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Background

Knowledges about health inequalities and their causes are a central concern in public health. Generally, these relate to the social patterning of health and the forces that affect health conditions in daily life. However, public health decision making has been criticized for excluding knowledges of particular importance for health equity. This poses a challenge since knowledges and understandings shape what policies and interventions are viewed as relevant, reasonable or even possible to think of. If certain knowledges are left out, there is a risk that both knowledge making and decision making with respect to health inequalities will exclude important measures.

Since intersectionality encompasses a wide range of knowledge-making practices centered around social justice, it may contribute diverse knowledges of importance to health equity. Intersectionality has recently gained traction within public health and represents an important shift in conceptualizing how different dimensions of inequalities, such as sexism, classism and racism, interlock to generate social exclusion and marginalization instead of working separately, one by one.

Aim

The overall aim of this thesis is to explore the possibility of using intersectionality as a tool for knowledge diversification within public health. The specific research question is:

What knowledges and understandings of health inequalities do the inter-categorical (studies I and II) and post-categorical (studies III and IV) approaches to intersectionality contribute and how are such contributions made?

Material and methods

The method of the cover story can be understood as a way of studying science or as a retrospective self-reflection based on the four individual studies, making up the material of the thesis. Specifically, the material was reassembled and retold in order to show how certain intersectional approaches generate different types of knowledges and understandings of health inequalities by involving different ways of operationalizing inequalities and managing categories.

In study I, a scoping review of the quantitative international literature was undertaken with the aim of mapping and describing inter-categorical inequalities in mental health. Study II was a quantitative analysis of a population-based survey with the aim of mapping inter-categorical inequalities in mental health in the Swedish adult population. Study III was a policy analysis of a government bill that proposes a national strategy on alcohol, drugs, tobacco and gambling with the study aim to examine the equity-perspective of the bill through an intersectional lens. Study IV was a post-qualitative inquiry based on participatory observations and interviews with the study aim to explore the becoming of social divisions among seniors as they participate in health-promoting activities.

Results

The inter-categorical approach to intersectionality (applied in studies I and II) generated knowledges about health inequalities as quantitative mean differences between population groups, and highlighted unexpected patterns and unpredictable inequalities in mental health. This implies the importance of building responsive systems that regularly monitor inequalities across different intersectional positions and contexts so that services can be directed and adapted to those most in need.

The post-categorical approach to intersectionality (applied in studies III and IV) generated knowledges about health inequalities as processes of marginalization, resistance, exclusion, or inclusion, and highlighted difficult trade-offs with respect to public health policy and practice. This enables a transformative way of thinking by providing the possibility of doing things differently in everyday practices in which marginalization and resistance becomes.

Conclusion

Different approaches to intersectionality contribute diverse knowledges and understandings about health inequalities. This is important since it expands the possibilities for fair decision making and health equity through different outlooks on social justice. Knowledge diversification through intersectionality could be particularly useful to release tension due to the restrictive forces of public health decision making and to increase accountability for the multiple social interests of the population. Thus, it has the potential to make public health decision making more flexible, transparent, reflexive, and democratic.

Bakgrund

Kunskaper om ojämlikheter i hälsa och deras orsaker är centrala inom folkhälsa. Dessa handlar generellt om hur hälsan är fördelad i befolkningen och om de strukturer som utgör förutsättningarna för hälsa i det dagliga livet. System för beslutsfattande inom folkhälsa har dock kritiserats för att utesluta vissa typer av kunskaper med särskild betydelse för jämlik hälsa. Det är en utmaning eftersom kunskaper och förståelser formar vad som anses vara relevanta, rimliga eller ens tänkbara åtgärder. Om vissa kunskaper utelämnas riskerar kunskapsproduktionen och beslutsfattandet att bortse från åtgärder med potential att öka jämlikheten i hälsa. 

Eftersom intersektionalitet är ett mångfacetterat begrepp som inbegriper en rad olika kunskaps-skapande praktiker med fokus på social rättvisa kan det bidra med kunskapsbredd för jämlik hälsa. Begreppet har nyligen vunnit mark inom folkhälsa och bidragit med en förändring i sättet att tänka kring hur dimensioner av ojämlikhet som sexism, klassism, och rasism gemensamt, snarare än var för sig, bidrar till socialt utanförskap och marginalisering.

Syfte

Det övergripande syftet är att utforska möjligheterna att använda intersektionalitet som ett verktyg för kunskapsbreddning inom folkhälsa. Den specifika frågeställningen är: 

Vilka kunskaper och förståelser om ojämlikheter i hälsa bidrar den inter-kategoriska (studie I och II) och post-kategoriska (studie III och IV) ansatsen till intersektionalitet med och hur?

