As a Research Administrator, my responsibilities include assisting faculty members make grant applications in Public Health research areas and coordinating capacity building workshops for early career researchers in grants writing and manuscript drafting. At one point in my career, it was but natural to pine for a deeper understanding of ‘field work’ to add value to the documents I would prepare. An opportunity to visit two ‘field sites’ to document successful best practices came through and I was happy to commit to them instantly. The first was to document record keeping by front line health workers in Eastern India. The second was to document health promotion in community settings in Western India. Both required engaging with health workers and community in equal measure. Both broadened my thinking and understanding beyond all the research papers and reports I had read.
One of the field site was a small dingy room without a window. About 30 women sat in the room, some mothers, some daughters, some newly weds and some with infants, all cheerful, oblivious to the dark interiors. A henna competition was on, to gauge whose henna bedecked palms were the best in terms of design and colour. Before prizes were announced, the women were asked to speak on what their dream was about their daughters. The henna competition had broken their inhibition and now they all spoke up. One woman said she wanted her daughter to be healthy, one said education and going to school was important, another spoke about financial independence. But they all spoke, and not about challenges they and their daughters face every day, not about the resource limited households they had to go back to, but about their dreams and aspirations for their next generation.
It was then that the Project Manager told the women about family planning methods, about how spacing between children was one way to keep both the mother and her children healthy, about discussing family planning options with their husbands and families and reaching out for resources and medical assistance in the nearby locality, in case they needed further advise. What I was observing was a participatory action or engagement, where the community is an active lead for any intervention being planned for them. The Project Manager was part of a larger project involving community, private and public medical practitioners and health centers. He was not an MD or a PhD, but was highly skilled in community engagements. There was a level of comfort that he demonstrated especially while handling a taboo subject like family planning methods with women from a very conservative section of the society. Later on he told us that it was important for him to understand what the community wanted first, before he aligned it with what he wanted to tell them about his project.
Six months later, I had an opportunity of being involved with a group of researchers planning to conduct a study on immunization coverage in Eastern India through community intervention. The Intervention specialists, began with a question for the community. Once again the question was about their dreams and aspirations. As per their experience, for any community intervention to be sustainable, it was important to have the community participate in the study, not as a recipient, but equal in status as the researcher conducting the study. Most often, community interventions require social and behavior changes to have positive outcomes and this can be achieved when the community believes that there are substantial gains from the study which align perfectly with roadmaps to their dreams.
In one of our institutional projects on rain water harvesting and storage in several villages, it was seen that when the community participated as equals, there was substantial ownership. At the end of the project, when the research project team pulled out of the community, the residents took up a mechanism to pool in resources and maintain the structures built and the processes for water regulation, as a regular mechanism. The project was renamed as ‘Aapno Yojana’ meaning ‘our/my project’.
Additionally, cultural contexts are often overlooked while designing community interventions. In a country like India, where each region is different from the other, be it in language, religion, tradition, beliefs etc, one intervention will not be replicable in another setting. Participation from the community in devising intervention strategies not only provide ways to conduct the intervention, but also help drawing out indigenous solutions in resource sharing in resource limited countries.
Participatory Action Research can be valuable in sustainable community interventions. Some of the methods use a lot of listening and then devising an intervention plan along with the community. What is required is a strong monitoring and evaluation component to measure progress at every step. The cons include
- Ethics- Both the researcher and the community have to believe that the intervention will benefit the community. While aligning the community’s goals with research objectives, there should not be a forcing on or manipulation to align research objectives leading to coercion.
- Choosing community leaders- especially in projects where community is required to openly discuss topics that lead to behavior change, often a few representatives from the community are first addressed who then in turn become a relay team of informing others in the community regarding the intervention. Sometimes, these leaders can become quite dominating and forceful with their ideas and thoughts. In order to maintain balance, adequate monitoring and constant dialogue with the leading team and the community is required.
- Not connecting with appropriate stakeholders- in addition to the community, the local health governance members have to be a part of the project. Once the project is completed, they would be required to continue to administer, monitor and guide the community.
