|Year : 2020 | Volume
| Issue : 3 | Page : 256-260
Relevance of community-based participatory research in community medicine training
Anand Krishnan1, Rajesh Tandon2, Baridalyne Nongkynrih1
1 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Society for Participatory Research in Asia, New Delhi, India
|Date of Submission||17-Aug-2019|
|Date of Acceptance||30-Mar-2020|
|Date of Web Publication||1-Sep-2020|
Dr. Baridalyne Nongkynrih
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Community-based participatory research (CBPR) is an approach in which researchers undertake research in partnership with those affected by the issue being studied, for the purpose of taking action or effecting social change. It can also incorporate those who will use the results to change practice and inform policy. The practice of CBPR is primarily focused on “Knowledge for Change.” Most research projects in such CBPR partnerships are funded through the academic partners. In many situations, academic and professional researcher institutions and researchers find it difficult to share the information and resources or to directly engage with local community and other local stakeholders. In practice, finding an intermediary partner who has good rapport with local community and local government can be very effective. While there are good initiatives in selected medical colleges for community orientation of medical undergraduates and postgraduates in community medicine, these are not immersive enough to cause an attitudinal change. It is time that we exposed our graduates and postgraduates to CBPR concepts and practice.
Keywords: Community medicine, community-based participatory research, teaching
|How to cite this article:|
Krishnan A, Tandon R, Nongkynrih B. Relevance of community-based participatory research in community medicine training. Indian J Community Med 2020;45:256-60
|How to cite this URL:|
Krishnan A, Tandon R, Nongkynrih B. Relevance of community-based participatory research in community medicine training. Indian J Community Med [serial online] 2020 [cited 2020 Sep 25];45:256-60. Available from: http://www.ijcm.org.in/text.asp?2020/45/3/256/294152
“The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life … The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.“
This Alma Ata Declaration of the WHO in 1978 gave the first global legitimacy to primary healthcare which was renewed in October 2018 through the Astana Declaration. In this perspective, individuals and families are seen as masters of their own health, with the support from health professionals.
| What Is Community-Based Participatory Research?|| |
Conventionally, research or generation of knowledge is understood as an act by professionally trained experts certified to be researchers and knowledge is what is published in journals and books, reviewed and accepted by professional peers. However, rural communities survived through generations – by producing and sharing their own ways of creating knowledge through practice and apprenticeship in the family. Acknowledging and valuing such knowledge, practical, local, and indigenous are the first building block of community-based participatory research (CBPR).
“CBPR is an approach in which researchers undertake research in partnership with those affected by the issue being studied, for the purpose of taking action or effecting social change; it can also incorporate those who will use the results to change practice and inform policy. CBPR is research with communities rather than research on or about communities.”
CBPR is an approach, but not a method, and brings research together with education, co-learning, and action to democratize knowledge production. This thereby amplifies the relevance and authenticity of the knowledge created and its potential of being used for positive change. While degrees and types of participation may vary depending upon the area of research, CBPR entails that all stakeholders must participate in decisions related to (a) the identification of the research question; (b) the methodology to be undertaken, data collection, and analysis; (c) the use or sharing of research findings. The phraseology of “co-construction” of knowledge is now commonly used to imply academics and civil society, as well as other stakeholders, produce, disseminate, and use knowledge together. For many of us trained as professional researchers and academics, it is difficult to understand how ordinary, semi-literate farmers, workers, and women can be knowledge producers. This acknowledgment requires an attitudinal and behavioral change.
Recent studies by the UNESCO Chair on Community-Based Research have demonstrated widespread use of such vocabulary though its actual practices are varied and inconsistent.
| Evolution of Community-Based Participatory Research|| |
One of the first “modern” theorizations of such an approach came from a German Scientist Kurt Lewin whose team was trying to persuade German homemakers to cook nutritious food for their families during meat shortage in war-torn country. They discovered that the actions by such homemakers resulted in new knowledge about the nutritive values of various nonmeat ingredients. He called it “action research” and it exemplified how, through discussion, decision, action in a participatory and democratic manner, research becomes meaningful.
Theories and methods of participatory research (PR) began from the field of adult education and practitioners of social change by the mid-1970s. PR emphasizes on the critical understanding of social problems, their structural roots, and the potentials of overcoming them. It necessitates a democratic interaction between the researchers and those who are “researched.” Furthermore, it challenges the way knowledge is produced by conventional social science research methods and disseminated by “elite” institutions, maintaining the “monopoly of knowledge.” PR is a highly context-sensitive approach. International development agencies of the UN and the World Bank began to take interest in PR by the late 1980s as a method of involving communities in planning, implementing, and monitoring the development projects. In the process, its variant evolved as participatory action research (PAR) which combines the principles of AR with PR. PAR thus became a method of action-oriented strategies and research and inquiry. Another variant that grew out of PR is participatory rural appraisal (PRA) which gained much acceptance for its easy to use tools and methods of data collection in rural settings. By the early 1990s, PRA became a leading methodology for developing local, context-specific projects, facilitating planning, monitoring, and evaluating interventions, and enabling greater participation of the recipients of change themselves. With primary healthcare also popularizing the concept of community participation, this gradually evolved into CBPR.
