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Equity-focused knowledge translation: A framework for "reasonable action" on health inequities

  • Saskatchewan Population Health and Evaluation Research Unit

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To identify gaps in procedural approaches to knowledge translation and outline a more relational approach that addresses health inequities based on creating collaborative environments for reasonable action. A literature review encompassing approaches to critical inquiry of the institutional conditions in which knowledge is created combined with a process for encouraging reflexive professional practice provide the conceptual foundation for our approach, called equity-focused knowledge translation (EqKT). The EqKT approach creates a matrix through which teams of knowledge stakeholders (researchers, practitioners, and policymakers) can set common ground for taking collaborative action on health inequities. Our approach can contribute to the call by the WHO Commission on the Social Determinants of Healths for more reasonable action on health inequities by being incorporated into numerous public health settings and processes. Further steps include empirical applications and evaluations of EqKT in real world applications.
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Equity-focused knowledge translation: a framework
for ‘‘reasonable action’’ on health inequities
J. R. Masuda T. Zupancic E. Crighton
N. Muhajarine E. Phipps
Received: 5 March 2013 / Revised: 12 September 2013 / Accepted: 25 September 2013
Swiss School of Public Health 2013
Objectives To identify gaps in procedural approaches to
knowledge translation and outline a more relational
approach that addresses health inequities based on creating
collaborative environments for reasonable action.
Methods A literature review encompassing approaches to
critical inquiry of the institutional conditions in which
knowledge is created combined with a process for
encouraging reflexive professional practice provide the
conceptual foundation for our approach, called equity-
focused knowledge translation (EqKT).
Results The EqKT approach creates a matrix through
which teams of knowledge stakeholders (researchers,
practitioners, and policymakers) can set common ground
for taking collaborative action on health inequities.
Conclusions Our approach can contribute to the call by
the WHO Commission on the Social Determinants of
Healths for more reasonable action on health inequities by
being incorporated into numerous public health settings
and processes. Further steps include empirical applications
and evaluations of EqKT in real world applications.
Keywords Health inequities
Equity-focused knowledge translation Social injustice
Health inequities are a major global health priority,
reflecting a longstanding public health agenda connecting
social and environmental injustices to population level
health inequalities. For example, in Canada, recent strate-
gic directives reflect a more ensconced commitment to
health equity in research (CIHR 2009), policy advocacy
(National Collaborating Centre for Determinants of Health
2010), and practice (Ontario Agency for Health Protection
and Promotion 2009; Lemstra and Neudorf 2008; Van-
couver Coastal Health 2006). There is also a concern about
policy inaction as health inequities continue to widen in
many jurisdictions (Friel and Marmot 2011; Goesling and
Firebaugh 2004). According to the WHO Commission on
the Social Determinants of Health (2008), health inequities
persist because of an inability or unwillingness to act on
entrenched social injustices, due to ideology, lack of
leadership, and societal indifference.
To address the injustices at the root of health inequities,
the Commission appeals to reasonable action for global
action on health inequities:
Where systematic differences in health are judged to
be avoidable by reasonable action globally and
within society they are, quite simply, unjust. It is this
that we label health inequity. (p. 26, emphasis added)
While it seems a truism to say that social injustices and
resulting health inequities are unreasonable, it is also evi-
dent that it is not a lack of reason that permits them to exist,
but rather competing rationalizations of their sources and
J. R. Masuda (&)T. Zupancic
Centre for Environmental Health Equity, Winnipeg, MB, Canada
J. R. Masuda
University of Manitoba, Winnipeg, MB, Canada
E. Crighton
University of Ottawa, Ottawa, ON, Canada
N. Muhajarine
University of Saskatchewan, Saskatoon, SK, Canada
E. Phipps
Canadian Partnership for Children’s Health and Environment,
Ottawa, ON, Canada
Int J Public Health
DOI 10.1007/s00038-013-0520-z
continued existence. Such reasons may originate in vested
interests, opaque decision-making processes, and dogmatic
ideologies that are operative within society. For Sen
(2009), of the key to achieving justice is to confront these
forms of bad reasoning head on:
central to the point in dealing with [injustices] is
that prejudices typically ride on the back of some
kind of reasoning–weak and arbitrary though it might
be. Indeed, even very dogmatic persons tend to have
some kinds of reasons, possibly very crude ones, in
support of their dogmasThere is hope in this, since
bad reasoning can be confronted by better reasoning.
(Sen 2009, p. xviii, emphasis added)
In this sense, the concept of knowledge translation, now
widely embraced among policymakers, researchers, and
practitioners provides one way to consider how to create
conditions for better reasoning within decision-making. In
this paper, we aim to contribute to this effort by outlining a
framework, called equity-focused knowledge translation
(EqKT) that provides a means to move toward better rea-
soning in knowledge translation practice.
The EqKT framework departs from the prevailing pro-
cedural focus in knowledge translation that focuses on the
movement of knowledge objects (e.g., scientific facts,
policy best practices), through better alignment of knowl-
edge production and decision-making domains (Graham
et al. 2006). Instead, EqKT proposes a relational perspec-
tive on knowledge subjects, emphasizing how the
conditions of knowledge production and use influence not
just what we decide to do with knowledge, but what
stakeholders are to be, in terms of how we act within and
through knowledge. This approach recognizes the rela-
tionship between knowledge and power in the institutional,
communicative, and regulatory conditions of knowledge
production and use that are either reasonable (equity pro-
ducing) or not (inequity producing).
