Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
The Ripple Effect series. Issue 2
Plamondon, K. & Shahram S.Z. (2024). How to Equity in Research CoProduction. The Ripple Effect Series (Issue Two). The Equity Science Lab, University of British Columbia & the Integrated Knowledge Translation Research Network: Syilx Territory (Kelowna, BC, Canada) & many other unceded, traditional territories spanning Turtle Island (Canada).
Equity Science Lab
Plamondon, Katrina
Shahram, Sana Z.
This document is intended to inform, guide and support people involved in research co-production strengthen their capacity for advancing equity through their work. The booklet is designed to be written on directly, either as a digital or hard copy.
the Ripple Effect series | Issue Two | HEALTH RESEARCH CO-PRODUCTIONhow to EQUITY inAcknowledgementsWe are grateful for the contributions of many perspectives and voices inthe process of developing this booklet. In particular, we wish toacknowledge members and partners of the Integrated KnowledgeTranslation Network for their vibrant and thoughtful contributions toadapting concepts of equity from other contexts. Content and examplesoffered here were also informed through the thoughtful insights of peoplewho contributed their time through a series of dialogues (see contributorsbelow). Funding for this booklet came, in part, through the Integrated KnowledgeTranslation Research Network (CIHR Foundation Grant, FDN# 143237, NPIDr. Ian D. Graham). Both Drs. Plamondon and Shahram hold MichaelSmith Health Research Scholar awards.Among many other leaders in the field who contributed theirwisdom to dialogues that informed this booklet, we are grateful toacknowledge the following contributors:Davina Banner, University of Northern British ColumbiaLaura Boland, PhD, Public Health Agency of CanadaCole Etherington, PhD, Ottawa Hospital Research InstituteIan D. Graham, PhD, University of OttawaAnita Kothari, PhD, University of Western OntarioChris McCutcheon, PhD(c), University of OttawaEmily Ramage, PhD, University of Newcastle This work is licensed under a Creative Commons Attribution-NonCommercial, NoDerivitives license. This work may be downloaded andshared with others as long as it is appropriately credited (seerecommended citation below). It cannot be changed in any way or usedfor commercial (for profit) purposes, in whole or in part. Recommended CitationPlamondon, K. & Shahram S.Z. (2024). How to Equity in Research Co-Production. The Ripple Effect Series (Issue Two). The Equity Science Lab,University of British Columbia & the Integrated Knowledge TranslationResearch Network: Syilx Territory (Kelowna, BC, Canada) & many otherunceded, traditional territories spanning Turtle Island (Canada). Available online at: http://hdl.handle.net/2429/89598 IntentionThis document is intended to inform, guide and support people who areparticipating in research co-production in some way, including all peopleinvolved in teams or advisory groups, to strengthen their capacity foradvancing equity through their work.CC BY-NC-ND (CC) PLAMONDON & SHAHRAM 2024DOI: 10.14288/1.0447198the RIPPLE EFFECT seriesTABLE OF CONTENTSWhy we made this guideHow to use this guideDefinitionsEthics and equityEquity thinkingOverviewThe Ripple EffectFramework Putting it into action:Know your roleCommit to equityAsk equity questionsMake equity choicesGauging success Making ripples of change Key resourcesSETTING THE STAGE01CORE CONCEPTS02THE FRAMEWORK03SUSTAINING PROGRESS04the RIPPLE EFFECT seriesSETTING THE STAGEWhy we made this guideHow to use this guideDefinitionspage 6page 8page 1001WHY WE MADE THISGUIDE While this booklet is inspired theoriginal equity framework co-produced with a municipality in BritishColumbia, it has been adapted andextended to the context of healthresearch co-production. It extends expertise from the EquityScience Lab and was informed by aseries of steps, including the earlystages of a scoping review and aseries of deliberative dialogues toprovide tailored resources withcontext-specific terminology orpractices, and real-world examples. The equity-advancing strategies andapproaches offered here can beadapted to a variety of contexts andsettings. We anticipate more volumeswill emerge still—all sparked from aninitial effort to build collectiveconfidence in the agency each of ushas in advancing equity, fromwherever we are positioned in theworld. The Ripple Effect Framework isgrounded in the belief that researchcan play a role in advancing moreequitable futures, and that doing sorequires skills, tools and supports toconnect evidence-informed equitypractices with equity action.We made this guide as a resource forpeople to develop and apply an equitylens, across a wide range of engagedapproaches to research, including co-production. Research co-productionis "a model of collaborative researchthat explicitly responds to knowledgeuser needs in order to produceresearch findings that are useful,useable, and used" (1). It includespeople who may use or be affected byresearch through the entirety of theresearch process, in different andoften intersecting roles (see Figure 1). Integrating equity practices inresearch co-production matters.Equity choices are abundant amid themessy and relational intersectionsbetween people, ideas and interestsinvolved in connecting knowledge withaction in co-production.06policy-makersindustryhealth systemsleadersadvisory panelsteering committeeinterestedpartiesWhat do we mean by equity? Weunderstand equity as (2): as an idea related to justice;as a benchmark to aim for; andas experience. Equity, as an idea, extendsjudgements about fairness in andacross society. Widely held ideasabout what ‘counts’ as fair translateinto policies, practices, andbehaviours in ways that are oftentaken-for-granted by those thatbenefit from the same ideas. 07As a benchmark, equity can be anaspirational bar for how ideas ofjustice come to life. It can guide howwe measure progress toward ensuringthat all people, regardless of theirsocial, economic or geographiclocation, can live full lives with well-being and dignity. Equity or its absence, is felt by peoplethrough the power dynamics theynavigate when they interact withothers and with social systems (2). patientsclinicianscommunitiesadvisorsknowledgeuser partnersresearchersissue powerholderspeople affectedco-productionteamFigure 1. The complex, messy intersections of roles and people involved inresearch co-production, in context, adapted from Research Coproduction inHealthcare (1).WHEREHOW TO USETHIS GUIDEIf you are involved in any kind ofengaged research or evaluation thataims to promote health or well-beingin society, then this booklet is foryou. Importantly, this book is aimedat all members of research co-production teams, across aspectrum of engagement. Researchco-production and equity work bothrequire people working togethertoward a future goal, inclusive of avariety of many possible roles,including researchers, knowledge‘users’, and others who are interestedin, affected by the topic of co-production.The booklet is intended to be astarting point for people engaged inresearch co-production teams orpartnerships. It is relevant toanyone interested in advancingequity in any form of engagedresearch. Throughout this book, the terms ‘you’and ‘we’ are used. ‘You’ refers to thereader (which we hope includes awide range of folks!). ‘We’ refers tothe collective of people who makeup the systems or settings whereresearch co-production unfolds.WHOThis guide introduces the concept ofequity and why it matters. It isgrounded in evidence, theory, andpractical experience and is designedto support a broad range of informaland formal work. You’ll find clickablelinks in purple text and click buttonsthroughout to access great resourcesto support your work.WHATWhile examples focus on those fromthe health sector, this guide can beused to support the work of any co-production team, including inuniversity, community, health-systemor other settings where research isbeing done with people who will useit or who may be affected by it. It isintentionally interactive, with a widerange of options for people toextend thinking, reading, orapplication.08WHENAdvancing social justice is onereason for doing equity work.Research co-production riskstokenism and reinforcing inequities insociety, particularly if equity choicesare overlooked. Because of this risk,ethical research co-production isalso equitable in its processes anddesired outcomes.Researchers and research teamshave an obligation to develop andpractice ethical processes, withoutcontributing to systemic harm.Meaningful attention to equity inresearch co-production is a socialobligation of public institutions thatsteward public resources. This work,and this booklet, emerges from ourwork in research coproduction ashealth research teams. We recognizethere are many interesting ways toshare and exchange with others,across sectors, who are also doingco-production!WHYYou can use this guide as a resourceto support you and your teams toprioritize equity thinking in allaspects of your engagement inresearch co-production, includingyour interactions with others and theday-to-day work. While the guidedoes not provide 'right' or 'wrong'answers, it can be used as aresource and guide to supportconversations that lead to identifyingand making equity-centred choices. As you navigate conversations andstrive to do better equity work, youmay find it takes time to readthrough and digest. You may use it tofind examples that extend yourpractice. It could be used as aworkbook, with the frameworkserving as a template. You may alsofind yourself progressing to using itas a quick-reference or visual cue tospark good equity-advancingconversations. All of these uses areokay!HOW09Use this guide daily, as a resourcefor your team to develop and applyan equity lens, across a wide rangeof engaged approaches. Build timeto talk about equity into everymeeting and discussion to grow yourconfidence and skills for askingequity questions.entirety of the research process, indifferent and often intersecting roles(see Figure 1). It is one, among many,ways of conceptualizing engagedapproaches to research that prioritizeresponsive, service-driven, and action-oriented processes.RESEARCH CO-PRODUCTION (FOR HEALTH)Research co-production is "a model ofcollaborative research that explicitlyresponds to knowledge user needs inorder to produce research findingsthat are useful, useable, and used" (1).It includes people who may use or beaffected by research through the DEFINITIONSWORDS ARE POWERFULPOWER HOLDERSPower holders are people who,because of their roles or positionswithin health systems, have decision-making authority, influence, or powerto affect change within the intendedsettings of impact around which aresearch coproduction team focusestheir efforts (1). They are knowledgeusers who are necessary partners andco-investigators on the team, bringingpractice expertise and organizationalinsights and connections to the work. RESEARCHERSResearchers are also power-holders byvirtue of their capacity to apply for,hold, and manage grants. Researchersmay be also be affected/interestedpeople, at least some of whom bringknowledge and skills in the practiceand conduct of research and someform of recognition as independentinvestigators eligible to apply forresearch grants from public fundinginstitutions. Often, they have graduateeducation and training. 