Participatory action research: considerations for ethical review

Walk With Me: reducing harm and confronting the toxic drug poisoning crisis in small British Columbia cities through community engaged research

In an era of escalating and intersectional crises, the toxic drug poisoning crisis stands out as a devastating and persistent phenomenon. Where we write from in British Columbia (BC), Canada, over 13,000 deaths have occurred in the eight years since the toxic drug poisoning crisis was declared a provincial health emergency. While many of these deaths have occurred in large urban centres, smaller rural communities in British Columbia are also grappling with the profound impacts of the toxic drug poisoning crisis and are struggling to provide adequate support for their vulnerable populations. In response to these challenges, the Walk With Me research project has emerged in the Comox Valley of Vancouver Island, BC, employing community-engaged methodologies grounded in pluralist knowledge production. Walk With Me seeks to understand the unique manifestations of the toxic drug poisoning crisis in small communities, identifying local harm reduction interventions that can foster community resilience, and aiming to catalyze sustainable change by amplifying the voices of those directly affected by the crisis to advocate for policy changes. This paper outlines the conceptual and methodological underpinnings of the Walk With Me project as a harm reduction initiative, which holds community partnerships and diverse ways of knowing at its heart. It presents the community-engaged research framework used by the project to address overlapping health and social crises, offering practical examples of its application in various research projects across sites and organizations. The paper concludes with a reflection on the impacts of Walk With Me to date, highlighting the lessons learned, challenges encountered, and opportunities for future research and action. Overall, this article captures the urgent need for community-engaged approaches to address the toxic drug poisoning crisis and other multidimensional crises facing society, particularly in smaller and rural communities, underscoring the potential for meaningful change through collaborative, grassroots efforts.

Research ethics and collaborative research in health and social care: Analysis of UK research ethics policies, scoping review of the literature, and focus group study

Current research ethics frameworks were developed on the footprint of biomedical, experimental research and present several pitfalls when applied to non-experimental social sciences. This work explores how the normative principles underpinning policy and regulatory frameworks of research ethics and the related operational processes work in practice in the context of collaborative health and social care research. The work was organised in three phases. First, UK research ethics policy documents were analysed thematically, with themes further organised under the categories of 'Principles' and 'Processes'. Next, we conducted a scoping review of articles about research ethics in the context of collaborative health and social care research, published in English between 2010 and 2022. We then held an exploratory focus group with ten academic researchers with relevant experience to gather their views on how the research ethics system works in practice in England (UK). The thematic framework developed in the first phase supported the analysis of the articles included in the scoping review and of focus group data. The analysis of policy documents identified twelve themes. All were associated to both a principle and a related operational process. The scoping review identified 31 articles. Across these, some themes were barely acknowledged (e.g., Compliance with legislation). Other themes were extensively covered (e.g., The working of Research Ethics Committees), often to discuss issues and limitations in how, in practice, the research ethics system and its processes deal with collaborative research and to suggest options for improvement. Focus group data were largely consistent with the findings of the scoping review. This work provides evidence of the poor alignment between how the research ethics system is normatively expected to work and how it works in practice and offers options that could make research ethics more fit for purpose when addressing collaborative research in health and social care.

Dark loops: contagion effects, consistency and chemosocial matrices in psychedelic-assisted therapy trials

What happens when an emerging programme of medical research overlaps with a surging social movement? In this article we draw on the anthropological term 'chemosociality' to describe forms of sociality born of shared chemical exposure. Psychedelic administration in the context of recent clinical trials appears to have been particularly chemosocial in nature. We argue that one consequence is that psychedelic-assisted therapy (PAT) clinical research trials tend to breach key assumptions underlying the logic of causal inference used to establish efficacy. We propose the concept of dark loops to describe forms of sociality variously emerging from, and impacting participant experiences in, PAT trials. These dark loops are not recorded, let alone incorporated into the causal pathways in the interpretation of psychedelic trial data to date. We end with three positions which researchers might adopt in response to these issues: chemosocial minimisation where research is designed to attenuate or eliminate the effects of dark loops in trials; chemosocial description where dark loops (and their impacts) are openly and candidly documented and chemosocial valorisation where dark loops are hypothesised to contribute to trial outcomes and actively drawn upon for positive effect. Our goal is to fold in an appreciation of how the increasingly-discussed hype surrounding psychedelic research and therapeutics continues to shape the phenomena under study in complex ways, even as trials become larger and more rigorous in their design.

Ethical considerations in engaging young people in European obesity prevention research: The CO-CREATE experience

Engaging youth in obesity prevention research and policy action is essential to develop strategies that are relevant and sensitive to their needs. Research with young people requires critical reflection to safeguard their rights, dignity, and well-being. The CO-CREATE project used various methods to engage approximately 300 European youth aged 15-19 years in the development of policies to prevent adolescent obesity. This paper discusses ethical considerations made in the project pertaining to the youth's voluntary participation, their protection from obesity stigma, respect for their time, data privacy and confidentiality, power balance, and equality of opportunity to participate in the research. We describe measures implemented to prevent or limit the emergence of ethical challenges in our interaction with youth and discuss their relevance based on our experience with implementation. While some challenges seemingly were prevented, others arose related to the youth's voluntary participation, time burdens on them, and the sustainability of participation under the Covid-19 pandemic. Concrete and ongoing ethical guidance may be useful in projects aiming to interact and build collaborative relationships with youth for long periods of time.

Embracing the Nutritional Assessment in Cerebral Palsy: A Toolkit for Healthcare Professionals for Daily Practice

Background: Nutritional status assessment (NSA) can be challenging in children with cerebral palsy (CP). There are high omission rates in national surveillance reports of weight and height information. Alternative methods are used to assess nutritional status that may be unknown to the healthcare professionals (HCP) who report these children. Caregivers experience challenges when dealing with feeding problems (FP) common in CP. Our aim was to assess the difficulties in NSA which are causing this underreport and to create solutions for registers and caregivers. Methods: An online questionnaire was created for registers. Three meetings with HCP and caregivers were held to discuss problems and solutions regarding NSA and intervention. Results: HCP mentioned difficulty in NSA due to a lack of time, collaboration with others, equipment, and childrens’ motor impairment. Caregivers experienced difficulty in preparing nutritious meals with adapted textures. The creation of educational tools and other strategies were suggested. A toolkit for HCP was created with the weight and height assessment methods described and other for caregivers to deal with common FP. Conclusions: There are several difficulties experienced by HCP that might be overcome with educational tools, such as a toolkit. This will facilitate nutritional assessment and intervention and hopefully reduce underreporting.