The core principle of the EqKT framework is that equity
enhancing decisions (i.e., better reasoning) must attend to
the relationships that we have with knowledge and, by
extension, with each other in collective processes of
knowledge formation and its use toward health equity
objectives. Such relationships can be achieved by a col-
lective commitment to examine and guide what knowledge
to produce, how it should be communicated, and what
impacts it is expected to deliver. To make our case, we first
provide an account of the progress and limitations in
knowledge translation, focusing on prevailing positivism in
the field. Second, we argue for a ‘‘Third Wave’’ in
knowledge translation that reflects a post-positivist turn
from ‘‘Second Wave’ population health research. Finally,
we set out parameters of an approach that is guided by
critical inquiry and reflexive practice as two necessary
conditions for collective knowledge translation practices
aimed at achieving health equity.
The state of the art in knowledge translation
Knowledge translation stems from a longstanding effort in
dissemination research and practice to address imbalances
between knowledge production and application (Kitson
2008). While the term is widely adopted, its theoretical and
empirical development is nascent, with Graham et al. (2006)
Knowledge-to-Action (KTA) model being the most widely
accepted approach, at least in the Canadian context. The
basic tenet of the KTA model is to guide the complex and
dynamic nature of knowledge-to-action processes, by plac-
ing knowledge production and its application into a cyclical,
iterative process. By aligning producers of research and
decision-makers around the specific ‘‘steps’’ within the
knowledge-to-action cycle, proponents suggest that more
effective and efficient knowledge translation can take place.
But mainstream knowledge translation practice rests
upon two assumptions that may limit its ability to discern
whether action can enhance health equity. First, an implicit
positivism within knowledge translation models depend
upon a ‘‘banking approach’’ to knowledge, implying that if
the ‘right amount’ of the ‘right’ facts (e.g., existence of a
disparity in a measurable population health outcome) can
get to the ‘right’ people (e.g., an agent with authority and
capacity to enact a decision), then health equity will be
enhanced. However, this approach misses a crucial point: it
assumes that health inequities are the result of a knowledge
deficit or a knowledge-to-action gap, rather than due to
intentional priorities, and interests such as productivity,
prosperity, austerity, or competitiveness, common in neo-
liberal approaches to health governance (Coburn 2000,
A second, assumption in conventional KT practice is
that stakeholders share a common aim, understanding and
ability to work together. This assumption implies that
barriers to knowledge translation arise mainly from pro-
cedural constraints (e.g., organizational obstacles, resource
constraints, or time), as opposed to epistemological dis-
tances or uneven power relations. The remedy is to
improve communication by ‘getting everyone in the same
room’ and using a shared model. But what is not addressed
is, ‘‘who’’ decides what knowledge is, when knowledge is
ready for translation, what participants are necessary to
effectively translate knowledge, which KT model should
be used, and when to know if stakeholders are equally
prepared, willing, and capable to engage in knowledge
translation. A mechanism is needed to respond to differ-
ences, limits, and politics in relation to the power to define
the conditions of knowledge translation, particularly when
J. R. Masuda et al.
there is ostensible agreement on a common goal—to
reduce health inequities—but in fact there lacks common
ground on how health inequities are even defined, let alone
acted on.
The need for ‘Third Wave’ knowledge translation
Scientific evidence does not exist in a vacuum, nor is it the
only form of knowledge to account for social injustice.
There are many alternative explanations for social
inequalities in health, each invoking justification for
(in)action, such as economic (e.g., no good cost-benefit
analysis), ideological (e.g., the ‘‘deserving poor’’), or
political (e.g., fixed, short term election cycles). Dis-
agreements even exist among proponents of health-centric
explanations (e.g., blame the system or victim). Thus a
problem of the knowledge deficit model is its limited
account for sources, strategies, and effects of particular
knowledge claims and their effects within a wider arena of
stakeholders, including politicians, lobbyists, the media,
activists, and the general population. There is a need for
critical contextual analysis of how health inequity priorities
are identified or obscured, prioritized or marginalized, and
acted upon or dismissed. By interrogating how priorities
emerge, it becomes possible to identify underlying logics
that create proximate organizational limitations, procedural
antecedents, and ideological leanings that obscure if not
obstruct health equity aims.
Two main traditions of inquiry in population health
research illustrate the difference between evidence of the
existence of health inequalities, and the interrogation of
their sociopolitical antecedents, commonly referred to as
Second and Third Wave research (O
¨stlin et al. 2011, see
Fig. 1
). Second Wave research is premised on the use of
quantitative population-based and spatial analysis as the
means to expose the existence and characteristics of social
inequalities in health in relation to geographic and demo-
graphic factors, and thus inform public health interventions
to mitigate them. But, Second Wave research has fallen
short in accounting for the conditions that create social
inequalities in health and allow them to persist over space
and time.
Third Wave research addresses this lacuna by focusing
on explaining the underlying societal arrangements through
which health inequities manifest, and thus informing action
to change such arrangements at the political level. Third
Wave research builds upon decades of theoretical devel-
opment and empirical demonstration within the social
sciences; exploring the historical, psychological, socio-
logical, and geographical dimensions of health inequities as
rooted in political ideology, culture, and economy. Unlike
the bird’s eye view of Second Wave research, social the-
ories of health provide in-depth accounts of health as a
function of and in society, connecting these to systemic
structures to overcome the artificial distinction between
research ‘‘about’’ the world and action ‘‘in’’ the world. In
the sense Third Wave research focuses not just on how
social injustices ‘‘get under the skin’’ to disrupt health, but
also ‘‘getting under our skin’’ in terms of prompting more
critical orientation to our own knowledge work as well as
to others who are complicit in rationalizing social injustice.
