An integrative literature review and critical reflection of intersectionality theory

Relationships Among Determinants of Health, Cancer Screening Participation, and Sexual Minority Identity: A Systematic Review

Purpose: To address cancer screening disparities and reduce cancer risk among sexual minority (SM) groups, this review identifies individual, interpersonal, and community/societal determinants of cancer screening (non)participation among differing SM identities. Methods: Seven scientific databases were searched. Inclusion criteria were as follows: (1) used quantitative methods; (2) English language; (3) cancer screening focus; and (4) at least one SM group identified. Articles were excluded if: (1) analysis was not disaggregated by SM identity (n = 29) and (2) quantitative analysis excluded determinants of cancer screening (n = 19). The Sexual and Gender Minority Health Disparities Research Framework guided literature synthesis. Results: Twelve studies addressed cervical (n = 4), breast (n = 3), breast/cervical (n = 3), or multiple cancers (n = 2). Other cancers were excluded due to inclusion/exclusion criteria. The total sample was 20,622 (mean 1525), including lesbian (n = 13,409), bisexual (n = 4442), gay (n = 1386), mostly heterosexual (n = 1302), and queer (n = 83) identities. Studies analyzing individual-level determinants (n = 8) found that socioeconomic status affected cervical, but not breast, cancer screening among lesbian and bisexual participants (n = 2). At the interpersonal level (n = 7), provider-patient relationship was a determinant of cervical cancer screening among lesbian participants (n = 4); a relationship not studied for other groups. Studies analyzing community/societal determinants (n = 5) found that rurality potentially affected cervical cancer screening among lesbian, but not bisexual people (n = 3). Conclusions: This review identified socioeconomic status, provider-patient relationship, and rurality as determinants affecting cancer screening among SM people. While literature addresses diverse SM groups, inclusion/exclusion criteria identified studies addressing cisgender women. Addressing disparities in the identified determinants of cervical cancer screening may improve participation among SM women. Further research is needed to understand determinants of cancer screening unique to other SM groups.

Interpersonal Transphobia Within Nursing: A Critical Concept Exploration

Transphobic perceptions negatively impact health care access and outcomes among transgender and gender-diverse people and challenge nurses' capacity to maintain ethical practice standards. The concept of transphobia has not been well defined in the literature or nursing. Using a critical realist lens, this concept exploration sought to define interpersonal transphobia through a review of purposefully selected literature. Attributes included discrimination and prejudice, while antecedents were cisnormativity, erasure, and stigma. Nurses can help reduce transphobia by seeking education and practicing gender-affirming care, including transgender people in research, and advocating for equitable policies and procedures.

Exploring the implementation of person-centred care in nursing practice

Person-centred care involves nurses working in partnership with patients to ensure their needs and preferences are at the centre of their healthcare, as well as considering the biographical and social factors that are relevant to the person's health. This aims to support patients in developing the knowledge, confidence and skills to make informed decisions about treatment and to manage their own care where possible. This article discusses the concept of person-centred care and considers some of the facilitators and barriers that may affect its implementation in healthcare practice. It also explores some of the approaches that nurses can use to support person-centred care, such as cultural humility and role modelling.

Obstetric violence in the United States and other high-income countries: an integrative review

Obstetric violence has been documented throughout the world, yet this human rights issue has mostly been investigated in middle- and low-income countries where the intensity and brutality of abuse and mistreatment is more easily recognised as problematic. This integrative review aimed to analyse sources about obstetric violence in high-income countries with the objective of identifying gaps in the research, challenges to the study of obstetric violence, and solutions to framing research that meets those challenges. A systematic search was conducted using the PubMed and CINAHL databases from February to June 2022. Empirical and non-empirical sources, published in English, with no date restrictions, were retrieved. Citation searching was also done. Forty-six sources were included. Identified gaps in the research were: (a) scarce attention to obstetric violence in most high-income countries; (b) most US sources are non-scientific and from outside the healthcare disciplines; (c) inconsistencies in terminology; (d) most studies were conducted with samples of women who had given birth, with scant research about healthcare providers and obstetric violence, and (e) the association between obstetric violence and traumatic birth was under-recognised. Identified challenges to the study of obstetric violence were: (1) factors that enable and perpetuate obstetric violence are multilevel and nonlinear; (2) the phenomenon is contextually complex; and (3) blind spots from routinised harmful practices and normalised mistreatment can prevent healthcare providers and birthing people from recognising obstetric violence. A systems approach and complexity theory are guiding frameworks recommended as solutions to the challenges of studying and correcting obstetric violence.

Intersectionality in nursing research: A systematic review

AIM

This systematic literature review aimed to identify, appraise and synthesize available research studies that apply intersectionality in nursing research.

