Vivian R Ramsden, RN, PhD, MCFP (Hon.) Associate Professor & - PowerPoint PPT Presentation

Community-Based Participatory Research and Transformative Action Research Vivian R Ramsden, RN, PhD, MCFP (Hon.) Associate Professor & Director, Research Division Department of Academic Family Medicine University of Saskatchewan Research Seminar at McGill, February 5, 2013

Learning Objectives  Describe how PHC and the elements of participatory methods are linked.  Describe ways in which community-based participatory research integrated with transformative action research contribute to effectively answering questions related to community-identified health concerns.  Discuss the differences related to guiding values/ethical considerations from other research designs.

Background Health is defined by the World Health Organization as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO (2009). Governance of WHO. Retrieved on February 1, 2009 from http://www.who.int/about/governance/en/index.html.

Background The Lalonde Report (1974), A New Perspective on the Health of Canadians , developed the idea of non-medical determinants of health. It recognized the importance of prevention and promotion of health and well-being. Health Canada (1974). A New Perspective on the Health of Canadians (Lalonde Report) (1973-1974). Retrieved on February 1, 2009 from http://www.hc-sc.gc.ca/hcs-sss/com/fed/lalonde-eng.

Background The Declaration of the Alma Ata (1978) defined primary health care as essential health care that is based on practical, scientifically sound and socially acceptable methods and technology; universally accepted and affordable to all in the community through their full participation; and geared toward self-reliance and self- determination. WHO & Unicef (1978). Alma-Ata 1978. Geneva, Switzerland: Author.

Concepts from the Alma Ata  Primary health care shifts the emphasis of health care to the people themselves and their needs, reinforcing and strengthening their own capacity to shape their lives.  Hospitals and primary health centres become only one aspect of the system in which health care is provided.  Primary health care is based on the intersecting philosophies of mutuality, social justice, equity and equality. WHO & Unicef (1978). Alma-Ata 1978. Geneva, Switzerland: Author.

Concepts from the Alma Ata Primary health care strategies :  Focus on individual and community strengths (assets) and opportunities for change (transformation).  Maximize the involvement of the community.  Include all relevant sectors.  Avoid duplication of services.  Use only health technologies that are accessible, acceptable, affordable and appropriate. WHO & Unicef (1978). Alma-Ata 1978. Geneva, Switzerland: Author.

Citizen control Degrees 8 Delegated power of citizen power 7 Partnership ← Optimal 6 Placation Degrees 5 Consultation of 4 tokenism Informing 3 Therapy 2 Manipulation Non-participation 1 E ight Rungs on a Ladder of Citizen Participation Arnstein SR (1969). A ladder of citizen participation. AIP Journal , 216-224.

Partnership Pentagon Policy Makers Health Health Health Service Managers Professionals Based on People’s Needs Communities Academic Institutions WHO, 2000. Towards unity for health: Challenges and opportunities for partnership in health development. Geneva, Switzerland: Author.

Participatory Methods  Participatory methods are at the heart of primary health care and are recognized in the Declaration of Alma Ata and various other documents such as the Ottawa Charter for Health Promotion.  Participatory methods or deciding what to do together are also very much a part of partnerships. Wass A (2000). Promoting health: The primary health care approach , 2 nd Ed. Marrickville, NSW: Harcourt Australia.

Participatory Learning Participatory learning has the critical elements of: equality, dialogue and mutual communication. The process utilized is that of praxis (action- reflection-action) – action research. Freire P (1972). Pedogogy of the Oppressed . New York, NY: The Continuum Publishing Co.

Facilitators of participatory methods recognize the importance of:  people’s readiness to learn;  the formation of a strong team;  knowing people's context and needs very well;  the improvement of abilities to reflect and act; and the  opportunity to experience an increased level of awareness and personal growth.

Building Relationships - 1  Spending time in the community meeting people with no expectations.  Inviting individuals in the community to collaborate on building a vision around the strengths and needs of the community.  Engage in an iterative process – dialogue, establishing values, survey development, data collection, data analysis, interpretation of the results/findings and the writing of a Final Report.

Building Relationships - 2  Returned the results/findings of the community survey to the communities.  Modified the Final Report taking into account the interpretation of the results/findings by the community.  Development of evidence-informed community-based programs and policies.

Participatory Methods weave together:  critical analysis of social situations and issues;  practice of communication skills and working together;  improvement of practical/technical abilities; and  spiritual growth and healing.

Participatory Analyses It is hoped that this process will facilitate dialogue, negotiation and decision-making in a respectful and transparent way that will bridge the gap between the data resulting from the research endeavour and its meaning for the community. Patton MQ (2002). Qualitative research & evaluation methods , 3 rd Ed. Thousand Oakes, CA: Sage Publications, Inc.

Outcomes of Participatory Methods  All members of the research team:  gain a sense of confidence in their ability to make and facilitate change.  develop a wide range of skills - negotiation, reflection and “working with”.  begin to understand success and are then able to build upon what they know from their experiences.

Values espoused and adhered to by Facilitators - 1 The values/ethics of the research endeavour need to be negotiated prior to engaging in the work.  trust  respect  shared decision-making  privacy and confidentiality  responsibility  collaboration

Values espoused and adhered to by Facilitators - 2  neutrality  kindness and compassion  flexibility  change agent  commitment*  patience and time*

Application of Theories into Practice

Core Communities - Saskatoon  The Community-Based Health Strengths and Challenges Survey (2000) which focused on primary health care reform was facilitated by an interdisciplinary team which included residents of the “core communities” in Saskatoon, academics and clinicians working together to develop new strategies for enhancing health and well-being in the communities.  Transformative Action Research, a methodology, which encompasses a high level of participation, transformative learning and action research evolved. Ramsden VR, Research Team, Cave AJ (2003). Learning with the Community – The Evolution to Transformative Action Research. Canadian Family Physician, 49 , 195-197.

Core Communities - Saskatoon  The Response Rate was 94% (343/366).  Risk Factors (self-reported) were:  59% - Tobacco mis-use (tobacco not used for ceremonial purposes);  22% - Hypertension/High Blood Pressure;  15% - High Blood Cholesterol; and,  7% - Diabetes.  Family Doctor (self-reported) indicated that:  86% - had a Family Doctor; and,  14% - did not have a Family Doctor.

Environmental Scan  An environmental scan was done by the community members themselves of organizations (formal and informal) providing services in the core communities.  The analysis and interpretation was conjointly done with the community members – ten areas of interest were not currently being done by an organization (e.g. learning to become free from tobacco mis-use, men’s health); however, there was a lot of overlap.  Health services were not available after 1700 hours with the exception of the Emergency Dept, St. Paul’s Hospital – changed practice and reality.

Sustainability It was from the process and the results of the research endeavour entitled, Transition to an Integrated Primary Health Service Model, that the context and concept for West Winds Primary Health Centre (a university owned complex in partnership with the Saskatoon Health Region) on Saskatoon’s west side evolved.

Building Together - Sustainability This was taken at the unveiling of West Winds Primary Health Centre - usask.ca/medicine/ family/wwphc/ A team of professionals working together with people and communities for better health.