Open access peer-reviewed chapter - ONLINE FIRST
Abstract
In the wake of COVID-19 and other global crises, where inequities have been reinforced or are widening, organizations and institutions in the health field have increasingly taken up equity, diversity, and inclusion (EDI) policies. At the same time, the actual impact of EDI on inequities—particularly for those who experience intersecting forms of marginalization—is debated. This chapter provides an overview of how EDI has been defined and taken up in relation to the health field and identifies the strengths and limitations of these initiatives in working toward health equity, diversity, and inclusion. It then discusses the value-added of an intersectionality-informed approach in helping address these limitations to harness the socially transformative potential of EDI. We illustrate this through a case example that looks at ways to strengthen EDI in medical education, highlighting how intersectionality brings to the fore what is often overlooked, namely, critical reflection on power, explicit attention to systems and structures, and the prioritization of meaningful engagement with those most impacted by inequities. We aim to show the necessity and timeliness of bringing an intersectionality-informed approach to EDI in the health field in beyond, particularly amid growing debate and backlash on the importance of EDI.
Keywords
- health policy
- intersectionality
- health equity
- equity
- diversity
- and inclusion (EDI)
- medical education
1. Introduction
In the wake of COVID-19 and other global crises, where inequities have been reinforced or widening, organizations and institutions have increasingly committed to stronger action to promote health and social equity. In this context, equity, diversity, and inclusion (EDI) policies have gained significant attention, particularly in the field of health.1 Health organizations and institutions have positioned EDI as central to their work, resulting in the development of EDI-supporting initiatives including revised mandates, protocols, diversity and EDI officers and committees, public calls to action, and new research and training initiatives [5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16].
Despite the proliferation of EDI initiatives particularly in last few years, the extent of the actual impact EDI on inequitable structures, relations, and experiences is debated. Critical research for example has argued that EDI work has tended to be taken up in a performative or superficial manner, without attending to the more systemic causes of inequity and exclusion within and beyond organizational structures [17, 18, 19]. More companies and organizations have publicly committed to EDI goals, yet many are deemed ill-equipped to reach them [20, 21]. In the context of growing public backlash and controversy as to the value added of EDI for society [21, 22, 23, 24], the transformative potential of EDI is not being fulfilled.
This chapter provides an overview of how EDI has been defined and taken up in relation to the health field and health policy, identifying the strengths and limitations of these initiatives in relation to achieving their goals of health equity, diversity, and inclusion. It then discusses the value-added of an intersectionality-informed approach to help address these limitations and, in so doing, harness the transformative potential of EDI. We illustrate this through a case example of EDI in medical education, demonstrating how intersectionality can help capture what has often been overlooked, namely, critical reflection on power, explicit attention to interacting systems and structures, and the prioritization of meaningful engagement with those most impacted by inequities.
Informed predominantly by critical research, policy and practice focused on advancing EDI in ways that promote social justice for diverse communities, and this chapter aims to show the necessity and timeliness of an intersectionality-informed approach to EDI, within and beyond the health field and beyond. The literature reviewed here is a part of a broader program of research that includes a scoping review of equity-oriented and intersectionality-informed frameworks, tools, and strategies.2 Of note, our scoping review findings show a common disconnect between rhetoric around the need to better promote equity and concrete direction on how to operationalize this in ways that address the social and structural complexities of inequity. This disconnect particularly exists within the EDI and health landscape. Importantly, this chapter is the first of its kind to demonstrate the application and value added of an intersectionality-informed approach to EDI-related initiatives and strategies relevant to medical education.
2. Equity, diversity, and inclusion (EDI) in the health field
EDI encompasses policy and program initiatives that aim to address the exclusion of underrepresented groups within institutional contexts including employment, health care, and education [31]. EDI developed out of the Civil Rights movement in the US to respond to entrenched forms of racial discrimination and placed large focus on improving representation in the workplace for groups who experience disadvantage [32]. The concept has been linked to the creation of the Equal Employment Opportunity Commission in 1965 which enabled individuals to report workplace discrimination on the basis of factors including gender, race, and age. EDI has continued to develop in the US and other jurisdictions, largely replacing policies within businesses and institutions focused on terms including affirmative action, and employment equity. One of the key strengths of EDI is that it has moved beyond a narrow focus on numerical representation as a measure of achieving equality and diversity toward fostering meaningful inclusion and change within and beyond institutional contexts [31]. A great deal of the focus of EDI efforts to date have been on workplaces and within academic settings.
