Fifty-three researchers (95% university-based) and 20 non-researcher stakeholders responded to the survey. For researchers, seniority was varied, with responses from PhD students through to full professors. Thirty-three researchers were women and 30 identified as White English/Welsh/Scottish/Northern Irish. Across both the survey and workshop, the policy and practice professionals represented a wide range of roles (e.g. evidence manager, director of communications, equality and diversity manager, administrator, director of public health, health improvement principal) and sectors (e.g. third sector, local government, National Health Service, national statutory agencies). All respondents were based in the United Kingdom, with a wide geographical spread, except four researchers who were based in Europe. Fifteen non-researcher stakeholders were women and just under half identified as White English/Welsh/Scottish/Northern Irish. The workshop involved 23 people, and as with the survey involved wide representation in terms of sociodemographic factors and professional backgrounds.
Current understandings of health inequalities
Policy and practice respondents to the survey were asked to comment on the kinds of explanations people in their field of work give for “why some social groups (e.g. according to gender, ethnicity, age, or socioeconomic factors) have better or worse health than others”. They were then prompted to rank each of the following potential explanations on a scale from 1 (barely or never used) to 5 (dominant explanation): “cultural”, “behavioural/lifestyle”, “political or economic” and “discrimination”.
Responses indicated that those working in policy and practice perceived a range of co-existing explanations within and across work arenas. Explanations rooted in the characteristics or (un)healthy behaviours of individuals and groups were mentioned spontaneously by most respondents. One respondent referred to this as “deficit” language. When prompted, 16/20 thought that behavioural/lifestyle, and 12/20 that “cultural”, explanations were dominant (scoring 4 or 5). A particular version of the latter explanation was identified as “culture and language” underpinning ethnic minority health disadvantage.
Most respondents also spontaneously identified “social determinants” or “wider determinants” as commonly articulated explanations for health differences between groups. These were understood primarily in terms of inequalities in material and financial resources, and in some cases place-based deprivation. A couple of respondents noted that inequalities tended to be understood as resulting from behavioural processes, especially in statutory organizations, with individual behaviours remaining the “go-to target” for action. A further respondent noted that political dimensions are not often made explicit in such “social” explanations. When prompted, just nine respondents identified “political or economic” factors as dominant explanations.
A further set of explanations mentioned spontaneously related to differential access to health services. Respondents felt that barriers to care, and problems “navigating the system”, were commonly employed explanations. In some cases, these understandings were linked to notions of individual obstacles. In others, the understandings appeared to be more structural, with service cutbacks, (in)adequacy and (in)eligibility being mentioned.
Exclusion and discrimination were less often identified as explanations. One respondent spontaneously referred to “minority stress theory”, another to “intergenerational adverse experiences” and another to “prejudice and discrimination”, as ways that the causes of health inequalities are understood by some colleagues. When prompted, just two respondents identified discrimination as a dominant explanation within their field of work.
After being presented with the vignette (Additional file 2), policy and practice survey respondents were asked to comment on how their area of work deals with these multiple factors, with four possible responses. Intersectionality had not been mentioned in the survey at this point to avoid leading respondents. Eleven respondents answered, “it mainly focuses on one attribute (e.g. gender or ethnicity) at a time”, and a further three answered, “it mainly focuses on one attribute at a time, but also considers how attributes might be mutually important”. Just six answered that “it mainly considers all attributes, but also focuses on one attribute at a time in some cases”, and none that “it mainly focuses on all attributes at the same time”.
Familiarity and appeal of “intersectionality” as a term
The term “intersectionality” was not spontaneously mentioned by any of the practice or policy survey respondents. However, when directly asked whether they were familiar with this term, just three reported that they had never heard of it and two that they had only “heard a little about it”. Among the researcher survey respondents, 37/53 reported being “fairly” or “very” familiar with the term, while 12 had heard a bit about it, and four reported that they had never heard of it.