| Use of Community-Based Participatory Research in Health Research|| |
PRA has often been used in health sector in the context of primary healthcare. It is noted that there is a lack of community needs assessment as well as community participation in the development and implementation of health education programs in India. PRA has been conducted to address health issues such as infant health, HIV/AIDS, and menstrual hygiene [Table 1].,,, More examples of use of CBPR exist in diabetes, hypertension, and obesity, among others. Environmental issues by their inherent close links to societal development provide one of the best areas for the demonstration of CBPR approach., Some of these examples of CBPR are described in [Table 1]. The use of CBPR increases the ownership of the program, better utilization, and compliance to advice and better sustainability.
|Table 1: Some examples of health-related participatory research methods in India and other developing countries|
Click here to view
In much of the developing world, research institutions did not get involved in these new methodologies of AR and PR until very recently. However, many universities and professional research institutions in Europe and North America integrated AR and PR methodologies in their mainstream research and launched formal courses for graduate students in the 1990s. It is only in the last 15 years or so that universities and academic researchers have begun to get acquainted with such research methodologies more widely. In its current manifestation, where academics are primary researchers, community-engaged and community-based research methods have begun to gain ascendancy since turn of this century. The recently launched Global Consortium of Knowledge for Change (K4C) by the UNESCO Chairs on Community-Based Research is nurturing hubs of research partnerships which bring university and academia to work together with local community and civil society to generate new knowledge for locally prioritized sustainable development goals.
| Steps of Community-Based Participatory Research|| |
The steps in CBPR methodology are not very different from traditional research. The key steps are the same; however, each step is conducted differently because knowledge is to be co-constructed. [Table 2] shows illustrates some of the differences between conventional research and CBPR.,
| Framing the Research Question|| |
Framing of the research question is rooted in the political economy of knowledge. In standard medical research, the research question is usually determined by experts. However, when community is regarded as a source of knowledge, the research questions emerge from the everyday challenges of life in the community itself. This does not do away with conventional literature review which highlights the existing body of knowledge and gaps on that issue. However, review of literature also needs to take into consideration what people already know. Collaborating with the community while framing the research question is the first step to open a process of discussion and reflection together with the population involved.
| Designing Methods for Data Collection|| |
The second critical step in knowledge creation is the choice of methods for data collection. CBPR approach emphasizes that community becomes co-facilitators in the process of data collection. CBPR can use number of creative methods for data collection such as arts, music, dance, theater, photography, audio-visuals, and stories. The methods for data collection that use visualization of situations trigger discussions on local knowledge. For example, the use of body mapping tool, in which the local women draw what they thought was their body, can be used to explain the ways in which contraceptives worked. Irrespective of the type of data needed, whether quantitative or qualitative, the idea is to involve the stakeholders themselves in the process. This brings ownership among the community and encourages critical discussions.
| Analysis and Recommendations|| |
Once data are collected and analyzed, it is taken back to the community for validation. A joint analysis of the patterns, causes, and linkages provides more nuanced understanding, for example, whether it would be useful to inform young women sex workers that having unprotected sex can make her at risk of HIV/AIDS. However, if this information is jointly analyzed with the group of women or individuals, it allows them to critically reflect on the consequences of a decision to have or to not have unprotected sex. This process itself is empowering because it provides a space for the girls to talk, discuss, and debate on these issues and to inform her ideas which may or may not comply with the current discourse on sexual practice.
| Sharing Findings, Knowledge Mobilization|| |
Conventional dissemination of knowledge takes place through journals, books, conferences, policy briefs, and dialogs. However, in CBPR, in addition to other forms of dissemination, the new knowledge generated is primarily used within the community through creative ways such that the community understands what is being talked about. Some of the methods could be holding a photo-exhibition that tells a story of the real situation, displaying of posters, dissemination of digital infographics, videos, etc. It is a two-way process wherein the results should be analyzed in health institutions to change the negative attitudes of the health personnel, to improve skills, and to establish better communication and cooperation with the community.
| What is the Value Addition of Adopting Community-Based Participatory Research in Community Medicine Training?|| |
The goal of community medicine is to introduce the understanding of social determinants of health in the population and complex interactions between these factors in the causation and mitigation of diseases to move away from a medical model of disease to a social model of health. Krishnan recently argued that the community medicine training should aim at graduates being able to make a community diagnosis and involve community and local governments in addressing them.
Currently, in India, departments of community medicine use the platforms of urban and rural health and training centers to provide a community orientation to students. Curative services are provided to an underserved community, while in turn the community serves as the “laboratory” of departments of community medicine wherein research activities are carried out. There are three major set of educational activities that take place in the community context – conducting an epidemiological study with the focus on data collection and management; allotment of families or index cases to conduct a detailed study to understand social factors in disease causation and management; and finally exposure to community level healthcare providers (about accredited social health activists, anganwadi workers, auxiliary nurse midwives, etc.). These activities expose students to patients within the community to understand the family, social, and community contexts of disease causation and coping. However, largely, these experiences are not immersive enough to cause an attitudinal change in students. While there have been some laudable initiatives in some medical colleges, these have not been picked up by other medical colleges. Apart from lack of interest, the key logistical challenges have been in selection of an appropriate community (distance, transport, hostels); lack of social sciences capacities in the department to undertake CBPR; and finally challenges at community level in terms of readiness and participation.
