Critical Dialogues for Action is a Research Methodology for Transforming Engagement into Impact

Critical Dialogues for Action is a Research Methodology for Transforming Engagement into Impact | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Critical Dialogues for Action is a Research Methodology for Transforming Engagement into Impact Lyn K. Sonnenberg, Ming-Ka Chan, David Wiljer, Victor Do, Madison Taylor, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8553339/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Critical Dialogues for Action (CDFA) is a structured, equity-centered methodology designed to transform dialogue into systemic change in health professions education and health systems. Developed over five years of iterative application, CDFA integrates lived expertise, structured facilitation, and implementation science directly into the dialogue process. In contrast to dialogic approaches that prioritize reflection without clear pathways to action, CDFA explicitly embeds accountability, follow-through, and implementation within its design. CDFA operates through three interdependent levels: Foundational Elements, Process and Engagement, and Action and Impact. Together, these levels establish the conditions necessary to foster meaningful connection, disrupt entrenched power dynamics, and generate actionable, system-relevant outcomes. Foundational elements attend to relational conditions such as humility, curiosity, and trust; process and engagement strategies structure inclusive, power-aware participation; and action and impact mechanisms integrate implementation scaffolding, accountability structures, and feedback loops to support sustained change. As a methodology, CDFA aligns with institutional efforts to advance the Sustainable Development Goals (SDGs), particularly reducing inequalities (SDG 10) and peace, justice, and strong institutions (SDG 16). By centering lived expertise, supporting inclusive participation, and strengthening institutional accountability, CDFA offers a practical approach for operationalizing equity and governance commitments within academic and health system contexts. This paper outlines the model’s theoretical evolution, compares CDFA with other participatory approaches, and illustrates its application across institutional, educational, and policy settings. Through applied examples, we demonstrate how CDFA supports the transformation of engagement into measurable, enduring impact, reframing dialogue not as an endpoint but as a methodology for sustainable, equity-driven systems change. Critical Dialogues for Action (CDFA) equity in health systems lived expertise integration participatory engagement structured facilitation Figures Figure 1 Figure 2 1. Introduction Dialogue lies at the heart of health professions education and health systems, shaping learning and decision-making. Panels convene, seminars explore key topics, and learning sessions expand knowledge. Patients and care partners join discussions, and strategic planning guides progress. Yet far too often, conversations fall short of producing sustained, systemic change, hindered by insufficient deep listening and the absence of the multi-directional dialogue needed for true progress. This persistent gap between knowledge and impact has sparked a search for new methodological approaches, grounded in the understanding that dialogue alone is not sufficient, especially when equity-driven transformation is urgently needed [ 1 ]. The Deliberative Dialogues (DD) methodology has long served as a respected tool in knowledge translation and policy discussion, offering space for reflection, diverse perspectives, and consensus-building [ 2 ]. Deliberative Dialogues involve a structured group process that brings together diverse participants in an environment conducive to open discussion, using research evidence and participants’ own experiences as inputs to collectively explore policy issues, consider alternative solutions, and build mutual understanding. Deliberative dialogues are particularly helpful for reaching common ground with complex problems and polarizing opinions. However, in practice, many DD initiatives emphasize process over outcome. While valuable in surfacing ideas and fostering discussion, these dialogues often do not focus on lasting shifts in policy or practice, particularly when addressing entrenched inequities in healthcare [ 3 , 4 ]. Too often, system-level accountability is absent, and action steps are unclear or lack resourcing. Beyond DD, several other participatory methodologies have informed engagement practices in health systems, education, and policy. Consensus Conferences engage both experts and lay participants in structured deliberation to generate shared recommendations. However, they often lack mechanisms for follow-up, and their reliance on expert framing can unintentionally reinforce hierarchy and limit inclusion of grassroots perspectives [ 5 ]. Participatory Action Research (PAR) centers participant engagement and co-creation, often leading to contextually grounded insights [ 6 ]. While PAR offers a valuable model for engaging communities in co-creation and knowledge generation, it is widely recognized as highly resource-intensive, often challenging to scale, and primarily rooted in localized contexts [ 7 ]. Citizen Juries offer a platform for public voice and inclusive deliberation on complex policy questions. While these processes elevate underrepresented perspectives, they often operate in isolation from policy implementation pathways and face limitations in duration and institutional reach [ 8 ]. Critical Dialogues for Action (CDFA) emerged in response to the need for approaches that link reflective dialogue with implementation, especially in equity-focused contexts [ 9 , 10 ]. This paper introduces CDFA, tracing its evolution and situating it within broader methodological and theoretical traditions. We describe its structure, distinct features, and application in real-world health and health education contexts, and examine how CDFA shifts deliberative dialogue methodology from reflection to action. By exploring its theoretical underpinnings, comparing it with DD and other related frameworks, and offering applied examples in health professions education and policy, we position CDFA as a complementary and equity-centered framework that enhances capacity to link dialogue with structural change. Given increasing expectations for academic institutions to demonstrate alignment with the Sustainable Development Goals (SDG), particularly those related to equity, governance, and inclusive decision-making, there is a growing need for methodologies that translate dialogue into accountable action. 1.1 Theoretical Foundations The development of CDFA is grounded in two primary theoretical influences: critical pedagogy and implementation science [ 11 , 12 ]. The critical pedagogical underpinning of CDFA is deeply informed by the work of Paulo Freire, who argued that authentic dialogue must address epistemic inequities and lead to transformation [ 11 ]. Freire emphasized that those most affected by oppression should be central to the processes of knowledge creation and change. In this spirit, CDFA positions lived experience as a vital form of expertise. It embeds relational, reflective, and power-aware practices into its structure to shift engagement from transactional consultation to co-creation and shared problem-solving. At the same time, implementation science offers a systematic approach for translating evidence into sustainable practices across complex systems. Drawing from frameworks such as Proctor et al.’s implementation outcomes and the equity-informed adaptations proposed by Baumann and Cabassa [ 12 , 13 ], CDFA incorporates principles such as feasibility, fidelity, and sustainability from the outset. This dual grounding supports both strategic implementation and social transformation. The duality allows CDFA to move beyond traditional knowledge exchange approaches that may reinforce systemic inertia, reorienting dialogue toward accountable, equity-centered action. 2. Materials and Methods: Developing CDFA The CDFA approach was led by Sanokondu, a multinational learning community fostering healthcare leadership education for learners ( https://www.sanokondu.com/ )) supported by the Office of Leadership Education, Rady Faculty of Health Sciences ( https://umanitoba.ca/health-sciences/office-leadership-education ) [ 14 ]. The CDFA series emerged at a time of profound societal reckoning, catalyzed by events such as the COVID-19 pandemic, the murder of George Floyd [ 15 ], and the death of Joyce Echaquan in a Canadian hospital [ 16 ]. These events underscored the urgent need for healthcare systems and Health Professions Education (HPE) to move beyond passive listening and commit to meaningful, sustained action. In partnership with Equity in Health Systems (EqHS), an international collaborative research group dedicated to advancing equity-driven transformation in health systems through innovative methodologies, partnerships, and actionable leadership scholarship ( https://www.EqHS.ca ) , located at the Bruyère Research Health Institute, the CDFA Series was created. It included monthly sessions designed to surface equity issues, elevate systemically excluded voices, and translate collective insights into concrete action within healthcare and health education systems ( www.eqhs.ca/cdfa ). It evolved over a five-year period through iterative design, implementation, and refinement. CDFA evolved through four major phases, outlined in Fig. 1 . From its inception, CDFA distinguished itself from traditional deliberative approaches by embedding the expectation that dialogue must lead to implementation. Over time, the process deepened its focus on structuring that action and ensuring it was co-created and sustained. Feedback from diverse perspectives from participants, facilitators and planning committee members informed the iterative work through each of the phases. Phase 1: Integration of Equity Principles (2021–2022) : CDFA launched with a deliberate focus on equity and implementation. From the beginning, lived experience was treated as essential expertise, and the model was designed to move beyond in-the-moment dialogue. Early convenings surfaced the need for clear pathways to action and highlighted the importance of explicitly resourcing and structuring this component. Phase 2: Action Orientation Enhancement (2022–2023) : As implementation emerged as a frequent bottleneck, CDFA evolved to include more intentional scaffolding for action planning. This strategy included dedicating time within each session to connect and collaboratively identify system levers, build alignment across roles, and co-create next steps that were both meaningful and feasible. Mechanisms to share learnings and resources were created and refined over time. Phase 3: Development of Structured Facilitation Techniques (2023–2024) : Recognizing the critical role of skilled facilitation, this phase focused on developing clear facilitation techniques grounded in relational learning, trauma-informed practice, and equity-centered inquiry. Facilitators were supported to draw out quieter voices, manage discomfort productively, and navigate power dynamics. Technology was used to further enhance engagement and learning. Phase 4: Establishment of Accountability Frameworks (2024–2025) : The most recent evolution embedded follow-up and feedback loops into the design itself. Strategies such as peer accountability groups, post-session debriefs, and progress tracking ensured that actions identified during dialogue translated into measurable change and informed future convenings. More deliberate partnership and coalition building were facilitated over time as relationships deepened, and trust became embedded in the work. Throughout its development, CDFA has remained adaptive, continuously shaped by real-time feedback, shifting conditions, and lessons drawn from each convening. It has clear utility as a facilitation model for advancing equity-focused change in health professions education and health policy environments. 