Received Jul 26; Accepted Oct This article has been cited by other articles in PMC. Abstract Background There has been a recent swell in activity by health research funding organizations and science journal editors to increase uptake of sex and gender considerations in study design, conduct and reporting in order to ensure that research results apply to everyone.
However, examination of the implementation research literature reveals that attention to sex and gender has not yet infiltrated research methods in this field. Discussion The rationale for routinely considering sex and gender in implementation research is multifold.
Sex and gender are important in decision-making, communication, stakeholder engagement and preferences for the uptake of interventions. Gender roles, gender identity, gender relations, and institutionalized gender influence the way in which an implementation strategy works, for whom, under what circumstances and why.
There is emerging evidence that programme theories may operate differently within and across sexes, genders and other intersectional characteristics under various circumstances. Furthermore, without proper study, implementation strategies may inadvertently exploit or ignore, rather than transform thinking about sex and gender-related factors.
Techniques are described for measuring and analyzing sex and gender in implementation research using both quantitative and qualitative methods. Summary The present paper describes the application of methods for integrating sex and gender in implementation research. Consistently asking critical questions about sex and gender will likely lead to the discovery of positive outcomes, as well as unintended consequences. The result has potential to strengthen both the practice and science of implementation, improve health outcomes and reduce gender inequities.
Electronic supplementary material The online version of this article doi: Sex, Gender, Knowledge translation, Implementation science, Realist evaluation, Gender transformative approaches Background Efforts to integrate sex and gender throughout all phases of the health research cycle have been rising sharply over the past two decades [ 1 — 4 ]. As of , the U. National Institutes of Health Research asks applicants to explain how they plan to factor consideration of sex as a biological variable into their research design and analysis [ 7 , 8 ].
Journal editors are encouraged to increase accountability around sex and gender reporting requirements, by using the Sex and Gender Equity in Research SAGER guidelines [ 10 , 11 ]. These events beg the question: For the purpose of this article, we will use the term implementation research and practice IRP to include knowledge translation, implementation research and practice. The opening argument for this debate article is that to date, despite the evidence on the impact of sex and gender on health, research methods in the field of implementation have neglected sex and gender considerations.
An analysis of selected literature in IRP supports this proposition. For example, a review of the tables of contents and indexes of three popular implementation science texts [ 12 — 14 ] reveals that none devote a chapter to the role of sex and gender in implementation science. Searching the top 10 articles of as reported by Implementation Science see Additional file 1: Sex and gender also do not appear to play a prominent role in implementation theories.
Furthermore, neither of the germinal papers on the Theoretical Domains Framework [ 20 , 21 ], a widely used and influential framework [ 22 ] that guides assessment of barriers to implementation, makes any reference to sex or gender. A recent assessment of a sample of systematic reviews from these two groups however, reveals limited consideration of sex and gender in the written report. It is possible that the review authors did consider sex and gender in their analyses and determined it was unimportant.
However, they failed to report this. Little research has been undertaken or reported to inform how sex and gender impact IRP, as evidenced by this analysis of key texts, well-used conceptual models, and Cochrane reviews on implementation strategies.
The objective of this paper is to describe the rationale for why and how sex and gender should be considered in IRP. Discussion What is sex? A first step for understanding how to integrate sex and gender in IRP involves operationalizing the two terms, and recognizing different components of gender. The term sex refers to a biological construct, whereby an individual is defined as being male or female according to genetics, anatomy and physiology [ 6 , 7 , 11 , 28 — 32 ].
Researchers should use the term sex when describing the number of male or female patients or committee members, or when stratifying outcomes by male versus female participants or health care providers.
Gender norms influence commonly accepted ways of how people behave, how they perceive themselves and each other, how they act and interact, and the distribution of power and resources in society [ 6 , 28 , 31 — 35 ]. Researchers often understand gender as a function of gender roles e. Gender as a broad term can also refer to the expressions and identities of girls, women, boys, men, and gender diverse people [ 39 , 40 ].