Most recently, EDI has started to be taken up in the field of health [33]. Specifically, it has been increasingly taken up in contexts including health workforce recruitment and employment policies [5], research processes, funding and publication [34, 35, 36], and education and training requirements [37, 38]. Many health organizations for example have made efforts to hire diverse employees, medical schools are working to recruit a diverse student body, health research funders and publishers have EDI agendas, and EDI task forces and expert staff have been created. Though the interpretation of what EDI entails and its objectives can differ across institutional and jurisdictional contexts, the majority of the focus to date has been on ensuring diversity across health workforces, and addressing bias and discrimination in training and education [39, 40, 41, 42]. Investing in EDI is considered to be an investment in health care systems as it can improve productivity, efficiency and outcomes [43].
At the same time, and from its very origins, EDI has been critiqued on a number of grounds. First, efforts can sometimes be focused on singular identities or two identity categories with little attention to how they interface [4, 33]. Second, a commitment to diversity, often firmly entrenched in EDI policies and approaches, can focus on accommodating differences within structures without tackling the root causes of inequity including the very institutions structures and processes that shape and sustain inequities [44]. Third, the premise and goals of EDI such as inclusion have been challenged as based on Eurocentric assumptions and worldviews, disconnected from historical and continuing processes of oppression like colonialism [45]. As a result of such shortcomings, EDI has only led to modest advancements.
Arguably, both within the health field and beyond, there is often a clear disconnect between the rhetoric and discourse of EDI and transformative strategies and actions that target and reduce systemic inequities. MacKenzie and colleagues et al. effectively summarize this disconnect in their examination of EDI&I (equity, diversity, inclusion, and Indigenization) within institutions of higher education:
Given the fairly nascent stage at which EDI is permeating the health sector, it is important to ensure that it considers the critiques that have emerged in health applications and more broadly. These include that taking up EDI must be more than a symbolic gesture to avoid approaching the work in a performative rather than substantive way [46, 47]. For example, EDI can be subsumed into a ‘box checking’ exercise, where having a EDI consultant or committee, holding a bias training for staff, or reaching a quota of staff reflecting diverse categories mean EDI is being achieved. The problem with these efforts is a failure to attend to or challenge systemic and structural forces creating inequity and exclusion within and beyond institutions and organizations [17, 18]. In this, EDI efforts often have limited impact on day-to-day experiences of inequity and disadvantage—particularly for multiply marginalized groups.
As part of the discussions of EDI, call has been made for a more critical lens for the conceptualization and operationalization of EDI [48, 49, 50]. Others yet have gone further in specifically calling for an intersectionality-informed intervention that could illuminate and challenge the complexities of disadvantage and oppression and engrained power structures including those within institutions [4, 51, 52, 53]. Persuasive arguments have been made that intersectionality is necessary for the progressive development of EDI, bringing a critical but complementary approach that expands and strengthens EDI’s focus on measuring institutional progress and metrics related to equity, diversity, and inclusion [31].
3. Intersectionality as a critical approach to EDI
Intersectionality provides a critical analytical framework for revealing how individual experiences of privilege and disadvantage are influenced by multi-level and interacting factors. The term ‘intersectionality’ was first coined in 1989 by Kimberlé Crenshaw—a Black feminist, lawyer, and civil rights advocate in the United States who sought to explain the multiple oppressions that African American women face from the converging effects of racism and sexism [54]. She argued that the dominant approach to discrimination focuses on exclusions occurring along a single categorical axis, overlooking how categories interact to shape experience. Notably, the central ideas of intersectionality have long historic roots within and beyond the United States. Black activists and feminists, as well as Latinx, post-colonial, working class, queer and Indigenous activists, and scholars have all produced work that reveals the complex factors and processes that shape human lives [55, 56, 57, 58, 59, 60, 61].