Through the contributions of Second and Third Wave
research, we know inequities are becoming more severe
and globally ubiquitous resulting in coalesced advocacy at
all levels to address root causes in social injustice. But
efforts to translate this knowledge into action have been
equivocal—little progress has been made in alleviating
social injustice or reducing inequities. This paradox of a
‘normative’’ state of inequity and seemingly insurmount-
able barriers to tackle them suggests we have not learned
how to ‘‘act’’. ‘‘Learning to act’’ is the definition of and
formidable task for, EqKT.
Equity-focused KT: implementing the ‘Third Wave’
We argue that knowledge translation to address health
inequities can be more effective by embodying a Third
Wave paradigm. For each wave of population health
research, it is possible to characterize corresponding
knowledge translation practice. Knowledge translation of
the First Wave, or ‘biomedical’ tradition in research, cen-
tres on evidence-based practice, where scientific insights
on biological mechanisms of disease and interventions are
provided to clinicians to improve the health of individuals.
Similarly, in Second Wave knowledge translation, typified
by Graham et al.’s (2006) KTA model, evidence-based
population health knowledge is scaled up to organizational
and system levels, where best practices are shared among
knowledge translation actors to support desired outcomes.
But how to translate Third Wave research has been
Part of the challenge is that the positivist approach in
knowledge translation (Rycroft-Malone 2007) conforms to
apluralist perspective of policy, which views knowledge
translation as the application of the ‘most accurate’, ‘most
valid’ or ‘most reliable’ facts to move decision-makers
toward better (i.e., more evidence based) health policies and
practices (Raphael et al. 2008). By contrast, Third Wave
health research applies social constructionist epistemology
where objective knowledge by the distant observer (Blaikie
2007) is rejected in favor of a willingness to intervene in the
The ‘‘First Wave’’ refers to the biomedical perspective in health
research, which, in its focus on physiological vulnerabilities and
clinical outcomes, has limited relevance to health equities, except
insofar as it takes up the lion’s share of health research funding in
Canada and around the world.
EqKT: a framework for ‘‘reasonable action’’ on health inequities
world. A social constructionist approach explores the social,
cultural, economic, ethical, emotional, and intellectual
conditions of knowledge production (Fook 1999). Ample
social science scholarship demonstrates that policies are
enacted as much on the basis of ideologies, party politics,
vested interests, and even outright prejudice as much as on
scientific evidence or expert influence (Fort et al. 2004;
Harvey 2005). This perspective on policy is what Raphael
et al. (2008) describe as the materialist perspective; policies
are proposed and rationalized that align with pre-estab-
lished ideologies which reproduce a particular ‘‘accepted
reality’’ that may not coincide with scientific facts, but
nonetheless advance particular political objectives.
Thus, a Third Wave approach to knowledge translation
would recognize the power relations that underpin policy
decisions that arise when certain ‘‘accepted realities’’ are
promoted over others. EqKT is not about mobilizing ‘‘what
we know’’ (i.e., Second Wave thinking), but introduces a
reasonable process for understanding and shifting ‘‘how
we know’’ so that a more equitable and just reality can be
pursued (i.e., Third Wave acting). Building on Sen’s appeal
for better reasoning we now describe the application of our
EqKT framework to build collaborative knowledge rela-
tionships to promote health equity.
Critical inquiry of knowledge
The first component of EqKT is to conceive of knowledge
translation as the circumstances that enable particular
realities to be accepted, and others to be subordinated or
dismissed. Through this view, knowledge translation
encompasses all of the techniques that mobilize knowledge
and permit it to have effect. Whether formal or informal,
driven or unanticipated, such techniques make particular
realities possible through the conditions in which knowl-
edge is produced, communicated, and acted upon (see
Foucault 1991,2001). To identify such techniques, we ask:
(a) How and where is knowledge produced? Techniques of
knowledge production involve the structures that
enable the creation of knowledge, including ‘‘hard’
infrastructure (such as universities, funding organiza-
tions, policy units, and think tanks) and also include
‘soft’’ infrastructure, including technologies and
resources that provide access to knowledge (for
instance, online databases, courses, newspapers, and
other methods of knowledge storage, aggregation, and
interpretation). Analyzing production techniques
involves examining where knowledge resides and is
channeled within ‘hard’ and ‘soft’ infrastructures, by
scrutinizing the resources and limits placed on knowl-
edge, as well as the methods or institutions that give
certain ways of knowing legitimacy over others.
Concomitantly critical inquiry scrutinizes the methods
by which knowledge confers legitimacy upon institu-
tions, and their spokespersons over others (e.g., the
authority ascribed to universities, conferences, profes-
sors as compared to community groups, street protests,
elders), as well as the implications of such effects.
(b) How is knowledge communicated? Techniques of
knowledge communication refer to the discursive
power of language in authorizing and delineating
boundaries over ways of knowing, including how the
language of ‘science’ elevates certain perspectives
over others. Techniques of communication include
the narratives that reproduce, reinforce, and legiti-
mize particular claims, including who is as an ‘expert’
and how expertise subordinates other perspectives
(e.g., how quantitative and qualitative perspectives
treat people as ‘‘data’’ rather than formidable sources
of knowledge and agency). Critical inquiry into
techniques of communication involves ‘‘thick
description’’ of knowledge claims in order to contex-
tualize the reality claims of the author(s) within their
positions in relation to such reality (i.e., above, or
apart from reality versus below and embedded within
(c) What does knowledge ‘‘do?’Techniques of knowl-
edge governance refer to knowledge put to work at a
distance to influence a population’s health choices
Fig. 1 Three waves in
contemporary health research.
