOD

Socio-Economic Panel (SOEP) data from the years 2018-2020 were analyzed. A total of 16,000 cases with information on changes in well-being (SF-12 scores and individual indicators) were included in the analyses. We use the classification method "random forests" to identify groups with different trends in well-being. For the interpretation of the content, we also present results from a regression model with social and health aspects as predictors.

RESULTS

Demographic and social characteristics explained only a very small part of the changes in subjective well-being (R² = 0.007-0.012) and did not allow for the differentiation of homogeneous risk groups. Although some significant predictors were found in the regression models, the corresponding effects were mostly small. In addition to the initial state of well-being before the pandemic began, the presence of chronic illnesses and disabilities in particular contributed to the explanation of subjective well-being.

DISCUSSION

The currently available data do not allow a clear identification of risk groups for losses in well-being in the first year of the COVID-19 pandemic. Health status before the onset of the pandemic appears to be more important for short-term changes in subjective well-being than socio-demographic and socio-economic categorization characteristics.

Testing for intersectional measurement invariance with the alignment method: Evaluation of the 8-item patient health questionnaire

OBJECTIVE

To demonstrate the use of the alignment method to evaluate whether surveys function similarly (i.e., have evidence of measurement invariance) across culturally diverse intersectional groups. Intersectionality theory recognizes the interconnected nature of social categories such as race, gender, ethnicity, and socioeconomic status.

DATA SOURCES

A total of 30,215 American adult's responses to the eight-item Patient Health Questionnaire depression assessment scale (PHQ-8) from the 2019 National Health Interview Survey (NHIS).

STUDY DESIGN

Using the alignment method, we examined the measurement invariance (equivalence) of the PHQ-8 depression assessment scale across 16 intersectional subgroups defined at the intersection of age (under 52, 52 and older), gender (male, female), race (Black, non-Black), and education (no bachelor's degree, bachelor's degree).

PRINCIPAL FINDINGS

Overall, 24% of the factor loadings and 5% of the item intercepts showed evidence of differential functioning across one or more of the intersectional groups. These levels fall beneath the benchmark of 25% suggested for determining measurement invariance with the alignment method.

CONCLUSIONS

The results of the alignment study suggest that the PHQ-8 functions similarly across the intersectional groups examined, despite some evidence of different factor loadings and item intercepts in some groups (i.e., noninvariance). By examining measurement invariance through an intersectional lens, researchers can investigate how a person's multiple identities and social positions possibly contribute to their response behavior on an assessment scale.

Gendered Racial Microaggressions and Black Women's Sleep Health

Gendered racial microaggressions reflect historical and contemporary gendered racism that Black women encounter. Although gendered racial microaggressions are related to psychological outcomes, it is unclear if such experiences are related to sleep health. Moreover, the health effects of gendered racial microaggressions dimensions are rarely investigated. Using a cohort of Black women (N = 400), this study employs an intracategorical intersectional approach to (1) investigate the association between gendered racial microaggressions and sleep health, (2) assess whether gendered racial microaggressions dimensions are related to sleep health, and (3) examine whether the gendered racial microaggressions-sleep health association persists after accounting for depressive symptoms and worry. Gendered racial microaggressions were associated with poor sleep quality overall and four specific domains: subjective sleep quality, latency, disturbance, and daytime sleepiness. Two gendered racial microaggressions dimensions were especially detrimental for sleep: assumptions of beauty/sexual objectification and feeling silenced and marginalized. After accounting for mental health, the effect of gendered racial microaggressions on sleep was reduced by 47 percent. Future research implications are discussed.

The Workforce Needed to Address Population Health

Policy Points Although a single definition of the population health workforce does not yet exist, this workforce needs to have the skills and competencies to address the social determinants of health, to understand intersectionality, and to coordinate and work in concert with an array of skilled providers in social and health care to address multiple health drivers. On-the-job training programs and employer support are needed for the current health workforce to gain skills and competencies to address population health. Funding and leadership combined are critical for developing the population health workforce with the goal of supporting a broad set of workers beyond health and social care to include, for example, those in urban planning, law enforcement, or transportation professions to address population health.

