Underpinnings of entangled ethnical and gender inequalities in obesity in Cochabamba-Bolivia: an intersectional approach

The prevalence of obesity has risen to epidemic proportions worldwide [1‐3]. This also applies to many Latin American countries, which over the last decade have experienced a remarkable increase in obesity, presumably associated to changes in lifestyle and demographics as nations transition from low-income to middle-income countries [1‐3]. According to the World Health Organization (WHO), about 60% of Latin American population is overweight or obese [4]. While similar patterns have been reported in the Andean region in South America (men = 56.8% and women = 61.2%) [4], a slighter higher prevalence have been reported in Bolivia (60–63%) [5‐7]. Consequently, the control and prevention of obesity is a priority in the Bolivian National Non-communicable Disease policy [8, 9].

The widespread social inequalities present a particularly daunting challenge for successful prevention and control of obesity In Bolivia as well as worldwide. For example, the increase in obesity has affected women more than men in Bolivia and in other Latin American countries [1, 4, 7, 8, 10]. These gender inequalities have been attributed to biological [11, 12], behavioral and social conditions, such as higher level of physical activity among men [7, 13], unemployment among women [14, 15], and the influence of gender roles in the choice of occupation [16, 17]. Social inequalities in obesity have been observed also by ethnic group [7]. In this case, obesity seems to be affecting more mestizo (people of mix European and Amerindian descendants) than indigenous [18‐21].

.As is evident by the studies cited above, research on various kinds of social inequalities in obesity, in Bolivia as well as internationally, has so far been dominated by approaches where each axis of inequality – such as gender or ethnicity – are understood, analyzed and interpreted as independent and disentangled from each other [22]. Such simplified approaches to the complex phenomenon of social inequalities in health have however been increasingly challenged within global and public health, spurred by notions from intersectionality theory [23, 24]. Intersectionality theory took shape within social sciences in the late 1980s and involves an explicit recognition of the compound nature of multiple intersecting inequalities [22, 25, 26], but has only in recent years started to emerge as a novel approach to health inequalities within public health research and policy [22, 27‐29].

In the case of Bolivian health and social policy, an emerging pressing concern is that particularly disadvantaged indigenous women is the group who fares the worst when it comes to health care access and social conditions such as quality of education, living wage and availability of food [9, 20]. This observation illustrates the entanglement of gender and ethnicity in the Bolivian context, and that approaches considering gender and ethnic inequalities as separate and disentangled may not be optimal as guidance for policy [8]. Therefore, understanding how ethnicity and gender intersect or combine to affect obesity would be particularly helpful to support the development of appropriate public health policies [30].

Intersectionality has to date mostly been applied to qualitative research but have become increasingly popular among quantitative public health researchers who are interested on analyzing inequalities in multiply marginalized populations [27, 29, 30]. To guide this line of research, Bauer [22] has formulated two complementary goals to intersectional, or compound, inequalities in health; first, to examine the health consequences of social positions of multiple advantage and disadvantage i.e. the pattern of intersectional inequalities; and second, to detail the processes whereby the social positions are expressed in population patterns of health. As an implementation of the first goal, Jackson et al. [31] have proposed an approach that considers the concept of a joint disparity, based on comparing absolute differences between dually as well as singly advantaged and disadvantaged groups. For the second goal, Blinder-Oaxaca decomposition [32, 33] has recently been suggested and exemplified as an appropriate method to disentangle the role of indicators representing social processes underpinning the inequalities [33, 34].

The present paper seeks to shed light on inequalities in obesity, in the intersectional space of gender and ethnicity, in Bolivia. The specific goals are i) to estimate the intersectional inequalities in obesity and ii) to identify the factors underlying the observed intersectional inequalities.

Despite the calls for intersectional global health approaches in low- and middle-income countries [23, 24], to the best of our knowledge, this is the first study estimating and explaining obesity inequalities in the intersection between gender and ethnicity in Bolivia and Latin America. First, we found that dually and singly disadvantaged groups (indigenous women, indigenous men and mestizo women) were less obese than the dually advantaged group (mestizo men), meaning that in this study population, the socially advantaged were in fact disadvantaged with respect to health. Second, the lower prevalence of obesity in the doubly disadvantaged group of indigenous women was mainly due to ethnic differences alone. However, they had higher obesity than we might expect from considering both genders alone and ethnicity alone. Third, the results highlighted intersectional disparities in health behaviors as a ubiquitously important factor to explain the observed inequalities, while differences in socioeconomic and demographic factors played a less important role.

