Nurses work within a multidimensional scope of practice, which includes a reactive approach of treating health problems, a proactive stance of health promotion, and disease prevention. The purpose of this paper is to discuss the contribution of the intersectionality framework in building nursing knowledge related to the PMTCT of HIV and show how the intersectionality framework can contribute to the improvement of nursing practice, policy, and research related to PMTCT of HIV. A comprehensive literature review was conducted to be able to discuss the contribution of intersectionality framework in nursing knowledge. Intersectionality is a nice perspective that gives insight into different identities that link and work together to provide inequalities. Intersectionality is a well-suited approach in a nursing profession where we strive to offer efficient and better care to our patients or clients; an excellent tool to explore more on the roots of inequality, oppression, and discrimination.
Many characteristics that contribute to exclusion and discrimination are historically linked. These include race or ethnicity, socioeconomic status, religion, age, mental health, disability, gender identity, and geographic location [1]. These characteristics are known to have a great influence on the health status of individuals, populations and communities [2]. Women and people of minority groups as clinical research participants were recognized as a priority in 2001 by the National Institutes of Health in the United States after realizing that exclusion of these groups continues to affect interventions to address their specific health needs and consequently health status [3]. Acknowledging the existence of multiple intersecting identities is an important and initial step in understanding the complexities of health disparities for people from multiple historically oppressed groups. The critical step is recognizing how systems of privilege and oppression result in numerous social inequalities, for example sexism, racism, heterosexism, and classism, intersect at the macro-social structural level which maintains health disparities [1].
Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) is one of the leading causes of mortality among women of reproductive age. Mother to Child Transmission (MTCT) or vertical transmission of HIV happens when a mother passes HIV to her baby during pregnancy, labor and delivery, or breastfeeding (through breastmilk). In 2021, approximately 38 million people worldwide are living with HIV, and 1.8 million people are newly infected with HIV [4] [5]. Additionally, estimated 180,000 children under 15 years old acquired HIV every day globally and more than 90% of them were due to MTCT of HIV [6]. Furthermore, 90% of MTCT of HIV occurred in sub-Saharan Africa (SSA) [7].
The PMTCT program is one of the strategies to prevent mother-to-child transmission of HIV. The risk of MTCT of HIV is 1% or less if the HIV positive women follow the Prevention of Mother to Child Transmission (PMTCT) strategies. The strategies that prevent MTCT of HIV and avoid HIV+ women to reach the AIDS level include HIV testing as early as possible before or during pregnancy; prevent unwanted pregnancies; start and continue Anti-Retroviral (ARV) and HIV counseling during pregnancy, labor, and breastfeeding; use safe childbirth practices; provide ARV prophylaxis to her infant; practice appropriate infant feeding; and accessing physical, social, and psychological support [8]. While efforts have been implemented to increase the effectiveness of the PMTCT program, its coverage remains low in Rwanda. Consequently, the HIV transmission rate is high [9]. There is an urgent need to understand the reasons for low uptake of the PMTCT program in Rwanda, in order to prioritize strategies to improve this uptake.
Critical ethnography was the design for this study as it allowed for an in-depth exploration of HIV+ women’s experiences of using the PMTCT program to prevent HIV transmission in Rwanda. Critical ethnography is an exploratory and descriptive method that helped us identify factors that influence and challenge the uptake of the PMTCT program, and critically examine the experiences of mothers using the PMTCT program to prevent HIV transmission. Intersectionality framework guided this study.
The purpose of this paper is to discuss the contribution of the intersectionality framework in building nursing knowledge related to the PMTCT of HIV and show how the intersectionality framework can contribute to the improvement of nursing practice, policy, and research related to PMTCT of HIV. We elaborate on the historical background of intersectionality, the significance of intersectionality, intersectionality as a theoretical framework for nursing research and for developing nursing knowledge, the use of the intersectionality framework in the context of research with HIV positive women, and the intersectionality framework in nursing practice, policy, and research related to PMTCT of HIV.
