An investigation of quantitative methods for assessing intersectionality in health research: A systematic review

Disparities in Diet Quality and Food Security Across Ethnic-Immigration Status and US Nativity

This study examines separate relationships between ethnic-immigration status, length of residence (US nativity), dietary quality, and food security status among US adults. Data from the National Health and Nutrition Examination Survey between 2017 and 2020 were used. The study sample included 6933 adults aged 18 and above. Food security status was categorized as either food secure or food insecure. Dietary quality was assessed using the Healthy Eating Index (HEI-2015) component scores. The ethnic-immigration status comprised US-born and immigrant groups, including Whites, Asians, Blacks, Hispanics, and multi-racial group. The US nativity was categorized as native, less than 5 years, 5-14 years, 15-30 years, and above 30 years of residency. Associations between ethnic-immigration status, US nativity, and food security were analyzed using logistic regression. Their associations with dietary quality used linear regression. The results showed that US-born Hispanics, multi-racial group, and immigrant Hispanics had about twice the odds of being at a risk of food insecurity compared to their US-born White counterparts, while US-born Blacks had about one and half odds. Food insecurity was higher among respondents with less than 5 years and over 30 years of residency in the USA, with odds slightly less than two. Immigrants had better overall dietary quality than US-born Whites and natives (p-values < 0.001). The study highlights the importance of nutrition interventions that consistently promote equitable access to affordable and nutritious foods while fostering the exchange of valuable dietary practices among groups and encouraging cross-cultural learning to improve overall health.

Invited commentary: mental health services utilization disparities at the intersection of Asian ethnoracial identity and limited English proficiency

Nguyễn et al. (Am J Epidemiol. 2024;193(10):1343-1351) analyzed data from the US National Survey of Drug Use and Health (NSDUH) to show that Asian American Native Hawaiian/Pacific Islander (AANHPI) adults with limited English proficiency have substantially lower levels of mental health services utilization compared with White adults without limited English proficiency. The findings add to the growing literature using an intersectionality framework to understand health and health care disparities. We comment on the authors' notable examination of intersecting minoritized identities in mental health services utilization and the welcome emphasis on AANHPI health. We discuss the limitations of the NSDUH data, which are administered in English and Spanish only, and their limited ability to support analyses disaggregated by ethnoracial subgroups. We conclude by identifying gaps related to funding, training, and data disaggregation, and we highlight the role of mixed-methods approaches to advance our understanding of intersectionality and health disparities research. This article is part of a Special Collection on Mental Health.

The Intersectional Influence of Experienced Stigma on Clinically Significant Depressive Symptoms Among Gay, Bisexual, and Other Men Who Have Sex with Men

We sought to determine how intersectional stigma, operationalized by interactions of perceived stigma experiences in adulthood attributed to various social identities/characteristics (age, gender, race, ethnicity/nationality, religion, height/weight, other aspect of appearance [unrelated to the identities/characteristics listed-e.g. height/weight/race/gender], physical disability, sexual orientation, and HIV status), associates with clinically significant depressive symptoms (DS). We used data from the Multicenter AIDS Cohort Study (Baltimore/Washington, DC; Chicago; Pittsburgh/Columbus; and Los Angeles) on 1,385 sexual minority men (SMM), collected April 1, 2008-March 31, 2009. Classification trees predicted DS. An exploratory factor analysis (EFA) identified stigmas that tended to co-occur. We calculated and decomposed the joint disparity in DS risk between stigmas comprising each EFA factor. Thirty-four percent of men were classified with DS. Stigma was most commonly attributed to sexual orientation. Participants with stigma attributed to multiple social identities/characteristics had an increased risk of DS. In classification trees, covariates (especially income) were stronger predictors of DS than stigmas. Intersectional effects were observed between appearance and physical disability stigma (positive effect), and between race and ethnicity/nationality stigma, and sexual orientation and HIV status stigma (negative effects). Interventions to reduce stigmas among SMM, as well as improve the socioeconomic position of SMM in general, are needed.

Critical feminist epidemiology in action: reflections from a multidisciplinary partnership between Mujeres Unidas y Activas and academic researchers

Critical feminist research addresses social inequities, encourages equitable partnerships between researchers and participants, and acknowledges that research can be inherently political. Building upon critical feminist research practices, community-based participatory research, and social and structural epidemiology, we propose the approach of critical feminist epidemiology. A critical feminist epidemiology approach can study community and population health inequities with an eye toward identifying interventions that reduce inequities, through research processes that center the lived experiences of people from minoritized genders. We describe how our interdisciplinary, community-led team used a critical feminist epidemiology approach for an applied public health research project. Mujeres Unidas y Activas, a community organizing nonprofit led by and for Latina and Indigenous immigrant women, partnered with academic researchers to conduct community-led research on how their approach to building community power affected the health and well-being of organization members and their families. Critical feminist epidemiology is a promising approach for conducting research that is grounded in and relevant to the lives of women and gender-expansive people. Building upon social epidemiology and community-based participatory research, critical feminist epidemiology can be a useful research approach to generate novel evidence to inform action toward health equity for communities and populations. This article is part of a Special Collection on Methods in Social Epidemiology.

Hearing Loss and Discrimination: Evidence of Intersectionality in the All of Us Research Program

OBJECTIVES

Hearing loss (HL) has significant implications on social functioning. Here, we study the relationship between HL, race, and these combined categories as risk factors for discrimination in the large national All of Us cohort.

METHODS

The National Institutes of Health All of Us dataset was analyzed after including individuals who completed the Everyday Discrimination Survey between November 2021 and January 2022. HL and potential medical confounders were defined per ICD-10 codes or demographics. Multivariable linear regressions analyzing the relationship between HL and discrimination were adjusted for potential confounders, including age, gender, race, ethnicity, other demographic factors, and relevant medical conditions, such as depression and dementia. Additional regressions were conducted to evaluate how combined HL and race categories associated with discrimination risk.

RESULTS

Totally 8,722 individuals ≥18 years old had complete data. The mean age was 65 years (SD = 13.0 years), and 41% were women. Individuals with HL, compared with those without, were more likely to report discrimination in six out of nine questions on the Everyday Discrimination Survey (p < 0.05, with effect sizes ranging from -0.05 to -0.16 on a 6-point scale from 0 = "Almost everyday" to 5 = "Never"). Notably, for four out of those six questions, combined Black race and HL was associated with a risk of discrimination independent from the risk conveyed by race and/or HL individually.

CONCLUSIONS

This study offers evidence of HL as a risk factor for self-reported discrimination. Further, this study provides support for an intersectional understanding between discrimination, race, and HL.

LEVEL OF EVIDENCE

III, Laryngoscope, 2024 Laryngoscope, 2025.

An intersectional examination of the relationship between racial/ethnic discrimination and psychotic-like experiences: the role of other psychiatric symptoms

BACKGROUND

Racial and ethnic experiences of discrimination (EODs) are associated with numerous psychiatric symptoms, including outcomes along the psychosis spectrum; however, less is known about mechanisms by which EODs confer risk for psychotic-like experiences (PLEs; common subthreshold psychotic symptoms). Furthermore, work on gendered racism asserts that the intersection of race and gender impacts the nature of EODs experienced and, in turn, may impact the relationship between EODs and PLEs.

AIMS

To utilize an intersectional lens (race and gender) to examine whether psychological correlates of EODs (post-traumatic stress, anxiety, depression, and dissociation) mediate the EOD-PLE relationship.

