A multilevel approach to modeling health inequalities at the intersection of multiple social identities

Evans, Clare R.; Williams, David R.; Onnela, Jukka‐Pekka; Subramanian, S. V.

doi:10.1016/j.socscimed.2017.11.011

Cited by 229 publications

(336 citation statements)

References 18 publications

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“…Such a multilevel view is consistent with the eco-epidemiological approach [36]. This view is also consistent with a growing methodological focus on using multilevel models to include not only individual-level variables but also community level and other contextual levels to understand their cross-level interactions [36–40]. An unfavourable social context can challenge binary thinking as it brings light to the stark reality of people’s lives.…”

Section: Discussionsupporting

confidence: 56%

Heterogeneities in utilization of antenatal care in Uttar Pradesh, India: the need to contextualize interventions to individual contexts

Sridharan

Pereira

Hay

et al. 2018

Global Health Action

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Background: This paper explores the heterogeneities in antenatal care (ANC) utilization in India’s most populated state, Uttar Pradesh. Taking an intersectionality lens, multiple individual- and district-level factors are used to identify segments of any antenatal care usage in Uttar Pradesh Objective: This paper seeks to understand the multilevel contexts of ANC utilization. The planning and programming challenge is that such knowledge of contextual specificity is rarely known upfront at the initial stages of planning or implementing an intervention. Exploratory data analysis might be needed to identify such contextual specificity. Methods: Tree-structured regression methods are used to identify segments and interactions between factors. The results from the tree-structured regression were complemented with multilevel models that controlled for the clustering of individuals within districts. Results: Heterogeneities in utilization of any ANC were observed. The multiple segments of ANC utilization that were developed went from a low utilization of 23.7% for respondents who were not literate and did not have home ownership to a high of 82.4% for respondents who were literate and at the highest level of wealth. Key variables that helped define the segments of ANC utilization include: woman’s literacy, ownership of home, wealth index, and district-level sex ratio. Based on the multilevel model of any ANC utilization, cross-level interactions also were obtained between sex ratio and ownership of home as well as between sex ratio and literacy. Increases in sex ratio increased the influence of ownership of home on any ANC, while increases in sex ratio reduced the impact of woman’s literacy on receiving any ANC. Conclusion: We argue that a focus on heterogeneous segments of utilization can help build knowledge of the mechanisms that underlie inequities in maternal health utilization. Such knowledge of heterogeneity needs to be incorporated in contextualizing interventions to meet a variety of recipients’ needs.

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Section: Discussionsupporting

confidence: 56%

Heterogeneities in utilization of antenatal care in Uttar Pradesh, India: the need to contextualize interventions to individual contexts

Sridharan

Pereira

Hay

et al. 2018

Global Health Action

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“…Justification for race‐based research may improve with consideration of intersectionality. Social science research contends that examination of interactions between numerous social identities is central to health inequalities research and that quantitative methods should incorporate this approach (Else‐Quest & Hyde, ; Evans, Williams, Onnela, & Subramanian, ). When considering the intersectionality of the studies and participants included for this review, the reported characteristics are quite homogenous.…”

Section: Discussionmentioning

confidence: 99%

Racial and ethnic differences in genetic counseling experiences and outcomes in the United States: A systematic review

Southwick

Esch

Gasser

et al. 2020

Journal of Genetic Counseling

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As genetic counseling services expand and reach a wider catchment of the population, there is a critical need to better understand the impact of services on a greater diversity of patients. We conducted a systematic review to evaluate genetic counseling experiences and outcomes among racial and ethnic minorities. Six databases extracted articles published from 2005 to 2019 that assessed genetic counseling participation, knowledge and awareness, motivators, barriers, perceptions, and outcomes for racial and ethnic minority populations in the United States. Genetic counseling outcomes were categorized using the Framework for Outcomes of Clinical commUnication Services. A total of 1,227 abstracts were identified, of which 23 papers met inclusion criteria. Results suggest the possibility of racial and ethnic differences in some genetic counseling experiences and outcomes but noted differences were not adequately replicated between studies. The few included studies differed greatly in aims, methods, and results, which made comparison across study designs challenging and effectively barred thematic analysis. Additional research is needed that includes more study populations and settings with patients of diverse racial and ethnic backgrounds, as well as more structured study designs that allow for elucidations of differences between White and non‐White populations.

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“…ethnicity, sexual orientation, geographical, and disability), conceptualization, estimation and interpretation of the individual inequities becomes increasingly challenging. If the aim is to estimate a large set of inequity dimensions, other intersectionality-informed methods developed for this purpose might be more suitable (37). Moreover, estimation is more straightforward for continuous compared to binary outcomes (38), a limitation that however is even more pronounced for alternative methods (37).…”

Section: Methodsological Considerationsmentioning

confidence: 99%

“…Bastos and colleagues (36) published one of the few studies on intersectionality in health care utilization and how it is patterned by racial disparities. Likewise, whereas multiple novel methodological approaches to analysing intersectional inequalities have been proposed in recent years (37)(38)(39), they concern assessment of health inequalities rather than health care inequities. In contrast to the paucity of intersectionality-informed methods for health care inequities, quantitative methods of estimating horizontal inequities have been widely applied in public health research, albeit only in the assessment of "simple" inequities such as income (40) rather than complex inequities.…”

Section: Introductionmentioning

confidence: 99%

Intersectional equity in health care: Assessing complex inequities in primary and secondary care utilization by gender and education in Northern Sweden

Nyamande

Mosquera

Sebastián

et al. 2020

Preprint

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Background: Knowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach.Methods: Data on participants (N=22,997) aged 16-84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization. Results: Joint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40-9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67-5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56−6.19), but with no significant horizontal inequity – by gender, education, or their combination – remaining after needs adjustment. Conclusion: This study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.

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A multilevel approach to modeling health inequalities at the intersection of multiple social identities

Cited by 229 publications

References 18 publications

Heterogeneities in utilization of antenatal care in Uttar Pradesh, India: the need to contextualize interventions to individual contexts

Heterogeneities in utilization of antenatal care in Uttar Pradesh, India: the need to contextualize interventions to individual contexts

Racial and ethnic differences in genetic counseling experiences and outcomes in the United States: A systematic review

Intersectional equity in health care: Assessing complex inequities in primary and secondary care utilization by gender and education in Northern Sweden

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