Functional Disability Among Middle-Aged and Older Adults in China: The Intersecting Roles of Ethnicity, Social Class, and Urban/Rural Residency

This study explores how ethnicity, family income, and education level differentiate patterns of functional limitations among urban and rural Chinese (aged 45 ≥ years). Based on the 2018 China Family Panel Studies (CFPS) (n = 16,589), this nationwide study employed binary/multinomial logistic regression analyses, stratified by urban/rural residency, to estimate the likelihood of instrumental activities of daily living (IADLs) disability (0/1-2/≥3 limitations) by social determinants of health (SDoH). The estimated overall prevalence of IADLs disability was 14.3%. The multivariable analyses did not find significant ethnic disparity in IADLs disability in urban China, while in rural China, ethnic minorities were 44% more likely to have IADLs disability than Han Chinese. Among rural residents, Mongolians, Tibetans, and Yi minority more than tripled the odds of having ≥3 limitations than Han Chinese; and the intersections of ethnicity and social class were associated with functional limitations. Long-term care and anti-poverty programs should target minority aging populations in rural China.

The salience of gender in the illness experiences and care preferences of people with Parkinson's disease

RATIONALE

In recent years, interest in sex characteristics and gender dimensions of Parkinson's disease (PD) has increased. Yet, much remains to be understood about how gender-related aspects specifically impact the illness and experiences of care in persons living with PD.

OBJECTIVE

The purpose of this study was to explore the salience of gender-related aspects in the illness experiences and care provision preferences of people with PD.

METHODS

A descriptive qualitative study including semi-structured life story interviews was conducted with men and women living with PD in the Netherlands. Between September 2020 and February 2021, forty people with PD (20 men and 20 women) participated in digital interviews of which thirty-one (18 men and 13 women) were included in the thematic analyses for this specific study.

RESULTS

Overall, most participants did not consider gender-related aspects salient towards their illness experiences. However, when prompted, a number of participants described several stereotypical views about gender as related to the visibility of PD, emotional experiences, help seeking, role patterns and physical appearance. While most men and women with PD did not express specific gender-related preferences for their healthcare providers, those that did, all preferred women as healthcare providers. These preferences were generally related to attributed feminine traits which are considered relevant in routine, particularly sensitive, physical examinations of people with PD.

CONCLUSION

This study demonstrates that although every person has a gender identity, the salience attributed to gender varies with illness experiences and in care provision preferences between people with PD. These findings highlight the need for precise and personalized methodologies to capture more nuanced insights into the impact of gender dimensions on PD. Furthermore, drivers behind gender-related preferences in care provision are multifactorial and warrant further investigation among people with PD.

Intersecting Early-Life Selection Mechanisms: Socio-Historical Changes in Racially Stratified Effects of Education on Functional Limitations in the United States

OBJECTIVE

Scant research has focused on the role of sociohistorical changes in shaping intersecting early-life selection mechanisms and their impacts on racially stratified effects of education on health across cohorts.

METHOD

Drawing from the Health and Retirement Survey, this study fitted negative binomial regression models to assess the impacts of childhood socioeconomic status (SES) on the relationship between education and functional limitations for Black and White adults across birth cohorts (n = 16,269, born 1931-1959).

RESULTS

The disparities between Black adults and White adults in impacts of childhood SES on both education and functional limitations were more pronounced in recent cohorts. The racial stratification in the impacts of education on functional limitations was documented across cohorts. However, after adjusting for childhood SES, this stratification narrowed considerably in recent cohorts.

DISCUSSION

This study underscores the role of a sociohistorical context in shaping the effects of education on health at the intersection of race and cohort.

Prioritising Children and Young People with Disability in Research About Domestic and Family Violence: Methodological, Ethical and Pragmatic Reflections

Purpose

The perspectives of children and young people with disability who experience domestic and family violence are under-researched, impeding the development of approaches that meet their needs. Knowledge gaps stem from the layered discursive positioning of disability, childhood/youth, or domestic and family violence in addition to the methodological, ethical and pragmatic complexity of research needed to understand their priorities and be attuned to their lived experience. This article explores methodological, ethical and practical challenges to centring their voices in research about domestic and family violence.