METHODS

Undergraduates at a diverse, semipublic university (N = 1,759) completed self-report questionnaires (Experiences of Discrimination Scale, Prodromal Questionnaire, Center for Epidemiologic Studies Depression Scale, State-Trait Anxiety Inventory, Dissociative Experiences Scale, and Post-Traumatic Stress Disorder Checklist - Civilian Version). Analyses stratified the sample by race (non-Hispanic White, Black, and Asian) and examined three multiple mediation models, moderated by gender, examining the pathway from EODs to PLEs, through other psychiatric symptoms.

RESULTS

In the full sample, all psychiatric symptoms significantly mediated the relationship between EODs and PLEs. Only depression varied by gender, such that the indirect effect was only significant in female participants (β = 0.09; 95% CI [0.02, 0.16]). Across race-stratified groups, significant mediators varied by both race and gender.

CONCLUSIONS

These findings underscore the importance of accounting for intersectionality and multiple psychological symptoms in understanding the EOD-PLE associations, which differ by race and ethnicity as well as gender, and should be considered in clinical treatment of individuals with PLEs and history of EODs.

Triple Jeopardy in Oral Health: Additive Effects of Immigrant Status, Education, and Neighborhood

PURPOSE

To estimate the additive effects of parent's nativity status/language spoken at country of birth, education, and area-level socioeconomic status (SES) on untreated dental caries among children aged 5 to 9 y in Australia.

METHODS

Cross-sectional population-based data were obtained from the 2014 National Child Oral Health Study (N = 12,140). Indicators of social position used to explore additive effects on dental caries included nativity status, language, university degree, and neighborhood socioeconomic level. Multiple-way interactions were examined, and departure from additivity resulting from 2- and 3-way interactions were estimated as relative excess risk due to interaction (RERI).

RESULTS

Children marginalized across multiple layers of disadvantage had substantially higher frequencies of dental caries compared with children in the most advantaged category. RERI for the 3-way interaction between immigrant status, education, and neighborhood SES was negative (RERI3: -0.14; 95% confidence interval [CI]: -1.68, 1.40). When operationalizing language, education, and neighborhood SES, the joint effect of the 3 marginalized positions was additive (RERI3: 0.43; 95% CI: -2.08, 2.95).

CONCLUSION

Children marginalized across multiple intersecting axes of disadvantage bear the greatest burden of dental caries, with frequencies surpassing the cumulative effect of each social position alone. Findings emphasize the need to account for intersecting inequities and their oral health effects among children with immigrant backgrounds.

KNOWLEDGE TRANSFER STATEMENT

Our analysis underscores the necessity for policies and public health strategies targeting dental caries-related inequities to comprehensively account for various indicators of social disadvantage, particularly encompassing language proficiency, educational attainment, and neighborhood socioeconomic status. Within the intricate interplay of these factors, we identify a vulnerable subgroup comprising children with the highest prevalence of dental decay. Therefore, prioritizing this specific demographic should be the focal point of policies and public health initiatives aimed at fostering equitable oral health outcomes.

The Impact of the Alma-Ata Declaration on Global Pediatric Health Disparities: An Intersectional Perspective

Purpose of Review

The purpose of this review is to examine the impact of the Alma-Ata Declaration on global pediatric health disparities, highlighting the potential value of innovative research approaches such as intersectional quantitative studies in broadening our understanding of how the drivers of marginalization and social privilege intertwine to reinforce (or diminish each other) in the development of pediatric health disparity.

Recent Findings

Despite the global reach of the Alma-Ata Declaration and decades of its implementation, pediatric health disparities persist, with poorer health outcomes and greater exposure to adverse social contexts borne by children living in low and middle income countries (LMICs).

Summary

This paper explores degree to which the Alma-Ata Declaration through its proxy pediatric policy, the Integrated Management of Childhood Illnesses (IMCI), has been able to reduce global pediatric health disparities and suggests the use of intersectional analytical approaches as a means of addressing shortfalls in effectiveness of pediatric health policies.

The temporal trend and disparity in short-term health impacts of fine particulate matter in California (2006-2019)

Most epidemiological studies assume that the relationship between short-term air pollution exposure and health outcomes is constant over time, which ignores potential changes in population composition and particulate matter emission sources. Limited studies have assessed changes in the relationship between fine particulate matter (PM2.5) and adverse health outcomes over time, with mixed results. Additionally, there is a need to identify which subgroups are disproportionately impacted over time by PM2.5-related health consequences. Therefore, we aimed to examine whether temporal trends exist in the relationships between daily PM2.5 exposure and circulatory and respiratory acute care utilization in California from 2006 to 2019. We further assessed whether certain subpopulations are more susceptible to PM2.5 exposure by demographic characteristics and extreme wildfire frequency. Daily PM2.5 concentrations estimated from a stacked ensemble model and daily cause-specific acute care utilization and demographic data from the California Department of Health Care Access and Information. We analyzed this relationship using modified two-stage Bayesian hierarchical models, where we first did not consider temporal trends, then stratified by two periods, and finally flexibly considered non-linear changes over time. Increases in circulatory (0.56 %; 95 % credible interval (CI): 0.17 %, 0.96 %) and respiratory acute care utilization risk (2.61 %; 95%CI: 2.29 %, 2.94 %) were found with every 10 μg/m3 increase in PM2.5 on the same day and previous two days. These risks were found to increase over time, where 0.13 % (95%CI: 0.02 %, 0.22 %) and 1.40 % (95%CI: 1.24 %, 1.54 %) increases were identified for circulatory and respiratory acute care utilizations, respectively, from the first (2006-2012) to second period (2013-2019). Differences by age, sex, race/ethnicity, and extreme wildfire frequency were noted. These findings confirm that air pollution guidelines should consider the dynamic nature of epidemiological dose-response and can provide insight for targeted air pollution control and adaptation policies designed to reduce PM2.5 exposure, particularly for the most susceptible subpopulations.

"Because of HIV, It Opened My Mind": Intersectional Stigma Experiences Among Filipino Gay and Bisexual Men Living With HIV

Previous work has demonstrated that gay, bisexual men, and other men who have sex with men (GBM) living with HIV are likely to experience intersectional stigma. However, mainstream systems often fail to recognize how power and privilege shape this experience. Such a complex psychological phenomenon requires an in-depth reflective inquiry that acknowledges individuals as experts in their own experiences. To explicate this matter, this study aimed to develop an understanding of how intersectional stigma impacts the experiences of GBM living with HIV and to illuminate how contexts (un)fuel inequities. The semi-structured interviews with five Filipino GBM living with HIV were analyzed using interpretative phenomenological analysis (IPA). Exploration of their accounts elucidated how cultural elements fueled power dynamics and privilege, which in turn shaped intersectional stigma and their experiences. Narratives accentuated how Filipino GBM living with HIV situate themselves from victims to agents of change who empower and liberate others in the community. Insights from this study underscore the critical role of collective actions in bridging gaps in inequities and guiding the improvement of policies and interventions that are well-suited to the context and culturally appropriate for people living with HIV and other multiply marginalized populations.

Acceptability and Feasibility of Using Hair Samples for Chronic Stress Measurement Among Transgender Women in Brazil

INTRODUCTION

The ability to objectively measure chronic stress has important implications for research, prevention, and treatment. Cortisol is currently the most used biological marker in the investigation of stress and can be measured via blood, saliva, and urine; however, these methods have disadvantages. The measurement of cortisol in hair is a more recently developed method that quantifies the cumulative production of cortisol over longer periods of time. Given the potential benefits of hair as a chronic stress biometric, research with this novel method is burgeoning, yet rarely involves transgender ("trans") populations, despite high levels of reported stress among trans people due to experiences of stigma and discrimination. Since hair is a key part of gender presentation, trans people might be less likely than cisgender people to donate hair for research. To explore the feasibility and acceptability of hair collection for use as a stress biometric with trans women, we nested a study into an ongoing clinical trial in São Paulo, Brazil, "Manas por Manas" (Sisters for Sisters). Here, we describe the hair biometric substudy protocol, as well as the feasibility and acceptability of collecting hair in the study cohort.

