Development and usability testing of tools to facilitate incorporating intersectionality in knowledge translation

Complexity and context are recognized as critical for implementation of evidence-informed health services and policies [1, 2]. Among many complex contextual factors, social factors, “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the condition of daily life” [3], are consistently identified as key determinants of health and health inequities [4, 5]. Implementation science, and the field of knowledge translation (KT) more broadly, has been criticized for neglecting social factors such as gender [6] and equity [7] and perpetuating inequities due to foundational evidence that underrepresents key populations such as women and racialized communities [8]. Numerous efforts are underway that address these criticisms, including calls for explicit consideration of equity in every implementation project [9], synthesis of implementation equity effectiveness data, adaptation of conceptual frameworks, and development of guidance to support integrating equity considerations specifically in implementation research and practice [10‐12] and more broadly in evidence-based decision-making to address global societal challenges [13].

Intersectionality is one approach that can advance equity considerations in KT and implementation. Intersectionality, a term coined by Dr. Kimberle Crenshaw [14], is a theoretical approach based on the work of Black feminist and critical race scholars who identified and emphasized how Black women faced multiple and intersecting forms of oppression [15‐17]. In the context of health, Hankivsky and colleagues described how intersectionality “focuses on the ways in which multiple axes of social inequality intersect and co-construct one another at the macro and micro levels to produce a broad range of unequal outcomes, in both individual and population health” [18]. Axes of social inequality include (but are not limited to) experiences of racism, classism, heteronormativity, cisnormativity, ageism, audism, and xenophobia. The social intersections inhabited by an individual are not inherently additive [19] and reflect larger systems of privilege and/ or exclusion [20]. As such, intersectionality explains how a person’s experiences of oppression and/ or privilege may shift depending on the specific situation and highlights how these experiences and inequities unfold within complex health and social system structures (Fig. 1).

We propose that taking an intersectional approach may improve the design, delivery, receipt, effectiveness, and impact of KT and implementation interventions by more directly addressing specific health inequities affecting individuals and groups. Conversely, neglecting intersecting social factors in KT and implementation may perpetuate inequities leading to poor health outcomes [21]. For example, an analysis of census data in Ontario, Canada showed that neighbourhoods with a higher concentration of people of colour during the COVID-19 pandemic had three times higher COVID-19 infection rates, four times higher hospitalization rates, and deaths twice as high compared to neighbourhoods with lower concentrations of people of colour [22]. People of colour are more likely to be employed in work most negatively affected by the pandemic (e.g., food services); newcomers are also overrepresented in jobs with greater potential exposure to COVID-19 [22]. Accordingly, newcomers who are people of colour face compounded challenges in health and well-being due to intersections in social determinants of health [22]. If public health strategies do not use an intersectional lens, we risk that these populations will continue to bear the brunt of morbidity and mortality in future COVID-19 waves. However, despite arguments supporting the principles of intersectionality, intersectionality is critiqued for being difficult to apply [23]. Practical guidance and strategies for applying intersectionality in KT and implementation are warranted. As such, our objective in this project was to develop, evaluate and refine a suite of tools to support the application of intersectionality in KT. Our ultimate goal of developing these tools is to increase knowledge, facilitate positive attitudes, and support adoption of intersectional considerations in KT.

We used a collaborative, reflective, comprehensive and rigorous approach to create a suite of tools to support the development of KT interventions that consider intersectionality. Our collaborative and reflective approach required us to be both responsive and iterative. For example, the development committee chose to focus the tools on each prioritized KTA phase rather than the associated intersectionality-enhanced MTFs. We see this focus as a strength that increases tools’ applicability because users are not limited to using the resources with a specific MTF. A second key point of response was the development committee’s decision to revise the focus of one tool on selecting and tailoring implementation interventions, reducing the emphasis on implementation of interventions, in response to usability test feedback.

Our comprehensive and rigorous approach is consistent with other tool development methods reported in implementation science [50, 51]. A framework for implementation tool development published after this project was launched emphasizes several components included in our development process, such as explore (define), develop, and integrated knowledge translation. We are also addressing evaluation and action planning through our ongoing work evaluating the effects of the tools when applied in an established KT training program. Our tools are distinguished from existing intersectionality guides [52, 53] in two important ways: first, the explicit focus on incorporating intersectionality in KT and implementation research and practice; and second, the explicit reporting of our methodology and approach for tool development. While other intersectionality guides have been identified as using a collaborative approach [52], few (if any) details are reported. There may be different standards for development and reporting for guides across disciplines, and while recognized as important in implementation science, it should not be viewed as a limitation of other guides. An important strength of this project is our interdisciplinary approach, in which we are among the first to bring together people working in both intersectionality and knowledge translation. Team and committee members addressed different foundational knowledge bases, biases and interpretations and were able to come together to produce the tools. This process was not straightforward, and we discuss in a companion paper the challenges, opportunities and tensions we worked through as a team [26].

We recognize the limitations of tools and the series of projects as a whole. Our overall project does not address all components of intersectionality equally. Prior to the current phase of tool development, the overall project team decided to focus on increasing consideration of intersecting social factors in KT, prioritizing this as an appropriate “first step” for our target knowledge user group (KT intervention developers). Other important features of intersectionality, in particular, power, privilege and social justice, were addressed through an embedded approach within the tools. We acknowledge known criticisms of our type of approach. Rice and colleagues argued that “it does intellectual disservice to coopt the parts of a theory that are compatible with existing structures and power relations (for the technical work the theory does in managing complexity) while ignoring aspects of the theory that orient to intervening in those structures and relations to liberatory ends” [23]. The overall project team’s decision to focus on intersecting social considerations may relate in part to the historical traditions of implementation science that do not explicitly consider social justice [54], and may reflect implicit biases towards aspects of intersectionality that are more congruent with implementation conventions. We maintain that even this introductory approach to intersectionality has disruptive potential for KT and implementation science. We recognize that while it is not always necessary to always address all intersections, it can be challenging to determine which components are relevant to the topic at hand, and thus tools need to support the full complement of intersectionality. We will continue to address this limitation in future work, and in the interim refer readers to complementary intersectionality guides with a stronger focus on advocacy and social justice [26].

A second important limitation of our work was that despite our efforts to engage diverse perspectives, not all voices are represented. We recognize that those involved in the project represent a limited range of privileged identities. We acknowledge that our tools were developed with mostly Canadian input, and entirely from high income countries. We recognize that we did not address Indigeneity, which is important in light of Canada’s colonial history (and relevant around the world). We address this limitation in detail on our project website [55]. The limited extent of Indigenous considerations has also been recognized in other intersectionality tools [56], which may reflect ongoing debates about the challenges associated with talking about Indigeneity using intersectionality, as there are questions as to whether this framework is appropriate for addressing colonial legacies and Indigenous values [57, 58]. Lastly, we recognize our methodological limitations whereby we only conducted a single round of usability testing due to financial constraints, and that we did not transcribe interviews due to budget limitations. However, interviews were recorded and reviewed by two staff members to identify salient data.

Our work makes important advancements to KT. The project as a whole has advanced explicit theoretical considerations of intersectionality in established frameworks, and in KT intervention planning. We developed practical tools that can be used by KT intervention developers to embed intersectionality into KT initiatives, going beyond recommending the use of intersectionality to providing practical guidance on how to do this. Our tools may help ensure that KT planning and resultant interventions are inclusive and have the most potential to help the most people. We invite readers to use the tools and report on their experiences with them so that we can learn, improve future iterations, and examine their effectiveness.