Chronic disease and healthy ageing at the intersections: social locations, biomarkers, and health practices;

Lead Research Organisation: University of Sheffield
Department Name: Sociological Studies

Abstract

Chronic diseases entail huge personal and societal costs and pose a significant challenge for public health. Furthermore, they are key drivers of inequalities in later life (50+) health. So far, health inequalities research has tended to focus on how health varies according to single categories of difference, such as gender or socioeconomic status. Yet in the real world we know that any given person is not just a man or woman, poor or rich, etc., but a combination of attributes, so that we might describe an older, poorer, ethnic minority man, for example (or any other combination that exists).

This project takes up a theory which addresses this complexity called intersectionality. In particular, it focuses on how each of the combinations possible from the interaction of gender, age, socioeconomic status, and ethnicity (and in ageing research, also typically retirement and marital status), is associated with a particular location in the social structure, which brings with it particular (yet overlapping) resources, policy effects, processes, and types of discrimination. In turn, each position is associated with a particular (yet overlapping) set of social determinants of health, with differential consequences for chronic disease outcomes. Different intersectional positions might also entail different cultural and social identities. For example, there might be distinctive aspects to the identity of a younger unemployed man that cannot be reduced to age, employment status, or gender alone.

In this project, we are particularly interested in the chronic diseases of type 2 diabetes, heart disease and obesity. These conditions are highly prevalent and have shared social determinants. We will analyse survey data from the English Longitudinal Study of Ageing, the Survey of Health, Ageing and Retirement in Europe, Understanding Society and the UK Biobank to identify which intersectional positions are at particular risk of these conditions. We will then investigate which factors might lead to this excess risk. We plan to focus on two types of factors. The first is events over the lifecourse, since we know that dis/advantage from womb to tomb is crucial to later life health outcomes. The second is health practices (i.e. health behaviours in social context) since there is strong evidence that these influence chronic disease outcomes. We will use a newly developed multilevel modelling technique and growth curve models; these methods allow for socially 'mapping out' health outcomes, and examining how they vary on time.

In this work, we plan to analyse biomarker data which is increasingly collected in inter/national surveys. Biomarkers are objective measures of underlying pathology. Commonly-known biomarkers include blood pressure, BMI, and for diabetes, HbA1c. The advantage is that biomarkers are objective, valid measurements of health. Furthermore, by analysing biomarker outcomes at intersectional positions, we are advancing a highly novel biosocial approach, bringing together sociological theory with medical measurements. In effect, we will be able to see how social disadvantage 'gets under the skin' where factors such as gender, age and ethnicity interact with each other.

What is the benefit of this research? It will highlight fine-grained inequalities that have previously escaped attention. It will suggest new ways to design, target and tailor public health policies and interventions. Academically, it takes up and runs with a theory which is currently seen as holding great promise to move health inequalities research forward. It will generate new conceptual, methodological and empirical knowledge which will be of substantial interest to the research community across multiple disciplines. Ultimately, the project offers a significant opportunity for a new approach to tackle the growing chronic disease burden negatively affecting the lives of many older people, but especially those in particularly deprived positions.

Planned Impact

New forms of knowledge are needed to tackle the challenge of chronic diseases in older age, and their inequalities, to help ensure that all members of society can age healthily. The proposed research offers a novel interdisciplinary, biosocial approach that is directly geared to generating such knowledge. In the process, it aims to shift the conversation around risk, vulnerability and disadvantage in older age. Accordingly, non-academic beneficiaries fall into two main categories.

First are practitioners and policy makers in the fields of public health and gerontology, especially those with an interest in health inequalities and social determinants. Here the goal is instrumental impact. These stakeholders will benefit because the project will generate evidence relevant to more sophisticated and nuanced approaches to designing interventions and policies on health inequalities. Ultimately, the aim is to effect an equitable change in the public health.

Second are those who use concepts around health inequalities and healthy ageing (this also includes the first group), chiefly ageing and chronic disease charities and NGOs. Here the goal is conceptual impact. These stakeholders will benefit because they regularly use concepts and methods concerning health inequalities in older age. Adding the concept of intersectionality to the conversation will highlight fine-grained inequalities that have previously escaped attention. Consequently, these organisations will be more equipped to use the concept of intersectionality.