10We note that we intentionally use thisterm in place of the word stakeholder,which has origins in the settler-colonialpractice of occupying the traditionaland unceded territory of Indigenouspeoples, by placing a stake in theground to claim it as ‘theirs’ (3).AFFECTED OR INTERESTED PEOPLEAll individuals and groups who mightbe interested in or affected byfindings, including knowledge users,funders or leaders in health systemssettings as well anyone who might beimpacted or implicated by the topicguiding research co-production. HEALTH INEQUITIESPOLICY PRACTICESsocial systems and settings (2).Advancing equity in research co-production means striving for or co-creating conditions of society so allpeople, everywhere, can reach theirfull potential without social, economic,or environmental disadvantage (4). EQUITYWe can think about equity in threeways: as a manifestation of whatsociety defines and values as ‘fair’; asa benchmark, aspirational ideal, orcollective future our equity actions canmove society toward; and as anexperience, where its presence orabsence is felt as people interact with They can be measured and compared.Health outcomes are robust indicatorsthat can reveal broader inequities.Research teams across disciplines andsectors can look to health inequities asreliable metrics for monitoring theimpact of a wide range of socialinterventions, including, for example,the Sustainable Development Goals.Inequities are differences in health orsocial outcomes that are unnecessary,avoidable, unfair, and unjust (4, 5).They are experienced (2, 6), andpersist in environments where they are'normalized' as though the result ofbad luck or individual behaviours,without attention to the systemsthrough which they emerge (7,8). Policy includes anything that shapeswhat is done or not done by anorganization or group. Policy can beformal or informal, written orunwritten (9). Policies set directionsand state intentions.Practices are routine, day-to-day waysof doing and interacting, shaped bytaken-for-granted patterns and norms.Can be formal or informal; written orunwritten (9). Practices are what putdirections or intentions into actions.11Changing the written and unwrittenrules that create and maintainpatterns of advantage anddisadvantage between sociallydefined groups requires redistributingpower. Power is always at play in researchco-production, both within teams andin the how those teams conceptualizetheir relationship in and obligations tosociety. Research co-productionteams, as public goods and activeinfluencers of health research systems,can share and redistribute power tocommunities experiencing inequities,cultivate power among thosecommunities, and mitigate powerimbalances that create unfair,unearned advantages (10, 12, 13).POWERPower is an ever-present and dynamicforce that exists in all relationships orinteractions between people,organizations, systems, ideas andaction (10, 11). Weber described poweras “any chance (no matter whereonthis chance is based) to carry thorughone’s own [individual or collective] will(even against resistance)” (11). It is complex and productive (i.e.,determines possibilities and actualoutcomes) (12, 13). It can includepolitical, bureaucratic, economic,expert, community, network, orindividual power (12). Communities,institutions, and people who hold morepower also experience advantage,which reinforces inequity, and use theirpower to maintain the status quo. 12SYSTEMS OF UNEARNED (DIS)ADVANTAGEINTERSECTIONALITYThese systems rest on pillars ofcolonialism, anti-Black racism andorientalism in ways that support thecultural, political and economicdomination of non-white groupsthrough oppressive systems ofunearned disadvantage. Whitesupremacy is a set of ideas about theworld that organizes all aspects of ourlived realities, creating systems ofunearned (dis)advantage that we allparticipate in regardless of how weare racialized (18).Society organizes and structures howhumans interact with each other, andhow we navigate our lives. It involvesmany systems and structures that, bydesign, differentially afford peopleadvantages and disadvantages.Understanding systems of privilegeand oppression is important for equitywork because dominant societal ideastend to presume a superiority of whiteracial identities, assuming particularpractices as the correct or right way oforganizing human life. Originally described by Crenshaw in1997, intersectionality is a theory andthinking tool recognizing the layeredpower relationships among socialpositions (e.g., race, class, gender)that combine and overlap to createdifferent intersections of disadvantagefor some and privilege for others (19). GOVERNANCEGovernance involves peopleorganizing and exercising power inresponse to challenges andopportunities (14). It is intimatelyinvolved in co-production (15), andincludes mechanisms and processesfor decision making, includingquestions about: How are decisionsmade? Who has a voice in makingthese decisions? and Who isaccountable? (17).SOCIAL JUSTICESocial justice is a concern for fairnessas it manifests in society, throughsocial systems and policies that shapethe quality of life, well-being anddignity of all people. Social justice isgrounded in principles of human rights,access (e.g., to basic essentials forlife, like shelter and food),participation (e.g., representation,voice) and equity (fairness in thedistribution of resources) (17).13REFERENCESGraham, I. D., Rycroft-Malone, J., Kothari, A., & McCutcheon, C.(Eds.). (2022). Research coproduction in healthcare. John Wiley &Sons.156Reed, M. (2022). Should we banish the word “stakeholder”? FastrackImpact Discussion Forum.Commission of the Pan American Health Organization on Equity andInequalities in the Americas. (2019). Just Societies: Health equity anddignified lives. Washington, DC.Plamondon K, Brisbois B, Dubent L, Larson CP. (2021). How are globalhealth partnerships assessed? An equity-informed critical interpretivesynthesis. Globalization & Health.3Plamondon, K. & Shahram, S. (2024). Defining equity, itsdeterminants, and the foundations of equity science. Social Science& Medicine, 351: 116940.2National Collaborating Centre on Determinants of Health, Glossary ofterms.478 Pauly B, Shahram SZ, van Roode T, Strosher HW, MacDonald M.(2018). Reorienting health systems towards health equity: The SystemsHealth Equity Lens (SHEL). Victoria, BC.Plamondon, K. M., Bottorff, J. L., Caxaj, C. S., & Graham, I. D. (2020).The integration of evidence from the Commission on SocialDeterminants of Health in the field of health equity: a scoping review.Critical Public Health, 30(4), 415-428.149 Plamondon KM, Caxaj CS, Graham ID, Bottorff JL. (2019). Connectingknowledge with action for health equity: A critical interpretivesynthesis of promising practices. Int J Equity Health;18(1).REFERENCES11National Collaborating Centre for Determinants of Health (2023).Let’s talk: redistributing power to advance health equity. Antigonish,NS: National Collaborating Centre for Determinants of Health, St.Francis Xavier University.10Wallimann, I., Tatsis, N. C., & Zito, G. V. (1977). On Max Weber'sdefinition of power. The Australian and New Zealand Journal ofSociology, 13(3), 231-235.1213 Plamondon, K., Ndube-Eyoh, S. & Shahram, S. (2022). Equity, powerand transformative research co-production. Chapter 2.2 in ResearchCo-Production in Healthcare (Graham, Rycroft-Malone, Kothari &McCutcheon (Eds). Sriram, V., Topp, S. M., Schaaf, M., Mishra, A., Flores, W.,Rajasulochana, S. R., & Scott, K. (2018). 10 best resources on power inhealth policy and systems in low-and middle-income countries. HealthPolicy and Planning, 33(4), 611-621.14 Fidler, D.P. (2007). Architecture amidst anarchy: global health’s questfor governance. Global Health Governance. 1 (1). 1515 Latulippe, N., & Klenk, N. (2020). Making room and moving over:knowledge co-production, Indigenous knowledge sovereignty and thepolitics of global environmental change decision-making. CurrentOpinion in Environmental Sustainability, 42, 7-14.1617 Gostin, L. O., & Meier, B. M. (Eds.). (2023). Global Health Law andPolicy: Ensuring Justice for a Healthier World. Oxford University Press.Institute on Governance. What is governance. Ottawa, ON.National Collaborating Centre for Determinants of Health (2018). Let’sTalk: Racism and Health Equity (Rev. ed.). Antigonish, NS: NationalCollaborating Centre for Determinants of Health, St. Francis XavierUniversity.18REFERENCES19 Crenshaw K. (1997). Demarginalizing the intersection of race and sex:A Black feminist critique of antidiscrimination doctrine, feminist theoryand antiracist politics. In: Maschke K, editor. Feminist Legal Theories.Routledge; p. 35–64. 16the RIPPLE EFFECT seriesthe RIPPLE EFFECT seriesCORE CONCEPTSEthics and equity Equity thinkingpage 20page 2302All people make unconscious choicesin their work. The mundane, day-to-day acts that propel work (andpeople) in and through our systemsare determinants of equity (1, 2).Becoming aware of the systemsaround us takes intentional effort tounpack and grapple with oftenunconscious choices. The morefrequently attention is drawn to thesechoices, the more frequently equityaction can be made possible. As partof social systems and structures,research and knowledge mobilization(in all of the many ways processes ofconnecting knowledge with actionare labelled) are inextricably shapedby issues of equity and power (1, 2). Research shows a predictable,causal relationship between thrivingpopulations, individual healthoutcomes, and equity. Health,economic, and social inequities are,by definition unfairly distributed.Burdens of inequities consistently fallto particular groups of people,mirroring social gradients that reflectpatterns of discrimination againstrace, Indigeneity, sex, gender, ability,age, and other intersecting identities(3). Public institutions, includinghealth research and health systems,are themselves complicit in theseinequities because they play a role inshaping how power and resourcesare distributed in society.ETHICS AND EQUITY INCO-PRODUCTIONWHY EQUITY MATTERS IN CONNECTINGKNOWELDGE WITH ACTION20Importantly, evidence shows uswhere we can intervene: healthinequities are caused by systems,structures (e.g., public policyenvironment), practices, andrelational interactions involved indistributing power, resources andwealth within and between societies(2, 