Comment
20 Gracia E, Merlo J. Intimate partner violence against women and the
Nordic paradox. Soc Sci Med 2016; 157: 27–30.
21 Bonsang E, Skirbekk V, Staudinger UM. As you sow, so shall you reap:
gender-role attitudes and late-life cognition. Psychol Sci 2017; 28: 1201–13.
22 Chen YY, Subramanian SV, Acevedo-Garcia D, Kawachi I. Women’s status
and depressive symptoms: a multilevel analysis. Soc Sci Med 2005;
60: 49–60.
23 Van de Velde S, Huijts T, Bracke P, Bambra C. Macro-level gender equality
and depression in men and women in Europe. Sociol Health Illness 2013;
35: 682–98.
Intersectionality and why it matters to global health
Leaving no one behind—a cornerstone of the Sustainable
Development Goals (SDGs) agenda—represents a shift
in thinking and enquiring about and tackling global
challenges. However, to achieve the ambitious global
health goals laid out in the SDGs, new ways to understand
the complex nature of health inequities, especially
among the most vulnerable populations around the
world, are required.
Increasingly, intersectionality is seen as a promising
approach to the analysis of multifaceted power struc­
tures and processes that produce and sustain unequal
health outcomes.1–4 Intersectionality emerged from
several theories—black feminist, Indigenous feminist,
third-world feminist, queer, and postcolonial—and was
first coined by American sociologist Kimberlé Crenshaw
in 1989.5 Intersectionality moves beyond examining
individual factors such as biology, socioeconomic
status, sex, gender, and race. Instead, it focuses on the
relationships and interactions between such factors, and
across multiple levels of society, to determine how health
is shaped across population groups and geographical
contexts.
This approach achieves two crucial aims. First, it brings
attention to important differences within population
groups that are often portrayed as relatively homogenous
such as women, men, migrants, Indigenous peoples,
and visible minorities.6 For example, it gives rise to
an understanding that a white woman from a lower
socioeconomic group might be penalised for her gender
and class when accessing health and social care but
has the relative advantage of race over a black woman.
These different aspects inform each other and are not
experienced separately. Second, it sheds light on the
fact that individual and group inequities are shaped by
interactions between multiple sites and levels of power:
institutions such as families, governments, laws, and
www.thelancet.com Vol 391 June 30, 2018
24 McLaughlin KA, Xuan Z, Subramanian SV, Koenen KC. State-level
women’s status and psychiatric disorders among US women.
Soc Psychiatry Psychiatri Epidemiol 2011; 46 1161–71.
25 Kawachi I, Kennedy BP, Gupta V, Prothrow-Stith D. Women’s status and
the health of women and men: a view from the States. Soc Sci Med 1999;
48: 21–32.
26 Flood M, Dragiewicz M, Pease B. Resistance and backlash to gender
equality: an evidence review. Brisbane: Crime and Justice Research Centre,
Queensland University of Technology, 2018.
policies; structures of discrimination such as sexism,
ableism, and racism; and broader processes of globalisation
and neoliberalism. The goal of an intersectionality-
informed analysis is to map health inequities with more
precision and then to chart more effective directions in
policy and programme development.
To illustrate the added value of inter­sectionality, we
consider two global health issues prioritised on the
SDGs agenda: cardiovascular disease and migration.
Cardiovascular disease is the leading cause of death
globally, and differences in its distribution and risk by
geography, socioeconomic status, race or ethnicity,
and sex are well documented. Such factors have often
been researched individually, with less attention to
within-group differences in terms of aetiology, onset,
trajectory, health-seeking, and outcomes across
differentially situated women and men. A recent study7
showed that although cardiovascular disease death
rates have declined considerably over the past 10 years
globally, there are stronger age-specific reductions in
rates for men than for women.
An intersectionality lens builds on this type of analysis
by advancing an approach that systematically exam­
ines various factors affecting cardiovascular disease
simul­taneously, bringing attention to the synergistic
effects of heterogeneous risk factors and experiences.8,9
For example, Indigenous populations in Canada
experience a disproportionate and growing burden of
cardiovascular disease compared with non-Indigenous
Canadians due to a unique combination of factors
including lower average socioeconomic status, higher
levels of alcohol and drug addiction, higher prevalence
of mental health issues including trauma, inadequate
infrastructure for physical activity, and greater barriers
to accessing or receiving health services.10 This burden
will in turn be experienced differently by Indigenous
2589
 Comment
Panel: How to incorporate intersectionality analyses into global health research
There is no single way to approach intersectionality and no preferred method. However,
there are some fundamental questions that researchers could ask at each stage of the
research process. Researchers need to also be self-reflexive throughout, by considering
how their own social positioning shapes how they approach the examination of any
research question in global health.
