A Participatory Action Research process was initiated with communities in a low income rural setting. Three village-based groups were convened and consulted on health related challenges. A range of structural and social root causes were identified, along with priority actions.
Problems and Purpose
The majority of people from low and middle–income countries (LMICs) experience barriers to accessing good quality health care . The problem can be related to a lack of information about the needs of those who are excluded from access. Health policy and planning that does not account for those who are excluded can give rise to a self–sustaining situation in which the health system, albeit inadvertently, is organized to maintain their exclusion. The first step toward overcoming this situation requires reliable evidence about those who are excluded in order to inform the equitable organization of care.
Background History and Context
Avoidable mortality among disadvantaged groups is strongly influenced by social conditions . Information on how the social determinants of health inequalities influence access to health services and health outcomes is therefore necessary to prioritize equity in health policy and planning. An extension of this school of thought prioritizes participatory research as an approach to elicit information on the social determinants of health inequalities by enabling the perspectives of disadvantaged populations. Participatory action research (PAR) is an approach concerned with fuller forms of participation . In PAR, knowledge is co–created, acted on, and learning from action is sought to bring about and sustain change.
Organizing, Supporting, and Funding Entities
The research was undertaken by the Verbal Autopsy Participatory Action Research (VAPAR) programme.
Participant Recruitment and Selection
The research was conducted in a rural province of South Africa in a health and socio–demographic surveillance site (HDSS). To prioritize and maintain prior linkages, participants involved in a previous community–based participatory research (CBPR) pilot study in the Agincourt HDSS were re-engaged. In the previous study, three village- based discussion groups had been convened. Villages had been selected on the basis of demographic variation and feasibility and in each village, discussion groups comprised women of reproductive age, family members, traditional healers, religious leaders, community health volunteers, health workers and community leaders. To mitigate any potential biases due to power differentials, in one village, the group consisted of women only.
Public Engagement Office staff approached individuals involved in the earlier CBPR study in villages, and described the current study, activities and intended outputs. Written consent forms and information sheets were provided, and participants were invited to ask questions at the time, or afterwards by telephone. For those willing to be involved, a convenient time was arranged for the first meeting at which participants were asked to sign and return the consent forms. Through this process, all 24 participants from the prior study agreed to be involved.
Methods and Tools Used
Participatory Action Research (PAR) was initiated, changing the usual way of doing research that emphasizes a divide between the researchers and the researched, transforming the subjects of research toward roles as active researchers and agents of change. The process involved focus group discussions and used Photovoice, a visual participatory technique.
What Went On: Process, Interaction, and Participation
PAR is a non–linear, context specific process, with cycles of observing, reflecting, acting and learning from action. The repeated cycles build a sustained process that enables community ownership. The first PAR process was to obtain an insight into the communities and their conditions. In the first meeting, and to encourage participant control over how the topics for discussion were framed, people were asked their opinions about conditions to examine. Department of Health (DoH) partners were previously consulted and considered conditions with high prevalence rates identified in Agincourt HDSS. Through this approach, under–5 mortality was selected.
The discussion groups then embarked on a series of six weekly meetings to consider the conditions in terms of causes, contributory factors, and actions to address the identified issues relating to under-5 mortality. Verbal Autopsy (VA) data on under–5 deaths were presented to the community groups, indicating multiple problems with access to care at and around the time of death. Specific issues identified were: families not calling for help, not going to a facility at the time of death, and that the overall costs of care were unaffordable. After presenting the VA data, participants were invited to share their knowledge and experiences in an open discussion. Participants were prompted to share views on symptoms, modern and traditional therapies, health service responses, and what happens in the village in acute situations.
In order to systematize individual views and experiences, ranking and diagramming were used. Other PAR methods were used such as a problem tree to organize issues identified into proximate determinants, mid–level systems factors, and social and structural causes of under–5 mortality. One discussion group used Photovoice to explore the use of contemporary methods employing mobile and digital technologies. Ranking was used to identify priorities for action through which only issues that were nominated by the group were registered. The focus group discussion method was employed using topic guides to structure the discussions. The visual and narrative data were thematically analyzed to complement the collective analyses.
Collective analysis on causes, contributors and priority actions to reduce under–5 mortality was done. Widespread poverty, unemployment, poor housing and inadequate water were repeatedly identified as direct causes of death within and between the village–based discussion groups. Health systems factors were also clearly identified as contributing to mortality. Participants identified areas for action to address the issues identified and some of them were to; generate employment; increase social amenities related to primary and secondary education, provide access to clean water, increase social amenities related to road safety and implementation of community based health promotion.
Influence, Outcomes, and Effects
Priority actions were specified, fed back to DoH partners, and subsequently a feedback forum was held with DoH partners and community participants in the Agincourt HDSS. Within the time and resources, it was not possible to develop the process into taking action, and reflecting on and learning from action, and so PAR was not fully achieved. Through the activities undertaken, however, willingness and commitment were expressed by participants and health authorities to continue the process into taking action, and reflecting and learning from this action.
Analysis and Lessons Learned
The process also helped to establish a commitment to partnerships between communities, health authorities and researchers. The study provided a basis from which to gain support to develop fuller forms of participatory research in this setting. Further steps included building deeper involvement of participants in the process, expanding to include the perspectives of those most marginalized and to further develop engagement with health systems stakeholders to enable action, and learning from action. In combination with routine HDSS, the use of PAR to elicit local knowledge on health problems has the potential to connect communities, researchers and health authorities to develop robust evidence for service delivery, policy and planning.
 World Health Organization. The World Health Report – Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organisation, 2010. Available: http://www.who.int/whr/2010/en/. Accessed: 28 February 2017.
 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. (2009). The health and health system of South Africa: historical roots of current public challenges. Lancet. 374:817-34. Medline:19709728 doi:10.1016/S0140-6736(09)60951-X
 Loewenson R, Laurell AC, Hogstedt C, D’Ambruoso L, Shroff Z. Participatory action research in health systems: a methods reader. Regional Network for Equity in Health in East and Southern Africa (EQUINET) in association with Training and Research Support Centre (TARSC), Alliance for Health Policy and Systems Research (AHPSR), World Health Orga-nization (WHO) and the International Development Research Centre (IDRC) Canada, 2014. Available: https://www.equinetafrica.org/sites/default/files/uploads/documents/PAR%20Methods%20Reader2014%20for%20web.pdf. Accessed: 28 February 2017.
 Wariri, Oghenebrume, Lucia D’Ambruoso, Rhian Twine, Sizzy Ngobeni, Maria van der Merwe, Barry Spies , Kathleen Kahn, Stephen Tollman, Ryan G Wagner, and Peter Byass. (2017). "Initiating a participatory action research process in the Agincourt health and socio–demographic surveillance site." Journal of Global Health, 7(1), 10.7189/jogh.07.010413.
The original submission of this entry was adapted from Wariri et al 2017. 10.7189/jogh.07.010413. under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Please refer to the revision history for a detailed account of subsequent edits and additions made by the Participedia community.
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