Selecting implementation models, theories, and frameworks in which to integrate intersectional approaches.

BACKGROUND: Models, theories, and frameworks (MTFs) provide the foundation for a cumulative science of implementation, reflecting a shared, evolving understanding of various facets of implementation. One under-represented aspect in implementation MTFs is how intersecting social factors and systems of power and oppression can shape implementation. There is value in enhancing how MTFs in implementation research and practice account for these intersecting factors. Given the large number of MTFs, we sought to identify exemplar MTFs that represent key implementation phases within which to embed an intersectional perspective. METHODS: We used a five-step process to prioritize MTFs for enhancement with an intersectional lens. We mapped 160 MTFs to three previously prioritized phases of the Knowledge-to-Action (KTA) framework. Next, 17 implementation researchers/practitioners, MTF experts, and intersectionality experts agreed on criteria for prioritizing MTFs within each KTA phase. The experts used a modified Delphi process to agree on an exemplar MTF for each of the three prioritized KTA framework phases. Finally, we reached consensus on the final MTFs and contacted the original MTF developers to confirm MTF versions and explore additional insights. RESULTS: We agreed on three criteria when prioritizing MTFs: acceptability (mean = 3.20, SD = 0.75), applicability (mean = 3.82, SD = 0.72), and usability (median = 4.00, mean = 3.89, SD = 0.31) of the MTF. The top-rated MTFs were the Iowa Model of Evidence-Based Practice to Promote Quality Care for the 'Identify the problem' phase (mean = 4.57, SD = 2.31), the Consolidated Framework for Implementation Research for the 'Assess barriers/facilitators to knowledge use' phase (mean = 5.79, SD = 1.12), and the Behaviour Change Wheel for the 'Select, tailor, implement interventions' phase (mean = 6.36, SD = 1.08). CONCLUSIONS: Our interdisciplinary team engaged in a rigorous process to reach consensus on MTFs reflecting specific phases of the implementation process and prioritized each to serve as an exemplar in which to embed intersectional approaches. The resulting MTFs correspond with specific phases of the KTA framework, which itself may be useful for those seeking particular MTFs for particular KTA phases. This approach also provides a template for how other implementation MTFs could be similarly considered in the future. TRIAL REGISTRATION: Open Science Framework Registration: osf.io/qgh64.

An intersectionality-based policy analysis framework: critical reflections on a methodology for advancing equity.

INTRODUCTION: In the field of health, numerous frameworks have emerged that advance understandings of the differential impacts of health policies to produce inclusive and socially just health outcomes. In this paper, we present the development of an important contribution to these efforts - an Intersectionality-Based Policy Analysis (IBPA) Framework. METHODS: Developed over the course of two years in consultation with key stakeholders and drawing on best and promising practices of other equity-informed approaches, this participatory and iterative IBPA Framework provides guidance and direction for researchers, civil society, public health professionals and policy actors seeking to address the challenges of health inequities across diverse populations. Importantly, we present the application of the IBPA Framework in seven priority health-related policy case studies. RESULTS: The analysis of each case study is focused on explaining how IBPA: 1) provides an innovative structure for critical policy analysis; 2) captures the different dimensions of policy contexts including history, politics, everyday lived experiences, diverse knowledges and intersecting social locations; and 3) generates transformative insights, knowledge, policy solutions and actions that cannot be gleaned from other equity-focused policy frameworks. CONCLUSION: The aim of this paper is to inspire a range of policy actors to recognize the potential of IBPA to foreground the complex contexts of health and social problems, and ultimately to transform how policy analysis is undertaken.

Critically examining diversity in end-of-life family caregiving: implications for equitable caregiver support and Canada's Compassionate Care Benefit.

