Participatory action research (PAR) differs from most other approaches to public health research because it is based on reflection, data collection, and action that aims to improve health and reduce health inequities through involving the people who, in turn, take actions to improve their own health.

PAR has a number of antecedents.¹ It reflects questioning about the nature of knowledge and the extent to which knowledge can represent the interests of the powerful and serve to reinforce their positions in society.² It affirms that experience can be a basis of knowing and that experiential learning can lead to a legitimate form of knowledge that influences practice.³ Adult educators in low income countries drew on these intellectual perspectives to develop a form of research that was sympathetic to the participatory nature of adult learning. This perspective was strongly supported by the work of Freire,⁴ who used PAR to encourage poor and deprived communities to examine and analyse the structural reasons for their oppression. From these roots PAR grew as a methodology enabling researchers to work in partnership with communities in a manner that leads to action for change.

DEFINITION OF PAR

PAR seeks to understand and improve the world by changing it. At its heart is collective, self reflective inquiry that researchers and participants undertake, so they can understand and improve upon the practices in which they participate and the situations in which they find themselves. The reflective process is directly linked to action, influenced by understanding of history, culture, and local context and embedded in social relationships. The process of PAR should be empowering and lead to people having increased control over their lives (adapted from Minkler and Wallerstein⁵ and Grbich⁶).

THE DISTINCTIVENESS OF PAR

PAR differs from conventional research in three ways. Firstly, it focuses on research whose purpose is to enable action. Action is achieved through a reflective cycle, whereby participants collect and analyse data, then determine what action should follow. The resultant action is then further researched and an iterative reflective cycle perpetuates data collection, reflection, and action as in a corkscrew action. Secondly, PAR pays careful attention to power relationships, advocating for power to be deliberately shared between the researcher and the researched: blurring the line between them until the researched become the researchers. The researched cease to be objects and become partners in the whole research process: including selecting the research topic, data collection, and analysis and deciding what action should happen as a result of the research findings. Wadsworth⁷ sees PAR as an expression of “new paradigm science” that differs significantly from old paradigm or positivist science. The hallmark of positivist science is that it sees the world as having a single reality that can be independently observed and measured by objective scientists preferably under laboratory conditions where all variables can be controlled and manipulated to determine causal connections. By contrast new paradigm science and PAR posits that the observer has an impact on the phenomena being observed and brings to their inquiry a set of values that will exert influence on the study. Thirdly, PAR contrasts with less dynamic approaches that remove data and information from their contexts. Most health research involves people, even if only as passive participants, as “subjects” or “respondents”. PAR advocates that those being researched should be involved in the process actively. The degree to which this is possible in health research will differ as will the willingness of people to be involved in research

METHODOLOGY/METHOD

Research methodology is a strategy or plan of action that shapes our choice and use of methods and links them to the desired outcomes.⁸ In contrast with a decade ago, when epidemiological methods were regarded as the only gold standard in public health research, many authors agree^9,9a,9b that effective public health research requires methodological pluralism. PAR draws on the paradigms of critical theory and constructivism and may use a range of qualitative and quantitative methods. For instance a participatory needs assessment would include extensive engagement with local communities and may also include a survey of residents who are less centrally engaged in the participatory process.¹⁰

APPLICATION OF PAR TO HEALTH

In the 21st century PAR is increasingly used in health research. By contrast, in the 1980s and in earlier decades, very little research using PAR was reported in health journals. Through the 1990s more participatory research was reported and textbooks including PAR became more common.^11,11a An example of this interest is the special edition of the Journal of Interprofessional Care, with an editorial and 16 articles reporting on PAR.¹² Initially PAR was mainly used in low income countries for needs assessment (see for example De Kroning and Martin¹³) and planning and evaluating health services (for examples see collection in Minkler and Wallerstein¹⁴). The work by Howard-Grabman¹⁵ provides a typical description of developing a community plan to tackle maternal and neonatal health problems in rural Bolivia. The project built on and strengthened existing women’s networks and the staff played the part of facilitators rather than educators. A community action cycle was developed whereby problems were identified and prioritised, joint planning took place, and the plan was implemented and then evaluated in a participatory way. The project developed innovative and engaging ways for staff and community members to work together effectively.

Recently PAR has been used more frequently in rich countries. In mental health research, for instance, PAR has been used in response to the survivor’s movement and demands for a voice in planning and running services and to stimulate choices and alternative forms of treatment.¹⁶ PAR principles also form the basis of “empowerment evaluation”¹⁷ that argue that the evaluation of health promotion should include those whose health is being promoted.¹⁸ While there has been some debate about the distinctiveness of empowerment evaluation¹⁹ it certainly strives to be more democratic, to build capacity, to encourage self determination and make evaluation less expert driven.

PAR is increasingly recognised as useful in Indigenous health research, both internationally^20,21 and in Australia.^22–24 It has the potential to reduce the negative—and some would argue colonising—effects much conventional research has had on Indigenous people. It does this by avoiding some of the criticisms made of health research including: (1) Indigenous people being exploited and treated disrespectfully, (2) research processes that see non-Indigenous researchers and research bodies retain all the power and control, (3) the lack of specified short and long term benefits to Indigenous communities and persons, and (4) the misrepresentation of Indigenous societies, cultures, and persons by non-Indigenous academics and professionals.^25–27

An example of the application of PAR in a remote Aboriginal Australian community is the work to support a men’s self help group to plan, implement, and evaluate their activities.²⁸ With support from the research team community members are acting as researchers exploring priority issues affecting their lives, recognising their resources, producing knowledge, and taking action to improve their situation. The ongoing PAR process of reflection and action, which incorporates participant observation, informal discussions, in-depth interviews, and a “feedback box”, is viewed by the participants as contributing to their self reported increased sense of self awareness, self confidence, and hope for the future.

