Implementation research is neither a single nor linear activity but a continuous, cyclical process that adopts the six steps outlined in this Toolkit.
Although an intersectional gender lens may be incorporated throughout the IR cycle, it should be incorporated as early as possible, such as during the study problem identification and proposal development phases. Further, it is recommended that an intersectional gender perspective is sustained throughout the entire IR cycle (Fig. 5) i.e., from contextualization of the research to dissemination and utilization of the research findings).21 (See: Road map of an IR project)
Since IR operates in real-life contexts where several factors including gender and other social factors intersect, researchers should adopt an intersectional gender approach during the IR stakeholder and community engagement processes, project execution and dissemination of research findings (Table 2).
For a successful IR project, a competent interdisciplinary research team (with expertise in biomedical and social sciences) must be assembled, and relevant stakeholders/community members must be identified and actively engaged. (See: Forming research teams, stakeholder analysis and community engagement sections)
A multidisciplinary team comprising researchers, policy-makers, programme implementors and health care providers is the core requirement for any IR project. The team should include social science researchers with the knowledge, experience and expertise needed to incorporate and apply an intersectional gender approach in health research. While designing the study, adopt an ‘insider perspective’ that relates to and identifies with the lived experiences of the study participants. This is important because it promotes empathy, trust and rapport-building, and ensures the research project is sensitive to the needs and experiences of participants.23 To achieve this, all research team members should reflect upon and recognize how their own values, experiences, knowledge and social positions may influence the research process and outcomes. Researchers can accomplish this through a reflexivity process, which is a cultivated awareness of the influence of relevant identity and power differentials. Reflexivity can help to transform the process of public involvement in health research when both researchers and engaged public research partners bring critical self-awareness about the assumptions and truths in their work12 (Table 3).
Furthermore, as researchers, you should be cognizant that reflexivity is a continuous process of engaging with and articulating the position of the researcher and the context of the research. The process involves the researcher exploring how their own social variables such as gender identity, ethnicity, level of education, age, religion etc., may affect fellow researchers, study participants and the entire research process. Therefore, an intersectional gender approach calls for a reflexive and continuous examination of the research context, including recognition of how biases influence researcher’s activities, and analysis of how multi-level factors interact during the research process and influence forces shaping health-related conditions.14
Stakeholders have been defined as individuals, organizations and communities that have a direct interest in the process and outcomes of a project, research or policy endeavour.24,25 Stakeholders include those people for whom the research will be beneficial. The type and number of stakeholders will vary depending on the nature of the research problem, but typically include research participants and other community members, policy-makers, government officials, health workers, funding agencies, programme officers, development workers and the researchers themselves. Since IR and intersectional gender analysis are participatory in nature, researchers should pay special attention to engaging stakeholders so that the group is diverse enough to include all stakeholders relevant to your IR study. Conducting a stakeholder analysis helps to understand the context of the intervention as well as to identify all relevant stakeholders, assess how they are likely to be affected by the research, and how they might respond to the research outcome. Similarly, it helps you as a researcher to identify their needs, understand their priorities and plan how to respond to them. The process of stakeholder identification and engagement should be iteratively led by the researchers and incorporated throughout the IR project cycle.
An intersectional gender perspective should be considered while selecting stakeholders from all relevant organizations and segments of the population. To ensure diversity of participants, consider how gender and other social variables impact on who wants to be involved, who can be involved, how those who are involved interact with each other and how that affects their contributions. As researchers, it is good to be cognizant that gender-related power dynamics influence stakeholder participation. During stakeholder meetings, the moderator has a key role in identifying stakeholders who are shy or being overridden by other participants, and encouraging them to engage and participate in the discussions. For example, female participants might not speak up if male participants consistently override them while speaking, but the moderator can encourage the female participants to speak. Power and position of a participant can also influence the engagement of other participants. For example, if two persons from the same organization with different hierarchical positions are involved, the junior person might not speak and shy away from taking leadership even when they have better knowledge and competence than their senior colleague(s). The key steps for conducting a stakeholder analysis are:
In addition, you should be mindful that the social variables of individuals involved in designing the study, recruiting participants, collecting, analysing and disseminating data are critical to effectively respond to the specific needs of the study participants.
