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The theoretical, historical, and practice roots of CBPR

Authors:
CHAPTER
2
THE THEORETICAL,
HISTORICAL, AND
PRACTICE ROOTS
OF CBPR
NINA WALLERSTEIN & BONNIE DURAN
If we do our [research] well, reality will appear even more unstable,
complex, and disorderly than it does now.
J. FLAX (1987, P. 643)
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26
Community-Based Participatory Research for Health
IN THE PAST few decades a new paradigm of participatory research has emerged, rais-
ing challenges to the positivist view of science. By the 1960s, simultaneous crises, within
academia and sociopolitical movements, challenged relationships between universities
and society and precipitated a global search for new social theories and practices of
inquiry. Issues such as ownership of knowledge, the role of the researcher in engaging
society, the role of community participation and agency, and the importance of power
relations began to permeate the research process with the challenge to use knowledge to
promote a more equitable society.
The long list of terms representing this new participatory research paradigm, which
links applied social science and social activism, has been fairly daunting, and the nuanced
differences between them are often diffi cult to decipher (see Chapter One). Some terms,
such as rapid assessment procedures, rapid rural appraisal, and participatory rural
appraisal, implemented primarily in developing nations, represent a methodological
emphasis (De Koning & Martin, 1996a). Specifi c disciplines have produced their own ter-
minology: classroom action research, critical action research, and practitioner research in
the fi eld of education (Kemmis & McTaggart, 2000); action learning, action science, action
inquiry, and industrial action research in the fi elds of organizational psychology and orga-
nizational development (Argyris, Putnam, & Smith, 1985; Torbert & Taylor, 2008); cooper-
ative, mutual, or re ective practitioner inquiry in psychology and human relations (Heron
& Reason, 2006; Reason, 1994; Rowan, 2006); constructivist or fourth-generation inquiry
in evaluation research (Lincoln, 2001); emancipatory inquiry in nursing (Henderson, 1995;
Hills, 2001); and popular epidemiology and street science in public health (Brown, 1992;
Corburn, 2005; Wing, 1998). Multiple concepts have come from the community develop-
ment and social action literature, including collaborative action research, participatory
research, emancipatory or liberatory research, and dialectical inquiry (Fals-Borda &
Rahman, 1991; Hall, 1992; Hall, Gillette, & Tandon, 1982; Kemmis & McTaggart, 2000;
Park, Brydon-Miller, Hall, & Jackson, 1993). A new term, community-partnered participa-
tory research, places an even greater emphasis on partnering (Jones & Wells, 2007: see also
Chapter Four), and tribal participatory research puts the focus on indigenous peoples
(Fisher & Ball, 2003). In an exhaustive monograph on the different paradigms of collabora-
tive social inquiry over the last twenty years, Trickett and Espino (2004) call for greater
transparency of the assumptions, practice, and outcomes in the different traditions.
Despite their different emphases, however, as development studies theorist Robert
Chambers (1992) notes, “these sources and traditions have, like fl ows in a braided stream,
intermingled more and more” (p. 2). Action research and participatory action research
(PAR), have often been used interchangeably in recent years to represent a convergence
of principles (well articulated in Chapter Three); under these principles the community
determines the research agenda and shares in the planning, data collection, analysis, and
dissemination of the research (Israel, Eng, Schulz, & Parker, 2005; Israel, Schulz, Parker,
& Becker, 1998; McTaggart, 1997; Reason & Bradbury, 2008; Stringer & Genat, 2004).
In the past ten years the use of the term community-based participatory research
(CBPR) has gained respectability and attention in the health fi eld. Like many of the terms
previously mentioned, CBPR takes the perspective that participatory research involves
three interconnected goals: research, action, and education (Hall, 1992). In a collaboration,
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Theoretical, Historical, and Practice Roots of CBPR 27
shared principles result in a negotiation of information and capacities in mutual direc-
tions: researchers transferring tools for community members to use to analyze conditions
and make informed decisions on actions to improve their lives, and community members
transferring their expert content and meaning to researchers in the pursuit of mutual
knowledge and application of that knowledge to their communities (Hatch, Moss, Saran,
Presley-Cantrell, & Mallory, 1993). A majority of these terms can be traced to one of two
historical traditions that represent two distinct approaches at opposite ends of a contin-
uum: collaborative utilization-focused research with practical goals of system improve-
ment, sometimes called the Northern tradition, and openly emancipatory research, which
challenges the historical colonizing practices of research and political domination of
knowledge by the elites, often called the Southern tradition (Brown & Tandon, 1983).
This chapter will articulate the historical roots of these two traditions and discuss the con-
tribution of theories of knowledge; postmodern, poststructural, postcolonial, and feminist
theories; and theories of power in order to clarify points of convergence and difference
within current theory and practice. This chapter ends with practical approaches for imple-
menting Freirian dialogical education in community-based participatory research.
Although the best of CBPR contains skills and dimensions from both traditions, this
chapter argues that the paramount public health goal of eliminating disparities demands a
research practice within the emancipatory perspective, a practice that fosters the demo-
cratic participation of community members to transform their lives.
HISTORICAL ROOTS
The initial user of the term action research within the Northern tradition was Kurt Lewin.
In the 1940s, Lewin challenged the gap between theory and practice and sought to solve
practical problems through a research cycle involving planning, action, and investigating
the results of the action (Lewin, 1948/1997). He rejected the positivist belief that research-
ers study an objective world separate from the meanings understood by participants as
they act in their world.
