Knowledge translation in health and wellness research focusing on immigrants in Canada

KEYwords: Knowledge translation; knowledge mobilization; immigrants; refugee; health and wellness; Canada; evidence-based practice; Research into practice

Knowledge translation (KT) is a complex concept that requires a comprehensive and multifaceted approach and meaningful collaboration among different levels of stakeholders including community members, community organisations, health and social service providers, researchers, and governments.^1–3 A deeper understanding of the multiple factors that influence personal, community, and systemic behaviour for the uptake of evidence-based knowledge in practice is warranted.¹ The Canadian Institutes of Health Research (CIHR) defines KT as ‘a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the health care system.’²

CIHR identifies two general KT frameworks. Integrated KT describes the process whereby knowledge-users and decision-makers, those who use the research findings to make informed decisions about health practices and policymaking, are engaged in the entire research process.² Different stages of the research where knowledge-users may engage include identifying the research questions, developing and selecting the research design, collecting data, and interpreting and disseminating the findings. Conversely, end-of-grant KT refers to the one-way transfer of knowledge from the researchers to knowledge-users and decision-makers without the involvement of the latter.² Limiting the definition of integrated KT within studies that involve knowledge-users in the entire research process may exclude some research that involves knowledge-users in only one stage of the research, such as planning or designing the research method. Therefore, in this study, we defined integrated KT as the research that actively engaged the knowledge-users at any stage of the research process from planning to dissemination.

There is room for improvement in the transfer of health knowledge into practice.³ The socio-cultural, organizational, community and individual context in which KT occurs play crucial roles in translating research outcomes and recommendations into action.^4–6 Engaging policymakers and clinicians is easier than engaging community members due to language and socioeconomic barriers.⁶ To address health and social inequities, it is essential to meaningfully collaborate with community members and organizations to develop and apply pragmatic programmes and policies that address social, economic, and cultural influencers of health.⁷

Many western countries such as Canada, New Zealand, Sweden, Norway, the United States and others welcome a substantial number of immigrants and refugees.^8,9 Health-related KT is important in these countries where immigrants often face challenges in adjusting to new social and health-care systems and environments.^6,7,10,11 Immigrant communities are also less likely than their native counterparts in western countries to accept relevant research knowledge and translate it into their lifestyle.^6,7,10,11 In general, KT research engaging knowledge-users in the research process and translating the research-obtained knowledge to users is more scarce among immigrants than non-immigrants.^6,7,11 The little KT research among immigrants that exists in the literature is not well developed or well defined.^6,7,11 This may be due to a lack of socio-culturally and economically appropriate KT activities through which knowledge-users are engaged in the research process¹² and is an example of a gap in the systemic response to the needs of immigrants that further creates health inequities.^13,14

Several immigrant-receiving countries, including Canada, New Zealand, Nordic and some other European countries, have seen diversification in their population fabric derived from immigration^15–17 due to the influx of many refugees surviving wars, political upheaval and economic downturn in their home countries, and inviting economic migrants through skilled migration programmes.¹⁸ The health-care systems of these countries are not designed to address the needs of these widely diverse immigrants and refugees and results in less uptake of evidence-based health knowledge and practice among them.^19,20 This urges immigrant-oriented KT research to improve and diversify the primary health-care services to meet their needs. Therefore, through this review, we attempted to scope the KT research that has been done to engage immigrants. We identify the nature, content, mode, and settings of KT research regarding the health and wellness of immigrants. We systematically explore the relevant theoretical, empirical, and grey literature on KT among immigrants and refugees with the following specific objectives:²¹

1. Explore the studies on KT among immigrants in Canada;

2. Extract the nature and content of immigrant-oriented KT activities in Canada from the literature;

3. Identify the level and extent of engagement of knowledge-users within the research process during the KT activities;

4. Determine the barriers and enablers of the conduction and effectiveness of KT activities;

5. Capture the outcome of different KT activities; and

6. Identify gaps in research that conduct KT activities among the immigrant population in Canada and potential scope for policy implications.

This scoping review was conducted following a methodology developed by Arksey and O’Malley (2005) and Levac et al. (2010).^22,23 We followed the five-step approach they outlined: scoping, searching, screening, data charting, and data analysis. Additionally, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria to carry out and report this review.²⁴

The research team held several informal meetings involving citizen researchers to develop the research questions and decide on the definitions and terminologies around KT (see Table 1 for definitions). This developed the following research questions: What do we know about KT among immigrants in Canada?; What types of KT activities have been studied concerning Canadian immigrants’ health and wellness?; and Who are the partners of KT activities among immigrants in Canada?