Community engagement is vital throughout an IR project, building on the strengths and resources within the community. ‘Community’ may be understood as a group of people who live in the same local geographical area or who have some other non-spatial element of shared social identity, such as a similar trade or group membership, or organized entities that operate within a community such as local government, district health teams, or other community-based organizations, such as religious or civil society groups.26,27 Community engagement is the meaningful, respectful and fit-for-purpose involvement of community members in one or more aspects of an IR project.27
Actively engage the community throughout the entire IR cycle (i.e. from problem conceptualization during the design and development of the research proposal, project planning and implementation, data collection, analysis, and interpretation of results). This involves consultation, communication, participation, partnerships and raising awareness. Community engagement also provides a conducive co-learning environment for both the researchers and the community, which is based on the communities’ experiences, historical and current social cultural context. In addition, it builds trust and rapport that aids the entire research process, enhancing a timely balance between research and action.28,29 (See: Eight reasons for community engagement in IR projects)
Table 4 summarizes the role of community engagement at the different phases of the IR cycle, and also highlights potential opportunities to incorporate an intersectional gender perspective.
Box 2 provides an example describing how engaging the community enabled implementers to identify the appropriate and effective medicine distribution points in a mass drug administration (MDA) programme for neglected tropical diseases (NTDs) in four west African countries.
Box 3 presents an example describing how community engagement with the Indigenous people in Australia was key in linking them with the health system, improving local health services, increasing their trust and access to care.
Study conceptualization that is rooted in gender and intersectionality analysis frameworks can examine the complex systems of feedback loops and interactions between different levels of the intersectionality wheel.34 (See: More information on IR feedback loops). The first step to incorporate an intersectional gender lens or approach in IR should be during the conceptualization of the research project.22 This can be systematically carried out through the collective engagement of relevant stakeholders. To avoid any potential conflicts arising later in the research process regarding interpretation of concepts, the definitions of social variables and research outcomes should be clear and concise from the outset. The definitions should be in alignment with the social, cultural, economic, political and historical context of the selected community or geographic location. You may start the process by brainstorming through the concepts awnd terminologies. It is also helpful to consult prior work done in that region to understand how the local community members perceive certain terminologies. It is critical for all team members to clearly understand the concepts and definitions before you proceed.
After your team has agreed on the relevant concepts and definitions, incorporating an intersectional gender approach allows for critical reflection about how gender intersects with other social variables in the context in which the study participants live and where the health interventions would ultimately be implemented. This enables exploration and understanding of these intersections and the societal and institutional factors that facilitate or impede a given IR study. Further guidance on incorporating an intersectional gender analysis throughout the six steps of the IR process to achieve the desired outcomes is highlighted in Figure 6.
Due consideration should be given to gender domains and social variables that are relevant to a specific research problem. Such an intersectional gender analysis process is a critical step and if it is skipped, then important social variables – that may play a significant role within a given study context – could be overlooked.35 (See: Related module of Module 3 of the WHO/TDR Intersectional gender analysis toolkit)
Various health system frameworks have evolved over time. WHO defines a health system as: “All organizations, people and actions whose primary intent is to promote, restore or maintain health”.36,37 The ‘building blocks’ of the WHO Health Systems Framework can be used as a guide by IR teams to assess how each of the building blocks might be implicated in the health intervention under study, as well as in the solutions to identified barriers. (See: WHO health systems framework)
Health systems are not gender neutral; gender is a key social variable and affects health system needs, experiences and outcomes.19,38 When designing and implementing health systems interventions, it is often assumed that an intervention will be equally effective for men, women and people of other gender identities across all socioeconomic strata.39 It is important to be cognizant that implementers often fail to recognize how power relations related to gender can affect how someone interacts with, accesses, uses or generally responds to a specific health intervention.19
An individual’s experiences while accessing health services also shape their decisions regarding utilizing a health intervention. For example, if an adolescent unmarried girl visiting a health facility for information on oral contraceptives is ridiculed or judged by a health worker for seeking such information, she will prefer not to seek care from that health facility irrespective of the best intervention rolled out in the future targeted for adolescent girls. Figure 7 shows how the intersectionality wheel is intrinsically linked to the health system, and can also affect the uptake of a health intervention in a given IR project.