This tradition emanates most broadly from the sociological theory of Talcott Parsons
and his predecessors, who viewed social progress as rational decision making based on
applying ever-increasing scientifi c knowledge to real-world problems. With an emphasis
on practitioners acting as coequals to the researchers in their research process, action sci-
ence researchers in the fi elds of organizational development and social psychology have
often worked in a consensus model, assuming that in organizations, for example, man-
agement and workers have equal power to infl uence quality improvement (Brown &
Tandon, 1983; Argyris & Schön, 1996). The assumption has been that problems could be
solved through institutional changes based on new knowledge, education, and transfor-
mational leadership that inspires a self-refl ective community of inquiry (Peters &
Robinson, 1984; Chisholm & Elden, 1993; Greenwood, Whyte, & Harkavy, 1993). In
education, for example, teachers have been encouraged to become researchers in their
classrooms to tackle questions previously left to academics (Stringer, 2007). In evalua-
tion, constructivist-focused evaluators have focused on the use of knowledge for action,
without having a political agenda (Lincoln, 2001).
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Community-Based Participatory Research for Health
Although a consensus model of action research can in practice be manipulated by
those in power when they dominate the decision making, humanistic psychology research-
ers have created a cooperative inquiry strand within this model, a strand that adopts a
rm belief in human agency and says that people can choose how they live through a pro-
cess of refl exive inquiry. This strand insists on researcher and community member reci-
procity, with no parties excluded or alienated from the research process as they exchange
ideas and actions (Rowan, 2006).
Since the early 1970s, a second tradition of participatory research, arising within
Latin America, Asia, and Africa and known collectively as the Southern tradition, has
developed, receiving much of its impetus from the structural crises of underdevelopment,
Marxist critiques by social scientists, liberation theology, and the search for new practice
by adult educators and community developers among populations vulnerable to global-
ization. An outfl ow of education and social science academics from universities to work
with land movements and community-based organizations transformed the concept that
knowledge emanated from the academy and created an openness to knowledge learned
from people’s experience, or vivencia, as Latin American philosopher José Ortega y
Gasset named it (Fals-Borda, 1991). Exiled Brazilian philosopher Paulo Freire, through the
publication of Pedagogy of the Oppressed (1970) and other writings, which were banned
during the Latin American military dictatorships in the 1970s, infl uenced the transforma-
tion of the research relationship from one in which communities were objects of study to
one in which community members were participating in the inquiry. Freire’s notion was
that reality is not an objective truth or facts to be discovered but “includes the ways in
which the people involved with facts perceive them. . . . The concrete reality is the con-
nection between subjectivity and objectivity, never objectivity isolated from subjectivity”
(1982, p. 29).
Rather than viewing research as neutral, participatory research intellectuals adopted
the commitment to critical consciousness, emancipation, and social justice as they chal-
lenged their own roles in communities with the political ideology that “self-conscious
people, those who are poor and oppressed, will progressively transform their environ-
ment by their own praxis” (Rahman, 1991, p. 13). Intellectuals were to be catalysts and
supports of educational processes but not the vanguard of social change (Hall et al.,
1982).
By 1976, progressive institutions outside academia began to take the lead, with the
creation of the Participatory Research Group by the International Council for Adult
Education in Toronto and its network of centers in India, Tanzania, the Netherlands,
and Latin America (Hall, 2001). Other nodes of activity in the same tradition have
included the Collaborative Action Research Group’s work with Aborigines in Australia
(Kemmis & McTaggart, 2000) and the Highlander Research and Education Center, in
Tennessee, the oldest adult education and social change center in the United States
(Horton & Freire, 1990; Horton, 1990; see also Appendix L). The fi rst International
Symposium on Action Research and Scientifi c Analysis dominated by professionals
outside the United States was held in Cartagena, Colombia, in 1977, with the eighth
held twenty years later and attracting two thousand delegates from sixty-one countries
(Fals-Borda, 2006).
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Theoretical, Historical, and Practice Roots of CBPR 29
The Southern tradition has incorporated post-Marxist approaches that integrate cul-
tural and social dimensions of oppression into theories of economic determinism (Laclau
& Mouffe, 1985; Said, 1994). The interests of CBPR participants from U.S. communities
of color often resonate with the Southern approach because these participants have recog-
nized the colonizing role of research, education, and religion in their own communities.
With indigenous peoples for example, public health and medical discourses have been
used by economic and government bodies to “deauthorize” traditional ways of knowing,
for the purposes of controlling Native populations and places. As recently as the 1950s
and ’60s, top public health journals were circulating “research” and medical discourse
that characterized indigenous peoples as being primitive, lacking basic knowledge of
child rearing and of hygiene, having exotic mental disorders, and being on the verge
of dying out (Bahl, 1961; Breed, 1958; Gerken, 1940; Havighurst & Illkevitch, 1949;
Hoffman, 1930). Reading these “research” papers based on misinformation and stereo-
types may tell us more about the paternalistic and biased frame of mind of our profession
than about the behaviors and beliefs of communities of color and other peoples disenfran-
chised by the system.
Placing each term used by the various disciplines at a specifi c point on the continuum
between the problem-solving utilitarian approach and the emancipatory approach of
CBPR is diffi cult because the actual research practice may vary with the local context,
history, and ideology of the stakeholders. The same term may even be used with opposite
meanings. Participatory action research, for example, has been used both to describe part
of the emancipatory participatory research tradition (Rahman, 1985) and to describe
part of the organizational development tradition (Whyte, 1991).
In general, however, action science, organizational action research, and the related
traditions grounded in the Lewinian model are to be found at the end of the continuum
focusing on pragmatic use of knowledge, with cooperative, psychological, and mutual
inquiry being found closer to the middle of the continuum. The participatory research and
PAR approaches associated with liberatory political Freirian goals and the Southern tra-
dition are generally to be found clustered at the other end. Understanding the issues
within the core concepts of participation, knowledge, and power and also Freire’s think-
ing around praxis will enable each of us to refl ect on our own practice within this
continuum.
