This article examines the typology of participatory approaches used in a youth health project based on the author’s experience as a researcher and facilitator in the “What every adolescent has a right to know” initiative for HIV/AIDS prevention among youth. In this case study, timely feedback of academic research, which was conducted concurrently with the facilitation of the project, provided important insights that helped to better conceptualize the goals of the project and improved its functioning. Furthermore, the academic research demonstrated that project participants emphasized one of three distinct types of PAR, variably emphasizing the research, education and action components of PAR to different degrees. This led to re-conceptualization of the initial theoretical model derived from the literature, and thus supported the academic goal of contributing to theory development in PAR. Considering that there are many participatory projects in health and other disciplines, more empirical studies involving process examination of participatory projects may be helpful for academics and practitioners to theorize PAR in order to learn what works and what does not work in community-based projects.
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Participatory approaches aim to promote participation of people whose voice has not been heard enough even though they are often targeted by policies, programs or research. They attempt to help people reflect on the constraints of social structures that limit their self-development and self-determination (Kemmis and McTaggart, 2000). While the popularity of participatory approaches is on the rise in international development and health projects, the effect of participatory approaches on people’s lives and society beyond the project or research framework is poorly understood (Cleaver, 2001; Flicker, 2008), It is partly because the process of a participatory approach in health projects has not been well examined. For example, the definition of “participation” in a participatory project, the purpose of using a participatory approach, and roles of various stakeholders (e.g. the community, funding agencies, academic researchers, the local government, NGOs) in the participatory project, may not be discussed and negotiated among various stakeholders at the beginning of the project (Guijt, 2001).
This paper examines the typology of participatory approaches used in a youth health project based on the author’s experience as a researcher and facilitator. Specifically, I present a case study in which timely feedback of academic research (data collection and analysis), which was conducted concurrently with a participatory project among youth, provided important insights that facilitated the goals of the project and improved its functioning in a health project through the re-conceptualization of participatory approaches. At the same time, the academic research led to re-conceptualization of the initial theoretical model derived from the literature, and also supported the academic goal of contributing to theory development in PAR.
Participatory action research
There are different types of participatory approaches that have been used by both academic researchers and practitioners. Participatory action research (PAR) is one of many participatory approaches that are widely used by academic researchers. PAR is particularly appropriate in situations where people want to make changes thoughtfully after critical reflection (Kemmis and McTaggart, 2000). It aims to blur the lines between the “researchers” and the “researched” (Hagey, 1997) and attempts to transform the theories and practices of researchers, practitioners and participants whose perspectives and practices may help to shape the conditions of life and work (Kemmis and McTaggart, 2000). The core principles and values of PAR have been shared between a number of participatory research typologies (e.g., critical action research, feminist research, community-based participatory research) that have been identified and examined in health projects (Holter and Schwarz-Barcott, 1993; Hart and Bond, 1996, Kemmis and McTaggar, 2000; Minkler and Wallerstein, 2003).
Research is the main component of PAR. The literature on PAR describes a variety of modes of participation between researchers and research participants. Some PAR projects are mainly conducted by academic researchers. In some cases a research team consisting of university researchers and community members employs conventional methods (interviews, surveys) to gather data from research participants, as seen in the participatory research with the disability community conducted by Minkler et al. (2002). Lately, some participatory tools such as “Photovoice,” “walking and windshield tours,” “community asset maps,” “risk mapping” and “creative arts” have been introduced in PAR (Wang, 1997; Minkler and Hancok, 2003).
Action is an important component in PAR following research. Some observers have argued that academic researchers’ involvement may help the community to discover its assets or strengthen its capacity, contributing to innovative and effective actions (Fals-Borda, 1991; Stringer, 1997, Greenwood and Levin, 1998; Kemmis and McTaggart, 2000). Some academic researchers work as facilitators or mediators to address problems and develop action (Forester, 1999; Ladipo, 2002; Pelletier et al., 1999; Minkler et al., 2002; Castro et al., 2004). However, empirical examination of the actions resulting from academics participation is rare, despite the emphasis on the research-action cycle in the theoretical literature. Furthermore, there is very little empirical evidence about whether and how academic research using more conventional methods, such as interviews and surveys, can contribute to effective project outcomes in a timely manner, although they have been proposed as effective tools (McQuiston et al., 2005). Even though the PAR research identifies issues needed for action, action may not take place due to stakeholders’ diverse interests in those issues (Baker et al., 2005).