The finding of socially advantaged population being more obese have commonly been reported in low and middle-income countries [47] where obesity has been associated with higher socioeconomic levels and high level occupations [32, 48]. In our study, indigenous women, who have been historically considered as socially disadvantaged due to low levels of education and income as well as low level occupations [14], were less affected by obesity than the mestizo men. Our findings overall confirm the already reported inequalities in obesity to the disadvantage of mestizo in Bolivia [7] and expands previous research in the Latin-American region focusing on single axis of inequalities such ethnicity [7, 19, 21, 49] and gender [7, 50].

The lower prevalence of obesity found in the doubly disadvantaged group was mainly attributed to ethnic inequalities. Previous studies have pointed out that the indigenous population has a lower prevalence of obesity among other cardiovascular risk factors than mestizo population [7]. This difference could be related to the indirect effects of social disadvantage on their health behaviors. For example, indigenous population engage in high levels of physical activity, in women for example due to raising animals for self-consumption (sheep, goat, etc.) as part of their domestic activities, which in some cases involve walking long distances in steep terrain [17, 19‐21]. Indigenous women also have a lower prevalence of other behavioral risk factors such as smoking and alcohol consumption commonly associated with the development of obesity [51, 52], which is considered inappropriate for women as part of moral regulations introduced by evangelical movements since the 1990s, especially strong among the indigenous communities [7, 53].

Moreover, despite that the dually disadvantaged group of indigenous women displayed lower obesity than the dually advantaged mestizo men; our findings showed that they still had higher obesity prevalence than we might expect from the fact that they were women on the one hand, and of ethnic disadvantage on the other, both facets of social disadvantage by themselves being protective against obesity. This pattern could reflect certain obesogenic exposures particular for this intersection of gender and ethnicity; for example, the high birth rates [54] specifically among indigenous women in Bolivia [18], where nearly half of the women are housewives as it is socially expected that they stay home taking care of child [55, 56], or possibly other forms of material and psychosocial disadvantage that may contribute to obesity through e.g. stress [57]. Moreover, despite the domestic work of indigenous women involving high levels of physical activity, it is still be less arduous than for the indigenous men who are not as bound to the confines of the home [56, 58].

Taken together, the seemingly paradoxical finding of overall low but nevertheless higher-than-expected obesity prevalence among indigenous women could be construed as reflecting a hidden form of inequality, resulting from dual social processes with counteracting effects on this aspect of health. In this case, the harmful consequences of pervasive social disadvantage on obesity appears to be partially hidden by the simultaneous presence of both a physically demanding life and the presence of gender norms that discourage indigenous women from engaging in other harmful health behaviors. These are undoubtedly additional facets of social disadvantage, oppression and marginalization, but which may be protective against obesity. These findings illustrate the contextually dependent, interacting and multifaceted structural roots of social processes that may shape complex population patterns in health, how social disadvantage and oppression may be expressed in paradoxical ways when it comes to health, and the unique value of intersectional perspectives to uncover such phenomena [23] . On the other hand, this difference between mestizo and indigenous people might be related to the type of diet or food preparation; further research is therefore needed to explain these differences [59].

Further clues to the social processes at play were suggested in the explanatory decomposition analyses of the joint and referent inequalities. Behavioral risk factors were consistently important to explain the gender and ethnic disparities. Overall, behavioral risk factors were more prevalent among men, especially in mestizo men, except for the low physical activity, which was more prevalent in women, especially mestizo women. These differences are likely a reflection of the social roles assigned to men in the Bolivian society; as described by other authors, men are disproportionally exposed to tobacco and alcohol consumption from an early age [60‐62] as well as to physically demanding work, which in some cases continues up to the old age. This is particularly the case for elderly indigenous men who performing vigorous physical activity throughout their life until very advanced ages [14], which furthermore could explain the low prevalence of abdominal obesity in indigenous men, especially in the elderly group.

