Developing the intersectionality supplemented Consolidated Framework for Implementation Research (CFIR) and tools for intersectionality considerations.

BACKGROUND: The concept of intersectionality proposes that demographic and social constructs intersect with larger social structures of oppression and privilege to shape experiences. While intersectionality is a widely accepted concept in feminist and gender studies, there has been little attempt to use this lens in implementation science. We aimed to supplement the Consolidated Framework for Implementation Research (CFIR), a commonly used framework in implementation science, to support the incorporation of intersectionality in implementation science projects by (1) integrating an intersectional lens to the CFIR; and (2) developing a tool for researchers to be used alongside the updated framework. METHODS: Using a nominal group technique, an interdisciplinary framework committee (n = 17) prioritized the CFIR as one of three implementation science models, theories, and frameworks to supplement with intersectionality considerations; the modification of the other two frameworks are described in other papers. The CFIR subgroup (n = 7) reviewed the five domains and 26 constructs in the CFIR and prioritized domains and constructs for supplementation with intersectional considerations. The subgroup then iteratively developed recommendations and prompts for incorporating an intersectional approach within the prioritized domains and constructs. We developed recommendations and prompts to help researchers consider how personal identities and power structures may affect the facilitators and inhibitors of behavior change and the implementation of subsequent interventions. RESULTS: We achieved consensus on how to apply an intersectional lens to CFIR after six rounds of meetings. The final intersectionality supplemented CFIR includes the five original domains, and 28 constructs; the outer systems and structures and the outer cultures constructs were added to the outer setting domain. Intersectionality prompts were added to 13 of the 28 constructs. CONCLUSION: Through an expert-consensus approach, we modified the CFIR to include intersectionality considerations and developed a tool with prompts to help implementation users apply an intersectional lens using the updated framework.

Sex-Specific Differences in the Association Between Childhood Adversity and Cardiovascular Disease in Adulthood: Evidence From a National Cohort Study.

BACKGROUND: Childhood adversity increases the risk for cardiovascular disease (CVD) in adulthood. Previously proposed mechanisms suggest that the association is mediated by stress reactivity-known to be higher in women-and is aggravated by adult stress, but this has not yet been confirmed. Therefore, we investigated sex differences to better understand possible pathways from childhood adversity to CVD. METHODS: The National Population Health Survey, a 15-year cohort study of Canadians aged 18-49 years at baseline was used. Logistic regression with interaction terms for sex and stressful life events was used to assess the risk of CVD after childhood adversity. In secondary analyses, we assessed mediation effects of depression, smoking, alcohol, exercise, and diet using the product of coefficient approach. Mediated moderation was subsequently used to explain sex-moderated effects. RESULTS: There was a strong association between childhood adversity and CVD (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.56-2.94) for 3+ childhood adversities. The association was stronger with increasing stressful events, and female patients with 3+ stressful events exhibited the highest risk of CVD (OR, 4.40; 95% CI, 1.98-9.75). No association was found in men. Depression, smoking, and poor diet partially mediated the relationship between childhood adversity and CVD (14%, 9%, and 9%, respectively), but differences in these behaviours did not fully explain the sex-specific differences in the mediated moderation analysis. CONCLUSIONS: The effect of childhood adverse events on CVD is heightened among women, particularly women with stressful adulthoods, and this difference is not mediated by depression, smoking, or poor diet. These findings have important implications for understanding sex differences in CVD risk.

Stress and development of depression and heavy drinking in adulthood: moderating effects of childhood trauma.

PURPOSE: Studies suggest that childhood trauma is linked to both depression and heavy drinking in adulthood, and may create a lifelong vulnerability to stress. Few studies have explored the effects of stress sensitization on the development of depression or heavy drinking among those who have experienced traumatic childhood events. This study aimed to determine the effect of childhood trauma on the odds of experiencing depression or heavy drinking in the face of an adult life stressor, using a large population-based Canadian cohort. METHODS: A total of 3,930 participants were included from the National Population Health Survey. The associations among childhood trauma, recent stress and depression/heavy drinking from 1994/1995 to 2008/2009 were explored using logistic regression, as were interactions between childhood trauma and recent stress. A generalized linear mixed model was used to determine the effects of childhood trauma and stressful events on depression/heavy drinking. Analyses were stratified by sex. RESULTS: Childhood trauma significantly increased the odds of becoming depressed (following 1 event: OR = 1.66; 95%CI 1.01, 2.71; 2+ events, OR = 3.89; 95%CI 2.44, 6.22) and drinking heavily (2+ events: OR = 1.79; 95%CI 1.03, 3.13). Recent stressful events were associated with depression, but not heavy drinking. While most interaction terms were not significant, in 2004/2005 the association between recent stress and depression was stronger in those who reported childhood trauma compared to those with no childhood trauma. CONCLUSIONS: Childhood trauma increases risk for both depression and heavy drinking. Trauma may moderate the effect of stress on depression; the relationship among trauma, stress and heavy drinking is less clear.