Background: Research consistently shows that colorectal cancer (CRC) screening uptake is socially patterned; however, sociodemographic determinants are usually analysed separately, overlooking how multiple social conditions jointly shape inequalities. This also applies to policy research, where heterogeneity in screening programme effects remains underexplored. Methods: Using data from the European Health Interview Survey (2014 and 2019; n=201,214; 24 countries), we applied Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to analyse CRC screening uptake across 72 subgroups defined by sex, education, living arrangement and employment. To assess heterogeneity in screening programme effects, we combined MAIHDA with difference-in-differences (MAIHDA-DiD). Results: MAIHDA revealed inequalities in uptake: lower- and middle-educated men, whether employed or unemployed, had the lowest uptake, whereas men and women not living alone, retired or living with disability, had the highest uptake. Lower-educated homemaker women were the only female group with below-average uptake. MAIHDA-DiD showed that programmes increased overall uptake but did not produce larger gains among groups with lower pre-intervention uptake, and therefore did not reduce inequalities. Instead, programmes generated above-average increases among groups with higher pre-intervention uptake, particularly lower- and middle-educated men and women not living alone and retired. Living arrangement explained more variation in programme effects than other factors, with individuals living alone benefiting less from the programmes. Conclusion: CRC programmes did not reduce (and may have widened) inequalities, underscoring the need for equity-focused strategies in population-based screening. By extending MAIHDA with difference-in-differences, this study introduces a novel approach for evaluating heterogeneous policy effects in public health.

Alcohol consumption is a major risk factor for death and disability, disproportionately harming disadvantaged groups. While a positive association between interpersonal discrimination and alcohol use is established, structural discrimination's impact remains unclear. We conducted a systematic review of the association between macro-level structural discrimination and alcohol consumption or related health outcomes. We searched four databases and grey literature, identifying 25 eligible studies, which considered racism (n = 11), sexism (n = 7), heterosexism (n = 4), and intersectional discrimination (n = 3). Most considered alcohol consumption (n = 17); fewer addressed harm (n = 4) or both (n = 4). The majority were US-based (n = 21), with four making cross-country comparisons. Associations varied by discrimination type, exposure measurement, alcohol outcome, and sociodemographic factors, though differential effects by sociodemographic factors remain understudied. Most structural racism studies considered segregation as the exposure, but findings were inconsistent, even when grouped by outcome. Emerging evidence suggests increased race-based poverty ratios and incarceration gaps are associated with higher consumption and harm, especially for Black and Hispanic populations. Studies of structural sexism often used composite measures, like state-level gender inequality indices. Evidence suggests that as gender equality increases, women are more likely to drink, while greater structural sexism may be linked to higher rates of risky drinking and alcohol-related mortality. Findings on heavy episodic drinking and drinking frequency were mixed, while associations with volume and quantity were mostly non-significant. The limited available evidence suggests structural heterosexism may be positively associated with high intensity drinking and alcohol use disorders among sexually minoritized groups. The simultaneous impact of multiple forms of structural discrimination remains underexplored. Advancing this field requires consensus on how to operationalize structural discrimination within alcohol studies and greater adoption of intersectional and longitudinal approaches.

BACKGROUND:Prior research has demonstrated substantial inequities in alcohol consumption, alcohol-related harms, and mortality. These inequities arise from a complex interplay of factors, unlikely addressed by single factor analyses or solutions. Conceptual frameworks, such as the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, aim to reflect this complexity and support multifaceted research and action. This paper adapts the NIMHD Framework to focus on alcohol-related inequities and integrate core intersectionality principles. METHOD:We developed the Intersectional Alcohol Inequities Framework (IAIF) through collaboration among leading scholars in alcohol, intersectionality, and policy modelling. In a workshop centred on the core ideas of intersectional frameworks, we identified key factors influencing alcohol consumption and related harms, using the United States as a case study. Using thematic analysis, we grouped the discussion points, then mapped them against the NIMHD Framework. We searched the literature to expand upon workshop insights, iteratively refining the framework until reaching idea saturation. RESULTS:To align with the core ideas of intersectionality, the IAIF introduced new elements absent in the NIMHD Framework, specifically a 'power' domain, a 'historical' level, and emphasis on relationality. We also incorporated a 'digital environment' domain, to reflect an important element of contemporary social context, as previously identified by other health equity scholars. We provided examples of their relevance to alcohol inequities, highlighted practical applications for stakeholders, and discussed adaptability to other public health issues and contexts. CONCLUSIONS:The Intersectional Alcohol Inequities Framework offers a tool for critical dialogue on how various factors, across multiple levels and domains, intersect to influence alcohol-related outcomes. It can provide support and guidance for researchers, facilitate the identification of research needs and gaps in current policies, support the design of new policies and interventions, and inform comprehensive patient management.

Intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) has been welcomed as a new gold standard for quantitative evaluation of intersectional inequalities, and it is being rapidly adopted across the health and social sciences. In their commentary " What does the MAIHDA method explain? " , Wilkes and Karimi (2024) raise methodological concerns with this approach, leading them to advocate for the continued use of conventional single -level linear regression models with fixed -effects interaction parameters for quantitative intersectional analysis. In this response, we systematically address these concerns, and ultimately find them to be unfounded, arising from a series of subtle but important misunderstandings of the MAIHDA approach and literature. Since readers new to MAIHDA may share confusion on these points, we take this opportunity to provide clarifications. Our response is organized around four important clarifications: (1) At what level are the additive main effect variables defined in intersectional MAIHDA models? (2) Do MAIHDA models have problems with collinearity? (3) Why does the Variance Partitioning Coefficient (VPC) tend to be small, and the Proportional Change in Variance (PCV) tend to be large in MAIHDA? and (4) What are the goals of MAIHDA analysis?

Alcohol is one of the leading causes of preventable deaths in the United States (US). Prior research has demonstrated that alcohol consumption and related mortality are socially patterned; however, no study has investigated intersectional disparities in alcohol consumption, i.e., attending to how social positions overlap and interact. In this study, we used an innovative intersectional approach (Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy, MAIHDA) and data from a large nationally representative survey (the National Health Interview Survey, 2000-2018) to quantify inter-categorical disparities in alcohol consumption in the US (proportion of current drinkers, and average consumption amongst drinkers), along dimensions of sex, race and ethnicity, age, and level of education. Our analysis revealed significant intersectional disparities in both the prevalence of drinking and the average consumption by drinkers. Young, highly educated White men were the most likely to be current drinkers and consumed the highest amounts of alcohol on average, whilst racially and ethnically minoritized women with lower education were the least likely to drink and had the lowest levels of alcohol consumption, across all age categories. Notably, we found significant interaction effects for many intersectional strata, with much higher consumption estimated for some groups than traditional additive approaches would suggest. By identifying specific understudied groups with high consumption, such as young American Indian or Alaska Native (AI/AN) men, adult Black men with low education, and older White women with high education, this analysis has important implications for future research, policy, and praxis. This is the first known application of MAIHDA to account for a skewed outcome, highlighting and addressing critical methodological considerations.

OBJECTIVES:Attempts to reduce health inequities in England frequently prioritise some equity dimensions over others. Intersectionality highlights how different dimensions of inequity interconnect and are underpinned by historic and institutionalised power imbalances. We aimed to explore whether intersectionality could help us shed light on young adults' understanding of health inequities. STUDY DESIGN:The study incorporatedqualitative thematic analysis of primary data. METHODS:Online focus groups with young adults (n = 25) aged 18-30 living in three English regions (Greater London; South Yorkshire/Midlands; North-East England) between July 2020 and March 2021. Online semistructured interviews (n = 2) and text-based communication was conducted for participants unable to attend online groups. RESULTS:Young adults described experiencing discrimination, privilege, and power imbalances driving health inequity and suggested ways to address this. Forms of inequity included cumulative, within group, interacting, and the experience of privilege alongside marginalisation. Young adults described discrimination occurring in settings relevant to social determinants of health and said it adversely affected health and well-being. CONCLUSION:Intersectionality, with its focus on discrimination and identity, can help public health stakeholders engage with young adults on health equity. An upstream approach to improving health equity should consider multiple and intersecting forms of discrimination along with their cultural and institutional drivers.