Material och metod

Ramberättelsens metod kan förstås som ett sätt att studera vetenskap eller som en retrospektiv självreflektion baserad på avhandlingens material i form av fyra individuella studier. Mer specifikt har materialet omorganiserats och återberättats för att visa på hur vissa intersektionella ansatser generar olika kunskaper och förståelser om ojämlikheter i hälsa genom olika sätt att operationalisera ojämlikheter och hantera kategorier.

Studie I var en kartläggande översikt baserad på internationell litteratur med syftet att kartlägga och beskriva inter-kategoriska ojämlikheter i psykisk hälsa. Studie II var en kvantitativ analys av en befolkningsbaserad enkätstudie med syftet att kartlägga inter-kategoriska ojämlikheter i psykisk hälsa i den svenska vuxna befolkningen. Studie III var en policyanalys av regeringens proposition om en ny strategi för alkohol, narkotika, dopning, tobak och spel om pengar med syftet att undersöka propositionens jämlikhetsperspektiv utifrån ett intersektionellt ramverk. Studie IV var en post-kvalitativ undersökning baserad på deltagande observationer och intervjuer med syftet att utforska uppförandet av sociala skillnader under hälsofrämjande aktiviteter för seniorer.

Resultat

Den inter-kategoriska ansatsen (studie I och II) generade kunskaper om ojämlikheter i hälsa som kvantitativa medelvärdesskillnader mellan intersektionella grupper vilket belyste oväntade mönster och oförutsedda ojämlikheter i psykisk hälsa. Detta ansågs antyda vikten av att bygga lyhörda system som regelbundet övervakar ojämlikheter mellan olika intersektionella positioner och sammanhang så att åtgärder kan formas och riktas med hänsyn till de med störst behov. 

Den post-kategoriska ansatsen (studie III och IV) genererade kunskaper om intersektionella ojämlikheter i hälsa som processer i termer av marginalisering, motstånd, uteslutning och inkludering vilket belyste svåra avvägningar inom folkhälsopolicy och praktik. Detta ansågs möjliggöra ett transformativt tankesätt genom att bidra med möjligheten att göra saker annorlunda i den dagliga praktiken där marginalisering och motstånd uppstår. 

Slutsats

Olika intersektionella ansatser bidrar med olika kunskaper och förståelser av ojämlikheter i hälsa. Detta är viktigt eftersom det utvidgar möjligheterna till ett välavvägt beslutsfattande och en jämlik hälsa genom olika syn på social rättvisa. Kunskapsbreddning genom intersektionalitet kan vara särskilt användbart för att öka ansvarsskyldigheten gentemot befolkningens olika intressen och behov. På så sätt har intersektionalitet potential att bidra till ett mer flexibelt, transparent, reflexivt och demokratiskt beslutsfattande inom folkhälsa.

Background: According to post-structural policy analyses, policies and interventions aiming at reducing social inequalities have been found to be part in producing and reifying such inequalities themselves. Given the central role of health inequalities on the public health policy agenda globally it seems important to examine the way policy on health inequalities may potentially counteract the goal of health equity. The aim of this intersectional policy analysis, was to critically analyze the representation of health inequalities in a government bill proposing a national strategy on alcohol, drugs, tobacco and gambling, to examine its performative power, and to outline alternative representations.

Method: A post-structural approach to policy analysis was combined with an intersectional framework. The material was analyzed through an interrogating process guided by the six questions of the “What’s the problem represented to be?” (WPR) approach. Thus, the underlying assumptions of the problem representation, its potential implications and historical background were explored. In a final step of the analysis we examined our own problem representations.

Results: The recommendations found in the gender and equity perspective of the bill represented the problem of health inequalities as a lack of knowledge, with an emphasis on quantitative knowledge about differences in health between population groups. Three underlying assumptions supporting this representation were found: quantification and objectivity, inequalities as unidimensional, and categorization and labelling. The analysis showed how the bill, by opting into these partly overlapping assumptions, is part of enacting a discourse on health inequalities that directs attention to specific subjects (e.g., vulnerable) with special needs (e.g., health care), in certain places (e.g., disadvantaged neighborhoods). It also showed how underlying processes of marginalization are largely neglected in the bill due to its focus on describing differences rather than solutions. Finally, we showed how different intersectional approaches could be used to complement and challenge this, potentially counteractive, problem representation.