INTRODUCTION: Family (i.e., unpaid) caregiving has long been thought of as a 'woman's issue', which ultimately results not only in gendered, but also financial and health inequities. Because of this, gender-based analyses have been prioritized in caregiving research. However, trends in current feminist scholarship demonstrate that gender intersects with other axes of difference, such as culture, socio-economic status, and geography to create diverse experiences. In this analysis we examine how formal front-line palliative care providers understand the role of such diversities in shaping Canadian family caregivers' experiences of end-of-life care. In doing so we consider the implications of these findings for a social benefit program aimed at supporting family caregivers, namely the Compassionate Care Benefit (CCB). METHODS: This analysis contributes to a utilization-focused evaluation of Canada's CCB, a social program that provides job security and limited income assistance to Canadian family caregivers who take a temporary leave from employment to provide care for a dying family member at end-of-life. Fifty semi-structured phone interviews with front-line palliative care providers from across Canada were conducted and thematic diversity analysis of the transcripts ensued. RESULTS: Findings reveal that experiences of caregiving are not homogenous and access to services and supports are not universal across Canada. Five axes of difference were commonly raised by front-line palliative care providers when discussing important differences in family caregivers' experiences: culture, gender, geography, lifecourse stage, and material resources. Our findings reveal inequities with regard to accessing needed caregiver services and resources, including the CCB, based on these axes of difference. CONCLUSIONS: We contend that without considering diversity, patterns in vulnerability and inequity are overlooked, and thus continually reinforced in health policy. Based on our findings, we demonstrate that re-framing categorizations of caregivers can expose specific vulnerabilities and inequities while identifying implications for the CCB program as it is currently administered. From a policy perspective, this analysis demonstrates why diversity needs to be acknowledged in policy circles, including in relation to the CCB, and seeks to counteract single dimensional approaches for understanding caregiver needs at end-of-life. Such findings illustrate how diversity analysis can dramatically enhance evaluative health policy research.

Attributing selected costs to intimate partner violence in a sample of women who have left abusive partners: a social determinants of health approach.

Selected costs associated with intimate partner violence were estimated for a community sample of 309 Canadian women who left abusive male partners on average 20 months previously. Total annual estimated costs of selected public- and private-sector expenditures attributable to violence were $13,162.39 per woman. This translates to a national annual cost of $6.9 billion for women aged 19­65 who have left abusive partners; $3.1 billion for those experiencing violence within the past three years. Results indicate that costs continue long after leaving, and call for recognition in policy that leaving does not coincide with ending violence.

Exploring the promises of intersectionality for advancing women's health research.

Women's health research strives to make change. It seeks to produce knowledge that promotes action on the variety of factors that affect women's lives and their health. As part of this general movement, important strides have been made to raise awareness of the health effects of sex and gender. The resultant base of knowledge has been used to inform health research, policy, and practice. Increasingly, however, the need to pay better attention to the inequities among women that are caused by racism, colonialism, ethnocentrism, heterosexism, and able-bodism, is confronting feminist health researchers and activists. Researchers are seeking new conceptual frameworks that can transform the design of research to produce knowledge that captures how systems of discrimination or subordination overlap and "articulate" with one another. An emerging paradigm for women's health research is intersectionality. Intersectionality places an explicit focus on differences among groups and seeks to illuminate various interacting social factors that affect human lives, including social locations, health status, and quality of life. This paper will draw on recently emerging intersectionality research in the Canadian women's health context in order to explore the promises and practical challenges of the processes involved in applying an intersectionality paradigm. We begin with a brief overview of why the need for an intersectionality approach has emerged within the context of women's health research and introduce current thinking about how intersectionality can inform and transform health research more broadly. We then highlight novel Canadian research that is grappling with the challenges in addressing issues of difference and diversity. In the analysis of these examples, we focus on a largely uninvestigated aspect of intersectionality research - the challenges involved in the process of initiating and developing such projects and, in particular, the meaning and significance of social locations for researchers and participants who utilize an intersectionality approach. The examples highlighted in the paper represent important shifts in the health field, demonstrating the potential of intersectionality for examining the social context of women's lives, as well as developing methods which elucidate power, create new knowledge, and have the potential to inform appropriate action to bring about positive social change.