For this reason, definitions of sex and gender are evolving as science changes, and it remains challenging to easily separate the biological from the social.
Sex and gender are often interrelated, interactive and potentially inseparable [ 6 , 11 ]. Given the epistemology of knowledge, and the social nature of implementation and behavior change, the effect of gender and other identity factors, either alone or in combination, can serve as barriers or enablers to the outcome or impact of IRP interventions.
Measuring and understanding sex and gender Collecting and analyzing data on sex in IRP is relatively simple if using typical male and female categories. Sex can be self-reported, designated by an examination of external genitalia, or genetically determined based on an XX, XY or intersex genotype [ 11 ]. Data on sex-related factors can include measuring sex hormones, body and organ size, metabolism, or fat tissue distribution [ 41 ].
Gender is more complex, and can be operationalized along four different constructs: Gender roles often categorize and define individuals within the family, the labour force, or the educational system. May form the basis for stereotypes. How can considering gender roles help us understand and anticipate barriers and opportunities facing health-care professionals in the uptake of new interventions? How can considering gender roles help inform dissemination strategies that are successful in reaching different audiences where they are?
The Gender Role Conflict Index [ 73 ] Other variables such as occupation [ 45 ], primary breadwinner status, time doing household chores and caregiving responsibilities can also be used to capture gender roles in data collection and analysis [ 46 ]. Gender identity [ 6 , 28 , 32 , 39 , 40 , 42 ] Describes how we see ourselves, and are seen by others, as female or male, or across a feminine-masculine continuum. Gender identity affects our feelings and behaviors.
The BEM sex role inventory [ 74 ] The Personal Attributes Questionnaire [ 75 ] Should the content of the implementation intervention consider gender identity or sexual orientation? Gender relations [ 6 , 28 , 33 ] Refers to how we interact with or are treated by people in the world around us, based on our ascribed or experienced gender.
How might the outcomes of implementation interventions differ by sex and gender according to whether the degree to which the geographic setting is culturally homogeneous, diverse or gender equitable? What are the implications of an implementation intervention being communicated or delivered to women only, men only, men and women separately or together? How is this mediated by cultural context? Institutionalized gender [ 6 , 28 , 33 ] Reflects the distribution of power between men and women in the political, educational, and social institutions in society.
The institutionalized aspect of gender also shapes social norms that define, reproduce, and often justify different expectations and opportunities for men and women. If particular decision-maker groups value, use, or require, different kinds of knowledge, have you considered how institutionalized gender might play a role? How might this change over time?
How can dissemination messages be crafted in a way that responds to sex and gender—related factors without reproducing or exploiting any negative stereotypes embedded in institutionalized gender? The use of qualitative methods e. Open in a separate window Traditionally, individuals are asked to categorize their sex as male or female and many assumptions, often based in gender and not biology, are made on the basis of their responses. Researchers are now rethinking this approach to be more inclusive of gender identity and expression [ 39 ].
Similarly, participants could also be given the option to disclose sexual orientation and whether they consider themselves part of the lesbian, gay, bisexual or transgender LGBT community. Researchers can also create gender scales using gender-related variables of relevance to their particular research topic [ 45 , 46 ].
They were able to demonstrate that gender, independent of sex, predicts poor outcome after acute coronary syndrome, pointing to new areas of intervention [ 44 ]. Qualitative methods are also useful for the collection of data on specific dimensions of gender. Qualitative methods can also be used to explore concepts of institutionalized gender, and to gain a more in-depth understanding of gender as a barrier or enabler to the use of implementation interventions, the uptake of the evidence-informed clinical interventions or program and the outcomes of implementation efforts.
A number of texts, casebooks, examples and online courses are available that provide guidance on how to conduct sex and gender science using commonly employed quantitative and qualitative methods [ 6 , 32 , 42 , 43 ].