Stakeholders will be involved right from the beginning of the project in co-design activities. An online survey will be disseminated which will ascertain views on what is important in analysing inequalities in chronic conditions and healthy ageing. Topics will include awareness and understanding of the concept of intersectionalities and related terms (risk, subgroup, disadvantage, vulnerability).

A co-design workshop will explore with stakeholders the utility of intersectionality for understanding inequalities in chronic disease. The workshop will be highly interactive and will invite participants to consider how the 'classic four' socio-demographic factors of socioeconomic position, age, gender, and ethnicity, as well as other factors, might together socially drive illness in later life. The workshop will also discuss current issues in intersectional theory and challenges to its application for policy-making and practice.

The public health elements of the project relate to the focus on health inequalities and producing evidence regarding targeted and tailored interventions and policies. The research team will utilise the public health networks they are members of and also seek to join new networks as appropriate in order to disseminate the project as widely as possible and maximise impact. This will help to increase participation in the other planned activities.

An end of project conference will take up the twin foci of conceptual and instrumental impact by aiming to share understanding of intersectionalities stakeholders as well as having a dedicated session on policy and practice significance. It will also be an opportunity to disseminate the findings, as well as inviting leading intersectionality researchers from Europe and the US to maximise productive knowledge exchange.

Finally, the project will publish both academic and non-academic blog posts and maintain a social media presence. Research briefs will distil papers into key results with clear illustration for stakeholders. These will be distributed to the identified stakeholders through e-mail lists and the final conference.
 
Title Intersectionality and health explained 
Description An animation explainer video on the topic of intersectionality and health. Produced by Posh Gecko for the project. The animation aims to explain the concept of intersectional health to a wider audience and make it accessible. This was produced alongside public health practitioners who provided feedback on earlier drafts. 
Type Of Art Film/Video/Animation 
Year Produced 2020 
Impact The video has over 2500 views. An employee from Epic Systems, a multi billion dollar company, got in touch to say that they use the animation as part of a Diversity Equity & Inclusion curriculum. 
URL https://www.youtube.com/watch?v=rwqnC1fy_zc&feature=emb_logo
 
Description We have published four papers from the project so far, three in leading international journals and one on a preprint online platform.
1. Development of a multilevel approach to intersectionality (https://psycnet.apa.org/fulltext/2019-30571-005.html). This paper helped to validate the multilevel approach to intersectionality (often termed 'MAIHDA' - Multilevel analysis of individual heterogeneity and discriminatory accuracy). We showed that this method is an improvement on conventional regression methods for analysing intersectionality e.g. using interaction terms/dummy variables. However we also suggested a number of potential ways forward to further strengthen and develop the approach. We provided full syntax for easy replication. The paper has been relatively well-cited already despite only being published in 2019.
2. Mapping intersectional inequalities in biomarkers of healthy ageing (https://www.nature.com/articles/s41598-020-69934-8). Our first empirical paper from the project in effect challenged the narrative that health inequalities, and how social determinants and processes 'get under the skin' occurs in a simple or as expected way in relation to different axes of inequality. Instead, gender, ethnicity, income and education together produce complex, granular patterns in biomarkers of health. Some intersections have on average worse health than others, but no group has better or worse biomarkers of healthy ageing/chronic disease across all outcomes. Our findings open the possibility of targeting interventions/policies but this possibility is caveated for reasons we explore in 4. below. In the paper we also suggest a number of future research questions and directions related to how biomarkers relate to health outcomes differently for different intersections and the life course processes that lead to such differences. We discuss these in 3.
3. Understanding unequal ageing: towards a synthesis of intersectionality and life course analyses (https://link.springer.com/article/10.1007/s10433-020-00582-7). This conceptual and theoretical paper aims to bring the frameworks of intersectionality and the lifecourse in conversation with each other in order to advance understanding on unequal ageing. Our main argument was that both frameworks are indispensable to understanding unequal ageing and each can inform the other. We outlined a number of methods and approaches that be used. We centred the analysis around the life course concepts of roles, life stages, transitions, age/cohort, cumulative disadvantage/advantage, and trajectories.
4. Can intersectionality help with understanding and tackling health inequalities? Perspectives of professional stakeholders (https://www.medrxiv.org/content/10.1101/2020.10.26.20217463v1). This was a co-produced paper that emerged from a stakeholder workshop and a consultation survey. Both elements included both academic and non-academics who shared their views on the value of intersectionality for health inequalities research, and how it can be implemented practically, and the barriers to doing this. The main findings were that stakeholders were generally positive about intersectionality, but challenges were also raised around the critical and transformative aspects of the framework, its apparent complexity, and how it should be operationalised. Suggestions to move the field on included the provision of guidelines and toolkits to better understand how to implement it.
Exploitation Route Those who are interested in applying intersectional analysis can use the method we have helped to develop and validate, for example by using the syntax we provided. We realise however that this might still be too complex for non-specialists, so we are applying for further funding to develop a toolkit to make the methods accessible.
The empirical paper will have relevance for those who are interested in understanding how inequalities in healthy ageing are much more heterogenous and complex than conventionally thought. This has implications for the types of policies we might implement to tackle inequalities and how they can be targeted.
We think the findings around the life course and intersectionality are topical and will have broad appeal. These findings can be taken up by those interested in healthy ageing and especially their inequalities - which includes a wide range of stakeholders. We would hope conceptual impact will follow from this analysis.
The findings of the stakeholder paper can be taken up by those who are also interested in how intersectionality is applicable in health inequalities research given how it outlines the barriers and opportunities to do so. It also makes a number of practical suggestions on ways forward.
Sectors Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice

URL http://intersectionalhealth.org
 
Description The animation that we produced is being used as part of a Diversity Equity & Inclusion curriculum for Epic Systems which are a transnational company with ~10k employees. The animation is being used across the whole company. I have given evidence to a government review (HOUSE OF LORDS SCIENCE AND TECHNOLOGY COMMITTEE INQUIRY ON AGEING: SCIENCE, TECHNOLOGY AND HEALTH LIVING (2019) and a national consultation (I authored a chapter for All Party Parliamentary Group for Longevity report 'The Health of the Nation' (2020)). These reports and reviews draw on learning from the project regarding ageing, health inequalities and social determinants.
First Year Of Impact 2021
Sector Digital/Communication/Information Technologies (including Software),Healthcare
Impact Types Societal

 
Description Animation explainer video used in company training
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Authored chapter for All Party Parliamentary Group for Longevity report 'The Health of the Nation'
Geographic Reach National 
Policy Influence Type Participation in a national consultation
URL https://appg-longevity.org/events-publications
 
Description EVIDENCE TO THE HOUSE OF LORDS SCIENCE AND TECHNOLOGY COMMITTEE INQUIRY ON AGEING: SCIENCE, TECHNOLOGY AND HEALTH LIVING
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
 
Description Strengthening the equity focus in public health research in and beyond SPHR
Amount £132,179 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 01/2020 
End 03/2022
 
Description WRDTP Collaborative Award
Amount £80,004 (GBP)
Funding ID 165776 
Organisation White Rose University Consortium 
Sector Academic/University
Country United Kingdom
Start 10/2020 
End 09/2024
 
Title Multilevel Intersectionality Models 
Description We helped to validate a new approach to study intersectionality using multilevel models and developed best practice guide for this approach (10.1027/1614-2241/a000167). We provide advice to make this promising method work robustly. We provided syntax files for others to reproduce the method. There has been a recent rise in the use of multilevel models to uncover complex interactions between social characteristics. This is driven by interest in intersectionality theory, focusing on the intersecting deprivations that result from different combinations of social characteristics such age, sex, ethnicity, and socioeconomic position on the one hand, and how these deprivations are the result of interlocking systems of discrimination, marginalization, oppression, and exclusion on the other. Sometimes the combination of social characteristics can have multiplicative effects that are more than the sum of their parts. For example, being either black or having a low income can be disadvantageous, but being both black and having a low income can be extra disadvantageous. Different combinations of attributes represent different socio-structural positions, entailing differential access to resources, and different social identities, since the social groups we belong to give us a sense of who we are. Intersectionality research has also been concerned with multiple marginalized intersectional positions/identities in relation to sexuality, disability, and nationality, for example. Despite the different strands of intersectionality research, recent multilevel analyses have so far focused on the "main" characteristics described, and on intersectional subgroups rather than wider systems of oppression. The multilevel approach is argued to be a "new gold-standard" for analyzing differences in health across societal groups. It empirically investigates intersectionality by explicitly taking into account subgroups defined by different combinations of social characteristics, while not assuming a priori that any particular variable or subgroup is a more important driver of intersectional effects than others. 
Type Of Material Data analysis technique 
Year Produced 2019 
Provided To Others? Yes  
Impact The methods paper has received a good deal of attention online including already 11 citations (Google Scholar). We have applied this method in an empirical paper (https://www.nature.com/articles/s41598-020-69934-8). 
URL https://psycnet.apa.org/fulltext/2019-30571-005.html#s6
 