We then presented respondents with the following definition of intersectionality:
Intersectionality addresses the fact that each of us has a particular gender, ethnicity, age and socioeconomic position. These “social attributes” overlap and interact with each other to give us a particular *position* in the social structure, and a particular *identity*, shaping our sense of who we are. These positions and identities influence the types of inequalities we might experience. Intersectionality scholars are particularly interested in discrimination and marginalization, such as sexism, racism and classism, which themselves work together to shape the life chances of those who are, for example, female, black and from a disadvantaged socioeconomic background. This understanding stands in contrast to traditional approaches to health inequalities which have tended to focus on one attribute at a time such as ethnicity or socioeconomic position.
Nearly all (19/20) of the policy and practice survey respondents felt that it “made sense” and had relevance to their work. However, concerns were expressed across both survey respondent groups that the term itself is off-putting and not “user-friendly” or “plain English”. Around a third of survey respondents in each group felt it was more unhelpful than helpful as a term.
Intersectionality is academic speak and prevents engagement with the public. Researcher, survey
If someone asked me what I did today I would say it was about looking at ways of tackling inequalities. Calling it intersectionality research may silo it. Workshop participant
I believe that this is a widely understood concept by practitioners in my field, but they would not necessarily adopt the word. Policy/practitioner, survey
Conceptual complexity and (in)consistency
In addition to scepticism about the term itself, a dominant theme among survey and workshop respondents related to conceptual complexity. Concerns were expressed regarding a lack of clarity and inconsistency in how intersectionality is understood.
It is a complex idea; it is not necessarily the term that is the problem. Researcher, survey
Intersectionality is an approach with fluid margins. Researcher, survey
I suspect there may be reluctance in applying this concept for several reasons—it is inherently complex... the specialist skillset required to use the concept meaningfully is limited. Policy/practitioner, survey
Furthermore, sharply contrasting responses between policy and practice participants suggested variability in levels of understanding across organizational contexts, with staff in specialist third-sector organizations perhaps having greater knowledge of the concept and its origins than those working in the statutory sector.
I think it is widely understood by practitioners in my team and with partner organisations. Policy/practitioner, survey
A lot of people don't really understand it, and perhaps dismiss it as postmodern social-justice-warrior work. Workshop participant
A particular concern expressed by some participants related to maintaining intersectionality’s critical edge; its focus on power, relational dynamics, institutionalized discrimination and systems of oppression, and on transformational change.
Intersectionality is more than simply describing differences in ever more refined disaggregations, but entails an institutional analysis of the occlusion of certain intersections. Researcher, survey
[Intersectionality] has an explicit commitment to social justice that goes beyond just an explanation or description of health inequities but taking that next step towards trying to find change and transformation. Workshop participant
Comments from other participants tended to confirm the absence of this critical understanding among at least some of those working in research, policy and practice.
Explain to me the difference to “statistical interaction”. Don't make people learn to speak intersectionality. Researcher, survey
Not sure what added value an intersectionality lens adds to this, as this is how design thinking would approach the problem but would also include capabilities, motivations and opportunities. Policy/practitioner, survey
Feels like a descriptive term as opposed to one that generates action like '“human rights”. Policy/practitioner, survey
An area of potential contestation and confusion related to which social identifiers and processes of disadvantage should be in view. For some, intersectionality is about disadvantage associated with minority ethnicity, rather than, say, disability or gender.
Main issue where I work is simply that diversity in our geographic area of focus is very low, therefore even initial discussions around diversity can be difficult, let alone intersectionality. Policy/practitioner, survey
Other participants were concerned that other axes of difference (notably age and gender) and dynamic processes of disadvantage (including across the life course) should not be overlooked.
I believe age and generation is an additional factor—periods of greater and lesser equality/welfare states and their cut backs Policy/practitioner, survey
I feel you have missed the cumulative aspect of intersectionality. It is a conferred and incremental (dis)advantage. Researcher, survey
Potential to improve understanding of patterns and causes of inequality
Most participants felt there was potential for intersectionality to provide new insights regarding patterns of inequality beyond those offered by currently dominant approaches.