Beyond sex and gender difference in funding and reporting of health research.

BACKGROUND: Understanding sex and gender in health research can improve the quality of scholarship and enhance health outcomes. Funding agencies and academic journals are two key gatekeepers of knowledge production and dissemination, including whether and how sex/gender is incorporated into health research. Though attention has been paid to key issues and practices in accounting for sex/gender in health funding agencies and academic journals, to date, there has been no systematic analysis documenting whether and how agencies and journals require attention to sex/gender, what conceptual explanations and practical guidance are given for such inclusion, and whether existing practices reflect the reality that sex/gender cannot be separated from other axes of inequality. METHODS: Our research systematically examines official statements about sex/gender inclusion from 45 national-level funding agencies that fund health research across 36 countries (covering the regions of the EU and associated countries, North America, and Australia) and from ten top-ranking general health (the top five in "science" and the top five in "social science") and ten sex- and/or gender-related health journals. We explore the extent to which agencies and journals require inclusion of sex/gender considerations and to what extent existing strategies reflect state of the art understandings of sex/gender, including intersectional perspectives. RESULTS: The research highlights the following: (a) there is no consistency in whether sex/gender are mentioned in funding and publishing guidelines; (b) there is wide variation in how sex/gender are conceptualized and how researchers are asked to address the inclusion/exclusion of sex/gender in research; (c) funding agencies tend to prioritize male/female equality in research teams and funding outcomes over considerations of sex/gender in research content and knowledge production; and (d) with very few exceptions, agency and journal criteria fail to recognize the complexity of sex/gender, including the intersection of sex/gender with other key factors that shape health. CONCLUSIONS: The conceptualization and integration of sex/gender needs to better capture the interacting and complex factors that shape health-an imperative that can be informed by an intersectional approach. This can strengthen current efforts to advance scientific excellence in the production and reporting of research. We provide recommendations and supporting questions to strengthen consideration of sex/gender in policies and practices of health journals and funding agencies.

Recent Suicide Attempts Across Multiple Social Identities Among Gay and Bisexual Men: An Intersectionality Analysis.

This study draws from intersectionality to describe variations in recent suicide attempts (RSA) among gay and bisexual men (GBM) across sociodemographics. Using survey data, logistic regression modeling explored RSA in two analytical stages: (1) the individual effects of each sociodemographic were measured; (2) two-way interaction terms between sociodemographics were tested and added to the models created in stage A. In stage A, only education and income achieved significance. In stage B, the study found that (a) education and income interacted significantly such that the odds of RSA increased for those with a lower income and a lower education; (b) sexual orientation and partnership status interacted, resulting in decreased odds among bisexual men in heterosexual partnerships; and (c) income and education interacted with geography; the effects of these variables were significant only among urban men. These findings suggest that GBM are at unequal risk of RSA according to intersecting sociodemographics.

The Importance of Community Consultations for Generating Evidence for Health Reform in Ukraine.

