Much of the discussion in this weeks readings resonated with the frustrations that arose for me during my summer practicum observing and documenting progress toward the achievement of the Millennium Development Goals (MDGs) in Northern Nicaragua. Working under an initiative that integrated every buzzword of the hour was a fascinating experience and I came to realize just how far buzzwords really make it beyond air-conditioned offices in capital cities. Intersectoral participatory work is complex and if trust can be cultivated while carefully treading around a “Christian, Socialist, and Solidarity!” government, it’s cherished.
During my short time there I found that proposals for intervention were drowning in evidence with each of the latest and greatest international declarations from social determinants of health, to health in all policies, to the most cost effective water purification strategies. With the crunch of funding deadlines and lack of time and financial resources to properly execute intersectoral work that truly valued local actor’s voices however, much of this evidence could not be put to good use. The call to action for “approaches that employ the principles of community-based participatory research and team science that take stakeholder and local perspectives and treat all collaborators as valued “experts” on their domains of interest” (Glasgow et al, p. 649) was acknowledged, but failed in practice.
My primary focus for this work was MDG 7, Target 10: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. In order to build off of these shortcomings I witnessed during my time in the field I’d like to explore this issue further in the context of the course. If domestic water quality management is the most cost effective water treatment strategy, how can that awareness be put into action in the community? How can trust built between intersectoral actors be fostered and taken advantage of to create sustainable change? Effective solutions for collaboratively translating the growing body evidence surrounding water security worldwide into sustainable changes are needed. Moving past buzzwords and into evaluating implementation strategies, I think a focus not only on effective interventions but on building effective long-term relationships across sectors in the effort to promote evidence-based practice will be a key to the on-going improvements of health outcomes.
Glasgow RE, Green LW, Taylor MV, Strange KC. (2012). Evidence integration triangle for aligning science with policy and practice. American Journal of Preventive Medicine, 42(6), 646-654.
This week’s readings included a call from Glasgow et al. (2012) for a greater community role in the knowledge production process. This necessitates opening up academic research to community participation, as well as including lay understandings and wisdom in our definition of knowledge. The assumption seems to be that if only academics and policymakers were more welcoming then the community would happily meet them in the middle. This may not be the case. Many of the forces that serve to create and maintain health inequities may also place constraints on community participation.
The articles we read this week explore neither what is meant by community participation, nor the ethical and logistic issues inherent in community participation in research. Accordingly, I would like to propose several questions so that we might begin to unpack the idea of community participation.
We might start by asking: What do we mean by community? On which attributes are we basing our definition? The definition of community we adopt should be grounded in the aims of our study or intervention. We might define a community geographically. We may equally refer to imagined communities, such as those based on ethnicity. Furthermore, there is the question of deciding who is and is not part of a community; membership may be decided by self-identification or imposed by others (the researcher, the state).
Having defined a community, we may then ask: Who speaks for these communities? Those who are speaking may not necessarily represent the views of their fellow community members. This leads us to consider whether we are engaging with a diverse cross-section of the community, or simply those members whom we find accessible.
On the subject of engagement: Does our model of community engagement mean placing a greater burden (economic or social) on communities that may already be under considerable stress? Certain communities may not be so keen on working with institutions that have historically played the role of the oppressor (and may continue to do so). Indigenous peoples in Canada have expressed consternation at perpetually being the subject of research (see Castellano, 2004 for further discussion). Indeed, targeting “at risk” communities can prove stigmatizing (Frohlich et al., 2012). Each new publication marking Indigenous communities as unhealthy and each intervention aimed at improving their lot only contributes to widely held stereotypes about indigenous peoples in Canada.
With these concerns in mind, we must pursue mechanisms that aim to temper power imbalances between researchers, health promoters, and community members. This is essential given that many public health initiatives concern communities that society marginalizes.
I understand that for the sake of brevity a journal article cannot examine every pertinent issue in depth. Nonetheless, I find it discouraging that none of the articles we read this week explicitly addressed these issues, even in passing. In the interest of treating community participation in a more than cursory fashion, I suggest we take up some of these questions and explore their implications for research and practice.
Castellano, M. B. (2004). Ethics of Aboriginal research. Journal of Aboriginal Health, 99, 98-114.
Frohlich, K. L., Poland, B., & Sareck, M. (2012). Contrasting entry points for intervention in health promotion practice: situating and working with context. Health Promotion in Canada: Critical Perspectives on Practice, 102.
Glasgow, R. E., Green, L. W., Taylor, M. V., & Stange, K. C. (2012). An evidence integration triangle for aligning science with policy and practice. American journal of preventive medicine, 42(6), 646-654.