Table 3 Reflective prompts using the intersectionality supplemented Consolidated Framework for Implementation Research

CFIR Domain: Outer setting

• How did the current structure (economic, political, geographical, environmental, structural (e.g., economic) and social context of the outer setting come to be (e.g., economic downturns, ideologies of government leaders, legal precedent)?

• How have different spheres (e.g., economic, political, and environmental) intersected to produce the current outer setting?

Patient needs and resources

• Do we accurately and comprehensively understand the diverse patient experience related to this intervention?

• How might a patient’s intersecting categories influence their experience related to this intervention?

• How have diverse patient perspective, values, needs, and voices been incorporated by the organization?

• How might previous work to integrate patient’s perspectives, values, and needs influence this intervention?

External policies and incentives

• To what extent are external strategies (e.g., policies, regulations, mandates, recommendations and guidelines, reporting) non-discriminatory and address institutional forms of marginalization (e.g., racism, sexism, ageism)?

• How might institutionalized forms of marginalization (e.g., racism, sexism, and ageism) influence the success of the intervention?

• To what extent are external strategies (e.g., policies, regulations, mandates, recommendations and guidelines, reporting) inclusive?

• What assumptions do external strategies make about those expected to change their behavior in the intervention (e.g., forms of (dis)ability, gender roles)?

• Do external strategies and incentives reinforce stereotypes? If stereotypes are reinforced, how might this influence the success of the intervention?

• Do all individuals and organizations have equal access to external strategies and incentives? How might this access influence the success of the intervention?

Outer structures and systems

• What systemic forms of oppression exist (e.g., sexism, ableism) within institutions? Who holds power in institutions?

• How are populations related to the intervention portrayed in the media?

• What structural inequities exist within the health area or population the intervention impacts?

Outer culture

• What assumptions does the society or community (outside the organization) make about those expected to change their behavior in the intervention (e.g., what assumptions does society make about the emergency room nurses expected to deliver a new questionnaire on fall prevention)?

• How might societal biases (hidden and overt) influence knowledge use? For example, does society respect the role of all health professionals equally (e.g., physiotherapists, nurses, physicians, physician assistants)?

• How might the roles that individuals are expected to play within society (e.g., gender roles) influence knowledge use?

• How does society view patients that are expected to use or be affected by knowledge use (e.g., what biases does society hold regarding older adults)?

CFIR Domain: Inner setting

• Who holds power within the organization? What intersecting categories do they represent? Are they similar intersecting categories to those whose behavior is targeted for change?

• How may these power relations affect the implementation intervention (positively and/or negatively)?

Networks and communications an organization.

• How might the principle of homophily (i.e., birds of a feather flock together) influence who has access to information and who does not? How might access to information impact the success of the intervention?

• Who are the leaders (formal and informal) at the organization? What intersecting categories do they represent? Are these leaders representative of the intersecting categories of those individuals expected to change their behavior?

• How might power structures influence informal communications? How might these communications affect the intervention?

• How does the organization support different ways of communicating? How can different ways of communicating support the success of the intervention?

• This includes physical access to communications (e.g., computers) and accessibility of communications (e.g., website meets accessibility standards).

• How might social structures influence informal communication systems? How might these informal communication systems impact the success of the intervention?

Inner culture

• What assumptions does the organization make about its staff? How might these assumptions influence the intervention?

• What assumptions does the organization make about the population it supports? How might these assumptions about the population influence the intervention?

• What are the values of the organization? How might these values influence the success of the intervention?

• How are projects prioritized? How might the prioritization process influence the intervention?

• What biases does the organization hold (hidden and overt)? Do these biases align, reinforce, or counter biases in the outer culture(s) (i.e., in broader society)? For example, does the organization assume the older adults are not active and frail?

Compatibility

(sub-construct to CFIR construct “Implementation climate”)

• Does the intervention align with the values, norms, ways of knowing, and existing workflow of those changing their behavior?

• What assumptions are being made about the abilities of those expected to change their behavior?

• What assumptions are being made about the workflow of those expected to change their behavior?

Organizational incentives and rewards

(sub-construct to CFIR construct “Implementation climate”)

• Does everyone in the organization have the same access to organizational incentives and rewards? How might this reward access impact the success of the intervention?

• Are there hidden or overt biases towards those who attain formal (e.g., promotions) or informal (e.g., stature or respect) organizational rewards? How might these biases influence the success of the intervention?

• Is the range of values and preferences of those whose behavior we are trying to change considered when establishing incentives? (i.e., do all people value the proposed or available incentives and rewards)?

Learning climate

(sub-construct to CFIR construct “Implementation climate”)

• How do leaders in the organization display vulnerability or considerations of power re-distribution? How might this leadership behavior influence the success of the intervention?

• Do all individuals expected to change their behavior have equitable access to sufficient time and space for reflective thinking and evaluation in multiple venues/means (e.g., do part-time staff or those who work from home have protected time for reflection)?

Access to knowledge and information

(sub-construct to CFIR construct “Readiness for implementation”)

• Does everyone involved in the intervention have access to information in a format that works for them?

• Have individual representatives of different user groups contributed to the creation and dissemination of the knowledge?

• Has the source of information been critically appraised by a diverse group of people occupying diverse intersecting categories?

• How does literacy, health literacy, ehealth literacy, vision, numeracy, impact access and digestibility of information about the intervention?

• Does the knowledge use universally understood analogies?

• Avoid using culture-specific analogies (e.g., sports terminology such as “hit a home run”)?

• Avoid using potentially offensive or triggering language (e.g., “in the trenches”).

CFIR Domain: Characteristics of Individuals

• What assumptions do individuals expected to change their behavior make about those affected by the intervention (e.g., what do providers assume about patients in precarious housing situations)?

• What assumptions are made about the agency of those expected to change their behavior? What do they have control over?

• How might the categories of the individuals expected to change their behavior intersect? How might these intersecting categories affect individuals’ interactions with others?

Knowledge and beliefs about the intervention and those receiving the intervention

• How might an individual’s intersecting categories (e.g., age, education, gender) influence their access to the facts, truths, and principles related to the intervention?

• How might an individual’s intersecting categories influence their knowledge and beliefs toward an intervention?

• How might an individual’s intersecting categories affect the value placed on the intervention in comparison to competing priorities?

Self-efficacy

• What, beyond an individual, may impact their self-efficacy (e.g., gender stereotypes)?

• How might an individual’s intersecting categories impact their self-efficacy to execute the intervention?

• How might systems of oppression (e.g., racism, sexism, and ageism) affect individuals’ self-efficacy to deliver the intervention?

Other personal attributes

• Reflect on our assumptions of what attributes we classify as modifiable by an individual. What external influences, beyond the individual, may be influencing these attributes?

• Think broadly: what intersecting categories and personal dimensions may influence the intervention? What is the relationship between these categories?

• Are the categories conceptualized in an additive or multiplicative way (e.g., values + learning style) or are they conceptualized as connected? Focus on the interdependencies and mutual constitution of these categories as opposed to considering them as independent categories.

• For those expected to change their behavior, what intersecting categories may be most influential (e.g., the intersection of values and tolerance for ambiguity)?

• How may an individual’s life experiences shape the traits (e.g., education) that enable them to engage in the target behavior?