Adapted from O
¨stlin et al
J. R. Masuda et al.
and behaviors. Techniques of governance are exer-
cised in the management of populations through
norms, routines and values that individuals are
empowered to abide by as ‘good’ or ‘active’ citizens
(Cruikshank 1999). In lifestyle approaches to popu-
lation health, we are motivated to exercise, eat well,
and not smoke in order to be healthy (i.e., a
behavioral imperative). In doing so, we are also
compelled to do our part to produce a healthy
population that is more efficient and less costly (i.e.,
an economic imperative) as opposed to taking polit-
ical action against social injustices that we see
everyday around us and make some of us unhealthy.
Critical inquiry into techniques of governance entails
the interrogation of strategies through which health
discourses encourage personal responsibility for the
health (e.g., by becoming self-managing, and com-
pliant with norms and regulations, or taking direct
action in pursuit of social and political change). The
analysis of techniques of governance makes it possi-
ble to discern who is obliged to act to reduce health
inequities (e.g., individual victims, public health
practitioners, and/or governmental policymakers),
and who benefits from such actions (e.g., presumably
healthier populations, but also the career advancement
of researchers and the institutions that they work in/
Together, these techniques of knowledge inquiry offer
an interpretative lens for critical analysis of knowledge
sources and uses, and provide the basis for reflexive
examination of one’s own capacities and limitations within
knowledge translation practice. Analyzing knowledge
translation through one’s own use of these techniques
illuminates the extent to which we may intervene to sup-
port more equity-focused approaches.
Reflexive practice in knowledge translation
While the substance, boundaries, and functions of accepted
realities can be discerned through critical inquiry, reflexive
practice reveals one’s own influence within these systems.
Locating our own position in reality construction provides
insight into our assumptions, biases, contradictions, and
possibilities for justice (Holland 1999; Jasper 2003). In
EqKT, reflexive practice identifies possible pathways to
overcome poor reasoning, including decisions that prevent
or evade social justice. In our framework, reflexive practice
includes the following process of self-examination:
(a) How do we recognize all perspectives? Inclusivity
involves recognizing that power dynamics are the
norm in knowledge relationships, particularly when
considering the plurality of stakeholders involved in
knowledge translation. Within research, exclusive
power and influence are often created through
specialized institutions, discourses, and practices that
reflect classes of experts. Within knowledge transla-
tion, affected groups may be seen as mere
beneficiaries of research, as opposed to experts whose
experiences and contextual understanding can mobi-
lize more just realities independently of formal
research processes. Inclusivity is the ability to discern
one’s own power to include (or exclude) others and to
identify where and why power is given (e.g., in terms
of social, professional or financial status or
(b) How can we be transparent about our motivations
and limitations? To be transparent means being open
and flexible about our goals, biases, and limitations in
collective work. In EqKT, transparency means prior-
itizing the access of those most affected by health
inequities to knowledge translation. Being accessible
facilitates questions and critique of our assumptions
and processes. Openly recognizing and discussing
shared limitations provide opportunities to recognize
the potential for group transformation, including
seeking out perspectives, resources, and opportunities
that reveal previously unseen or unacknowledged
(c) How do we work together toward common goals?
Finally, humility as a reflexive practice invokes the
notion of ‘‘servant leadership’’ in working collectively
(see Morris et al. 2005). Effective leaders work for the
benefit of others, many of whom occupy social
positions with less influence. Humility is a willing-
ness to check one’s own claims to expertise or
authority and to realize that our contributions are no
more important than—and are in fact often predicated
on—the insights and contributions of others, partic-
ularly among those perceived as occupying socially
disadvantaged positions. Thus, through humility, the
locus of action can be as much on transforming one’s
own organizational priorities as it is on a collective
external policy pursuit.
Integrating critical inquiry and reflexive practice
Our EqKT framework places critical inquiry and reflexive
practice on a matrix (Table 1). Working through this
matrix provides individuals and groups with a pathway for
‘reasonable action’’. Set in this way, reasonable action
involves working collectively through the questions in the
13 cells (letters ‘‘a’’ through ‘‘m’’). The reflections gener-
ated from this process provide understanding of ‘how we
know’ in terms of the root causes of social injustices, and
EqKT: a framework for ‘‘reasonable action’’ on health inequities
in discerning our own and other’s stake within such sys-
tems to identify collective approaches to change. The first
step is for each knowledge stakeholder to situate them-
selves within the production of a particular reality (cells a,
b, and c) which sets a process through which to critique
that reality (cells d through l) and transform it (cell m).
With techniques of production, reflexive practice allows
stakeholders to deconstruct the institutional ‘bricks and
mortar’ from their collective position, including the rela-
tive access to institutions among colleagues and partners,
as well as those institutions that are not typically given
authority. This process allows groups to determine the
origins of inclusionary and exclusionary power (cell ‘d’),
as well as each group member’s possible complicity and
leverage within this field of power (cell ‘e’). Finally, it
allows knowledge subjects to identify the collective power
in working in service to others’ identified aspirations and
accomplishments (cell ‘f’).