METHODS

We randomly selected a subsample (n = 180) from the Manas por Manas cohort (n = 392), all of whom are trans women, age 18 or older. We messaged participants via phone, WhatsApp, or social media for at least three attempted contacts. Study visits included four components: (1) video introduction, including a demonstration of hair sampling; (2) informed consent; (3) a brief survey with the validated Short Stress Overload Scale (translated to Portuguese) and questions on hair care that could moderate stress hormone results; and (4) hair sample collection. Hair samples were collected and stored using validated protocols. Participants were reimbursed for travel costs.

RESULTS

Between April and December 2022, we messaged with 143 individuals out of the 180 sampled (79%) and invited them to participate in the study. Of those invited to participate, we scheduled study visits with 102 people (71.3% of those invited to participate), of whom 100 attended their study visits and completed all activities. Two people did not attend their study visits and stopped communication. Of those who were invited to participate and declined a study visit, four individuals declined due to the hair sample collection procedures (2.8% of those invited to participate). Other reasons for declining to participate included having moved (n = 7), lack of time (n = 11), not interested in research participation (n = 8), or unknown/stopped responding to messages (n = 11). Most participants reported that they chemically treated their hair to bleach, color, or straighten it, which could impact laboratory assays.

CONCLUSION

We found hair sampling for stress measurement to be feasible and acceptable to our participants. We successfully completed all study activities for our desired sample size, and most recruited individuals volunteered to participate. Reasons provided for declining study participation reflected general barriers to research participation, with only four people declining due to hair sample collection procedures.

Assessing mental health treatment receipt among Asian adults with limited English proficiency using an intersectional approach

US Asian adults and people with limited English proficiency (LEP) confront mental health treatment receipt disparities. At the intersection of racial and language injustice, Asian adults with LEP may face even greater disparity, but studies have not assessed this through explicitly intersectional approaches. Using 2019 and 2020 National Survey of Drug Use and Health data, we computed disparities in mental health treatment among those with mental illness comparing: non-Hispanic (NH) Asian adults with LEP to NH White adults without LEP (joint disparity), NH Asian adults without LEP to NH White adults without LEP (referent race disparity), NH Asian adults with LEP to those without LEP (referent LEP disparity), and the joint disparity versus the sum of referent disparities (excess intersectional disparity). In age- and gender-adjusted analyses, excess intersectional disparity was 26.8% (95% CI, -29.8 to 83.4) of the joint disparity in 2019 and 63.0% (95% CI, 29.1-96.8) in 2020. The 2019 joint disparity was 1.37 (95% CI, 0.31-2.42) times that if the race-related disparity did not vary by LEP, and if LEP-related disparity did not vary by race; this figure was 2.70 (95% CI, 0.23-5.17) in 2020. These findings highlight the necessity of considering the intersection of race and LEP in addressing mental health treatment disparities. This article is part of a Special Collection on Mental Health.

Oppression-Based Stress and Alcohol Inequities Among Sexual and Gender Minority People: An Intersectional Multilevel Framework

PURPOSE

Sexual and gender minority (SGM) people are at heightened risk for alcohol use, hazardous drinking, and alcohol use disorder compared to heterosexual and cisgender individuals. This paper: (a) presents an oppression framework that integrates intersectionality, stress, stigma, and addiction-based theories to examine the complex and nuanced ways oppression-based stress (e.g., minority stress) leads to sexual orientation and gender identity inequities in alcohol use; (b) conducts a narrative review that summarizes recent and novel advancements in the literature on the impact of oppression-based stressors on alcohol use outcomes across structural, interpersonal, and intrapersonal domains among SGM people; and (c) provides future research and intervention directions for the alcohol field.

SEARCH METHODS

A select review of the literature was conducted on July 10, 2023, using multiple electronic databases (i.e., PsycInfo, PubMed, Web of Science) and focusing on studies that had examined the associations between oppression-based stressors and alcohol use outcomes across structural, interpersonal, and intrapersonal levels. Search terms focused on alcohol consumption; SGM people, particularly SGM people of color; and oppression-based stress. Cross-sectional studies that focused on heterosexism-based and anti-bisexual oppression-based stressors at the interpersonal or intrapersonal levels and alcohol use outcomes were excluded as they have been included in prior reviews of the literature.

SEARCH RESULTS

The initial and combined search across the databases resulted in 3,205 articles. Of those, the narrative review included 50 peer-reviewed articles that focused on the following four areas of the literature on the associations between oppression-based stressors and alcohol use outcomes: (1) experimental, longitudinal, and experience sampling studies of heterosexism- and anti-bisexual oppression-based stressors (22 articles); (2) any studies of cissexism-based stressors (12 articles); (3) any studies of intersectional oppression among SGM people of color (seven articles, one article overlapped with the first category and another overlapped with the fourth category); and (4) any studies of structural oppression (11 articles).

DISCUSSION AND CONCLUSIONS

Results of this narrative review indicate that mounting evidence implicates oppression-based stress in inequities in alcohol use, hazardous drinking, and alcohol use disorder in SGM populations. This reflects SGM people's embodiment of oppression and injustice at the structural, interpersonal, and intrapersonal levels. Given some inconsistent and mixed patterns of findings, future research needs greater specificity in drinking inclusion criteria, robust and well-validated measures, more attention to culturally and developmentally relevant moderating and mediating mechanisms across the lifespan, application of sophisticated methodologies, and integration of intersectional and addiction frameworks.

Prevalence of alcohol use disorders documented in electronic health records in primary care across intersections of race or ethnicity, sex, and socioeconomic status

BACKGROUND

Diagnosis of alcohol use disorder (AUD) in primary care is critical for increasing access to alcohol treatment. However, AUD is underdiagnosed and may be inequitably diagnosed due to societal structures that determine access to resources (e.g., structural racism that limits opportunities for some groups and influences interpersonal interactions in and beyond health care). This study described patterns of provider-documented AUD in primary care across intersections of race, ethnicity, sex, and community-level socioeconomic status (SES).

METHODS

This cross-sectional study used EHR data from a regional healthcare system with 35 primary care clinics that included adult patients who completed alcohol screenings between 3/1/2015 and 9/30/2020. The prevalence of provider-documented AUD in primary care based on International Classification of Diseases-9 (ICD-9) and ICD-10 diagnoses was compared across intersections of race, ethnicity, sex, and community-level SES.

RESULTS

Among 439,375 patients, 6.6% were Latine, 11.0% Asian, 5.4% Black, 1.3% Native Hawaiian/Pacific Islander (NH/PI), 1.5% American Indian/Alaska Native (AI/AN), and 74.2% White, and 58.3% women. The overall prevalence of provider-documented AUD was 1.0% and varied across intersecting identities. Among women, the prevalence was highest for AI/AN women with middle SES, 1.5% (95% CI 1.0-2.3), and lowest for Asian women with middle SES, 0.1% (95% CI 0.1-0.2). Among men, the prevalence was highest for AI/AN men with high and middle SES, 2.0% (95% CI 1.1-3.4) and 2.0% (95% CI 1.2-3.2), respectively, and lowest for Asian men with high SES, 0.5% (95% CI 0.3-0.7). Black and Latine patients tended to have a lower prevalence of AUD than White patients, across all intersections of sex and SES except for Black women with high SES. There were no consistent patterns of the prevalence of AUD diagnosis that emerged across SES.