An intersectionality approach would, in my view, enable a better understanding that targeted interventions to address one axis of discrimination, such as gender, may actually make matters worse for certain intra-categorical subpopulations by directing focus and resource away from those in greatest need, whilst giving the illusion of effective action being taken. Workshop participant
We miss high risk groups or inequalities by only considering single statuses or identities. Researcher, survey
Intersectionality therefore offers a way to recognize that multiple factors play an intrinsic role in how individuals interface with their environments, which may offer clues in how to prevent and address health inequalities. Workshop participant
However, a minority were less convinced of its utility.
We think in a general sense about people who may be disadvantaged. I am not sure that it would be necessary for us to be much more granular, though we are aware that we know little about ethnic minority experiences. Policy/practitioner, survey
I do not think that it really stands in contrast to traditional approaches, it just has a broader focus than traditional ones. Researcher, survey
Among those participants who considered intersectionality to be an important tool, there was also variation in understandings. For instance, some participants suggested that intersectionality is a framework through which identification of—perhaps previously unrecognized—disadvantage can emerge.
What we would be talking about here is emphatically not university researchers analysing policy outcomes against a list of predefined subgroups. Intersectionality would require community interaction and critical perspectives on what the relevant groups are. Researcher, survey
The whole point of intersectionality is to attempt to recognise complexity—and that the immediately apparent lines of discrimination might not be the only ones that matter. Researcher, survey
In contrast, another participant saw the contribution as one of highlighting the circumstances of groups already assumed (or demonstrated) to be severely disadvantaged.
I thought that this questionnaire might be about looking at the really troubling and hard to reach groups impacted upon by health inequalities and am disappointed that it doesn't (I have worked with older prisoners who are mainly sex offenders and issues of inequality, stigma, shame, discrimination are so sharp for them). Researcher, survey
Similarly, mixed opinions were expressed regarding the potential for intersectionality to improve our understanding of the causes of health inequalities. Caution was expressed by some workshop participants that intersectionality may be a new “buzzword” that fails to add value.
However, several participants suggested that an intersectionality approach has the potential for greater attention to processes of “group” formation, that is, how people come to be identified, or to self-identify, with particular social locations and the implications that these have for health. Rather than taking such “groups” for granted, participants felt that intersectionality could help to interrogate their meaning and relevance over space and time, including attention to individual biography and collective histories. Intersectionality was also seen as useful in highlighting agency, and the divergent experiences of people who make up groups labelled as disadvantaged, thereby providing more nuanced understandings.
The impact of the social attributes you have, or establish, may differ by location, affluence and social makeup of the wider community, location and demographics. Generalisability would not be sound. Researcher, survey
We should also not forget (nor overstate) the reflexivity or agency that multiply disadvantaged individuals and groups can deploy. Researcher, survey
Operationalizing an intersectional approach in research and policy analysis
Survey respondents and workshop participants were also asked to comment on the practicality and feasibility of using an intersectional approach to describe and understand health inequalities, with the majority identifying significant challenges.
Most researchers and policy and practice participants raised the issue of data availability limiting the potential for intersectional approaches to quantitatively describing health inequalities. Large datasets that include multiple social attributes measured well are typically not available. Some intersections are easier to examine than others due to the categories that are typically employed—or overlooked—in routine datasets and research studies. Participants noted that data on ethnicity continues to be of poor quality and completeness in many United Kingdom administrative datasets, while data on sexuality, disability and migration status is often totally absent.
Several researcher participants highlighted the specialist statistical expertise needed to undertake technically complex analyses, and the limits of accepted quantitative approaches to health inequalities analyses. This is particularly the case where intersecting variables are highly correlated, making it difficult to conceptually (let alone statistically) separate the effects of those variables.
To consider several factors at the same time and not focusing on one can be difficult as the factors correlate with each other and it is difficult to estimate the true effects of single measures. Researcher, survey
Socioeconomic position and sex or race are not causally independent. The investigation of intersectionality seems to me to be difficult to put in some counterfactual frame in quantitative method. Researcher, survey
More fundamentally, several survey and workshop participants highlighted perceived dangers of employing quantitative methods alone.