Reflexive practice within techniques of communication
examines our use of language and claims to expertise as a
Table 1 A practice-based
framework for equity-focused
knowledge translation
J. R. Masuda et al.
basis for exerting authority when making knowledge
claims. It provides an opportunity to reflect on the extent to
which language reflects the perspectives and priorities of
affected people or communities (cell ‘g’) and determines
whether the community’s voice is authentic or co-opted by
the (mis)interpretations of others (cell ‘h’). In seeking
community perspectives, reflexive practice debunks the
assumption that one has more validity than others, sug-
gesting that collective consciousness-raising can lead to a
complete understanding of complex problems as well as
appropriate priorities (cell ‘I’).
Finally, reflexive practice within techniques of gover-
nance questions the aims of stakeholders engaged in EqKT.
It involves reflection upon the extent individual roles and
communities are coordinated or differentiated (cell ‘j’),
both in terms of positions (e.g., researchers/researched
binaries versus knowledge partnerships) as well as the
goals within these roles. Through collective reflexivity, it
becomes possible to discern how roles are limiting or self-
serving (cell ‘k’), and how individually produced or initi-
ated strategies contribute to the problem (cell ‘l’).
Ideally, the matrix in Table 1can be applied continu-
ously and intuitively, by those committed to working
toward common goals. Examples include a research team
engaging with a community to study a particular health
inequity, a knowledge translation workshop by public
health officials to learn how to work together on shared
problems, or in direct community action among community
leaders who seek to build collective action toward a com-
mon solution. In a collective process, each participant
works through the matrix to identify their own knowledge
practices. Individuals share their reflections with others,
thus forming the basis of relationships. Assumptions are
mapped out, with both complementary and distinct per-
spectives juxtaposed and integrated (see Fig. 2). Ideally,
the process continues as an inherent part of people’s rela-
tionships with each other, so assumptions are revisited, and
avenues for inclusivity, transparency, and humility identi-
fied (e.g., gaps closed, collective changes proposed).
Through this cyclical process, gaps, strengths, synergies,
and priorities will become clear, and collective strategies
for reasonable actions will emerge that are better posi-
tioned to advance common equity aims (cell ‘m’).
In this paper, we have outlined a conceptual framework for
EqKT, premised on a notion of knowledge translation as a
collective commitment to critical inquiry and reflexive
practice. Our framework departs from the procedural focus
of more positivist models, arguing for ‘Third Wave’
knowledge translation that focuses on the relational
dimensions of knowledge construction.
The EqKT approach serves three main purposes. First, it
provides a means to critically analyze existing systems
responsible for defining and delineating ‘‘how we know’
about health inequities. Second, in adopting a reflexive
orientation, our approach scrutinizes prevailing systems
from one’s own position and influence, exposing its flaws,
gaps, and openings in relation to its constituent techniques
of production, communication, and governance. Third,
EqKT provides the opportunity to transform one’s own
relationship to knowledge, so that in knowledge practice
one can learn to work with inclusively, transparently, and
with humility to reveal alternative realities and pathways
for collective action on health inequities.
The outcome of EqKT might entail a resetting of
assumptions of knowledge institutions, discourses, and
aims (e.g., universities and hospitals as main repositories
of health knowledge occupied by scientist ‘heroes’ and
‘progress’; communities as simply beneficiaries or even
disenfranchised victims in need of education or guid-
ance). In opening up alternative possibilities, we may
discover new forms of expertise and leadership, espe-
cially among those worst affected by health inequities.
We may uncover the limitations and possible biases
within the numerical emphasis of scientific approaches to
health equity, which claim to be objective accounts of the
Fig. 2 Cyclical process of EqKT. Through repeating cycles, both
individual and collective ‘positions’ within knowledge systems are
exposed and ultimately acted upon (represented by ‘m’)
EqKT: a framework for ‘‘reasonable action’’ on health inequities
truth, in favour of powerful testimonials of social injus-
tice encounters and resiliences that speak truth to power
(Holmes et al. 2006). We may find ourselves opposing
governmental policymakers that are beholden to ideology,
mobilized by vested interests, as much as they are pur-
veyors of ‘evidence’ and of ‘best practices’. Finally, in
mobilizing Third Wave knowledge translation, we may
find that the business of health equity is not exclusive to
research, policy, regulations, and public awareness cam-
paigns, but may include direct action, including civil
disobedience measures communicating anti-poverty, anti-
racism, anti-sexism, and anti-corporate messages such as
we are witnessing in grassroots led actions taking place
around the world.
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J. R. Masuda et al.
... Evidence suggests that work to increase public awareness of health inequalities may unintentionally exacerbate experiences of stigma and shame (Smith & Anderson, 2017). Masuda (2014) describes a practice-based framework to strengthen the delivery of Equity-focused Knowledge Translation (EqKT), building collaborative knowledge relationships to promote health equity, asking individuals and groups to: situate themselves; identify their inclusionary practices; discern the extent of transparency; reflect on their approach to leadership; followed by reasoned action to envision change. This study explores the use of the Health Inequalities Assessment Tool (HIAT), which was designed to help individuals and projects consider health inequalities in an applied research setting. ...
... Divided into four sections, the HIAT is a coproduced, researchderived, 'actionable tool' (Cooke et al., 2017) that guides its users to: clarify the health inequality dimension of the problem to be addressed: design the work to address the problem; evaluate the work as it is implemented; monitor and plan for wider impacts on health inequalities (Porroche-Escudero & Popay, 2021). CLAHRC-NWC used HIAT as a vehicle to support its strategic aim of embedding a health equity focus across all levels of the partnership, promoting a shared understanding and language, which has traditionally hampered efforts to address the issues (Masuda et al., 2014;McMahon, 2022). As such, the HIAT appears to fit well with the concept of a boundary object, a toolkit that facilitates the creation, transmission, and adoption of new information about health inequalities across multiple and diverse stakeholders. ...
