The challenge of genuine power sharing in participatory research: the gap between theory and practice

Exploring clinical reasoning in child language assessment through decoloniality

PURPOSE

Clinical reasoning has been taught, practised, and researched under Western epistemologies, which have been fallible in addressing the complexity of clinical reasoning within Indigenous cultures and societies. We explored how speech-language pathologists in Sri Lanka negotiate and value Indigenous and Western perspectives in clinical reasoning within a decolonial framework.

METHOD

This study used participatory research methodology within the decolonised qualitative research paradigm to produce data collaboratively with eight Sri Lankan speech-language pathologists. Oral history narratives and object-based textual reflections generated the necessary data for the study. Systematic visual-textual analysis and reflexive thematic analysis were carried out iteratively, and the data analysis and interpretation were undertaken collaboratively with the participants.

RESULT

We generated four key themes about professional education, individuality in practice, holistic thinking, and balancing interests and priorities. The results demonstrate that social, political, and economic forces impact practitioners' clinical reasoning.

CONCLUSION

Practising science in its original form within Indigenous contexts is challenging. Colonial roots and imperialism impact the delivery of appropriate services in socially and politically marginalised communities. Practitioners' self-awareness about authentic identities and practical wisdom can develop culturally relevant knowledge for equitable practice.

A Connected Community Approach: Citizens and Formal Institutions Working Together to Build Community-Centred Resilience

Urban resilience research is recognizing the need to complement a mainstream preoccupation with “hard” infrastructure (electrical grid, storm sewers, etc.) with attention to the “soft” (social) infrastructure issues that include the increased visibility of and role for civil society, moving from (top-down, paternalistic) government to (participatory) governance. Analyses of past shock events invariably point to the need for more concerted efforts in building effective governance and networked relations between civil society groupings and formal institutions before, during, and after crisis. However, the literature contains little advice on how to go about this. In this paper, we advance a Connected Community Approach (CCA) to building community resilience with a specific focus on the relationship between community and formal institutions. In the literature review that informs this work, we assess the current, limited models for connecting communities to formal institutions, as well as the emerging role of community-based organizations in this work, and we offer our own assessment of some of the key tensions, lacunae, and trends in the community resilience field. Principally, we explore the potential of the CCA model, as spearheaded by the East Scarborough Storefront and the Centre for Connected Communities in Toronto, Canada, as a promising approach for building the relational space between civil society and the state that is so often called for in the literature. The paper concludes with future directions for research and practice.

Power, Privilege and Knowledge: the Untenable Promise of Co-production in Mental "Health"

This paper examines the concept and practice of coproduction in mental health. By analyzing personal experience as well as the historical antecedents of coproduction, we argue that the site of coproduction is defined by the legacy of the Enlightenment and its notions of "reason" and "the cognitive subject." We show the enduring impact of these notions in producing and perpetuating the power dynamics between professionals, researchers, policy makers and service users within privileged sites of knowledge production, whereby those deemed to lack reason-the mad and the racialized mad in particular-and their knowledge are radically inferiorised. Articulating problems in what is considered knowledge and methods of knowing, we argue that modern "psy" sciences instantiates the privilege of reason as well as of whiteness. We then examine how the survivor movement, and the emergent survivor/mad knowledge base, duplicates white privilege even as it interrogates privileges of reason and cognition. Describing how we grapple with these issues in an ongoing project-EURIKHA-which aims to map the knowledge produced by service users, survivors and persons with psychosocial disabilities globally, we offer some suggestions. Coproduction between researchers, policy makers and those of us positioned as mad, particularly as mad people of color, we argue, cannot happen in knowledge production environments continuing to operate within assumptions and philosophies that privilege reason as well as white, Eurocentric thinking. We seek not to coproduce but to challenge and change thinking and support for psychosocial suffering in contexts local to people's lives.

