March EDI Corner - Advancing Equity by Incorporating Intersectionality

An individual’s social identity may include different elements such as the commonly acknowledged variables of race and ethnicity, gender, socio-economic status, sexuality, nationality and citizenship status, and disability status. As dental public health professionals, we understand that these factors are associated with health status and access to care. However, the majority of oral health research continues to focus on particular elements affecting oral health and access to care without examining the interrelationship between different elements of an individual’s identity. Intersectionality, as defined below, is a lens for studying the social determinants of health, reducing health disparities, and promoting health equity and social justice (Lopez and Gadsden, 2016).

What is “intersectionality”?

Intersectionality is a theoretical research framework that acknowledges that people belong to more than one group and, consequently, may experience overlapping health and social inequities. Acknowledging the existence of multiple intersecting identities is an initial step in understanding the complexities of health disparities for populations from multiple historically oppressed groups. By incorporating intersectionality theory into oral health research and practice we promote a deeper understanding of the development of oral health inequities and advance population oral health. An intersectional public health lens embraces the heterogeneity of people’s lived experiences.

The figures above are from “Advancing Equity by Incorporating Intersectionality in Research and Analysis,” by Mbah O, Sevak P, et al. Washington, District of Columbia: 2022.

History of intersectionality

The term was first coined in 1991 but its roots can be traced back to Black feminism in the U.S. as championed by Sojourner Truth’s “Ain’t I a Woman?” speech in 1851. She deconstructed the notion that race, ethnicity, and gender were mutually exclusive.

In dental public health, we might consider intersections between identities such as:

• Black, Hispanic, American Indian or Indigenous or Native American, Alaska Native, Asian American and Pacific Islander, and other persons of color
• Members of religious groups
• LGBTQAI+ persons
• Persons living with disabilities
• Persons living in rural areas
• Persons adversely affected by poverty or persistent inequality

Planning oral health research with an intersectional framework

Intersectional theory is often found in conventional oral health research under the banner of inequality research. Numerous studies have examined connections between social identities and oral health inequalities, showing most disadvantaged members of society bear the greatest burden of poor oral health. However, these groups are continually theorized as homogenized collectives. Using both quantitative and qualitative data sources that include people with intersecting identities may lead to a deeper understanding of the contextual factors driving inequities.

Strategies for incorporating intersectionality in oral health research include:

• Engage people with lived experience not only as research participants but also as contributors and co-developers of the research design, data collection, analysis, and reporting processes. Approaches such as participatory action research (PAR), community-based participatory research (CBPR), and culturally responsive evaluation (CRE) are best practices for collaborating meaningfully with individuals with lived experience. Participatory research methods can be used to identify relevant research questions by involving and engaging participants and stakeholders.
• Develop research questions and data collection plans that address intersectionality
• Obtain additional training to overcome potential knowledge and skills deficits
• Seek multidisciplinary research collaborations
• In quantitative analyses, standard statistical models can be used to estimate outcomes of interest or construct models that address intersectionality. In multivariable regression analyses, interaction terms can be used to examine how two or more factors (i.e. race and gender) interact to produce an outcome. Considerations include whether certain information is collected and measured as well as sample size considerations for subgroups. Analyses may not be possible if there are insufficient numbers of participants from marginalized groups to allow comparisons and if information is not collected about different social identities to enable detailed explorations of intersections.
• Many intersectionality researchers feel that qualitative and mixed methods research is preferable to quantitative research alone. Qualitative analyses can help us achieve a deeper understanding of the experiences, barriers, and assets of groups with various intersecting identities. This type of research may also be used to corroborate or refute quantitative results and explain factors that could be at play. It is important to note that historically in oral health research, there are many fewer qualitative research studies than quantitative.

Adopting an intersectionality framework

Intersectionality poses research questions that seek to understand the complex experiences of people, reflecting their lived realities, thereby overcoming the limitations of the mainstream simplistic single-variable oral health inequality research. Intersectionality research instead aims to unpack how multiple social identities simultaneously impact an individual’s oral health. Adopting an intersectional framework enables us to identify populations who are more likely to be a target of stigma, experience exclusion from dental services, likely to self-stigmatize, and disengage from services.

Resources:

U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. “Advancing Equity by Incorporating Intersectionality in Research and Analysis,” by Mbah O, Sevak P, et al. Washington, District of Columbia: 2022.

Muirhead EV, Milner A, Freeman R, Doughty J, Macdonald ME. What is intersectionality and why is it important in oral health research? Community Dent Oral Epidemiol. 2020;48(6):464-470.

Bowleg L. Evolving intersectionality within public health: From analysis to action. Am J Public Health. 2021;111(1):88-90.

Lopez N, Gadsden VL. Health inequities, social determinants, and intersectionality. Discussion paper, National Academy of Medicine, Washington, D.C., 2016.

February EDI Corner - Black History Month

During Black History Month, let us be mindful of the centrality of African American history in U.S. history, as well as past and current attempts to erase or alter the teaching of Black history. Because antiracist action requires foundational historical knowledge, we provide a reading list below in an effort to build our capacity as Dental Public Health professionals to engage in antiracism. This list comprises works that highlight Black History and Black authors, and is provided for those wishing to build or deepen their knowledge. 