... This is reflective of Star's (2010) description of the interpretive flexibility of a boundary object, where the difference depends on the use and interpretation of the object. In enabling ideas to emerge and be discussed, the HIAT allows different types of evidence to be negotiated and framed (Gabbay et al., 2020), laying the building blocks of collaborative knowledge mobilisation to promote health equity as described by Masuda (2014). As a boundary object, HIAT helped to extend and enhance understanding and ideas about health inequalities that translated across culturally defined boundaries (Fox, 2011). ...
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The Health Inequalities Assessment Toolkit (HIAT) was developed to support those involved in health research to integrate a focus on health inequalities. Our study focuses on bringing together the concepts of boundary objects (BO) and brokers-as-bricoleurs to explain the implementation of the HIAT within a research capacity building programme. Exploring the extent to which (i) the HIAT operated as a BO and (ii) the ideal conditions to nurture and enhance its effectiveness during knowledge mobilisation. We employed a qualitative approach to analyse: semi-structured focus groups and telephone interviews; secondary data from an evaluation of the wider research programme within which the capacity building was situated. Data was thematically analysed incorporating the properties of a BO: meaningfulness, convergence, resonance and authenticity. Four main themes identified: (1) Generating convergence through creating a focus (2) Reconciling differences to create a common language (3) Workshop facilitators: boundary brokers-as-bricoleurs, (4) Thoughts into action. The HIAT operated as a BO, enabling individuals across the different project teams to galvanise around the issue of health inequalities, explore collaboratively and incorporate equity within service evaluations. Highlighting the importance of involving brokers with an ability to improvise and mobilise around the HIAT, using their expertise to translate and interpret across boundaries and emphasise shared goals. Reflecting on this, a modified tool with additional resources beyond socio-economic causes has been launched as a forum to consider health inequalities from diverse perspectives for use beyond UK health and social care research.
... Mainstream approaches to knowledge translation and education rests upon two assumptions that limit the ability to strengthen environmental justice (Masuda et al. 2014). First, there is the assumption that inequities result from a knowledge deficit rather than competing priorities, vested interests, and fiscal austerity. ...
... Masuda and colleagues outline that an equity-focused approach to knowledge transfer recognizes the relationship between knowledge and power and the institutional and/or regulatory conditions in which knowledge is produced, translated, and communicated. Their prescribed framework for an equity-focused approach to knowledge transfer involves a reflexive practice that embraces inclusivity, transparency, and humility (Masuda et al., 2014). In the context of translating knowledge from urban foresters to community members about the value and benefits of urban trees, inclusivity involves recognizing and acknowledging power dynamics across stakeholder groups. ...
The distribution of trees and access to nature is rarely equitable across urban neighborhoods. This injustice is present in many cities, and its origins are predominantly rooted in enduring procedural and recognitional injustices. The purpose of this research was to systematically investigate Urban Forest Management Plans (UFMPs) prepared by municipalities across the United States (107 total) for their mention and explanation of environmental justice themes relevant to urban forestry. UFMPs describe municipal urban tree-planting and stewardship goals as well as pathways for both implementation and monitoring. Using a mixed-method approach that combines qualitative content analysis and quantitative measurement, we interrogated UFMPs for reference to three specific environmental justice pillars: distribution, procedure, and recognition. Mentions and explanations of these concepts were identified and counted for all UFMPs. Summary counts were then investigated for association with a UFMP’s publication year, its municipal population, and its racial composition. The frequency of reference to environmental justice themes was greater in UFMPs published more recently and whose authoring municipalities have a larger population. A positive association exists between the proportion of Black residents in a city with an UFMP and the frequency of identified distributional justice explanations. While a positive association with procedural justice mentions was found with the proportion of white residents in UFMP authoring cities, environmental justice, overall, is not a central theme across most UFMPs published to date. More generally, we discovered that where UFMPs referenced environmental justice concepts, it was often brief and lacking in substance; recognitional justice themes were absent in almost all documents. Improving environmental justice goals and implementation strategies in UFMPs that validate the perspectives and experiences of residents can strengthen accountability between urban foresters and the communities they serve.
... Although widely acknowledged that social injustices and resulting health inequalities are unnecessary, there is a lack of common ground on definitions, which hinders effective action. 22 A focus on reducing inequalities is essential in advancing population health furthermore integrating an equity focus into projects is necessary to spend public money 'wisely'. 23 However, relatively little evidence has an explicit focus on equity, and some policies and interventions may inadvertently differentially benefit more socioeconomically advantaged groups. ...