Conclusions: The problem representation of health inequalities and its underlying assumptions may have counteractive effects on health equity, and even though some of its strengths are raised, it seems to be profoundly entangled with a system resisting the kind of change that the bill itself advocates for. If carefully used, intersectionality has the potential to support a more comprehensive and inclusive equality-promoting public health policy and practice.

Intersectionality has recently gained traction in health inequality research emphasizing multiple intersecting dimensions of inequality as opposed to the traditional unidimensional approaches. In this study inequalities in mental health were estimated across intersections of gender, income, education, occupation, country of birth, and sexual orientation. The outcomes and inequalities of intersectional strata were disentangled analogously to the possibilities described by intersectionality theory; as a result of either of the two inequality dimensions, as a result of the sum the dimensions, or as a unique outcome not equaling the sum. Furthermore the study examined the discriminatory accuracy of the six inequality dimensions as well as the intersectional space comprising 64 strata. The study population (N = 52,743) consists of a yearly random sample of the Swedish population 26–84 years between 2010 and 2015, from The Health on Equal Terms survey. Mental health was measured through a self-administered General Health Questionnaire (GHQ)-12, and sociodemographics through survey and linked register data. Intersectional inequalities in mental health were estimated for all pairwise combinations of inequality dimensions by joint inequalities, excess intersectional inequalities and referent inequalities. The findings of the study found that the sum of dimensions contributed to the overall (joint) inequality in mental health rather than a reinforced adverse effect of multiple disadvantages or the contribution by a single dimension. Nevertheless, the dimension of income was found to be the most important in terms of relative contribution. The discriminatory accuracy was low indicating that policy action targeting mental health should be universal rather than focusing on particular groups. The results highlight the unpredictable inequality patterns revealed by an intersectional approach, even for a single health outcome and within one country, and illustrate the need for empirical investigations into the actual population patterns in health that appear in the intersections of multiple disadvantages.

Background: Depression and anxiety are associated with adverse outcomes in educational achievements and economic performances. Moreover, the prevalence of these disorders is unequally distributed among different population subgroups. Our objective is to investigate whether the economic consequences of depression and anxiety differ between population subgroups of different gender, socioeconomic status (SES), ethnicity and age, in Europe. Methods: A systematic scoping literature review was performed to identify studies where exposure to depression or anxiety was identified at baseline and consequences in education, sickness absence, disability pension, unemployment and income/earnings were measured at follow-up. Results: Seventeen articles were included in this review and most of these were conducted in the Nordic countries. The consequences of depression and anxiety were stratified by gender in most of the articles. However, only in a few studies, the findings were stratified by SES, age and ethnicity. The negative consequences of depression in educational performance, disability pension and income are larger for men compared to women. Moreover, low SES individuals have more depression- and anxiety-related absence from work than high SES individuals. Conclusion: Our findings imply that the economic consequences of depression differ between population subgroups in Europe. This could have an impact on social stratification, shifting people who experience mental ill-health to lower SES groups or reinforcing an already disadvantaged position. More research is needed on unequal economic consequences of depression and anxiety in different population subgroups in Europe.

The concept of intersectionality has gradually been introduced to health inequality research, adding depth and breadth to the way inequalities in health are approached. We conducted a scoping review with the purpose to systematically map, describe and analyze the literature about intersectional inequalities in mental health. For eligibility, the study had to analyze and report inequality defined by combinations of socioeconomic position, gender, race/ethnicity, sexual orientation or religion. The mental health outcome had to be measured as self-reported symptoms assessed through validated scales, or disorders assessed through diagnostic interviews. The search strategy was applied in two databases and the screening process yielded 20 studies. The interaction of intersectional positions showed no consistent patterns in mental health across studies, but both synergistic and antagonistic effects were observed. In most studies an absolute measure of inequality was used and few studies analyzed factors potentially explaining the intersectional inequalities. Taken together, the findings of this review highlight the value of assessing intersectional inequalities across population groups for priority setting and action on mental health inequalities.

Background: Social inequalities in mental health is a growing public health concern, but has so far been approached in a disentangled manner. To better capture the complexity of reality with multiple interlocking axes of inequalities, intersectionality theory instead highlights how health is expressed in the interactions between these axes. This may expose important knowledge about particular risk groups and protective factors. In this study, we explore how mental health is distributed across intersections of gender, income, education, class, country of birth and sexual orientation as well as their interaction effects.