CORE CONCEPTS AND NEW THEORIES
Participation
Habermas (1974) observed that “in the process of enlightenment, there can only be par-
ticipants” (p. 40). If we adopt Habermas’s succinct statement in our CBPR work, the core
question becomes, What do we mean by participation ? Who is participating, for whom
are we participating, in what spheres are we participating, to what ends are we participat-
ing, and perhaps most important of all, who or what is limiting participation in shaping
our lives? In other words, where does the power lie (Bopp, 1994; Cornwall & Jewkes,
1995; Gaventa & Cornwall, 2008; Rifkin, 1996)?
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30
Community-Based Participatory Research for Health
For community-based participatory research, in particular, we need to ask, “If all
research involves participation, what makes research participatory?” (Cornwall &
Jewkes, 1995, p. 1668). In health, this question is critical, as international conferences
since Alma Ata (in 1978) through Ottawa (in 1986) and Jakarta (in 1996) have declared
the importance of community participation in improving health conditions. With health
viewed as a resource originating from people within their social contexts rather
than from the health care system, participation is seen as critical to reducing depen-
dency on health professionals, ensuring cultural sensitivity of programs, facilitating
sustainability of change efforts, and enhancing health in its own right (Jewkes &
Murcott, 1998).
Despite the decades of using a value-based rhetoric of participation in development
studies, public health, and participatory research, only relatively recently have research-
ers begun to question whether the reality of participation refl ects the ideal. Some have
questioned the authenticity of the participatory process (Tandon, 1988) or have viewed
participation in a more limited fashion, as in the use of rapid rural appraisal to engage
community members as informants (Cornwall & Jewkes, 1995). Others have suggested
that participation is a developmental, emergent process that requires nurturing beyond
the initial intentions (Goodman, 2001; Greenwood et al., 1993).
The most important issue for community-based participatory researchers is the rela-
tionship between outside researchers and community members (Brown & Vega, 1996;
Jones & Wells, 2007). Habermas offers insights into these relationships through his theo-
rizing about modernity (Habermas, 1987). To Habermas, modern societies have created
two distinct worlds: the systems world of differentiated legal, economic, and political
systems and the life world of families and cultural traditions in which individuals form
and reproduce their identity and belief systems.
As the life world has increasingly become dominated by the systems world, people
have begun to defi ne themselves by their roles within systems. They become objects—
clients and consumers—rather than subjects or democratic members of civil society. The
results of being objectifi ed can be seen in powerlessness, increases in mental disease,
and the overall decline in people’s belief that their participation makes a difference (as
may, for example, be evidenced in decreased voting patterns). In applying CBPR, outside
researchers may unwittingly become part of this dynamic, as universities often reinforce
community member roles as clients and consumers.
Even within a CBPR practice that promotes authentic partnership, the actual practice
between researchers and community members remains complex and involves making
the power differences transparent, whether these differences are recognized or not. This
means addressing such issues as who represents the community and university, who owns
the data, and who represents the research project to the external world.
Although CBPR researchers expect that building collaborative relationships with
community members will be suffi cient to surmount any differences, power differentials
can and often do remain substantial. Academic researchers almost always have greater
access to resources, scientifi c knowledge, research assistants, and time than small com-
munity-based organizations do (Chataway, 1997). In a participatory evaluation study of
healthy communities in New Mexico, lack of recognition of the power differences
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Theoretical, Historical, and Practice Roots of CBPR 31
between communities and the evaluator inhibited collaboration and restricted use of
research fi ndings (Wallerstein, 1999).
One of the principles of CBPR involves recognizing that both outside researchers
and community members have needs and agendas, which may sometimes be shared and
at other times divergent or confl icting, especially if professional researchers pursue their
career advancement at the expense of the community (Fine, 1994; Huberman, 1991;
Lather, 1986). For example, community members might be more interested in jobs that
research projects may bring to a community than in the knowledge production itself.
Increasingly, CBPR researchers interested in genuine partnership face communities,
previously taken advantage of by researchers, that are now demanding their rights to
determine what research is done and who will do it (De Bruyn, Chino, Serna, & Fullerton-
Gleason, 2001). Historically, “helicopter research” in Indian Country (or “drive-by” research
in urban settings), for example, was epitomized by the researcher fl ying in and taking
information without leaving anything in return (Deloria, 1992). If CBPR practitioners
fail to recognize the validity of these historical issues, they might be denied entry or
have their research undermined through overt or hidden forms of resistance. In some
tribal communities, institutional review boards directly control (and deny) access to
researchers who are not fulfi lling community needs, including the ability to publish
ndings. Good CBPR practice therefore demands a recognition of historical or current
relationships and of potential natural skepticism resulting from historical patterns, and
also an assurance that all parties will materially benefi t from the knowledge produced
(Duran & Duran, 1999; Duran, Duran, Brave Heart, & Davis, 1998; Fletcher, 2003; see
also Appendix H).
At the same time, the contribution of CBPR researchers should not be undervalued.
Academics often know of funding opportunities and have key expertise to offer about
important health issues. They also face their own challenges for academic tenure and pro-
motion, outcomes sometimes diffi cult to achieve in the context of building long-term
relationships with communities (Goodman, 2001; see also Appendix E). Negotiation of a
mutual code of collaborative working relationships and ethics (see Chapter Three) there-
fore becomes critical when adopting a participatory partnership (Fawcett, 1991; Gitlin &
Russell, 1994; Perkins & Wandersman, 1990; see also Appendix G). Recently, research-
ers have developed instruments to evaluate the extent to which their research will serve
the community and the extent of community participation in the research itself (Brown &
Vega, 1996; Flicker, Travers, Guta, McDonald, & Meagher, 2007; George, Daniel, & Green,
1998–1999; see also Appendixes A, C, and G). These instruments, coupled with codes
of ethics developed with and by local tribes and communities (Macaulay et al., 1998;
Canadian Institutes of Health Research, 2008; see also Appendix H), provide a welcome
opportunity to ensure that communities are a driving force in their own research. Codes
of ethics may also need to be renegotiated periodically, as different research stages gener-
ate different levels of excitement, buy-in, or concerns about possible abuse of fi ndings.