Description Co-production of research output 
Organisation International Longevity Centre (ILC-UK)
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Partners attended a co-production workshop where they inputted into the research agenda of the project. They also completed a consultation survey on the research. Following this, they were invited to co-author a paper which is a write up for the workshop and survey. The paper is now drafted, and all members contributed to the draft and each wrote a 'policy/practice perspective' short section in relation to their professional roles. The contributions made by the research team were sharing of knowledge and expertise around intersectionality and the current cutting edge methods, approaches, and conceptual issues, and offers of authorship on an academic paper.
Collaborator Contribution Following the above, the partners' contribution was their professional stakeholder insight on a new theoretical/conceptual approach to inequalities, which is actively shaping the research agenda, plans for follow on work, and more concretely the academic paper to be submitted soon.
Impact The drafted paper is entitled 'Can intersectionality help with understanding and tackling health inequalities? Perspectives from research, policy and practice'.
Start Year 2019
 
Description Co-production of research output 
Organisation National Institute for Health Research
Department INVOLVE
Country United Kingdom 
Sector Public 
PI Contribution Partners attended a co-production workshop where they inputted into the research agenda of the project. They also completed a consultation survey on the research. Following this, they were invited to co-author a paper which is a write up for the workshop and survey. The paper is now drafted, and all members contributed to the draft and each wrote a 'policy/practice perspective' short section in relation to their professional roles. The contributions made by the research team were sharing of knowledge and expertise around intersectionality and the current cutting edge methods, approaches, and conceptual issues, and offers of authorship on an academic paper.
Collaborator Contribution Following the above, the partners' contribution was their professional stakeholder insight on a new theoretical/conceptual approach to inequalities, which is actively shaping the research agenda, plans for follow on work, and more concretely the academic paper to be submitted soon.
Impact The drafted paper is entitled 'Can intersectionality help with understanding and tackling health inequalities? Perspectives from research, policy and practice'.
Start Year 2019
 
Description Co-production of research output 
Organisation Public Health England
Country United Kingdom 
Sector Public 
PI Contribution Partners attended a co-production workshop where they inputted into the research agenda of the project. They also completed a consultation survey on the research. Following this, they were invited to co-author a paper which is a write up for the workshop and survey. The paper is now drafted, and all members contributed to the draft and each wrote a 'policy/practice perspective' short section in relation to their professional roles. The contributions made by the research team were sharing of knowledge and expertise around intersectionality and the current cutting edge methods, approaches, and conceptual issues, and offers of authorship on an academic paper.
Collaborator Contribution Following the above, the partners' contribution was their professional stakeholder insight on a new theoretical/conceptual approach to inequalities, which is actively shaping the research agenda, plans for follow on work, and more concretely the academic paper to be submitted soon.
Impact The drafted paper is entitled 'Can intersectionality help with understanding and tackling health inequalities? Perspectives from research, policy and practice'.
Start Year 2019
 