Conceptualising the research
What and who are being studied, who is being compared to whom, and why (ie, what
assumptions underlie these choices)? What new issues of disadvantage, privilege, and
resistance or agency are addressed by the research?
Designing the study
Is there adequate information on aspects of social location of the study population (eg,
disaggregated by sex, ethnicity, class, and other categories of relevance) and processes
that might determine their health? Do these considerations inform the selection of a
population to capture diversity of experiences? Who is excluded? How will the research
capture dynamic interactions—rather than simple additions—between multiple health
influencing factors?
Interpretation and impact
How will commonalities and differences within and across population groups be
recognised without being reductionistic or universalising categories and cultures? Does
the analysis link interactions at individual levels of experience to social institutions and
processes, broader structures of power, and historical or contemporary patterns of
inequality? What are the implications of the research for reducing inequities and
advancing global health goals?
men and women, and over the lifespan. Furthermore,
the interactional effects of these factors (negative or
protective) vary among Indigenous peoples because
Indigenous populations are made up of distinct nations
characterised by geographical, linguistic, and cultural
differences.11
By providing a more nuanced understanding of
cardiovascular disease across population groups, inter­
sectionality shows why policies and interventions
that target alcohol and tobacco use, unhealthy diets,
and physical inactivity but fail to consider the broader
context that shapes these choices, behaviours, and
specific realities of differently situated groups, can be
ineffective. Returning to the Indigenous example, for
cardiovascular disease interventions to sustainably im­
prove outcomes, they must address broad political and
economic factors including commercial determinants
of health (such as availability and pri­cing of unhealthy
products) alongside interconnected structures of power
(eg, colonialism, racism, and sexism) that influence
Indigenous peoples’ access to adequate housing, food
security, culturally appropriate health and social care, and
self-determination.
2590
As a second example, migration is recognised as a key
determinant of health in an era of deepening globalisation
and growing numbers of people on the move. Migration
is a complex phenomenon. It is well known that the
conditions in which migrants travel, live, and work often
create risks to mental and physical wellbeing.12 However,
these risks are not evenly distributed. They are shaped
by diverse factors and social structures such as gender,
nationality, ethnicity, and class—and its associated
economic and educational privileges—among others,
as well as the migration processes, trajectories, and
laws. Yet research and policy have tended to focus on
specific health events, such as violence or infectious
disease outbreaks, and the particular vulnerabilities of
people within singular administrative or legal categories
(eg, refugees, asylum seekers, farm or labour migrant
workers, or internally displaced people). Such narrow
focus con­ceals differential risks—and occasion­ally
protections—resulting from migrants’ unique social
position and conditions at different stages of their
mobility and settlement.13 For example, among those
fleeing war-ravaged and economically fragile contexts
to seek refuge or asylum in the European Union, young
men from Afghanistan, Pakistan, and North Africa have
met with greater resistance, entry restrictions, violence,
and exploitation at European Union borders than have
refugees from Syria.14,15 Although Syrian refugees share
the threat of racism and institutional barriers in accessing
crucial services, their movement has been facilitated by
more open reception in many countries in Europe as well
as health system reforms to be more responsive to their
needs.
An intersectional lens also highlights the limits of
health-care responses to migration that overemphasise
cultural and ethnic differences of migrants, or that
focus primarily on addressing linguistic and cultural
barriers—ie, by trying to improve cultural competencies
among providers.16 Steps such as these are necessary but
inadequate to address the multilevel factors shaping
health-care provision and use among various migrant
groups, including fear of deportation, xenophobic and
discriminatory attitudes, exclusion or marginalisation
in national health systems, and the experience of
restrictive laws and institutional barriers.12,17,18 In
addressing these factors, an intersectional lens demands
turning away from siloed to more coordinated,
multisectoral strategies across health, immigration,
www.thelancet.com Vol 391 June 30, 2018

humanitarian aid, security, and labour, as well as
attention to its structural roots (such as unemployment,
poverty, and conflict) and sources of protection or
advantage in contexts of transit and destination.