Method

A conceptual framework of feminist disability theory and intersectionality informed our co-designed research, across three phases: (1) quantitative large-scale data linkage and case file analysis; (2) qualitative research with children and young people, their families and service providers and (3) stakeholder engagement workshops.

Results

We reflect on how our research was able to prioritise the contextual agency of children and young people with disability, ways it could not, and other constraints.

Conclusion

Children and young people with disability experiencing domestic and family violence hold an expert and unique vantage point on what happens to them. Amplifying their priorities for directing policy and organisational change requires more of researchers in terms of methods, but also more flexibility in how projects are funded to enable creativity and innovation. We call for collective attention to frameworks for supported decision-making and child ethics to progress inclusive research which recognises the importance of participation for children and young people with disability.

Race and ethnicity moderate the associations between lifetime psychedelic use (MDMA/ecstasy and psilocybin) and major depressive episodes

BACKGROUND

Psychedelics are receiving renewed attention within Western medicine as they represent potential treatments for many difficult-to-treat mental health disorders. However, psychedelic science is limited in its focus and inclusion of racial and ethnic minorities. Hence, this study examines whether race and ethnicity moderate the associations that naturalistic 3,4-methylenedioxymethamphetamine (MDMA)/ecstasy use and psilocybin use share with major depressive episodes (MDEs).

METHOD

Data for this project are from The National Survey on Drug Use and Health (2005-2019). Participants were adults aged 18 years and older (unweighted N = 596,187). This study used multivariable logistic regression to test the interaction between race and ethnicity and MDMA/ecstasy use and psilocybin use for predicting lifetime, past year, and past year severe MDEs.

RESULTS

Race and ethnicity significantly moderated the associations between MDMA/ecstasy use and psilocybin use and MDEs. For White participants, MDMA/ecstasy use and psilocybin use each were associated with lowered odds of all three MDE outcomes (adjusted odds ratio (aOR) range: 0.82-0.92). For Hispanic participants, MDMA/ecstasy use and psilocybin use each conferred lowered odds of only a past year MDE (MDMA/ecstasy aOR: 0.82; psilocybin aOR: 0.79). For Non-Hispanic Racial Minority participants, MDMA/ecstasy and psilocybin use did not confer lowered odds of any MDE outcomes.

CONCLUSION

Race and ethnicity have an impact on the associations that psychedelics share with mental health outcomes. Future research should explore the impact of identity and discrimination on the effects of psychedelics and should explore whether these substances can serve as effective treatments for minorities when used in culturally informed contexts.

Social determinants of depression in systemic lupus erythematosus: A systematic scoping review

Social determinants of health (SDOH) influence inequities in systemic lupus erythematosus (SLE). While these inequities contribute to overall disease experience, there is little consensus guiding our understanding of the psychological implications of SDOH in SLE. Given the paucity of evidence in this area, the aim of this scoping review was to systematically assess the volume and features of available research literature on associations of SDOH with depression in SLE over the past 20 years, from 1 January 2000 to 16 November 2021. We developed a search strategy for PubMed and EMBASE that included keywords for depression and lupus. After screening 2188 articles, we identified 22 original articles that met our inclusion criteria. At least one SDOH was associated with depression in two of the six studies with unadjusted estimates and 13 of the 16 studies with adjusted estimates. Results provide consistent but sparse evidence that SDOH are associated with depression in SLE. Additionally, depression epidemiology in SLE may differ from the general population such that depression risk is more similar across genders and racial/ethnic groups. More work is needed to identify the SDOH that have the greatest impact on depression and mental health among SLE patients, as well as how and when to intervene.

Typologies of mental healthcare discrimination experiences and associations with current provider care ratings: A latent class analysis

Background

Discrimination is experienced across demographic attributes (e.g., race and gender) and vantage points (e.g., personal and vicarious), yet few studies have classified these different experiences of discrimination within healthcare systems. Moreover, which discriminatory experiences have greater influence on patient-reported quality outcomes remains poorly understood. To address these gaps, we used latent class analysis (LCA) to identify typologies of past experiences with healthcare discrimination among adults with depression-who experience more frequent and stigmatizing healthcare interactions than the general population-and assess the relationship between class membership and current ratings of patient-reported quality outcomes.

