Applying intersectionality in health and healthcare

Applying intersectionality in health and healthcare

Some views from social epidemiology

Davide MalmusiAgència de Salut Pública de Barcelona

ADAPT meeting, Bologna, 22 January 2015

Conceptual framework: determinants of health inequalitiesCommission to Reduce Social Inequalities in Health in Spain

• Some issues on inequality in healthcare by socioeconomic position (SEP) and gender

• Intersectionality in health and in policy evaluation: guide and examples

• Migrant status and intersectionality: an example• Summing up

Outline

• Self-ratings of health capture true inequalities in health by SEP – or they even underestimate them1,2

• GPs disagree more often on low SEP patients’ health ratings – tending to overestimate their health3

Evidence on SEP inequality in quality of care - within public systems (1)

1. Bago d’Uva T, et al. Differential health reporting by education level … Int J Epidemiol. 2008;37:1375-83. 2. Beam Dowd J, Todd M. Does Self-reported Health Bias ... J Gerontol B Psychol Sci Soc Sci. 2011;66:478-89.3. Kelly-Irving M, et al. Do general practitioners overestimate the health ... Soc Sci Med. 2011;73:1416-21.

Patient’s education level GP agrees GP under-rates GP over-rates

High education 75% 11% 14%

Medium education 74% 11% 16%

Low education 50% 12% 37%

• Among the chronically ill, low SEP patients perceive lower quality of doctor-patient relationship4

• Coronary risk scores overestimate mortality risk – much more in higher than lower social classes5

Evidence on SEP inequality in quality of care - within public systems (2)

4. Vonneilich N, et al. [Social inequality and perceived quality...]. Gesundheitswesen. 2011;73:211-6.5. Ramsay SE, et al. Prediction of coronary heart disease... Eur J Cardiovasc Prev Rehabil. 2011;18:186-93.

• Poverty screening – and referral6

• Socioeconomic factors in risk algorithms7

• Consciousness of own bias, positive discrimination8

• Resource allocation and quality incentives in deprived areas9

• Population-wide vs opportunistic programs10

SEP inequality in quality of care: some steps in the good direction

6. Bloch G. Poverty: a clinical tool for primary care in Ontario. Revised Nov 2013. Available at http://ocfp.on.ca 7. Fiscella K, et al. Adding socioeconomic status to Framingham scoring… Am Heart J. 2009;157:988-94.8. Bærøe K, Bringedal B. Just health: On the conditions for acceptable... J Med Ethics. 2011 ;37:526-9.9. Kiran T, et al. The association between quality of primary care... J Epidemiol Community Health. 2010;64:927-34.10. Palència L, et al. Socio-economic inequalities in breast and cervical cancer... Int J Epidemiol. 2010;39:757-65.

• GPs more likely to overestimate women’s health than men’s3

• But are women’s and men’s health self-ratings equally valid?

Gender inequalities in quality of care

3. Kelly-Irving M, et al. Do general practitioners overestimate the health ... Soc Sci Med. 2011;73:1416-21.

Gender inequalities in health: Perception or real illness?

• Women live longer but (in most countries) report poorer health than men

• Is this a matter of perception or illness behaviour?


Data source: Spanish National Health

Survey 2006


• Women live longer but (in most countries) report poorer health than men

• Is this a matter of perception or illness behaviour?NO -> They really suffer from more (non-life-threathening but limiting and painful) chronic conditions


• As healthcare systems and professionals, we prioritise action on life-threathening diseases

• Conditions that don’t kill, but cause lot of suffering and disability in large shares of the population, fall behind

• Reorienting healthcare towards these conditions may be also good for gender equity

Gender inequalities in health: What does this matter for healthcare?

• Some issues on inequality in healthcare by SES and gender• Intersectionality in health and in policy evaluation: guide

and examples • Migrant status and intersectionality: an example• Summing up

Outline

Intersectionality: a quick guide

The analysis of health inequalities and health equity impacts of policies is usually centered on social class / socio-economic position.

Other social relations that generate health inequalities are usually more neglected – or treated separately.

Intertwined mechanisms of power relations that interact among them: need for intersectional approaches.

Palència L, Malmusi D, Borrell C. Incorporating intersectionality in policy evaluation analysis. A quick guide.


Intersections between axes create complex social locations that are more central to the nature of social experiences than any single axe of inequality.

Groups in society are affected by their position in multiple systems of power and oppression, a “matrix of domination” that changes over time and place and in different institutional domains.



The health effects of an intervention, context, condition… differ depending on one’s position according to the intersection of several axes / dimensions of inequality / power relations.

When designing/implementing interventions, targeted policies can be as ineffective as general ones in addressing multiple identities and power relations. Tools include multistrand/equality/power mainstreaming and Intersectionality-Based Policy Analysis.



The health effects of an intervention, context, condition… differ depending on one’s position according to the intersection of several axes / dimensions of inequality / power relations.

