Community-Based Research: Creating Evidence-Based Practice for Health and Social Change
Marcia Hills, R.N., Ph.D.
Jennifer Mullett, Ph.D.
Community Health Promotion Coalition
University of Victoria
Victoria, BC, Canada
Paper presented at the Qualitative Evidence-based Practice Conference, Coventry University, May 15-17 2000.
Evidence-based practice usually refers to gathering quantitative data upon which to base decisions about what constitutes effective or efficient practice or what is sometimes referred to as "best practices". The authors argue that, when gathering evidence about practice concerning people in communities which is often the case in the health sector, different evidence is needed and, consequently, different methodologies and methods for collecting that evidence must be used. In this context, the notion of basing practice on evidence raises the question "what do we accept as evidence upon which to base our practices that involve people in communities?"
Within the health sector, community-based research is emerging as a way to encourage meaningful and relevant evidence about practices in communities. Community-based research is a particular form of research that attempts to counter the currency of academic research by valuing the contribution that community groups make in the development of knowledge about community practice. It is research that tries to make a difference in the way people in communities work, think, and relate to others. It is more concerned with methodology than it is with method. This does not mean that the methods used in community-based research are not important but more that the research is not method driven. The adherence to a participatory, iterative, reflective methodology is critical to communitybased research. This focus on methodology in community-based research demands "an argument to connect the choice and practice of particular methods to the way that the problem is conceived and the utility and limitations of the outcome" (Schratz & Walker, 1995, p. 12).
Community-based research is based on a philosophy of participatory paradigm (Heron & Reason, 1997) and, as such, it rests on a set of assumptions about what constitutes evidence and on a set of principles for conducting research. The participatory nature of community-based research assists in the uptake of knowledge for both communities and policy makers. The philosophy, assumptions and principles upon which community-based research is based have several implications for the methodologies and methods chosen and therefore the evidence upon which practice is based. This paper describes the contribution that community-based research makes to providing qualitative evidence for effective practice in the community through participatory methodologies and methods.
Definition and Principles of Community-Based Research
Community-based research is becoming increasingly important in the health care field as communities are being required to take greater ownership and control over decisions affecting the health of the people in the communities. Community-based research is first and foremost about people.
Community-based research is a collaboration between community groups and researchers for the purpose of creating new knowledge or understanding about a practical community issue in order to bring about change. The issue is generated by the community and community members participate in all aspects of the research process. Community-based research therefore is collaborative, participatory, empowering, systematic and transformative (Hills & Mullett, 2000).
Community-based research is guided and defined by the following set of principles (Hills & Mullett, 2000):
Community-Based Research is a Planned Systematic Process
Community-based research is a systematic process requiring careful planning of each stage. Most community workers begin researching by asking questions about their programs, the needs of their clients, the effectiveness of their work, whether new ideas are feasible, possible solutions to existing community problems, and so on. These issues become community-based research by formalizing the community issue into a researchable question and systematically planning for "data" collection and analysis. This formalized research process creates new knowledge upon which to base practice. It is the focus on knowledge development that distinguishes community-based research from community development.
Community-Based Research is Relevant to the Community
Community-based research must have a high degree of relevance to the community. Community-based research focuses the research endeavour in the context of daily work activities in order to solve problems and help make those activities more effective and ultimately more satisfying. The research should result in decision-making by the community (i.e. individuals, community agencies, health units, program managers, etc.) or provide information which is in some other way directly useful to the community in which it is initiated.
It involves asking questions such as:
What are the practical problems we are facing in our work in the community?
What are some questions and concerns regarding the community and health-related activities within that community?
What issues are the focus of community attention?
Questions such as these guide the selection of meaningful research topics and provide for the development of appropriate research questions for community-based research.
Community-Based Research Requires Community Involvement
In community-based research, the community is actively involved in and understands the research process. The research is driven by a partnership between the community and researchers, and tends to be multi-disciplinary in nature. It is a collaborative effort involving the community at all stages of the research process. The level of community and/or researcher involvement may vary at each stage of the research, but community-based research involves joint responsibility and decision-making during every step. It requires the researcher(s) and the community stakeholders to share power and control of decision-making throughout the process. In a community-based research process, the distinction between the researcher and the researched may be minimized or eliminated. Rather than viewing participants as making "equal" contributions, in the sense of doing the same thing, community-based research emphasizes the unique strengths and contributions of the participants. It goes beyond respect and trust for the person and includes valuing the work and perspectives of each participant. It is a synergistic alliance that maximizes the contributions of each participant and it focuses on shared responsibility for the research and research process.
Community-Based Research Has a Problem-Solving Focus
Effective community-based research is usually designed to illuminate and solve practical problems. This problem-solving focus means that the research deals with a problem or practical issue which has been identified by the community as being important to the life/health of that community. The primary objective is frequently to guide decision-making, so effective community-based research focuses on gains to the community through both the results and the research process itself. It focuses on change by creating solutions for existing problems and identifying future actions and policies that will most likely contribute to the health of the community.
Community-Based Research Focuses on Societal Change
Unlike conventional orthodox research which focuses on prediction or understanding alone, community-based research seeks to bring about change. It is premised on the fact that engaging in a participatory, collaborative research process, and being involved the decision-making about that process is empowering and transforming. Engagement in the process allows people to develop new ways of thinking, behaving and practising.