2. Historical Background of Intersectionality
A lawyer and African American feminist scholar, Kimberlé Crenshaw, introduced the term intersectionality in the late 1980s and early 1990s [10]. In her early scholarly work, she was inspired by both women and people of color. According to Crenshaw, intersectionality is not merely a multiplying of identity categories like race and gender. It is rather a type of analysis for how particular identities and conditions are located within power structures [11] [12]. Furthermore, intersectionality is a way of understanding social location in relation with how systems of social class, race, gender, and other identities interact on multiple and often simultaneous levels, contributing to inequality [13].
In 1990, Patricia Hill Collins, an African American sociologist and feminist scholar, began including intersectionality in her work. Her writings on feminist thought on knowledge, consciousness, and the politics of empowerment started to integrate intersectionality [14]. For her, intersectionality is defined as a theoretical framework used to analyze how social and cultural categories intertwine [2].
The philosophical underpinnings of intersectionality are situated within a transformative paradigm that has roots in critical social theory and feminism [10]. An epistemological assumption of intersectionality is that the development of knowledge should arise from the perspective of the oppressed, not from the perspective of the dominant social groups [15] [16]. Intersectional scholarship development arose from the unique position of women of color with the aim of framing social inequalities and seeking social justice as a product of differences such as class, gender, and race [17] [18]. Intersectional scholars consider the social constructions of race, gender, and class to be unequal social relationships of groups of people, rather than being individual attributes [19].
Intersectionality helps people critically think about how different factors contribute to discrimination. At the same time, there is a need to have a language and the ability to see the different causes of discrimination in order to address them. Moreover, Kaushik and Walsh [20] have argued that different identities and social categories are linked and work together, consequently, resulting in inequality. The main goal of intersectionality is to grasp the relationships between identities and cultural categories instead of looking at various sources of discrimination separately [21].
3. Significance of Intersectionality
The concept of intersectionality was first used by feminists who focused on how the experiences of women were shaped by intersecting factors [10]. Since then, it has been adopted by researchers from various disciplines to explore the sources of oppression, discrimination, and inequality for people. It is a perspective that highlights different identities that link and contribute to inequalities. An intersectionality framework is a well-suited approach in nursing since it can help nurses understand ways in which social locations and identities affect individuals, families, and communities. It exposes complexities around a phenomenon and illuminates social forces shaping inequalities. For example, it is suitable for PMTCT policy makers and researchers to address program challenges and provide better care to patients. Ultimately, this framework can contribute to building nursing knowledge and improving nursing practice, policy, and research related to PMTCT of HIV.
4. Intersectionality as a Theoretical Framework for Nursing Research and for Developing Nursing Knowledge
As stated above, intersectionality is a theoretical framework for understanding how multiple social identities such as race, gender, sexual orientation, socioeconomic status, and disability intersect at the micro level of individual experiences. At the macro-social structural level, intersectionality fosters reflection on the interlocking systems of privilege and oppression [22] [23]. In addition, intersectionality provides health disciplines with a critical unifying interpretive and analytical framework for framing how scholars conceptualize, investigate, analyze, and address health disparities and social inequality.
During fieldwork, researchers use different strategies to increase the likelihood of getting valid and reliable data, and to ensure their research is rigorous. One of the strategies is to apply a theory to strengthen the research approach. This theory then acts as a framework through all stages of the research process. Reeves and colleagues [24] strongly advise using a theory and highlight that it provides researchers with a lens to question complex, complicated problems, and social issues, to focus on different aspects of the data, and to provide a framework to conduct their analysis. Beavis and colleagues purport that an intersectionality perspective is a means by which nurses can respond to issues of privilege and oppression within their profession and practice in general [15]. In addition, healthcare providers such as nurses, doctors, sociologists, psychologists, and nutritionists work in different conditions that affect healthcare access, such as racism, oppression, and disadvantage, which are fundamental contributing to inequalities in healthcare outcome [25]. Clients are well cared for if they are considered holistically. Intersectionality mirrors holistic care in nursing.