When evaluating interventions (or testing associations) we have to consider that populations are not uniform (nor binary or categorical either), and go beyond the simple “whether” it works, to understand “for whom” (and “why” and “how”)



Intersectionality: a quick guideExample 1. Family composition and healthRuiz-Cantero MT et al. A framework to analyse gender bias… JECH 2007

Model adjusted by sex and social class: Larger household size slightly associated with poorer self-rated healthCohabiting with a >65 aged person slightly associated with better health


Model stratified by sex and adjusted by social class: Household size and cohabiting with elderly strongly associated with poorer self-rated health among women but not among men



Model stratified by sex and social class: Household size and cohabiting with elderly strongly associated with poorer self-rated health only among manual women



Intersectionality: a quick guideExample 2. Crisis and mental healthBartoll X et al. The evolution of mental health in Spain… Eur J Public Health 2014

Prevalence (%) of poor mental health (GHQ-12>2)

The “zero change” in the whole population masks a worsening in men and improvement in women.


2006/07 2011/12 Prevalence Ratio

Total 19,6 19,8 1,01

Men 14,7 16,9 1,15**

Women 24,6 22,7 0,92*

* p<0,05 ** p<0,01 *** p<0,001



Men 14,7 16,9 1,15**

15-24 11,3 11,2 0,98

25-34 15,2 16,1 1,05

35-44 15,0 18,7 1,24*

45-54 14,8 19,1 1,29**

55-64 16,9 17,3 1,02

* p<0,05 ** p<0,01 *** p<0,001





Men 14,7 16,9 1,15**

Social class I 11,8 12,2 1,04

II 14,6 15,4 1,06

III 15,9 15,4 0,97

IV 14,8 18,2 1,23**

V 15,3 18,6 1,21

* p<0,05 ** p<0,01 *** p<0,001



Within men, the worsening is concentrated among the middle-aged and the manual social class, and stronger in immigrants.



Men 14,7 16,9 1,15**

Born in Spain 14,7 16,4 1,11*

Foreign-born 14,5 19,3 1,33*

* p<0,05 ** p<0,01 *** p<0,001



Intersectionality: a quick guideExample 3. Urban renewal and healthMehdipanah R et al. The effects of an urban renewal project… JECH 2014



Effects also varied by neighbourhood: clearer health improvement in the periphery (intervention with strong residents’ participation, including subway, elevators, escalators,) but not in the inner city (where the program was one among the many changes going on)

Qualitative studies are also key to study intersectionality: in an inner city neighbourhood, age and immigrant status shaped the perception on changes occurring - a senior group reported mainly discontent with gentrification and immigration, an immigrant-background youth group was satisfied with new public spaces and youth centers(Mehdipanah et al., Health Place 2013; Mehdipanah et al., Soc Sci Med 2015)


• Some issues on inequality in healthcare by SES and gender• Intersectionality in health and in policy evaluation: guide

and examples • Migrant status and intersectionality: an example• Summing up

Outline

Intersectionality: my first (?) encounter

Intersectionality in health status in Catalonia

Objectives: To propose a health-equity-based classification of migration types. To analyse inequalities in self-rated health in Catalonia in the intersections of migration type, gender and social class. To analyse the contribution of socioeconomic conditions to migration-related health inequalities in Catalonia.Methods: Cross-sectional analysis of two 2005-06 population surveys (Health and Living Conditions). Population aged 25 to 64. “Age-adjusted” prevalences and logistic regressions.


Migration type internal/international, rich/poor, recent/less recent based on birthplace and year of arrival:• Catalonia (Local-born)• Rest of Spain

– High tertile of regional development in 1981– Medium or low tertile of development

• Foreign countries– Very highly developed countries (UN HDI) in 2006– Rest of the world, divided based on year of arrival:

• Recent immigrants (since 2000)• Less recents (until 1999)

Intersectionality in health status in Catalonia2 dimensions: Migration type and gender

Odds Ratio of fair/poor self-rated health by migration typeAdjusted by age (Model 1) + class (M2) + standards of living (M3)

Women Men


Social class based on current, last or partner’s occupation:• I: higher-level professionals, managers, directors of large

companies• II: medium-level professionals and directors of small companies• III non-manual: administrative workers, clerks, safety and

security workers• III manual: self-employed and supervisors in manual occupations• IV-a: skilled manual occupations• IV-b: semi-skilled manual occupations• V: unskilled manual occupations

Intersectionality in health status in CataloniaSample by social class and migration type (women)

1192

880

171

108

88

33

102

342

146

33

17

3

60176

139

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No manual Manual qualificat Manual no qualificat

Estranger-pobre

Estranger-ric

Espanya-pobre

Espanya-rica

Catalunya

Intersectionality in health status in Catalonia3 dimensions: Gender, social class and migration

Age-adjusted prevalence of material deprivation

Intersectionality in health status in Catalonia3 dimensions: Gender, social class and migration

Age-adjusted prevalence of fair/poor self-rated health

The two bars for the same category show results in the two surveys

Summing up

Gender and class also determine inequities in quality of care

People’s positions of power arise from (time- and place-specific) matrices of domination according to multiple axes

In quantitative studies, multi-stratified analysis can reveal the specific groups that are disadvantaged or whose health is affected by a policy, condition… – and give us hints of why, which can be further explored with qualitative studies

sophie-project.eu

@sophieproject

[email protected]@aspb.cat

Thank you! Gràcies!Grazie!

Photos: Roberto Brancolini, Roberto Malaguti, Fredi Roig

Applying intersectionality in health and healthcare

Health & Medicine

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