The Utility of Participatory Action Research in the Nursing Field: A Scoping Review

Participatory action research (PAR) is a method of inquiry that promotes a collaborative approach to knowledge creation. This article examined areas of research interest that included PAR methods, highlighting the areas of improvement that such approaches might offer to researchers and scientists in the nursing field. Among the 20 included studies, participatory concepts are more likely used to direct research design than to select participants. About two-thirds of the studies reviewed used PAR principles in designing projects. Although only a few research collaborative efforts involved partners in selecting participants, 70% involved participants in data gathering. Participatory approaches to data processing and interpretation were found in over 60% of articles assessed across all content categories. Approximately half of the studies included suggestions for participatory implementation approaches; a quarter discussed participatory ways to disseminate results. The findings demonstrate how researchers are incorporating PAR principles into a variety of areas of nursing research. Promises to fully include participants and promises of reciprocal benefit are essential in order to pursue meaningful PAR.

Let all know: insights from a digital storytelling facilitator training in Uganda

BACKGROUND

Digital storytelling (DST) is a participatory, arts-based methodology that facilitates the creation of short films called digital stories. Both the DST process and resulting digital stories can be used for education, research, advocacy, and therapeutic purposes in public health. DST is widely used in Europe and North America, and becoming increasingly common in Africa. In East Africa, there is currently limited in-country DST facilitation capacity, which restricts the scope of use. Through a Ugandan-Canadian partnership, six Ugandan faculty and staff from Mbarara University of Science and Technology participated in a pilot DST facilitation training workshop to enhance Ugandan DST capacity.

OBJECTIVE

This Participatory Action Research (PAR) study assessed the modification of DST methodology, and identified the future potential of DST in Uganda and other East African settings.

METHODS

In the two-week DST Facilitator Training, trainees created their own stories, learned DST technique and theory, facilitated DST with community health workers, and led a community screening. All trainees were invited to contribute to this study. Data was collected through daily reflection and journaling which informed a final, post-workshop focus group where participants and researchers collaboratively analyzed observations and generated themes.

RESULTS

In total, twelve stories were created, six by trainees and six by community health workers. Three key themes emerged from PAR analysis: DST was a culturally appropriate way to modernize oral storytelling traditions and had potential for broad use in Uganda; DST could be modified to address ethical and logistical challenges of working with vulnerable groups in-country; training in-country facilitators was perceived as advantageous in addressing community priorities.

CONCLUSION

This pilot study suggests DST is a promising methodology that can potentially be used for many purposes in an East African setting. Building in-country DST facilitation capacity will accelerate opportunities for addressing community health priorities through amplifying local voices.

What are Important Ways of Sharing Power in Health Research Priority Setting? Perspectives From People With Lived Experience and Members of the Public

Community engagement (patient and public involvement) is gaining prominence in health research worldwide. But there remains limited ethical guidance on how to share power with communities in health research priority setting, particularly that which has been informed by the perspectives of those being engaged. This article provides initial evidence about what they think are important ways to share power when setting health research projects' topics and questions. Twenty-two people with lived experience, engagement practitioners, and members of the public who have been engaged in health research in the United Kingdom and Australia were interviewed. Thematic analysis identified 15 key ways to share power, many of which are relational. This study further demonstrates that tensions exist between certain ways of sharing power in health research priority setting. More research is needed to determine how to navigate those tensions.

Co-Creating Descriptors and a Definition for Person-Centred Coordinated Health Care: An Action Research Study

The aim of this study was to co-create a definition and generic descriptors for person-centred coordinated care for Ireland generated from service users’ narratives. An overarching action research approach was used to engage and empower people to tangibly impact health policy and practice. Through focus groups and a qualitative survey, primary data were collected from a national sample of health services users, caregivers and health care service users’ representative groups. Thematic analysis was used to analyse the data. Three major themes were co-produced as essential care elements. These were: ‘My experience of healthcare’, ‘Care that I am confident in’ and ‘My journey through healthcare’. Through an IPPOSI partner project steering group and their membership groups’ contribution, these themes were further refined into a definition of person-centred coordinated care and nineteen related generic descriptors. Key findings demonstrate that within complex, fragmented healthcare systems, the subjective expectations of service users should be integrated into care delivery, with a scaffolding of services to meet service users’ needs between care settings and disciplines and over time.

A scoping review of the use of co-design methods with culturally and linguistically diverse communities to improve or adapt mental health services

Mental health services are increasingly encouraged to use co-design methodologies to engage individuals and families affected by mental health problems in service design and improvement. This scoping review aimed to identify research that used co-design methods with Culturally and Linguistically Diverse (CALD) communities in mental health services, and to identify methodological considerations for working with this population. In October 2019, we searched five electronic databases (CINAHL, PsycINFO, EMBASE, MEDLINE, Web of Science) to identify papers published in which people from CALD backgrounds were engaged in the co-design of a mental health service or program. Searches were limited to peer-reviewed articles published in English in the last 25 years (1993-2019). The search identified nine articles that matched the inclusion criteria. Using a scoping review methodology, the first author charted the data using extraction fields and then used qualitative synthesis methods to identify themes. Data were grouped into themes relevant to the research question. The two key themes relate first, to improving the experience for CALD communities when engaging in co-design research and second, to the development of co-design methods themselves. These findings support the need for further research into the transferability of co-design tools with CALD communities, particularly if co-design is to become a best practice method for service design and improvement. This scoping review identified methodological and practical consideration for researchers looking to use co-design with CALD communities for mental health service design, re-design or quality improvement initiatives. Further research is required to explore experiences of co-design methods, including documented protocols such as experience-based co-design, with CALD communities. This review indicates that explanatory models of mental health, community and co-design impact partnerships with CALD communities, and need to be understood to optimise the quality of these relationships when using co-design methods.