BACKGROUND: The paper presents the results of community consultations about the health needs and healthcare experiences of the population of Ukraine. The objective of community consultations is to engage a community in which a research project is studying, and to gauge feedback, criticism and suggestions. It is designed to seek advice or information from participants directly affected by the study subject of interest. The purpose of this study was to collect first-hand perceptions about daily life, health concerns and experiences with the healthcare system. This study provides policy-makers with additional evidence to ensure that health reforms would include a focus not only on health system changes but also social determinants of health (SDH). METHODS: The data collection consisted of the 21 community consultations conducted in 2012 in eleven regions of Ukraine in a mix of urban and rural settings. The qualitative data was coded in MAXQDA 11 software and thematic analysis was used as a method of summarizing and interpreting the results. RESULTS: The key findings of this study point out the importance of the SDH in the lives of Ukrainians and how the residents of Ukraine perceive that health inequities and premature mortality are shaped by the circumstances of their daily lives, such as: political and economic instability, environmental pollution, low wages, poor diet, insufficient physical activity, and unsatisfactory state of public services. Study participants repeatedly discussed these conditions as the reasons for the perceived health crisis in Ukraine. The dilapidated state of the healthcare system was discussed as well; high out-of-pocket (OOP) payments and lack of trust in doctors appeared as significant barriers in accessing healthcare services. Additionally, the consultations highlighted the economic and health gaps between residents of rural and urban areas, naming rural populations among the most vulnerable social groups in Ukraine. CONCLUSION: The study concludes that any meaningful reforms of the health sector in Ukraine must include a broad range of factors, including the healthcare system but importantly, must extend to SDH approach and include the prioritization of health promotion, limiting alcohol and tobacco availability and enforcing environmental protection.

The odd couple: using biomedical and intersectional approaches to address health inequities.

BACKGROUND: Better understanding and addressing health inequities is a growing global priority. OBJECTIVE: In this paper, we contribute to the literature examining complex relationships between biological and social dimensions in the field of health inequalities. Specifically, we explore the potential of intersectionality to advance current approaches to socio-biological entwinements. DESIGN: We provide a brief overview of current approaches to combining both biological and social factors in a single study, and then investigate the contributions of an intersectional framework to such work. RESULTS: We offer a number of concrete examples of how intersectionality has been used empirically to bring both biological and social factors together in the areas of HIV, post-traumatic stress disorder, female genital circumcision/mutilation/cutting, and cardiovascular disease. CONCLUSION: We argue that an intersectional approach can further research that integrates biological and social aspects of human lives and human health and ultimately generate better and more precise evidence for effective policies and practices aimed at tackling health inequities.

Beijing and beyond: women's health and gender-based analysis in Canada.

On the tenth anniversary of the Fourth World Conference on Women, held in Beijing, this article evaluates Canada's progress in the area of women's health by critically examining the Women's Health Strategy. Introduced in 1999 by Health Canada, the Strategy is considered Canada's key response to its international commitments for promoting women's health and in particular for implementing a gender-based analysis in all programs, services, policies, and research. By reviewing each objective of the Strategy, the article illustrates the limited progress that has been made to date. It provides arguments for why and how all levels of government should work to improve their response to women's health in Canada and, specifically, how the Women's Health Strategy can be redesigned to be more effective in attending to the needs and concerns of all Canadian women.

Women's health, men's health, and gender and health: implications of intersectionality.

Although intersectionality is now recognized in the context of women's health, men's health, and gender and health, its full implications for research, policy, and practice have not yet been interrogated. This paper investigates, from an intersectionality perspective, the common struggles within each field to confront the complex interplay of factors that shape health inequities. Drawing on developments within intersectionality scholarship and various sources of research and policy evidence (including examples from the field of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality and in particular, the wide-ranging benefits of de-centering gender through intersectional analyses.

Gender and health inequities: a comment on the Final Report of the WHO Commission on the Social Determinants of Health.

The Final Report of the World Health Organization (WHO) Commission on the Social Determinants of Health is a substantial and important contribution to understanding the social factors that shape global health inequities. Although gender is highlighted as a key social determinant of health, the report's conceptual approach inappropriately equates gender and health with women's health. This essay discusses the analytic and policy implications of this shortcoming.

The economic costs of child sexual abuse in Canada: a preliminary analysis.

This paper describes a study of the economic costs attributable to child sexual abuse in Canada for the 1997-98 fiscal year. The preliminary cost estimate of child sexual abuse in Canada exceeds $3.6 billion dollars annually. This includes both public and private costs across four policy areas: health, social/public services, justice, and education/research and employment. These estimates have important policy implications in the area of child sexual abuse. The effectiveness of remedies, and options for new initiatives, policies and programs can be further evaluated using these economic calculations.