Additionally, as public health professionals, we need to remember and tell the stories of historical trauma committed against African Americans in medicine and public health, as well as celebrate and recognize past and current Black leaders in public health and related fields. Among many extraordinary Black leaders in Dental Public Health, this month we celebrate Dr. Caswell Evans, an incredible changemaker who has been studying and advocating for racial equity in oral health for decades. Dr. Evans has served in many leadership roles, including as Associate Dean at the University of Illinois Chicago College of Dentistry; Executive Editor and Project Director for the Oral Health in America: A Report of the U.S. Surgeon General; and Past President of the American Public Health Association, the American Board of Dental Public Health, and the American Association of Public Health Dentistry. AAPHD and our discipline has benefited greatly from his leadership.

Black History Month Reading/Watch List

• The 1619 Project: A New Origin Story by Nikole Hanna-Jones, and accompanying The 1619 Project: Born on the Water children’s book and The 1619 Project on Hulu
• Caste and The Warmth of Other Suns, both by Isabel Wilkerson, and accompanying film Origin, directed by Ava DuVernay and based on Caste
• The Color Purple by Alice Walker, and accompanying film adaptation
• The Fire Next Time by James Baldwin
• Legacy: A Black Physician Reckons with Racism in Medicine by Uché Blackstock
• Under the Skin by Linda Villarosa
• The Immortal Life of Henrietta Lacks by Rebecca Skloot, and accompanying film adaptation
• Rustin, drama/documentary film directed by George C. Wolfe
• 13th, documentary film directed by Ava DuVernay
• When They See Us, limited series based on a true story, executive produced by Ava DuVernay, Oprah, and others
• The Tuskegee Airmen, film based on a true story, directed by Robert Markowitz
• Harriet, film based on the story of Harriet Tubman, directed by Kasi Lemmons
• Selma, historical drama film directed by Ava DuVernay
• Hidden Figures, biographical drama film directed by Theodore Melfi

January EDI Corner - Experiences with Racism in Healthcare Settings

Individual/interpersonal racism occurs between individuals and refers to one’s own racist assumptions, beliefs, or behaviors. It can manifest as implicit bias or overt racial discrimination and is connected to broader socio-economic histories that are supported and reinforced by systemic racism.

The scientific literature is inundated with research demonstrating differences in health outcomes between racial groups.  There is profoundly less scientific evidence linking healthcare differences to the precise mechanisms that produce them, such as racism and discrimination.  As clinicians and dental public health advocates, we need to acknowledge that race is a proxy measure for exposure to experiences of structural and individual racism resulting in a lack of health justice.¹

There is a growing call for more national surveys to incorporate items that solicit individuals’ experiences with discrimination that accurately depict the healthcare experiences of marginalized groups. The CareQuest Institute for Oral Health sponsored a national study that examined discrimination and dignity experiences in prior oral health care visits and their relationships with oral health inequities. The results were striking.

• Nearly 1 in 10 (9%) Black respondents reported having been denied oral care in their lifetime due to discrimination, the highest of any racial/ethnic group. Discrimination experiences in dental settings were associated with poorer oral health status and less probability of planning a future dental visit. 
• Participants’ experiences of feeling disrespected or not trusting their provider to act in their best interest were associated with odds that were more than three-and-a-half-times as great of reporting not having had an oral health visit in the prior 2 years.²

Another recent landmark national study from the Kaiser Family Foundation examined racial discrimination experiences in healthcare settings broadly.³  Key findings are highlighted below. 

• A substantial proportion of Black (18%), American Indian/Alaska Native (12%), Hispanic (11%), and Asian (10%) respondents reported being treated unfairly or with disrespect by a healthcare provider because of their race in the past three years.
• The majority of Black (60%), American Indian/Alaska Native (52%), and Hispanic (51%) adults report preparing for possible insults or feeling they must be very careful about their appearance to be treated fairly during healthcare visits.
• In open-ended responses describing instances of unfair treatment, individuals describe experiences such as not being taken seriously, not being believed about pain, experiencing rude or harassing behavior, having assumptions being made about them, and being blamed for health conditions or problems they were experiencing.
• Patient-provider racial/ethnic concordance matters. Black, Hispanic, and Asian Adults who have at least half of their visits with providers who share their racial or ethnic background report having more frequent positive and respectful interactions.

These results serve as a call to action for medical and dental healthcare providers and institutions to support high-quality and anti-racist care. 

Anti Racist actions for individuals in healthcare settings:⁴

• Utilize self-reflection tools, participate in unconscious bias training, watch this video about unconscious bias among healthcare providers. 
• Foster a culture of belonging for patients through active listening, unconditional respect, and empathy. 
• Take the 21-day Racial Equity Habit Building Challenge⁵

• For 21 days, do one action to further your understanding of power, privilege, supremacy, oppression, and equity.

• Plan includes suggestions for readings, podcasts, videos, observations and ways to form and deepen community connections

Anti Racist actions for healthcare institutions:⁶

• Provide ongoing training for staff at all levels that include concepts related to racism and unconscious bias.
• Institute patient/staff reporting mechanisms for discrimination and follow up on them.