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Background: We report on a study of a facilitated interactive group learning approach, through Collaborative Implementation Groups (CIGs), established to enhance capacity for equity-sensitive evaluation of healthcare services to inform local decision-making: (1) What was the experience of participants of the CIGs? (2) How was knowledge mobilisation achieved? (3) What are the key elements that enhance the process of coproducing equity-sensitive evaluations? Methods: A thematic analysis of qualitative data obtained from focus group (FG) discussions and semistructured interviews exploring the experiences of participants. All FGs included representation of participants from different projects across the programme. Interviews were conducted with a member from each of the teams participating in the first cohort after their final workshop. Results: We identified four themes to illustrate how the approach to delivering intensive and facilitated training supported equity-sensitive evaluations of local healthcare services: (1) Creating the setting for coproduction and knowledge mobilisation; (2) establishing a common purpose, meaning and language for reducing health inequalities; (3) making connections and brokering relationships and (4) challenging and transforming the role of evaluation. Conclusion: We report on the implementation of a practical example of engaged scholarship, where teams of healthcare staff were supported with resources, interactive training and methodological advice to evaluate their own services, enabling organisations to assemble timely practical and relevant evidence that could feed directly into local decision-making. By encouraging mixed teams of practitioners, commissioners, patients, the public and researchers to work together to coproduce their evaluations, the programme also aimed to systematise health equity into service change. The findings of our study illustrate that the approach to delivering training gave participants the tools and confidence to address their organisation's stated aims of reducing health inequalities, coproduce evaluations of their local services and mobilise knowledge from a range of stakeholders. Patient or public contribution: The research question was developed collaboratively with researchers, partner organisations and public advisers (PAs). PAs were involved in meetings to agree on the focus of this research and to plan the analysis. N. T. is a PA and coauthor, contributing to the interpretation of findings and drafting of the paper.
... Thus, integrating S/G into health-related PR and associated integrated knowledge translation activities requires specific skills to engage simultaneously with two inseparable processes: the partnership process and the research process. The two are equally important since they enhance partners' capacity, promote reflexivity, contribute to building trust, encourage knowledge translation, yield better results, and, ultimately, have the potential to transform inequities and improve health and well-being (Bagnol et al., 2015;Friedson-Ridenour et al., 2019;Masuda et al., 2014;Ward et al., 2018). There are guidelines for successful partnership building in PR, providing recommendations on issues such as engagement, reflection on process and relationships, and collaboration (Drahota et al., 2016;Huang et al., 2018;Sarkies et al., 2017). ...
Objective: Conducting participatory research (PR) aimed at improving health implies considering inequitable power relations, including those related to sex/gender (S/G). This necessitates specific skills and methods and may be challenging especially since guidelines are scarce. Our objective was to perform a scoping review to provide a typology of existing guidelines for researchers on how to take account of S/G in the context of PR in public health, with a focus on occupational and environmental health. Methods: All steps of the research were conducted with the collaboration of an advisory committee, following PR principles. Nineteen documents were retained from 513 references identified in nine scientific databases and grey literature between 2000 and 2020. Data on recommendations were extracted and coded qualitatively. Cluster analysis based on similarities in recommendations proposed in the documents identified four types: (1) empowerment-centered; (2) concrete action-centered; (3) macrosystem-centered; and (4) stakeholder-centered. Synthesis: Many sources gave pointers on how to include S/G during data collection and analysis or during the dissemination of findings, but there was a dearth of suggestions for building partnerships with stakeholders and producing sustainable S/G sociopolitical transformations. Occupational health PR showed less similarities with other public health subfields including environmental health PR. Power relationships with workplace stakeholders generated specific obstacles related to S/G integration that require further attention. Intersectionality and reflexive practices emerged as overarching themes. Conclusion: This review provides helpful guidelines to researchers at different stages of planning PR, ranging from familiarizing themselves with S/G approaches to anticipating difficulties in their ongoing S/G-transformative PR.
... [12][13][14] However, translation of knowledge to action and practice is also needed to promote staff action toward HE. Various existing frameworks 15,16 and models 17,18 can help organizations not only increase KABs around HE and SDOH concepts among health professionals but also promote knowledge to action so that knowledge is put into practice. 19 Over time, the proportion of respondents who reported wanting "introductory training sessions" and "general tools" to help them include HE in their work decreased significantly (36% at baseline to 18% in wave 3 and 40% at baseline to 18% in wave 3, respectively), indicating a desire for tailored resources that focus on integrating HE, rather than a need for more general knowledge. ...
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This study presents survey results assessing the impact of the American Cancer Society (ACS) health equity (HE) training on staff knowledge, attitudes, and beliefs about HE and social determinants of health (SDOH). This study is a quasi-experimental design examining survey responses over time and comparing responses from staff who participated in ACS HE training sessions and education opportunities and those who did not. An electronic Web survey was distributed to all ACS and American Cancer Society Cancer Action Network (ACS CAN) staff in each of the 3 years that the training was held (2018-2020). ACS and ACS CAN staff who chose to take the survey were included in the study. Engagement with training hosted by the ACS HE team was examined. Training sessions were intended to introduce staff to HE and SDOH in the context of cancer outcomes and provide staff with the skills to become HE champions in the organization. This study examines whether participation in training sessions hosted by the HE team had an impact on knowledge of HE terms, attitudes, and beliefs about HE and engagement with HE. Trained respondents had a significantly higher HE knowledge summary score (98%) than those who were not trained (79%, SD = 0.26100, P < .001). Respondents who participated in training were more likely to believe that they could advance HE through their work at ACS and ACS CAN (88% compared with 66% of those who were not trained, SD = 0.47300, P < .001). Respondents who participated in training scored an average of 4.7 out of 6 on HE engagement compared with 3.8 among the untrained (SD = 1.425, P < .001). These findings demonstrate that participation in HE training is associated with higher levels of knowledge about HE and stronger personal attitudes and beliefs about the importance of addressing SDOH. This is a foundational step in staff taking action to integrate HE concepts into their day-to-day work toward reducing inequities in access to cancer treatment and health outcomes.