Adoption of the term by quantitative researchers may dilute it through overuse and, due to the often atheoretical (implicit theory) nature of much quantitative research, stripping out of its theoretical grounding and interest in concepts such as marginalisation. Researcher, survey
Several respondents expressed concern that categorization may be driven by data availability rather than by prior evidence and associated hypotheses regarding processes of disadvantage impacting upon subgroups of people.
You would need some evidence to support subgroup choice—so why age 50–55 rather than 50–65 or 40–55 or whatever, why Black women, why low education—need to draw on relevant evidence to support choices. Researcher, survey
Intersectionality would lose its critical edge if it becomes a data-mining exercise in which we search for differences across an infinite number of categorisations. Researcher, survey
However, a minority of researcher respondents were in favour of exploratory analyses across the range of intersections represented in available datasets.
The importance of moving beyond description towards explanation and modifiable factors was also emphasized across the survey and workshop. Here mixed-methods approaches were advocated by many participants for generating understanding of the processes that (re)produce disadvantage. Limitations of quantitative approaches included difficulties in measuring discrimination operating at structural and institutional levels. Qualitative methods were seen as particularly suitable for grasping the lived experience of intersectional identities and reducing the risk of stigmatization of marginalized groups by giving them voice and explaining the processes through which health disadvantages come about. Nevertheless, participants felt that effective integration of qualitative and quantitative approaches requires training, support and a change in research culture, with them often remaining in “separate boxes” currently.
Micro-categorisation is a trap. Use a mixed-methods approach. Nothing gives you more heterogeneity than a story, the things that are told and that are not told. Researcher, survey
Let’s not try to explain everything but stick to sufficient and remediable areas of explanation of difference in outcomes. Researcher, survey
Most researcher respondents agreed that there was value in exploring advantaged positions—the “contours of privilege”—as well as marginalized subgroups.
A number of participants felt that the potential of intersectionality to generate new insights was so far largely untapped. One workshop participant argued that methods lag behind the theory, especially regarding intersectionality’s focus on the relationship between social power and identity, and the need to elucidate dynamic events, contexts and processes. Another felt that academics “shy away from” actually identifying practical solutions to inequalities in processes and outcomes revealed by intersectional analysis.
A prompt to action
In terms of whether intersectionality can inform more effective action on health inequalities, survey and workshop participants were asked to consider the merits of using intersectionality to target and tailor interventions to the needs and circumstances of specific population subgroups. Opinions were mixed and nuanced, with around two thirds of survey respondents seeing some merit in such an approach.
Some participants highlighted the important distinction between ascertaining which intersectional categories have the worst outcomes on paper and identifying population subgroups that are meaningful and practicable for action in the real world.
There definitely needs to be a move away from one-size-fits-all, so the idea is good in principle. One thing to consider is the extent to which any groups formed actually do share a unique point of view, i.e. do members share the same needs in terms of an intervention. ... For example, in terms of health inequalities policy, is there a meaningful case to [conceptually] isolate those aged 50–55? Policy/practitioner, survey
Some noted that targeting by geography, such as specific communities, rather than by other social identifiers is often more feasible.
A further distinction was drawn between higher-level policy on the one hand, and the design and delivery of interventions or services on the other. At the former, more strategic, level tailoring was felt to be more difficult.
Nice in principle, probably impractical in reality. Interventions might be better suited to this but it seems to me policy does not lend itself well to nuance and tailoring. Researcher, survey
Policy makers want things to be kept simple. ... Although I think there is substantial recognition that there are few (if any) cases where a one-size-fits-all solution works, many actors in social policy have yet to figure out how to create policy that effectively accounts for this. Policy/practitioner, survey
Other concerns with targeted approaches expressed by survey and workshop respondents included excluding people with needs who do not fall into the targeted category; stigmatizing and reinforcing deficit narratives about recipients; fragmented approaches; and addressing downstream factors while leaving upstream inequalities unchanged.
The big issues of race, sex, and class don’t need targeted interventions but structural changes. Researcher, survey
Some respondents felt that intersectional analysis could generate knowledge to inform effective tailored and targeted responses to need, but only if the approach is operationalized through the use of participatory approaches that effectively include marginalized people.