Methods

We surveyed a nationally representative sample of adults with depression (n = 803) to assess past experiences of discrimination by medical providers in terms of both the characteristics targeted for discrimination and whether healthcare discrimination was experienced personally or by friends and family members. We conducted an LCA to identify discrimination-exposure classes and a modified Poisson regression to identify associations between class membership and patient-reported quality outcomes (e.g., overall medical provider quality, respect, clear communication, and careful listening), while adjusting for covariates.

Results

We identified four latent classes of healthcare discrimination: low discrimination (LD; referent class: 72.2% of total sample), vicarious linguistic discrimination (VL; 13.9%), elevated personal and vicarious racial discrimination (EPVR; 10.5%), and high racial/ethnic discrimination (HRE; 3.4%). Compared to those in the LD class, individuals in the EPVR class had higher rates of reporting their current medical provider's respect and careful listening skills as sometimes or never, (Respect aIRR: 1.90, 95% CI: 1.05-3.42; Listening aIRR: 2.18, 95% CI: 1.29-3.66). Those in the HRE class reported higher rates of reporting their medical provider's quality and communication as poor or fair and lower ratings of careful listening (Quality aIRR: 2.06, 95% CI: 1.08-3.93; Communication aIRR: 1.97, 95% CI: 1.00-3.63; Listening aIRR: 2.41, 95% CI: 1.27-4.59), compared to those in the LD class. Those in the VL class had higher rates of reporting that their medical provider never or sometimes respected or carefully listened to them (Respect aIRR: 2.12, 95% CI: 1.20-3.72; Listening aIRR:1.67, 95% CI:1.03-2.71) than those in, the LD class.

Conclusions

Healthcare organizations committed to providing equitable patient care should establish more robust quality improvement approaches to prevent discrimination at the medical provider level as well as structures of accountability to reconcile previously embedded social inequities within the healthcare system.

The Relationship Between Intersectional Drug Use and HIV Stigma and HIV Care Engagement Among Women Living with HIV in Ukraine

This study used an intersectional approach to explore the association between enacted and internalized drug use and HIV stigma on HIV care outcomes among HIV-positive women who inject drugs in Ukraine. Surveys were conducted in Kyiv in 2019-2020. Among the 306 respondents, 55% were engaged in HIV care. More than half (52%) of participants not engaged in care reported internalized stigma related to both drug use and HIV status (i.e., intersectional stigma), compared to only 35% of those who were engaged in HIV care. Among those engaged in care, 36% reported intersectional enacted stigma compared to 44% of those not engaged in care; however, this difference was not statistically significant in the univariable analysis (p = 0.06). In the univariable analysis, participants who reported intersectional internalized stigma had 62% lower odds of being engaged in HIV care (OR 0.38, 95% CI 0.22, 0.65, p < 0.001). In the adjusted model, reported intersectional internalized stigma (aOR 0.52, 95% CI 0.30, 0.92, p = 0.026), reported intersectional enacted stigma (aOR 0.47, 95% CI 0.23, 0.95, p = 0.036), and knowing their HIV status for more than 5-years (aOR 2.29, 95% CI 1.35, 3.87, p = 0.002) were significant predictors of HIV care engagement. These findings indicate that interventions to improve HIV care engagement must address women's experiences of both HIV and drug use stigma and the different mechanisms through which stigma operates.

Shifting the discourse on disability: Moving to an inclusive, intersectional focus

Individuals with disabilities comprise one of the largest marginalized groups in the United States and experience systemic barriers in health care. In Westernized communities, disability has historically been conceptualized via the medical model, which considers disability an individual-level deficit in need of correction. Although other models of disability (e.g., social model) have been developed to address the medical model's ableist shortcomings, these fail to consistently acknowledge intersectionality. Specifically, these models fail to consider that (a) a disabled individual may hold other marginalized or oppressed identities and (b) these intersecting oppressions may exacerbate health inequities. Intersectionality, which originates from Black feminist literature, describes the ways that systems of power and oppression (e.g., racism, sexism) interact to form an individual's unique experience. To date, the intersection of disability and other marginalized identities has been neglected in psychology and related fields, leaving little guidance for how scholars, clinicians, and other stakeholders can address disability via an intersectional lens. The present article discusses how a disability-affirmative, intersectional approach can serve as a strategy for challenging and reforming oppressive systems across the field of psychology. We assert that, ultimately, this approach has the potential to optimize and expand access to equitable, inclusive mental health care, and we propose actionable steps psychologists can take in research, practice, training, and policy in pursuit of this aim. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessment of the individual and compounding effects of marginalization factors on injury severity, discharge location, recovery, and employment outcomes at 1 year after traumatic brain injury