Intersectionality is unique in that it moves beyond single axis or additive approaches to show how structures and processes of power cannot be teased apart but are rather mutually constitutive. In brief, it promotes understanding of human beings
In the field of health, intersectionality is well established as an essential approach to understanding and responding to health inequities. A central underlying principle of intersectionality is a commitment to social justice—substantive social and structural change—by recognizing and challenging the status quo of oppressive systems and processes. Bringing intersectionality as a critical analytical approach and praxis to promote EDI and health equity thus cannot be done at the level of lip service but rather integrated throughout EDI development, implementation, and evaluation.
It is important to note, however, that where intersectionality has started to gain traction within EDI efforts, observations have been made that it is being applied in a way that misrepresents what it is, or pays lip service to this approach, failing to apply intersectionality systematically and in accordance with its core principles in a way that would create meaningful change [33]. This makes it imperative to start with clear and accurate definitions of intersectionality.
Recently, Kelly et al. [31] have underscored the conceptual confusion between intersectionality, health inequities, and EDI. In response, they focus their efforts on distinguishing important differences between the three concepts in the context of health research, emphasizing how intersectionality is a methodological approach and EDI as an organizational tool to assessing and implementing change that fosters equitable, diverse, and inclusive environments. This sets an important foundation from which to better understand the value and distinct features of intersectionality.
In sum, intersectionality can be considered as the foundation or roots on which progress toward health equity can be achieved. As Figure 1 illustrates, intersectionality helps do the critical work of identifying what needs changed and working toward this change, in ways that inform and promote the objectives of EDI while moving toward health equity and social justice.
Figure 1.
The links between intersectionality, EDI, and health equity.
Below, we provide a case example of how intersectionality can inform and strengthen EDI initiatives in the area of medical education and the training of medical professionals in ways that promote health equity.
4. An intersectional approach to EDI: a case example of medical education
The field of medical education and training has been a dominant focus of EDI efforts in recent years, particularly as the global call to better address health inequities has gotten louder. There is now greater attention to of how, in Western settings, medical education has been shaped by patriarchal and colonial histories and values which has led to institutional cultures and educational content that confers privilege on certain people and certain kinds of knowledge [48]. For example, sexism and other forms of discrimination persist within medicine, with medical curricula often assuming a ‘standard patient’ norm that underrepresents the experiences of diverse groups such as racial and ethnic minorities and people with disabilities [63].
Promisingly, medical schools are making increasing commitments to EDI which include: mandating implicit bias training, offering courses focused on the social and structural determinants of health, and better engaging with underrepresented groups within community practice. Below we describe how intersectionality can inform such initiatives in ways that better promote equity, diversity, and inclusion for all. For each initiative, we provide sample guiding questions that facilitate an intersectionality informed approach.
4.1 Intersectionality requires critical self-reflection
Examining potential biases within health professional education and development
UB training has been deemed a critical step for health care professionals to move toward greater awareness of how discrimination and inequities are reproduced. However, such trainings tend to promote a superficial awareness of individually-held beliefs or stereotypes, rather than explore the relationships between one’s biases and broader power dynamics [65, 66]. In this, both the problem of focus (an individual’s lack of awareness) and the solution (improving awareness) remain at the individual level, rather than on the systems and structures that perpetuate biases and inequities. Not surprisingly then, although UB training has shown some success in changing the beliefs and actions of individuals [67, 68, 69], it has also been shown to potential reinforce discriminatory or othering perceptions [70], and a there is a lack of evidence linking it to a reduction of inequities within organizations and systems—both for health care workers and the patient populations they serve [66, 71, 72, 73].
Given the acknowledged limits of UB training, greater focus has been paid to enhancing its attention to power dynamics with critical approaches including cultural humility, cultural safety, decolonization, and structural competence. Within these discussions, more attention has been paid to intersectionality, particularly its central tenet of reflexivity which entails critical reflection on how one is situated within power dynamics and how this influences their beliefs and practices. Assessing how individuals and organizations are implicated in broader processes of oppression is particularly important in the field of medical education, where dynamics of historical and institutional power including colonization, racism, and ableism receive insufficient attention [74, 75, 76].