CONCLUSION

The prevalence of provider-documented AUD in primary care was highest in AI/AN men and women and lowest in Asian men and women. Findings of lower prevalence of provider-documented AUD in Black and Hispanic than White patients across most intersections of sex and SES differed from prior studies. Findings may suggest that differences in access to resources, which vary in effects across these identity characteristics and lived experiences, influence the diagnosis of AUD in clinical care.

Differential rates of induced abortion in Spain: educational attainment and age among native and immigrant women

OBJECTIVE

Analyzing the variations in induced abortion (IA) rates across different subpopulations in Spain based on country of origin, while considering educational and age composition.

METHOD

Using 2021 Voluntary Termination of Pregnancy register and 2021 Spanish Census microdata, we calculated crude IA rates and age-specific abortion rates. We used age-standardized IA rates (ASIAR) to account for the confounding effect of age composition. We compared seven subpopulations residing in Spain, taking into account simple ages and educational levels aggregated into four categories.

RESULTS

Immigrant women, especially those from Sub-Saharan and Latin American countries, consistently had higher IA rates compared to native Spanish women. According to age-specific IA rates, university-educated women had considerably fewer abortions than women with other education levels at any age. Age-standardized rates stratified by migratory origin revealed that native Spanish women with primary education or less had higher IA rates than their immigrant counterparts. There was a clear non-linear, association between educational level and IA rates among immigrants. The highest propensity for IA was found among secondary school graduates, while university graduates had the lowest IA rate.

CONCLUSIONS

The study demonstrated that variability in sociodemographic characteristics had an impact on IA rates. Young women with middle educational attainment and immigrant background had a higher likelihood of undergoing IA in Spain. The relationship between educational level and IA rates was complex, with variations observed among different groups and changes over time.

Unequal Access to Primary Care Providers at the Intersection of Race/Ethnicity, Sexual Orientation, and Gender

Background

Not all U.S. populations have equal access to a primary care provider (PCP). This study presents one of the first population-based evidence of inequities in access to PCPs at the intersection of race/ethnicity, sexual orientation, and gender.

Methods

We analyzed pooled data from the Behavioral Risk Factor Surveillance System from 2016 to 2021 across 42 states and 1 territory in the United States. The final sample encompassed 1,142,344 respondents aged 18 and older. Logistic regression models, stratified by gender spectrum, were estimated to compare predicted probabilities of having a PCP across 20 sexual and racial/ethnic identity groups.

Results

Among those on the feminine spectrum, most sexual minorities of color exhibited lower rates of having a PCP compared to heterosexual White individuals. Even when sociodemographic and health factors were accounted for, PCP access disadvantages remained significant in some groups of Native and Hispanic sexual minorities. Among sexual minorities of color on the masculine spectrum, inequities were less prominent, and sociodemographic and health factors nearly explained all their disadvantages.

Conclusions

Sexual orientation, gender, and race/ethnicity intersect to shape the access to PCPs. Future research, policy designs, and clinical practices should adopt an intersectional approach to achieve a better understanding of healthcare inequities and to reduce inequities.

Exploring the Impact of Equity, Diversity, and Inclusion Initiatives Within a Canadian Nursing Program: A Pilot Study

Interventions that aim to address equity, diversity, and inclusion (EDI) within the health professions often strive to promote the retention, recruitment, and success of individuals from historically underrepresented groups, who often belong to the same groups experiencing underservicing in health care. A pilot study aimed to examine the impact of ongoing EDI initiatives at Dalhousie University in Nova Scotia, Canada by exploring sense of belonging and curricular inclusion/representation from the perspectives of enrolled students. Intersectionality Theory was operationalized by way of considering the relational and contextual nature of marginalization. Results showed differences in perceptions of impacted sense of belonging and curricular inclusion/representation of diverse groups between respondents in the underrepresented subgroup as compared to their overrepresented counterparts. Differences in underrepresented and overrepresented subgroups' perceptions of impacted sense of belonging and curricular inclusion/representation suggest a need for further research to better understand the impact of EDI interventions on nursing students.

Unequal uptake of skilled maternal health care services in Ethiopia: cross-sectional data analyses informed by the intersectionality theory

OBJECTIVE

To investigate intersectional inequality encompassing socioeconomic, geographical and demographic variables in the use of competent birth and postnatal care services in Ethiopia.

DESIGN

Data for the study came from a series of the Ethiopia Demographic and Health Surveys. Four major surveys were taken place between 2000 and 2016 and all were included in the study. 9867, 9075, 10 592 and 9915 live births born 5 years preceding the surveys that were attended by skilled health workers in 2000, 2005, 2011 and 2016, respectively, were included in the study. For the postnatal care, only the 2016 survey was used due to sample size issues in the other surveys, and 3843 women having live births 2 years preceding the survey had complete data, allowing for fitting of a model. Since the outcome measures are binary, the logit model was used. Intersectionality was analysed by entering interactions into models.

SETTINGS

Population-based representative surveys encompassing all areas of Ethiopia.

PARTICIPANTS

The study subjects are women of reproductive age who had live births 2 years preceding the 2016 survey (for postnatal care) and live births born 5 years preceding the respective surveys (for birth care).

OUTCOME MEASURES

The outcome measures are skilled birth and postnatal care services. The postnatal care was for mothers within the first 2 days of giving birth and did not include care for the newborn. Competent maternal health care services are those that are provided by competent health workers: doctors, nurses, midwives and health officers.

RESULTS

It was observed that women at the crossroads of multiple axes of advantage and disadvantage had better and worse utilisation, respectively. For example, maternal education and residence intersected and predicted coverage of birth care was the highest among secondary schooling women who dwelt in urban settings with the values of 0.255; 95% CI 0.113 to 0.397 in 2000 and 0.589; 95% CI 0.359 to 0.819 in 2016 but was the lowest among non-educated women who lived in rural areas with the values of 0.0236; 95% CI 0.0154 to 0.0317 in 2000 and 0.203; 95% CI 0.177 to 0.229 in 2016.

CONCLUSIONS

It appeared that some women who were at the intersections of multiple axes of disadvantage had the lowest predicted coverage for maternal health care services. The study suggests that targeted interventions be developed for women who are at the intersection of multiple axes of marginalisation and that multiple sectors work in their sphere of resposibility to tackle social determinants of maternity care inequality. Policymakers may consider using intersectionality to inform development of targeted policies and or strategies. Further, future studies include structural drivers in the analysis of intersectionality to gain a better insight into the causes of disparities.

An Equity-Based Research Agenda to Promote Social Inclusion and Belonging for People With IDD

Having a sense of social inclusion and belonging, typically characterized by our personal relationships and community participation, is the central essence of life for most people, yet it remains elusive for many people with intellectual and developmental disabilities (IDD). This article summarizes the work of a diverse group of researchers and advocates to propose 6 big-picture, equity-based goals to drive future research in the field: (1) understanding the role of intersectionality, (2) understanding intimate relationships, (3) promoting formation of communities of care to support social inclusion, (4) understanding life course trajectories of social inclusion, (5) understanding social inclusion in virtual spaces, and (6) understanding how to promote social inclusion in the entire research process.