Intersectionality can further the “leave no one be­
hind” agenda by attending to multiple dis­ advantages
(and simultaneous advantages) that underpin exclusion
of certain population groups. The power analysis that an
intersectional approach entails enhances understanding
of not only who is left behind but why and how. Its
application in global health requires greater attention
to intergroup and intragroup differences, specific social
positions (which exist at the crossing of multiple axes of
inequalities), and the wider social processes and macro-
level factors that shape health (panel).
These insights are essential to charting new policy
actions at global and national levels. To realise its full
transformative potential, intersectionality deserves
much more attention and mainstreaming in global
health policy and systems research.
*Anuj Kapilashrami, Olena Hankivsky
Global Public Health Unit, University of Edinburgh, Edinburgh
EH8 9LD, UK (AK); and Institute for Intersectionality Research &
Policy, School of Public Policy, Simon Fraser University, Vancouver,
BC, Canada
anuj.kapilashrami@ed.ac.uk
We declare no competing interests.
1 Hankivsky O, Doyal L, Einstein G, et al. The odd couple: using biomedical
and intersectional approaches to address health inequities.
Glob Health Action 2017; 10: 1326686.
2 Kapilashrami A, Hill S, Meer N. What can health inequalities researchers
learn from an intersectionality perspective? Understanding social dynamics
with an inter-categorical approach? Soc Theory Health 2015; 13: 288–307.
www.thelancet.com Vol 391 June 30, 2018
Comment
3 Bauer GR. Incorporating intersectionality theory into population health
research methodology: challenges and the potential to advance health
equity. Soc Sci Med 2014; 110: 10–17.
4 Larson E, George A, Morgan R, Poteat T. 10 Best resources on…
intersectionality with an emphasis on low- and middle-income countries.
Health Policy Plan 2016; 31: 964–69.
5 Crenshaw K. Demarginalizing the intersection of race and sex: a black
feminist critique of antidiscrimination doctrine, feminist theory and
antiracist politics. Univ Chic Leg Forum 1989; 140: 139–67.
6 Hankivsky O. Women’s health, men’s health, and gender and health:
implications of intersectionality. Soc Sci Med 2012; 74: 1712–20.
7 Bots SH, Peters SAE, Woodward M. Sex differences in coronary heart
disease and stroke mortality: a global assessment of the effect of ageing
between 1980 and 2010. BMJ Glob Health 2017; 2: e000298.
8 Wemrell M, Mulinari S, Merlo J. Intersectionality and risk for ischemic heart
disease in Sweden: categorical and anti-categorical approaches.
Soc Sci Med 2017; 177: 213–22.
9 Shim JK. Heart-sick. The politics of risk, inequality, and heart disease.
New York, NY: New York University Press, 2014.
10 Reading J. Confronting the growing crisis of cardiovascular disease and
heart health among aboriginal peoples in Canada. Can J Cardiology 2015;
31: 1077–80.
11 Prince SA, McDonnell LA, Turek MA, et al. The state of affairs for
cardiovascular health research in Indigenous women in Canada: a scoping
review. Can J Cardiol 2018; 34: 437–49.
12 Wickramage K, Gostin LO, Friedman E, et al. Missing: where are the
migrants in pandemic influenza preparedness plans? Health Hum Rights
2018; published online May 30. https://www.hhrjournal.org/2018/05/
missing-where-are-the-migrants-in-pandemic-influenza-preparedness-
plans
13 Alsaba K, Kapilashrami A. Understanding women’s experience of violence
and the political economy of gender in conflict: the case of Syria.
Reprod Health Matters 2016; 24: 5–17.
14 Tazzioli M. The temporal borders of asylum. Temporality of control in the
EU border regime. Polit Geogr 2018; 64: 13–22.
15 Skodo A. How Afghans became second-class asylum seekers.
The Conversation. Feb 20, 2017. https://theconversation.com/how-afghans-
became-second-class-asylum-seekers-72437 (accessed June 21, 2018).
16 Hollinsworth D. Forget cultural competence: ask for an autobiography.
Soc Work Edu 2013; 32: 1048–60.
17 Suphanchaimat R, Kantamaturapoj K, Putthasri W, Prakongsai P.
Challenges in the provision of healthcare services for migrants: a systematic
review through providers’ lens. BMC Health Serv Res 2015; 15: 390.
18 Van Der Leun J. Excluding illegal migrants in the Netherlands:
Between national policies and local implementation. West Eur Polit 2006;
29: 310–26.
2591
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.