Reflexivity is essential at the outset and throughout any intersectionality-informed process, prompting exploration of how one’s identity and experiences of advantage and disadvantage have shaped how they think and behave, including their potential biases. Integrating reflexivity into unconscious bias training can help contextualize bias within a broader analysis of power, as seen in these reflexive questions for health care providers:
How do my experiences of advantage or disadvantage related to social and structural locations and processes (e.g., age, race, religion, ethnicity, gender, colonialism, capitalism) influence how I see or do my work?
How has my education, training, and work experience, including access to professional networks and leadership opportunities, relate to or account for privilege?
Which kinds of evidence, tools, and analyses have I prioritized and engaged with? Do these reflect the perspectives, knowledge, and health-relevant needs of diverse groups?
Who is on my work team? Do they share the knowledge or lived experiences of the communities we serve? Are power relationships within the team or between me and my patients recognized?
What is the mission and related priorities of my organization? (e.g., target issues, populations, interventions) What values and assumptions have underpinned these priorities? What broader level factors (e.g., systems, sociopolitical conditions, and institutions) underpin these priorities?
(Questions adapted from guiding questions in Hankivsky and colleague’s
Reflexivity can help broaden the scope and impact of unconscious bias trainings, particularly when it becomes integrated into ongoing professional development processes rather than a one-off event that may only skim the surface of power concerns. Importantly, it can foster critical consciousness among health professionals as to how their positionalities are inextricable from how they do their work, and most importantly, allows for potentially harmful and exclusionary views and practices to be better recognized, understood, and challenged [74, 78]. It can also prompt learners to appreciate the limits of their knowledge while contributing to a more comprehensive sense of professional identity for themselves, as well as gain insight into the complex identities of the individuals they serve [52, 79]. On the whole, reflexivity is considered an essential precursor to understanding and gaining insights from education focused on the social and structural determinants of health [80].
4.2 Intersectionality makes structural forces visible
Beyond supporting critical reflection, intersectionality pays explicit attention to the structural contexts of health and health outcomes. Medical education has long been critiqued as insufficiently attending to the social, structural, and historical contexts of population health, which can inadvertently teach that certain health issues and illnesses are problems of particular populations rather than produced within complex socio-structural contexts [63]. These reductive understandings can lead to reductive limited understandings of and approaches to addressing patient diversity in medical practice. Intersectionality is deemed essential to widen the scope of dominant medical education models to reposition the causes and remedies for ill health as including but not limited to health systems [52, 81].
EDI initiatives in the health field often emphasize the importance of better engaging with and meeting the needs of marginalized and underserved communities such as Black, Indigenous, and LGBTQI populations [82, 83]. An intersectional approach in medical education can facilitate this, by broadening the common focus on the health needs or risks of assumedly homogenous categories of people toward illuminating the interconnections between the biological and structural. In the US, for example, Black populations disproportionately experience poorer health than white populations, and are regularly treated differently than white people in ways that are less attentive, respectful, effective, prompt, or thorough [84, 85]. A 2020 survey showed that seven in ten Black Americans said the health care system treats patients unfairly based on their race or ethnicity and medical mistrust is persistent barrier to care [86]. This inequitable treatment and mistrust is particularly prevalent for racialized groups who experience intersecting forms of marginalization [87, 88].
Yet despite these trends, many initiatives that have sought to reduce barriers to health care and foster trust in medicine among Black people and other marginalized communities have been narrow in scope, perpetuating a commonly conceived stereotype of mistrust as a ‘cultural’ characteristic of particular populations [85, 89]. Promisingly, the focus in medical education has begun to move beyond individual-level factors, toward a more multilevel look at population health with critical attention to structural issues, including discriminatory policies, and the historical harms perpetuated by the medical system [85, 90]. Intersectionality-informed medical education and training can aid in this shift, helping students and providers better reframe health differences as not a problem of individuals but a symptom of multi-level interacting factors.