Who represents the community remains a key issue in participation. Often service
providers are asked to serve on community advisory boards, yet they may or may not rep-
resent their constituents (Jewkes & Murcott, 1998). As Aiwa Ong (1991) has stated, there
is a First World in every Third World community. If stakeholders refl ect people who
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Community-Based Participatory Research for Health
make up the power base of the First World, are they appropriate to fully represent local
community residents (Green & Mercer, 2001)? As expressed throughout this book, CBPR
represents the view that community members themselves need to be brought into the
research process as decision-making participants. Least inclusive are participatory meth-
ods that seek input from community members solely as focus group or interview partici-
pants, with greater inclusion when advisory council members become facilitators,
interviewers, or research coordinators within their own communities. Although a chal-
lenge, inclusion is greatest when advisory council members engage in decision making in
all stages of the research, from beginning stages through data analysis, interpretation, and
dissemination. The relationships that favor the community most are those that place fund-
ing and decision making within the community’s lead agencies, which then subcontract
to researchers (Duran & Duran, 1999).
A provocative book, Participation: The New Tyranny? (Cooke & Kothari, 2001),
challenges the orthodoxy of participation, arguing that communities are too often viewed
naively, concealing power relations and masking biases. Three tyrannies are proposed:
the tyranny of decision making, in which community decision-making processes are
overridden by development experts; the tyranny of the group, where group dynamics
may reinforce the individuals in the community already in power; and the tyranny of
methods. A method like participatory rural appraisal, for example, may use dialogue and
visualization processes to honor local knowledge for local problem solving (De Koning
& Martin, 1996b, p. 2) yet at the same time may obscure the need to challenge state or
global institutional policies that override local determinants of well-being (Francis,
2001). These are important challenges and remind those of us working in the fi eld that
CBPR is not “reifi ed out there, but constructed by a cadre of . . . professionals, be they
academics, practitioners or policymakers, whose ability to create and sustain this dis-
course is indicative of the power they possess” (Cooke & Kothari, 2001, p. 15).
Unlike these authors, however, the authors of this chapter take a more optimistic
stand, that refl exivity within ourselves and with our community collaborators can inspire
a continual cycle of learning about our successes and about our failures. As Rifkin (1996)
states, participation should not be seen as a magic bullet but as a complex and iterative
process, which can change, grow, or diminish, based on the unfolding of power relations
and the historical and social context of the research project.
Theories and Use of Knowledge
The creation and the use of knowledge are inherently the motivating forces behind all
research; yet like participation, CBPR raises questions of by whom, about whom, and for
what purpose this knowledge is defi ned (Cornwall & Jewkes, 1995; Gaventa & Cornwall,
2008; Hall, 1992; Tandon, 1988). Although positivist research paradigms consider knowl-
edge creation to be a neutral and value-free activity, CBPR researchers have often drawn
from more refl exive and interpretative modes of inquiry that explore the dialectic between
researcher and what is being researched (Denzin & Lincoln, 2000; Poland, 1996; Reason,
1994).
CBPR critiques of positivists’ search for objective truths have been pointed, stating
that traditional inquiry discounts experiential knowledge, reinforces subjects’ passivity,
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Theoretical, Historical, and Practice Roots of CBPR 33
and obscures other voices (Gaventa & Cornwall, 2008; Wallerstein, 2007; see also Chap-
ter Fourteen). In relation to public health theory, the critique of positivism fi nds that not
only is it “not the only method for gaining valid knowledge, but it is a powerful ideology
that thwarts the fi eld’s interests in alleviating suffering and promoting social justice”
(Buchanan, 1998, p. 440). Indigenous researchers, taking the view that “one of the can-
ons of good research is that it should never hurt the people studied” (Peacock, quoted in
Crazy Bull, 1997), have posed this difference as knowledge for the sake of knowing
(that is, for describing and categorizing objective reality) versus knowledge for the sake
of decolonizing, healing, transforming, and mobilizing (Crazy Bull, 2004; Smith,
1999).
The emancipatory traditions of CBPR have drawn on critical social theory, which
views knowledge as historically and socially constructed. Ideas about knowledge
espoused by critical theorist Habermas are particularly relevant for CBPR and can be
seen as three distinct aims of research (Habermas, 1971; Kemmis, 2008). Empiricoana-
lytic reason supports the aim of technical or instrumental control over problems, which is
a rationale for the Northern tradition of utilitarian problem solving to make systems work
better. Practical reason is normative in that actors orient themselves to living within
common cultural and social values, a view that can inform both the Northern and South-
ern traditions. Dialogue around norms can, for example, support community and cultural
renewal, and at the same time open the door for changes desired by community members.
Critical reason, or emancipatory reason, refl ects the research aim to better understand
existing power struggles, that is, to understand how confl icts or power imbalances have
come about based on human actions and what the future could be. These considerations
in turn refl ect central organizing principles of the Southern tradition (Habermas, 1971;
Kemmis, 2008; Kemmis & McTaggart, 2000).
Freire provides a psychosocial understanding of how emancipatory knowledge can
lead to having the power to make change. As people engage in dialogue with each other
about their communities and the larger social context, their own internal thought patterns
and beliefs about their social world change; their relationships to each other become
strengthened; and ultimately, they enhance their capacities to refl ect on their own values
and to make new choices. These three dimensions have been called the “power of compe-
tence, connection, and confi dence” (Park, 2006, p. 89).
Power Relations
Although knowledge is a major source of power and control, other material and institu-
tional power relations are also central for understanding the dynamic relationships
between researchers and communities. CBPR takes place not only in the context of the
personal and historical relationships among researchers, their universities, and the com-
munities where research is conducted but also in the much broader context of power rela-
tions involving the societal context in which the research takes place, the origins of the
research, and the purpose of the research itself. CBPR researchers who hope to act on
the most important problems in society, such as disparities based on race, class, gender,
sexual orientation, or other identities, need to produce knowledge that clarifi es and seeks
to change unequal distributions of power and resources.