3). Accelerating progress towardhealthier societies is possible, byoperationalizing commitments andcalls for equity action. Doing sorequires people working acrosspublic institutions—including thosesituated in research systems—toengage in redistributive systems-levelchanges that can effectively mitigateinequities arising from the structuresand practices. Across all sectors and settings, howto address issues of equity andinequity are increasingly centralconsiderations and topics of debate.In the wake of mounting evidenceand widening of social and healthinequities as a result of climate crisis(4) and the COVID-19 pandemic (5),alongside social movements thathave called out long-standing harmsof systemic racism and discrimination(6-8), public institutions, in particular,are being called to account for theirrole in advancing equity. In Canada, advancing equity isconsidered a guiding principle anddesired outcome for health research,looked to as a means of actioninglegislated commitments to promotinghealth and well-being of Canadiansand all people, worldwide (9).Research co-production carries animplicit commitment to advancingmore inclusive and engaged changesin health systems, research, policyand practice. While the goalssuggest research co-production iswell suited to promote the kinds oftransformative change required toadvance equity, its processes andpractices have been criticized foreuro-centrism and inattention toissues of power (10-13). With its goalof generating more inclusive andresponsive processes of findingcollective solutions to complexproblems, research co-productionborrows much and has much to learnstill from Indigenous approaches togovernance.21Research co-production relationshipsand outcomes can be moreimpactful and more meaningful whenthey are guided by equity.Given the overwhelming researchevidence that connects equity tohealth and health outcomes, equityis a logical and ethical concernfor research co-production, even ifit is not named as often as it couldbe. At this moment of collectivereckoning with waves of rhetoricalenthusiasm for equity, diversity, andinclusion, there is a high risk ofpeople being caught up in work thatis incoherent and/or misaligned withintervening on known causes ofinequities, misleading those whomake up ‘systems’ to believe theirwork is more equity-promoting than itactually is. More than a benign risk of upholdingnaïve optimism, when people inpositions of power and influence(e.g., highly educated people in jobsas research faculty at a university)falsely label efforts that hold systemsof inequitable power distribution inplace as equity-advancing, it isunethical, harmful, and a means oflegitimizing passive violence.Responding to this risk requiresrecognition of the impact ofassumptions, norms, and beliefs thatperpetuate inequities. We needcollective skills and tools toauthentically advance equity.22Some differences in health outcomesare expected of human bodies (e.g.,people without ovaries cannot getovarian cancer), while others havecomplex social causes. One of themost powerful social causes is bothsimple and ubiquitous: dominantideas about fairness and justice arepowerful determinants of equity(2).Widely-held ideas are reflections ofvalues and beliefs about how theworld works. There are different waysof thinking about the reasonablenessor fairness of differences in well-being, health, and health outcomesacross populations. These ways ofthinking extend to creating socialconditions of daily life by serving asthe assumptions that justifyreasonable and tolerable actions orinactions. Some ways of thinkingsimply describe the presence of differences, without explaining whythey exist or are predictable.Describing these differences as'inequalities' or 'disparities', forexample, does not necessarilyexplain or judge reasonableness.Descriptions without naming causesor contexts can lead to policies thatdo not recognize determinants ofequity, and therefore do notintervene on known social systemsand causes.Naming these systematic differencesin life trajectories and healthoutcomes as inequities applies anethical value judgement, assertingthey are human-caused, avoidable,unfair and intolerable. Applying asocial justice lens goes beyonddescription to suggest thesedifferences are ethically wrong (14).Earlier, we established healthinequities follow patterns of EQUITY THINKINGEQUALITY DOES NOT EQUAL FAIRNESS“JUST” EQUALITY?23discrimination against race,Indigeneity, sex, gender, ability, age,and other intersecting identities.Using the word inequity is anintentional choice, stating somethingobservational about predictable,and what warrants attention withinsocial systems and structures thatgive rise to the conditions of dailylife. Social systems and structuresare made of people, whoseinteractions are both reflections andgenerative of dominant norms andvalues. When the people workingwithin social systems (including Metaphors are useful forunderstanding equity thinking (15).The parable of two fish shows howwe can be so immersed in systemsthat their very existence is taken forgranted (16). It is a simple story:SOCIAL SYSTEMS ARE LIKE WATER IS TO FISHHEALTH DATA ARE SIGNALS OF EQUITYsystemic patterns observed in healthoutcomes among differentpopulations; and somethingnormative (i.e., values-basedjudgement) about ethical and socialobligations to respond.Two fish come up to one another.One fish says, “how’s the water?” Theother fish says, “what’s water?” In this parable, the ‘water’ serves as ametaphor for the social systems wenavigate in day-to-day life.Health outcomes data are a powerfulsignals of equity in society. Theyreveal the consequences of theideas, policies, conditions andactions that collectively shape howresources, power, and wealth aredistributed within and betweenpopulations. They are manifestationsof unspoken views about the world 24Canada is often portrayed as avibrant place where people enjoyhappiness and well-being; but thereality is that experiences in andaccess to healthcare varies greatly,as do conditions of living and lifetrajectories. Systemic disadvantagerelated to race, Indigeneity, sex,gender, ability, age, and/or otherintersecting social identities lead tosome people experiencing shorterlife expectancy and higher rates ofboth chronic and acute illnessesdirectly in Canada (17). Given their invariable influence andpresence, health and socialinequities are essentialconsiderations for any healthresearch. Wonderfully, because ofthis direct and consistentrelationship, any effort to advanceequity in a specific topic will carrybroader benefits for society. Whether focused on chronic disease,active living, quality of work life,housing policy, food sovereignty,suicide prevention, literacy, earlychildhood education, or any otherhealth-related topic, when researchco-production is attentive to issuesof equity in its processes andoutcomes, all of society benefits. Research institutions, healthcareorganizations, and other communitiesor networks that can contribute toco-production are, themselves, systems--embedded in other systems.They play an important policy andcommunity-building role in advancingequity and creating more inclusiveplaces. Research co-productionteams involve people from differentsettings together to find solutions tocomplex cross-sector problems. Theybring different languages and ideasabout how the world does or shouldwork, including differentexpectations, norms, needs, andsocial or positional power. Professional titles, credentials andnotions of ‘expertise’ carry significantsocial capital, often extended inways that celebrate or condonepostures of superiority that posechallenges for research co-production teams (18). When co-production teams include peoplewith lived or living experience,differences in social or positionalpower create pre-conditions ofinequitable power dynamics.EQUITY THINKING INSYSTEMS SETTINGSresearch, health, education, orjustice systems, et cetera) accept therelationship between systemicdeterminants of equity, and believethese differences are unfair andactionable, they set a foundation forembracing agency and hope forequitable futures. With its interest inpromoting research impact, researchcoproduction brings a powerful setof tools and levers to advanceequity. 25All people involved in research co-production teams, regardless of theirreasons for involvement, can useequity thinking in their navigation ofpower dynamics and inequities.Equity thinking involves learningabout the messy mix of assumptions,ideas, attitudes, and actions thatcreate systems-level patterns. It is anactive process of learning and un-learning, unpacking one's ownviewpoints and blind-spots. As people become more aware andtake time to understand systems-level patterns, they are able to makemore equity-promoting choicesabout what they do within the samesystem.Like dropping a pebble in the water,even small actions can have ever-expanding impacts. We call thismaking ripples of change. In thisbooklet, we invite you to use equitythinking to become aware of andtransform the systems in which yourresearch co-production teams areembedded. You can do this bymoving through a process ofunpacking your assumptions, ideas,attitudes, and actions that contributeto making up the 'water’. This booklet is an invitation to thinkand act in new ways. It is a guide for how to be becomean excellent observer and question-asker, equipping those who use itwith the beginning set of tools needed to become aware of thesystems we navigate every day. Youwill start asking questions about howyour work could be part ofmaintaining or transformingconditions of inequity and injustice.This is not easy or obvious work!Equity choices exist in the mundane,day-to-day interactions, where themost powerful forces for change areoften the least visible aspects of thesystems we navigate (16).If at first, the work seemsoverwhelming, or you are not surewhat to do, our advice is to just getstarted. Just try it. Work through thesections of the framework. Ask thequestions aloud. Talk it through witha colleague. Apply the questions towhatever problem you are workingon, and see: does it generate newideas, new questions, new ways ofunderstanding the problem? Likelearning any new skill, the more youtry, the better you get at seeing thewater, asking equity questions, andmaking ripples of change.26REFERENCES134567The Intergovernmental Panel on Climate Change. (2021). AR6Synthesis Report: Climate Change 2022. Chiriboga, D. et al. (2020). Health inequity during the COVID-19pandemic: A cry for ethical global leadership. The Lancet, 395(10238),1690–1691.Addressing Racism Review. (2020). In Plain Sight: AddressingIndigenous-specific Racism and Discrimination in B.C. The BritishColumbian Quarterly (209), 7-17.Plamondon, K., Ndube-Eyoh, S. & Shahram, S. (2022). Equity, powerand transformative research co-production. Chapter 2.2 in ResearchCo-Production in Healthcare (Graham, Rycroft-Malone, Kothari &McCutcheon (Eds). Commission of the Pan American Health Organization on Equity andInequalities in the Americas. (2019). Just Societies: Health equity anddignified lives. Washington, DC.Came, H., & Griffith, D. (2018). Tackling racism as a “wicked” publichealth problem: Enabling allies in anti-racism praxis. Social Science &Medicine, 199, 181–188. 