For academics, dilemmas arise in the use of PAR because it is time consuming and unpredictable, unlikely to lead to a high production of articles in refereed journals and its somewhat “messy” nature means it is less likely to attract competitive research funding.²⁹ Acceptance of PAR as a legitimate research methodology will require change from public health journals, funding bodies, and universities in the way that they judge research performance. For instance most public health academic units assess their academic researchers’ suitability for promotion according to the number of peer reviewed journal articles. The ability of a researcher to engage with communities and bring about real change to their quality of life and health status rarely counts. The global research community is already being urged to adapt its grant assessment methods and its assessment of research performance to ensure that the engaged processes typical of PAR are valued and encouraged.³⁰

PAR also requires health researchers to work in close partnership with civil society and health policy makers and practitioners. This requires each of these players to learn methods of working together effectively and to manage the different and sometimes competing agendas of the partners. The focus of the research partners should also be on health improvement for the community involved.³¹

PARTICIPATION

Participation has been central to improving health since the WHO Health for All Strategy and its importance to health promotion strategies has been reinforced by subsequent statements on health promotion.³² Participation has been seen as a means to overcome professional dominance, to improve strategies (whether they are for practice or research), and to show a commitment to democratic principles. In the 1970s debate on development emphasised that development should no longer be a top-down process but should emphasise participation of those whose development was being attempted.³³ PAR came to be used in many development projects as a mechanism through which to put the rhetoric of participation into action. Associated methods are rapid assessment methods and rapid rural appraisal both of which aim to produce knowledge that combines professional and community perspectives.

POWER/EMPOWERMENT

Power is a crucial underpinning concept to PAR. PAR aims to achieve empowerment of those involved. Labonte³⁴ conceptualises empowerment as a shifting or dynamic quality of power relations between two or more people; such that the relationship tends towards equity by reducing inequalities and power differences in access to resources. Power itself is an elusive concept about which there has been considerable discussion. Foucault’s position is particularly relevant to PAR because he sees power as something that results from the interactions between people, from the practices of institutions, and from the exercise of different forms of knowledge.³⁵ His work on discipline and control shows that disciplinary power functions through surveillance and internal discipline of people to achieve their subjugations and “docility”.³⁶ The PAR movement challenges the system of surveillance and knowledge control established through mainstream research. When communities seek control of research agendas, and seek to be active in research, they are establishing themselves as more powerful agents. In health services and public health initiatives in recent years community members and consumers have gained more power over the practices of institutions and the production of knowledge. Developments in participation have implications for health services and public health organisations that, if they are to be true to the principles of participation, must initiate organisational change to improve their capacity to work in partnership with a wide variety of communities.^37,37a

Many dilemmas of the PAR approach revolve around contested power dynamics in research relationships. Wallerstein detailed the power conflicts in research on New Mexico’s Healthier Communities Initiatives and concluded that handling these requires “a painful self-reflective process”.³⁸ These included differences in perceptions of priorities between researchers and community members, dealing with community politics in the different communities involved in the study and resolving different ways in which researchers and communities might interpret findings.

LIVED EXPERIENCE

PAR stands in contrast with what Husserl (quoted in Crotty³⁹) describes as the mathematisation of the scientific world by Galileo, for whom the real properties of things were only those that could be measured, counted, and quantified. Husserl argued that the scientific world is an abstraction from the lived world, or the world we experience. This scientific world is systematic and well organised, unlike the uncertain, ambiguous, idiosyncratic world we know at first hand.³⁹ On the other hand, PAR draws on the work of phenomenologists who expand the breadth and importance of experience when they argue that humans cannot describe and object in isolation from the conscious being experiencing that object; just as an experience cannot be described in isolation from its object. Experiences are not from a sphere of subjective reality separate from an external, objective world. Rather they enable humans to engage with their world and unite subject and object.⁴⁰ One example of a use of lived experience is research using feminist theory, which refers to “women’s ways of knowing or women’s experience”.⁴¹

CRITICAL REFLECTION AND A CRITICAL EDGE

Crotty⁴² argues that while interpretivists place confidence in the authentic accounts of lived experience that they turn up in their research, this is not enough for critical theorists who see in these accounts voices of an inherited tradition and prevailing culture. Critical theorists use critical reflection on social reality to take action for change by radically calling into question the cultures that they study. This critical edge is central to PAR.

CRITICAL REFLECTION ON PROFESSIONAL PRACTICE

PAR draws heavily on Paulo Freire’s epistemology that rejects both the view that consciousness is a copy of external reality and the solipsist argument that the world is a creation of consciousness. For Freire, human consciousness brings a reflection on material reality, whereby critical reflection is already action. Freire’s concept of praxis flows from the position that action and reflection are indissolubly united: “reflection and action on the world in order to transform it”.⁴³ It is from this position that Freire derives his famous dictum that reflection without action is sheer verbalism or armchair revolution and action without reflection is pure activism, or action for action’s sake.⁴⁴ In the same vein, PAR sees that action and reflection must go together, even temporally so that praxis cannot be divided into a prior stage of reflection and a subsequent stage of action. When action and reflection take place at the same time they become creative and mutually illuminate each other.⁴⁵ Through praxis, critical consciousness develops, leading to further action through which people cease to see their situation as a “dense, enveloping reality or a blind alley” and instead as “an historical reality susceptible of transformation”.⁴⁶ This transformative power is central to PAR.