Objective

The aim of this study is to examine the effect of eight distinct marginalized group memberships and explore their compounding effect on injury severity, recovery, discharge location, and employment outcomes 1-year after traumatic brain injury (TBI).

Methods

Individuals with medically confirmed, complicated mild-severe TBI (N = 300) requiring inpatient rehabilitation care between the ages of 18 and 65 were recruited at two urban (public and private) health systems between 2013 and 2019. Data were collected from self-report and medical record abstraction. Marginalized group membership (MGM) includes racial and ethnic minority status, less than a high school diploma/GED, limited English proficiency, substance abuse, homelessness, psychiatric hospitalizations, psychiatric disorders, and incarceration history. Membership in four or more of these groups signifies high MGM. In addition, these factors were explored individually. Unadjusted and adjusted linear and logistic regressions and Kruskal–Wallis tests were used to assess the associations of interest in RStudio.

Results

After adjusting for age, sex, and cause of injury, compared to TBI patients with low MGM, those with high MGM experience significantly longer post-traumatic amnesia (95% CI = 2.70, 16.50; p = 0.007) and are significantly more likely to have a severe TBI (per the Glasgow-Coma Scale) (95% CI = 1.70, 6.10; p ≤ 0.001) than a complicated mild-moderate injury. Individuals with high MGM also are significantly less likely to be engaged in competitive paid employment 1 year after injury (95% CI = 2.40, 23.40; p = 0.001). Patients with high MGM are less likely to be discharged to the community compared to patients with low MGM, but this association was not significant (95% CI = 0.36, 1.16; p = 0.141). However, when assessing MGMs in isolation, certain associations were not significant in unadjusted or adjusted models.

Conclusion

This exploratory study's findings reveal that when four or more marginalization factors intersect, there is a compounding negative association with TBI severity, recovery, and employment outcomes. No significant association was found between high MGM and discharge location. When studied separately, individual MGMs had varying effects. Studying marginalization factors affecting individuals with TBI has critical clinical and social implications. These findings underline the importance of addressing multidimensional factors concurrent with TBI recovery, as the long-term effects of TBI can place additional burdens on individuals and their economic stability.

Race in public health dentistry: a critical review of the literature

OBJECTIVE

To carry out a critical review of the literature on the use of race, color, and ethnicity in the field of public health dentistry.

METHODS

A literature search was conducted in MEDLINE via PubMed for articles published between 2014 and 2019. Using a data extraction form, we collected information on (1) bibliographic characteristics of the selected papers; (2) race, color, and ethnicity of the study participants and their sociodemographic profiles; and (3) the extent to which the original publications followed the recommendations by Kaplan and Bennett (2003) on the use of race, color, or ethnicity in biomedical research.

RESULTS

Our initial search identified 2,032 articles, 53 of which were selected for full-text examination and assessment following pre-established eligibility criteria. Around 60% (n = 32) of the included studies did not justify the use of race, color, or ethnicity in their analyses, and 9% (n = 5) took these variables as indicators of the participants’ genetic makeup. On the other hand, 68% (n = 36) of the reviewed papers considered race, color, and ethnicity as risk markers – not risk factors – for adverse oral health outcomes, whereas 80% (n = 42) adjusted racial/ethnic inequities for a range of socioeconomic and demographic factors in statistical models. Only one study (2%) explicitly took race, color, or ethnicity as a contextually dependent dimension of the participants’ identities.

CONCLUSION

Our findings indicate that research on oral health inequities is often based on reductionist and stigmatizing conceptions of race, color, or ethnicity. Such harmful misconceptions should be replaced with anti-racist narratives in order to effectively address racial oral health inequities.