A hidden activism and its changing contemporary forms: Mental health service users / survivors mobilising

This commentary concerns how the organisation of State welfare benefits in the UK have changed over the last 20 years, arguing that this has had harmful, even fatal, consequences for people with disabilities and particularly those with mental distress of psychosocial disabilities. This current situation may be called that of austerity. The paper describes how a ‘hidden activism’ has emerged to contest this situation and explains why it is, and to a degree, must be hidden. I then focus on the discourse of responsibilisation where every citizen must take responsibility for embodying the virtues of the good, working person. To ensure this, unemployment has been framed as a psychological problem and psychologists are now employed to ‘treat’ this problem in order that everybody might enter the world of work. I argue that in current conditions this is not possible for all with mental distress. Engaging then with community psychology, I address the issue of allies and how the absence of attention to mental distress might be remedied by this form of work. I draw on the emerging field of user / survivor-led research in mental health and argue that collaboration with community psychology will not be without problems.

Participatory research: real or imagined

BACKGROUND

Participatory research has as a central tenet that power relations between researcher and researched be reduced. In the last 20 years, a substantial literature has demonstrated the difficulties inherent in this as well as the troublesome nature of certain central concepts.

AIMS

(1) To describe and illustrate a new form of participatory research where the researchers share at least something with the participants in the research. That is, all are users of mental health services. (2) To reflect on the novel form of participatory research in terms of whether it shares, mitigates or avoids some of the difficulties of more traditional forms and to pose the question: what is a mental health community?

RESULTS

The model described is new in that the researchers have a different status than in conventional participatory research. But it is illuminated by and itself illuminates issues of power relations in research and difficulties in reducing that; gatekeepers and the exclusion of crucial groups of service users; the confusion of demographic representativeness with the silencing of marginalized perspectives; coming out of the academic space and the shifting issue of what counts as 'communities' in mental health.

CONCLUSION

The examples given are moderate in scale and relevant to social psychiatry. Yet they may change methods and the definition of participatory research and at the same time be vitiated by but also illuminate dilemmas already identified in the literature albeit in different formations.

Expectations of new treatment in rheumatoid arthritis: developing a patient-generated questionnaire

BACKGROUND

Service-user partnerships in research exist in mental health, but there have been few advances in other disciplines, apart from cancer.

OBJECTIVES

To develop a patient-generated expectancy measure for new treatments in rheumatoid arthritis (RA), using a participatory method.

METHOD

Stage 1: three repeated focus groups and two expert panels with patients with RA conducted by a patient researcher to generate items for the draft questionnaire. Stage 2: feasibility study of draft scale with consecutive outpatient attendees.

RESULTS

Patients identified 21 dimensions of new treatment expectations, grouped into (i) physical, (ii) psycho-social and (iii) expectations relating to the impact of treatment. This resulted in a draft instrument assessed in a feasibility study.

DISCUSSION AND CONCLUSION

The participatory research method was useful in involving patients actively in research and to produce collaboratively a feasible, valid and acceptable measure in RA. The scale will be included in a longitudinal observational study, with newly diagnosed patients, to assess (i) whether the new scale demonstrates sensitivity to change for expectations when receiving new treatment and (ii) participants' completion rate of the new scale compared with five instruments included in the future study.

L’autre côté de la clôture. Quand le monde de la santé mentale et de la rue rencontre celui de la recherche

Si les thèmes du patient partenaire et du patient collaborateur sont de plus en plus en vogue dans le domaine de la recherche en santé mentale, les dynamiques relationnelles entre patients et chercheurs et les enjeux qu’elles soulèvent sont relativement peu documentés au Québec. Cet article vise à alimenter le débat sur ces dynamiques à partir d’un cas d’étude : la participation d’un pair à deux équipes de recherche d’un projet de recherche et de démonstration dans le champ de la santé mentale et de l’itinérance. Le récit de son expérience dans le projet explore notamment la manière dont les réalités qu’il vit – au croisement des problèmes de santé mentale, de son expérience de la rue et de la consommation – ont un impact sur les relations qu’il entretient avec ses collègues. Réciproquement, ses conditions de travail semblent l’affecter de manière négative et produire une perte d’identité conduisant, entre autres, à son départ du projet. L’analyse tend à montrer que les conflits vécus entre le pair et ses collègues sont le reflet de hiérarchies qui existent entre les statuts et les savoirs reconnus ou à reconnaître dans le champ de la recherche.