2.1 CDFA as a Methodology for Studying and Advancing Equity-Focused Change Exploring how Critical Dialogues for Action (CDFA) functioned beyond a facilitation model to a methodology for investigating and supporting equity-oriented transformation was a natural next step. Five core features enable researchers, facilitators, and participants to generate, analyze, and act on contextually grounded insights within real-world systems. Grounded in Theory. CDFA draws on critical pedagogy and implementation science, framing dialogue as both a reflective and generative act. It treats lived experience as legitimate evidence and positions participants as co-analysts and co-designers of change. Embedded Data Generation. Each CDFA session provides opportunities for qualitative data collection, including participant reflections, co-created documents, and observed group dynamics. These data illuminate how equity is understood, negotiated, and operationalized in practice. Iterative and Adaptive Design. Structured as a continuous cycle with built-in feedback loops and follow-up, CDFA operates as both intervention and method. Outcomes emerge not only through observation but through participation in the process itself. Equity-Centered Knowledge Production. By explicitly surfacing and challenging power dynamics, CDFA is particularly well-suited for examining epistemic injustice, institutional bias, and the inclusion of systemically excluded voices in decision-making. Tracking Change Over Time. The use of progress mapping, peer accountability, and alignment with system-level timelines allows CDFA to examine how insights lead to action—and how that action shapes policies, practices, and institutional culture. Taken together, these methodological features position CDFA as both a research approach and an applied framework for equity-centered transformation. 2.2 Clinical Trial Number Not applicable. Results Through a series of predominately virtual two-hour workshops involving interdisciplinary leaders from multiple regions, CDFA enabled dialogue on urgent equity and social justice topics in healthcare, providing insights into how equity-oriented professional development could support systems transformation. The two-hour duration was a deliberate decision to allow for time to build connection and to facilitate a deeper immersion in the topic with time to learn from facilitators and each other. Over the past five years, the CDFA methodology has been implemented in more than 40 sessions, engaging participants ranging from learners, frontline care providers and educators to senior leaders, patient partners, community members, members from other disciplines/professions and policymakers. Feedback and outcomes from these sessions have been previously published and have directly informed the iterative refinement and maturation of the CDFA methodology over time [9]. The diversity of facilitators and participants based on lived expertise, roles, geography etc., enriched the dialogue and engagement sometimes extended beyond the formal session time. Partnership with other organizations, such as the Canadian Association for Medical Education [17], broadened the reach of CDFA and expanded the opportunities for networking and shared learning. Topics addressed through CDFA have included systemic racism in healthcare education, Indigenous and Black health equity, ableism, weight stigma, digital health and inclusivity, structural bias in leadership pathways, and the ethical integration of AI in health systems, among others (listed in the Appendix). Despite the diverse focus areas, each session followed a consistent facilitation arc and applied the same core values and accountability mechanisms. 3.1 Operationalizing CDFA: From Values to Action Drawing from this collective experience, the CDFA model operates across three interdependent levels, outlined in Figure 2: Foundational Elements, Process and Engagement, and Action and Impact . Together, these levels support a transition from meaningful dialogue to tangible systems change. Foundational Elements: This level anchors CDFA in values that create the conditions for meaningful, equity-centered engagement. Humility invites participants to set aside assumed expertise and remain open to others’ lived realities and to receiving feedback. Curiosity fosters a learning posture rather than a performative one, while vulnerability signals a readiness to confront discomfort and unlearn entrenched assumptions. These foundational values are intentionally cultivated through pre-session preparation, open and deliberate invitations to participate, and psychological safety practices that help establish mutual trust and accountability. In early CDFA sessions, for example, opening reflections and shared agreements for engagement were co-developed to signal shared ownership and set the tone for relational accountability. Process and Engagement: This level operationalizes the foundational values through structured facilitation and engagement strategies. Sessions are not simply open forums but follow a deliberate arc: setting context, surfacing lived expertise, identifying systemic levers, and co-creating actions. Facilitation techniques include small-group breakout sessions, use of real-time collaborative tools, and guided reflection prompts to draw out quieter voices and mitigate power imbalances. Engagement is further deepened through cross-sector participation and co-creation, ensuring that those often excluded from decision-making have influence in or guide the dialogue's direction. Action and Impact: The third level focuses on integrating implementation into the dialogue process, rather than treating it as an afterthought. CDFA includes built-in mechanisms for tracking commitments, following up on actions, and feeding results back into future sessions. These mechanisms include post-session debriefs, progress mapping, peer accountability groups, and alignment with organizational or policy cycles to maximize relevance and uptake. Over time, CDFA initiatives have led to tangible changes, including revised institutional policies, reallocation of funding, and the establishment of new collaborative networks. The impact of CDFA is not measured solely by participant satisfaction but by the durability of the structural shifts it enables. Together, these interdependent levels illustrate how CDFA moves beyond traditional engagement models by embedding action and accountability at every stage of the process. 4.2 Observed Impacts Across Contexts Application of the CDFA methodology across diverse settings has yielded tangible impact at multiple levels. In the short term, participants consistently reported increased awareness of equity concepts and greater readiness to integrate new perspectives into their work. Connections for peer support, mentorship, sponsorship and explicit problem solving were made leading to reported enhanced wellbeing and changes at the individual level. Intermediate outcomes included revisions to training materials and the adoption of new practices aligned with equity, inclusion, and accountability principles. Over time, CDFA has supported the formation of peer support groups, collaborative networks, and the gradual integration of equity-focused strategies into leadership development and institutional culture. These impacts span a range of domains, from health professions education to community health. In academic contexts, CDFA has informed curriculum redesign efforts addressing systemic racism, resulting in updated assessment policies and pedagogical practices. In community health settings, dialogues surfaced key barriers and opportunities related to resource allocation for underserved populations, informing future planning and advocacy efforts. At the healthcare institutional level, CDFA methodology has been embedded into strategic planning processes, influencing hiring practices, diversity policies, and equity audit mechanisms. Together, these outcomes underscore CDFA’s capacity to generate sustained and meaningful change. They also reveal consistent patterns in how CDFA fosters transformation across diverse settings. Building on its use as a facilitation and change-making model, Critical Dialogues for Action (CDFA) is being applied as a formal research methodology to explore structural inequities and co-create actionable solutions within health systems. This evolution is grounded in the need to move beyond describing inequities to understanding how they emerge, are sustained, and can be transformed through collaborative inquiry. To make these patterns visible, we now describe the internal structure of the CDFA methodology that enables this impact. In recent projects, CDFA has been intentionally structured to support formalized knowledge generation through a three-step process: (1) facilitation of Critical Dialogue for Action sessions, (2) member-checking through follow-up interviews and group sessions, and (3) consolidation and analysis by the research team. These steps enable participants to surface lived expertise, identify equity tensions, and contribute to the development and refinement of research-informed, system-relevant interventions. To illustrate its application, one research example comes from EqHS’ collaboration with AMS Healthcare, a national organization dedicated to reimagining healthcare through a dual focus on technology and compassion. In this initiative, CDFA was used to design and facilitate a multi-session dialogue series that convened health professionals, educators, and individuals with lived expertise from across Canada. The dialogue structure emphasized relational learning, interdisciplinary exchange, and co-development of actionable strategies. As a result, the sessions generated system-level recommendations aimed at shifting institutional culture and advancing equity-informed innovation. This collaboration exemplified how CDFA can be scaled for national-level implementation, while preserving its commitment to local voices, structured facilitation, and follow-through on change. Since CDFA incorporates social action as a core output, it is being used to center systemically excluded voices, examine individual and institutional biases, and inform the design of equity-oriented competencies and policies. As such, CDFA serves not only as a dialogic