4.1. Core Tenets of Intersectionality Relevance to Health
Many scholars use intersectionality; however, fewer social scientists use it as it does not specify core elements or variables to be operationalized and empirically tested [1] [2] [11]. Several studies have described the core tenets of intersectionality: those social identities are not independent and unidimensional but rather multiple and intersecting that people from multiple historical oppressed and marginalized groups are the focal and starting point; and that multiple social identities at the micro-level intersect with macro-level structural factors to produce or illustrate disparity in health outcomes [1] [11]. Race, gender, and socioeconomic status, for example, are at the micro level and can intersect with poverty, sexism, and racism, which are at the macro level, resulting in poorer health outcomes. A key tenet of intersectionality is the notion that social categories are not independent and unidimensional but rather interdependent, multiple, and mutually constitutive [11]. The intersectionality perspective states that single social identities such as race and gender cannot explain the unequal or disparate outcomes without the intersection of the other identities. Based on multiple intersecting categories, there are complex ways in which multiple social categories intersect with social discrimination to create disparity and social inequality in health. Intersectionality focuses on the intersecting identities of people, from historically oppressed and marginalized groups. These groups include ethnic/racial minorities, low-income people, lesbian, gay, bisexual, and transgender people, to those with disabilities [2]. Central theoretical tenets of intersectionality, as described by Heard and colleagues [17], serve as a useful framework of the intersectionality approach which described three central constructs, including contextually specific social constructions, multilevel power relations, and simultaneity.
4.1.1. Contextually Specific Social Constructions
The assumption behind the social construction of race is not based on biological facts, but rather on social and historical constructions of reality. These constructions have allowed for example slavery and segregation, and how it led to inequality based on hierarchies and systems of oppression [19].
4.1.2. Multilevel Power Relations
Social relationships, which are a central focus of intersectionality, are marked by power differential in which one group is dominant and another is subordinate [13]. The way in which power differences persist also mark these relationships [2]. Social relationships are defined as interactions between people that belong to socially constructed categories of differences. For example, belonging to a subordinate or dominant group can be based on race, gender, and class. In such case, the dominant group may retain power because of greater access to social and material resources [17]. As long as power relationships persist and hierarchies are preserved, dominant social groups become the standard for all group comparisons, resulting in subordination of the marginalized group [17]. According to Heard and colleagues [17], micro level power differentials are present at the individual level when one person exercises power over another. Conversely, macro-level power differentials manifest structurally in the form of rules, policies, or laws, benefiting only certain groups of people.
4.1.3. Simultaneity
Socially constructed differences in race, class, and gender do not intersect as inequality in an intersectional approach. They vary from one to another depending on the particular race, gender, and class to which an individual belongs [19]. The social location of an individual based on mutually constituted social inequalities is an important concept in intersectionality. The intersectionality approach does not consider gender as the primary dimension of inequality; it rather proclaims the multiple dimensions that shape social inequality; those include socioeconomic status, employment opportunities, levels of health literacy, transportation and healthcare access [19].
4.2. Social-Structural Context of Health
A core tenet of intersectionality is social-structural factors, which are beyond the influence of individual factors. The intersections that exist between race and gender in the lives of black women and women’s health have been the primary focus of intersectionality [11] [26] [27] [28]. Intersectionality has the power or the potential to elucidate and address health-related disparities [18] [28].
4.3. Intersectionality and Social Determinants of Health
Social determinants of health involve the health care system and conditions in which people are born, grow up, live, work, and age which deeply influence the health of individuals and populations [13] [29]. Social determinants of health such as occupation, gender, race/ethnicity, and income can influence health outcomes in creating hierarchies of health and illness [30]. Many feminist and sociology scholars have researched the influence of unequal power distribution and socio-economic situations in positioning people in the social world, and on how those socioeconomic situations could contribute to health inequities [16] [17]. The intersectional framework is well suited to examine the complexities of social determinants of health and how they interact to cause health inequities [16] [17]. However, the use of intersectionality in nursing research related to determinants of health, health inequities and social injustice, is in its early stages [16].