Ethnic diversity and racism have not featured strongly in English research, policy or practice centred on understanding and addressing health inequalities. However, the COVID-19 pandemic and the Black Lives Matter movement have shone fresh light on deep-rooted ethnic inequalities and mobilised large segments of the population into anti-racist demonstration. These recent developments suggest that, despite strong counterforces within national government and the mainstream media, there could be a shift towards greater public awareness of racism and potentially a willingness to take individual and collective action.This paper addresses these developments, and specifically engages with the contested notion of 'allyship'. We bring together the experiences of 25 young adults living across England and prior literature to raise questions about whether and how racialized White individuals can play a role in dismantling systemic racism and reducing ethnic inequalities in health. Our analysis reveals a variety of complexities and obstacles to effective and widespread allyship. Findings suggest the need to nurture contingent, responsive and reflexive forms of allyship that can attend to the harms inflicted upon racially minoritized people as well as push for systemic transformation.White allyship will need to take a variety of forms, but it must be underpinned by an understanding of racism as institutional and systemic and a commitment to tackling interlocking systems of oppression through solidarity.The issues addressed are relevant to those occupying public health research, policy and practice roles, as well as members of the public, in England and other multi-racial settings.

Our research focuses on human-robot interaction (HRI) during life-or-death emergencies. We have developed an immersive virtual reality (VR) testbed because conducting real-world crisis simulations would pose prohibitive logistical difficulties, as well as to leverage the affordances of VR technology to measure motor behavior (e.g., distance maintained between self and robot), information foraging (e.g., as indexed by headset movement variability and eyetracking), or autonomic arousal (e.g., as indexed by shifts in pupil dilation or grip strength). Findings to date using minimally haptic VR confirm that participants treat the simulated active-shooter crisis seriously, and act in ways which validly mirror prior studies of real-world HRI under threat. We will describe these methods, including our manipulation of robot anthropomorphism and our current move to integrate full-body haptics to maximize both experiential immersion and incentives to avoid pain.

This paper describes our recent effort to use virtual reality to simulate threatening emergency evacuation scenarios in which a robot guides a person to an exit. Our prior work has demonstrated that people will follow a robot's guidance, even when the robot is faulty, during an emergency evacuation. Yet, because physical in-person emergency evacuation experiments are difficult and costly to conduct and because we would like to evaluate many different factors, we are motivated to develop a system that immerses people in the simulation environment to encourage genuine subject reactions. We are working to complete experiments verifying the validity of our approach.

Background: Intersectionality theory posits that considering a single axis of inequality is limited and that considering (dis)advantage on multiple axes simultaneously is needed. The extent to which intersectionality has been used within interventional health research has not been systematically examined. This scoping review aimed to map out the use of intersectionality. It explores the use of intersectionality when designing and implementing public health interventions, or when analysing the impact of these interventions. Methods: We undertook systematic searches of Medline and Scopus from inception through June 2021, with key search terms including “intersectionality”, “interventions” and “public health”. References were screened and those using intersectionality and primary data from high-income countries were included and relevant data synthesised. Results: After screening 2108 studies, we included 12 studies. Six studies were qualitative and focused on alcohol and substance abuse (two studies), mental health (two studies), general health promotion (one study) and housing interventions (one study). The three quantitative studies examined mental health (two studies) and smoking cessation (one study), while the three mixed-method studies examined mental health (two studies) and sexual exploitation (one study). Intersectionality was used primarily to analyse intervention effects (eight studies), but also for intervention design (three studies), and one study used it for both design and analysis. Ethnicity and gender were the most commonly included axes of inequality (11 studies), followed by socio-economic position (10 studies). Four studies included consideration of LGBTQ+ and only one considered physical disability. Intersectional frameworks were used by studies to formulate specific questions and assess differences in outcomes by intersectional markers of identity. Analytical studies also recommended intersectionality approaches to improve future treatments and to structure interventions to focus on power and structural dynamics. Conclusions: Intersectionality theory is not yet commonly used in interventional health research, in either design or analysis. Conditions such as mental health have more studies using intersectionality, while studies considering LGBTQ+ and physical disability as axes of inequality are particularly sparse. The lack of studies in our review suggests that theoretical and methodological advancements need to be made in order to increase engagement with intersectionality in interventional health.