Food and Housing Insecurity in Nevada During the COVID-19 Pandemic

The COVID-19 pandemic intensified concerns regarding food and housing insecurity in the United States, particularly among vulnerable populations. After the pandemic prompted a shutdown of nonessential businesses in Nevada, unemployment rose dramatically as the gaming, tourism, and hospitality industries struggled. This study analyzed the results of two telephone surveys of Nevada adults' experiences in 2020 (n = 1000) and 2021 (n = 1002). The results demonstrate between 2020 and 2021 an 8.24 percentage point decline in food insecurity (FI) from 30.2% to 21.96% and a 12.58 percentage point increase in housing insecurity (HI) from 12.27% to 24.85%. Age, disability status, and certain categories of race/ethnicity and income were associated with both HI and FI in 2020, but disability was no longer significant in 2021. Instead, spouse/partner-status, living with children ≤ 18-years-old and receipt of SNAP benefits were significantly associated with FI in 2021. In particular, health status became a significant factor of both HI and FI. People of color experienced FI disparities compared to Whites. Asians/Hawaiians/Pacific Islanders were 3.22 times (95% CI 1.51, 6.86) more likely to experience FI in 2021 than Whites. A matched, longitudinal analysis also revealed that Whites experienced a significant 9.1 percentage point estimated decline in the probability of FI between 2020 and 2021. However, the reduction among non-White participants was statistically insignificant at 2.5 percentage points. Results indicate the importance of supporting the food and housing needs of people of color and individuals with disabilities. Further research should especially investigate the comparative FI rate among Asians/Hawaiians/Pacific Islanders in 2021 and offer solutions to the soaring prevalence of housing insecurity.

Initial Development and Validation of the Brief Internalized Heterosexist Racism Scale for Gay and Bisexual Black Men: A Measure of Internalized Heterosexist Racism

We introduce internalized heterosexist racism (IHR), or the internalization of damaging stereotypes, harmful beliefs, and negative attitudes about being a sexual minority person of color. We also present the initial development and validation of the Brief Internalized Heterosexist Racism Scale for gay and bisexual Black men (IHR-GBBM), a unidimensional, 10-item measure of IHR. Exploratory factor analyses on an internet-obtained sample of gay and bisexual Black men (N = 312; Mean age = 30.36 years) show that the IHR-GBBM had evidence of good internal consistency, and good convergent, discriminant, concurrent, and incremental validity. The IHR-GBBM was positively correlated with internalized racism, internalized heterosexism, and discrimination (racist, heterosexist). IHR was also negatively correlated with race stigma consciousness, weakly positively correlated with sexual identity stigma consciousness, but not correlated with either race identity, sexual identity, or social desirability. Hierarchical regressions showed that the IHR-GBBM explained an additional variance of 2.8% and 3.1% in anxiety symptoms and substance use coping, respectively, after accounting for (1) sociodemographics, (2) internalized racism and internalized heterosexism, and (3) an interaction of internalized racism and internalized heterosexism. Older participants and those who were "out" about their sexual identity reported lower IHR. Those who did not know/want to report their HIV status reported greater IHR. Results revealed no sexual identity, sexual position, relationship status, income, education, or employment status differences in IHR. We hope the development of the IHR-GBBM spurs future research on predictors and consequences of IHR. We discuss limitations and implications for the future study of internalized heterosexist racism.

Drug Use-Related Discrimination in Healthcare Settings and Subsequent Emergency Department Utilization in a Prospective Cohort Study of People With a History of Injection Drug Use

BACKGROUND

 People with a history of injection drug use face discrimination in healthcare settings that may impede their use of routine care, leading to greater reliance on the emergency department (ED) for addressing health concerns. The relationship between discrimination in healthcare settings and subsequent ED utilization has not been established in this population.

METHODS

 This analysis used longitudinal data collected between January 2014 and March 2020 from participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based observational cohort study of people with a history of injection drug use in Baltimore, Maryland. Logistic regressions with generalized estimating equations were used to estimate associations between drug use-related discrimination in healthcare settings and subsequent ED utilization for the sample overall and six subgroups based on race, sex, and HIV status.

RESULTS

 1,342 participants contributed data from 7,289 semiannual study visits. Participants were predominately Black (82%), mostly male (66%), and 33% were living with HIV. Drug use-related discrimination in healthcare settings (reported at 6% of study visits) was positively associated with any subsequent ED use (OR = 1.40, 95% CI: 1.15-1.72). Positive associations persisted after adjusting for covariates, including past sixth-month ED use and drug use, among the overall sample (aOR = 1.28, 95% CI: 1.04-1.59) and among some subgroups.

CONCLUSIONS

 Drug use-related discrimination in healthcare settings was associated with greater subsequent ED utilization in this sample. Further exploration of mechanisms driving this relationship may help improve care and optimize healthcare engagement for people with a history of injection drug use.

Unpacking Intersectional Inequities in Flu Vaccination by Sexuality, Gender, and Race-Ethnicity in the United States

Health care research has long overlooked the intersection of multiple social inequalities. This study examines influenza vaccination inequities at the intersection of sexuality, gender, and race-ethnicity. Using data from the 2013 to 2018 National Health Interview Survey (N = 166,908), the study shows that sexual, gender, and racial-ethnic identities jointly shaped flu vaccination. Specifically, White gay men had the highest vaccination rate (56%), while Black bisexual women had the lowest rate (23%). Across Black, Hispanic, and White individuals, sexual minority women had lower vaccination rates than heterosexual women, but sexual minority men had higher or similar vaccination rates than heterosexual men. Economic enabling, noneconomic enabling, and need-based factors together explained a substantial portion of these gaps. However, they cannot explain all the disadvantages faced by Black lesbian, bisexual, and heterosexual women and Black heterosexual men. Findings offer new evidence of hidden health care inequities and inform health policies from an intersectional perspective.

Examining the prevalence of adverse childhood experiences (ACEs) among justice-involved youth in the U.S.: The importance of accounting for race/ethnicity, gender, and gendered racial/ethnic groups

BACKGROUND

Youth in the U.S. juvenile justice system are exposed to adverse childhood experiences (ACEs) at higher rates than youth in the general public. Additionally, research has demonstrated ACEs can vary by race/ethnicity and gender. However, little is known about how ACEs are experienced across gendered racial/ethnic groups of justice-involved youth.

OBJECTIVE

To address this gap, this exploratory study is the first to apply an intersectional lens to examine the prevalence of ACEs among a group of justice-involved youth in the U.S.

PARTICIPANTS & SETTING

Using secondary data, this study examines ACEs by gender, race/ethnicity, and six gendered racial/ethnic groups of justice-involved youth referred to the Division of Youth and Family Services (DYFS) in Milwaukee, Wisconsin.

METHODS

Descriptive analyses are presented by gender and race/ethnicity separately, followed by gendered racial/ethnic groups to understand differential rates of exposure to ACEs.

RESULTS

The study's findings align with previous research and reinforce that justice-involved youth experience higher rates of adversity than the general public. The results also support the feminist pathway's perspective within an intersectional context, emphasizing the importance of accounting for race/ethnicity and gender simultaneously to identify the unique experiences of ACEs among justice-involved youth.

CONCLUSION

Recommendations related to these findings and considerations surrounding ACE measures are discussed. Specifically, findings from this study stress the importance of accounting for gender and race/ethnicity simultaneously when measuring experiences of adversity. This is a critical step to providing equitable treatment and services to address trauma-related needs across gendered racial/ethnic groups of system-involved youth.

Race/Ethnicity and Contexts: Associations of Racial/Ethnic Discrimination with Underage Youth's Alcohol Use and Drinking Contexts

Background

This study examined how racial/ethnic discrimination may shape alcohol use behaviors, related problems, and contexts of alcohol use among underage youth (<21 years old). Age group differences were also explored.