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Community-Based Participatory Research for Health
In addressing imbalances of power in society, participatory researchers may be aided
by theories of political economy, which make up a broad, multidisciplinary framework
that emphasizes how the structure of the economy and society affects the lives (and the
health) of individuals (Alford & Friedland, 1985). A political economy view assumes that
resources are allocated not according to merit or relative effi ciency but on the basis of
power. In the area of health and health care, it suggests that the behaviors and dynamics
of both visible and behind-the-scenes players can be understood only in relation to these
players’ power and class position in society (Minkler, Wallace, & McDonald, 1994–1995;
Navarro, 1984).
Gaventa (1980) and Gaventa and Cornwall (2008) identify four dimensions of power
in CBPR, analyzing how power is exercised and who is excluded. The pluralist liberal
democratic view assumes that power is a product of an open system of equal competing
agendas, with lack of participation seen as a function of apathy or choice (Polsby, 1963).
The second view argues that there is a hidden face to power in which some actors and
issues are kept from open discussion through a mobilization of bias by powerful social
norms or organizations against community interests (Bachrach & Baratz, 1962). CBPR
researchers may unwittingly play into this bias in calling, for example, for evidence-
based interventions. Although evidence-based practice is useful and can justify increased
resources for community-based work, use of “evidence” language alone as an academic
norm may inadvertently discredit the healing practices or beliefs in local cultures or the
evidence that comes from practice (Green, 2006).
Stephen Lukes (1974) raises a third, and more insidious, dimension of power, one
that excludes grievances by preventing confl icts or community ideas from even surfac-
ing. Certain interests are favored without the need for conscious decisions or manipula-
tion of language or policy (Minkler et al., 1994–1995; Wallace, Williamson, Lung, &
Powell, 1991). Internalized oppression (see Chapter Five for more detail), for example,
may contribute to a culture of silence in which people doubt they even have healing prac-
tices to offer.
All three of these dimensions—power as a function of equal competing agendas in
an open system, as hidden power, and as the unspoken, hegemonic dominance of certain
powerful groups—represent, in Foucault’s framework (1977), repressive forms of power.
Such power may be exercised through direct control or indirect language that shapes peo-
ple’s opportunities to fulfi ll their rights to have better education, employment, and living
conditions. Emancipatory CBPR uncovers these mechanisms of control, biases, and
internalized representations of reality, as a key strategy for change.
Foucault (1977, 1979) has best articulated the fourth perspective of power; in this
view power is productive and based on relationships. Rather than seeing repressive power
as monolithic, he conceptualizes power as a web of discourses and practices found in
institutions, communities, and families and exercised through actions in multiple rela-
tionships. These power relationships are inherently unstable and therefore open to
challenge.
For Foucault, knowledge symbolizes power. Repressive power, as expressed, for
example, through the use of research language that is overly technical, can inhibit
how communities may respond to researchers. As productive power, however, research
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Theoretical, Historical, and Practice Roots of CBPR 35
knowledge can open the possibility of communities challenging existing limits and con-
ceptualizing new practices (Foucault, 1980; Gaventa & Cornwall, 2008). As Deveaux
(1999) has noted, “Where there is power, there is resistance” (p. 242). As community
members learn about research, they can gain decision-making power in the research rela-
tionship and also enhance their capabilities to bring those decision-making skills to other
community issues (Le Compte, 1995).
In CBPR, as noted earlier, the relationship between researchers and communities
requires trust and mutual commitment over time. These relationships do not take place in
a vacuum. When researchers walk into a community, they bring the history of the research
institution and of other researchers with them. Relationships unfold within the particular
historical and institutional context of trust or mistrust as well as through the personal con-
nections between the partners (Minkler, 2004). In an analysis of community dialogue,
Scott (1990) has outlined public and hidden discourse (see Chapter Five). In relation to
research, public transcripts contain information in offi cial language about what outside
researchers bring to the table and what community members offer in return. Yet hidden
transcripts, what community members fully think, may remain outside the purview of
what is observed by the outside research team. Some of these hidden transcripts may also
become public over time, as relationships evolve.
CBPR practice therefore must be about all partners asking questions within historical
and current contexts and examining their own positions of power, whether by virtue of
race or ethnicity, education, or community status, and being willing to negotiate these
dynamics over time. As seen in Foucault’s framework, positions of power can reverse,
and the initial power of the researcher may give way to the knowledge and gatekeeper
functions of community members. The researcher then becomes only one player in the
telling and interpretation of stories (Buroway et al., 1991). If the goal is to create reci-
procity, then both outside researchers and community members become, in the words of
singer Chris Williamson, “the changer and the changed” (Lather, 1986, p. 263).
In CBPR, there is never a perfect equilibrium of power. All research efforts undergo
cycles of participation and questioning by community members, bringing greater or lesser
participation and greater or lesser ownership. In times of frustration, community mem-
bers may retreat to hidden discourse, expressing concerns in private (especially if they
speak a language different from that of the outside researchers) or simply pretending
greater willingness to participate. In more open times, public discourse may represent
more sharing and access to hidden discourse. This dialectic of collaboration and skepti-
cism between research partners and community participants presents a continual chal-
lenge. As one community member has stated, however, a committed research relationship
based on an underlying context of trust makes a difference; even if there is an incident
where trust is challenged, the underlying relationship enables both parties to keep work-
ing together and to renegotiate shared power and trust.
FEMINISM, POSTSTRUCTURALISM, AND POSTCOLONIALISM
Feminist participatory researchers add critical dimensions to our understanding of the
theory and practice of CBPR. In early critiques they challenged both the exclusion of
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36
Community-Based Participatory Research for Health
women through the use of universal language of “the oppressed” and the lack of attention
to gender differences in participation in data collection and analysis (Maguire, 1987).