Table 1. Definitions of KT-related terms used in the study

Inconclusiveness about what constitutes knowledge and KT has caused confusion in KT research development. Patients’ perspectives, health professionals’ experiences, knowledge synthesis through systematic reviews, and dissemination of knowledge through activities such as publications, conferences, and communication platforms are all forms of KT.²⁵ To identify the studies relevant to our research questions, we conducted a search of academic and grey literature databases (Table 2) using keywords based on the following three key terms: ‘knowledge translation’, ‘immigrants’ and ‘Canada’ (Table 3). We connected keywords for each term with ‘OR’ and later collectively linked all keywords for each main terms using the Boolean operator ‘AND’. We also reviewed the reference lists of reviews and relevant primary papers to identify further records. We restricted the search to English-language papers and did not place time restrictions.

Table 2. Databases searched

Table 3. Keywords searched

To obtain relevant articles, we defined inclusion and exclusion criteria corresponding to our research question. For initial title and abstract screening, we focused on reports about Canadian immigrants and refugees. We excluded publications about Canadian-born populations, including indigenous people and second-generation immigrants. Based on the insights from our internet scan, we generated further eligibility criteria following the PICOS²⁶ (population, intervention, comparisons, outcomes and study design) framework (Table 4).

Table 4. Inclusion and exclusion criteria

Systematic reviews were not included, but were used to find potential primary studies. All records were screened in Endnote (Clarivate Analytics, Philadelphia, PA, USA). Both screenings were conducted by two reviewers and disagreements were resolved through consensus.

We extracted the following information about each study: author(s); publication year; type, objective and location of the study; population size and age; study sample; KT target group (i.e. knowledge-users or decision-makers), modes, partners, and providers; outcome measures, limitations, and directions for future research (Table 5). Two reviewers tested the charting independently and the study team revised it during the search. Differences in data charting were resolved by discussion with a third reviewer. We undertook descriptive analyses to outline relevant studies and to detect research scope. Finally, the research team analysed and discussed results to identify key themes and findings. NC extracted data.

Table 5. Study characteristics

We analysed the data and reported findings following the strategy suggested by others.^22,23 Table 6 presents specific content and language of KT activities, specific types of KT activities involving knowledge-users, nature of the programme and partnership with knowledge-users (engaged or partnered individuals or organizations), and settings of KT activities. We outlined the processes of KT used among immigrants in Canada and arranged them in process modes. We identified KT activities that were used for engaging knowledge-users at each level of the research (planning and conceptualization, data collection, interpretation, and dissemination). Further analysis revealed nested concepts or categories that illustrated particular themes. We also extracted the factors influencing successful conduct of KT research and reported outcomes (Table 7).

Table 6. Description of KT activities in included studies according to WIDER criteria⁴⁵

Table 7. Barriers to, enablers and outcomes of KT

The search of academic databases conducted up until 31 August 2019 yielded 10,524 citations. After removing duplicates, 8,618 articles remained. The screening of titles and abstracts ensured the rejection of 8,512 articles. The remaining 106 were selected for full-text review. The author and one reviewer examined the articles for inclusion and exclusion criteria: 18 articles were eligible for inclusion. We used a PRISMA flow chart to track the number of studies at each stage of the review (Figure 1).

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart to track the number of studies at each stage of the study.

Eleven of the 18 studies were conducted in Ontario, five in British Columbia, and one study in each of Nova Scotia and Manitoba.

Most studies (8/18) included immigrants from multiple ethnic origins in their KT activities. Overall, Chinese immigrants were the most frequently studied ethnicity group (5/18), followed by Punjabi immigrants (4/21). Some studies reported their study population as a much broader ethnic identity; namely, South Asians (3), Latin (1), African (1), Asian (1) and Caribbean (1). The rest included Tamil (Sri Lankan) (1), Somalis (1), Polish (1), and Gujrati (1) participants.

All studies were conducted among immigrants. Refugees were part of one study, but no research was specifically focused on refugees, temporary migrants or undocumented migrants.