References:

1. Lett E, Asabor E, Beltrán S, Cannon AM, Arah OA. Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research. Ann Fam Med. 2022 Mar-Apr;20(2):157-163.
2. Raskin, S.E., Thakkar-Samtani, M., Santoro, M. et al. Discrimination and Dignity Experiences in Prior Oral Care Visits Predict Racialized Oral Health Inequities Among Nationally Representative US Adults. J. Racial and Ethnic Health Disparities (2023)
3. Artiga S, Hamel L,  Gonzalez-Barrera A, Montero A, Hill L, Presiado M, Kirzinger A, and LopesL. Survey on Racism, Discrimination and Health: Experiences and Impacts Across Racial and Ethnic Groups. Kaiser Family Foundation. Published: Dec 05, 2023 Survey on Racism, Discrimination and Health: Experiences and Impacts Across Racial and Ethnic Groups | KFF  
4. Hassen N, Lofters A, Michael S, Mall A, Pinto AD, Rackal J. Implementing Anti-Racism Interventions in Healthcare Settings: A Scoping Review. Int J Environ Res Public Health. 2021 Mar 15;18(6):2993.
5. https://www.americaandmoore.com/21-day-re-challenges
6. Hassen N, Lofters A, Michael S, Mall A, Pinto AD, Rackal J. Implementing Anti-Racism Interventions in Healthcare Settings: A Scoping Review. Int J Environ Res Public Health. 2021 Mar 15;18(6):2993. 

Resources:  

Anti-racism Resources | AAMC

December EDI Corner - Disrupting Unconscious Bias

Unconscious bias (also called implicit bias) is a negative attitude or social stereotype about a social group that we are not consciously aware of.^1,2 If left unchecked, unconscious biases we all carry from past experiences (e.g., culture, environment, caregivers, media) can negatively influence our decision-making, our interactions with others, and our ability to create a welcoming environment, even when we have the best intentions. Actively disrupting unconscious biases by building awareness and taking action can help align our behaviors with our values to create a more equitable, diverse, and inclusive environment for everyone.

There are evidence-based approaches to reduce unconscious bias. Project Implicit offers resources to become aware of biases and the Kirwan Institute at The Ohio State University provides a self-guided training program. The Perception Institute has compiled strategies to reduce implicit bias in education and healthcare, and some of these are described below:

• Improve decision-making conditions: When making important decisions, slow down thinking or pause to prevent implicit biases from determining behaviors.
• Counter-stereotypic imaging: Broaden the definition of a successful other beyond traditional stereotypes and expectations, e.g., Latine astronaut.
• Stereotype replacement: Recognize when a thought is based on stereotypes, label the thought as stereotypic, and reflect on why the thought occurred. Then, replace the stereotypical thought with a non-stereotypical one.  
• Perspective taking: Seeing oneself as part of a stereotyped group can lead to a greater sense of connection to that group.
• Increasing opportunities for contact: More frequent interactions among people from different backgrounds increase feelings of connection and reduces prejudices, e.g., expand inner circles.
• Individuation: Obtaining specific information about each member to avoid making generalizations about a group.
• Doubt objectivity: Learning about non-conscious thought processes leads to skepticism of objectivity and better guarding against biased evaluations.
• Count: Use data to identify patterns leading to unequal outcomes (e.g., racial disparities) and consider if bias plays a role.
1. American Psychological Association. November 2022. Implicit Bias. https://www.apa.org/topics/implicit-bias 
2. University of San Francisco Office of Diversity and Outreach. n.d. Unconscious Bias Training. https://diversity.ucsf.edu/programs-resources/training/unconscious-bias-training

November EDI Corner - Inclusive Communication

Words matter! Improving equity is within the DNA of Dental Public Health, and we often talk about “underserved” or “vulnerable” populations as the targets of research, interventions, or initiatives. However, using those terms is problematic because they victimize and otherize people, and they aren’t specific about the ways in which particular populations face barriers to health or health care. 
For guidance on how to use more inclusive, person-centered language, the CDC recently released Principles for Inclusive Communication, and these two articles (Sotto-Santiago 2019 and Black, Cerdeña, and Spearman-McCarthy 2023) elucidate why we need to avoid using the term “minorities” when referring to people or groups who are racially minoritized. 
Here are some key inclusive communication tips from these resources as a start:

• Instead of “underserved populations”, try “people who face financial/transportation/etc. barriers to care”
• Instead of “low-SES populations”, try “people with lower income” or “people experiencing poverty”
• Instead of “Medicaid patients”, try “people with Medicaid”
• Instead of “disabled people”, try “people with an intellectual or developmental disability”
  • Note that some populations prefer identity-first terminology, such as Autistic people. 
• Instead of using racial identity as a noun (e.g., Blacks, Latinos, Whites), use it as an adjective (e.g., Black/Latino/White people/adults/children)

Regardless of our stage of life or career, we’re all on a journey toward communicating in ways that are more inclusive and empowering. Let’s keep working toward this goal together!