Methods

Cross-sectional data were obtained from California youth identified as racial and ethnic minoritized youth (n=605; ages 14-20). An adapted version of the Everyday Discrimination Scale was used to assess racial/ethnic discrimination. Demographics were also assessed. Outcomes included drinking status, past-6-month alcohol frequency and quantity, number of types of alcohol-related problems, risk for alcohol addiction, and past-6-month alcohol frequency and quantity in public and private settings. Multinomial, negative binomial, and linear regression analyses were conducted, controlling for demographics and exposure to context settings.

Results

Experiencing racial/ethnic discrimination was positively associated with lifetime drinking, any past-6-month drinking, and risk for alcohol addiction. It was also positively associated with the past-6-month typical number of drinks participants consumed in public settings. Age-group differences were observed with some greater risks for older underage youth (18-20 years old).

Conclusions

Findings suggest the importance of trauma-informed interventions for youth of diverse racial/ethnic groups and for addressing racial/ethnic discrimination in schools or communities to address alcohol use inequities in young people.

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.

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.

Intersectional race and gender disparities in kidney transplant access in the United States: a scoping review

BACKGROUND

Gender and racial disparities in kidney transplant access are well established, however how gender and race interact to shape access to kidney transplant is less clear. Therefore, we examined existing literature to assess what is known about the potential interaction of gender and race and the impact on access to kidney transplantation in the US.

METHODS

Following PRISMA guidelines, we conducted a scoping review and included quantitative and qualitative studies published in English between 1990 and May 31, 2023 among adult end-stage kidney disease patients in the US. All studies reported on access to specific transplant steps or perceived barriers to transplant access in gender and race subgroups, and the intersection between the two. We narratively synthesized findings across studies.

RESULTS

Fourteen studies met inclusion criteria and included outcomes of referral (n = 4, 29%), evaluation (n = 2, 14%), waitlisting (n = 4, 29%), transplantation (n = 5, 36%), provider perceptions of patient transplant candidacy (n = 3, 21%), and patient preferences and requests for a living donor (n = 5, 36%). Overall, we found that White men have the greatest access at all steps of the transplant process, from referral to eventual living or deceased donor transplantation. In contrast, women from racial or ethnic minorities tend to have the lowest access to kidney transplant, in particular living donor transplant, though this was not consistent across all studies.

CONCLUSIONS

Examining how racism and sexism interact to shape kidney transplant access should be investigated in future research, in order to ultimately shape policies and interventions to improve equity.

U.S. Breastfeeding Outcomes at the Intersection: Differences in Duration Among Racial and Ethnic Groups With Varying Educational Attainment in a Nationally Representative Sample

BACKGROUND

As breastfeeding rates in the United States increase, barriers persist for Black, Latine, and low-socioeconomic status household dyads when compared to White and high-socioeconomic status household dyads. Previous breastfeeding disparities research has almost exclusively considered the influence of race, ethnicity, and socioeconomic status separately, although these attributes are not randomly distributed across the population.

RESEARCH AIM

To identify breastfeeding duration patterns by race/ethnicity and educational attainment in a nationally representative U.S. National Immunization Survey sample.

METHOD

We conducted a cross-sectional, secondary analysis of the U.S. Centers for Disease Control and Prevention's 2020 National Immunization Survey-Child public-use data. To examine breastfeeding and exclusive breastfeeding durations at the intersection of race/ethnicity and educational attainment, we created a 12-item, cross-classified variable using three educational attainment groups and four race/ethnicity groups. We used linear regressions to test these associations.

RESULTS

In all, 83% of the sample breastfed. Mean durations of breastfeeding were 7.5 (SE = 1.95) months and exclusive breastfeeding duration was 4.9 (SE = 0.87) months. In adjusted models, multi-race/other high-educational attainment participants had the longest breastfeeding duration by almost 3 weeks (β: 19.53, 95% CI [5.27, 33.79]), and Black low-educational attainment participants exclusively breastfed for 1 month less than White high-educational attainment participants (β:-30.23, 95% CI [-40.87, -19.58]).

CONCLUSIONS

Examining race/ethnicity and educational attainment together provides an intersectional understanding of breastfeeding outcomes and can inform targeted, culturally appropriate interventions.

A Quantitative Intersectionality Analysis of HIV/STI Prevention and Healthcare Access Among Transgender and Nonbinary People

BACKGROUND

Transgender and nonbinary people experience substantial barriers to accessing healthcare, including prevention of HIV and other sexually transmitted infections (HIV/STI), due to structural inequities. We examined differences in insurance, HIV/STI prevalence, testing, and preexposure prophylaxis use among transgender and nonbinary people living in Washington State by race and ethnicity and gender.

METHODS

We pooled data from five 2019-2021 Washington State HIV/STI surveillance data sources to obtain a large and diverse sample of 1648 transgender and nonbinary participants. We calculated the risk difference (RD) for each outcome and used Poisson regression to estimate a surrogate measure of additive interaction-attributable proportion (AP)-that measures the proportion of the excess prevalence of the outcome observed at the intersection of gendered and racialized experience, beyond that expected from gender or race and ethnicity alone.

RESULTS

Participants reported overall high levels of poverty (29% incomes <$15,000 and 7% unstable housing). Certain groups, especially racial/ethnic minority transgender women, were disproportionately impacted by HIV/STIs (RDs from 20% to 43% and APs from 50% to 85%) and less likely to currently have insurance (RDs from 25% to 39% and APs from 74% to 93%) than that expected based on gendered or racialized experience alone.

CONCLUSIONS

Our findings highlight the heterogeneity in insurance access, HIV/STI positivity, and prevention utilization within transgender communities. We observed that a large proportion of increased HIV/STI prevalence among racial/ethnic minority transgender women was attributable to the intersection of gender and race and ethnicity. Our findings highlight the importance of trans-inclusive models of HIV/STI prevention that address multilevel barriers rooted in cissexism and structural racism.

Intergenerational effects of maternal lifetime stressor exposure on offspring telomere length in Black and White women

BACKGROUND

Although maternal stressor exposure has been associated with shorter telomere length (TL) in offspring, this literature is based largely on White samples. Furthermore, timing of maternal stressors has rarely been examined. Here, we examined how maternal stressors occurring during adolescence, pregnancy, and across the lifespan related to child TL in Black and White mothers.

METHOD

Mothers (112 Black; 110 White; Mage = 39) and their youngest offspring (n = 222; Mage = 8) were part of a larger prospective cohort study, wherein mothers reported their stressors during adolescence (assessed twice during adolescence for the past year), pregnancy (assessed in midlife for most recent pregnancy), and across their lifespan (assessed in midlife). Mother and child provided saliva for TL measurement. Multiple linear regression models examined the interaction of maternal stressor exposure and race in relation to child TL, controlling for maternal TL and child gender and age. Race-stratified analyses were also conducted.

RESULTS

Neither maternal adolescence nor lifespan stressors interacted with race in relation to child TL. In contrast, greater maternal pregnancy stressors were associated with shorter child TL, but this effect was present for children of White but not Black mothers. Moreover, this effect was significant for financial but not social pregnancy stressors. Race-stratified models revealed that greater financial pregnancy stressors predicted shorter telomeres in offspring of White, but not Black mothers.

CONCLUSIONS

Race and maternal stressors interact and are related to biological aging across generations, but these effects are specific to certain races, stressors, and exposure time periods.