A range of research methods were used in these 18 studies. Most were qualitative (13/18); four were quantitative and one was mixed-methods. Qualitative studies used a community-based participatory action research approach (n = 3), a randomised-controlled trial (n = 2), case study (n = 2), interviews (n = 4), qualitative report (n = 1), and community organisation model (n = 1). Quantitative studies included a randomised-controlled trial (n = 1), matched cohort study (n = 1), and questionnaires (n = 2). The only mixed-method study used community-based surveys and focus group discussions to conduct their research.

Among the 18 articles, 15 studies were published between 2008 and 2018. Only three studies were published before 2008, in 1993 (n = 1) and 2002 (n = 2).

The focus of the KT research varied from specific health content, such as the proper use of the inhaler for chronic obstructive pulmonary disease (COPD)²⁷ to broad initiatives for applied health services research to increase health behaviours such as cancer screening.²⁸ Cancer screening, including breast, cervical and colon cancer, was the most common focus, with three studies in this area.^28–30 Two studies were conducted on hepatitis B in Chinese immigrants, and it was found that they possess a greater risk of this condition.^31,32 Two articles focused on maternal health-related issues,^33,34 health and safety at work,^35,36 and community mental health.^37,38 Other topics were the focus of KT research only once.

We categorized the 18 articles according to the CIHR classifications of integrated KT and end-of-grant KT.² Nine studies fit into the integrated KT approach. These involved the knowledge-users in the research process at any of the stages: planning and conceptualization, data collection, interpretation and dissemination, or implementation. Nine other studies used the end-of-grant KT approach. They did not actively engage knowledge-users in any of the research stages, but transferred knowledge vertically to knowledge-users, explored influencing factors, or compared and evaluated the outcomes that were included as the end-of-grant KT approach in this study.

Several studies used multiple activities (presented in Table 6). Discussions in the form of meetings or roundtables were the most frequent method used across all studies. Five studies used meetings to engage immigrants in the integrated KT research.^{32,34,37–39} Meetings with immigrants were not held in any of the studies using end-of-grant KT approaches.

Information or education sessions for community members was the next most common approach for integrated KT, used by three studies.^29,34,38 They engaged community peer-leaders and outreach workers in the research process as session co-facilitators,^29,34 or hired community researchers to conduct the information sessions independently.³⁸ Hiring community researchers was a strategy to include the communities in every step of the study as it demonstrates respect for the community’s culture.^38,40 Two end-of-grant KT research studies used this approach, with researchers⁴¹ and a registered nurse⁴⁰ conducting sessions for community participants.

The community forum was also used to engage knowledge-users in the research process, allowing people to contribute to the development of study frameworks, initiatives, or projects intended to benefit their community.^37,38 Although conferences are usually used to disseminate research findings, Ochocka et al. used community conferences to develop the framework of their project, as well as engage knowledge-users in the research phases in a process similar to community forums.³⁷

An English as a Second Language (ESL) programme was used by one research group to translate knowledge among Chinese immigrants.^31,32 They partnered with five Chinese community organisations running ESL programmes and through the programme instructors, they conveyed Hep-B-related knowledge to students. Another study partnered with community organisations and through immigrant volunteers, provided educational materials and talks to the knowledge-users.⁴² One study found the translation of COPD-related information either by other COPD patients’ role-playing video or a physician-made instructional video was more effective than reading an educational pamphlet.²⁷ One research team recruited selected women from communities (Punjabi and Gujrati) to conduct workshops with fellow women in their respective communities. The participants themselves were enabled to plan, organise, promote, and conduct their separate workshops autonomously.³⁹

Different activities used to disseminate the knowledge gathered from their research were conducted in both the integrated KT and end-of-grant KT approaches, with knowledge-users being involved in the dissemination phase of the research process in the integrated KT research, and the researchers vertically disseminating knowledge to the knowledge-users in the end-of-grant KT research. For instance, in one integrated KT study, skits were aired on television and team members, including community participants, made appearances in many television and radio programmes to keep the issue in the community’s view.³⁴ Examples of KT dissemination in end-of-grant KT studies included a sexual health workshop comprising a game, story, open question time, lecture with diagrams, demonstration, and related hands-on and reading-aloud activities to achieve positive outcomes among immigrant youth.⁴³

One study evaluated the effectiveness of the Canada Food Guide on the transfer of knowledge about maternal nutrition among immigrants and found them ineffective in KT for certain immigrant groups. The authors advised updating these resources with culturally and linguistically appropriate materials for immigrant women.³³

We report the partners of the KT activities in Table 6. We categorized them into two groups, community level and provider level. Most of the KT researchers worked with multiple partners to accomplish their research goals; these were both community- and provider-level partners (Table 6).