Finally, critical thinking, advocated by Freire (1973), has been recognized as an important process in PAR in the field of health education. It has been hypothesized that critical thinking is part of the educational process of the participatory approach toward empowerment and action (Wallerstein 1992). However, Cahill (2007) argues that participatory research may become “just some sort of set aside space for developing critical thinking and consciousness” (p. 28) without subsequent action for social change. Thus, the definition and goal of PAR may not always be discussed and negotiated among researchers, participants and other stakeholders.
Participatory Rural Appraisal (PRA)/Participatory Learning and Action (PLA)
While PAR is often utilized by academic researchers, participatory rural appraisal (PRA) or participatory learning and action (PLA) have attracted agencies and NGOs in the field of international development. The ideology of “poor and local people were the problem, and the problem was to be solved by education and the transfer of technology” has been questioned, and it is argued that professional or rich people need to “hand over the stick” to the poor or the oppressed (Chambers, 1998). The characteristics of PRA/PLA include utilizing visual and artistic tools, such as mapping and diagrams, in order for local people to “express, enhance, share and analyze their knowledge of life and conditions, to plan and to act” (Chambers, 1994). This is quite different from participatory action research led by academic researchers who may not always emphasize the importance of participatory and visual tools.
PRA/PLA is often used in the planning stage of a participatory project as research or assessment, and the results of PRA/PLA are used in the implementation stage of the project (action), in which local people are recipients/participants. There is also a growing recognition that PRA/PLA should be used during monitoring and evaluation, involving different kinds of stakeholders including local people (Estrella, 2000). However, the modes of participation by local people in the planning, implementation, and monitoring/evaluation stages of a participatory project vary between projects (Gibbon, 2000). Critics of PRA or PLA argue that the manipulation by outsiders and local leaders often takes place in the name of “participation” (Mosse 2001). It is argued that participatory approaches and methods represent “external interests as local needs, dominant interests as community concerns” (ibid, p 22). However, it is not clear whether shifting from local people’s partial participation to full participation positively affects people’s lives and society beyond project efficiency.
As Cleaver (2001) argues, evidence of the effects of local people’s participation in participatory projects is surprisingly lacking despite more than two decades of the implementation of participatory approaches. It indicates that there is a poor understanding of the process of participatory approaches including who participates with what extent and for what reasons in each stage of participatory approaches. To date, the typology of different participatory approaches has not been well theorized and understood. Furthermore, although the evaluation of PAR has been documented in some studies (Bagamoyo College of Arts et al, 2002; Sy-ar, 2004; Maglajlic and Tiffany, 2006), relatively little academic research has been conducted for the explicit purpose of contributing to theory building in participatory approaches for health.
This paper examines the typology of participatory approaches used in a participatory project designed to inform HIV prevention efforts among youth. Academic researchers’ roles in re-conceptualizing PAR and facilitating the use of different types of PAR were also examined by reflecting on my experience of assisting in the youth health project. The following empirical cased study is based on my ongoing participant observations of the project as a facilitator, as well as qualitative interviews I conducted as an academic researcher.
Case Study: “What Every Adolescent Has a Right to Know” (RTK) initiative
Overall roles of academic researchers in RTK
My work was conducted as part of UNICEF’s “What every adolescent has a right to know” (RTK) initiative, which involved the youth community in fourteen countries on four continents facing different phases of the HIV epidemic. UNICEF sought the collection of source data for the production of the information package “What every adolescent has a right to know”, (RTK), which aimed to promote the healthy development of adolescents by providing basic facts and messages for the prevention of HIV/AIDS in a manner that ensures that young people not only receive accurate information but are also empowered to make informed choices (UNICEF, 2002).
Recognizing the importance of youth participation, RTK initiative planners selected PAR as the approach that would best engage young people themselves in the project and provided youth the opportunity to become researchers themselves and carry out research with other adolescents. As a researcher with expertise in PAR and PRA at Cornell University, the technical partner of UNICEF in this project, I provided technical assistance in PAR in a Caribbean country that participated in RTK in order to ensure an effective participatory process and subsequent actions.
Orientation workshop and participatory action research by youth
In the initiation phase of the project, I co-facilitated an RTK/PAR orientation workshop introducing the concept of PAR and PAR tools and techniques to youths who had been recruited to work on the project. The youth came primarily from local NGOs and many were active as peer educators. The academic researchers served as facilitators, introducing PAR using generally accepted theoretical definitions of participatory research. The terms “participation”, “action” and “research” were discussed and defined with the youth. The specific objectives of RTK were then explored and linked to the concept of PAR. They youth also learned many visual and creative participatory tools that are widely used in PRA/PLA. This project was unique in that young people, instead of trained academic researchers, became participatory action researchers with support from adults. Thus, it provided me with the opportunity to pay particular attention to the roles of different stakeholders in RTK, including youth researchers, youth research participants, UNICEF, NGO project managers, and academic researchers.