Over the past forty years, feminism has shifted from studying women as a universal
construct to understanding gender culturally and historically, with shifting identities of
class, race and ethnicity, sexual orientation, and other areas of differences (Collins, 2000;
Hesse-Biber, Gilmartin, & Lydenberg, 1999; Maguire, 2006; Olesen, 2000; Reid & Frisby,
2008). Gender is seen as central in power relations, with various mechanisms in use that
can silence women, such as censorship, intimidation, marginalization, or trivialization
(Devault, with Ingraham, 1999; Maguire, 2006).
Poststructuralism focuses on the ways that language and narratives construct reality
and our view of social institutions, such as academia, public health, or medicine, and how
these constructions are resisted by communities. Postcolonialism takes this further by
using race or ethnicity as a primary lens through which to understand European coloniza-
tion of other peoples and lands. To counter the dominant portrayals of the other, CBPR
research within a postcolonial tradition seeks to uncover and honor community explana-
tions and narratives of the condition of people’s lives (Duran & Duran, 1995; Walters &
Simoni, 2002). The role of the outside researcher in this context may therefore be largely
to weaken the power of dominant culture explanations and create spaces for competing
community ideas and practices to emerge. Empirically based youth interventions that
research the effectiveness of resistance to peer pressure, for example, may be too individ-
ualistic for the cultural norms of some minority groups.
In CBPR, poststructuralist, postcolonialist, and feminist theory share certain meth-
ods and goals: analyzing personal lives in relation to the structures (both overt and hidden)
that might control people’s lives; celebrating strengths and agency, not just emphasizing
victimization; working for goals of social justice (Maguire, 2006); and undermining the
notion of the objectivity of science.
Issues within feminism and within racism (discussed in detail in Chapter Five), such
as how women in general (or in some cases women of color) state their identities in dif-
ferent contexts, elucidate the complexities CBPR faces in understanding the richness of
community life and change processes (Bell, 2006). African American women, for example,
as detailed in Patricia Hill Collins’s work (2000), can appear in public spaces to conform to
societal roles yet in other contexts, such as church or family, be adopting more powerful
roles. In complex ways, then, they are not accepting stories of themselves as the other
but are creating new stories based on strong identities as sisters, mothers, or advocates—
providing an illustration of Foucault’s idea of productive power (Collins, 1999, 2000; Fine,
Weis, Weseen, & Wong, 2000).
Postcolonial, postmodern, and poststructural theories have challenged the right of
researchers to overstate their interpretations and thereby silence the community (Fine et al.,
2000; Mohanty, 1988; Spivak, 1988). In CBPR processes, interpretation of data often
falls to the outside researcher; participatory data analysis is very diffi cult to achieve. In
the case of quantitative data, the knowledge and software needed for statistical analyses
often are situated in universities or other research institutions. In the case of qualitative
data, the mountain of transcripts to be examined may be daunting, and the iterative pro-
cesses, even with specialized software, are time consuming. Yet when undertaken and
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Theoretical, Historical, and Practice Roots of CBPR 37
done well, participatory analysis of both qualitative and quantitative data not only can
improve external validity of the data but can force a different approach to publication as
well (see Chapter Sixteen).
Michelle Fine (1994) articulates three researcher stances in relation to community
voices and their publication: (1) ventriloquy, when researchers describe the other as
objective truth, never using the word “I” in their interpretation and never connecting
themselves to their analysis of the data; (2) voices, when researchers speak for the other,
recording people’s words and stories and presenting quotes from interview or focus group
transcripts without a critical analysis of the context or history of people’s experience; and
(3) activist feminist research, when researchers develop a negotiated stance, being explicit
about their own identity, and creating through dialogue with community members a
context-based interpretation and portrayal of knowledge. This third stance cautions
against simply presenting multiple community voices, because some voices may be more
powerful than others or may refl ect internalized oppression rather than fostering an eman-
cipatory perspective (Fine, 1994; Le Compte, 1995). Fine et al. (2000) call on us as out-
side researchers to be wary of research intended to “help” communities and encourages
us to engage in the diffi cult task of negotiating data interpretation and presentation with
community members throughout the research process.
PAULO FREIRE AND PRAXIS
Although community-based participatory research rests solidly on our understanding of
the complexities of participation, knowledge, and power relations, this orientation
to research also cannot exist without its practical applications in the community. CBPR
research, whether focused on disease causation or direct community improvement,
always takes an intervention activist approach. To explore the actualities of CBPR prac-
tice and methods, therefore, it is helpful to return to Brazilian educator Paulo Freire, a
major source of inspiration within the Southern emancipatory tradition.
Freire’s starting point of concern for the powerless is refl ected in his initial literacy
teaching in the slums with the marginalized poor, who had what he termed a naive or
magical consciousness that they could not be actors in their own fate. Using emotionally
and socially charged words and pictures, Freire (1970, 1982) generated dialogue to facili-
tate people’s transformation to conscientization (or critical consciousness) and praxis
(action based on conscientization) in order to improve their lives. Exiled from Brazil at
the time of the military coup in 1964, Freire fl ed to Chile, from which he was later also
exiled. He worked for the World Council of Churches until he was able to return to Brazil
in the early 1990s.
To Freire (1970) the purpose of education is human liberation, which means that
people are the subjects of their own learning, not “empty vessels” fi lled by the knowledge
of experts. To promote the learner as subject, Freire proposes a listening-dialogue-action
approach (Wallerstein & Auerbach, 2004). The fi rst step is listening to the generative
themes or issues of community members in order to create a structured dialogue in which
everyone participates as a co-learner to jointly construct a shared social reality. Individu-
als must be not only involved in efforts to identify their problems but also engaged in
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Community-Based Participatory Research for Health
conscientization to analyze the societal context for these problems. The Portuguese word
conscientização connotes both critical consciousness and personal engagement with the
knowledge (Freire, 1970; Park, 2006). The goal of dialogue and conscientization is
praxis, the ongoing interaction between refl ection and the actions people take to promote
individual and social change. It is only through actions and encountering barriers to
change that people truly shape their knowledge of how the world works, linking their
cognitive understanding with the visceral and emotional.