tool, but as an investigative method capable of generating empirical insight, supporting participatory analysis, and tracking implementation over time. To support consistent application and evaluation of the Critical Dialogues for Action (CDFA) methodology, we developed the CDFA Fidelity & Reflexivity Tool (see Appendix for the tool). This tool guides facilitators and participants in planning, delivering, and reflecting on CDFA sessions by assessing alignment with ten core principles, including accountability, humility, curiosity, power-sharing, and alignment with equity values. It offers a flexible structure for rating fidelity, documenting observations, and identifying actionable improvements, thereby strengthening both the rigor of implementation and opportunities for ongoing reflexive practice. This shift formalizes CDFA as both an intervention and a dialogical model, offering a flexible yet rigorous methodology for those working at the intersection of health equity, education, and systems transformation. Discussion Critical Dialogues for Action (CDFA) complements and extends dialogic methodologies by embedding accountability, intentional facilitation, and implementation scaffolding into the engagement process. Drawing from critical pedagogy and implementation science, CDFA positions lived experience as legitimate expertise, disrupts power dynamics, and structures dialogue toward change, promoting co-created outcomes that move beyond reflection toward transformation. While informed by the principles of Deliberative Dialogues (DD), CDFA was developed to address persistent limitations in equity integration, follow-through, and implementation. Both methods emphasize structured dialogue, evidence-informed input, and inclusive engagement; however, CDFA adds design elements specifically intended to ensure that insights lead to action. CDFA builds on DD’s foundation to better meet the demands of contemporary systems change [18]. It shifts the emphasis from shared understanding to structured, equity-oriented implementation. Whereas DD often leaves follow-through to participants or external mechanisms, CDFA prioritizes pathways to action directly into the process [19]. In exploring other dialogic methodologies that strive toward principled action and moral agency, a particularly resonant parallel can be found in the Critical Dialogue method described by Delany et al. in the context of clinical ethics consultation [20]. The methodological alignment between CDFA and Delany et al.'s Critical Dialogue (CD) method for clinical ethics consultation is particularly noteworthy. While developed independently in differing contexts, CDFA within systems-level equity dialogues and the CD method within clinical ethics, their shared emphasis on structured facilitation, moral agency, and value-based deliberation reflects a convergent evolution in dialogic methodology. Delany et al. explicitly outline a seven-step facilitation model designed to scaffold participants' ethical reasoning and moral growth, rather than prescribing normative conclusions [20]. Similarly, CDFA emphasizes structured engagement rooted in humility, curiosity, and vulnerability, fostering spaces for unlearning, unpacking assumptions, and surfacing lived expertise. Both approaches center participants as active moral agents and embed accountability and implementation into the design of the dialogue itself. Critical Dialogues for Action builds upon this foundation by adding an explicit commitment to structural change, real-time feedback loops, and embedded implementation science. This convergence points to an emerging dialogic paradigm that transcends traditional deliberative engagement by integrating relational ethics, critical pedagogy, and systemic transformation. While the term “Critical Dialogues” is used in multiple contexts, our CDFA methodology was derived from DD; as such, our CDFA are distinct from other CD references. Beyond DD and CD, several other participatory methodologies were mentioned in the introduction. While each dialogic method provides opportunities as a methodology, their limitations further clarify CDFA’s distinctive contribution. CDFA draws from each of these methodologies: adopting PAR’s emphasis on lived expertise, Citizen Juries’ commitment to inclusivity, and Consensus Conferences’ structured deliberation, while also addressing their respective challenges. Through its built-in implementation mechanisms, skilled facilitation, and adaptability across settings, CDFA presents a more integrated and action-oriented alternative suited as a research methodology to conducting focus groups, leading to the ultimate outcome of health systems transformation. Critical Dialogues for Action is intentionally designed to balance deep contextual engagement with strategic scalability. Its structured facilitation, cross-sector adaptability, and built-in mechanisms for implementation and follow-up, position it as a likely more nimble, transferable methodology for advancing equity-focused systems change. As illustrated throughout this paper, CDFA is best understood not as a wholesale replacement for existing dialogue models, but as a methodological evolution. It reflects increasing demands across health professions education and health systems for participatory models that are not only inclusive but also effective in catalyzing structural change. Critical Dialogues for Action builds on the strengths of other models, while enhancing the field’s capacity to drive impact in equity-sensitive domains. 5.1 Addressing Gaps in the Existing Literature As the demands on health systems continue to evolve, there is growing recognition that dialogue alone is insufficient. Increasingly, practitioners and scholars call for methodologies that catalyze, not just convene, transformative action. While the literature on deliberative and participatory engagement is well established, key gaps persist in four areas: implementation, equity integration, scalability, and structural influence, all of which CDFA works to address. Equity-Driven Design : While representation is often a goal in participatory engagement, few models explicitly interrogate power or prioritize systemically excluded voices. CDFA leverages critical consciousness and skilled facilitation to center equity in both process and outcome. This approach reflects growing consensus that engaging those most impacted is not only ethical but essential to shaping meaningful change. For example, both the Patient-Centered Outcomes Research Institute (PCORI) and equity-focused implementation scholars have argued for greater inclusion of lived expertise in research and policy design processes [21,22]. Scalability and Digital Adaptability : The dialogue literature continues to emphasize in-person formats. CDFA’s success with in-person, virtual, and hybrid flexible or HyFlex settings, which allow participants to choose either in-person or virtual for the same session, demonstrates that equity-driven engagement can be inclusive, accessible, and scalable across geographies and sectors [19,23]. Linkage to Structural-level Change: While many dialogues surface ideas, fewer offer pathways to institutional transformation. CDFA embeds system-level levers like co-design, leadership engagement, and evaluation to translate dialogue into action [24,25] Implementation Integration : Many existing dialogue models stop short of structured follow-up. CDFA incorporates tangible accountability mechanisms and follow-up processes from the outset, addressing the challenge of ensuring dialogue leads to lasting change [12]. By addressing these gaps, CDFA strengthens the theoretical and practical contributions of the dialogue literature, offering a replicable methodology for advancing equity-oriented systems change. 5.2 Limitations of CDFA Despite its strengths, CDFA is not without limitations. First, it requires a high degree of facilitation expertise. Facilitators must be able to hold complex dialogues, manage power dynamics, and guide participants through discomfort and reflection. Second, CDFA relies on participants’ willingness to approach dialogue with humility, curiosity, and openness to unlearning, learning and re-learning, qualities that may not always be present or easily cultivated. CDFA is also dependent on the ability to build trusting relationships to foster the willingness to engage in hard and ongoing work, especially in complex, and often negative, socio-political environments around the globe. Ensuring participants and facilitators have enough time to feel comfortable with one another at the start of a session, instead of going too soon to context over connections, offers critical insights into potential solutions. Scaling CDFA across diverse cultural, political, or institutional contexts can be challenging, especially when adaptation is needed to align with local needs while preserving fidelity to core principles. Additionally, achieving true power redistribution remains difficult in environments shaped by entrenched hierarchies. These limitations underscore the need for ongoing methodological refinement, including tools to support scalability, sustain engagement, and measure impact. While CDFA represents a structured framework for action-oriented dialogue, its successful adoption by institutions requires addressing several practical challenges. Institutions may face difficulties integrating CDFA into existing governance structures, particularly in bureaucratic environments where decision-making is slow, and change is often met with resistance. Strategies for embedding CDFA into institutional policies and frameworks need to be developed, including training programs for facilitators and leaders to better align CDFA strategies with institutional priorities and workflows. Real-world implementation of CDFA can encounter barriers, such as lack of investment from key interest-holders, often due to time constraints or perceptions that the co-design process lacks value. These challenges can result in varying levels of participant and community engagement. Additionally, power imbalances within institutions can hinder open discussions, requiring skilled facilitation to ensure equitable participation. For example, Mitchell et al. discuss ethical tensions in policy dialogues and highlight how navigating complexity requires clear normative commitments and facilitation structures that prioritize transparency and legitimacy [26]. Additionally, addressing these challenges involves fostering a culture of shared ownership, ensuring leadership support, and integrating CDFA into existing decision-making workflows. Despite these challenges, CDFA continues to evolve as both a practical tool and a research methodology. The development of the CDFA Fidelity and Reflexivity Tool represents a proactive step toward ensuring that core principles are upheld and that each dialogue remains intentional and impactful. While this tool still requires formal validation, it signals a commitment to continuous learning and accountability. Addressing the practical hurdles of implementation, such as scaling across contexts, securing institutional support, and fostering trust among participants, will be critical for realizing CDFA’s full potential. Yet these