Following the workshop, I helped the youth researchers prepare to conduct two months of research. The objective of their research was to examine the knowledge and perceptions of HIV/AIDS and other topics such as violence, gender and livelihood among a diverse group of adolescents. Four regional teams, representing different organizations located in different parts of the country, were established. The regional teams consisted of youth researchers, project managers, and other participants who were identified and recruited by the youth researchers. Each team was assigned to conduct three sessions on three different topics, such as HIV/AIDS, violence, gender and livelihood. The data gathered by the youth researchers were compiled at the country level and were submitted to the UNICEF headquarters’ office.
The teams then went on to plan and implement actions. In my role as a PAR facilitator I assisted in adapting and applying PAR to RTK stakeholders’ activities; facilitated inter-organizational activities among RTK stakeholders; and facilitated the development of UNICEF’s RTK resource materials, including a country-specific PAR guide written in collaboration with young people.
Re-conceptualization of PAR and development of Three Types of PAR
After the participatory research was completed by the youth, I interviewed 21 of the 23 youth researchers, 12 project managers, and 17 youth research participants. These were transcribed, and ATLAS/ti, a qualitative data analysis software program, was used to analyze the transcripts and field notes while the project was on-going. Pre-identified and newly identified themes, such as perceptions of PAR among the participants, were examined, compared and synthesized across the interviews. Preliminary findings based on the interviews were also shared with some of the study participants in order to validate them.
The analysis of the interviews with the PAR youth participants, as well as extensive participant observations I conducted on a daily basis, revealed a heterogeneity of perspectives on PAR among youth. While they all felt that PAR was useful for their HIV/AIDS prevention work, within the group there appeared to be distinct perspectives, which were further refined by using a method called Q methodology (Goto et al., 2008). I have characterized these perspectives as follows: Education-oriented PAR, Research-oriented PAR and Action-oriented PAR. Action-oriented PAR is the most similar to the definition advanced by academic PAR researchers. Some of the youth researchers perceived that PAR was an empowerment process for both researchers and participants and action needed to be taken based on PAR. On the other hand, some youth researchers thought PAR was a research tool for their needs assessment and program planning and the participants in PAR were perceived as informants (Research-oriented PAR). Lastly, some youth researchers, especially those who were active peer educators, saw it as an educational tool that permitted them to interact with others in a more participatory manner (Education-oriented PAR).
Learning about how youth researchers perceived the participatory action research they conducted in RTK also helped me further conceptualize the typology of PAR with focus on the following questions: 1) What are objectives of PAR activities?; 2) Who feels a need for action before the initiation of PAR activities?; 3) Who does research?; 4) What are roles of PAR researchers? What are the roles of community participants?; and 5) Who takes action after PAR? Some of the youth researchers did not have a clear idea about the objectives of the research. Also, because the project was initiated by UNICEF, the youth researchers felt they were conducting “Research-oriented PAR” for UNICEF. As a result, the results of the PAR research submitted to UNICEF were not utilized by the organizations the youth researchers belonged to. On the other hand, directly involving researchers in the process of PAR research as provided them with the great opportunity to explore different possibilities that PAR may offer to their organizations, such as Education-oriented PAR and Action-oriented PAR.
Introduction and use of Three Types of PAR
With support from other researchers, I concluded that the orientation of individual youth researchers structured their interpretations of their research results and affected the actions that they fostered in their community organizations. Without passing judgment on whether their interpretations of PAR facilitated or impeded their organizational effectiveness, I felt it would be useful for the individual youth researchers to become aware that there were other perspectives and orientations within the larger group. Therefore, I developed a framework describing the three types of PAR derived from my analysis (see Table 1).