Much of the creativity of the Freirian approach, also called popular or empowerment
education, lies in the development of codes, or physical forms of the themes generated by
participants. These codes (sometimes called triggers or discussion catalysts) might be
pictures, videos, role plays, and so on—any form that helps participants to “see” their
reality with new eyes and develop alternative ways of thinking and acting. Multiple dia-
logue and communication methods—such as identifying issues through photodocumen-
tary research and photovoice (see Chapter Nine), employing the techniques of Augusto
Boal’s theater of the oppressed (Boal, 1979) for characterizing conditions, and substitut-
ing video portrayals of research results for written reports—are expressions of this
approach (Horton & Freire, 1990; Sohng, 1996). A Freirian, structured-questioning approach
facilitates dialogue based on the triggers and thus can benefi t the participatory process,
especially during the research interpretation phase (Arnold, Burke, James, Martin,
& Thomas, 1995; Hope & Timmel, 1999; Nadeau, 1996; Vella, 1995; Wallerstein &
Auerbach, 2004). In the United States, the Highlander Research and Education Center
has been an inspiration in this area with its comparable dialogue-based approach devel-
oped during its sixty-year history of participatory education and research on labor issues,
civil rights, voting rights, youth, and environmental organizing (Horton, 1990; Lewis,
2006).
Freire’s writings reinforce a deep belief in humanity and people’s role in making
change and as such have critical importance to CBPR:
To be a good [participatory researcher] means above all to have faith in people; to believe
in the possibility that they can create and change things. You need to love . . . to be con-
vinced that the fundamental effort of community . . . education is the liberation of people,
never their “domestication.” This liberation begins to the extent that men [and women]
refl ect on themselves and their condition in the world—the world in which and with which
they fi nd themselves. To the extent that they are more conscientized, they insert them-
selves as subjects into their own history [adapted from Freire, 1971, p. 61].
In Teaching to Transgress, bell hooks (1994) builds on Freire and Thich Nhat Hanh
(1987) to challenge us to examine the mutual process of “engaged pedagogy,” or in our
case engaged CBPR. Rather than expecting only that community members become
immersed in the creation of their history, CBPR research is a process in which outside
researchers also become transformed. When we bring our own understandings and inter-
pretations, “it eliminates the possibility that we can function as all-knowing silent
interrogators” (hooks, 1994, p. 21).
Freire returns to this theme of researcher engagement in a dialogue book with Ira Shor,
where he discusses the risks and fears of transformation, acknowledging that resistance
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Theoretical, Historical, and Practice Roots of CBPR 39
may be real, “but if you don’t risk, you don’t create anything. Without risking, for me,
there is no possibility to exist” (Shor & Freire, 1987, p. 61). Concerns about becoming
liberatory researchers may be based on our own previous socialization as researchers; our
fears (often unspoken) that we will not be seen as experts, that we will be ignored, or in
some cases, our fears or expectations that we will be devalued or dismissed.
In a grand tour of participatory action research, Kemmis and McTaggart (2000) call for
transcending “either-or dichotomies” for a critical social science engaged in a “refl exive-
dialectical view of subjective-objective relations and connections” (p. 576). They call
for an eclectic and complex research practice that draws from Marxist critical theory,
applied utilitarian problem solving, and poststructuralist and feminist approaches, all of
which promote our understandings of personal and collective agency under specifi c local
and global historical conditions. Ultimately, they situate the emancipatory tradition in
CBPR in its aim to work with communities to “release themselves from the constraints of
irrational, unproductive, unjust, and unsatisfying social structures that limit their self-
development and self-determination” (p. 597). Freirian methodologies can be helpful in
pointing researchers and communities to the dialogical processes that facilitate these
complex understandings.
SUMMARY
Issues of participation, knowledge creation, power, and praxis are not abstract phenom-
ena but rather authentic tensions that are enacted both in academia and in community set-
tings. If, for example, we are not honest about our own power bases as researchers with
education, resources, skills, and privilege (possibly due to race or ethnicity, gender, or
other identities), there is little hope that we will be able to transform power dynamics. We
need to understand how our personal biographies inform our ability to interpret the world,
both in understanding the problems and in visioning community strengths. This is also
true for our community partners. We further need to remember that we likely will not
have full access to the phenomena being studied, though we can be open to mutual learn-
ing and to the notion that community knowledge can greatly enrich our understanding of
the world.
A major challenge for those of us in the CBPR fi eld lies in the potential limits of
CBPR, given the realities of globalization, the imposition of Western cultural and eco-
nomic structures on the rest of the world, and the diffi culties for local communities in
making meaningful change. Scaling up has become a buzzword in world institutions
seeking to bring lessons from small communities to nation-states (Gaventa & Cornwall,
2008). Can CBPR be scaled up when so much depends on relationship building and com-
mitment to collaborative work over time? Can realities be transformed at the local level
in order to enhance health and contribute to a more equitable society? Although these
questions are important, we must ensure that critiques and challenges of CBPR do not
play into conservative strategies that dismiss the role of communities participating in
change (or that, conversely, leave the work of change to local communities without ade-
quate public government support). Another major challenge is in recognizing the poten-
tial consequences of our research. As we produce negotiated versions of community
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Community-Based Participatory Research for Health
“truths” from our investigations, these meanings may in turn supercede the very perspec-
tives we worked to uncover. In a dynamic world this is cause for both grave concern and
celebration. In many ways CBPR relies on the process that N. Scott Momaday captured
so beautifully: “We are what we imagine. Our very existence consists in our imagination
of ourselves” (cited in Vizenor, 1978, p. vi).
