Using Participatory Action Research to Overcome Public Health Obstacles
by Audra Gold
I was first introduced to the Change Agents: Applying Cross-Sector Collaboration project as a graduate research assistant at Georgetown during the initial systematic review on cross-sector collaboration (CSC) literature in developing countries. Knowing that cross-sector collaboration is an effective method for achieving public health challenges, we thought that there would be a solid evidence base for CSC in developing countries. However, the opposite turned out to be true. The systematic review revealed that the evidence for cross-sector collaboration in developing countries was fragmented and inconclusive. Because of this, the Ghana model was constructed using research from developed and developing countries.
My experience with participatory research prior to this project was a combination of my academic training in global health and knowledge gained from working with the Western Pacific Regional Office of the World Health Organization in Manila, Philippines. I was well versed in the popular community-based participatory research (CBPR) method. CBPR is an approach to “research that equitably involves community members, practitioners, and academic researchers in all aspects of the process, enabling all partners to contribute their expertise and share responsibility and ownership” (Israel et al, 1998). As the title suggests, the focus is on the community-driven initiatives and continuous community involvement. Our research model incorporates CBPR to understand the needs of the Old Fadama community, but the real novel method is using participatory action research (PAR), as a tool to achieve CSC. PAR is a process that involves researchers and participants working together to define the problem and to formulate research questions and solutions. It is distinct from CBPR in that the focus is shifted from the community to the stakeholders. When I first learned of the difference between the two participatory models in the context of this project, it was truly a revelatory moment because of how much sense it made. What better way to ensure stakeholder engagement and sustainability than to provide an action-driven, transparent, and supportive research environment?
One of the aspects that I appreciate most about our model is how the combination of PAR and CBPR helped overcome a classic public health obstacle: tension between the community and the government, due to mistrust.
To set the scene in Accra prior to our project, the government believed that the Old Fadama slum was on completely uninhabitable property and did not want anyone living there, let alone a highly populous slum community. Therefore, the community had an innate sense of mistrust, leading residents to be belligerent and defensive. The previous Director of Public Health, Accra Metropolitan Assembly (AMA), Simpson Boateng, said that prior to our project, the Old Fadama slum was a “no go area.”
Further, while tension already existed, in the beginning of the project, the municipal government demolished part of the Old Fadama slum that was encroaching on the nearby river and lagoon. Publicly, the city said that the encroachments kept water from going into the nearby lagoon, pushing it to greater depths upstream. The community said that the bulldozing was to distract from the fact that the city did not install proper road infrastructure. Clearly, the bulldozing incident escalated an already stressed situation.
Part of the effectiveness of our model was partnering with the Catholic Sisters. The Sisters provided early guidance and insight into the community, were well regarded in the slum community as trustworthy, and could bridge the gap with the AMA. Their ability to understand and communicate with the community and AMA-DPH allowed us to proceed with focus group discussions.
By coordinating moderated focus group discussions with the slum community, the Catholic Sisters, the government, and the stakeholders, the collaboration was able to overcome previous disputes by forming a shared understanding of the challenges the community faced. Once there was a shared understanding, the collaboration members were empowered to work together to create realistic solutions. This is when they decided that the first project should improve sanitation in Old Fadama, and that that could be done through building latrines. The focus groups engendered a sense of inclusion and transparency that helped the project to move forward.
Once the project details were agreed upon, the AMA changed its policies to permit latrines being installed in Old Fadama. This action was monumental for the slum community because it meant that the AMA was following through on its commitment and acting on behalf of the community. The Catholic Sisters raised the funding to install the latrines. This supported the city’s sanitation agenda, and engaged the city and community in site selection and management. Further, local businesses became involved and adopted the strategy to improve sanitation through building latrines, thereby creating local sustainability.
Old Fadama faced not only the challenge of lack of sanitation but also a history of failure as previous initiatives taken to acquire latrines had been unsuccessful because the community and the government could not overcome their differences. Our novel approach to CSC using PAR led to increased community and stakeholder engagement such that the collaboration members achieved their goals and are now moving towards new goals to further benefit the community.
For related reading, please see these other articles published in the Journal of Public Health Management and Practice*:
- Common and Critical Components Among Community Health Assessment and Community Health Improvement Planning Models
- Developing a Culture of Health: Addressing Health Inequities Through a Health Department and Community Organizer Partnership
- Ebola Preparedness in the Netherlands: The Need for Coordination Between the Public Health and the Curative Sector
*Articles may require a subscription to JPHMP or purchase.
Audra Gold, Global Health Research Associate for Georgetown’s Initiative on Health and Peace, provides strategic global health guidance and research support for the cross-sector collaboration project in Accra, Ghana. Her professional interests are in international health policy, and health system strengthening through strategic public-private partnerships to improve the public health of vulnerable populations. She previously supported the publication of articles in The Lancet, The New England Journal of Medicine, and JAMA, regarding the Global Burden of Disease for the Institute of Health Metrics and Evaluation. Audra holds a Master’s of Science in Global Health from Georgetown University.
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