Methods: The study population (N = 52,743) consists of a yearly random sample of the Swedish population 26-84 years between 2010 and 2015, from The Health on Equal Terms survey coordinated by the Public Health Agency of Sweden. Mental health was measured through self-administered General Health Questionnaire (GHQ)-12, and gender, income, education, class, country of birth and sexual orientation through survey and linked register data. Intersectional inequalities in mental health were estimated for all pairwise combination of inequalities by joint disparity, excess intersectional disparity and referent disparities.

Results: The prevalence of symptoms of poor mental health were highest among non-heterosexuals with low income (40%) followed by non-heterosexual women (38%). However, intersectional inequalities showed unpredictable patterns; among non-heterosexuals, those with long education reported more symptoms (36%) than those with short education (31%). The excess intersectional disparity showed synergistic effects for income in combination with education; country of birth and class, but antagonistic effects for the intersections of gender and income as well as education and class.

Conclusions: Multiple inequalities in mental health may add up in various and unexpected manners, which needs to be considered in efforts for equity in mental health.

Key messages:

• Mental health is distributed in various and unexpected manners across intersections of inequality dimensions.

• Intersectionality theory may be useful when addressing mental health inequalities.

Mental health is an increasing concern in all European countries. Social inequalities may appear both in the distribution of mental health and the social and economic consequences. In 2016, the government commissioned The Public Health Agency of Sweden (PHAS) to increase knowledge on socioeconomic determinants of mental health problems. The present study addresses the social distribution of mental health problems and what mediates this.

Drawing on patient registry data of the population from 2014 and a national survey representative of the population aged 16-84, years 2013-2016 (n = 155339) we analyze how mental health is distributed in social groups and what determinants mediate poor mental health. Outcomes include psychiatric in- and outpatient care (numbers and cases/1000), and for self-reported measures (ie. GHQ, stress, anxiety) odds ratios (OR) from multivariate logistic regression, adjusting for social and economic determinants.

Preliminary results show that most outcomes in self-reported poor mental health and psychiatric diagnoses were more common among women. Social patterns differed between diagnoses.

Among working ages in- and outpatient care, low educated showed fourfold increased risk of psychotic disorders, while neurotic stress related disorders showed a doubled risk among low educated. Care for any mental disorder (excluding dementia) was more common among lower educated men and women aged 65+ but had a reverse social gradient. In analyses modelling the risk of poor mental health (GHQ12), controlling for background-, social and economic factors in particular financial strain (OR 2.42, CI 2.11-2.77) mediated poor mental health among women 25-64.

An educational gradient was found in most mental health outcomes with more pronounced gradient in more severe outcomes. Patterns differ by age groups, social group, and outcome. Results will be used to inform practitioners and policy makers at national and regional level to decrease inequalities in mental health.

Key messages:

• Social inequalities in mental health and its’ determinants are found in most age groups, and most outcomes studied.

• Focusing on living conditions, particularly economic strain is essential for achieving equity in mental health.

Mental health is an increasing concern in all European countries. Social inequalities may appear in both the distribution of mental health and the social and economic consequences. In 2016, the government commissioned The Public Health Agency of Sweden (PHAS) to increase the knowledge on mental health inequalities and their underlying determinants. In all, 18 research projects were initiated within different universities in Sweden and PHAS.

Research questions addressed dimensions of inequality such as age, gender, SES, sexual orientation and disability. PHAS involved researchers from the fields of social medicine, epidemiology and economics to explore all levels of social determinants, different mechanisms, interacting forces of inequalities and consequences of disease. Evidence from scoping literature reviews were coupled with analyses of Swedish data on a range of outcomes; from positive mental health to in-patient care.

Preliminary results have been discussed in joint workshops and show social inequalities in mental health in all age groups in Sweden, including small children, with a more pronounced gradient in severe outcomes. Generally, the results points towards policy actions focusing girls and women, low income earners, those experiencing financial strain, hbtq persons and persons with disability. Also, the interaction of different dimensions of inequality need consideration.

The project is a collaboration between PHAS and a range of research disciplines all joining to discuss mental health and inequalities. Though challenging as interpretations may differ due to field of research, overall it has allowed for a broad approach and joint learning as experts have collaborated. This is a step towards understanding country specific determinants of mental health inequalities. Combined, the results make up a knowledge base that will guide policy makers and practitioners to develop efficient policies and practices in order to decrease inequalities in mental health.

Key messages:

• Combining evidence from international literature with context specific secondary data analyses improves its local relevance.

• Collaboration between research fields enables a more comprehensive basis for decision making.