Most cases involved various community organisations of diverse immigrant groups, including: ethnocultural community organisations (n = 3),^28,38,39 community organisations providing ESL services (n = 2),^31,32 community-based mental health organisations (n = 1),³⁸ and umbrella organisations in mental health and diversity (n = 1).³⁸ Others included: community-based peer-leaders (n = 1),²⁹ ESL teachers (n = 2),^31,32 ESL students (n = 2),^31,32 COPD patients (n = 1),²⁵ community development officers (n = 1),³⁹ community outreach workers (n = 1),³⁴ community researchers (n = 1),^37,38 and a community-based research centre (n = 1).³⁸

Four studies partnered with interdisciplinary and inter-university academics to design and execute their research.^34,37,38,44 Other provider-level partners included public health nurses,³⁹ a provincial authority for the cancer screening programme,²⁸ a designated public health organisation,²⁸ hospitals,^33,34 and health service providers and practitioners.^28,29,37

We examined the settings of KT activities for Canadian immigrants according to the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendation.⁴⁵ The WIDER criteria are a checklist to measure, compare and evaluate KT research activities.⁴⁵ Overall, most studies were conducted in community settings such as restaurants, community and religious centres, allowing the researchers to engage with communities and involve them in the research process (see Table 6). Three studies were set in health-care settings and eight studies did not report their study settings.^27,35,39

No research explicitly mentioned that their KT activities or any of its component strategies were based on an established KT model or framework.¹ However, three studies used the Community-Based Participatory Action Research framework. We included them as CIHR identifies this as a form of integrated KT.² Community-Based Participatory Action Research works towards the same goal as integrated KT to engage knowledge-users in research so that both researchers and knowledge-users can generate evidence to help implement research outcomes.⁴⁶

Table 6 shows the level of intervention identified for each KT activity. Most studies of both integrated KT and end-of-grant KT designs engaged knowledge-users at the dissemination level (Table 6). Only two activities (hiring community-researchers^38,47 and creating a project steering community for research guidance)³⁸ were used to engage knowledge-users throughout the research process. KT activities that were used at the dissemination level include educational sessions, workshops, information videos, posters, community media, telephone talks and bulletins.

The studies variably reported barriers and enablers to executing their KT research or interventions among Canadian immigrants. Nine studies reported 17 barriers and most of them were unique. Ten studies reported 19 enablers, which were also mostly unique. We identified four categories of barriers and enablers of KT: knowledge-users, researchers or providers, partners (organisation or individual), and systemic (Table 7). Most reported barriers and enablers were related to the KT researchers or providers, followed by partners, knowledge-users, and systems.

Table 7 lists the outcomes of the KT activities within four categories: for knowledge-users, for researchers, for partners, and for the system. Eleven studies reported overlapping outcomes that contributed to nine types of outcomes in total. All outcomes were positive. Four studies explicitly reported that their KT activities developed and improved understanding of the respective KT content.^27,29,31,40 Three other studies concluded that their KT activities empowered participants to create and share knowledge within their communities.^27,31,39 Studies did not report the outcomes as short- or long-term, but we interpreted most reported outcomes as short-term. Only one study was able to mobilise knowledge-users to sustain their KT activities and to engage them further to work on these issues.³⁴

In this review, we show the breadth and depth of KT among immigrant and refugee populations of Canada. This synthesis of the current literature provides insight into the importance of collaborating with immigrant knowledge-users, practitioners, researchers, and stakeholders of immigrant health and wellbeing in knowledge translation. This scoping review generated a knowledge base of the range of KT research activities among immigrants, the contents of the conducted KT activities, the nature and goal of the approaches and the depth of the engagement of knowledge-users in these approaches. We also identified barriers and enablers to KT research with immigrants and the outcomes of these studies. Twenty-two types of KT activities were identified from studies that followed either of the two broad approaches: integrated KT and end-of-grant KT.

As the KT research demands input from the knowledge-users, ‘meetings’ or ‘discussions’ were the most common KT activity, probably due to its feasibility. In particular, ‘meetings’ or ‘discussions’ were chosen for planning and conceptualising research to help researchers ensure their work is acceptable and appropriate for the particular community and their culture. However, knowledge-users were involved through the entire research process only if they were hired as community researchers or made part of an advisory group or project-steering committee. They were paid incentives for their long-term commitment to the research. For dissemination-focused research in both integrated KT and end-of-grant KT streams, information or education sessions were commonly used, creating a learning environment for knowledge-users where they can question the providers and researchers and clarify the research.