When social identities intersect: understanding inequities in growth outcomes by religion- caste and religion-tribe as intersecting strata of social hierarchy for Muslim and Hindu children in India

BACKGROUND

Minority social status determined by religion, caste and tribal group affiliations, are usually treated as independent dimensions of inequities in India. This masks relative privileges and disadvantages at the intersections of religion-caste and religion-tribal group affiliations, and their associations with population health disparities.

METHODS

Our analysis was motivated by applications of the intersectionality framework in public health, which underlines how different systems of social stratification mutually inform relative access to material resources and social privilege, that are associated with distributions of population health. Based on this framework and using nationally representative National Family Health Surveys of 1992-93, 1998-99, 2005-06, 2015-16 and 2019-21, we estimated joint disparities by religion-caste and religion-tribe, for prevalence of stunting, underweight and wasting in children between 0-5 years of age. As indicators of long- and short-term growth interruptions, these are key population health indicators capturing developmental potential of children. Our sample included Hindu and Muslim children of <  = 5 years, who belonged to Other (forward) castes (the most privileged social group), Other Backward Classes (OBCs), Schedule Castes (SCs) and Schedule Tribe (STs). Hindu-Other (forward) caste, as the strata with the dual advantages of religion and social group was specified as the reference category. We specified Log Poisson models to estimate multiplicative interactions of religion- caste and religion-tribe identities on risk ratio scales. We specified variables that may be associated with caste, tribe, or religion, as dimensions of social hierarchy, and/or with child growth as covariates, including fixed effects for states, survey years, child's age, sex, household urbanicity, wealth, maternal education, mother's height, and weight. We assessed patterns in growth outcomes by intersectional religion-caste and religion-tribe subgroups nationally, assessed their trends over the last 30 years, and across states.

FINDINGS

The sample comprised 6,594, 4,824, 8,595, 40,950 and 3,352 Muslim children, and 37,231, 24,551, 35,499, 1,87,573 and 171,055 Hindu children over NFHS 1, 2, 3, 4, and 5, respectively. As one example anthropometric outcome, predicted prevalence of stunting among different subgroups were as follows- Hindu Other: 34.7% (95%CI: 33.8, 35.7), Muslim Other: 39.2% (95% CI: 38, 40.5), Hindu OBC: 38.2 (95%CI: 37.1, 39.3), Muslim OBC: 39.6% (95%CI: 38.3, 41), Hindu SCs: 39.5% (95%CI: 38.2, 40.8), Muslims identifying as SCs: 38.5% (95%CI: 35.1, 42.3), Hindu STs: 40.6% (95% CI: 39.4, 41.9), Muslim STs: 39.7% (95%CI: 37.2, 42.4). Over the last three decades, Muslims always had higher prevalence of stunting than Hindus across caste groups. But this difference doubled for the most advantaged castes (Others) and reduced for OBCs (less privileged caste group). For SCs, who are the most disadvantaged caste group, the Muslim disadvantage reversed to an advantage. Among tribes (STs), Muslims always had an advantage, which reduced over time. Similar directions and effect sizes were estimated for prevalence of underweight. For prevalence of wasting, effect sizes were in the same range, but not statistically significant for two minority castes-OBCs and SCs.

INTERPRETATION

Hindu children had the highest advantages over Muslim children when they belonged to the most privileged castes. Muslim forward caste children were also disadvantaged compared to Hindu children from deprived castes (Hindu OBCs and Hindu SCs), in the case of stunting. Thus, disadvantages from a socially underprivileged religious identity, seemed to override relative social advantages of forward caste identity for Muslim children. Disadvantages born of caste identity seemed to take precedence over the social advantages of Hindu religious identity, for Hindu children of deprived castes and tribes. The doubly marginalized Muslim children from deprived castes were always behind their Hindu counter parts, although their differentials were less than that of Muslim-Hindu children of forward castes. For tribal children, Muslim identity seemed to play a protective role. Our findings indicate monitoring child development outcomes by subgroups capturing intersectional social experiences of relative privilege and access from intersecting religion and social group identities, could inform policies to target health disparities.

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.

Racism and Electronic Health Records (EHRs): Perspectives for research and practice

Informatics researchers and practitioners have started exploring racism related to the implementation and use of electronic health records (EHRs). While this work has begun to expose structural racism which is a fundamental driver of racial and ethnic disparities, there is a lack of inclusion of concepts of racism in this work. This perspective provides a classification of racism at 3 levels-individual, organizational, and structural-and offers recommendations for future research, practice, and policy. Our recommendations include the need to capture and use structural measures of social determinants of health to address structural racism, intersectionality as a theoretical framework for research, structural competency training, research on the role of prejudice and stereotyping in stigmatizing documentation in EHRs, and actions to increase the diversity of private sector informatics workforce and participation of minority scholars in specialty groups. Informaticians have an ethical and moral obligation to address racism, and private and public sector organizations have a transformative role in addressing equity and racism associated with EHR implementation and use.

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

INTRODUCTION

Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.

RESEARCH DESIGN AND METHODS

This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.

RESULTS

Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.

CONCLUSIONS

A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

Associations between social network characteristics and sexual minority disclosure concern among Black men who have sex with men living with and without HIV

In addition to the pervasive anti-Black racism faced by Black people in the United States, Black men who have sex with men (BMSM) face sexual minority stigma and, among BMSM living with HIV, HIV-related stigma. These multilevel social forces shape social networks, which are important sources of resources, support, and behavior regulation. This study quantitatively examined the relationship between social network characteristics and sexual minority stigma (e.g., homophobia, biphobia), assessed by reported concerns around disclosing one's sexual minority status, among BMSM in Baltimore, Maryland in 2014 (N = 336). A majority of participants (63.7%) reported experiencing medium or high levels of sexual minority disclosure concern. In a multiple linear regression model, participants with higher sexual minority disclosure concern reported lower network density and having fewer good friends who are gay or bisexual men. Stratifying the same multiple linear regression model by HIV status supports the importance of an intersectional understanding of sexual minority and HIV-related stigma. These findings can help health-related programs address the complex relationships between sexual minority stigma, social networks, and HIV status within this multiply-marginalized and high-priority population.

Health occupations salary outcomes: intersections of student race, gender, and first-generation status

Greater diversity in the healthcare workforce has been identified as a critical need in serving an increasingly diverse population. Higher education institutions have been tasked with increasing the number of underrepresented students in the health occupations pipeline to better align with the demographics of the general population and meet the need for a diverse health occupations workforce. This study used the National Science Foundation's National Survey of College Graduates dataset to capture data across time, examining the intersectionality of race, gender, and first-generation status on the salary outcomes of students who earn degrees related to health occupations. Results indicate that the intersecting identities of students who earn a bachelor's degree or higher in the health professions impact salary outcomes. Results of this study have implications for higher education policies that can impact increased diversity in the health occupations workforce pipeline.

Kenton Award Lecture-Stroke Disparities Research: Learning From the Past, Planning for the Future

Inequities in stroke care and outcomes have been documented both within and among countries based on factors, such as race, geography, and socioeconomic status. Research can help us to identify, understand, and address inequities, and this article offers considerations for scientists working in this area. These include designing research aimed at identifying the underlying causes of inequities, recognizing the importance of the social determinants of health, considering interventions that go beyond the individual patient and provider to include policies and systems, acknowledging the role of structural racism, performing community-engaged participatory research, considering intersecting social identities, learning from cross-national comparisons, maintaining the data sources needed for inequities research, using terminology that advances health equity, and improving diversity across the research enterprise.