Self-Reported Anxiety in Spain: A Gendered Approach One Year After the Start of COVID-19 Pandemic

The COVID-19 pandemic has an impact on mental health. However, there is little evidence on how different axes of social inequity influence mental health from a gender perspective and over time. Our aim is to analyze anxiety according to gender identity and other axes of social inequities (migration status, sexual orientation, age, and employment conditions) one year after the start of the COVID-19 pandemic in Spain. We conducted a cross-sectional study among adults living in Spain with an online survey from April 8 to May 28, 2021. The main variable was anxiety measured by Generalized Anxiety Disorder Scale (GAD-7). Sex-stratified multivariate logistic regression models were constructed to assess the association between axes of inequities and anxiety. Our findings (N = 2,053) suggest that women have greater anxiety risk than men (35.2 vs. 28.2%, respectively). We observe in both genders that there is a clear age gradient, with anxiety decreasing as age increases; and that there is an association between worsening employment status and anxiety risk, although there is a difference between women by education level. Additionally, not having Spanish nationality is also associated with greater anxiety risk in women. In men, identifying as non-heterosexual is associated with a higher risk of anxiety. The axes of inequities have different effects according to gender identity. These differences in anxiety risk by population subgroup must be taken into account in order to sensibly and equitably treat the surge in mental health disorders brought on by the COVID-19 pandemic.

Real-time remote outpatient consultations in secondary and tertiary care: A systematic review of inequalities in invitation and uptake

Background

Health policies in most high income countries increasingly recommend provision of routine outpatient care via remote (video and/or telephone) appointments, especially due to the pandemic. This is thought to improve access to care and promote efficiency within resource-constrained health services. There is limited evidence about the impact on existing inequalities in the invitation and uptake of health services when remote outpatient care is offered.

Aim

To systematically review the evidence on the offer and/or uptake of real-time remote outpatient consultations in secondary and tertiary care, assessed according to key sociodemographic characteristics.

Methods

Seven electronic bibliographic databases were searched for studies reporting the proportion of patients with key characteristics (following PROGRESS Plus criteria) who were offered and/or accepted real-time remote outpatient consultation for any chronic condition. Comparison groups included usual care (face-to-face), another intervention, or offer/uptake within a comparable time period. Study processes were undertaken in duplicate. Data are reported narratively.

Results

Twenty-nine studies were included. Uptake of video consultations ranged from 5% to 78% and telephone consultations from 12% to 78%. Patients aged over 65, with lower educational attainment, on lower household incomes and without English as a first language were least likely to have a remote consultation. Females were generally more likely to have remote consultations than males. Non-white ethnicities were less likely to use remote consultations but where they did, were significantly more likely to choose telephone over video appointments (p<0.001).

Conclusions

Offering remote consultations may perpetuate or exacerbate existing health inequalities in access to healthcare. More research is needed on current health disparities by sociodemographic characteristics and to explore what works well for different patient groups and why so that processes can be designed to ameliorate these health disparities.

Trial registration

PROSPERO registration no: CRD42021241791.

Changing Care: Applying the Transtheoretical Model of Change to Embed Equity, Diversity, and Inclusion in Long-Term Care Research in Canada

Healthcare policy reform is evident when considering the past, present and future of long-term care (LTC) in Canada. Some of the most pressing issues facing the LTC sector include the changing demographic composition in Canadian LTC homes, minimal consideration for the role of intersectionality in LTC data collection and analysis, and the expanding need to engage diverse participants and knowledge users. Using the Transtheoretical Model of Change (TTMC) as a framework, we consider opportunities to address intersectionality in LTC research. Engaging diverse knowledge users in LTC (e.g., unpaid caregivers, paid care staff), community (e.g., advocacy groups, service providers) and policy decision-makers (e.g., provincial government) is crucial. Empowering individuals to participate, modifying environments to support engagement, and facilitating ongoing partnerships with knowledge users are critical aspects of change efforts. Addressing structural barriers (e.g., accessibility, capacity, jurisdictional policies, and mandates) to research in LTC is also essential. The TTMC offers a framework for planning and enacting individual, organizational, and system-level changes for the future of LTC.