DESIGN

Systematic review.

DATA SOURCES

Empirical and theoretical nursing studies published before February 2022 were identified from the PubMed and CINAHL databases. Studies were eligible for inclusion if they substantially covered the topics of intersectionality and nursing, had undergone peer-review, and were written in English.

REVIEW METHODS

The PRISMA 2020 statement for reporting systematic reviews was used to report findings. The Joanna Briggs Institute Critical Appraisal tools were used to assess the quality of the included research studies.

RESULTS

Out of 331 identified studies, 60 studies were substantially about nursing and intersectionality, and were included in the review. There are a myriad of ways that the concept of intersectionality has been adopted in nursing research. Furthermore, there was great heterogeneity in the definition and application of the concept of intersectionality, and only a few studies were empirical.

CONCLUSION

There is a need for robust and clear framing of how the concept of intersectionality is defined and understood in nursing research. There is also a need for more empirical research effectively adopting the concept of intersectionality to enhance our understanding of how health inequities operate within the field of nursing.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, caregivers or members of the public were involved in this work.

Intersectionality in nursing research: A scoping review

Background

An intersectional approach to health research provides an analytical foundation to explain the multidimensionality of health status, resource accessibility, privilege, oppression, and current and historical context. The use of intersectionality in health research has known limitations. Its use in health-related fields too often focuses on outcomes, such as health disparities, rather than processes, such as power structures and social determinants.

Objective

This scoping review serves to examine how intersectionality has been implemented by nurses in the peer-reviewed literature. We offer insight into how it may be incorporated to inform future nursing research and healthcare provision.

Design & Methods

Systematic searches of PubMed (n = 257), SCOPUS (n = 807), EMBASE (n = 396), CINAHL (n = 224), and Health Source: Nursing and Academics (n = 491), published since the seminal publication on intersectionality (1989 - 2023), identified 131 research articles that met inclusion and exclusion criteria. Data extraction and synthesis were used to describe the breadth and depth of the literature specific to the application of intersectionality in nursing research.

Results

The included studies used intersectionality to examine the intersections of numerous identities, such as race, gender, and immigration status. However, most studies were descriptive/observational in nature, underreported their methods, and conducted deficit-based research instead of strength-based inquiries. Of note, the vast majority of included articles were published within the last five years.

Conclusions

Future researchers using intersectionality as a framework can improve their approach by reporting clear definitions and operationalization of intersectionality. Observational science dominated the included studies; future research should focus on intervention development and evaluation using an intersectional lens. Lastly, caution should be placed on research that focuses solely on deficits among marginalized communities, which places scientists at risk of perpetuating stereotypes or enhancing already-existing stigmas.

An Assessment of Patient Portal Messaging Use by Patients With Multiple Chronic Conditions Living in Rural Communities: Retrospective Analysis

BACKGROUND

Patient portals can facilitate the delivery of health care services and support self-management for patients with multiple chronic conditions. Despite their benefits, the evidence of patient portal use among patients with multimorbidity in rural communities is limited.

OBJECTIVE

This study aimed to explore the factors associated with portal messaging use by rural patients.

METHODS

We assessed patient portal use among patients with ≥1 chronic diagnoses who sent or received messages via the Epic MyChart (Epic Systems Corporation) portal between January 1, 2015, and November 9, 2021. Patient portal use was defined as sending or receiving a message through the portal during the study period. We fit a zero-inflated negative binomial model to predict portal use based on the patient's number of chronic conditions, sex, race, age, marital status, and insurance type. County-level characteristics, based on the patient's home address, were also included in the model to assess the influence of community factors on portal use. County-level factors included educational attainment, smartphone ownership, median income, and primary care provider density.

RESULTS

A total of 65,178 patients (n=38,587, 59.2% female and n=21,454, 32.92% Black) were included in the final data set, of which 38,380 (58.88%) sent at least 1 message via the portal during the 7-year study period. As the number of chronic diagnoses increased, so did portal messaging use; however, this relationship was driven primarily by younger patients. Patients with 2 chronic conditions were 1.57 times more likely to send messages via the portal than those with 1 chronic condition (P<.001). In comparison, patients with ≥7 chronic conditions were approximately 11 times more likely to send messages than patients with 1 chronic condition (P<.001). A robustness check confirmed the interaction effect of age and the number of diagnoses on portal messaging. In the model including only patients aged <65 years, there was a significant effect of increased portal messaging corresponding to the number of chronic conditions (P<.001). Conversely, this relationship was not significant for the model consisting of older patients. Other significant factors associated with increased portal use include being female; White; married; having private insurance; and living in an area with a higher average level of educational attainment, greater medical provider density, and a lower median income.