8 Wotherspoon, T., & Hansen, J. (2013). The “Idle No More” Movement:Paradoxes of First Nations Inclusion in the Canadian Context. SocialInclusion, 1(1), 21–36. 27Plamondon, K. & Shahram, S. (2024). Defining equity, itsdeterminants, and the foundations of equity science. Social Science& Medicine, 351: 116940.2910Canadian Institutes of Health Research. (2021). CIHR Strategic Plan2021-2031: A vision for a healthier future. Ottawa, ON.Conde, M., & Walter, M. (2022). Knowledge co-production inscientific and activist alliances: Unsettling coloniality. EngagingScience, Technology, and Society, 8(1), 150-170.REFERENCES1112131415Egid, B. R., Roura, M., Aktar, B., Quach, J. A., Chumo, I., Dias, S., ... &Ozano, K. (2021). ‘You want to deal with power while riding onpower’: global perspectives on power in participatory health researchand co-production approaches. BMJ global health, 6(11), e006978.Rose, D., & Kalathil, J. (2019). Power, privilege and knowledge: theuntenable promise of co-production in mental “health”. Frontiers inSociology, 4, 57.Turnhout, E. et al. (2020). The politics of co-production: participation,power, and transformation. Current Opinion in EnvironmentalSustainability, 42, 15-21.National Collaborating Centre for Determinants of Health. (2020).Let’s Talk: Ethical Foundations of Health Equity. Antigonish, NS:NCCDH, St. Francis Xavier University.Kania, J., Kramer, M., & Senge, P. (2018). The water of systemschange. FSG. Boston, MA.Shahram, S.Z. et al. (2017). Health Equity Metaphors for EffectiveCommunication. Victoria, BC: The Equity Lens in Public Health (ELPH)Research Project.16Public Health Agency of Canada. (2018). Key Health Inequalities inCanada: A national portrait. Ottawa, ON.172818 Plamondon, K., Banner, D., Cary, M. A., Faulkner, M., Gainforth, H.,Ghag, K., ... & Wick, U. (2024). Relational practices for meaningfulinclusion in health research: Results of a deliberative dialogue study.Health Expectations, 27(1), e13865.the RIPPLE EFFECT seriesthe RIPPLE EFFECT seriesTHE FRAMEWORKOverviewThe Ripple Effect Framework Putting it into actionKnow your roleCommit to equityAsk equity questionsMake equity choicespage 32page 34page 3503EQUITABLE CO-PRODUCTION BEGINSWITH YOUrecognizing their own role in thesystems they themselves aresituated. Next, the framework encouragesusers to commit to equity, ask equityquestions, and make equity choices.Bringing these practical steps toequity into research co-productionopens possibilities for more achievinglong-held aspirations for a moreequitable world, where regardless ofsocial, geographic or economiclocation, people can live full liveswith dignity. Evidence shows us that advancingequity requires re-distributing powerand resources, so that all people(individuals, groups and communities)can reach their full potential. Itchallenges and transforms socialstructures that afford advantage anddisadvantage based on class,gender, age, ability, race, culture,language, or other intersectingidentities. Research can play animportant role in responding tocomplex societal problems. Itilluminates how different populationsHOW CAN WE CENTREEQUTY IN RESEARCHCO-PRODUCTION?The Ripple Effect Frameworkbegins with and extends frompeople, whose thoughts about theworld are the sparks of possibilityand potential for advancing equityaction. It draws upon the fish-in-water metaphor to suggest that,even by changing the way we thinkabout our work (or our communities,our organizations, or contexts), wecan make ripples of change. Theframework invites four kinds of equitythinking, starting with peopleOVERVIEW32When equity is centred in thegovernance of research co-production teams, teams considerhow their efforts and decisions affectthe distribution of resources andpower within their team and as anoutcome of their efforts. This is whyadvancing equity in research co-production involves finding ways tointegrate equity considerations in itsprocesses (i.e., creating equitableteams, partnerships, and processes)anddesired outcomes. Advancing equity in and throughresearch co-production requiresbalancing action on systemic issuesthat push against equity; andintegrating equity practices, policiesand processes throughout ourefforts. Research co-production teams can,for example, consider the role ofequity within their own partnership.They could consider equity in theirchoices about what to study, how toframe the problem, and who toinvolve in understanding thedimensions and characteristics of theproblem that implicate equity. They can infuse all stages of theirresearch process, from determiningquestions to study design, and fromanalysis and interpretation todissemination, knowledgemobilization, and evaluation. or communities experience or areaffected by different conditions orexperiences, shaping policydirections and guiding the practicesof helping professions who providecare in health (or other) systems.Working towards equitable futuresrequires connecting good intentionswith action across all of theseintersecting systems, so our solutionsare attuned and responsive equityconsiderations.By doing research alongside peoplewho might use or be affected by it,research co-production should leadto more meaningful (e.g., useful,responsive, impactful, transformative—as defined by the needs affectedcommunities) research outcomes.While it offers tremendous potentialto support research that servescommunities and society, is not defacto ‘better’ at responding toinequities than other researchapproaches. Research co-production, in principle,prioritizes inclusion. But we knowfrom research that the researchecosystems in which co-productionunfolds do not offer the sameconditions, quality of experience,benefits, or opportunities for allpeople (1, 2). Setting researchagendas and priorities, applying forfunding, creating a program ofresearch, and choosing who to workwith (and how) all involve acts ofgovernance and assertions of power. 33COMMIT TO EQUITYASK EQUITY QUESTIONSMAKE EQUITY CHOICESTHE TEAM (& YOU)identify implications, all the timecreate cohesive rhetoric + actioncultivate shared goals and accountabilitiesembrace agencyAdvance Equititable FuturesCommunity & RegionProvince & CountryContinental RegionsWorldTHE RIPPLE EFFECTFRAMEWORK Figure 2. The ripple effect conceptual framework for advancing equitable futuresthrough (health) research co-production. CO-PRODUCTIONTEAMS &ADVISORSEquity is never a surprise outcome of anyresearch co-production effort: it is alwayspurposeful. Research co-production canserve as a bridge toward more equitablefutures, bringing multiple intersections ofperspectives, systems, roles, and spheresof influence into a collaborative solution-seeking effort. The strength of that bridgedepends on the capacity of research co-production teams to understand andrespond to power dynamics (3), andbegins with each person embracing theirown agency in whatever part of thesystem their work is situated. It extendsthrough cultivating shared equityintentions and commitments, andproceeds when people ask good equityquestions, all the time, so the equityimplications of their work can beunderstood. When intentions and actionsalign, greater possibility for advancingequity emerges and ripples of changeextend outward, across systems, when allpeople, across all spheres of influence,consistently take up equity work. Across Research Ecosystems 34KNOW YOURROLEPUTTING IT INTO ACTIONAN APPLIED EXAMPLEEquity work is everyone's work. Eachof us has a role to play. From big tosmall tasks, we make equity choicesin everything we do, including everyresearch co-production moment thatinvolves interaction with others.Choices we make about ourinteractions can advance or restrictequity. People’s inability, or theabsence of incentive to share poweraffect the possibilities for equity inresearch co-production. In particular,the reluctance to acknowledgeproblems or solutions that are not yet‘tested’ or filtered through a researchlens can serve to de-legitimize theworldviews, needs or ideas of others.The very act of identifying a‘problem’ to gather people, attention,time and resources around is, ineffect, an act of governance andassertion of power. In this way, fromits very earliest burbling of ideas orpotential problems to which it mightrespond, research coproduction canreinforce or challenge inequities.In 2021, a group of learnersparticipating in the CCGHR Equity-Centred Knowledge TranslationCourse lead an equity-centred co-production process to explore thisissue and the evidence available toguide policy and practice (read morehere). The group’s communityconnections and lived experience ledthem to focus on transgenderedpeople’s access to healthcareservices in British Columbia. Theyfound that assumptions about whocan be pregnant reinforce exclusionin research agendas, furthermarginalizing transgendered people.As they worked alongside peopleaffected by this issue, they were ableto illuminate systemic gaps. KNOW YOUR ROLE, EMBRACE AGENCYIlluminating systemicinequities is morepossible when we workalongside, and listen fordirection, from thosemost affected by them.35challenge assumptions and deeplyheld beliefs about ‘fairness’.Advancing equity through researchco-production can begin when webecome aware of the systemsimplicated in our work and recognizeour own roles within those systems.People are not separate from thesystems we are part of, and mustalso navigate. For this reason, equityconsiderations start with everyindividual person involved in researchco-production. Each of personinvolved in research co-production isresponsible for understanding theirown positionality (the socialposition one occupies, and how it sitsin relationship to others), engaging inreflection about who they are, theirperspectives and socio-geographiclocations, and the reasons motivatingtheir involvement in research co-production. They are also individuallyand collectively responsible forensuring they understand therelationship between equity andhealth, the role of power andprivilege in society, and the agencyand influence every person holds. For some, their personal lifeexperiences will position them inways that make this knowledge anintegral part of their lived and livingexperience. For others, their personallife experiences will position them inways that make this knowledge newor even unsettling to their ideasabout how the world works. HOW TO EMBRACEYOUR ROLE(continued) They found that whileaccess to healthcare is generallyupheld as a human right in Canada,who gets access to essential servicesis shaped by dominant ideas andassumptions, including those aboutgender. Under an assumption that ciswomen are the people who canbecome pregnant, abortion rightsactivism (and services) has largelyfocused on cisgender women’saccess to care—excludingtransgender people in ways thathave create systemic barriers tocare. A major finding of their co-production effort was thatassumptions about who can bepregnant reinforce a researchagenda that reinforces exclusion andmarginalization of transgenderedpeople. Their recommendationsprovide guidance for abortion rightsactivists, policy makers, andhealthcare providers to take actionat protecting the fundamental rightsof trans people. Embracing systems change involvesbecoming aware of the power of ourideas and worldview, and itsrelationship to our ways of thinkingand acting. For example, recognizinghard truths about inequities andinjustices, in and of itself, can 36READREFLECTfor becoming aware of the water innew ways. Consider how issues ofequity and representation mightaffect the body of literatureavailable in a field of interest. Payattention to whose perspectives andvoices are amplified in the literatureyou know. Be purposeful in choosingthe literature that informs yourscholarship. Spend time readingthings, including news and socialmedia, position statements, or callsfor action that offer a diversity ofperspectives, particularly from thosewith worldviews or experiences thatdiffer from your own.Becoming aware of the water can behard because we are not socializedto be conscious of it. It surrounds allof us, in everything. Expanding thecontent, stories, histories, andcontexts we are exposed to, from theliterature we immerse ourselves in tothe news we engage with or thebooks we read, can open possibilitiesRegardless of where we arepositioned in relationship tounearned (dis)advantage in society,advancing equity benefits all of us.Advancing equity is an investment inour shared humanity and ourcollective liberation. Equity workinvites all people to become awareof their role in unfair systems ofpower, and to make intentionalefforts to define their presence andengagement in society (and onresearch co-production teams) inways that privilege balance in thedistribution of power and resources.While no person is entirely withoutpower, people coming together todo research co-production bringdifferent kinds of power anddifferent experiences of unearnedadvantage or disadvantage in theirown navigation of social systems.This work is not about feeling badabout the existence of power, butrather about feeling entitled andobligated to pay attention to theways in which power is functioning. Reflect on why you care about yourwork, what motivates you, and whyyou believe in research co-production. Spend timecontemplating and sitting with whatyou are learning. Reflect on how whoyou are and where you come from,including your experiential anddisciplinary backgrounds, affect howyou understand the world. Criticallyreflexive practice/praxis is commonamong some research traditions. Itcan involve journalling, dialogue, art(e.g., poetry, collage, drawing),documentary, and any number ofways of collaboratively exploringnotions of finding or making meaningout of complexity. Consider includingsomeone with experience in thispractice/praxis on your co-production teams! 37TALK WITH OTHERSQUESTIONASSUMPTIONS‘UDUSTL’USOOSDUTAT’EN-I :BEYOND COLOURINGLean into collective reflection andlearning. Doing equity work requirescollective capacity to engage inconversations about equity. It mayrequire a little more time and spaceat first. As you, your team orpartnership, and others you work withstart building your shared capacityfor advancing equity, it will becomemore intuitive and integrated.Always, even when you think youknow your blind-spots, question theassumptions guiding a thought oraction. Understanding our own rolesin equity requires us to becomeaware of the assumptions andnarratives that contribute to how wemake sense of the world, what wesee (or don’t see), and what weexperience as we navigate it. Bothresearch co-production and equityare relational concepts that requirerelational practices that are oftenunder-valued by colonial systems ofthought and organizational culture(4). The relational practices ofresearch co-production can beenhanced with when teams paygreater attention to equity (5).Questioning our assumptions andworldviews is one strategy to raisecollective awareness and valueplaced on relationality. Through art, humans can findpathways to meaning, understanding,and insight. The Health Arts ResearchCentre offers an incredibly useful setof tools to support critically reflectivepractice. This colouring book offersbeautiful text and images, with ahope that the “meditative andcalming process of working withbeautiful images, and thenresponding to open-ended prompts,will move both your heart and mind.”Visit their website for more.EXTEND YOURLEARNINGAssessing power in health policy andsystems in low and middle-incomecountries (relevant for any resource-limited setting, or on teams whereaccess to resources or power variesamong team members)National Collaborating Centre onDeterminants of Health, Let’s TalkSeriesFSG Reimagining Social ChangeResources (See especially theBlueprint for Racial Equity)38MAKE TIME & SPACEFOR EQUITYEquity can be centred in theprocesses of co-production and as adesired outcome. Making time andspace to pay attention to equity in co-production processes can inform newways of thinking about outcomes. Justlike building trust requires intentionaleffort, intention and effort are neededto centre equity throughout all phasesof research co-production, fromplanning to securing funding, toholding meetings, to generating dataand mobilizing results. Start by makingequity considerations a standingagenda item on your meetings. Equity work cannot be done inisolation, because systems (i.e., thewater) are always made up of manypeople. Committing to equity involvesmaking collective and strategiccommitments at whatever level ofequity action your work is focused. For example, a university-basedresearch unit or faculty committed toco-production might co-create anequity action statement as part of itsvision, mission, or strategic plan.Research co-production teams orpartnerships might create an equityaction statement as part of itspartnership agreement. A researchteam working on a specific projectmight embed an equity commitment inits study design and protocol. In eachexample, the likelihood of equity beingintegrated in the processes or possibleoutcomes of collaborative efforts willbe greatly enhanced if collectiveeffort has been made at articulatingshared commitments.COMMIT TO EQUITY, CREATE SHARED GOALSENGAGE WITH EACHOTHERPUTTING IT INTO ACTIONEQUITY & PLANNINGPARTICIPATIONExtend your learning by using ourguide for mapping power dynamicsand planning equity-centredparticipation!39LISTEN & LEARNEquity work invites us to listen toothers and learn with openness, so wecan understand the impacts of ourwork on others. Making time andbuilding capacity to approach thework from a position of learning,rather than knowing, is a practice ofhumility and a commitment to equity.When we engage in research co-production with an intention to listen,rather than tell, we open pathways formore meaningful and inclusiveprocesses. As we learn-through-doing,accepting imperfection along theway, we can create equity-responsiveco-production that lends to morenuanced and impactful outcomes. Not all research co-production will beexplicitly focused on health inequitiesor the topic of equity. Yet, equity isrelevant to all research co-productionbecause it involves: Interactions between people whobring different ideas assumptions,norms and values, needs,experiences, etc., making powerdynamics important to its ownprocesses; Making decisions about whatproblems warrant attention, andwho should be involved in definingand responding to that problem;andGenerating knowledge abouthealth or health systems, which arealways characterized in some wayby inequities (as discussed before). Effectively, engaging in research co-production, in and of itself, serves as amechanism that distributes resources(e.g., people’s time and energy,research funding, access to people inhealthcare settings) and power (e.g.,in who is afforded voice and how, orwho has a say in determining theimplications of research findings) insociety.Research co-production,is, in and of itself, amechanism thatdistributes resources andpower in society.LEARNING ABOUTPOWER & PRIVILEGEIn the health sciences, generally,issues of equity largely focus onsymptoms of injustice, or inequities.Systemic, unearned disadvantagethat leads to inequity can only existin relationship to systemic, unearnedadvantage. Dr. Stephanie Nixonexplains this concept well in thisvideo about her ‘coin model’ ofprivilege.40BUILD CAPACITYDoing equity work requires collectivecapacity to engage in conversationsabout equity, conduct equity andpower analysis, and understand thecomplexities of equity issues presentin our co-production processes orrelative to the topics of co-production. Invest time and energy inprofessional development andtraining for advancing equity,individually and collectively. Spend time building a collectivelanguage for equity. Cultivate goodpractices of listening to each other inways that prioritize curiosity Buildcapacity for equity across all levelsof work and leadership. Institutionshave ethical obligations to respondand co-develop strategies,approaches and tools that canadvance equity. TAKE INSPIRATIONFROM OTHERSECTORSIdeas about governance and itsrelevance in research co-productionshape possibilities for equity. Nicole Latulippe and Nicole Klenk’s(2020) discussion about sovereignty,change making and decision makingin the context of globalenvironmental change is thoughtprovoking and inspiring. They offerinsights about the relationshipbetween governance, power, andequity in research co-production.Take courses in cultural safety andhumility, power analysis andmitigation, critical theory, coloniality,Indigenous histories or issues,transformational methods, among awide range of possible courses thatcan equip all members of researchco-production teams to engage incritically reflective and nuanceddialogue. 