We found cancer screening to be the most common content of KT research among immigrants. This may be because cancer screening rates are lower in immigrant groups than in non-immigrant groups, necessitating exploration of barriers to cancer screening and effective KT practices.^48,49

Across the articles in this review, most did not report any KT theories or frameworks that they might have used. Only three studies applied frameworks such as Community-Based Participatory Research. This suggests that knowledge translation to the immigrant community requires extensive involvement within the community during the research process. Community-Based Participatory Research is a practice rooted in social justice⁴⁶ and has demonstrated success in community engagement. It is also recognised by CIHR as a useful KT framework.² It is a suitable model for the transfer of research knowledge to the immigrant community.

Most research partners were community-level partners, likely because the target knowledge-users of most of these studies were immigrant community members and their acceptance of the research is facilitated by the involvement of community organisations as partners. Community partnerships in research facilitate trust among community members, resulting in greater authenticity and credibility of research findings in the community’s eyes.⁵⁰

Most barriers and enablers to effective KT were related to the researchers, indicating that researchers could be more attentive to conducting KT research among immigrant populations and give more control of the research process to knowledge-users. Among our eligible studies, we did not find any research with negative outcomes; however, most reported outcomes were short-term and one study indicated a decline in effects over time. Future research should consider long-term outcomes while planning KT research.

Many studies were inconsistent in describing and reporting their KT activities, which made it challenging to identify KT activities and code themes. The number of eligible studies was low and some KT activities were undertaken in only one study, which does not permit any generalisable inferences based on their results. We did not include evaluation in our review as our goal was to explore all the KT research activities on immigrant populations. However, we noted that only a few studies evaluated the outcomes of their KT activities, as advocated by guidelines, for the inclusion of an evaluation process to determine the success and worthiness of the KT activity.⁵¹

Another gap we found in the KT research is that there was no description of underlying theories of frameworks for KT. There are several recommended KT models, theories, and frameworks that give research a solid structure for planning, implementation, dissemination, evaluation, scalability and outcomes.⁵² The involvement of knowledge-users was also under-described across the studies. According to a few studies, when the researchers hired community researchers, they were involved in the whole process;^29,34,38 however, they did not describe clearly how they were engaged in the data analysis or interpretation process. This review concurs with other studies reporting that research remains largely researcher-driven^53,54 and knowledge-users are often not truly involved as integral partners.⁵⁵

The strengths of this review include its comprehensive literature search strategy covering most possible keywords and multidisciplinary databases. This strategy helped include research evidence on knowledge translation from a wide perspective and across diverse methodologies and objectives. The members of the research team are experienced and include a trained librarian to ensure the search strategy and extraction of data were appropriate. We also engaged citizen researchers and community representatives in the research group while formulating research questions.

The exclusion of non-English studies, in particular excluding French-language studies when this is an official language of Canada, may be considered a limitation of the study. Moreover, knowledge translation is a complex concept and the nature and range of activities associated with knowledge translation made it difficult to extract the evidence. It is also a new concept and its definition and interpretation may vary according to whether it is used in the health-care or social justice context or in a different context. The primary search delivered over 8000 studies, which was reduced to 106 by a diligent title and abstract screening process. Finally, the synthesis and interpretation of the data may not be clear due to the scarcity of research focusing on immigrant community knowledge translation in Canada. Despite these various limitations, this study is novel in synthesising a practical knowledge base that will help develop a strategic approach to effective knowledge translation within various groups of immigrant populations.

Addressing immigrant and refugee health is a critical challenge to any host country. Although this review searched for articles on KT research engaging immigrants in Canada, the findings can be relatable and implementable to other immigrant-receiving countries, especially those welcoming refugees, asylum seekers, and economic migrants from all over the world such as New Zealand, Sweden, Norway, Germany, and some other European countries.¹⁸ The growing number of immigrants and refugees often poses challenges to the primary health-care system of these countries to accommodate their diversified needs.⁵⁶ The knowledge of applied KT research and activities among immigrants in Canada, the level of engagement in the KT activities, their barriers and enablers, as well as outcomes gained from this scoping review will inform taking up appropriate KT activities and help the overall improvement of the primary health-care services in these host countries.

The authors declare no competing interests.

No financial support was received for this study.