Description Co-production of research output 
Organisation Race Equality Foundation
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Partners attended a co-production workshop where they inputted into the research agenda of the project. They also completed a consultation survey on the research. Following this, they were invited to co-author a paper which is a write up for the workshop and survey. The paper is now drafted, and all members contributed to the draft and each wrote a 'policy/practice perspective' short section in relation to their professional roles. The contributions made by the research team were sharing of knowledge and expertise around intersectionality and the current cutting edge methods, approaches, and conceptual issues, and offers of authorship on an academic paper.
Collaborator Contribution Following the above, the partners' contribution was their professional stakeholder insight on a new theoretical/conceptual approach to inequalities, which is actively shaping the research agenda, plans for follow on work, and more concretely the academic paper to be submitted soon.
Impact The drafted paper is entitled 'Can intersectionality help with understanding and tackling health inequalities? Perspectives from research, policy and practice'.
Start Year 2019
 
Description Collaboration with Rabiya Gangreker (Public Health Knowledge Analyst) 
Organisation Blackburn With Darwen Council
Country United Kingdom 
Sector Public 
PI Contribution This collaboration involved working together to develop an intersectionality and health workshop for the National Institute for Public Health School for Public Health Research annual meeting. Rabiya is a public health practitioner (Public Health Knowledge Analyst). We were keen to involved a non-academic in the workshop to boost audience engagement. Unfortunately, though we developed plans and materials for the workshop it was cancelled due to Covid. We are exploring the possibility of running the workshop virtually at this year's annual meeting.
Collaborator Contribution Rabiya provided feedback on the workshop slides and produced her own slides. She was due to help facilitate some of the session.
Impact N/A as noted this was cancelled due to Covid.
Start Year 2020
 
Description Blog on intersectionality and unequal ageing 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact We wrote a post for a blog ('Ageing Issues') summarising our paper published in the European Journal of Ageing (https://link.springer.com/article/10.1007/s10433-020-00582-7) on bringing together intersectionality with the life course perspective. The number and type of of reader is unknown but the blog is very active being the official blog of the British Society of Gerontology.
Year(s) Of Engagement Activity 2020
URL https://ageingissues.wordpress.com/2020/11/27/intersectionality-and-the-life-course/
 
Description Intersectionality and health website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact A project website was set up which includes updates on project activities and outputs. The website regularly gets international visitors, so far from almost 30 countries. The website has had over a 1000 views from 500 visitors. The audiences are listed as 'other' above because this information is not known.
Year(s) Of Engagement Activity 2020,2021
URL http://intersectionalhealth.org
 
Description Researcher/policy/practice workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact A workshop was held at the University of Sheffield on May 20th 2019 on the topic of intersectionality in health inequalities research, organised by Dr. Daniel Holman, Professor Sarah Salway, and Dr. Andy Bell as part of the ESRC funded project 'Chronic disease and healthy ageing at the intersections'. The audience were a mixture of academics, patient representatives, third sector organisations, local city councils and other national and local bodies.

The purpose of the workshop was to facilitate an exchange around the idea of intersectionality, which although 'jargony' sounding, is at heart the simple idea that social attributes such as gender, age, ethnicity, socioeconomic position, disability, sexuality, etc., together shape inequalities. Intersectionality is currently becoming very popular in health inequalities research, so now is the ideal time to get input from people who have expertise in this area to 'sense check' how it is being and should be implemented. To do this, we purposively invited people from a range of backgrounds, the idea being that (i) academics should be guided by the concerns of those from policy/practice, and (ii) these stakeholders might also consider the relevance of intersectionality to their own work.

Following the workshop a co-production paper was drafted alongside selected attendees, and attendees reported back how they were inspired by an intersectionality approach.
Year(s) Of Engagement Activity 2019
 
Description Summary of researcher/policy/practice workshop dissemination 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact A four page summary of the stakeholder workshop was distributed to 45 academics and non-academics across the UK, Europe and further. The purpose was to disseminate findings fro the workshop to a wider audience.
Year(s) Of Engagement Activity 2019
 
Description Webinar on intersectionality and health inequalities 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact This webinar included a panel of four speakers sharing various research on intersectionality and health. The speakers were from different UK institutions. All the tickets to the webinar went well in advance. A waiting list was set up. Attendees were from many different institutions and organisations, both academic and non-academic. We also had international attendees, though most were form the UK. The webinar was recorded and is available online.
Year(s) Of Engagement Activity 2020
URL http://intersectionalhealth.org