41PUTTING IT INTO ACTIONAsking equity questions opens oureyes to the systems (or, from ourmetaphor about fish, the ‘water’) inwhich we are situated. It helps us tobecome aware of the often invisibleparts of these systems. Like learningany new skill, becoming excellentquestion-askers takes time andpractice. Principles for equity can provide asystematic approach and practicefor asking good equity questions (6).The CCGHR Principles for Equity-Centred Research and KnowledgeTranslation focus on practicinghumility, sharing benefits, ASK EQUITY QUESTIONS, ALL THE TIMEacting on causes of inequities,cultivating inclusion, committing tothe future, and partneringauthentically. This set of equity-centred principles resonates widelyacross settings. They are integratedas a standard of excellence infunding policy (e.g., CIHR’s strategicplan). Your teams can use thesequestions as guiding prompts foridentifying equity opportunities,understand possible equityimplications, and guide richconversations that can inform goodequity choices. They can extendgood principles for partnerships, likethe IKT Guiding Principles (7).IKT GUIDINGPRINCIPLESCo-developed to supportpartnerships for quality, ethical spinalcord injury, the IKT Principles offerguidance for co-production partnersand partnerships. They set astandard for how people engage inthe act of partnering. The IKT GuidingPrinciples are an excellent resourcefor co-production teams who want tooperationalize their equity intentions.CCGHR PRINCIPLESEvolved through a co-productionseries of dialogues held acrossCanada, this set of six equity-centred principles provides a guidefor critical reflection. It supportspeople to identify equity choicesavailable in any collaborativeresearch or knowledge mobilizationprocess. They are used widely,outside of global health and arerelevant to co-production.42PRACTICE HUMILITY A practice of humility means leaninginto the work from a position oflearning rather than knowing.Practicing humility is an activestrategy for overcoming normativepower hierarchies, counteractingpaternalism that commonlysocialized into researchers and theresearch process. It supports ethical engagement inco-production. A general practice ofcuriosity is one way to embraceequity thinking without the pretenceof perfection or superiority. Yourteam can commit to being verycurious about the ‘water’ and how itis experienced differently bydifferent groups of people insociety. Your co-production team can ask: How are we listening andlearning from and with others inthis work? How are we approaching ourwork (and each other) from aplace of curiosity, rather thanknowing or ‘expertise’? How open are we to learning-from-doing? How do we identify and respondto mistakes we make? How are we honouring pluralityand many ways of knowing? How have we listened fordirection about priorities? Whose priorities are guiding thiswork? How are we mitigating thepressures of academicproductivity, individualism, andcompetition?43thinking habitskeeping equity workstuckmental modelseuphemismsusing soft words toavoid naming theknown causes ofinequitiesmiddle groundpoliteness andneutrality thatavoidsaccountabilitydistractionsconstantlymoving goalposts beforecommitting toactionmysterygazing at systemsand inequitiespassively, withoutacknwoledging ourown powercapacitysuggesting equitywork is outsideour expected skill setFigure 3. Mental models to contemplate and challenge as a practice of humility (adaptedfrom Shahram, S. Z. (2023). Five ways ‘health scholars’ are complicit in upholding healthinequities, and how to stop. International Journal for Equity in Health, 22(1), 15.).Enthusiasm for description andcritique of health inequities iscommon in the health sciences.Rhetoric of equity, diversity andinclusion is increasingly evoked bymany co-production teams, as well.Yet, they are relatively quiet aboutthe ways in which our own systemsand systemic ways of thinking anddoing recreate oppressive powerdynamics. Attitudes, behaviours, andfoundational content knowledge are impactful. Sometimes, theseways of thinking and doing are moreimpactful than recognized.Integrating equity considerations inany kind of health research requiresmoving beyond nice sounding orpolitically-correct words. One of themost important ways we canoperationalize equity throughresearch co-production is byexamining the mental models thatkeep equity work stuck (Figure 3).44SHARING BENEFITSWhen planning, work toward sharedbenefits. Identifying topics,knowledge-to-action problems oropportunities all involve equitychoices. From the earliest stages ofplanning, pause to identify whatsystems are implicated by yourresearch co-production efforts andask how inequities are present withinand between those systems. Thereare many questions that can beasked about sharing benefits, manyof which are often taken for grantedon research teams. Research co-production can causeharm or be (re)traumatizing,particularly if there is any possibilityor perception of tokenism. Unpackingassumptions about benefits is criticalto avoiding this risk. Despite commonrhetoric of the importance ofresearch impact, in universitysettings, academic publication isoften considered sufficientlyimpactful and privileged above allother research outputs (8, 9). Your co-production team can ask: How are different groupsbenefiting from this work? How are benefits distributedamong those involved? How will meet the needs ofdifferent audiences?W ho might be affected by yourteam’s decisions? What are the proposed outcomesof this work? Whose needs dothose outcomes serve? Are thereother needs that could beincluded in your planning?How are we cultivatingtransparency and openness inconversations about the differentneeds of people involved in thisresearch co-production? What do we understand abouthow we are distributing risks,time- and resource-costs,workload, capacity building, andopportunities implicated by thiswork? How have we navigatedrelational accountability to thepeople who contribute togenerating knowledge or data inthis research co-production?How are we honouringcontributions and upholdingstandards such as reciprocity,respect and relationality? Howdoes this work contribute tocollaborative solutions to aproblem?How does adding equityconsiderations to the workenhance that problem-solving?ACCOUNTABILITYIf the concept of relationalaccountability is new, considerviewing this recorded webinarfeaturing Harlan Pruden.45When we know the causes ofinequities, we can respond in waysthat are more or less productive.Identifying strategies that are moreproductive requires deep equitythinking. Sometimes, our ownorganizational cultures and norms canserve to exacerbate inequities andexperiences of inclusion, even onresearch co-production teams thatare intended to cultivate collaboration(10).Power dynamics are always at play inresearch co-production, often in waysthat reflect broader inequities acrosssociety. It can seem like a subtle rippleof change, but understanding powerdynamics is at the core of equitythinking. Integrating equity incollaborating and partnering requiresasking questions about power. ACT ON CAUSES OFINEQUITIESYour co-production team can ask: How does this work serving torespond to issues of equity? What inequities relative to theissue of focus do we knowabout? What inequities might we beunaware of, and how will wework toward illuminating those?How well do we understand thecauses of inequities in theparticular context of thisresearch co-production?How do we understand thepower dynamics relative to thiswork? How are we sharing power withothers? How am I leveraging the power I(we) hold in ways that serve tomitigate inequities within thisteam, and/or through our effortsor projects? How does this work act on the'water' (i.e., the systems andstructures we know perpetuateinequities)? How are we working tounderstand the issues of equityimplicit in our own research co-production processes? What are we doing to designgovernance processes andpractices that centre equity inour own team and throughoutour study design?EQUITY ACTIONEfforts to assess the degree of equityintegration or possibility are oftenmisaligned with the best evidenceabout known causes. The SystematicEquity Action Analysis frameworkprovides a set of analytical elementsand practices that can be applied toanything. It can support co-production teams to self-assess theirwork or used to guide co-productionresearch.46PARTNERAUTHENTICALLYHumans are creatures of habit.Sometimes, not only do we not noticethe water around us, but we can alsomiss noticing that we tend to swimwith the same fish. When reaching out to others to, forexample, create co-productionresearch teams or establish advisorycommittees or to plan knowledgemobilization or exchange events, it isimportant to think about whose voicesare being given meaningfulopportunities to be heard or amplified.CULTIVATE INCLUSION Your co-production team can ask: Who (and how) does this workimpact? How do we know who isimpacted by this work? How have we involved thosepeople? How have we made it possiblefor everyone to participate inmeaningful ways? How are we including seldomheard voices and perspectives?What are we doing to createopportunity for representationand voice among those whosenavigate systemic exclusion ordisadvantage? What are we doing to make thewater easier to navigate foreveryone?PRACTICES OFINCLUSIONIn a co-production study focused onunderstanding research-relatedexperiences of people who navigatesocial exclusions. The study invitedpeople to reflect on the things thatcreated a genuine feeling ofinclusion on research teams, advisorycommittee or councils, or other partsof health research ecosystems.Results led to a set ofrecommendations focused oncreating welcoming systems, spaces,and relationships. Find out moreabout this co-produced set ofrecommendations to guide co-production teams toward moremeaningful inclusion by visiting thepublication here.Standards and metrics ofaccountability are determinants ofequity. When naming desired impactsand outcomes of research co-production, consider those that sit inrelationship to your processes as wellas the possible long-term impacts. Asingle pebble dropped in watercreates ripples that spread across theentire water body. How we think aboutthe impacts and outcomes of our workdetermines what we measure, monitorand report on as ‘progress’. How welearn from what does not work shapeswhat we do moving forward. 