Co-creation of services to maintain independence and optimise well-being: Learnings from Australia's Older Women Living Alone (OWLA) project

For many populations at risk of social isolation, including Older Women Living Alone (OWLA), existing services to maintain independence and optimise well-being are difficult to access, unsuitable or unavailable. Co-creation is a strategy to develop 'person-centred' services that meet the needs of individuals. We adapted an existing framework for co-creation and used participatory action research methods, supported by an evidence base comprising a systematic review, analysis of routinely collected data and interviews, to develop person-centred services for OWLA. This approach achieved co-creation through an iterative process of consultation and review, involving a series of facilitated discussions with women living alone and stakeholders. A total of 13 women living alone, aged ≥55 years, and 11 stakeholders representing service providers and advocacy groups, were recruited to participate in these discussions. Sessions with between three and five OWLA, were held across Melbourne. The information was compiled and presented to service stakeholders in a single facilitated forum, held in central Melbourne. Smaller facilitated sessions with OWLA followed, to review and discuss the collated service stakeholder input. The information from these OWLA sessions were again compiled and directed back to the service stakeholders for consideration and further discussion. The two groups came together for a final forum to prioritise the co-created ten services that they believed would be feasible and would address unmet need to support OWLA maintain independence. The process of co-creation was time-consuming and required considerable preparation to facilitate input from the target population. Small groups, gathering at convenient local locations, with transport support were essential in removing barriers to participation. However, co-creation was a viable method of eliciting the women's preferences and developing services more likely to meet their needs.

Yarning about oral health: perceptions of urban Australian Aboriginal and Torres Strait Islander women

BACKGROUND

Many factors influence how a person experiences oral health and how such experiences may facilitate supportive oral health behaviours. Women in particular face different challenges due to their environment, responsibilities and physiological differences to men. Within Australia, Aboriginal and Torres Strait Islander women are reported to have poorer oral health and are faced with additional barriers to supporting their oral health compared with non-Indigenous women. The objective of this paper is to report the experiences and perceptions of oral health from the perspective of urban, Aboriginal and Torres Strait Islander women.

METHODS

The present data derive from a descriptive study that used yarning circles and face-to-face interviews with women who were mothers/carers of urban, Aboriginal and/or Torres Strait Islander children. This was a qualitative study to investigate the impact of child oral health on families. Participants used the opportunity to share their own personal experiences of oral health as women, thus providing data for the present analyses. Information collected was transcribed and analysed thematically.

RESULTS

Twenty women shared their personal narratives on the topic of oral health which were reflective of different time points in their life: growing up, as an adult and as a mother/carer. Although women are trying to support their oral health across their life-course, they face a number of barriers, including a lack of information and the costs of accessing dental care. The teenage years and pregnancy were reported as important time periods for oral health support.

CONCLUSIONS

To improve the oral health of Indigenous Australian women, policymakers must consider the barriers reported by women and critically review current oral health information and services. Current oral health services are financially out of reach for Indigenous Australian women and there is not sufficient or appropriate, oral information across the life-course.

Green Schoolyards as Outdoor Learning Environments: Barriers and Solutions as Experienced by Primary School Teachers

With a growing number of primary schools around the globe greening their schoolyards, opportunities arise to realize outdoor learning in natural areas on the school’s premises. Despite their promising potential, green schoolyards as outdoor learning environments remain mostly unintegrated in teachers’ educational practices. In the current study, teachers of five primary schools in Netherlands were followed for two consecutive years during a participatory action research project. Based on their experiences in this project, teachers identified barriers when integrating the green schoolyard as a learning environment and found practice-based solutions to overcome these barriers. Across schools, a total of 20 meetings were organized, with 75 teachers participating in the project. Results revealed four broad themes encompassing barriers and solutions. Teachers feel hindered by outdoor learning having no formal status in their current educational practice, experience barriers related to a lack of confidence in their own outdoor teaching expertise, find it difficult to get started, and experience barriers related to physical constraints. Teachers, professionals, and researchers together found solutions to overcome each specific barrier. These solutions can be translated to general recommendations: just do it, get educated and inspired, engage in real-life experiences, get an outdoor pedagogical mindset, and follow a tailored process. The findings can be used by primary schools and other institutions to develop interventions that support teachers to further integrate the green schoolyard as a learning environment.

A scoping review: The utility of participatory research approaches in psychology

Consistent with community psychology's focus on addressing societal problems by accurately and comprehensively capturing individuals' relationships in broader contexts, participatory research approaches aim to incorporate individuals' voices and knowledge into understanding, and responding to challenges and opportunities facing them and their communities. Although investigators in psychology have engaged in participatory research, overall, these approaches have been underutilized. The purpose of this review was to examine areas of research focus that have included participatory research methods and, in turn, highlight the strengths and ways that such methods could be better used by researchers. Nearly 750 articles about research with Indigenous Peoples, children/adolescents, forensic populations, people with HIV/AIDS, older adults, and in the area of industrial-organizational psychology were coded for their use of participatory research principles across all research stages (i.e., research design, participant recruitment and data collection, analysis and interpretation of results, and dissemination). Although we found few examples of studies that were fully committed to participatory approaches to research, and notable challenges with applying and reporting on this type of work, many investigators have developed creative ways to engage respectfully and reciprocally with participants. Based on our findings, recommendations and suggestions for researchers are discussed.

Participatory approach to flood disaster management in Thohoyandou

In recent years, there has been a paradigm shift in research from 'top-down' directives to 'bottom-up' planning. Thus, there has been a change from imposing strategies to a participatory approach by indigenous people. This study uses the participatory approach to flood disaster management in Thohoyandou and its environs. The aim of this study is twofold: first, to understand the perception of communities towards floods hazards; and second, to probe how communities respond to flood hazards and how this knowledge can be used in the planning and management of future disasters. In order to achieve these objectives, participatory rural appraisal (PRA), interviews and observation were used as data collection techniques. The study found that there was consensus among the participants that flooding is a natural process, but human activities enhance the risks of flooding. Human activities that were found to be the causes of flood included clearance of vegetation, cultivation in steep slope areas, the effect of relief, urbanisation, poor designs and maintenance of drainage system and settlement in inadequate areas. The study found that local communities did not cope when there was flooding. However, they suggested strategies that should be used to cope with future flood hazards.

