By Kim Ozano
The Participatory Action Research (PAR) approach and paradigm is gaining ground within implementation and operational research agendas for international health interventions and programmes. The action planning, implementation and reflection stages allow for immediate research uptake and modification. This meets the need for partner governments and implementers, donors, and researchers to demonstrate impact and ensure new strategies become embedded within health systems. Furthermore, the participatory values align well with the overall development ideology including respect for diversity, community strengths, reflection of cultural identities, power-sharing, and co-learning (Minkler, 2000). Participatory health research (PHR), of which PAR is a form, is not a methodology but a paradigm that embodies these concepts and governs how researchers operate (Carr and Kemmis, 1986, Minkler and Wallerstein, 2008). The characteristics and quality criteria for participatory health research (PHR) are explained well in the position paper from the International Collaboration for participatory health research (ICPHR). The authors discuss the goal of PHR:
‘to maximize the participation of those whose life or work is the subject of the research in all stages of the research process, including the formulation of the research question and goal, the development of a research design, the selection of appropriate methods for data collection and analysis, the implementation of the research, the interpretation of the results, and the dissemination of the findings.’
The position paper stresses the need for PHR to produce and share knowledge that is locally situated, collective, co-created, conversational and diverse. For those of us who are passionate about PAR, it is easy to see the benefits of using this approach, however how we demonstrate impact to partner organisations and funders who may not be as familiar with the process is more challenging.
I was fortunate enough to spend a week in Alberta, Canada at the International Institute for Qualitative Research who hosted the ‘Thinking Participatively’ conference and the annual working meeting for the ICPHR. Here participatory researchers from around the globe explored the various concepts, challenges and successes of PHR. We specifically discussed the question of how to design effective evaluation frameworks that capture and demonstrate the impact of using participatory approaches compared with other research options. I also presented the PAR cycle currently being implemented in Nigeria to tackle Neglected Tropical Diseases as part of the COUNTDOWN research consortium. This included reflexive accounts of the researchers involved in this cross-country collaboration and the influence that power, hierarchy, cultural and gender differences had on translating community based knowledge to policy makers and stakeholders involved in action planning within the health system.
One of the key realisations from the week was that while our overall aim in Nigeria is to increase community engagement with the NTD programme, the PAR process is being used to strengthen health system capacity to critically look at programme implementation from the perspective of the community and community level health implementers so that it is more responsive to their needs and contexts. We used a wide range of participatory methods to capture voices from the community but the community context is continually changing, therefore as researchers we need to support health systems to be able to listen to communities and respond to these changes by annually reflecting on programme implementation and initiating change from within. The PAR process will be key to challenging hierarchy in Nigeria, so that a bottom up approach may be applied and that solutions posed by the community may be integrated in action planning every year. In addition, we as a consortium need to demonstrate the micro changes that will lead to this transformation (see quote below as an example) and to provide an evidence trail of impact for funders and partners. We need to show how using a PAR approach adds value to the project and how successful partnerships and collaborations strengthen outcomes. Using existing models that have been validated in a variety of contexts may help. The Community Based Participatory Research Conceptual Model is one example of this (Oetzel et al., 2018). For tools and resources associated with the CBPR model, see Engage for Equity.
Dr Oluwatosin Adekeye, COUNTDOWN Social Science Research Lead in Nigeria speaking about the PAR process during a reflexivity session
‘the [frontline] implementers who are part of the research process from the beginning… they go back and share experiences…even with their superiors at the implementation level, a lot of information exchange has occurred. A lot of people have heard things differently and they are willing to change…somebody from the state is also coming on one of our [evaluation] trainings and he is excited, he is optimistic, you can see that it’s like a snowballing or something like that, it’s like the information is going from one person to another and I think if we continue to keep engaging at all levels, frequently, I think it will make the difference.’
Within the ICPHR there will soon be a position paper on Impact in PHR and this will be a good starting place for research partners to consider how they may demonstrate impact from project inception. One of the ways of doing this is to have a robust evaluation framework that can track these micro changes through reflexivity and assessing the processes that strengthen partnerships and collaborations. During the annual working meeting there was a workshop led by Professor Nina Wallerstein, a leader in PHR, to look at how participatory researchers can support each other to do this better. The result was an ICPHR Evaluation Learning Committee (ELC) that seeks to explore ‘Participatory Evaluation Methods and Collective Reflection Processes for Strengthening Partnerships and Collaborations’. A series of blogs and webinars will be set up to by the ICPHR to improve communication, gain feedback on evaluation tools and frameworks and discuss challenges to programmes globally. We will also be discussing our varying theories of change for moving towards greater health and social equity.
What would be good to see moving forward is more examples and representation from Asian and African colleagues working with PHR, so please do consider joining this collaboration which has really helped our team to critically look at our project and to access resources and global dialogue on PHR.
CARR, W. & KEMMIS, S. 1986. Becoming Critical : Education Knowledge and Action Research, London, Falmer Press.
MINKLER, M. 2000. Using Participatory Action Research to Build Healthy Communities. Public Health Reports, 115, 191-197.
MINKLER, M. & WALLERSTEIN, N. 2008. Community Based Participatory Research for Health: From Process to Outcome, San Francisco, Jossey-Bass.
OETZEL, J. G., WALLERSTEIN, N., DURAN, B., SANCHEZ-YOUNGMAN, S., NGUYEN, T., WOO, K., WANG, J., SCHULZ, A., KAHOLOKULA, J. K., ISRAEL, B. & ALEGRIA, M. 2018. Impact of Participatory Health Research: A Test of the Community-Based Participatory Research Conceptual Model. BioMed Research International, 2018, 12.7081405