Integrating critical consideration of the intersecting drivers of health in medical education can allow for current and future health care providers to better understand, communicate with, and meet the needs of their patients. Examples of questions that promote such reflection within educational content for medical students can include:
Does the learning material and guidance account for the experiences of diverse groups? For example, are factors including gender, race, disability, Indigeneity, or sexuality and their relationship to health and health care reflected in the materials? Which factors aren’t discussed and what blind spots can this create? Are these factors discussed in relation to each other, and to systemic forms of oppression and advantage?
What health-relevant problems/topics does the curriculum tackle? How have representations of these ‘problems’ come about? Who has defined the problem? Whose perspectives have been overlooked and why? How might diverse populations be differently affected by this problem? Does the curriculum account for these differences or the structures that influence them?
Has there been acknowledgement or space to reflect on the limits or tensions inherent in medical education in relation to historical power dynamics? For example, has the exclusion of Indigenous knowledge systems from Western medical models been identified as a problem to be addressed? Has the role of the medical system in perpetuating processes of exclusion and discrimination for diverse groups been discussed?
Are diverse perspectives and geographies (esp. from countries and populations that are the subject of study) reflected in the learning content (e.g., reading list and guest speakers)? Are other forms of expertise—including ‘embodied expertise’ derived from lived experiences of oppressions—acknowledged or utilized?
(Adapted from Hankivsky et al.’s
Critical attention to the structural intersections of health in medical education is necessary, particularly when the experiences and perspectives of groups who disproportionately experience mistrust, discrimination, and health inequity continue to be overlooked in medical contexts [88, 92, 93]. When the health issues and affected groups continue to be looked at in uncritical or reductive ways, the unique needs of patients will be insufficiently understood, potentially reinforcing relations of discrimination, particularly for those experiencing multiple forms of disadvantage.
4.3 Intersectionality prioritizes engagement of those most affected
In order to truly attend to the needs of diverse populations, EDI planning and related policies need to be informed by members of groups that are often underrepresented in health policy processes and decision making [31]. Within the field of medical education, there has been a push toward greater inclusion of diverse groups, as patients, as medical students, and within the medical workforce. Some medical schools, for example, are introducing community-based learning experiences to expose students to diverse patient populations and improve understanding of the unique needs of underserved communities [94, 95].
An intersectional approach prioritizes community engagement and the inclusion of diverse forms of knowledge, particularly in relation to those most affected by any particular policy issue or process. Specifically, this approach highlights how the voices of people experiencing interacting forms of oppression and disadvantage have been the least heard and considered, including within medical research, education and decision making. Groups who experience discrimination, such as sexism, racism, colonialism, cis-normativity, heterosexism, ableism, and poverty, experience disproportionate health burdens, are often targets for health interventions, yet are underrepresented in health care-relevant processes and decision making [96].
This issue has been noted in critiques of EDI initiatives that seek to better serve certain marginalized groups. For example, health professional training focused on improving care for diverse groups is often not informed or evaluated by marginalized groups, or measured for impact based on group health outcomes. Correspondingly, there is limited evidence on the effectiveness of such training on promoting quality, non-discriminatory care [97, 98, 99]. Importantly, meaningful involvement of diverse populations in evaluating the effectiveness and impact of equity promoting health education interventions is now on the increase [100, 101].
Similarly, strides have been made in expanding the purview of EDI frameworks for health equity beyond a common focus on internally driven processes in health settings toward a more explicit focus on patient and community engagement [91, 102, 103]. For example, one family health team’s
Where possible, does the educational initiative specifically engage patients in local contexts that experience intersecting forms of marginalization?
Where possible, does the educational initiative adequately consider:
Methods to capture and report on data related to equity and the social determinants of health.
Engagement with community partners and stakeholders who are also doing work to improve health, well-being, and health equity in the community.
Ways to inform and co-design the initiative with people with lived experience—are local needs driving this?
Where possible, does the design of the initiative consider barriers to engagement, including precarious housing, financial difficulties, or care coordination?
Where possible, does the initiative engage diverse patient groups including Indigenous, racialized (particularly Black), immigrant and refugee, 2SLGBTQIA+, disabled, homeless & precariously housed, and drug-using populations, inside and outside of family health team practices?
