The time for social justice in research and higher education, it seems, is now. Many countries, including Canada, the United Kingdom, Australia, and the United States of America, adopted comprehensive national initiatives to promote equity in higher education with the goal of “deeper cultural change within the research ecosystem” [1–4]. Research funders and universities have employees, departments, and strategic plans dedicated to equity, diversity and inclusion (EDI) and variations on this phrase.Footnote 1 While there is a new sense of urgency, this moment is embedded in an ongoing history of interventions from feminist and women’s studies scholars who call upon researchers to include gender as a category of analysis [5, 6], and perhaps more difficult, for institutions and academic fields to include women as researchers and producers of knowledge [7]. There are parallel efforts addressing the inclusion of people of African/Black descent, people of color, people with disabilities, diverse gender identities, Indigenous people, and additional groups who are historically marginalized in higher education and research settings.Footnote 2
In the context of team-based health research, competitive funding supports large scale, high impact studies and is used as a key metric for individual career progression. The transformative EDI initiatives cited above acknowledge the importance of funding in academia and seek to redress systematic biases in research award allocations. A study looking at research funding gaps at the Canadian Institutes of Health Research found gender disparities related to “less favorable assessments of women as principal investigators" [8]. Notably the authors of the study were not able to analyze based on race or other relevant characteristics due to lack of data collection by the funding agency at that time [8]. In 2011, a landmark review of the National Institute of Health Research (USA) found “applications from white Principal Investigators (PIs) were 1.7 times more likely to be funded than applications from African-American/Black PIs” [9]; in 2019, this disparity still existed [10, 11]. There is a stark funding divide between research teams in the global north compared to those in the global south [12]. Yet, despite these documented gaps in research funding, it is also recognized that diverse research teams lead to more innovative research [13] and research that is more sensitive to the needs of equity-seeking communities [14].
In tandem with growing recognition of systematic bias in funding allocations, major health research funders call for research that focuses on equity topics [15–19]. The growing interest in equity-oriented projects is laudable, but also leads to an influx of established researchers tackling the topic for the first time. Researchers describe a phenomenon dubbed “health equity tourism” [20], where (white) high impact researchers from other fields successfully apply to health equity funding opportunities building on their previous funding track record, producing research with easily avoidable mistakes. As Lett et al. explain, studying issues such as structural racism requires a careful, nuanced approach and collaboration with people with lived experience, and health equity “tourists” can incorrectly assume that their conventional research methods are transferable to this context [21]. The resulting studies fail to capture the complexity of racial disparities, do not produce meaningful or actionable results, and may even risk perpetuating racial stereotypes and biases. Similarly, Smith et al. 2018 argue health equity is too often divorced from social justice aims and focuses more on “proximal” disparities rather than structural drivers [22]. Some scholars argue that institutions and individuals tend to undertake EDI work in a performative manner, without actually confronting systemic causes of inequity and exclusion within their structures [23, 24].
In response to the growing demand for equity research balanced with the problem of health equity tourism, this commentary is geared at principal investigators and health research teams who are developing research proposals and want to consider equity issues in their research, perhaps for the first time. In particular, we distinguish three commonly used concepts: intersectionality, health equity, and EDI. We offer guidance for interdisciplinary health research teams at the conceptualization stage of their research projects and when deciding among these approaches. We present the history and definitions of each term and summarize key differences, similarities, and considerations for use. In the context of research, intersectionality is a methodology (a combination of epistemology and techniques) that can identify the relationships among individual identities and systems of oppression. Intersectionality typically includes an explicit commitment to social justice and is a common paradigm mobilized in grassroots activist settings. Health equity is a societal goal. As a research framework, health equity operationalizes the social determinants of health to document and address health disparities at the population level. EDI initiatives measure and track progress towards “diversity” within organizations or teams and are best suited to inform the infrastructure and human resourcing “behind the scenes” of a project. We encourage researchers to consider these definitions and strive to tangibly move health research towards equity both in the topics we study and in the ways we do research.
Defining intersectionality
Intersectionality posits that individual identities and social locations such as gender, race, and class intersect and reflect systems of oppression such as sexism and racism [25]. Intersectionality is attributed to critical race theorist and feminist legal scholar Kimberlé Crenshaw [25] and the activism of the Black, feminist, and lesbian Combahee River Collective (1977). In the late 1970s, these and other Black feminist activists and scholars, were excluded from both the women’s movement and the anti-racist movement [26, 27]. It is integral to reference this history when using intersectionality as the contributions of Black women scholars are often erased through abstraction. The overlap of multiple identities, or intersections, represent unique experiences that are overlooked by focusing on one identity over another [28]. As such, intersectionality helps explore differences within and among groups. Intersectionality typically includes an explicit commitment to social justice—that is, an aim to redistribute wealth, opportunities, and privileges at a societal level [29]. Achieving social justice would require a dramatic re-orientation of contemporary institutions, laws, and economic systems.
Intersectionality suggests that privilege and oppression shift based on context, and thus one may be privileged in one context but disadvantaged in another. For example, while all women may be subject to discrimination based on gender, Black women have distinct experiences of sexism and racism. Intersectionality is a successful theoretical and activist intervention. It is a core orientation in women’s and gender studies, remains commonly used as a paradigm in activist groups, is cited as a theoretical approach in many empirical studies [30–32], and is a focal point for high-level theorizing [33, 34]. It is so successful that there are concerns that it may be a “buzzword” [35, 36].