The case for considering sex and gender in implementation research methods Emerging evidence suggests that sex and gender are important in decision-making, stakeholder engagement, communication and preferences for the uptake of interventions. Furthermore, when gender norms, identities and relations are ignored, unintended consequences may occur. The following five scenarios give examples of when and why sex and gender should be measured and considered in implementation research: When the implementation of an intervention requires decision-making on the part of individuals or organizations.
Decision-making is a critical component of behavior change interventions, and plays a key role in the uptake of new organizational practices and programs [ 47 ]. Research from the fields of business and management offer insights for IRP on important sex and gender factors related to decision-making [ 48 — 50 ]. Qualitative research conducted by Deloitte Consulting with 18 large business organizations suggests that female executives have a tendency to be more attuned to micro-level signaling during meetings, and may favour discovery options and iterative thinking during decision-making processes [ 48 ].
Male executives tend to end a conversation once they connect with a good idea or solution. Different leadership traits among male and female leaders can therefore influence the outcome of decision-making processes [ 49 , 50 ]. When sex and gender dynamics may play a role in stakeholder engagement and conflict resolution. Females may also engage in more collaboration and consensus building, not only to make sound decisions but also to elicit common support for a course of action [ 49 , 50 ].
The outcome of an implementation intervention may therefore depend on the sex and gender dynamics in each particular context. When communication strategies are being tested, as sex and gender may be differentially responsive to the choice of language used, the strength of persuasion of the communication strategy, and the way promotional information is processed.
The way messages and interventions are primed or packaged to reflect gender norms or stereotypes may also influence the outcomes of health promotion interventions. For instance, priming individuals to the perception that women eat healthier foods than men leads both male and female study participants to prefer healthy foods, whereas priming masculinity results in unhealthy food preferences [ 53 ].
When the packaging and healthiness of the food are gender congruent i. When negative or harmful gender stereotypes may impede the uptake and outcomes of an IRP initiative [ 54 ]. A realist review of the implementation of school-based interventions to prevent domestic abuse for children and young people reported that lesbian, gay, bisexual and transgender youth felt excluded from the programmes, as the content did not address gender identity or sexual orientation in high-risk populations [ 55 ].
Similarly, data suggest that masculine norms around emotional control and self-reliance are associated with recurrent non-suicidal self-injury [ 56 ]. Stigma related to healthcare seeking for male depression and suicide [ 57 , 58 ], may explain why women are more likely to benefit from psychosocial treatment for the prevention of suicide and suicidal ideation compared to men [ 59 ].
Some studies purport that gender bias in prescription patterns among health care providers results in more women receiving treatment with antidepressants for mental health [ 60 ] and pain symptoms, but only among female clinicians [ 61 ]. Men, on the other hand, may be preferentially managed with orthopaedic surgery to manage knee arthritis [ 62 ]. However, in some cases these programs exacerbated gender relations and gender inequalities, such as when women were pressured to give the phones provided by the program to their husband if he did not already own a phone, or when conflicts about phone use led to cases of spousal abuse.
The World Health Organization outlines a spectrum of gender-responsive programs, illustrating the progression from the exploitative use of gender stereotypes in IRP messaging, through to accommodation and ultimate transformation to gender equity Fig. Making active choices reflecting content, messaging and decision-making processes during the implementation of an intervention can have a critical impact on gender equity for women and men. Gender transformative approaches are preferred as they anticipate unintended barriers and consequences and address the causes of gender-based health inequities where they exist [ 67 ].
Recent guidance based on qualitative research suggests de-linking messages for men and for women when promoting tobacco reduction during pregnancy and post partum, since the uptake of the intervention can be hindered by negative couple dynamics if the partners have different smoking behaviours or attitudes about smoking during this period [ 68 — 70 ].
Another transformative approach to encourage uptake of smoking cessation interventions would be to focus on a wider range of non-stereotypical gendered roles that include fathering for men and work for women as potential motivators.