Initiating Participatory Action Research with Older Adults: Lessons Learned through Reflexivity

La recherche-action participative (RAP) apporte une perspective intéressante pour la recherche abordant l'exclusion et l'inclusion sociale des personnes âgées. Les exemples et réflexions sur la RAP impliquant des personnes âgées sont rares, en particulier à l'étape de l'initiation de la recherche, lorsque l'action participative cyclique est mise en place. Dans cet article, nous décrivons le démarrage d'un projet de recherche-action participative avec des personnes âgées et analysons la concordance entre ce processus et les principes clés de la participation, ainsi que son arrimage aux structures de recherche typiques. Les résultats soulignent les tensions entre le développement de relations de plus long terme et les demandes de financement préparées dans de courts délais. Cette étude montre comment les conceptions traditionnelles de la recherche peuvent influer sur la création de partenariats équitables et met en évidence la nécessité d'élaborer des lignes directrices en matière d'éthique et de publications qui traitent explicitement des approches participatives. Ces observations clés pourront être appliquées pour utiliser les potentialités de la recherche-action participative, qui consiste à aborder les enjeux importants à travers un travail collaboratif et une approche équitable intégrant les personnes les plus affectées.

Participatory action research (PAR) is well suited to research that aims to address social exclusion and inclusion in older age. Illustrations of and reflections on PAR with older adults are scarce, particularly the initiation stage, which sets the stage for the cyclical participatory action that follows. In this article, we describe the initiation of a PAR project with older adults and reflect on the alignment of this process with key participatory principles and fit within typical research structures. Findings point to the tensions between developing relationships over time and time-sensitive calls for funding, how traditional conceptions of research can influence creating equitable partnerships, and the need for development of ethical and publishing guidelines that address participatory approaches. These key insights can be applied to help achieve the potential of PAR: to address issues of concern by collaboratively and equitably working with the people most affected.

Strengthening stakeholder engagement through ethics review in biomedical HIV prevention trials: opportunities and complexities

INTRODUCTION

Clinical trials of biomedical HIV prevention modalities require the cooperation of multiple stakeholders. Key stakeholders, such as community members, may have stark vulnerabilities. Consequently, calls for HIV prevention researchers to implement "stakeholder engagement" are increasingly common. Such engagement is held to benefit inter-stakeholder relations, stakeholders themselves and the research itself. The ethics review process presents a unique opportunity to strengthen stakeholder engagement practices in HIV prevention trials. However, this is not necessarily straightforward. In this article, we consider several complexities. First, is stakeholder engagement a legitimate component of what Research Ethics Committees (RECs) should review for HIV prevention trials? Second, what are the core features of engagement that should be under ethics review? Third, what are the key practices that should be highlighted in ethics review?

METHODS

To address these questions, we examined the international ethics guidelines specialized for such trials (UNAIDS 2012, UNAIDS-AVAC GPP 2011) and directly applicable to such trials (CIOMS 2016; WHO 2011). Thematic analysis was used to code and analyse these guidelines.

RESULTS AND DISCUSSION

Ethics guidelines support REC review of engagement. Guidance recommends that engagement be broad and inclusive; early and sustained; and dynamic and responsive. Broad engagement practices include evaluating the context, planning in writing, and resourcing. RECs should assess engagement as part of a comprehensive review, and recommend revisions where necessary. Researchers should profile key elements of engagement valued in ethics guidance, when they draft ethics submissions. Importantly, the ethics review process should not undermine the 'dynamic responsiveness' required for excellent engagement in this field.

CONCLUSIONS

As evidence-informed engagement strategies emerge, these should inform the ethics submission and review process. Both parties in the review process should strive to avoid a superficial, check-list type approach that caricatures what should be a thorough, nuanced ethics review of a rich, responsive engagement process.

Citizen Science for public health

Community engagement in public health policy is easier said than done. One reason is that public health policy is produced in a complex process resulting in policies that may appear not to link up to citizen perspectives. We therefore address the central question as to whether citizen engagement in knowledge production could enable inclusive health policy making. Building on non-health work fields, we describe different types of citizen engagement in scientific research, or 'Citizen Science'. We describe the challenges that Citizen Science poses for public health, and how these could be addressed. Despite these challenges, we expect that Citizen Science or similar approaches such as participatory action research and 'popular epidemiology' may yield better knowledge, empowered communities, and improved community health. We provide a draft framework to enable evaluation of Citizen Science in practice, consisting of a descriptive typology of different kinds of Citizen Science and a causal framework that shows how Citizen Science in public health might benefit both the knowledge produced as well as the 'Citizen Scientists' as active participants.

The development of a participatory assessment technique for infrastructure: Neighborhood-level monitoring towards sustainable infrastructure systems

Climate change and increasing natural disasters coupled with years of deferred maintenance have added pressure to infrastructure in urban areas. Thus, monitoring for failure of these systems is crucial to prevent future impacts to life and property. Participatory assessment technique for infrastructure provides a community-based approach to assess the capacity and physical condition of infrastructure. Furthermore, a participatory assessment technique for infrastructure can encourage grassroots activism that engages residents, researchers, and planners in the identification of sustainable development concerns and solutions. As climate change impacts disproportionately affect historically disenfranchised communities, assessment data can further inform planning, aiming to balance the distribution of public resources towards sustainability and justice. This paper explains the development of the participatory assessment technique for infrastructure that can provide empirical data about the condition of infrastructure at the neighborhood-level, using stormwater systems in a vulnerable neighborhood in Houston, Texas as a case study. This paper argues for the opportunity of participatory methods to address needs in infrastructure assessment and describes the ongoing project testing the best use of these methods.

Reflections on the ethics of participatory visual methods to engage communities in global health research

There is a growing body of literature describing conceptual frameworks for working with participatory visual methods (PVM). Through a global health lens, this paper examines some key themes within these frameworks. We reflect on our experiences of working with with an array of PVM to engage community members in Vietnam, Kenya, the Philippines and South Africa in biomedical research and public health. The participants that we have engaged in these processes live in under-resourced areas with high prevalence of communicable and non-communicable diseases. Our paper describes some of the challenges that we have encountered while using PVM to foster knowledge exchange, build relationships and facilitate change among individuals and families, community members, health workers, biomedical scientists and researchers. We consider multiple ethical situations that have arisen through our work and discuss the ways in which we have navigated and negotiated them. We offer our reflections and learning from facilitating these processes and in doing so we add novel contributions to ethical framework concepts.