Ultimately, CBPR is about knowledge creation and the value of practical and critical
emancipatory reason for understanding power dynamics, for recognizing the intercon-
nections between the personal and the social and between life worlds and system worlds,
and for identifying the barriers to and facilitators of human actions that move toward the
goal of social change. This can be a daunting and contradictory task but one full of prom-
ise and hope as we engage with community to promote more just societies.
QUESTIONS FOR DISCUSSION
1. What are the contributions of the various participatory research traditions (for exam-
ple, Freirian theory and practice, feminist participatory research, Lewinian action
research, and so forth) to community-based participatory research for health?
2. How does CBPR challenge and contribute to the fundamental role(s) of research?
3. As an opportunity for self-refl ection, what is your particular theoretical approach to
CBPR, or what are the components from which you draw?
4. How are the tensions embedded in the concepts of knowledge creation, purpose of
research, participation, power, and praxis expressed in your own work? Or how
might they be expressed in future work you hope to do?
KEY TERMS
Southern and northern traditions
Participatory research, action research,
participatory action research
Theories of participation, knowledge,
power, and praxis
Popular education empowerment
Poststructuralism, postcolonialism,
and feminism
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... Action research, developed by Kurt Lewin (1946), sits at one end of the continuum with the focus on involving people who are affected by the problem in 'practical problem solving through a cyclical process of fact finding, action, and evaluation' (Minkler and Wallerstein 2008, 9). This approach which sometimes called the Northern tradition is, therefore, collaborative and utilitarian and has practical goals of system improvement (Wallerstein and Duran 2008). ...
... At the other end of the CBPR continuum is the more emancipatory focus of PAR tradition advanced by the work of Paulo Freire (1970) (Wallerstein and Duran 2008). This openly emancipatory approach arose in the early 1970s within Latin America, Asia, and Africa and known collectively as the Southern tradition (Wallerstein and Duran 2008). ...
... At the other end of the CBPR continuum is the more emancipatory focus of PAR tradition advanced by the work of Paulo Freire (1970) (Wallerstein and Duran 2008). This openly emancipatory approach arose in the early 1970s within Latin America, Asia, and Africa and known collectively as the Southern tradition (Wallerstein and Duran 2008). It disputes 'the historical colonising practices of research and political domination of knowledge by the elites' (Wallerstein and Duran 2008, 27). ...
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... Applying a team-based approach -often with the involvement of other stakeholders such as treatment and or delivery services, local governments, etcetera -CBPR aims for improving the situations for and together with people with lived experience (Coughlin et al., 2017;D'Angelo & Her, 2019). In theory, PAR and CBPR largely share the epistemological articulations of participation, action, community-involvement, research and (social) change (Wallerstein & Duran, 2017). Sometimes the notions are even used interchangeably (Huffman, 2017). ...
... The focus on structural social/societal change within PAR -especially in the Southern tradition articulated by 7 Interestingly, many participatory research projects take place in Canada. Both the country and its big cities (such as Vancouver, Toronto and Ottawa) have a prominent history in harm reduction peer movements and count a number of organisations with significant ties to (local) authorities, universities and services [such as the Vancouver Borda & Rahman, 1991;Freire, 1970;Wallerstein & Duran, 2017). In other words, rather than training or educating people in apt research skills and (partly) fitting popular knowledge into practical or academic designs and existing structures, what people have 'to offer' and how they construct knowledge, is seen as the prime basis for a project and how it will further develop. ...
... Generally, people know an aspect of a phenomenon very well but are less familiar with the details of other elements. Similar to solving a riddle, gathering diverting knowledges and peering into each other's positions, is an exercise in putting more pieces together (Bourdieu, 1999;Wallerstein & Duran, 2017). ...
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... In essence, CBR is included in community development. Wallerstein and Duran (2008) characterize CBR as a new research paradigm; it challenges the assumptions of neutrality and objectivity that drive the traditional way to perform inquiries. In other words, CBR contests the discourse formed within the community of professional researchers responsible for giving academic knowledge the status of truth (Peet & Hartwick, 2015). ...
... In other words, CBR contests the discourse formed within the community of professional researchers responsible for giving academic knowledge the status of truth (Peet & Hartwick, 2015). The discourse cause researchers to relate with community groups as mere objects and validates research procedures that do not take into account the lived experience of the research participants (Wallerstein & Duran, 2008). Consequently, the traditional way to perform research marginalizes alternative ontologies and different ways of knowing which creates possibilities for the co-optation of voices and material practices of community groups as researchers advance their agenda (Hanson & Ogunade, 2016). ...
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In the face of post-normal problems, uncertainties must become central to developing legitimate quality control in engaging social actors through the extended peer communities. However, it is necessary to recognize the constraints of legitimate participation as well as the emergent misinformation crisis in digital social media. This essay explores the relevance of the shared dialogue of participatory research approaches in processes of integrating uncertainties in quality assurance of scientific production and related decision-making. It also discusses the importance of participation in overcoming cognitive exclusion and promotes reflections on the emergent barriers associated with the infodemic in the context of the COVID-19 crisis. Some characteristics of participatory research approaches are highlighted, such as multi-level dialogical interactions involving different social actors, empowerment of marginalized people, and mitigation of inequities through transforming the conventional unilateral relationship between science and society into a more fair and more symmetrical process. The adaptive properties of participatory approaches can help overcome cognitive exclusion and contribute against the anti-dialogical ruptures of the infodemic, contributing to integrating uncertainties. Participatory approaches can be conceived as a methodological asset to boost extended peer communities. Their dialogical attributes can promote a diversity of solutions and knowledges and stimulate self-reflection among academics.
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Background Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts. Methods Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations. Results We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration. Conclusion We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact. Plain language abstract There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.