- No linkages with national/ state programmes/resource agencies- In order to be sustainable, the community intervention has to have linkages with ongoing national, state programmes. The project team should also be able to forge linkages with resource people who can be sought locally, like front line health workers, medical practitioners, hospitals, healthcare centers, diagnostic agencies and pharmacies. This would be valuable when the project is completed and the community still has people to reach out to.
In case of community interventions where participatory action cannot be utilized, appropriate ways to conduct research dissemination should be explored. Often research dissemination is done at a higher level, involving government functionaries, policy makers, research groups. The people who would benefit most, the community is not informed regarding the research results. Importantly, changes are being driven by some funding agencies who advise for strong dissemination components at proposal stage itself. Medical research involving drug and patient trial results are often not shared due to ethical factors. However, there are many public health research projects where dissemination mechanisms are not explored adequately. As a result, public health research is still conducted in silo and shut down in large cumbersome reports that are not accessible for wider reading.
A few interesting examples of participatory community interventions using different methods are-
- The Maternal and Perinatal Death Surveillance and Response project initiated by the Ministry of Health and Family Welfare in Bangladesh, which helped make substantial improvements in maternal death indicator. During open discussions with the community on maternal death at childbirth, the project team realized that excessive bleeding during delivery and delay in seeking appropriate medical care, delay in accessing appropriate transport to the nearest hospital, caused an increase in maternal deaths. Interventions were created to address these issues followed by policy level changes that led to better indicators.
- Community Photovoice project, where community members took photos or wrote and spoke stories regarding barriers and promoters of eye care in rural India. Their voice identified a few key barriers such as alcoholism, unregulated blood sugar and hypertension. These can now be adequately addressed by strengthening the healthcare fabric within the locality.
- Participatory Women’s group addressing maternal and child health– front line health workers used participatory methods to prioritize neonatal and maternal health issues amongst a women’s group that in turn spread the information amongst women through implementation projects that they themselves assessed.
- Developing smoke free homes in Kerala– Pilot studies suggested that Community participatory action helped substantially reduce second hand smoking in homes. Interestingly, the study showed that husbands, who did not stop smoking on request of their wives, did so when the community together aimed at a ‘smoke free home’ drive.
It is also important for Public Health researchers to obtain information regarding various successful participatory action research methods that have been tried and tested. A compilation of literature on various approaches to participatory action research is required. This would help researchers understand the implications of community participation and then to design intervention plans that have potential to be scaled up. Perhaps all the major funding agencies working with communities could come forward to collate information on their successful community intervention projects, at one place. Or perhaps scientific publication houses could bring out commissioned papers in this direction.
At a time when Public Health research funding is slumping across the world, it would benefit to test out different methods of participatory action that have scalability and sustainability while being minimally resource intensive. In developing countries where population numbers are high, people are the true strength and the only resource. Bringing them together, learning from them and linking them to the local resources available should be the primary objective of the researcher involved in designing community interventions. Participatory Action Research can help bridge the gap between people and the Sustainable Development Goals we have set for ourselves to a great degree. As researchers, we have to merely facilitate this connection.
 Biswas, A., Rahman, F., Eriksson, C. and Dalal, K. (2014) Community Notification of Maternal, Neonatal
Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh. Health, 6,
 Rani PK. et. al. (2017) Envisioning eye care from a rural perspective: A photovoice project from India. Int.Q.Community Health Educ. doi: 10.1177/0272684X17736153
 Tripathy, P. et. al. (2016) Effect of participatory women’s groups facilitated by ASHAs on birth outcomes in rural eastern India: a cluster-randomised controlled trial. The Lancet Global Health, Vol 4, No.2, e119-128. DOI: http://dx.doi.org/10.1016/S2214-109X(15)00287-9
 Nichter M. et.al. (2015) Developing a smoke free homes initiative in Kerala, India. BMC Public Health. 15:480. doi: 10.1186/s12889-015-1815-1