Life in acute mental health settings: experiences and perceptions of service users and nurses

Background. Acute psychiatric provision in the UK today as well as globally has many critics including service users and nurses. Method. Four focus groups, each meeting twice, were held separately for service users and nurses. The analysis was not purely inductive but driven by concerns with the social position of marginalised groups - both patients and staff. Results. The main themes were nurse/patient interaction and coercion. Service users and nurses conceptualised these differently. Service users found nurses inaccessible and uncaring, whereas nurses also felt powerless because their working life was dominated by administration. Nurses saw coercive situations as a reasonable response to factors 'internal' to the patient whereas for service users they were driven to extreme behaviour by the environment of the ward and coercive interventions were unnecessary and heavy handed. Conclusion. This study sheds new light on living and working in acute mental health settings today by comparing the perceptions of service users and nurses and deploying service user and nurse researchers. The intention is to promote better practice by providing a window on the perceptions of both groups.

User-generated quality standards for youth mental health in primary care: a participatory research design using mixed methods

OBJECTIVES

To develop user-generated quality standards for young people with mental health problems in primary care using a participatory research model.

METHODS

50 young people aged 16-25 from community settings and primary care participated in focus groups and interviews about their views and experiences of seeking help for mental health problems in primary care, cofacilitated by young service users and repeated to ensure respondent validation. A second group of young people also aged 16-25 who had sought help for any mental health problem from primary care or secondary care within the last 5 years were trained as focus groups cofacilitators (n=12) developed the quality standards from the qualitative data and participated in four nominal groups (n=28).

RESULTS

46 quality standards were developed and ranked by young service users. Agreement was defined as 100% of scores within a two-point region. Group consensus existed for 16 quality standards representing the following aspects of primary care: better advertising and information (three); improved competence through mental health training and skill mix within the practice (two); alternatives to medication (three); improved referral protocol (three); and specific questions and reassurances (five). Alternatives to medication and specific questions and reassurances are aspects of quality which have not been previously reported.

CONCLUSIONS

We have demonstrated the feasibility of using participatory research methods in order to develop user-generated quality standards. The development of patient-generated quality standards may offer a more formal method of incorporating the views of service users into quality improvement initiatives. This method can be adapted for generating quality standards applicable to other patient groups.

Patient and public involvement in health research: ethical imperative and/or radical challenge?

Patient and public involvement in health research, including mental health research, is promoted by research funders in England. However, it is poorly conceptualised. One argument is that patient and public involvement in research is an ethical imperative because those who research is for should have a stake in how it is done. This could be developed through concepts of citizenship and democratic science. More strongly, it can be argued that changing the knowledge producers will change knowledge itself. Starting with feminist standpoint epistemology, it is argued that a political conceptualisation best captures the new knowledge that marginalised health groups can produce.

A participatory action research methodology in the management of self-harm in prison

BACKGROUND

Self-harm in custody is a well-researched phenomenon. This is particularly true for women in prison who demonstrate disproportionately high rates of self-harm. Despite the growing body of prison research, there has been a lack of service user involvement (SUI). Aims To outline the first use of SUI in a custodial setting in developing care pathways for self-harm.

METHODOLOGY

A participatory action research approach was used to engage women prisoners and staff.

RESULTS

Participants were able to identify strengths and weaknesses of current care pathways and offer suggestions for service development based upon their experience of receiving and delivering care.

CONCLUSION

The authors conclude that despite participatory approaches being in their infancy in prisons the engagement of service users when aimed at effecting positive change can be successful.

The politics of action research: "if you don't like the way things are going, get off the bus"

Participatory action research is lauded for its emancipatory potential and practice relevance. Little research has focused on the ethical and political dimensions of power relations between management gatekeepers and staff in large organizations in the negotiation of action research. To illuminate the dynamics of this engagement, this paper is informed by Aristotle's practical ethics of phronesis, arguing that ethics emerge through human interaction. The paper reports on a multi-method study and intervention in inter-professional learning and collaboration, conducted between 2008 and 2010, across an Australian health system. It draws on results from researchers' progress notes, 139 semi-structured interviews and focus groups (492 participants), more than 200 h of organizational document analysis, and more than 200 h of ethnographic observation. From conventional thematic analysis, we note that the project had considerable support from senior managers who were gatekeepers for the research. Such support stemmed from managerialist tendencies, with senior managers explicitly aligning inter-professionalism with prospective health reforms and improvements to quality of care and patient safety. Senior managers were also enthusiastic about standardized processes. Many frontline staff were less supportive, and some were suspicious of or hostile towards management-led processes to improve and evaluate care. Some senior managers' self perceived alignment with and support for the research process changed to resistance once this finding was presented. This paradox in the interplay of research findings and research process evinces the inherent tension between organizational politics and conducting action research that reflexive researchers need to negotiate in knowledge translation, exchange or mobilization exercises.