The first opportunity to introduce it to youth researchers was in a PAR training activity that was requested by Youth Action (pseudonym), one of the RTK participating youth community organizations. The staff members of Youth Action explored different scenarios regarding their objectives/goals, whom to involve in different stages, tool selection, and findings utilization in their own work context. Because the youth involved as researchers were also experienced peer educators, they readily grasped the distinctions between the different types and applications of PAR and contextualized the typology with various exercises. They also learned that these three types of PAR were inter-related to each other and the initiation of “Research-oriented PAR” or “Education-oriented PAR” might feed into “Action-oriented PAR” throughout the PAR process
Youth Action initially implemented “Research-oriented PAR” using a condom mapping technique. The results of condom mapping informed the work of a government agency that sought to set up places where teens can go and feel comfortable to buy condoms. Later, the three types of PAR were included in the PAR guide developed by the UNICEF country office, and Youth Action was featured as one of the leading organizations effectively using PAR in research, education and action without much technical support from other agencies.
I continued to facilitate PAR-training activities with other youth community organizations. The Teen AIDS Network (pseudonym), which was initially using PAR exclusively for educational activities, expressed a desire to conduct youth-to-youth PAR training for other members of their organizations who were not familiar with PAR. This time I played a role as a PAR advisor for the youth researchers. During the youth-to-youth PAR training conducted by Teen AIDS Network, the concept of three types of PAR and practical tools were introduced by youth who were experienced trainers and peer educators. Using the three types of PAR framework, the youth researchers conducting the training emphasized the need to be clear about why and how PAR was being used as well as the objectives sought -- the goals that groups hope to achieve by implementing PAR. At the end the training, the youth trainers expressed the idea that by teaching PAR to other members they had come to feel much more comfortable with implementing PAR themselves and had developed clearer ideas about what they could do using PAR in their organization.
After the youth-led PAR training, Teen AIDS Network, which had initially used “Education-oriented PAR,” conducted “Action-oriented PAR” with other young people in the community without extensive technical support from project managers or academic researchers. Teenage pregnancy had been identified as a critical issue by the community. In this youth-led “Action-oriented PAR,” youth participants decided topics and there was a strong emphasis on critical analysis of social factors for problem solving. After their analysis of data gathered within the community, the youth researchers in the organization took further action to solve the problem by creating a skit and presenting it to facilitate further discussions with adults in the community.
Conceptualization of three types of PAR in relation to health among youth
I continued to examine the PAR process as an academic researcher by further interviewing the youth researchers and doing participant observations. My facilitation and observation of re-conceptualizing and utilizing PAR among the different youth organizations participating in RTK helped me further refine the relationships between the three types of PAR, expected PAR outcomes, and subsequent actions. Interviews with the youth researchers, youth participants and project managers demonstrated diverse perceived outcomes of the PAR process based on their experience in RTK, described in detail somewhere else (Goto, 2004). The participatory research in RTK, considered to be Research-oriented PAR using visual and interactive tools, appeared to enhance the comfort level of participants and contributed to individual empowerment among participants. Participants felt their opinions and experience were respected and appreciated during the PAR research, which made them feel comfortable and empowered with increased self-esteem. Critical awareness of social factors affecting their lives and health was another perceived outcome of PAR, according to some of my interviewees. Some participants mentioned that sharing their knowledge, ideas and values with other youth helped them think about their own lives and the lives of others. On the other hand, those who perceived PAR as “education” mentioned that factual knowledge and internalization of scientific knowledge was an important outcome of PAR for participants besides empowerment and critical awareness. Furthermore, the youth researchers of Teen AIDS Network who were involved in youth-led “Action-Oriented PAR” thought participants gained skill development of critical analysis through their active participation in PAR.
Based on my interview analysis and observations of the subsequent actions by the youth organizations described above, Table 2 summarizes the relationships between the three types of PAR, perceived PAR outcomes and subsequent actions.
The following key points emerged from my analysis: 1) Education-oriented PAR can address context specific social issues, possibly using creative tools, facilitating knowledge internalization. 2) Knowledge gained through Education-oriented PAR may empower participants, which may help them learn more and/or assist their peers. 3) Research-oriented PAR utilized for program improvement may increase critical awareness of social issues related to a topic such as HIV/AIDS. 4) Research-oriented PAR employed for program improvement may contribute to improved health services for a broader public population, as observed in action by Youth Action. 5) Action-oriented PAR may reach people who are not initially interested in the topic and may help participants to increase critical analysis. 6) Action-oriented PAR may lead to the involvement of participants in collective action that addresses social issues within each context, as observed in actions performed by Teen AIDS Network.
This case study illustrates a process of timely feedback of academic research, which was conducted concurrently with a PAR project. This feedback provided insights that facilitated the goals of the project and improved its functioning in a community-based health project. At the same time, the academic research led to re-conceptualization of the initial theoretical model, as well as theory building in the application of PAR for health promotion, thus supporting the academic goal of contributing to theory development in PAR. Forester (1999), Peters (2002a and 2002b), and Greenwood and Levin (1998) discuss the importance of the documentation of PAR processes for theory building.