Relationship between intersectionality and cancer inequalities: a scoping review protocol

INTRODUCTION

Persistent inequalities in cancer care and cancer outcomes exist within and between countries. However, the evidence pertaining to the root causes driving cancer inequalities is mixed. This may be explained by the inadequate attention paid to experiences of patients with cancer living at the intersection of multiple social categories (eg, social class, ethnicity). This is supported by the intersectionality framework. This framework offers an alternative lens through which to analyse and understand how these interlocking systems of oppression uniquely shape the experiences of patients with cancer and drive inequalities. In this protocol, we outline a scoping review that will systematically map what is known about the relationship between intersectionality and inequalities in care experience and cancer outcomes of patients with cancer; and to determine how the intersectionality framework has been applied in studies across the cancer care pathway and across countries.

METHODS AND ANALYSIS

This study will be guided by Arksey and O'Malley's, and Levac et al's frameworks for scoping reviews. We will identify and map the evidence on cancer inequalities and intersectionality from 1989 to present date. Electronic databases (EMBASE, PsychINFO, CINAHL, Medline, Web of Science, ProQuest) and a systematic search strategy using a combination of keywords and Boolean operators AND/OR will be used to identify relevant studies. Screening of eligible papers and data extraction will be conducted by two independent reviewers, and disagreements resolved by discussion with the research team. We will use an iterative process to data charting using a piloted form. Findings will be collated into a narrative report.

ETHICS AND DISSEMINATION

Ethical approval is not required since data used are from publicly available secondary sources. Findings will be disseminated through peer-reviewed journals, conferences and stakeholder meetings. Further, findings will inform the next phases of a multistage research project aimed at understanding inequalities among patients with breast cancer.

Mechanisms Connecting Police Brutality, Intersectionality, and Women's Health Over the Life Course

Police brutality harms women. Structural racism and structural sexism expose women of color to police brutality through 4 interrelated mechanisms: (1) desecration of Black womanhood, (2) criminalization of communities of color, (3) hypersexualization of Black and Brown women, and (4) vicarious marginalization. We analyze intersectionality as a framework for understanding racial and gender determinants of police brutality, arguing that public health research and policy must consider how complex intersections of these determinants and their contextual specificities shape the impact of police brutality on the health of racially minoritized women. We recommend that public health scholars (1) measure and analyze multiple sources of vulnerability to police brutality, (2) consider policies and interventions within the contexts of intersecting statuses, (3) center life course experiences of marginalized women, and (4) assess and make Whiteness visible. People who hold racial and gender power-who benefit from racist and sexist systems-must relinquish power and reject these benefits. Power and the benefits of power are what keep oppressive systems such as racism, sexism, and police brutality in place. (Am J Public Health. 2023;113(S1):S29-S36. https://doi.org/10.2105/AJPH.2022.307064).

Exploring the Application of Intersectionality as a Path toward Equity in Perinatal Health: A Scoping Review

OBJECTIVE

To conduct a scoping review to determine how past studies have applied the theory of intersectionality, a critical feminist research paradigm, to understand the physical health and mental health outcomes of perinatal people as a step toward addressing maternal health disparities and injustice. The study includes a review of existing research on maternal physical and mental health outcomes, presents the strengths and limitations of existing studies, and provides recommendations on best practices in applying intersectionality in research to address systemic issues and improve outcomes for the perinatal population.

METHODS

We conducted an extensive literature search across four search engines, yielding 28 publications using the intersectionality framework that focused on the outcomes of perinatal people, with a total sample of 9,856,042 participants. We examined how these studies applied intersectionality and evaluated them based on three areas: conceptualization, research method, and interpretation/findings.

RESULTS

Our findings indicate that maternal health researchers have provided good descriptions of the interaction of systemic inequalities and have used analysis that allows for the examination of interlocking and mutually reinforcing social positions or systems. We find that improvement is needed in the areas of conceptualization, reflexivity, and understanding of power structure. Recommendations are provided in the form of a checklist to guide future research toward an impactful approach to addressing perinatal health disparities.

RELEVANCE

Our scoping review has implications for improving applied health research to address perinatal health disparities, mortality, and morbidity. Recommendations are given along with references to other tools, and a guidance checklist is provided to support scholars in creating an impactful approach to applying intersectionality in the goal of addressing maternal health disparities.

How Can Quantitative Analysis Be Used to Improve Occupational Health without Reinforcing Social Inequalities? An Examination of Statistical Methods

Taking account of sex and gender in occupational health studies poses statistical challenges. Other sociodemographic variables, such as racialization, class, and age, also affect the relations between workplace exposures and health and interact with sex and gender. Our objective was to perform a critical review of conventional and emerging statistical tools, examining whether each analysis takes account of sociodemographic variables (1) in a way that contributes to identification of critical occupational determinants of health (2) while taking account of relevant population characteristics to reflect intersectional approaches to health and (3) using sample sizes and population characteristics available to researchers. A two-step search was conducted: (1) a scientific watch concerning the statistical tools most commonly used in occupational health over the past 20 years; (2) a screening of the 1980-2022 literature with a focus on emerging tools. Our examination shows that regressions with adjustment for confounders and stratification fail to reveal the sociodemographic mechanisms that interact with occupational health problems, endangering the identification of occupational risks. Multilevel (notably MAIHDA) analyses, decision tree, cluster, and latent analyses are useful methods to consider when seeking to orientate prevention. Researchers should consider methods that adequately reveal the mechanisms connecting sociodemographic variables and occupational health outcomes.

A systematic review of sociodemographic reporting and representation in eating disorder psychotherapy treatment trials in the United States

OBJECTIVE

Eating disorders (EDs) were once conceptualized as primarily affecting affluent, White women, a misconception that informed research and practice for many years. Abundant evidence now discredits this stereotype, but it is unclear if prevailing "evidence-based" treatments have been evaluated in samples representative of the diversity of individuals affected by EDs. Our goal was to evaluate the reporting, inclusion, and analysis of sociodemographic variables in ED psychotherapeutic treatment randomized controlled trials (RCTs) in the US through 2020.

METHODS

We conducted a systematic review of ED psychotherapeutic treatment RCTs in the US and examined the reporting and inclusion of gender identity, age, race/ethnicity, sexual orientation, and socioeconomic status (SES) of enrolled participants, as well as recruitment methods, power analyses, and discussion of limitations and generalizability.

RESULTS

Our search yielded 58 studies meeting inclusion criteria dating back to 1985. Reporting was at times incomplete, absent, or centered on the racial/gender majority group. No studies reported gender diverse participants, and men and people of color were underrepresented generally, with differences noted across diagnoses. A minority of papers considered sociodemographic variables in analyses or acknowledged limitations related to sample characteristics. Some progress was made across the decades, with studies increasingly providing full racial and ethnic data, and more men included over time. Although racial and ethnic diversity improved somewhat, progress appeared to stall in the last decade.

DISCUSSION

We summarize findings, consider context and challenges for RCT researchers, and offer suggestions for researchers, journal editors, and reviewers on improving representation, reporting, and analytic practices.

PUBLIC SIGNIFICANCE

Randomized controlled trials of eating disorder psychotherapeutic treatment in the US are increasingly reporting full race/ethnicity data, but information on SES is inconsistent and sexual orientation absent. White women still comprise the overwhelming majority of participants, with few men and people of color, and no gender-diverse individuals. Findings underscore the need to improve reporting and increase representation to ensure evidence-based treatments are effective across and within diverse groups.

Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers

Importance

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.

Objective

To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.

Design, Setting, and Participants

This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.

Exposures

Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.

Main Outcomes and Measures

Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.

Results

The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.

Conclusions and Relevance

Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.