The recent introduction of competency-based curriculum by the Medical Council of India in 2018 provides us an opportunity to revisit this issue. Inclusion of the competency to work with communities and identifying their health problems at undergraduate level and working with communities to resolve the problems by designing, instituting corrective steps and evaluating outcome of such measures at postgraduate level could be a starting point. However, doing so would need strengthening of the department of community medicine to carry out community-based activities. They either need to enlarge the staff pool with community networking abilities or identify NGOs which can facilitate their interaction with the communities.
Another model that can be adapted is the Community Action Research Track (CART) model developed by the University of Texas to integrate population medicine, health promotion/disease prevention, and social determinants of health into the medical school curriculum through CBPR and service–learning experiences. CART is an optional 4-year service–learning experience for medical students interested in community health. The curriculum includes a coordinated longitudinal program of electives, community service–learning experience, and lecture-based instruction. Significant improvements in mean knowledge were found when measuring the principles of CBPR and levels of prevention and determining health literacy and patient communication strategies. CART can be replicated by other medical schools interested in offering a longitudinal CBPR and service–learning track in an urban metropolitan setting. Lessons can also be drawn from the Advancing Environmental Health Science Research and Translation in India through CBPR Workshop jointly organized by PR in Asia, India, and College of Public Health, University of Iowa, USA. Several sessions of this important workshop stressed on understanding history, methodology, and impact on CBPR and its application to environment health research.
| Conclusion|| |
CBPR approach in health research requires the researcher to develop a collaborative framework to articulate a relevant research question. The process of collaboration with the community in framing the research question entails building trust, fostering partnership, and acknowledging community's knowledge as significant to the process of knowing. Despite its name, community medicine practitioners are not the practitioners of CBPR. There is a substantial need for department of community medicine to strengthen their community-based teaching to be able to effectively transmit the concept of CBPR to its students.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adelman C. Kurt lewin and the origins of action research. Educ Action Res 1993;1:7-24.
Miller MB. Education, research, and action: Theory and methods of participatory action research. In: From Subjects to Subjectivities: A Handbook of Interprative and Participatory Methods. New York and London: New York University Press; 2001. p. 76-86.
Tandon R. Introduction: Revisiting the roots. In: Participatory Research: Revisiting the Roots. New Delhi: Mosaic Books; 2002. p. 7-8.
Sharma M. Health education in India: A strengths, weaknesses, opportunities, and threats (SWOT) analysis. Int Electr J Health Educ 2005;8:80-5.
Wells KJ, Preuss C, Pathak Y, Kosambiya JK, Kumar A. Engaging the community in health research in India. Technol Innov 2012;13(4):10.3727/194982412X13292321140886.
Stolba SS. Oral rehydration therapy: the behavioural issues. In: Monograph no. 1. Washington DC: USAID; 1990. P. 5-17.
Dongre AR, Deshmukh PR, Garg BS. The effect of community-based health education intervention on management of menstrual hygiene among rural Indian adolescent girls. World Health Popul 2007;9:48-54.
Nyamathi AM, William RR, Ganguly KK, Sinha S, Heravian A, Albarran CR, et al
. Perceptions of women living with AIDS in rural India related to the engagement of HIV-trained accredited social health activists for care and support. J. HIV/AIDS Soc Seriv 2010;9:385-404.
Tremblay MC, Martin DH, McComber AM, McGregor A, Macaulay AC. Understanding community-based participatory research through a social movement framework: a case study of the Kahnawake Schools Diabetes Prevention Project. BMC Public Health 2018;18:487.
Chimberengwa PT, Naidoo M. A description of community-based participatory research of hypertension awareness, prevention and treatment in a district of Matabeleland South Province, Zimbabwe. Afr J Prim Health Care Fam Med 2019;11:e1-e9.
Coughlin SS, Smith SA. Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-Americans: A literature review. J Racial Ethn Health Disparities 2017;4:259-68.
Ablah E, Brown J, Carroll B, Bronleewe T. A community-based participatory research approach to identifying environmental concerns. J Environ Health 2016;79:14-9.
Commodore A, Wilson S, Muhammad O, Svendsen E, Pearce J. Community-based participatory research for the study of air pollution: A review of motivations, approaches, and outcomes. Environ Monit Assess 2017;189:378.
Cornwall A. Towards Participatory Practice: PRA and participatory process. In: Koning KD, Martin M. Participatory Research in Health. United Kingdom: Redwood Books; 1996. p. 96-103.
Krishnan A. Revisiting the Relevance of Community Medicine in Undergraduate Medical Curriculum. Indian J Community Med 2019;44:9-11.
] [Full text]
Gimpel N, Kindratt T, Dawson A, Pagels P. Community action research track: Community-based participatory research and service-learning experiences for medical students. Perspect Med Educ 2018;7:139-43.
[Table 1], [Table 2]