Participatory research. Part 2: Practical considerations

Participatory research can make heavy demands upon both the researcher and the community with whom they work. Nonetheless, it can also be a very rewarding process for all involved and lead to real changes. It is important that a number of issues are considered and addressed both before the research commences and during the life of the research project. This paper explores five key areas: participatory, ethical, financial, time, and personal considerations. In each instance, personal experience and wider literature is used to explore the practical issues which need to be identified and managed. It is concluded that while not all research will be participatory, consideration of these issues should assist readers in developing participatory research studies.

Participatory research. Part 1: Key features and underlying philosophy

The potential of participatory research to improve health and wellbeing, particularly within marginalised communities, is increasingly being recognised. Such research is characterised by working with a community, changing the balance of power, a different role for the researcher, active participation of the community at all stages of the research process, the production of ‘useful’ knowledge and a commitment to action. Each of these areas is explored to provide readers with an understanding of both the key features of participatory research and its underlying philosophy.

The ethics in qualitative health research: special considerations

A sound knowledge of the nature of qualitative research, along with an appreciation of some special ethical considerations, is needed for rigorous reviews to be conducted. The overall character of qualitative research is described with an emphasis on the tendency of qualitative researchers to explore sensitive topics using theoretically informed methods. A number of specific features of qualitative that require additional ethical attention and awareness are also examined including the following: 1) participants are frequently quite vulnerable and require protection because the data collection methods, such as in-depth interviews, can delve into personally and politically charged matters; 2) naturalistic observation can raise concerns regarding privacy and consent; 3) the potential for the identifiability of the results of this research may require extra efforts to maintain confidentiality. Ultimately, Reseach Ethics Committee members must be knowledgeable about qualitative approaches to be able to assess the potential harms and benefits in a protocol carefully. Without this knowledge gaining ethics approval can be overly difficult for researchers and the best practices for protecting human participants can be overlooked.

Ethics and Science in the Participatory Era: A Vignette-Based Delphi Study

Participatory researchers rely on relationship-based ethical considerations to address ethical challenges, but little is known about how these considerations shape day-to-day decision-making. We presented vignettes describing ethical dilemmas to health researchers with varying degrees of experience in participatory research in an online modified-Delphi panel. Panelists rated potential solutions to dilemmas and provided rationales for choosing solutions in text boxes and discussion boards. Panelists agreed on a preferred solution for three of five vignettes. Panelists indicated that ethical research decision-making should be inclusive of diverse perspectives. Panelists prioritized scientific goals above participatory ones and viewed tenets of scientific validity as value-free. Panelists indicated that participatory research ethics would be difficult to codify, but that vignette-based learning could support didactic objectives.

Advancing engagement methods for trials: the CORE study relational model of engagement for a stepped wedge cluster randomised controlled trial of experience-based co-design for people living with severe mental illnesses

Background

Engagement is essential in trials research but is rarely embedded across all stages of the research continuum. The development, use, effectiveness and value of engagement in trials research is poorly researched and understood, and models of engagement are rarely informed by theory. This article describes an innovative methodological approach for the development and application of a relational model of engagement in a stepped wedge designed cluster randomised controlled trial (RCT), the CORE study. The purpose of the model is to embed engagement across the continuum of the trial which will test if an experience-based co-design intervention improves psychosocial recovery for people affected by severe mental illness.

Methods

The model was developed in three stages and used a structured iterative approach. A context mapping assessment of trial sites was followed by a literature review on recruitment and retention of hard-to-reach groups in complex interventions and RCTs. Relevant theoretical and philosophical underpinnings were identified by an additional review of literature to inform model development and enactment of engagement activities.

Results

Policy, organisational and service user data combined with evidence from the literature on barriers to recruitment provided contextual information. Four perspectives support the theoretical framework of the relational model of engagement and this is organised around two facets: the relational and continuous. The relational facet is underpinned by relational ethical theories and participatory action research principles. The continuous facet is supported by systems thinking and translation theories. These combine to enact an ethics of engagement and evoke knowledge mobilisation to reach the higher order goals of the model.

Conclusions

Engagement models are invaluable for trials research, but there are opportunities to advance their theoretical development and application, particularly within stepped wedge designed studies where there may be a significant waiting period between enrolment in a study and receipt of an intervention.

Everyday ethics of participation: a case study of a CBPR in Nunavik

INTRODUCTION

Multiple reports highlight the need for community-based family-oriented prevention services for Aboriginal peoples in order to address important health and social inequalities. Participatory, empowerment-based approaches are generally favoured for these means. Faced with important social issues, in a context of colonisation and complex power dynamics, we question how community members experience participation, as well as the everyday dynamics that take place when attempting to create community-level change.

CONTEXT

The initial steps of this community-based participatory research (CBPR) took place over a two-year period in a community of Nunavik, a large northern region of the province of Quebec. The objective of the CBPR was to develop a community-driven project aimed at supporting families to be able to keep children within their homes or communities, rather than having to be placed under child welfare services.

METHOD

We participated in, and documented, various group meetings, community workshops, informal reflexive discussions, and formal interviews with community partners to explore their everyday experiences of participation in community-based change.

RESULTS

We describe some of the initial actions taken in this project. We describe how certain social and power dynamics infiltrated into the process of participation leading to various tensions, personal and interpersonal experiences and needs.

DISCUSSION

We discuss how these experiences led to everyday ethical dilemmas regarding participation. We conclude that although participatory approaches towards community change may be effective, they are also ethically challenging and at times disempowering for those who participate. We describe some of the approaches used to work with these ethical challenges.

Recognizing Risk and Vulnerability in Research Ethics: Imagining the "What Ifs?"

Research ethics committees (RECs) may misunderstand the vulnerability of participants, given their distance from the field. What RECs identify as the vulnerabilities that were not adequately recognized in protocols and how they attempt to protect the perceived vulnerability of participants and mitigate risks were examined using the response letters sent to researchers by three university-based RECs. Using a critical qualitative method informed by feminist ethics, we identified an overarching theme of recognizing and responding to cascading vulnerabilities and four subthemes: identifying vulnerable groups, recognizing potentially risky research, imagining the "what ifs," and mitigating perceived risks. An ethics approach that is up-close, as opposed to distant, is needed to foster closer relationships among participants, researchers, and RECs and to understand participant vulnerability and strength better.

Giving the community a voice: Lessons learned from a comprehensive survey in an urban neighborhood

Weinland Park, an urban neighborhood adjacent to The Ohio State University, has been targeted for revitalization following several decades of disinvestment. The goal of these efforts is to develop holistic solutions that break the cycle of poverty. Such an undertaking requires collecting baseline data to understand community needs, inform programming, and guide revitalization efforts. This paper describes the development and implementation of the Weinland Park Evaluation Project (WPEP) - a collaborative and comprehensive neighborhood survey and needs assessment. Using the RE-AIM framework as a conceptual model, the paper describes how the WPEP was designed to meet short-, medium-, and long-term community needs. In addition, it offers lessons learned as a guide for researchers designing neighborhood surveys and conducting community assessments. An Appendix A includes indicators measured via the survey tool.

Health promotion and intellectual disability: listening to men

Taking responsibility for your own health has been a central tenet of public health policy internationally for a number of decades. Governments in the UK and internationally continue to promote a plethora of health promotion strategies, encouraging individuals and communities to adopt healthy lifestyle choices. Although it is widely recognised that men are not as proactive in seeking out medical help or taking on health promotion advice as women, limited gender-sensitive research exists in the field of intellectual disability. Despite many health promotion policy and practice strategies targeted at this population, little research exists exploring whether men with intellectual disability acknowledge health promotion advice. The study aimed to explore how men with mild-to-moderate intellectual disability understood and perceived their health and what health promotion messages they acted upon. The study was based on a participatory approach which enabled 11 men with intellectual disability to contribute as steering group members and as participants through one-to-one interviews. Data were collected between September 2011 and July 2012. Thematic analysis was undertaken. The participants demonstrated a capacity to understand their own health. This was inclusive of a concern about associating being obese with being unhealthy. The participants reported good relationships with their general practitioners (GPs) and felt valued, in particular when the GP was prepared to offer specific intellectual disability and health promotion advice. More gendered research inclusive of the views of this male population is required and the study reiterates the importance of promoting the health of men and women with intellectual disability.

"It's in the Cards": The Contribution of Illustrated Metaphor Cards to Exploring Values Within Narratives

In this article, we present the use of illustrated metaphorical cards as a technique to enrich the qualitative narrative interview. We examine the advantages of incorporating a projective tool to assist in constructing and understanding personal narratives of people living with severe mental illness. We interviewed 25 participants-staff and members of a clubhouse in Israel (an international community model of rehabilitation in mental health)-and sought to understand their stories focused on personal and organizational values. The findings revealed that, in most cases, the cards contributed to data collection by enhancing the interviewees' ability for expression and by facilitating richer, more comprehensive stories and descriptions. This in turn enhanced the researcher's ability to understand the messages and stories presented. The research conclusions discuss the cards' potential contribution to improving data collection and analysis. The cards became an additional channel for expressing participants' experiences, emotions, and unique voice.

Political representation for social justice in nursing: lessons learned from participant research with destitute asylum seekers in the UK

The concept of social justice is making a revival in nursing scholarship, in part in response to widening health inequalities and inequities in high-income countries. In particular, critical nurse scholars have sought to develop participatory research methods using peer researchers to represent the 'voice' of people who are living in marginalized spaces in society. The aim of this paper is to report on the experiences of nurse and peer researchers as part of a project to explore the experiences of people who find themselves destitute following the asylum process in the UK. In seeking to explore social injustice, three challenges are identified: lack of a robust political theory, institutional/professional constraints and an absence of skills to engage with the politics of social (in)justice. Each challenge is presented, opposing voices outlined and some possible solutions are suggested. The work of political theorist Nancy Fraser is used as a conceptual framework, in particular her focus on mis/framing and political representation for social justice. In addition, it is suggested that social justice needs to be further embedded in nursing policy and curriculum. Finally, nurses are encouraged to develop practical political skills to engage with both politics and the media in a neoliberal globalizing world.

Mixed-Status Immigrant Families in the United States: The Role of Social Justice in Intervention Research

More than 4 million unauthorized parents of legal status children currently reside in the United States (Capps, Fix, & Zong, 2016). Developmental scientists and intervention researchers hoping to work with these mixed-status families face a myriad of challenges, largely generated from the population's policy-driven social exclusion. Despite the challenges, there is a moral imperative to work with and support parents and children currently living in mixed-status households. This chapter applies a social justice perspective, largely stemming from Prilleltensky's critical community psychological framework, to improve the relevance and usefulness of research on mixed-status families (Prilleltensky & Nelson, 1997). We discuss the utility of this social justice perspective in theory building, study design and implementation, and dissemination of findings regarding mixed-status families, with exemplars from recent research.

Research Ethics Committees and Participatory Action Research With Young People: The Politics of Voice

Participatory action research (PAR) is a methodological approach that seeks to maximize the participation of people whose lives it researches. It is underpinned by an ethical concern to research "with" people, rather than "on" people. However, this ethical approach to research is often, paradoxically, problematized by universities' research ethics committees (RECs). This article explores one site of tension between PAR and RECs-the requirement for anonymity for below 18-year-olds. It explores this tension by exploring a case study of a peer-to-peer research project undertaken by young women in East London, and using our own experiences and perspectives, it argues that anonymity can be unjust, disempowering, and unnecessary, and can reduce "pride." Without wanting to develop specific recommendations, given the limited scope of our case study, this article uses firsthand experiences to add weight to the broader discussions calling for a critical rethink of REC guidelines.

Why should ethics approval be required prior to publication of health promotion research?