... The major advantage is the involvement of SDHRCs researchers with knowledge production, and this is consistent with the Measurement and Evidence Knowledge Network of WHO Commission Social Determinates of Health advice, which is essential to develop evidence based on SDH and health inequities (25). Much more important than describing social injustice, SDHRCs must participate in knowledge translation to move research into policy and provide community-based evidence for policymaking to promote health equity (26). There is evidence that demonstrates the importance of science in the development of actions and policies in reducing health inequities (24). ...
... There are distinct KT frameworks for addressing health inequalities and developing strategic actions to address social justice issues with health care for people affected by health inequalities (Masuda et al., 2014). Arguably, this aspect is included in the core and the protective belt of this SPR, contributing to its progression. ...
Over the years, nursing research and practice have been through remarkable transformations in response to evolving and emerging healthcare systems and practices. Regarding research, nurses moved beyond merely using the quantitative methodology to combining qualitative, quantitative and mixed methods. In practice, nurses have transitioned from the delivery of medical‐based care to nursing theory‐guided practice, evidence‐based practice, knowledge translation and transformative practice. Some domains of nursing research and practice became progressive, while others degenerated. This paper aims to examine how different domains of nursing research and practice progress and degenerate using Imre Lakatos's methodology of scientific research programs. Lakatos differentiated scientific and pseudoscientific knowledge and coined the idea of scientific research programs. He believed that science in any discipline develops so that some programs are more progressive and others’ degenerative. The degeneration and progression of programs occur steadily and rationally and are determined based on the extent of development and programs’ potential to predict new solutions to old problems. Adopting this idea could enable nurses to critically analyse research programs in everyday knowledge development to use valid and legitimate programs for informing nursing practice.
Greenspaces promote mental and physical health, yet racialized immigrants are known to experience inequitable greenspace access. There is growing interest in the ability of greenspace to support immigrant settlement and wellbeing. This paper responds to the need for greater attention to equity and inclusion within greenspace and wellbeing studies by examining the unique experiences facing immigrant populations. Given increasing immigrant settlement into rural and suburban places globally we also address the lack of knowledge on urban and rural greenspace differences, despite known distinctions in place-based attributes (e.g., density, accessibility, level of diversity/xenophobia). We explore urban and rural greenspace experiences in one of the top immigrant-receiving countries in the world through focus group and interview data from immigrants living in a dense, highly diverse Canadian urban neighbourhood, in addition to an outlying rural community. These insights are complemented by perspectives from planners, decision-makers and designers with influence over greenspace. development/management. Our findings contribute towards the development of more equitable and inclusive greenspace by addressing the dearth of knowledge on related experiences and impacts facing immigrant populations specifically. We illuminate challenges and/or assets involved in supporting immigrant wellbeing and settlement in greenspaces including factors unique to and/or exacerbated by urban or rural contexts. Place-based attributes (e.g., distance, connectivity, space, density, demographics, level of familiarity with diversity, presence of culturally inclusive infrastructure, environmental quality, etc.) must be better understood and managed through planning, design and decision-making to support wellbeing given their influence upon physical activity, social interactions, feelings of safety and belonging.
Neoliberalism--the doctrine that market exchange is an ethic in itself, capable of acting as a guide for all human action--has become dominant in both thought and practice throughout much of the world since 1970 or so. Writing for a wide audience, David Harvey, author of The New Imperialism and The Condition of Postmodernity, here tells the political-economic story of where neoliberalization came from and how it proliferated on the world stage. Through critical engagement with this history, he constructs a framework, not only for analyzing the political and economic dangers that now surround us, but also for assessing the prospects for the more socially just alternatives being advocated by many oppositional movements.
Transforming Social Work Practice shows that postmodern theory offers new strategies for social workers concerned with political action and social justice. It explores ways of developing practice frameworks, paradigms and principles which take advantage of the perspectives offered by postmodern theory without totally abandoning the values of modernity and the Enlightenment project of human emancipation. Case studies demonstrate how these perspectives can be applied to practice.
Background: Drawing on the work of the late French philosophers Deleuze and Guattari, the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena. Objective: The philosophical work of Deleuze and Guattari proves to be useful in showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm – that of post-positivism – but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure. Conclusion: The Cochrane Group, among others, has created a hierarchy that has been endorsed by many academic institutions, and that serves to (re)produce the exclusion of certain forms of research. Because ‘regimes of truth’ such as the evidence-based movement currently enjoy a privileged status, scholars have not only a scientific duty, but also an ethical obligation to deconstruct these regimes of power.
Just as the concept “paradigm”energized the human sciences in spite of its manydefinitions and uses, so now does the concept“reflexive” seem to be of increasingsalience, again with many definitions and uses. It is argued thatreflexivity, as a fundamental human quality underliesvarious attempts to understand and intervene in humanrelationships. By juxtaposing paradigms, reflexivity, and therapeutic progression it is possible toset out several types of reflexivity, some relativelyself-contained and others at the edge of our possible“knowledges.”
As noted by McGill and Slocum (1998), effective leadership tends to operate as a contingency theory. The romanticized notion of celebrity CEOs that has been lionized in the popular business press has its place in the leadership pantheon, but, like any other approach to leadership, has limitations in its application. In particular, as discussed by Collins (2001a), sustained organizational functioning is more likely to be the result of the celebrity’s antithesis, a person possessing a blend of humility and strong personal will. This article draws from a diversity of sources in order to explore this potential nexus between humility and leadership. It offers a precise conceptualization of the concept of humility, identifies traits that are predictors of humility as well as the specific leadership behaviors that are likely to be the outcomes of high levels of humility.