I think it [the suggestion of using intersectionality to target/tailor interventions] is a good one, especially where it gives more voice, choice and power to people who are less listened too. It is when service providers and policy makers listen to anticipated beneficiaries that they can learn about what can work for them and what are their needs, wants and barriers to achieving good health. Policy/practitioner, survey
Respondents were more consistently positive about the suggestion that intersectionality could be used to identify and understand the differential effects of existing policies.
I would certainly agree that better work, which incorporates an intersectional lens, should be done to understand the impact of national or local policies on different groups in society. This would contribute to improved policy making. Policy/practitioner, survey
I like it. National and local level policies often disadvantage groups when they are supposedly designed to advantage them. The more these impacts can be articulated the better. Researcher, survey
A more robust understanding of intersectionality, and the methodologies that accompany it, has the potential to better capture the lived experience of people who experience discrimination, at the same time as helping social action have an impact that does not just accumulate benefits to some. Workshop participant
Again, the importance of community engagement and recognition of power were highlighted by some.
Intersectionality would require community interaction and critical perspectives on what the relevant groups are, the different power dynamics, how and why the policy is having an impact, and whether the outcomes are even the right ones to be measured. Researcher, survey
Aside from the generation of knowledge that could theoretically inform better action, several participants questioned whether an intersectionality approach could influence the direction and focus of current health inequalities policy.
Suggested obstacles to intersectionality having an influence on policy were a desire for clear and simple solutions, fear of uncertainty, and the predominance of cost–benefit (or even invest-to-save) justifications for action on inequality. The latter was felt to be particularly significant among “cash-strapped public services”.
We struggle to act when we examine one aspect, so this idea may feel overwhelming. Policy/practitioner, survey
An approach/policy devised in this way creates higher budgetary pressures since they reduce the savings from economies of scale. It may be that there needs to be a greater shift from a cost–benefit approach to a rights-based approach Policy/practitioner, survey
In addition, some participants emphasized that the prioritization of socioeconomic inequality over other axes of difference and disadvantage could undermine the perceived relevance of intersectionality to policy-makers. This was linked to organizational structures that lack diversity and cultures that fail to recognize axes of difference and discrimination (across both academia and policy-making bodies).
The political context, and probably the lack of diversity in the work place, and the organisational culture, I believe, provide barriers to intersectionality. Policy/practitioner, survey
There needs to be a shift in general because one barrier is that people don't see how certain factors can lead to inequality. It is as if some kind of “inequality blindness” is built into society. Policy/practitioner, survey
Having a new term in itself does not necessarily move things forward. Researcher, survey
Lack of representation by people who occupy particular social positions and identities. The academy is predominately white middle class which fosters institutionalised racism and classism. Researcher, survey
And, while some participants offered examples of existing policy work that they felt had incorporated attention to intersectionality, these appeared to be cases where attention had been expanded beyond socioeconomic status as a sole axis, but it was less clear that there had been a noticeable shift towards a focus on power and processes of marginalization, or that real engagement of those who are marginalized, had been achieved.
My experience is that public health policy often does not engage particularly well with theory or with critical perspectives. It is reasonably willing to engage with the idea of multiple variables (and notions such as dual discrimination under the equality act do allow for this kind of “additive approach”). I think it is a lot less willing to engage with questions of epistemology and of power. Researcher, survey
The obstacle isn’t [understanding the concept]—it’s putting emphasis on structural inequalities and social justice rather than an individual approach. Workshop participant
However, other respondents were more optimistic that intersectionality approaches could be influential in shaping public debates and policies, for instance if they were able to highlight the differential benefits and harms of government action for subgroups within society. Case studies and real-life narratives were suggested as a way to do this.
Show how it matters. That not all women are the same, not all ethnic minorities and not all lower educated is obvious. But the implications of this fact for public health policies are not and these should be articulated. Researcher, survey
Community activism may be a mechanism for pointing out to policy-makers that there are dynamics and concerns that there are overlooking. However, I have to agree that this is a challenge. Researcher, survey