A model for developing outcome measures from the perspectives of mental health service users

It is becoming increasingly recognized that conventionally derived outcome measures in mental health research are problematic. This is both because of the methodology used and because a 'good' outcome is framed from the perspective of clinicians and researchers. This paper describes a methodology for developing outcome measures for use in large studies entirely from the perspective of mental health service users. It is a mixed methods model starting with a participatory and qualitative methodology and proceeding to psychometric testing. At all stages, the researchers are themselves mental health service users. In the first phase of the model, focus groups are convened comprising people who have received the treatment or service being measured. The focus groups meet twice resulting in a draft mixed-methods questionnaire devised from thematic analysis of the focus group data. This is then taken to expert panels, again comprising individuals who have received the treatment or service being evaluated for refinement. Following this, a feasibility study is conducted with N ∼ 50 participants and changes made iteratively to the questionnaire in light of feedback. The final measure is subject to psychometric testing both to ensure it is robust and to explore similarities and differences with conventionally derived measures.

Developing a user-generated measure of continuity of care: brief report

OBJECTIVE

This paper describes a measure of continuity of care, establishes its reliability and tests it in a field trial sample for evidence of its validity. In contrast to others, this measure has been generated from the perspectives of service users. As continuity of care is a concern particularly for those with severe mental illness, we have confined our work to this population group.

METHOD

Service users in focus groups and expert panels generated the measure. The researchers were themselves service users. Test-retest reliability was assessed with an independent sample. The measure was administered to a final independent field trial sample to determine their experiences of continuity of care and for further psychometric testing.

RESULTS

The measure generated by service users has satisfactory psychometric properties. Service users in the field trial sample were more satisfied when continuity, as assessed by this measure, was in place.

CONCLUSION

It is possible and valid to construct outcome measures in mental health entirely from the user perspective. This has not been done before.

Structuring an inter-sector research partnership: a negotiated zone

Objectives:

To document and analyze the initial steps in building a health research partnership. To enable a greater appreciation of what these processes entail and also to provide guidance in negotiating the inevitable tensions between parties with different aims and objectives.

Methods:

This case study is based on participant-observation and document analysis. It employed three general analytic strategies: developing a case description, relying on theoretical propositions and thinking about rival explanations.

Results:

The development of a research partnership ramework entails a complex negotiation process marked by tensions: one of representing the interests of the various parties; and one establishing the basis for collaboration. Some factors can facilitate these processes: acknowledging the specific interests and organizational culture of the various organizations involved; designating a mediator to develop a climate of trust; and mitigating the inequalities among partners, in a process which requires considerable efforts over a rather long period of time.

Conclusion:

The process of structuring the relations among the associated partners does not end with negotiating a partnership accord. Denying this would be tantamount to denying the political nature of a research partnership, and denying those involved any autonomy in future research projects.

Investigating Issues Surrounding Depression in Adolescent Girls Across Ontario: A Participatory Action Research Project

This study gathered data from adolescent girls in four regions (Ottawa, North Bay, Toronto, Windsor) concerning key issues in the prevention of depression in young women. Using a participatory methodology, a team of young women worked with researchers to design and conduct focus groups with 48 adolescent girls across Ontario. Major themes emerging from the focus group data fell into five categories: (a) symptoms, (b) contributing factors, (c) alleviating depression, (d) prevention, and (e) barriers to receiving help. These findings should be considered when designing programs targeting depression in young women in order to maximize the accessibility and effectiveness of such initiatives.

Recruitment of older African Americans for survey research: a process evaluation of the community and church-based strategy in The Durham Elders Project

PURPOSE

The disproportionately high burden of morbidity and mortality among older African Americans is due, in part, to a lack of understanding of the factors contributing to these outcomes. In order to more fully understand the factors that contribute to African American morbidity and mortality, researchers must identify strategies for increasing the inclusion of older African Americans in research on social and health phenomena.