same challenges also offer opportunities for innovation and growth. Beyond its use in local or institutional settings, CDFA’s design makes it adaptable for applications in global health governance, interprofessional education, and systems transformation research. By embedding mechanisms for tangible action directly into the dialogue process, CDFA serves not only as a facilitation model but as a framework for investigating complex systemic issues and generating solutions grounded in real-world contexts. Future research and refinement will be essential to maximize CDFA’s impact. As health systems and education sectors increasingly seek approaches that translate dialogue into meaningful change, CDFA stands ready to help bridge the gap between conversation and sustained action. Conclusions Critical Dialogues for Action (CDFA) represents a significant methodological evolution in the landscape of deliberative engagement. By embedding equity, lived expertise, and concrete implementation pathways into the dialogue process, CDFA bridges the persistent gap between reflection and systemic change. It reframes dialogue not merely as a forum for discussion but as a catalyst for relational accountability, knowledge generation, and tangible, co-created transformation. Unlike conventional approaches that conclude with conversation, CDFA integrates structured facilitation, critical consciousness, and built-in mechanisms for follow-up and accountability. In doing so, it offers a practical methodology for advancing institutional commitments aligned with the Sustainable Development Goals (SDGs), particularly reducing inequalities (SDG 10) and peace, justice, and strong institutions (SDG 16), by operationalizing equity, participation, and accountability within decision-making and governance processes [27]. Its flexibility across local, national, and international contexts further underscores its potential as a scalable tool for equity-focused and sustainability-oriented systems change. While challenges remain—including the need for skilled facilitation, institutional alignment, and adaptation to diverse sociopolitical environments—these challenges also represent opportunities for further refinement and innovation. As health systems and academic institutions continue to grapple with persistent inequities and increasing demands for transparency and accountability, CDFA stands out as a timely, responsive, and action-oriented methodology. Future research should deepen empirical examination of CDFA’s effectiveness, validate the Fidelity and Reflexivity Tool, explore metrics for assessing impact, and expand its application across broader policy and institutional landscapes. Advancing CDFA strengthens the field’s capacity to ensure that dialogue becomes not merely a space for listening, but a deliberate strategy for achieving lasting, equity-driven, and sustainable transformation. Declarations Conflicts of Interest: The authors declare no conflicts of interest. Authorship The corresponding authors (L.K.S. & J.M.) have read the journal policies and are submitting this manuscript in accordance with those policies. Ethics Not applicable. Ethics approval was not required for this manuscript, as all individuals whose perspectives informed the development of the CDFA methodology are listed as co-authors and contributed in their scholarly capacities. Separately, feedback on the overall CDFA process has been collected through activities approved by the Bruyère Health Research Institute Research Ethics Board (#E-24-002), and insights from that work have informed methodological refinement. Consent to Participate Not applicable. Consent to Publish Not applicable. Funding statement: This research received no external funding; in-kind administrative support was provided by the University of Manitoba, Sanokondu, and EqHS. Author Contribution Conceptualization, L.K.S., M-K.C., J.O.B., and J.M.; methodology, L.K.S., M-K.C., J.O.B. and J.M.; writing—original draft preparation, L.K.S.; writing—review and editing, L.K.S., M-K.C., J.O.B., V.D., D.W., M.T., and J.M.; funding acquisition, J.M., M-K.C. All authors have read and approved the final manuscript. Acknowledgement We would love to thank Holly Harris for insights and critical review of the paper; we are all benefiting from her input and expertise. 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Joyce Echaquan: Indigenous woman dies after hospital staff’s racist remarks. Available online: https://bbc.com/news/world-us-canada-58819203 (accessed on 28 June 2025). Canadian Association for Medical Education. Available online: https://www.came-acem.ca/ (accessed on 28 June 2025). Abelson J, Forest PG, Eyles J, Smith P, Martin E, Gauvin FP. Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Soc Sci Med. 2003. https://doi.org/10.1016/s0277-9536(02)00343-x . Friess D, Eilders C. A systematic review of online deliberation research. Policy Internet. 2015. https://doi.org/10.1002/poi3.95 . Delany C, Feldman S, Kameniar B, et al. Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible. J Med Ethics. 2025. https://doi.org/10.1136/jme-2024-109927 . Fleurence RL, Selby JV, Odom-Walker K, Hunt G, Meltzer D, Slutsky JR, Yancy C. How the Patient-Centered Outcomes Research Institute is engaging patients and others in shaping its research agenda. Health Aff. 2013. https://doi.org/10.1377/hlthaff.2012.1176 . Baumann AA, Long PD. Equity in Implementation Science is Long Overdue. Stanf Soc Innov Rev. 2021. https://doi.org/10.48558/GG1H-A223 . Beauchamp N. Modeling and measuring deliberation online. In: González-Bailón B S., editor. The Oxford Handbook of Networked Communication; Foucault Welles. Oxford, UK: Oxford University Press; 2020. pp. 320–49. https://doi.org/10.1093/oxfordhb/9780190460518.013.23 . Loper A, Woo B, Metz A. Equity Is Fundamental to Implementation Science. Stanf Soc Innov Rev. 2021. https://doi.org/10.48558/QNGV-KG05 . Quinn AE, Drummond R, Clement F, Columbus M, Moss SJ, Fitzgerald E, Daya R, Mastikhina L, Leigh JP, Stelfox HT. A North Star Vision: Results from a Deliberative Dialogue to Identify Policy Strategies to Improve Value in Healthcare. Healthc Policy. 2023. https://doi.org/10.12927/hcpol.2023.27089 . Mitchell P, Reinap M, Moat K, Kuchenmüller T. An ethical analysis of policy dialogues. Health Res Policy Syst. 2023. https://doi.org/10.1186/s12961-023-00962-2. \ . United Nations Department of Economic and Social Affairs, Statistics Division. The Sustainable Development Goals Report 2025. New York, NY: UN DESA. 2025. Available from: https://unstats.un.org/sdgs/report/2025/The-Sustainable-Development-Goals-Report-2025.pdf Additional Declarations No competing interests reported. Supplementary Files AppendixA.docx AppendixB.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8553339","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":588079456,"identity":"efceb90f-a635-4802-b6e0-8917df9a0cbe","order_by":0,"name":"Lyn K. Sonnenberg","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIie3QMQuCQBTA8QvhprNbnwj1FQRB+jgngS4RgktDhBDUV/BjJEHzwQNb/AAOEYXQ1ODYJBnUVFy2Ndx/ecv9eI8jRKf7w/rPKTghPexE6ItYCSEPAt2JIzsTjnkVzQ5TtxyfMJodFzwxzrWSQBC6aXGJvTJwMC1iAEld5SoKzLPNFfq7UjhorgQQydTXUV60pEF/m4Y1mo2AoWTGTUnIpCUJ+huYtFsSAY5k9MthQWCzHGMorhGmubAypN5IRXj7Yzab45Svw6yK5oIP9suqVJEPGT++1+l0Ot17dxXTR1lHofliAAAAAElFTkSuQmCC","orcid":"","institution":"Bruyère Health Research Institute","correspondingAuthor":true,"prefix":"","firstName":"Lyn","middleName":"K.","lastName":"Sonnenberg","suffix":""},{"id":588079457,"identity":"3c3324f2-1335-4a30-b90a-fba6cf45537d","order_by":1,"name":"Ming-Ka Chan","email":"","orcid":"","institution":"Bruyère Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Ming-Ka","middleName":"","lastName":"Chan","suffix":""},{"id":588079458,"identity":"15a308b7-c529-4a86-8144-b3ce3fa6de1a","order_by":2,"name":"David Wiljer","email":"","orcid":"","institution":"Bruyère Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Wiljer","suffix":""},{"id":588079459,"identity":"eb337556-9dff-4069-b638-f108a344e0a7","order_by":3,"name":"Victor Do","email":"","orcid":"","institution":"Bruyère Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Victor","middleName":"","lastName":"Do","suffix":""},{"id":588079460,"identity":"d5232fa8-a4aa-4fbb-abe7-af44c8caff9b","order_by":4,"name":"Madison Taylor","email":"","orcid":"","institution":"University Health Network","correspondingAuthor":false,"prefix":"","firstName":"Madison","middleName":"","lastName":"Taylor","suffix":""},{"id":588079461,"identity":"ad7375d7-8df5-475c-9de0-ea8344cfa872","order_by":5,"name":"Jamiu O. Busari","email":"","orcid":"","institution":"Bruyère Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Jamiu","middleName":"O.","lastName":"Busari","suffix":""},{"id":588079462,"identity":"cf900709-f235-4302-8bc0-9c3652b961de","order_by":6,"name":"L. Jayne Beselt","email":"","orcid":"","institution":"Bruyère Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"L.","middleName":"Jayne","lastName":"Beselt","suffix":""},{"id":588079463,"identity":"82303fd6-f06e-403a-a80d-d2a375ddfc0b","order_by":7,"name":"Jerry M. Maniate","email":"","orcid":"","institution":"Bruyère Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Jerry","middleName":"M.","lastName":"Maniate","suffix":""}],"badges":[],"createdAt":"2026-01-08 15:53:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8553339/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8553339/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104397110,"identity":"7cce9d90-72c1-4239-9b83-aceca823a104","added_by":"auto","created_at":"2026-03-11 11:26:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":232549,"visible":true,"origin":"","legend":"\u003cp\u003eFour major phases of CDFA refinement\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8553339/v1/ee6e30dcd7f6c6291163c42b.png"},{"id":102414185,"identity":"10843032-0302-4cd3-b091-c49953cc22c0","added_by":"auto","created_at":"2026-02-11 12:34:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":108427,"visible":true,"origin":"","legend":"\u003cp\u003eThree interdependent levels of CDFA: Foundational Elements, Process and Engagement, and Action and Impact.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8553339/v1/9a0ad1b6d38448f001ec3c07.png"},{"id":109172154,"identity":"70115685-599b-4466-b743-7381f4ae41ff","added_by":"auto","created_at":"2026-05-13 09:03:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":601553,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8553339/v1/ad6ff16c-0bfe-4dfd-8b69-2279b09139f0.pdf"},{"id":102414187,"identity":"566305be-d40e-47cd-b5e7-b87c47fdf762","added_by":"auto","created_at":"2026-02-11 12:34:19","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":8011,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-8553339/v1/df2bb55c2033a87f26e9e721.docx"},{"id":102414188,"identity":"1cb475ec-c0c4-44e7-bd12-7566667118e7","added_by":"auto","created_at":"2026-02-11 12:34:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":10094,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixB.docx","url":"https://assets-eu.researchsquare.com/files/rs-8553339/v1/173d45457411542152333c85.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Critical Dialogues for Action is a Research Methodology for Transforming Engagement into Impact","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eDialogue lies at the heart of health professions education and health systems, shaping learning and decision-making. Panels convene, seminars explore key topics, and learning sessions expand knowledge. Patients and care partners join discussions, and strategic planning guides progress. Yet far too often, conversations fall short of producing sustained, systemic change, hindered by insufficient deep listening and the absence of the multi-directional dialogue needed for true progress. This persistent gap between knowledge and impact has sparked a search for new methodological approaches, grounded in the understanding that dialogue alone is not sufficient, especially when equity-driven transformation is urgently needed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Deliberative Dialogues (DD) methodology has long served as a respected tool in knowledge translation and policy discussion, offering space for reflection, diverse perspectives, and consensus-building [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Deliberative Dialogues involve a structured group process that brings together diverse participants in an environment conducive to open discussion, using research evidence and participants\u0026rsquo; own experiences as inputs to collectively explore policy issues, consider alternative solutions, and build mutual understanding. Deliberative dialogues are particularly helpful for reaching common ground with complex problems and polarizing opinions.\u003c/p\u003e \u003cp\u003eHowever, in practice, many DD initiatives emphasize process over outcome. While valuable in surfacing ideas and fostering discussion, these dialogues often do not focus on lasting shifts in policy or practice, particularly when addressing entrenched inequities in healthcare [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Too often, system-level accountability is absent, and action steps are unclear or lack resourcing.\u003c/p\u003e \u003cp\u003eBeyond DD, several other participatory methodologies have informed engagement practices in health systems, education, and policy. Consensus Conferences engage both experts and lay participants in structured deliberation to generate shared recommendations. However, they often lack mechanisms for follow-up, and their reliance on expert framing can unintentionally reinforce hierarchy and limit inclusion of grassroots perspectives [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Participatory Action Research (PAR) centers participant engagement and co-creation, often leading to contextually grounded insights [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While PAR offers a valuable model for engaging communities in co-creation and knowledge generation, it is widely recognized as highly resource-intensive, often challenging to scale, and primarily rooted in localized contexts [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Citizen Juries offer a platform for public voice and inclusive deliberation on complex policy questions. While these processes elevate underrepresented perspectives, they often operate in isolation from policy implementation pathways and face limitations in duration and institutional reach [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCritical Dialogues for Action (CDFA) emerged in response to the need for approaches that link reflective dialogue with implementation, especially in equity-focused contexts [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This paper introduces CDFA, tracing its evolution and situating it within broader methodological and theoretical traditions. We describe its structure, distinct features, and application in real-world health and health education contexts, and examine how CDFA shifts deliberative dialogue methodology from reflection to action. By exploring its theoretical underpinnings, comparing it with DD and other related frameworks, and offering applied examples in health professions education and policy, we position CDFA as a complementary and equity-centered framework that enhances capacity to link dialogue with structural change.\u003c/p\u003e \u003cp\u003eGiven increasing expectations for academic institutions to demonstrate alignment with the Sustainable Development Goals (SDG), particularly those related to equity, governance, and inclusive decision-making, there is a growing need for methodologies that translate dialogue into accountable action.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Theoretical Foundations\u003c/h2\u003e \u003cp\u003eThe development of CDFA is grounded in two primary theoretical influences: critical pedagogy and implementation science [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The critical pedagogical underpinning of CDFA is deeply informed by the work of Paulo Freire, who argued that authentic dialogue must address epistemic inequities and lead to transformation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Freire emphasized that those most affected by oppression should be central to the processes of knowledge creation and change. In this spirit, CDFA positions lived experience as a vital form of expertise. It embeds relational, reflective, and power-aware practices into its structure to shift engagement from transactional consultation to co-creation and shared problem-solving.\u003c/p\u003e \u003cp\u003eAt the same time, implementation science offers a systematic approach for translating evidence into sustainable practices across complex systems. Drawing from frameworks such as Proctor et al.\u0026rsquo;s implementation outcomes and the equity-informed adaptations proposed by Baumann and Cabassa [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], CDFA incorporates principles such as feasibility, fidelity, and sustainability from the outset.\u003c/p\u003e \u003cp\u003eThis dual grounding supports both strategic implementation and social transformation. The duality allows CDFA to move beyond traditional knowledge exchange approaches that may reinforce systemic inertia, reorienting dialogue toward accountable, equity-centered action.\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Materials and Methods: Developing CDFA","content":"\u003cp\u003eThe CDFA approach was led by Sanokondu, a multinational learning community fostering healthcare leadership education for learners \u003cem\u003e(\u003c/em\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sanokondu.com/\u003c/span\u003e\u003cspan address=\"https://www.sanokondu.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e))\u003c/span\u003e \u003cem\u003esupported by the Office of Leadership Education, Rady Faculty of Health Sciences (\u003c/em\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://umanitoba.ca/health-sciences/office-leadership-education\u003c/span\u003e\u003cspan address=\"https://umanitoba.ca/health-sciences/office-leadership-education\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e)\u003c/span\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The CDFA series emerged at a time of profound societal reckoning, catalyzed by events such as the COVID-19 pandemic, the murder of George Floyd [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and the death of Joyce Echaquan in a Canadian hospital [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These events underscored the urgent need for healthcare systems and Health Professions Education (HPE) to move beyond passive listening and commit to meaningful, sustained action. In partnership with Equity in Health Systems (EqHS), an international collaborative research group dedicated to advancing equity-driven transformation in health systems through innovative methodologies, partnerships, and actionable leadership scholarship (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.EqHS.ca\u003c/span\u003e\u003cspan address=\"https://www.EqHS.ca\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e)\u003c/span\u003e, located at the Bruy\u0026egrave;re Research Health Institute, the CDFA Series was created. It included monthly sessions designed to surface equity issues, elevate systemically excluded voices, and translate collective insights into concrete action within healthcare and health education systems (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.eqhs.ca/cdfa\u003c/span\u003e\u003cspan address=\"http://www.eqhs.ca/cdfa\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e).\u003c/span\u003e It evolved over a five-year period through iterative design, implementation, and refinement.\u003c/p\u003e \u003cp\u003eCDFA evolved through four major phases, outlined in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. From its inception, CDFA distinguished itself from traditional deliberative approaches by embedding the expectation that dialogue must lead to implementation. Over time, the process deepened its focus on structuring that action and ensuring it was co-created and sustained. Feedback from diverse perspectives from participants, facilitators and planning committee members informed the iterative work through each of the phases.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePhase 1: Integration of Equity Principles (2021\u0026ndash;2022)\u003c/b\u003e: CDFA launched with a deliberate focus on equity and implementation. From the beginning, lived experience was treated as essential expertise, and the model was designed to move beyond in-the-moment dialogue. Early convenings surfaced the need for clear pathways to action and highlighted the importance of explicitly resourcing and structuring this component.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePhase 2: Action Orientation Enhancement (2022\u0026ndash;2023)\u003c/b\u003e: As implementation emerged as a frequent bottleneck, CDFA evolved to include more intentional scaffolding for action planning. This strategy included dedicating time within each session to connect and collaboratively identify system levers, build alignment across roles, and co-create next steps that were both meaningful and feasible. Mechanisms to share learnings and resources were created and refined over time.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePhase 3: Development of Structured Facilitation Techniques (2023\u0026ndash;2024)\u003c/b\u003e: Recognizing the critical role of skilled facilitation, this phase focused on developing clear facilitation techniques grounded in relational learning, trauma-informed practice, and equity-centered inquiry. Facilitators were supported to draw out quieter voices, manage discomfort productively, and navigate power dynamics. Technology was used to further enhance engagement and learning.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePhase 4: Establishment of Accountability Frameworks (2024\u0026ndash;2025)\u003c/b\u003e: The most recent evolution embedded follow-up and feedback loops into the design itself. Strategies such as peer accountability groups, post-session debriefs, and progress tracking ensured that actions identified during dialogue translated into measurable change and informed future convenings. More deliberate partnership and coalition building were facilitated over time as relationships deepened, and trust became embedded in the work.