As described in the case study, documenting and analyzing the process of PAR in RTK enabled me to develop the three types of PAR and observe the use of that conceptual framework among youth. The framework consists of elements of PAR and PRA/PLA described in the introduction section. Moreover, while some might argue that conducting Action-oriented PAR with the high participation of local people in each stage of the project is desirable in a “participatory” project, some socio-cultural factors, such as hierarchical culture, raised expectations for PAR, poor initial participation, gender biases, and heterogeneity of the community, are considered to be challenges (Leurs, 1998). PAR is dynamic, and Education-oriented PAR or Research-oriented PAR easily becomes Action-oriented PAR, or Education-oriented PAR can become Research-oriented PAR during the PAR activities. This relates to the argument by Webler et al. (2001) that people define good participation differently, and it is important to “resist the temptation to strategize by advocating the process based solely on its ability to produce the ends you advocate” (p. 448). PAR advocates may promote the process that leads to collective action by participants, but the process may not allow everybody to be heard and to have a say in the outcomes of the process (ibid). Thus, the three types of PAR may be used to facilitate the discussion and negotiation of objectives of PAR and roles of researchers and participants in both research and action, creating mutual understanding of the type of PAR and the mode of participation between researchers and participants.
This case study also illustrates how three types of PAR appeared to contribute to PAR outcomes and subsequent actions in RTK (Table 2), which may affect behavioral change for health. The relationships between PAR outcomes identified by my interviewees, such as critical thinking and empowerment, and behavioral change have been well theorized (Wallerstein, 1992). Furthermore, the three types of PAR can be an effective tool for refining the process that may lead to behavioral change for health. For example, while Education-oriented PAR may work well for participants who follow the Health Belief Model (Becker, 1974), it may be inappropriate for others. For some, the specific emphasis on critical analysis for problem solving and subsequent action of engaging in action-oriented PAR may provide the path to behavior change.
According to Gillies (1998), there are no simple solutions or approaches to the promotion of health and it is important to conceptualize different paths leading to behavioral change and improved health at different levels. Although my work did not attempt to measure the effects of PAR on individual health behavior, integrating my analysis of the three types of PAR (and my observations of subsequent actions) with the existing literature may help develop better conceptualization of the relationships among PAR, individual and collective action, and behavioral change for health. My study suggests that different types of PAR (Education-oriented PAR, Research-oriented PAR and Action-oriented PAR) that were observed in the study may lead to behavioral changes through different paths. Figure 1 shows the relationships between three types of PAR, subsequent actions and behavioral change/health improvement.
The three types of PAR presented seem to play roles in developing different possibilities or paths for ultimate behavioral change. Participants may change behavior through the process of Education-oriented PAR, Research-oriented PAR, or Action-oriented PAR. Therefore, the program needs to be comprehensive in order to provide the opportunity for synergistic effects throughout the collective effort. Furthermore, because individual health behaviors are deeply embedded within social and cultural contexts, didactic and generic templates for health interventions may have limited impact on behavior change (Maglajlic and Tiffany 2006; Johnson et al. 2008) and there is a need for cultural adaptation of participatory health interventions. Further empirical studies are needed to examine the effects of different types of participatory youth projects on health related outcomes in different cultural contexts.
Participatory approaches, which rest on the creation of interactions between and across multiple levels and sectors, have been repeatedly proposed as a means of organizing social actions for health in a fashion that is more congruent with current understandings about the determinants of health conditions and the requirements for social change. The lack of empirical studies of the mechanisms of PAR is still a constraint to demonstrating the strengths and challenges of the participatory approach for health. Based on the case study and discussion presented in this essay, I conclude that examining the PAR process while providing technical assistance in adapting PAR to needs identified within specific organizational contexts can be one of the ways that academic researchers can contribute to both the theoretical and practical development of PAR for community action and health promotion. More empirical research on PAR in different cultural contexts is needed to further conceptualize the typology of PAR and discuss effective use of the typology for a better link between theory and practice.
I would like to express my gratitude to Gretel Pelto, David Pelletier, Jennifer Tiffany, and the staff and participants of the UNICEF RTK initiative.
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Keiko Goto, Ph.D.
Keiko Goto, Ph.D. is an assistant professor at California State University, Chico, CA, USA.