5. Intersectionality Framework and HIV Positive Women
An intersectionality framework is a strong approach to investigating health disparities. It can generate a better understanding of the social determinants of health, social inequality, and power structures [2]. An intersectional framework focusses on knowledge development by uncovering the intersecting factors influencing minority, non-dominant, and marginalized groups. Knowledge development can be improved through continuous training, using community support group with people living with HIV/AIDS, HIV campaigns, couples counselling, health education sessions, mass media, use of community radio station and television, and consistent messaging from health care providers. Furthermore, multisectoral approaches are necessary with the involvement of government, churches, and Non-Governmental Organizations (NGO). In our study, the choice is based on the magnitude of HIV disease burden and disparity in health outcomes which is clear across racial, gender, and socioeconomic groups [2].
Why Are Women and Girls More Vulnerable to HIV?
Biological factors make women more likely to contract HIV than men during vaginal intercourse. For example, the reproductive system of the adolescent girls is not fully developed which make them more vulnerable to become infected during sexual intercourse [31]. Gender inequality is often linked with legal, cultural, and political factors that impede a woman to protect herself against HIV [31]. Women’s powerlessness to abstain from sex and persuade their husband to use a condom is also a result of the afore-mentioned disparities. Sex between married people is habitual without protection and several new infections happen in women after marriage [31].
The concept of vulnerability is defined as susceptibility to poor health [32]. Collins [2] explains the conceptual relationships in the intersectional model and illustrates the intersection of different factors that create the vulnerability of HIV positive women, which jointly determine access to health care and determine their health status. HIV positive mothers are challenged to cross the intersection safely, protecting both her infant and her. These challenges include but are not limited to how social determinants of health intersect to create a mutually constituted vulnerability; the number of vulnerabilities, and how it problematize how the mothers manage their health condition and accessing quality healthcare; how race, gender, and class are socially constructed categories involving sources of unequal relationships between group of people, rather than genetic or biological attributes of individuals; how certain factors positively influence the ability of a mother living with HIV to navigate the intersections, and consequently influence health outcomes and Mother-To-Child Transmission (MTCT) of HIV; and how the health outcomes of the children depend on the health outcomes of the mother and her ability to navigate the intersection [13] [14].
6. Intersectionality Framework in Nursing Practice, Policy, and Research Related to PMTCT of HIV
It is reasonable to use an intersectionality perspective to study a phenomenon using critical ethnography methodology. Harvey [33] explains that critical ethnography is a particular approach to ethnography, which attempts to link the detailed analysis of ethnography to wider social structures and systems of power relationships in order to get the truth that lies beneath the surface of oppressive structural relationships. Intersectionality fits well with the critical ethnography ontology which focuses not only on the obvious, but what truth lies beneath of surface. We can observe increased MTCT of HIV as an obvious phenomenon, but the contributing factors may have a root in different identities. In addition, critical ethnography holds in its ontology that reality and meaning are socially constructed; further, truth is neither conclusive nor linear. Truths are multiple and history realism plays an important role. Within this context, critical ethnography contributes to relativist truth; what is truth to one individual or social group may not be true to another [34] [35].
An intersectionality approach can have a positive impact on nursing research, practice, and policy related to PMTCT of HIV in several noteworthy ways. It provides a unifying language and theoretical framework for scholars who are engaged in research investigating intersections of race, gender, ethnicity, social orientation, socioeconomic status, and disability to reduce and eliminate health disparities [1]. Intersectionality prompts scholars to conceptualize and analyze disparities and social inequalities in health in multidimensional or complex ways that mirror the experiences of the populations for whom adverse health outcomes are most disproportionate [2] [17]. Furthermore, intersectionality focusses on how macro-level social-structural factors align with contemporary advocacy to consider the substantial effect of factors beyond the level of the individual, for example, socioeconomic status is one of the predicting factors of health status [36].