Adapted from Upadhya-O’Brien and Janssen’s
It is important to note, that working toward EDI in medical education that is informed by engagement with diverse groups must explicitly counter the historical tendency in health research policy and practice tokenistic and often harmful engagement practices that have not prioritized the voices or needs of multiply marginalized groups. Priority must also be placed on the meaningful engagement and expertise of people who may be excluded or underrepresented in their communities. Incorporating intersectionality in engagement processes can help ensure that processes of disadvantage for those engaged are not reinforced. For example, it can help capture and contextualize community inputs and live experiences in ways that move beyond medicalized and deficit models of marginalized patient populations requiring intervention [104, 105]. In this, intersectionality helps move the focus beyond groups or individuals considered to be targets of support or change, toward transforming institutional and organizational structures and ways of working to foster equity and inclusion.
5. Recommendations
With EDI being increasingly taken up within medical education and beyond, it is now recognized as a necessary tool toward creating equitable, diverse, and inclusive environments that help improve health equity [106, 107]. Given the recognized critiques and limitations of EDI to date, and growing misinformation and backlash around what it is and what it does, a critical intersectionality-informed approach is pressing. This work needs to ensure that both intersectionality and EDI initiatives do not become appropriated in policy processes in ways that ignore their social justice origins and imperative. More explicitly, consistent attention to the principles underpinning intersectionality as illustrated in our case example—integrating reflexivity, attending to systems and structures, and prioritizing meaningful engagement—is critical to ensure this.
Moving forward, we recommend that efforts to take up EDI are transparent from the beginning around their goals and objectives for EDI, and define why and how a critical approach such as intersectionality can help reach them. This can counter the common tendency for commitments to be made to EDI without demonstrating why it is important and what it entails [53]. It is also important for EDI initiatives to be clear about what they can and cannot accomplish, how they plan to get there, and strategies they will use to overcome possible barriers, in order to avoid watering down their potential for meaningful change [33]. These efforts can benefit from looking to promising guidance in intersectionality-informed EDI such as those presented in the case example, and taking up such guidance in ways that reflect the needs, perspectives, and contexts of the people involved and impacted. As a recent expert report underscores, EDI needs to be seen as both relevant, actionable, and grounded in the everyday to get the public buy-in it requires to make meaningful change [1].
6. Conclusion
Intersectionality is a promising approach to harnessing the potential of EDI toward the promotion of health equity. However, intersectionality-informed EDI policy initiatives are but one piece of a larger project toward social justice. UB trainings for health care providers for example cannot change historically engrained discriminatory structures. However, these efforts, such as those being developed in the field of medical education, can help change behaviors and mindsets of health stakeholders, impacting for example how provider related to each other and their patients in ways that foster equity. Importantly, improved understanding of how intersecting inequities manifest and possible sites of intervention can contribute to greater commitment, advocacy, and collaboration across diverse stakeholders around the promotion of health equity and social justice.
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Notes
- Other dominant variations of the acronym EDI are Equality, Diversity and Inclusion, and Diversity, Equity and Inclusion (DEI) with most websites and articles not providing a rationale for using either variation. Some organizations and EDI practitioners explicitly justify using EDI vs. DEI as a way to place more attention on equity [1, 2, 3]. A recent scoping review found EDI to be the most prevalent term used in academic literature [4]. Some initiatives use D&I specifically. Other versions of EDI highlight additional dimensions to consider, including Equity, Diversity, Inclusion and Accessibility (EDIA), Equity, Diversity, Inclusion and Decolonization (EDID), EDIB (which adds "belonging"), justice, equity, diversity, and inclusion, etc. In this chapter, we use the acronym EDI and focus on overall trends across the EDI landscape.
- Canadian Institute of Health Research Project Grant (PJT-180461, 2022–2026) on which Co-Author Hankivsky is the Primary Applicant. The scoping review component of the project draws upon a methodological approach [25, 26] which is rigorous and well suited to capture a comprehensive range of peer reviewed and gray literature in research and policy [27, 28]. We also drew upon current expert-informed protocol and a criteria checklist for conducting scoping reviews [29, 30].