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThroughout its development, CDFA has remained adaptive, continuously shaped by real-time feedback, shifting conditions, and lessons drawn from each convening. It has clear utility as a facilitation model for advancing equity-focused change in health professions education and health policy environments.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 CDFA as a Methodology for Studying and Advancing Equity-Focused Change\u003c/h2\u003e \u003cp\u003eExploring how Critical Dialogues for Action (CDFA) functioned beyond a facilitation model to a methodology for investigating and supporting equity-oriented transformation was a natural next step. Five core features enable researchers, facilitators, and participants to generate, analyze, and act on contextually grounded insights within real-world systems.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGrounded in Theory.\u003c/b\u003e CDFA draws on critical pedagogy and implementation science, framing dialogue as both a reflective and generative act. It treats lived experience as legitimate evidence and positions participants as co-analysts and co-designers of change.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEmbedded Data Generation.\u003c/b\u003e Each CDFA session provides opportunities for qualitative data collection, including participant reflections, co-created documents, and observed group dynamics. These data illuminate how equity is understood, negotiated, and operationalized in practice.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eIterative and Adaptive Design.\u003c/b\u003e Structured as a continuous cycle with built-in feedback loops and follow-up, CDFA operates as both intervention and method. Outcomes emerge not only through observation but through participation in the process itself.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEquity-Centered Knowledge Production.\u003c/b\u003e By explicitly surfacing and challenging power dynamics, CDFA is particularly well-suited for examining epistemic injustice, institutional bias, and the inclusion of systemically excluded voices in decision-making.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTracking Change Over Time.\u003c/b\u003e The use of progress mapping, peer accountability, and alignment with system-level timelines allows CDFA to examine how insights lead to action\u0026mdash;and how that action shapes policies, practices, and institutional culture.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eTaken together, these methodological features position CDFA as both a research approach and an applied framework for equity-centered transformation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Clinical Trial Number\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results ","content":"\u003cp\u003eThrough a series of predominately virtual two-hour workshops involving interdisciplinary leaders from multiple regions, CDFA enabled dialogue on urgent equity and social justice topics in healthcare, providing insights into how equity-oriented professional development could support systems transformation. The two-hour duration was a deliberate decision to allow for time to build connection and to facilitate a deeper immersion in the topic with time to learn from facilitators and each other.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOver the past five years, the CDFA methodology has been implemented in more than 40 sessions, engaging participants ranging from learners, frontline care providers and educators to senior leaders, patient partners, community members, members from other disciplines/professions and policymakers. Feedback and outcomes from these sessions have been previously published and have directly informed the iterative refinement and maturation of the CDFA methodology over time [9]. The diversity of facilitators and participants based on lived expertise, roles, geography etc., enriched the dialogue and engagement sometimes extended beyond the formal session time. Partnership with other organizations, such as the Canadian Association for Medical Education [17], broadened the reach of CDFA and expanded the opportunities for networking and shared learning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTopics addressed through CDFA have included systemic racism in healthcare education, Indigenous and Black health equity, ableism, weight stigma, digital health and inclusivity, structural bias in leadership pathways, and the ethical integration of AI in health systems, among others (listed in the Appendix). Despite the diverse focus areas, each session followed a consistent facilitation arc and applied the same core values and accountability mechanisms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 Operationalizing CDFA: From Values to Action\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDrawing from this collective experience, the CDFA model operates across three interdependent levels, outlined in Figure 2: \u003cstrong\u003eFoundational Elements, Process and Engagement,\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003eAction and Impact\u003c/strong\u003e. Together, these levels support a transition from meaningful dialogue to tangible systems change.\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eFoundational Elements:\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;This level anchors CDFA in values that create the conditions for meaningful, equity-centered engagement. Humility invites participants to set aside assumed expertise and remain open to others\u0026rsquo; lived realities and to receiving feedback. Curiosity fosters a learning posture rather than a performative one, while vulnerability signals a readiness to confront discomfort and unlearn entrenched assumptions. These foundational values are intentionally cultivated through pre-session preparation, open and deliberate invitations to participate, and psychological safety practices that help establish mutual trust and accountability. In early CDFA sessions, for example, opening reflections and shared agreements for engagement were co-developed to signal shared ownership and set the tone for relational accountability.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProcess and Engagement:\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;This level operationalizes the foundational values through structured facilitation and engagement strategies. Sessions are not simply open forums but follow a deliberate arc: setting context, surfacing lived expertise, identifying systemic levers, and co-creating actions. Facilitation techniques include small-group breakout sessions, use of real-time collaborative tools, and guided reflection prompts to draw out quieter voices and mitigate power imbalances. Engagement is further deepened through cross-sector participation and co-creation, ensuring that those often excluded from decision-making have influence in or guide the dialogue\u0026apos;s direction.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAction and Impact:\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The third level focuses on integrating implementation into the dialogue process, rather than treating it as an afterthought. CDFA includes built-in mechanisms for tracking commitments, following up on actions, and feeding results back into future sessions. These mechanisms include post-session debriefs, progress mapping, peer accountability groups, and alignment with organizational or policy cycles to maximize relevance and uptake. Over time, CDFA initiatives have led to tangible changes, including revised institutional policies, reallocation of funding, and the establishment of new collaborative networks. The impact of CDFA is not measured solely by participant satisfaction but by the durability of the structural shifts it enables.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTogether, these interdependent levels illustrate how CDFA moves beyond traditional engagement models by embedding action and accountability at every stage of the process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Observed Impacts Across Contexts\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApplication of the CDFA methodology across diverse settings has yielded tangible impact at multiple levels. In the short term, participants consistently reported increased awareness of equity concepts and greater readiness to integrate new perspectives into their work. Connections for peer support, mentorship, sponsorship and explicit problem solving were made leading to reported enhanced wellbeing and changes at the individual level. Intermediate outcomes included revisions to training materials and the adoption of new practices aligned with equity, inclusion, and accountability principles. Over time, CDFA has supported the formation of peer support groups, collaborative networks, and the gradual integration of equity-focused strategies into leadership development and institutional culture.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese impacts span a range of domains, from health professions education to community health. In academic contexts, CDFA has informed curriculum redesign efforts addressing systemic racism, resulting in updated assessment policies and pedagogical practices. In community health settings, dialogues surfaced key barriers and opportunities related to resource allocation for underserved populations, informing future planning and advocacy efforts. At the healthcare institutional level, CDFA methodology has been embedded into strategic planning processes, influencing hiring practices, diversity policies, and equity audit mechanisms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTogether, these outcomes underscore CDFA\u0026rsquo;s capacity to generate sustained and meaningful change. They also reveal consistent patterns in how CDFA fosters transformation across diverse settings. Building on its use as a facilitation and change-making model, Critical Dialogues for Action (CDFA) is being applied as a formal research methodology to explore structural inequities and co-create actionable solutions within health systems. This evolution is grounded in the need to move beyond describing inequities to understanding how they emerge, are sustained, and can be transformed through collaborative inquiry. To make these patterns visible, we now describe the internal structure of the CDFA methodology that enables this impact.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn recent projects, CDFA has been intentionally structured to support formalized knowledge generation through a three-step process: (1) facilitation of Critical Dialogue for Action sessions, (2) member-checking through follow-up interviews and group sessions, and (3) consolidation and analysis by the research team. These steps enable participants to surface lived expertise, identify equity tensions, and contribute to the development and refinement of research-informed, system-relevant interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo illustrate its application, one research example comes from EqHS\u0026rsquo; collaboration with AMS Healthcare, a national organization dedicated to reimagining healthcare through a dual focus on technology and compassion. In this initiative, CDFA was used to design and facilitate a multi-session dialogue series that convened health professionals, educators, and individuals with lived expertise from across Canada. The dialogue structure emphasized relational learning, interdisciplinary exchange, and co-development of actionable strategies. As a result, the sessions generated system-level recommendations aimed at shifting institutional culture and advancing equity-informed innovation. This collaboration exemplified how CDFA can be scaled for national-level implementation, while preserving its commitment to local voices, structured facilitation, and follow-through on change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince CDFA incorporates social action as a core output, it is being used to center systemically excluded voices, examine individual and institutional biases, and inform the design of equity-oriented competencies and policies. As such, CDFA serves not only as a dialogic tool, but as an investigative method capable of generating empirical insight, supporting participatory analysis, and tracking implementation over time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo support consistent application and evaluation of the Critical Dialogues for Action (CDFA) methodology, we developed the CDFA Fidelity \u0026amp; Reflexivity Tool (see Appendix for the tool). This tool guides facilitators and participants in planning, delivering, and reflecting on CDFA sessions by assessing alignment with ten core principles, including accountability, humility, curiosity, power-sharing, and alignment with equity values. It offers a flexible structure for rating fidelity, documenting observations, and identifying actionable improvements, thereby strengthening both the rigor of implementation and opportunities for ongoing reflexive practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis shift formalizes CDFA as both an intervention and a dialogical model, offering a flexible yet rigorous methodology for those working at the intersection of health equity, education, and systems transformation.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eCritical Dialogues for Action (CDFA) complements and extends dialogic methodologies by embedding accountability, intentional facilitation, and implementation scaffolding into the engagement process. Drawing from critical pedagogy and implementation science, CDFA positions lived experience as legitimate expertise, disrupts power dynamics, and structures dialogue toward change, promoting co-created outcomes that move beyond reflection toward transformation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile informed by the principles of Deliberative Dialogues (DD), CDFA was developed to address persistent limitations in equity integration, follow-through, and implementation. Both methods emphasize structured dialogue, evidence-informed input, and inclusive engagement; however, CDFA adds design elements specifically intended to ensure that insights lead to action. CDFA builds on DD\u0026rsquo;s foundation to better meet the demands of contemporary systems change [18]. It shifts the emphasis from shared understanding to structured, equity-oriented implementation. Whereas DD often leaves follow-through to participants or external mechanisms, CDFA prioritizes pathways to action directly into the process [19]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn exploring other dialogic methodologies that strive toward principled action and moral agency, a particularly resonant parallel can be found in the Critical Dialogue method described by Delany et al. in the context of clinical ethics consultation [20]. The methodological alignment between CDFA and Delany et al.\u0026apos;s Critical Dialogue (CD) method for clinical ethics consultation is particularly noteworthy. While developed independently in differing contexts, CDFA within systems-level equity dialogues and the CD method within clinical ethics, their shared emphasis on structured facilitation, moral agency, and value-based deliberation reflects a convergent evolution in dialogic methodology. Delany et al. explicitly outline a seven-step facilitation model designed to scaffold participants\u0026apos; ethical reasoning and moral growth, rather than prescribing normative conclusions [20]. Similarly, CDFA emphasizes structured engagement rooted in humility, curiosity, and vulnerability, fostering spaces for unlearning, unpacking assumptions, and surfacing lived expertise. Both approaches center participants as active moral agents and embed accountability and implementation into the design of the dialogue itself. Critical Dialogues for Action builds upon this foundation by adding an explicit commitment to structural change, real-time feedback loops, and embedded implementation science. This convergence points to an emerging dialogic paradigm that transcends traditional deliberative engagement by integrating relational ethics, critical pedagogy, and systemic transformation. While the term \u0026ldquo;Critical Dialogues\u0026rdquo; is used in multiple contexts, our CDFA methodology was derived from DD; as such, our CDFA are distinct from other CD references.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeyond DD and CD, several other participatory methodologies were mentioned in the introduction. While each dialogic method provides opportunities as a methodology, their limitations further clarify CDFA\u0026rsquo;s distinctive contribution. CDFA draws from each of these methodologies: adopting PAR\u0026rsquo;s emphasis on lived expertise, Citizen Juries\u0026rsquo; commitment to inclusivity, and Consensus Conferences\u0026rsquo; structured deliberation, while also addressing their respective challenges. Through its built-in implementation mechanisms, skilled facilitation, and adaptability across settings, CDFA presents a more integrated and action-oriented alternative suited as a research methodology to conducting focus groups, leading to the ultimate outcome of health systems transformation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCritical Dialogues for Action is intentionally designed to balance deep contextual engagement with strategic scalability. Its structured facilitation, cross-sector adaptability, and built-in mechanisms for implementation and follow-up, position it as a likely more nimble, transferable methodology for advancing equity-focused systems change. As illustrated throughout this paper, CDFA is best understood not as a wholesale replacement for existing dialogue models, but as a methodological evolution. It reflects increasing demands across health professions education and health systems for participatory models that are not only inclusive but also effective in catalyzing structural change. Critical Dialogues for Action builds on the strengths of other models, while enhancing the field\u0026rsquo;s capacity to drive impact in equity-sensitive domains.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.1 Addressing Gaps in the Existing Literature\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs the demands on health systems continue to evolve, there is growing recognition that dialogue alone is insufficient. Increasingly, practitioners and scholars call for methodologies that catalyze, not just convene, transformative action. While the literature on deliberative and participatory engagement is well established, key gaps persist in four areas: implementation, equity integration, scalability, and structural influence, all of which CDFA works to address.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEquity-Driven Design\u003c/strong\u003e: While representation is often a goal in participatory engagement, few models explicitly interrogate power or prioritize systemically excluded voices. CDFA leverages critical consciousness and skilled facilitation to center equity in both process and outcome. This approach reflects growing consensus that engaging those most impacted is not only ethical but essential to shaping meaningful change. For example, both the Patient-Centered Outcomes Research Institute (PCORI) and equity-focused implementation scholars have argued for greater inclusion of lived expertise in research and policy design processes [21,22].\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eScalability and Digital Adaptability\u003c/strong\u003e: The dialogue literature continues to emphasize in-person formats. CDFA\u0026rsquo;s success with in-person, virtual, and hybrid flexible or HyFlex settings, which allow participants to choose either in-person or virtual for the same session, demonstrates that equity-driven engagement can be inclusive, accessible, and scalable across geographies and sectors [19,23].\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLinkage to Structural-level Change:\u0026nbsp;\u003c/strong\u003eWhile many dialogues surface ideas, fewer offer pathways to institutional transformation. CDFA embeds system-level levers like co-design, leadership engagement, and evaluation to translate dialogue into action [24,25]\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eImplementation Integration\u003c/strong\u003e: Many existing dialogue models stop short of structured follow-up. CDFA incorporates tangible accountability mechanisms and follow-up processes from the outset, addressing the challenge of ensuring dialogue leads to lasting change [12].\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBy addressing these gaps, CDFA strengthens the theoretical and practical contributions of the dialogue literature, offering a replicable methodology for advancing equity-oriented systems change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.2 Limitations of CDFA\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite its strengths, CDFA is not without limitations. First, it requires a high degree of facilitation expertise. Facilitators must be able to hold complex dialogues, manage power dynamics, and guide participants through discomfort and reflection. Second, CDFA relies on participants\u0026rsquo; willingness to approach dialogue with humility, curiosity, and openness to unlearning, learning and re-learning, qualities that may not always be present or easily cultivated. CDFA is also dependent on the ability to build trusting relationships to foster the willingness to engage in hard and ongoing work, especially in complex, and often negative, socio-political environments around the globe. Ensuring participants and facilitators have enough time to feel comfortable with one another at the start of a session, instead of going too soon to context over connections, offers critical insights into potential solutions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eScaling CDFA across diverse cultural, political, or institutional contexts can be challenging, especially when adaptation is needed to align with local needs while preserving fidelity to core principles. Additionally, achieving true power redistribution remains difficult in environments shaped by entrenched hierarchies. These limitations underscore the need for ongoing methodological refinement, including tools to support scalability, sustain engagement, and measure impact. While CDFA represents a structured framework for action-oriented dialogue, its successful adoption by institutions requires addressing several practical challenges. Institutions may face difficulties integrating CDFA into existing governance structures, particularly in bureaucratic environments where decision-making is slow, and change is often met with resistance. Strategies for embedding CDFA into institutional policies and frameworks need to be developed, including training programs for facilitators and leaders to better align CDFA strategies with institutional priorities and workflows.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReal-world implementation of CDFA can encounter barriers, such as lack of investment from key interest-holders, often due to time constraints or perceptions that the co-design process lacks value. These challenges can result in varying levels of participant and community engagement. Additionally, power imbalances within institutions can hinder open discussions, requiring skilled facilitation to ensure equitable participation. For example, Mitchell et al. discuss ethical tensions in policy dialogues and highlight how navigating complexity requires clear normative commitments and facilitation structures that prioritize transparency and legitimacy [26]. Additionally, addressing these challenges involves fostering a culture of shared ownership, ensuring leadership support, and integrating CDFA into existing decision-making workflows.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite these challenges, CDFA continues to evolve as both a practical tool and a research methodology. The development of the CDFA Fidelity and Reflexivity Tool represents a proactive step toward ensuring that core principles are upheld and that each dialogue remains intentional and impactful. While this tool still requires formal validation, it signals a commitment to continuous learning and accountability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAddressing the practical hurdles of implementation, such as scaling across contexts, securing institutional support, and fostering trust among participants, will be critical for realizing CDFA\u0026rsquo;s full potential. Yet these same challenges also offer opportunities for innovation and growth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeyond its use in local or institutional settings, CDFA\u0026rsquo;s design makes it adaptable for applications in global health governance, interprofessional education, and systems transformation research. By embedding mechanisms for tangible action directly into the dialogue process, CDFA serves not only as a facilitation model but as a framework for investigating complex systemic issues and generating solutions grounded in real-world contexts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFuture research and refinement will be essential to maximize CDFA\u0026rsquo;s impact. As health systems and education sectors increasingly seek approaches that translate dialogue into meaningful change, CDFA stands ready to help bridge the gap between conversation and sustained action.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions ","content":"\u003cp\u003eCritical Dialogues for Action (CDFA) represents a significant methodological evolution in the landscape of deliberative engagement. By embedding equity, lived expertise, and concrete implementation pathways into the dialogue process, CDFA bridges the persistent gap between reflection and systemic change. It reframes dialogue not merely as a forum for discussion but as a catalyst for relational accountability, knowledge generation, and tangible, co-created transformation.\u003c/p\u003e\n\u003cp\u003eUnlike conventional approaches that conclude with conversation, CDFA integrates structured facilitation, critical consciousness, and built-in mechanisms for follow-up and accountability. In doing so, it offers a practical methodology for advancing institutional commitments aligned with the Sustainable Development Goals (SDGs), particularly reducing inequalities (SDG 10) and peace, justice, and strong institutions (SDG 16), by operationalizing equity, participation, and accountability within decision-making and governance processes [27]. Its flexibility across local, national, and international contexts further underscores its potential as a scalable tool for equity-focused and sustainability-oriented systems change.\u003c/p\u003e\n\u003cp\u003eWhile challenges remain\u0026mdash;including the need for skilled facilitation, institutional alignment, and adaptation to diverse sociopolitical environments\u0026mdash;these challenges also represent opportunities for further refinement and innovation. As health systems and academic institutions continue to grapple with persistent inequities and increasing demands for transparency and accountability, CDFA stands out as a timely, responsive, and action-oriented methodology.\u003c/p\u003e\n\u003cp\u003eFuture research should deepen empirical examination of CDFA\u0026rsquo;s effectiveness, validate the Fidelity and Reflexivity Tool, explore metrics for assessing impact, and expand its application across broader policy and institutional landscapes. Advancing CDFA strengthens the field\u0026rsquo;s capacity to ensure that dialogue becomes not merely a space for listening, but a deliberate strategy for achieving lasting, equity-driven, and sustainable transformation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of Interest:\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAuthorship\u003c/strong\u003e \u003cp\u003eThe corresponding authors (L.K.S. \u0026amp; J.M.) have read the journal policies and are submitting this manuscript in accordance with those policies.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eEthics\u003c/em\u003e \u003c/p\u003e \u003cp\u003eNot applicable. Ethics approval was not required for this manuscript, as all individuals whose perspectives informed the development of the CDFA methodology are listed as co-authors and contributed in their scholarly capacities. Separately, feedback on the overall CDFA process has been collected through activities approved by the Bruy\u0026egrave;re Health Research Institute Research Ethics Board (#E-24-002), and insights from that work have informed methodological refinement.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Participate\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Publish\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eFunding statement:\u003c/h2\u003e \u003cp\u003eThis research received no external funding; in-kind administrative support was provided by the University of Manitoba, Sanokondu, and EqHS.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization, L.K.S., M-K.C., J.O.B., and J.M.; methodology, L.K.S., M-K.C., J.O.B. and J.M.; writing\u0026mdash;original draft preparation, L.K.S.; writing\u0026mdash;review and editing, L.K.S., M-K.C., J.O.B., V.D., D.W., M.T., and J.M.; funding acquisition, J.M., M-K.C. All authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would love to thank Holly Harris for insights and critical review of the paper; we are all benefiting from her input and expertise.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eNo new datasets were generated or analyzed in this study. The CDFA Fidelity and Reflexivity Tool developed as part of this work is included in the Appendix of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e \u003cli\u003e\u003cspan\u003eGoddard A, Gillespie A. Textual Indicators of Deliberative Dialogue: A Systematic Review of Methods for Studying the Quality of Online Dialogues. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://unstats.un.org/sdgs/report/2025/The-Sustainable-Development-Goals-Report-2025.pdf\u003c/span\u003e\u003cspan address=\"https://unstats.un.org/sdgs/report/2025/The-Sustainable-Development-Goals-Report-2025.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Critical Dialogues for Action (CDFA), equity in health systems, lived expertise integration, participatory engagement, structured facilitation","lastPublishedDoi":"10.21203/rs.3.rs-8553339/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8553339/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCritical Dialogues for Action (CDFA) is a structured, equity-centered methodology designed to transform dialogue into systemic change in health professions education and health systems. Developed over five years of iterative application, CDFA integrates lived expertise, structured facilitation, and implementation science directly into the dialogue process. In contrast to dialogic approaches that prioritize reflection without clear pathways to action, CDFA explicitly embeds accountability, follow-through, and implementation within its design.\u003c/p\u003e \u003cp\u003eCDFA operates through three interdependent levels: Foundational Elements, Process and Engagement, and Action and Impact. Together, these levels establish the conditions necessary to foster meaningful connection, disrupt entrenched power dynamics, and generate actionable, system-relevant outcomes. Foundational elements attend to relational conditions such as humility, curiosity, and trust; process and engagement strategies structure inclusive, power-aware participation; and action and impact mechanisms integrate implementation scaffolding, accountability structures, and feedback loops to support sustained change.\u003c/p\u003e \u003cp\u003eAs a methodology, CDFA aligns with institutional efforts to advance the Sustainable Development Goals (SDGs), particularly reducing inequalities (SDG 10) and peace, justice, and strong institutions (SDG 16). By centering lived expertise, supporting inclusive participation, and strengthening institutional accountability, CDFA offers a practical approach for operationalizing equity and governance commitments within academic and health system contexts.\u003c/p\u003e \u003cp\u003eThis paper outlines the model\u0026rsquo;s theoretical evolution, compares CDFA with other participatory approaches, and illustrates its application across institutional, educational, and policy settings. Through applied examples, we demonstrate how CDFA supports the transformation of engagement into measurable, enduring impact, reframing dialogue not as an endpoint but as a methodology for sustainable, equity-driven systems change.\u003c/p\u003e","manuscriptTitle":"Critical Dialogues for Action is a Research Methodology for Transforming Engagement into Impact","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 12:34:12","doi":"10.21203/rs.3.rs-8553339/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66eb7660-82dd-4de5-8993-22ce09ff94c5","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-13T08:44:32+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T09:01:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 12:34:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8553339","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8553339","identity":"rs-8553339","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}