What is Reflexive Practice and Why Does it Matter?

The primary focus of the Health Equity Impact Assessment (HEIA) is to reduce health inequities and increase positive health outcomes for various population groups. Conducting the HEIA requires a thoughtful process of identifying and producing mitigation strategies for population groups that may face unintended health impacts caused by the initiative of interest. One way of ensuring that the HEIA is conducted in the most effective way possible is by practicing reflexivity.

Reflexive practice, or reflexivity, is a form of critical reflection whereby practitioners become aware of and examine their underlying values, assumptions, and beliefs and how they may affect the assessment (Alley, Jackson, & Shakya, 2015). When seeking to address the determinants of health or health inequities, it is critical that practitioners recognize their internal biases that can sometimes result in important considerations being overlooked. By examining these biases, we can uncover their limitations and avoid becoming complacent or ritualistic in our work (MacDonald, 2013). To do so, we must first understand the lens through which we view the world (Alley, Jackson, & Shakya, 2015; Rix, Barclay, & Wilson, 2014), including the broader social and political contexts that influence us (Fleming, 2007). Reflexive practice is not only a mental event; it must be reinvested and applied to how one conducts the HEIA (Tremblay, Richard, Brousselle, & Beaudet, 2013).  

Applying Reflexivity to the HEIA Process (5 Steps)

Reflexive practice is important at each step of the HEIA process.  

1. Scoping

Scoping is perhaps the most critical step in conducting the HEIA. The appropriate identification of population groups and relevant determinants of health will determine the usefulness of the entire assessment.  

Use several forms of evidence to identify the population groups to be included in the assessment, ensuring an objective process (TIP: Gather insight from colleagues, key informants, focus groups, or the literature to gain a clearer picture of which groups are experiencing the most unintended impacts associated with the initiative).

Carefully consider whether you may be overlooking or lacking understanding about the experiences of some population groups (TIP: Ask yourself, “Am I fully grasping the experiences all population groups, or do I need more information?).

Be cognizant of the language used to define population groups as language can influence our attitudes or beliefs (National Collaborating Centre for Determinants of Health, 2013). Although the HEIA distinguishes between several population groups, remember that individuals can fit into more than one ‘box’; one can face many inequities at the same time.

2. Potential Impacts

The second step involves careful consideration of the unintended positive and negative impacts of the initiative on the population groups selected.

Colleagues or health intermediaries (practitioners who work directly with the identified populationgroups) may be able to help with understanding a range of positive and negative unintended impacts (TIP: Even though the HEIA can be conducted independently, it is better to collaborate whenever possible, throughout all of the steps).

Consider speaking with the end‐users of the initiative, who can provide additional insight on the impacts they face (TIP: This is one way for a practitioner to overcome the limitations of one’s underlying values, assumptions, and beliefs).  

3. Mitigation

The third step requires the practitioner to identify ways to reduce the unintended negative impacts and amplify the unintended positive impacts identified in Step 2.   

Use objective criteria to consider the feasibility of each mitigation strategy, since underlying values, assumptions, and beliefs can influence the strategies in which we deem feasible.

4. Monitoring

In Step 4, the practitioner must identify ways to measure the success of each mitigation strategy identified.  

The most effective monitoring strategies may be best identified through collaboration with colleagues (TIP: Hold an internal focus group or meeting to gather perspectives on how to best measure the success of each mitigation strategy).  

5. Dissemination

This step involves sharing the results and recommendations of the HEIA.

Since the purpose of the HEIA is to reduce health inequities, the dissemination can be a critical component in ensuring that the results and recommendations are applied in a useful way. Use dissemination strategies that involve collaboration or the involvement of several parties, whenever possible (TIP: Consider a focus group with key parties in order to de‐brief on the HEIA results and recommendations).  

References

Alley, S., Jackson, S. F., & Shakya, Y. B. (2015). Reflexivity: A Methodological Tool in the Knowledge Translation Process? Health Promotion Practice, available online.

Fleming, P. (2007). Enhancing the empowerment agenda in health promotion through reflective practice. Reflective Practice, 8(3), 315‐330.  

MacDonald, Marjorie. (2013). PHABC Summer School: Building reflexive and cultural competencies – Practicing reflexivity.

National Collaborating Centre for Determinants of Health. (2013). Let’s talk: Populations and the power of language. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University.  

Rix, E. F., Barclay, L., & Wilson, S. (2014). Can a white nurse get it? ‘Reflexive practice’ and the non‐Indigenous clinician/researher working with Aboriginal people. Rural and Remote Health, 14(2), 2679.  

Tremblay, M‐C., Richard, L., Brousselle, A., & Beaudet, N. (2013). Learning reflexively from a health promotion professional development program in Canada. Health Promotion International, 29(3), 538‐548.