Intersectionality considers the intersection of multiple-level social structural factors as well as the intersection between micro-level and macro-level factors. This can assist in the development of structural level interventions that are likely to affect social inequalities in health. In additional, researchers that use intersectionality, target and tailor a stronger solution for minority and underserved communities as its vantage point, so the results from their research can facilitate and inform the development of health promotion messages, interventions, and policies to improve PMTCT of HIV practice [2]. Finally, the intersectionality perspective supports the collection, analysis, and presentation of health data that allow examination of multiple interlocking social identities across several categories beyond race and gender [1]. The theoretical framework used in different studies cannot simply identify the complex interaction that presumed to exist and cause the mothers to adhere or not to the PMTCT program. However, an intersectionality framework could help to explore the complex interactions around MTCT of HIV and offer support that the interaction of multiple statuses influence health and behavior of HIV positive mothers in ways that are difficult to identify with other theoretical frameworks. Intersectionality framework challenges us to consider the social determinants or personal identities not in terms of single factors but in terms of interacting and multiple factors [37].
Nurses working within a multidimensional scope of practice which includes not only a reactive approach of treating health problems, but also a proactive stance of health promotion and disease prevention [38]. To understand the complexities of health behaviour related to health problems, intersectionality is thus a well-suited approach. It may bring to the forefront complexities and interrelated factors on a specific phenomenon, and consequently, influence practice, research and/or nursing education. Moreover, it suitable to explore the experiences of mothers using PMTCT program to prevent HIV transmission in Rwanda.
The success of the PMTCT of HIV as described in the literature is a complex phenomenon in which social identities are multiple and intersecting. There are reciprocal interactions between gender, race, dissimilarities in individuals’ lives, and other categories such as social practices, religious beliefs, education level, institutional norms, cultural ideologies, legal and political aspects, poverty and outcomes of these interactions in terms of power [23] [39]. An intersectionality framework for this research provided resources for more comprehensive identification of inequalities, contributing factors and directions for developing intervention strategies specific to the community studied [40] [41]. The intersecting factors that contribute to the complexity of the issues of PMTCT of HIV were better understood through inter-categorical approaches to intersectionality, that is, the pragmatic use of categorization to explore health impacts of multiple identities or social positionalities [1] [40].
Furthermore, intersectionality aims to address different issues like racism, patriarchy, class oppression and other systems of discrimination that create inequalities, and in turn shape the relative position of minorities. Likewise, it considers the historical background of people, their lived social and political contexts [33]. In many studies, intersectional projects center on the experiences of participants whose voices have been ignored [1] [37] [42]. Usually, the intersectionality framework suggests and seeks to delve into how various biological, social, and cultural categories such as class, gender, sexual orientation, race, and other identities interact on multiple and often simultaneous levels are contributing to inequality.
In our study, the intersectionality framework is an excellent tool to explore the roots of inequality, oppression, and discrimination that contributed to MTCT. It offered a way to study complexity around a phenomenon and illuminates social forces shaping inequalities, which then may be useful to PMTCT implementers, policymakers, and researchers to address the high rate of MTCT of HIV. Furthermore, it can contribute to building social justice knowledge and improving nursing practice, policy, and research related to PMTCT of HIV.
7. Conclusion
Intersectionality originated from feminists who explained that the experiences of women are shaped by intersecting factors. Later, it has been used in different disciplines to find the sources of oppression, discrimination, and inequality so that people live egalitarian life [2]. It is a perspective that gives insight into different identities that link and work together to provide inequalities. Intersectionality is a well-suited approach in a nursing profession where we strive to offer efficient and better care to our patients or clients. Moreover, it supports exploring the experiences of mothers using PMTCT program to prevent HIV transmission. We found intersectionality to be an excellent tool to explore the roots of inequality, oppression, and discrimination. It offers a way to study complexity around a phenomenon and illuminates social forces shaping inequalities, which then may be useful to PMTCT implementers, policy makers, and researchers working in PMTCT program to address the high rate of MTCT of HIV. Furthermore, it can contribute to building nursing knowledge and improving nursing practice, policy, and research related to PMTCT of HIV.
Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.
Cite this paper
Kamanzi, J., Richter, S.M., Paul, P. and Jarvis, K. (2021) The Intersectionality Framework and Its Contribution to Nursing Knowledge Related to the Prevention of Mother to Child Transmission (PMTCT) Program. Open Journal of Nursing, 11, 1052-1063. https://doi.org/10.4236/ojn.2021.1112084
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