ISSUE ADDRESSED

Most academic journals that publish studies involving human participants require evidence that the research has been approved by a human research ethics committee (HREC). Yet journals continue to receive submissions from authors who have failed to obtain such approval. In this paper, we provide an ethical justification of why journals should not, in general, publish articles describing research that has no ethics approval, with particular attention to the health promotion context.

METHODS

Using theoretical bioethical reasoning and drawing on a case study, we first rebut some potential criticisms of the need for research ethics approval. We then outline four positive claims to justify a presumption that research should, in most instances, be published only if it has been undertaken with HREC approval.

RESULTS

We present four justifications for requiring ethics approval before publication: (1) HREC approval adds legitimacy to the research; (2) the process of obtaining HREC approval can improve the quality of an intervention being investigated; (3) obtaining HREC approval can help mitigate harm; and (4) obtaining HREC approval demonstrates respect for persons.

CONCLUSION

This paper provides a systematic and comprehensive assessment of why research ethics approval should generally be obtained before publishing in the health promotion context. So what? Journals such as the Health Promotion Journal of Australia have recently begun to require research ethics approval for publishing research. Health promotion researchers will be interested in learning the ethical justification for this change.

On using ethical principles of community-engaged research in translational science

The transfer of new discoveries into both clinical practice and the wider community calls for reliance on interdisciplinary translational teams that include researchers with different areas of expertise, representatives of health care systems and community organizations, and patients. Engaging new stakeholders in research, however, calls for a reconsideration or expansion of the meaning of ethics in translational research. We explored expert opinion on the applicability of ethical principles commonly practiced in community-engaged research (CEnR) to translational research. To do so, we conducted 2 online, modified-Delphi panels with 63 expert stakeholders who iteratively rated and discussed 9 ethical principles commonly used in CEnR in terms of their importance and feasibility for use in translational research. The RAND/UCLA appropriateness method was used to analyze the data and determine agreement and disagreement among participating experts. Both panels agreed that ethical translational research should be "grounded in trust." Although the academic panel endorsed "culturally appropriate" and "forthcoming with community about study risks and benefits," the mixed academic-community panel endorsed "scientifically valid" and "ready to involve community in interpretation and dissemination" as important and feasible principles of ethical translational research. These findings suggest that in addition to protecting human subjects, contemporary translational science models need to account for the interests of, and owe ethical obligations to, members of the investigative team and the community at large.

The heroines of their own stories: Insights from the use of life history drawings in research with a transnational migrant community

In this paper, we discuss how life history drawings can serve as a valuable method for global health research. The introduction discusses qualitative approaches to concepts such as reliability, validity and triangulation, and situates the use of participatory visual methods within the broader field of participatory research. The paper reports on an experience using life history drawings as part of extended ethnographic research in rural Mexico and among Mexican migrants living in Atlanta. The primary method for that parent project was comparative ethnographic research, which included life histories collected from 13 pairs of women over 15 months of participant observation. Early in the research, the drawings contributed to a major reorientation in the direction of the research project. The insights generated through analysis of the life history drawings exemplify how this participatory research technique can direct attention to social processes that feel salient to community members. In this case, they called attention to the enormity of social change in this community over one generation, reorienting the study from one focused on change causes by migration to one that focused on two trajectories of change: generational and migration-related.

Ethics in Community-University-Artist Partnered Research: Tensions, Contradictions and Gaps Identified in an 'Arts for Social Change' Project

Academics from diverse disciplines are recognizing not only the procedural ethical issues involved in research, but also the complexity of everyday “micro” ethical issues that arise. While ethical guidelines are being developed for research in aboriginal populations and low-and-middle-income countries, multi-partnered research initiatives examining arts-based interventions to promote social change pose a unique set of ethical dilemmas not yet fully explored. Our research team, comprising health, education, and social scientists, critical theorists, artists and community-activists launched a five-year research partnership on arts-for-social change. Funded by the Social Science and Humanities Research Council in Canada and based in six universities, including over 40 community-based collaborators, and informed by five main field projects (circus with street youth, theatre by people with disabilities, dance for people with Parkinson’s disease, participatory theatre with refugees and artsinfused dialogue), we set out to synthesize existing knowledge and lessons we learned. We summarized these learnings into 12 key points for reflection, grouped into three categories: community-university partnership concerns (n = 3), dilemmas related to the arts (n = 5), and team issues (n = 4). In addition to addressing previous concerns outlined in the literature (e.g., related to consent, anonymity, dangerous emotional terrain, etc.), we identified power dynamics (visible and hidden) hindering meaningful participation of community partners and university-based teams that need to be addressed within a reflective critical framework of ethical practice. We present how our team has been addressing these issues, as examples of how such concerns could be approached in community-university partnerships in arts for social change.

Harnessing the potential of community-based participatory research approaches in bipolar disorder

Background

Despite the rapid growth in the sophistication of research on bipolar disorder (BD), the field faces challenges in improving quality of life (QoL) and symptom outcomes, adapting treatments for marginalized communities, and disseminating research insights into real-world practice. Community-based participatory research (CBPR)—research that is conducted as a partnership between researchers and community members—has helped address similar gaps in other health conditions. This paper aims to improve awareness of the potential benefits of CBPR in BD research.

Methods

This paper is a product of the International Society for Bipolar Disorders (ISBD) Taskforce on Community Engagement which includes academic researchers, healthcare providers, people with lived experience of BD, and stakeholders from BD community agencies. Illustrative examples of CBPR in action are provided from two established centres that specialize in community engagement in BD research: the Collaborative RESearch Team to study psychosocial issues in BD (CREST.BD) in Canada, and the Spectrum Centre for Mental Health Research in the United Kingdom.

Results and discussion

We describe the philosophy of CBPR and then introduce four core research areas the BD community has prioritized for research: new treatment approaches, more comprehensive outcome assessments, tackling stigma, and enhanced understanding of positive outcomes. We then describe ways in which CBPR is ideal for advancing each of these research areas and provide specific examples of ways that CBPR has already been successfully applied in these areas. We end by noting potential challenges and mitigation strategies in the application of CBPR in BD research.