In the context of health research, intersectionality shares affinities with other ideas from feminist methodologies and these perspectives are often gathered through qualitative research. For example, standpoint epistemology argues that people in the margins have clearer knowledge about structures of oppression than those at the centers, and so foregrounds marginalized voices [26, 37]. Intersectionality requires researchers to be reflexive of their own social locations and state a theoretical orientation (rather than attempt to control for bias) in protocols and publications [38]. Reflexivity applies to the entire research process, including the formation of the team, hiring, and recruitment of participants. There are also efforts to develop intersectionality measures to be used in survey research [39–42]. However, intersectionality loses its historical connection when used only as a method in data collection/analysis rather than as a comprehensive methodology incorporating reflexivity on behind the scenes research processes [43]. That is, teams “using” intersectionality in their research must also “do” intersectionality through practices such as self-identification questionnaires to ensure diversity on the team, providing additional mentorship or opportunities to students and scholars who may face barriers in academia, and cultivating an awareness of bias and discrimination that can be perpetuated through research [44].
Defining health equity
Health equity is a societal goal of global and public health research and practice, seeking to eliminate unjust health disparities at the population level that are shaped by the social determinants of health [45]. The World Health Organization (WHO) describes: “Health equity is achieved when everyone can attain their full potential for health and well-being” [46]. Historical research traces the concept of health equity back as far as 1801, and the 1948 constitution of the WHO formally endorsed elements of the contemporary concept [47]. Health equity gained momentum and an explosion of interest in the 1990s following Marmot’s highly influential work on the social determinants of health [48–50], that is “non-medical factors that influence health outcomes” [51]. Research framed with the social determinants of health has generated a significant technical evidence base that documents health disparities within and between populations through the use and creation of local, national and international health datasets [51].
In 2008, the WHO Commission on Social Determinants of Health outlined three principles of action required to achieve health equity: i) improve the conditions of daily life, ii) tackle structural drivers of health, that is the inequitable distribution of power, money, and resources, and iii) measure and evaluate outcomes [52]. The second action resonates with the definition of social justice mobilized in intersectionality, but this area of action proves the most difficult to apply in the context of health research. Braveman recently posited a complete definition of health equity that emphasizes structural drivers and social justice:
“Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, powerlessness, and their consequences—including lack of access to good jobs with fair pay, safe environments, and quality education, housing, and health care. For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” [53].
As with intersectionality, surging popularity has led to some confusion. Specifically, not all measured differences in health outcomes qualify as health disparities, which refers to differences in health outcomes that occur among populations who are economically and/or socially disadvantaged [54]. Populations who systematically and persistently experience disadvantage include people from lower socio-economic backgrounds, racial or ethnic populations, women, Indigenous groups, and 2SLGBTQIA+ people. In a global health context, disadvantaged populations may also refer to the entire population of a low-income country.
Defining equity, diversity, and inclusion
Equity, diversity, and inclusion (EDI) is a policy-focused initiative aimed at addressing the ongoing exclusion of under-represented groups in employment, education, and other institutional contexts. EDI emerged out of the American Civil Rights Movement in the 1960s as a “response to deeply entrenched patterns of racial discrimination” [55]. Early iterations emphasized increasing the numbers of people from groups that have been disadvantaged in the workplace [55]. While the policy context and development of EDI varies from country to country, it is generally recognized that the terms equity and diversity replace previous discourses of ‘affirmative action’, ‘equal opportunity’ and ‘employment equity’ in human resource policies [56, 57]. Further, EDI takes up the shortcomings of previous policies by moving beyond numerical representation to fostering meaningful, sustainable change toward inclusion in the workplace, education, and broader public sphere.
It is important to distinguish equity from equality. Equality refers to treating all people the same (e.g., offering the same opportunities), while equity refers to achieving fair outcomes, recognizing diversity, and addressing inequality through intervention [24]. Diversity refers to the welcoming and embracing of difference, in relation to social demographics as well as a diversity of perspectives and ideas [24, 58, 59]. Inclusion is a critical component to EDI, representing the idea that it is not enough to invite a variety of people into institutions [23]. Inclusion is fostering an environment and culture that is welcoming and supports diverse individuals and/or groups of people, and may also require concrete changes (e.g., accommodations to address physical and social barriers to inclusion) [59].
There are other variations of the EDI acronym that bring their own histories and perspectives, most commonly the addition of “A” for access or accessibility, drawing on the history of disability rights and accessibility policies and legislation. There is sometimes a “D” to bring in the complex and unique experience of Indigenous people working towards decolonialization; this is more common in Canada and Australia than other countries with smaller Indigenous populations.
While EDI efforts typically focus on institutional level change, funding bodies are increasingly requiring researchers and research teams to implement EDI within their research designs (e.g., participants, budgeting lines for accessibility) and in research practices in a way that echoes feminist reflexivity. For example, the Canadian funding body, the Social Sciences and Humanities Research Council produced a guide to implementing EDI in research practice and research design [60]. EDI in research practice refers to “promoting diversity in team composition and trainee recruitment” and “fostering an equitable, inclusive and accessible research work environment” while EDI in research design might involve using “intersectionality, gender-based analysis plus, anti-racist approaches, and disaggregated data collection and analysis that includes consideration of diversity and identity factors” [60]. EDI can be used as an institutional mechanism for compelling health researchers to consider the exclusions of specific teams and projects.