DESIGN AND METHODS

This article is a process evaluation describing the successes and challenges associated with recruitment of older African Americans into research. It considers an effort to nurture collaboration between university and community institutions to both facilitate research endeavors and offer meaningful and culturally-appropriate contributions to the community.

RESULTS

The primary challenges discovered in this observational process evaluation of a church-based recruitment strategy include the effective coordination of a community research advisory board, ensuring participant autonomy, and reducing concerns of exploitation among potential participants.

IMPLICATIONS

A strategy of coordinating a community research advisory board to incorporate the views of community members and to drive a church-based recruitment procedure provides a starting point for tapping into an immensely important segment of society historically ignored by the research community.

Action research: a hospital responds to domestic violence

Using action-research methods and the principles of community development, a small working group initiated an organization-wide process to sensitize the Sunnybrook and Women's College hospital community to the relationship between violence and women's health. In this article, we explore the process by which the initiative was successfully introduced into the newly merged hospital. We describe critical factors for the initiative's success and offer some suggestions on how to maximize opportunities for organizational change.

Technology for independence: a community-based resource center

Despite the prominence of the disability civil rights model--with its values of inclusion and empowerment--the majority of social and policy research conducted to date has not sufficiently included the perspective of persons with disabilities in the research process and as uniquely qualified researchers themselves. This article describes a new project, "Technology for Independence: A Community-Based Resource Center" (CBRC). Over a five-year period, the CBRC will attempt to enhance community and consumer-directed disability organizations to design, implement, and disseminate research that promotes access to and use of assistive technology (AT). The CBRC will use strategies such as leadership training, participatory action research, technical assistance, web-assisted training, and annual symposia. A primary goal of the CBRC is to increase the capacity of community organizations to conduct research on AT that is scientifically rigorous and relevant to disability services, policy, and law.

Involving street youth in peer harm reduction education. The challenges of evaluation

OBJECTIVES

To describe and discuss the challenges in evaluation of a participatory action research with street-involved youth.

METHODS

A combination of quantitative and qualitative methods were utilized for both process and outcome evaluations. Process evaluation methods included in-depth individual interviews, focus groups, participant observation, and session debriefing forms. Summative evaluation research included focus testing of the harm reduction video and a survey of video users.

FINDINGS

Members of the youth team reported favourably on the experience, citing friendship, skills development, fun, and pride of accomplishment among the key benefits of participation. Political tensions arose because of the focus on reducing harm from drug use rather than encouraging abstension. The heavy demands of participatory research and development, resource constraints and the priority given to product development in these kinds of projects necessarily precludes extensive youth participation in the design, implementation and analysis of additional evaluation research. Even when resources are directed towards evaluation, there is a tendency to focus on data collection, which may limit time and resources for data analysis. Finally, there is an inclination to focus on the product development rather than dissemination and impact of the product.

INTERPRETATION

Despite the challenges inherent in participatory action research and its evaluation, this project was regarded as an empowering experience by the street youth who participated in it. It is worthwhile to direct resources to evaluation which optimally gives proportional attention to data collection as well as data analysis, and focusses not only on product development but also on its dissemination and impact.

Families as full research partners: what's in it for us?

This article describes a children's managed mental health care program that incorporates both a family participation service model and a family-initiated evaluation model. The authors begin by tracing the evolution of the family support and the participatory research movements leading to current developments in children's mental health services research. In the King County Blended Funding Project, three service systems pool funds that are spent flexibly by child and family teams. Family advocates have led efforts to design and implement the project evaluation. During this process, many tensions have arisen between meeting the demands of both scientific rigor and multiple community stakeholders. Examples are given of the issues raised by family advocates and research scientists as together they established a theory of change, identified meaningful outcomes, selected measurement tools, and implemented the evaluation protocol. Guidelines are given for how services research partnerships can be successfully built to better address community needs. This article was selected as a distinguished research paper based on a presentation by the authors at the 1998 11th annual research conference titled "A system of Care for Children's Mental Health: Expanding the Research Base." This conference is sponsored annually by the Research and Training Center for Children's Mental Health, Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa.