Our interdisciplinary team aimed to supplement the CFIR to incorporate intersectional considerations. Following three subgroup meetings and several rounds of iterative revisions, the resulting intersectionality supplemented CFIR includes the five original domains with two additional constructs for a total of 28 constructs. Intersectionality prompts were added to 13 of the 28 constructs. We included several considerations and prompts to help researchers reflect on how individual identities and structures of power may play a role in implementing evidence-based interventions.
Intersectionality is an analytic tool – a way of thinking about identity and its relationship to power [26]. Originally articulated by Black feminists to describe the experiences of Black women, intersectionality has brought to light the importance of considering the compounding of individual characteristics with the systems of oppression and privilege [40]. Numerous academics have explored the value of bringing an intersectional perspective to empirical research, and as a result, recommendations for integrating intersectionality in qualitative research have been proposed [40,41,42,43]. However, the employment of quantitative methodologies with an intersectional approach have been heavily criticized by intersectionality scholars, who emphasize the dangers of additive, single-axis thinking [40,41,42,43]. For example, Bowleg and colleagues argue that the notion of social identity and social inequality based on ethnicity, sexual orientation, sex, gender, among other characteristics, are intersectional rather than additive [42,43,44]. The authors argue that a key dilemma for intersectionality researchers is that the additive assumption (e.g., Black + Lesbian + Woman) is inherently distinct from the intersectional lens (e.g., Black Lesbian Woman) [44]. The term intersectionality continues to be named, but not deeply embedded in research, particularly in implementation research, which is a critical gap given the massive health inequities that exist worldwide.
Our intersectionality supplemented CFIR offers recommendations for considering intersectionality at various stages of the implementation process. The reflection prompts in Table 3 consider each construct in the original CFIR and attempt to operationalize these with intersectional considerations. We specifically selected definitions and prompts that could be applied in research. The prompts are meant to guide researchers, thinking processes rather than be copied and pasted into an interview guide. Our considerations and prompts for the CFIR are designed to assist researchers in asking questions about intersecting, interdependent, and mutually constitutive experiences without resorting to an additive approach. Researchers are responsible for interpreting data in the societal context that it was collected from regardless of whether qualitative or quantitative approaches are used [44]. Thus, asking questions within the context of the sociohistorical and structural society can provide insight into such constructs. We recognise that as research advances in this area, additional revisions may be required to reflect the evolving understanding of using an intersectionality lens in research.
One example of where intersectional considerations may be helpful is when considering the “patient needs and resources” construct [outer setting domain]; for example, a study identified that cervical screening rates among South Asian Muslim immigrants in Canada were much lower compared to women born in Canada [45]. The research reported that lack of knowledge about cervical cancer, transportation, and language were barriers to screening; however, considering intersecting categories of religion and education may have prompted different interview questions and a better understanding of what patients deemed important and what system changes needed to happen. The coexistence of implementation and intersectional considerations also launches the potential to examine interesting questions regarding interactions between the dimensions of oppression and privilege across different levels [41]. The use of intersectional considerations in implementation science are still in its infancy, but we predict such considerations will have a meaningful and profound impact on our healthcare system as they shift the focus from individual level change to system change, which is needed to tackle health inequities.
After identifying a research question, the qualitative research process involves choosing a framework or theoretical lens (e.g., phenomenology, grounded theory, ethnography), a methodology (e.g., observation, case study), and a data collection technique (e.g., focus groups, photographs). When utilizing the intersectionality supplemented CFIR, researchers should consider when and how they intend to incorporate intersectionality into their study. For example, researchers can decide whether to use our supplemented framework to guide the entire study process or incorporate the updated framework into the data analysis stage (e.g., mapping of facilitators and barriers using CFIR). The supplemented CFIR can also be used to guide the interview process by explicitly asking about barriers such as how historical distrust of the medical system may affect uptake of an intervention (see Table 2 for specific intersectionality constructs). We recommend that intersectionality be considered during the study conceptualization phases as the constructs supplemented in our framework can generate important considerations for interactions with participants during the recruitment, data collection, analysis, and dissemination phases.
In implementation science, researchers often need to assess context. CFIR is commonly used to assess such context; however the CFIR is a framework, not an assessment tool [38]. Usually, researchers use the CFIR to operationalize a method of assessment; for instance, using the CFIR technical assistance website to transform domains into surveys, develop an interview guide, or categorize interview data. The way researchers phrase questions shape how participants respond to them and a pivotal aspect of asking good questions is to understand intersecting categories in relation to power structures [44]. It is also important to reflect on who is asking and guiding the interview questions (e.g., is there a power dynamic between the interviewee and interviewer?). Typically, not all domains and constructs are utilized when using the original CFIR [37]. Similarly, we recognize that it may not be feasible to consider all 15 prompts alongside standard operationalizations of the CFIR. Instead, we recommend that users prioritize prompts that they consider will be useful and relevant to their study. Additionally, researchers should reflect on how power and privilege operate within themselves, their research study team, and research organization as this can affect stakeholder relationships and collaboration [46]. For example, the growing lexicon of academic language that privileges researchers can become an oppressive and exclusionary factor for populations of focus, especially in implementation science where the field is growing at an exponential rate [46]. Our intent was not to replace the original CFIR, but rather to provide researchers with an additional lens.
An important consideration is the introduction of outer systems and culture as constructs in our supplemented CFIR tool. Outer culture is a broader based determinant of health that acts at the community, population, and national level [47]. There is growing recognition of the need for culturally safe, patient-centered care to improve health outcomes, particularly among minority populations [47]. Health practitioners, healthcare organizations, and healthcare systems need to engage towards culturally safe environments; to do this they (i.e., individuals in power) must be prepared to critique the power structures and challenge their own culture and culture systems [48]. The prompts proposed in our supplemented CFIR tool may help researchers challenge their own ways of thinking to possibly improve the quality of the information gained when conducting surveys or interviews guided by CFIR. Continued neglect of social considerations, as well as the larger systemic power structures in which the social considerations are embedded, may result in missed opportunities for effective implementation. As a result, lack of intersectional considerations may perpetuate future systematic health inequities. The explicit use of CFIR with the greater application of intersectional considerations within implementation science has the potential to improve researchers’ collective abilities to more specifically document inequalities within intersectional groups.
Strengths and limitations
Our study has several strengths. First, we strove to build a team of practitioners and implementation science users from across Canada with various expertise in implementation science and intersectionality. We also engaged with implementation science users who were not yet familiar with intersectional concepts, which we believe helped create a tool that was potentially more accessible to the novice researcher or practitioner. We also considered accessibility limitations, and so, we engaged in multiple video conferences and teleconferences. Lastly, our comprehensive and rigorous approach is consistent with other tool development methods reported in implementation science [36].
Our methods also had limitations. As described, we engaged with implementation science users who, were not yet familiar with intersectionality concepts. To reduce this limitation, we created small group discussions of no more than five individuals to review concepts. We also held capacity building sessions on intersectionality led by experts in the areas of implementation science and intersectionality. Nevertheless, it is possible that a group of different interdisciplinary researchers may have prioritized a different set of theories, models, and frameworks for intersectionality enhancements. We also recognize that those involved in the project represent a limited range of privileged identities and may affect the generalizability of the results. Furthermore, we recognize that biases may have influenced our approach, due to the lack of representation of historically marginalized social identities in our subgroup. In efforts to limit these biases, we drew upon works and guidance authored by individuals from marginalized groups to inform our decision making [49]. Future research can further build on the intersectionality categories presented to develop tailored, culturally-relevant prompts and interventions for subsets of marginalized groups (e.g., Indigenous considerations). Lastly, this work was completed prior to the publication of the updated CFIR [46]; however the principles of intersectionality outlined in this paper can be applied to the updated framework.
Future directions
This project is part of a larger program of research. The next steps are to test the usability of these tools with implementation scientists, researchers, and clinicians, and then pilot the tools under real-world conditions. We do not expect that the supplemented framework and tool alone will change behavior. During the pilot trial, we will aim to understand the facilitators of and barriers to using the intersectionality supplemented CFIR and tool in practice. In addition, it is recommended that future research build on the intersectionality categories presented to develop tailored, culturally relevant prompts and interventions for subsets of marginalized groups.