47Your co-production team can ask: How are we identifyingassumptions, values, and theoriesunderpinning our work? How are we integrating criticalreflection and evaluation into ourteam processes? How do relationships in thisprocess need to be framed/re-framed or created/re-created?What ethical considerations needto be part of our processes,including and beyondrequirements by institutionalresearch ethics boards? What ethical tensions are wenavigating?What steps have we taken toarticulate individual andcollective accountabilities, withinour team and to the communitieswe hope will benefit from thiswork? How are we thinking aboutpossible consequences of thechoices we make? How are we prioritizing the well-being of future generations aswe move through this work? How are the indicators we use totrack progress showing us whatwe need to know about equityimpacts? How are we telling the story ofthe impacts of this work? How are we being creative andcurious in our thinking?What are we doing to promoteand elevate equity in thiscollaboration?48ASSESSING EQUITYIN PARTNERSHIPSCo-created through a process ofdialogues and workshops, the EquityTool for Assessing Global HealthPartnerships is an open-accessresource to support teams withdiverse interests, needs, andresources think about how equity isexperienced by people involved intheir work. This resource includes anarticle that can be helpful forflagging different perceptions abouthow equitable (or inequitable)aspects of partnerships might be,including governance, processes,procedures and day-to-day work,progress and impacts, andconsiderations of power andinclusion.PUTTING IT INTO ACTIONMAKE EQUITY CHOICES, WITH COHERENCEWhen the causes of a problem areknown, the most productiveresponses attempt to intervene onthose causes. For example, when weknow an illness is caused by a virus,the response is different than if itwere caused by bacteria. Inequitiesare caused by systemic forces thatdistribute power, wealth, andresources. When our actions respondto the systems problems, we can more productively respond toinequities; yet, most social programsand policies ignore the evidenceabout the causes of inequities. Equity choices are alwaysavailable. One way to extend equitythinking into equity action is toquestion how our efforts attempt tointervene on the known causes ofinequities. EQUITYINEQUITYpossible actions on the distribution of power, wealth and resourcesIlluminate whatdeterminesdistributionDisregard ordistract fromunfairdistributionAcknowledge (and donothing) about unfairdistributionDisrupt todistribute fairlyFigure 4. Assessing the choices available in any work, across the spectrum of daily work,operational mechanisms, policies and strategies (adapted from Plamondon KM. A tool toassess alignment between knowledge and action for health equity. BMC Public Health.2020;20).49WHERE & WHEN ARE EQUITY CHOICES MADE?what we believe is ‘real’ or whatconstitutes ‘knowledge’. Thesefoundations serve as a compass thatguides all aspects of research co-production. They set high-level goalsand desired outcomes of research co-production. Some research traditions are moreinclined to include content on theirfoundational paradigm underpinninga project or program of research,while others in the health disciplinesimply alignment with a positivistparadigm. Regardless of theparadigm, clarity and transparencyabout these foundations can supportequity choices and enhance thepossibility of meaningful equityaction. Equity choices are possible across anyparadigm! Equity-centred choicesabout the foundational philosophiesguiding research co-productionembrace plurality, challenge linearityand are adaptive. They privilegecultivating mutual understanding,nuance and centre a relational way ofunderstanding and engaging in theworld, and identify building trust as aguiding value (12). For all research co-production efforts, working tocollaboratively articulate a sharedview of equity is an importantreflection of worldview (11). EQUITY CHOICES INOUR PHILOSOPHICALAND THEORETICALFOUNDATIONSResearch co-production, like anyresearch, extends from a set of“patterns of beliefs and practicesthat regulate inquiry by providinglenses, frames and processes” (citeweaver). Philosophical andtheoretical underpinnings of researchbring a set of values andassumptions about how the worldworks, what matters within it, whatproblems warrant attention, what isconsidered ‘ethical’ or ‘fair’, andeven Foundations | Study Design | Protocols and Procedures | Daily WorkAdvancing equity action in andthrough research co-production ismore likely when there is strongcohesion between equity thinkingand equity work. When we integrateequity cohesively, from strategic andvision-setting efforts through to theways in which they areoperationalized and enacted in day-to-day routines, our research co-production efforts can transformsystems and contribute to advancingequity (3, 11).50Policy can also be considered those ofthe co-production team itself, guidingthe decisions a team makes internally.It also involves decisions about studydesign.Study design extends foundationalnotions of rigour, accountability andquality to a set of proposed researchco-production activities andprocesses. Research ecosystems areshaped by a wide variety of policiesand procedural standards, many ofwhich provide externally-determinedparameters and expectations forresearch co-production. For example,research co-production teams arerequired to uphold the policies onresearch ethics set by Tri-Council andinstitutional research ethics boards. Research co-production teams alsocreate their own policy andprocedural standards when theycreate a study design. These policiesand procedural standards set the ‘bar’of expectation for co-production workor initiatives. They establish who willparticipate, in what ways. Beyond thebeginning step of creating a studydesign that includes people whomight use or be affected by aresearch process, they include policiesabout reciprocity and accountability.Reducing the ‘co-production’ part ofresearch to a diversity check-list canundermine the spirit of collaboration,erode trust, and falsely convincePolicy, from an equity perspective, isanything that is done or not done,formally or informally and written orunwritten. In research co-production,the kinds of ‘policies’ that guide whatwe do can be external, ranging fromformal federal guidelines to peerreview, or tenure and promotionpolicies, among others. IN OUR STUDY DESIGNxaȼqanaǂ ʔitkiniǂA recipient of a BC AchievementFoundation Reconciliation Awardand funded by CIHR, xaȼqanaǂʔitkiniǂ is a partnership betweenKtunaxa Nation, Interior Health andthe University of British ColumbiaOkanagan. It is a nation-ledcollaboration, centering Ktunaxaunderstandings of wellness to co-develop health services that honourKtunaxa culture, language andworldviews. Their website featuresproject findings, research principlesand a range of videos, media andimagery. It is a powerful example ofhow examining the philosophical andmethodological foundations of co-production can be equity responsiveand equity advancing. This partnership is included as part ofthe IKTRN Casebooks (Vol 5).MANY WAYS OFWORKING ON THESAME THING 51researchers that they are doingsomething more equitable than theyactually are. Study designs thatintentionally create reciprocity,shared solution-seeking and createcapacity to work together in waysthat honour many kinds of expertiseand knowledge are more equity-centred. Good co-production, bydefinition, involves collaborative co-design. Adding equity considerationsto the process enhances, amplifiesand accelerates the possible impactsof co-production. can involve creating a governancestructure for the work, including, forexample, community advisorycouncils. Procedures throughout the process ofresearch co-production can be moreor less inclusive as well. Data analysisis often less inclusive and engagedthan other aspects of the researchand knowledge-to-action process.Including people in interpreting resultscan dramatically shift the nature andpossibilities of research. Governance is central to researchco-production. It is about howdecisions are made about thedistribution of power and resources,including decisions about where ourattention will focus. It also includesdecisions about how we will worktogether, and what we will use tohold each other to account. Structures created to cultivateinclusion in research co-production GET INSPIREDA number of examples show how co-production designs that account forequity in productive ways. Here are afew promising examples to inspireequity choices in co-production studydesigns:A framework for identifying theequity impacts of COVID-19Troubling the indicators used tomonitor racism, sexism, heterosexism,and gender binaries in healthresearchA Research Manifesto for theDowntown Eastside (Vancouver, BC)52Infusing co-prouctiongovernance with equityenhances, amplifies andaccelerates positive impactsand outcomes.inclusivity or what gets published. Further, it can inform compensationpractices and allocation of resources,inviting open and transparentconversations about power and thedistribution of resources—noting thatresource distribution can be aboutother things that determine thedegree to which people areauthentically included (e.g., peoplecannot participate in co-productiontables if they do not have the financialor technical means to do so) (10).Study protocols and procedures guidehow we engage in research co-production. They are important pointsof intersection between research co-production teams and thecommunities or populations their workaims to engage. All research co-production efforts revolve aroundsome engagement mechanism thatenables or operationalizes notions ofcollaboration. Study protocols andprocedures are mechanisms throughwhich our philosophical andtheoretical foundations come to life,and our study design isoperationalized. These are the thingswe use to guide our work andimplement the vision, goals andobjectives of our research co-production. Some examples of co-productionstudy protocols and proceduresinclude stated (or taken-for-granted)authorship practices, expectations fortransparency, partnership agreements,consent processes and practices,data generating and handlingprocedures, mentoring guidelines,among others. Research co-production teams can consider co-producing their own protocols andprocedures, so they work for everyoneinvolved. This can extend ideas aboutauthorship and reciprocity, addingconsiderations about language IN OUR PROTOCOLSAND PROCEDURESIn addition to routine practices forintegrating ethics standards inprotocols and procedures, considerexploring equity-responsiveapproaches for authorship orincluding people affected orinterested in the topic in youranalysis procedures. Here are someuseful examples. Collaborative decision making aboutauthorship order (video)Co-production procedures forqualitative analysis (article)The Federation of CanadianMunicipalities offers a toolkit forgood practices for equity-centredgovernance (can be applied to co-production)GET INSPIRED53Beyond the formalized structures,processes, and mechanisms thatguide research co-production areeveryday kinds of interactions amongpeople on the team. Daily tasks androutines actually make up the bulk ofour work and including things likehow we communicate, how we shareinformation, how we facilitatemeetings, how we relate to eachother, and how differentcontributions are received as acollective. Mundane, small interactions betweenpeople in the context of research co-production are often taken-for-granted and powerful points,moments, or places that determineexperiences of equity or inequity—particularly among the team itself. Day-to-day work and interactionsreflect both organizational cultureand people’s unique perspectives,disciplinary norms, habits, and waysof being in the workplace. Researchco-production is often initiated bypeople situated in academicinstitutions, which are places knownto