Conclusions

We believe that CBPR approaches have significant potential value for the BD research community. The observations and concerns of people with BD, their family members, and supports clearly represent a rich source of information. CBPR approaches provide a collaborative, equitable, empowering orientation to research that builds on the diversity of strengths amongst community stakeholders. Despite the potential merits of this approach, CBPR is as yet not widely used in the BD research field, representing a missed opportunity.

Youth Participatory Action Research (YPAR) 2.0: how technological innovation and digital organizing sparked a food revolution in East Oakland

This article argues that technological innovation is transforming the flow of information, the fluidity of social action, and is giving birth to new forms of bottom up innovation that are capable of expanding and exploding old theories of reproduction and resistance because 'smart mobs', 'street knowledge', and 'social movements' cannot be neutralized by powerful structural forces in the same old ways. The purpose of this article is to develop the concept of YPAR 2.0 in which new technologies enable young people to visualize, validate, and transform social inequalities by using local knowledge in innovative ways that deepen civic engagement, democratize data, expand educational opportunity, inform policy, and mobilize community assets. Specifically this article documents how digital technology (including a mobile, mapping and SMS platform called Streetwyze and paper-mapping tool Local Ground) - coupled with 'ground-truthing' - an approach in which community members work with researchers to collect and verify 'public' data - sparked a food revolution in East Oakland that led to an increase in young people's self-esteem, environmental stewardship, academic engagement, and positioned urban youth to become community leaders and community builders who are connected and committed to health and well-being of their neighborhoods. This article provides an overview of how the YPAR 2.0 Model was developed along with recommendations and implications for future research and collaborations between youth, teachers, neighborhood leaders, and youth serving organizations.

Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol

INTRODUCTION

Although fragmentation in the provision of healthcare is considered an important obstacle to effective care, there is scant evidence on best practices in care coordination in Latin America. The aim is to evaluate the effectiveness of a participatory shared care strategy in improving coordination across care levels and related care quality, in health services networks in six different healthcare systems of Latin America.

METHODS AND ANALYSIS

A controlled before and after quasi-experimental study taking a participatory action research approach. In each country, two comparable healthcare networks were selected--intervention and control. The study contains four phases: (1) A baseline study to establish network performance in care coordination and continuity across care levels, using (A) qualitative methods: semi-structured interviews and focus groups with a criterion sample of health managers, professionals and users; and (B) quantitative methods: two questionnaire surveys with samples of 174 primary and secondary care physicians and 392 users with chronic conditions per network. Sample size was calculated to detect a proportion difference of 15% and 10%, before and after intervention (α=0.05; β=0.2 in a two-sided test); (2) a bottom-up participatory design and implementation of shared care strategies involving micro-level care coordination interventions to improve the adequacy of patient referral and information transfer. Strategies are selected through a participatory process by the local steering committee (local policymakers, health care network professionals, managers, users and researchers), supported by appropriate training; (3) Evaluation of the effectiveness of interventions by measuring changes in levels of care coordination and continuity 18 months after implementation, applying the same design as in the baseline study; (4) Cross-country comparative analysis.

ETHICS AND DISSEMINATION

This study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country's ethical committee. A variety of dissemination activities are implemented addressing the main stakeholders. Registration No.257 Clinical Research Register of the Santa Fe Health Department, Argentina.

Participatory research, people with intellectual disabilities and ethical approval: making reasonable adjustments to enable participation

AIMS AND OBJECTIVES

The aim of this paper is to explore how making reasonable adjustments to the process of securing ethical approval for research can facilitate the meaningful involvement of people with intellectual disabilities as members of a research team. This is achieved through critical reflection upon the approach taken within one participatory research study whose objective was to explore how people with intellectual disabilities understand abuse.

BACKGROUND

Internationally participatory research studies (in which active involvement of community members in all stages of the research process is sought) are becoming increasingly common in the context of health care and, more specifically, within research involving people with intellectual disabilities. However, whilst it is acknowledged that participatory research gives rise to specific ethical challenges, how (or if) involvement in securing ethical approval is facilitated, is not discussed in most research reports. The significance of this paper is that it seeks to address this gap by exploring how meaningful participation can be promoted by making reasonable adjustments.

METHODS

Within the study, the research team worked in collaboration with the ethics committee to identify potential barriers that could prevent the participation of members of the research team who had intellectual disabilities. Reasonable adjustments (such as redesigning forms) were made to the processes involved in securing ethical approval.

CONCLUSIONS

This study demonstrated that it is possible to ensure that ethical standards are upheld and the requirements of ethics committees met whilst also facilitating the meaningful involvement of people with intellectual disabilities.

RELEVANCE TO CLINICAL PRACTICE

The reasonable adjustments approach explored within this paper can be translated into the context of clinical practice: making changes to the way that services are delivered can promote greater involvement of people with intellectual disabilities in their own health care.

Piloting a nationally disseminated, interactive human subjects protection program for community partners: design, content, and evaluation

Funders, institutions, and research organizations are increasingly recognizing the need for human subjects protections training programs for those engaged in academic research. Current programs tend to be online and directed toward an audience of academic researchers. Research teams now include many nonacademic members, such as community partners, who are less likely to respond to either the method or the content of current online trainings. A team at the CTSA-supported Michigan Institute for Clinical and Health Research at the University of Michigan developed a pilot human subjects protection training program for community partners that is both locally implemented and adaptable to local contexts, yet nationally consistent and deliverable from a central administrative source. Here, the developers and the analysts of this program discuss its development, its content, and the results of its evaluation.

Gold mining on Mayan-Mam territory: social unravelling, discord and distress in the Western highlands of Guatemala

This article examines the influence of a large-scale mining operation on the health of the community of San Miguel Ixtahuacán, Guatemala. An anti-colonial narrative approach informed by participatory action research principles was employed. Data collection included focus groups and one-on-one interviews from August to November of 2011. Over this period, we interviewed 15 Mam Mayan men and 41 women (n = 56) between the ages of 18 and 64 including health care workers, educators, spiritual leaders, agricultural workers and previous mine employees from 13 villages within the municipality. Participants' accounts pointed to community health experiences of social unravelling characterized by overlapping narratives of a climate of fear and discord and embodied expressions of distress. These findings reveal the interconnected mechanisms by which local mining operations influenced the health of the community, specifically, by introducing new threats to the safety and mental wellbeing of local residents.