CONCLUSIONS

Patients' use of the portal to send messages to providers was incrementally related to their number of diagnoses. As the number of chronic diagnoses increased, so did portal messaging use. Patients of all ages, particularly those living in rural areas, could benefit from the convenience and cost-effectiveness of portal communication. Health care systems and providers are encouraged to increase the use of patient portals by implementing educational interventions to promote the advantages of portal communication, particularly among patients with multimorbidity.

Using a Structural Intersectionality Approach to Understand Drivers of Health Inequities

Clinical nurses and nurse scientists should consider how societal systems of inequality interact, affect the health of individuals, and exacerbate health inequities, especially for Black women. In this short review, we examine a recent study that introduces an innovative approach to measuring intersectional systems of inequality at the state level and their impact on health referred to as structural intersectionality. Implications for nursing practice and nursing science are discussed.

Analysis and Evaluation of Intersectionality Theory for the Study of Access to Mental Health Services of Children With Refugee Background

Multiple and complex factors contribute to the health inequities faced by refugee children accessing mental health care. Nurses play a critical role in addressing health inequities through education, practice, policy, and research. Intersectionality theory holds the potential to support nursing research that seeks to critically examine intersecting social identities and power structures that impact health inequities experienced by refugee children with mental health difficulties. Using Fawcett's framework, this article examined intersectionality theory and its applicability to the topic of inquiry. The findings revealed that much work is still required for intersectionality theory to meet the criteria for theory evaluation.

Critical Reflection Practice in Nursing Health Care Policy Education

BACKGROUND

A call to action is in effect for nurses to be change agents and bridge the gaps between the delivery of health care and the social needs of individuals, families, and communities. Response to this charge requires nurses to address long-standing inequity in health care policy and practice realms.

METHOD

This article describes the creative teaching-learning approach of critical reflection practice as a first step in developing skills and attitude for nurses to do this work.

RESULTS

Early observations of the effect of critical reflection practice on learners show improved appreciation for the intersection of social, economic, and political dimensions operating in health care policy and practice that influence health inequities.

CONCLUSION

When nurses engage in a practice of critical reflection, they are more likely to identify offensive social determinants, act to ameliorate disparities, and advance the agenda for health equity. [J Nurs Educ. 2023;62(X):XXX-XXX.].

Integration of Case-Based Dialogue to Enhance Medical Students' Understanding of Using Health Communication to Address Social Determinants of Health

BACKGROUND AND OBJECTIVES

With the ever-growing diversity within our communities, it is imperative that we integrate social determinants of health (SDOH) such as racial disparity, economic instability, lack of transportation, intimate partner violence, and limited social supports, and the importance of health literacy into undergraduate medical education. By incorporating evidence-based curriculum on the disproportionality within healthcare faced by racial and ethnic minorities, we have the opportunity to develop more culturally sensitive providers. The purpose of this study was to assess the impact of a case-based debrief experience on medical students' knowledge about how social determinants of health can impact health and healthcare within a family medicine clinical setting and their intent to practice in an underserved community.

METHODS

We utilized a retrospective paired-sample t-test analysis of program data from 640 third-year medical students who engaged in a family medicine clerkship between July 2020, and April 2022. For inclusion in the study, students must have engaged in a case-based exercise and corresponding small group debrief around the impact of social determinants of health on patient care.

RESULTS

We found a statistically significant improvement in students' reported knowledge about SDOH, as well as the confidence and intent to work with and care for individuals of diverse cultural and socioeconomic backgrounds.

CONCLUSION

Medical students must have the knowledge and self-efficacy to understand how social determinants of health can impact health and healthcare within a family medicine clinical setting. As a result of integrating more active learning strategies such as the case-base and debrief experience, students may have a more robust medical education experience.

Exploring the relevance of intersectionality in Australian dietetics: Issues of diversity and representation

Through an exploration of the origins of dietetics in the West, and specifically in Australia, we problematise the lack of diversity within the profession through the lens of intersectionality. Dietetics in Australia continues to be dominated by Australian-born women, and ideologies about dietitians perpetuate narratives of white, young, slim, women. Intersectional approaches to critiquing diversity in dietetics provides a useful framework to extend critical studies of health disparities into disparities in the dietetics professional workforce, which is advanced through structural, political and representational intersectionality guided critique. Through the analysis, a dialog is prompted in order to chart paths forward to find 'how differences will find expression' within the professional group. To do this, dietetics as a profession must reckon with its historical roots and step forward, out of a perceived position of objective neutrality regarding people and diversity, and into a position that can recognise that professional institutions have the power to exclude and marginalise, along with the power to include and transform.