perpetuate inequities. Academicnotions of leadership evolved incontext of colonialism, creatingconditions that are highly resistant toequity (13, 14). How we lead andfacilitate conversations throughlistening, seeing, and validating others can be away of showing our willingness to beaware of the 'water'. We can useequity thinking to guide choices wemake in virtually any parts of our dailywork. Team meetings represent touch-points where equity thinking can beincluded. You can also incorporateequity when preparing variouscommunications materials ormodelling equity-centred practices forintroductions. It extends to our day-to-day practices for report writing,identifying implications andrecommendations, or navigatingadministrative work. Other examples of daily routinesinclude: land acknowledgements;routine meeting processes andagendas; research, data handlingpractices; project management andcoordination; and interpersonalcommunications.IN OUR DAY-TO-DAYWORKHere are a few resources thatshow different ways of weavingequity considerations in day-to-day work, all of which offerrelevance to co-production:CIHR’s Citizen EngagementResourcesNixon’s (2019) Coin Model ofPrivilege and Critical AllyshipGET INSPIRED54REFERENCES1234567Ocloo, J., & Matthews, R. (2016). From tokenism to empowerment:progressing patient and public involvement in healthcareimprovement. BMJ quality & safety, 25(8), 626-632.Todic, J., Cook, S. C., Spitzer-Shohat, S., Williams Jr, J. S., Battle, B. A.,Jackson, J., & Chin, M. H. (2022). Critical theory, culture change, andachieving health equity in health care settings. Academic Medicine,97(7), 977.Plamondon, K. M., Caxaj, C. S., Graham, I. D., & Bottorff, J. L. (2019).Connecting knowledge with action for health equity: a criticalinterpretive synthesis of promising practices. International journal forequity in health, 18, 1-10.Plamondon, K., Ndube-Eyoh, S. & Shahram, S. (2022). Equity, powerand transformative research co-production. Chapter 2.2 in ResearchCo-Production in Healthcare (Graham, Rycroft-Malone, Kothari &McCutcheon (Eds). Askheim, O. P. (2021). The co-researcher role in the tension betweenrecognition, co-option and tokenism. In Involving Service Users inSocial Work Education, Research and Policy(pp. 133-144). Policy Press.Plamondon, K. M., & Bisung, E. (2019). The CCGHR Principles for GlobalHealth Research: Centering equity in research, knowledge translation,and practice. Social Science & Medicine, 239, 112530.Gainforth, H. L., Hoekstra, F., McKay, R., McBride, C. B., Sweet, S. N.,Ginis, K. A. M., ... & Willms, R. (2021). Integrated knowledge translationguiding principles for conducting and disseminating spinal cord injuryresearch in partnership. Archives of Physical Medicine andRehabilitation, 102(4), 656-663.55REFERENCES8910111213Plamondon, K., Banner, D., Cary, M. A., Faulkner, M., Gainforth, H.,Ghag, K., ... & Wick, U. (2024). Relational practices for meaningfulinclusion in health research: Results of a deliberative dialogue study.Health Expectations, 27(1), e13865.Plamondon, K. M., Dixon, J., Brisbois, B., Pereira, R. C., Bisung, E.,Elliott, S. J., ... & Shahram, S. (2023). Turning the tide on inequitythrough systematic equity action-analysis. BMC Public Health, 23(1),890.Tuck, E., & Yang, K. W. (2014). R-words: Refusing research.Humanizing research: Decolonizing qualitative inquiry with youth andcommunities, 223, 248.Paylor, J., & McKevitt, C. (2019). The possibilities and limits of “co-producing” research. Frontiers in sociology, 4, 23.Sibley, K. M., Khan, M., Banner, D., Driedger, S. M., Gainforth, H. L.,Graham, I. D., & Plamondon, K. (2022). Recognition of knowledgetranslation practice in Canadian health sciences tenure andpromotion: A content analysis of institutional policy documents. Plosone, 17(11), e0276586.Quijano, A. (2000). Coloniality of power and Eurocentrism in LatinAmerica. International sociology, 15(2), 215-232.14Plamondon, K. & Shahram, S. (2024). Defining Equity, itsDeterminants, and the Foundations of Equity Science. Social Science& Medicine (Under Review).56the RIPPLE EFFECT seriesthe RIPPLE EFFECT seriesSUSTAINING PROGRESSGauging successMaking ripples of changeKey resourcespage 60page 62page 6304Advancing equity invites re-thinkingwhat questions are asked and whatdata are considered as meaningfulindicators of progress. It can bemessy. It invites imagining new waysto track and monitor impacts to knowif we are doing a good job. The moreinclusive our efforts are tounderstand impacts, the more likelywe are to monitor things that revealequity impacts.Health and social sciences are goodat monitoring and measuring theconsequences of unfair systems andstructures. Good data exists showingthe relationship between poor healthoutcomes (e.g., lower lifeexpectancy) and the unfairdistribution of resources, wealth andpower. By tracking just about anyhealth outcome or social indicator toshow inequities. The truth is thatpeople are still figuring out how tomeasure work that acts on theseknown causes of inequities. Part ofthe work of building more equitablefutures involves creating new ways topay attention to the impacts ofdecisions and actions (orinactions).Two equity-centredconsiderations for monitoring and evaluation include: (a) asking new,equity-centred questions of dataalready routinely gathered; and (b)asking new, equity-centred questionsabout data that could and should begathered.There will always be ways to re-frame the way existing data arehandled, interrogated, or used tojustify or challenge a particularpolicy direction. Paying attention tohow power is distributed in andthrough research co-production, andhow imbalances are mitigated,matters.One of the ways in which equityconsiderations might be applied toexisting data is by applying equityquestions as those data are beingdefined or used (e.g., to develop areport). Inviting diverse perspectivesin the analysis and interpretation ofdata, and its relevance to equity, isan important step in making the bestuse of existing data. We can alsoextend ideas of what data are usefulfor monitoring equity impacts byworking with others who combinefederal or provincial data sets withlocal data sets. Consider buildingefforts to collaboratively define GAUGING SUCCESSHOW WILL WE KNOW WE PROMOTINGEQUITY?60metrics of equity into research co-production efforts, both as means ofmonitoring how people on teams areexperiencing equity and to monitorbroader impacts of the work. Equityimplications are context-specific so,new questions and new indicatorsmight be needed. An equity-centredprocess for identifying indicatorswould invite people most affected toparticipate in identifying how to tellthe equity story of a particulardecision, action, or policy direction. Our efforts should help usunderstand the ways in whichbenefits are being distributed, orburdens being carried related to anyco-production effort.British Columbia’s Office of theHuman Rights Commissioner releaseda promising (and inspiring!) resourceto guide practices for disaggregateddemographic data collection in2020. The grandmother perspectivedraws attention to the powerful roledisaggregated data can play inmaking systemic inequities visible,while cautioning that these samedata can be used in ways that moveus toward or away from equity.Importantly, the authors emphasizehow process and purpose determinehow data are defined, handled,analyzed and interpreted aredeterminants of equity (1). A PROMISINGAPPROACHThe framework identifies threeelements to guide consideration ofrace-based data disaggregation:purpose (eliminating systemic racism,promoting equity); process(respectful relationship, communitygovernance); and tool(disaggregation as a means ofachieving purpose). While all of theseelements may be relevant toresearch co-production teams, thefocus on process is particularly so. Itdraws attention to the relationshipbetween research and society, andthe role research can play inaddressing inequities.More information is available on theirwebsite, including backgroundresources and recommendations foruse in different settings. 61COMMIT TO EQUITYASK EQUITY QUESTIONSMAKE EQUITY CHOICESEMBRACEEmbrace agencyAdvance EquityEmbrace agencyMAKING RIPPLES OFCHANGEEach of us has our own sphere ofinfluence and agency to make choicesabout what we think about and howwe work. Our engagement in equitywork is influenced by many interactingforces, across many spheres ofinfluence. Research co-productionteams include people whose spheresof influence extend to broaderinstitutions, such that the capacitybuilding efforts emerging from theseteams can have ripple effects byextension through service, teachingand supervision, and publicengagement. Extending impact invites us to examineintersectionalities in new ways, notonly as a tool for reflection aboutone’s own (and the team’s) identity orpositionality, but also as a means ofexamining the intersections ofpositional influence carried by eachperson involved in (or affected by)research co-production (2). Manyinteracting levels of influence shapethe social systems and structures thatsurround us. These interactions areunavoidable and do not deter equitywork; but they can present contextsthat facilitate or hinder equity. Be bold. Share what you are doing.Equity work is catalytic: the morewe do it, the more is possible!EVERYONE HAS ASPHERE OF INFLUENCEFigure 5. Extending impact by leveraginginteractions between spheres of influence.CO-PRODUCTIONTEAMS &ADVISORSCommunity & RegionProvince & CountryContinental RegionsWorldAcross Ecosystems 62AGENCYKEY RESOURCESREADWATCHReclaiming Power and Place: TheFinal Report of the National Inquiryinto Missing and MurderedIndigenous Women and Girls. July2019.Addressing Racism: An independentinvestigation into Indigenous-specificdiscrimination in B.C. health care.November 2020.A Municipal Guide to the Truth andReconciliation Commission’s Calls toAction. July 2021.National Collaborating Centre forDeterminants of Health, Let's TalkSeries. This series covers a range oftopics about equity, including racism,ethics, place, and communityengagement.Stephanie Nixon talks about Power &Privilege in this useful video on thecoin model for thinking aboutsystemic and intersecting issues ofequity.STRENGTHEN THE FOUNDATIONS OF YOUREQUITY PRACTICEVISIT US FOR MORE!www.equityscience.ca 63British Columbia’s Office of the Human Rights Commissioner.(2020).Disaggregated demographic data collection in British Columbia: Thegrandmother perspective. Vancouver, B.C., Canada.REFERENCES1Plamondon, K. & Shahram, S. (2024). Defining Equity, itsDeterminants, and the Foundations of Equity Science. Social Science& Medicine (Under Review).2the RIPPLE EFFECT seriesSyilx Territory | Kelowna, British Columbia Turtle Island | CanadaContact: info@equityscience.caLAB
Report
eng
Unreviewed
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Faculty
How to equity in health research co-production
Text