Commentary: Centering Oppression in Research Methodology Toward Developing Interventions to Address Health Inequities

Regular physical activity can promote cardiovascular, brain, and psychosocial health (Hillman et al., 2011; Janssen & Leblanc, 2010) and, thus, may benefit youths with congenital heart disease (CHD) who experience elevated risk for suboptimal cardiac, neurodevelopmental, and psychosocial outcomes (Cassidy et al., 2018). Jackson et al. (2021) conducted critical work to further our understanding of the individual-level mechanisms that might explain physical activity levels in adolescents with CHD by testing if physical activity levels were associated with theory of planned behavior (TPB) factors, that is, attitudes, perceived social norms, and perceived control (Ajzen, 1991). Both lower perceived social support and greater perceived barriers were associated with lower physical activity. Additionally, Jackson et al. go further to also assess disparities in physical activity by gender. Jackson et al. identified deficits in both TPB factors and physical activity levels in female adolescents with CHD (although gender did not moderate tested associations between TPB factors and physical activity) and concluded that the deficits in females compared to the male reference group might be best addressed through gender-tailored psychosocial interventions. These findings provide valuable knowledge about gender disparities in physical activity in adolescents with CHD and how we may target TPB factors to increase engagement in physical activity via psychosocial interventions. With regards to ameliorating gender disparities in physical activity in adolescents with CHD, the findings, conclusions, and interpretations of Jackson et al. may be further expanded upon by explicitly considering the social–structural inequalities subsumed within gender as a grouping variable (Corr et al., 2019; Cowley et al., 2021).

Examining health disparities without explicit attention to health inequalities can unintentionally perpetuate “default” narratives that individuals, families, or groups bear responsibility for health behavior states (i.e., recommendations for individual-level interventions), that are largely attributable to social–structural inequalities (Shim, 2021). Quantitative methodologies used to represent disparities in health behaviors between groups of people are subject to biases in implementation and interpretation and, thus, require a critical examination to clarify how our methods shape our understanding of health disparities, their causes, and their remedies. Quantitative Critical Theory, an integration of quantitative methods with Critical Race Theory, calls to reform the use of quantitative methods and seat oppression and social–structural inequalities at the center of our quantitative research process (Garcia et al., 2018; Stage, 2007; Suzuki et al., 2021). For example, for Jackson et al., the construal of gender labels as also capturing historical experiences of sexism (temporally precedent to study assessment) and/or ongoing exposure to everyday sexism (temporally proximal to study assessment) might have led to different choices and conclusions throughout the research process.

First, had Jackson et al. construed gender as a proxy for everyday experiences of sexism, they might have directly hypothesized that females, due to exposure to everyday sexism, would experience weaker associations between TPB factors and physical activity compared to males (Stock et al., 2017). Yet, Jackson et al. did not describe a theoretical rationale or hypothesis for why or how gender groups would vary in the direction of effect or strength of association between TPB factors and physical activity. Only the main effects of gender were theorized—that male adolescents with CHD would perceive more optimal status on TPB factors and engage in more physical activity when compared to female adolescents with CHD (i.e., both X and Y variables are more optimal in one group compared to a reference group). This main effect theoretical assumption appeared to lead to an analytic choice that restricted the potential findings with regards to gender as a moderator. Specifically, Jackson et al. tested moderation by gender only when both the TPB and physical activity variables significantly differed by gender. This approach preselected for X–Y associations with strong main effects of gender, leaving the identification of any moderation patterns less likely. Had the original hypothesis and analytic plan been contextualized with social–structural inequality in mind, the choice to test moderation only where both TPB factors and physical activity were less optimal in females might have been set aside. Instead, researchers might propose testing moderation anywhere a TPB factor might be dampened in its association with physical activity in females, as theorized to occur due to exposure to everyday sexism.

Second, had Jackson et al. construed gender as a proxy for accumulated experiences of sexism prior to study participation, they might have retained their original main effect theory, that females would perceive less optimal status in TPB factors and engage in less physical activity but interpreted their disparity findings through the lens of structural inequality. This centering of oppression in research questions, analytic plans, and interpretations of disparity findings also substantively shifts the recommendations emerging from research findings. For example, grounded in this Quantitative Critical Theory approach, Jackson et al. might recommend more systemically framed future directions:

1. to conduct community-based participatory research with adolescents with CHD that identify as a marginalized gender, live in poverty, or are a person of color, not with a goal of increased recruitment, but to center the experiences of individuals living through oppression when studying social–structural determinants of physical activity;

2. to explore the impact of health systems factors on physical activity, such as how health care provider relationships are primary resources through which adolescents with CHD and families may shape gendered perceptions of CHD-related physical activity limitations, and how the dissemination of this guidance shapes perceptions of physical activity across the lifespan;

3. to consider developing multilevel interventions that address individual, family, and social–structural factors to support recommended levels of physical activity in adolescents with CHD inclusive of those with genetic disorders and marginalized identities (e.g., nonbinary and transgender adolescents) across a full spectrum of CHD anatomical presentations (Brown et al., 2019; Dankwa-Mullan et al., 2010); and

4. to encourage pediatric psychologists to use expertise in interdisciplinary practice to engage in advocacy for a policy that supports multisectoral interventions with the goal of influencing changes in all environments where adolescents with CHD and their families live, learn, and play (Agurs-Collins et al., 2019; Stokols, 2006).

In summary, Jackson et al.’s findings play an indispensable role in advancing our understanding of gender disparities in physical activity among adolescents with CHD. These findings provide an ideal foundation for further exploration of disparities in physical activity that center systems of oppression at the forefront of analytic approaches, research questions, and interpretations. Acknowledging and highlighting social–structural barriers to health can help guide our research around a continued call to address social–structural inequality and encourage the development of multilevel interventions that integrate psychosocial, community, and public health approaches to remedy persistent health inequities (Cleary et al., 2012).