While social and spatial determinants of biomarkers have been reported, no previous study has examined both together within an intersectional perspective. We present a novel extension of quantitative intersectional analyses using cross-classified multilevel models to explore how intersectional positions and neighbourhood deprivation are associated with biomarkers, using baseline UK Biobank data (collected from 2006 to 2010). Our results suggest intersectional inequalities in biomarkers of healthy ageing are mostly established by age 40-49, but different intersections show different relationships with deprivation. Our study suggests that certain biosocial pathways are more strongly implicated in how neighbourhoods and intersectional positions affect healthy ageing than others.

Background: The concept of ‘intersectionality’ is increasingly employed within public health arenas, particularly in North America, and is often heralded as offering great potential to advance health inequalities research and action. Given persistently poor progress towards tackling health inequalities, and recent calls to reframe this agenda in the UK and Europe, the possible contribution of intersectionality deserves attention. Yet, no existing research has examined professional stakeholder understandings and perspectives on applying intersectionality to this field. In this paper we seek to address that gap. Methods: drawing upon a consultation survey and workshop undertaken in the UK. The survey included both researchers (n=53) and practitioners (n=20) with varied roles and levels of engagement in research and evaluation. Topics included: familiarity with the term and concept ‘intersectionality’, relevance to health inequalities work, and issues shaping its uptake. Respondents were also asked to comment on two specific policy suggestions; targeting and tailoring interventions to intersectional sub-groups, and evaluating the intersectional effects of policies. 23 people attended the face-to-face workshop. The aims of the workshop were to: share examples of applying intersectionality within health inequalities research and practice; understand the views of research and practice colleagues on potential contributions and challenges; and identify potential ways to promote intersectional approaches Results: Findings indicated a generally positive response to the concept and a cautiously optimistic assessment that intersectional approaches could be valuable. However, opinions were mixed and various challenges were raised, especially around whether intersectionality research is necessarily critical and transformative and, accordingly, how it should be operationalised methodologically. Nonetheless, there was general agreement that intersectionality is concerned with diverse inequalities and the systems of power that shape them. Conclusions: In the UK health inequalities policy and practice context there are a number of potential ways forward for intersectionality in helping to understand and tackle such inequalities.

Intersectionality has received an increasing amount of attention in health inequalities research in recent years. It suggests that treating social characteristics separately-mainly age, gender, ethnicity, and socio-economic position-does not match the reality that people simultaneously embody multiple characteristics and are therefore potentially subject to multiple forms of discrimination. Yet the intersectionality literature has paid very little attention to the nature of ageing or the life course, and gerontology has rarely incorporated insights from intersectionality. In this paper, we aim to illustrate how intersectionality might be synthesised with a life course perspective to deliver novel insights into unequal ageing, especially with respect to health. First we provide an overview of how intersectionality can be used in research on inequality, focusing on intersectional subgroups, discrimination, categorisation, and individual heterogeneity. We cover two key approaches-the use of interaction terms in conventional models and multilevel models which are particularly focussed on granular subgroup differences. In advancing a conceptual dialogue with the life course perspective, we discuss the concepts of roles, life stages, transitions, age/cohort, cumulative disadvantage/advantage, and trajectories. We conclude that the synergies between intersectionality and the life course hold exciting opportunities to bring new insights to unequal ageing and its attendant health inequalities.

Since the early 1990s, the European service sector has been growing and employment in this sector has risen. Within the service sector the Health and Care Sector (HCS) plays a dominant role – as part of the social protection system but also in economic terms. Against this background, the HCS has particular relevance: it is not only the ageing of society that is responsible for a rising demand of care workers, but also changing family and household structures as more persons are living alone and depend on professional or informal care (Schulz & Radvanský 2014: Schulmann, Reichert & Leichsenring 2019).

The UK health system must take urgent action to better understand and meet the health needs of migrants and ethnic minority people, say Sarah Salway and colleagues