Socioeconomic and demographic factors were of less universal importance to explain the inequalities, except for level of education and age which contributed to the explanation of the ethnic and gender disparity respectively. For example, on explaining the lower prevalence of obesity among indigenous men compared to mestizo men, the higher rate of indigenous men with no formal schooling or only primary education may have played a role. Specifically, because of their low education, indigenous men are mainly involved in non-skilled manual occupations (like agricultural work) which involve vigorous physical activity, while in contrast their mestizo peers have a greater chance to achieve higher educational levels [16, 63] and therefore are mainly involved in non-manual occupations which are related with sedentary life styles [64].

Overall, the population patterns of abdominal obesity identified in this study highlight the value of considering intersectionality for the generation of public health policies that adequately prioritize subgroups in needs, in accordance with the “leave no one behind” agenda [23]. So far, health policies in Bolivia have generally emphasized interventions targeting the socially vulnerable or disadvantaged populations [8, 65], but in the case of abdominal obesity, the group with a double social advantage requires a high attention. More specifically, interventions taking into account the gender and ethnic intersection could be aimed at increasing levels of physical activity among mestizo men [10, 49, 63, 66] and indigenous woman as well as to reduce tobacco and alcohol consumption among both mestizo and indigenous men [13].

Our study is based on a representative population sample of Cochabamba Bolivia, the information was collected through a standardized process validated by WHO / PAHO, in addition to the application of innovative statistical approaches for the analysis of health inequities.

The drop-out analysis showed that older people, women, less educated, homemakers and residents of the central valley were more likely to not have complete data and therefore to be excluded from the complete case analyses. These signs of selection bias, in combination to the unknown extent of selection when it comes to participation in the study as a whole, means that caution should be applied when interpreting and generalizing the findings.

Concerning the analysis, Oaxaca decomposition can be viewed as a useful method to identify factors underlying inequalities, however, it cannot provide causal inference, a matter that is only reinforced by the cross-sectional nature of our data.

The individuals who did not answer the questions about their economic income were not included in this study, reducing the sample size and potentially introducing a degree of selection bias, as indicated by our drop-out analysis. Whereas this might bias the estimated overall prevalence of obesity, it is less likely that the main analyses building on group differences and decompositions are severely biased.

It should also be considered that the information about risk factors is self-reported, and measurement bias in some of the exposures could be introduced. Because, participants were wary and suspicious of answering some questions, especially those about alcohol and tobacco use (some persons scared of being judged or felt ashamed to answer affirmatively) their prevalence could have been underestimated. This in turn might have led to an underestimation of the role of these factors on explaining the inequalities.

The explained fraction of ethnic referent disparity was very small for traditional risk factors included in the WHO-STEPS approach used in our study, which are also the factors traditionally associated with abdominal obesity in almost all previous studies reviewed. This suggests the need to explore other factors not covered by the WHO STEPS questionnaire (i.e. stress, poverty, diet, etc.) and that could help to improve the understanding of this phenomenon, as well as the development of more specific strategies for these population groups.

The information collected was disaggregated by municipalities and sociodemographic macro-regions, but the specific rural/urban location of the participant communities was not available and therefore not included in the analysis. It is probable that occupation, the level of physical activity and dietary habits vary significantly between rural and urban indigenous and mestizo population groups missing therefore the potential contribution of rurality to the obesity inequality.

Our study illustrates that abdominal obesity is distributed in a seemingly paradoxical pattern in the intersectional space of ethnicity and gender, where a high social advantage was related to higher rates of abdominal obesity. Nevertheless, the doubly disadvantaged group of indigenous displayed a higher prevalence of obesity than were to be expected, which we interpret as an expression of counteracting health effects of compound social disadvantage.

The behavioral risk factors were those that most influenced the explanation of inequities in the socially doubly advantaged group compared to the other subgroups. This can give guidance to health prevention programs that seek to improve health as well as equity in health. Importantly, from a public health perspective, our findings indicate that intervention strategies cannot be approached in the same way in all population subgroups, a key notion of intersectional public health. This observation requires prioritization of certain intervention groups, in order to reduce the compound gender and ethnic inequalities in health based on the contextual population patterns of abdominal obesity.

More broadly, the present study illustrates the added value of applying an intersectional perspective and analysis to public health. More studies on intersectionality are necessary to understand the complex interaction between gender and ethnicity on obesity, considering those non-traditional risk factors that can show a more complete panorama of this phenomenon and be able to generate more precise prevention and control strategies.