Community-Based Research is About Sustainability
With orthodox research and many forms of qualitative research, as the research ends, so too does the project. Community based research makes a lasting contribution to the community. This may be in the form of a new program that is ongoing, or a new service that is delivered. At times products such as manuals or workbooks may be created. One of the most significant contributions is the enhanced capacity of the community to continue to engage in future research or evaluation. The acquisition of new skills and knowledge related to research and evaluation is an essential component of community-based research.
These principles distinguish community-based research from other more orthodox forms of research including other forms of community research that are done in or for communities. In addition, these key principles situate community-based research in a different paradigm than orthodox research and determine, to a large extent, what methodologies and methods are used.
Paradigm, Ontology, Epistemology And Axiology
Community-based research is based on a participatory paradigm (Heron & Reason, 1997) that includes a subjective-objective ontology; an extended epistemology and an axiology that values practical knowing and human flourishing.
A paradigm is "a set of basic beliefs (or metaphysics) that deals with ultimates or first principles. It represents a worldview that defines, for its holder, the nature of the world, the individuals place in it, and the range of possible relationships to that world and its parts, as , for example, cosmologies and theologies do" (Guba & Lincoln, 1994, p. 105). Guba & Lincoln made a significant contribution in articulating four differing worldviews of research - positivist, post positivist, critical, and constructivist- based on their ontological, epistemological and methodological assumptions. Heron and Reason (1997) argue for a fifth worldview a participatory paradigm. Community-based research is situated within this paradigm and also embraces the ideology and methodology of co-operative inquiry created by Heron & Reason (1988; 1994; 1996; 1997).
A participatory paradigm rests on the belief that reality is an interplay between the given cosmos, a primordial reality, and the mind. The mind "creatively participates with [the cosmos] and can only know it in terms of its constructs, whether affective, imaginal, conceptual or practical" (Heron, p.10) "Mind and the given cosmos are engaged in a creative dance, so that what emerges as reality is the fruit of an interaction of the given cosmos and the way the mind engages with it" (Heron & Reason, 1997 p. 279). As Skolimowski (1992) states; "we always partake of what we describe so our reality is a product of the dance between our individual and collective mind and "what is there", the amorphous primordial givenness of the universe. This participative worldview is at the heart of the inquiry methodologies that emphasize participation as a core strategy", (p.20).
Ontology refers to the form and nature of reality and what can be known about it (Guba & Lincoln, 1994). In contrast to orthodox research that utilizes quantitative methods in its claim to be value free (but which is more accurately described as valuing objectivity), and many qualitative approaches that value subjectivity, community based research endorses a subjective-objective stance.
An subjective-objective ontology means that there is "underneath our literate abstraction, a deeply participatory relation to things and to the earth, a felt reciprocity" (Abram, 1996, p. 124). As Heron and Reason (1997) explain, this encounter is transactional and interactive. "To touch, see, or hear something or someone does not tell us either about our self all on its own or about a being out there all on its own. It tells us about a being in a state of interrelation and co-presence with us. Our subjectivity feels the participation of what is there and is illuminated by it", (p.279). So community-based research is interested in investigating peoples understandings and meanings as they experience them in the world.
Epistemology refers to the nature of the relationship between the knower and the what can be known. Guba & Lincoln (1994) claim that orthodox science, because of its belief in a "real" world that can be known, requires the knower to adopt a posture of objective detachment in order "to discover how things really are" (p.108). There is a presumption that the knower and the known are separate and independent entities that do not influence one another. There is a search for the "truth"; for the facts in objective and quantifiable terms which holds empirical data in the highest esteem.
In contrast, community-based research rests on an extended epistemology that endorses the primacy of practical knowing. In community-based research, the knower participates in the known and that evidence is generated in at least four interdependent ways experiential, presentational, propositional, and practical (Heron & Reason, 1997; Heron, 1996).
Experiential Knowing. Experiential knowing refers to direct encounters with persons, places or things. "It is knowing through participatory, empathic resonance with a being, so that as the knower, I feel both attuned with it and distinct from it" (Reason, 1997,p281). Experiential knowing incorporates the participatory nature of perception as postulated by Husserl (1964 ) and Merleau-Ponty (1962). "Hardness and softness, roughness and smoothness, moonlight and sunlight, present themselves to us not as sensory contents but as certain kinds of symbiosis, certain ways the outside has of invading us and certain ways we have of meeting the invasion (Merleau-Ponty, 1962, p.317). Experiential knowing is "lived experience of the mutual co-determination of person and world" (Heron,1996. p.164).
Presentational Knowing. Presentational knowing is grounded in experiential knowing and is the way we represent our experiences through spatio-temporal images such as drawing, writing, dance, art or stories. "These forms symbolize both our felt attunement with the world and the primary meaning embedded in our enactment of its appearing" (Reason, 1987, p. 281)
Empirical Knowing. Empirical knowing is factual knowledge; knowing about something conceptually. This type of knowledge is usually expressed in terms of statements, facts, or theories. This way of knowing is of utmost importance in orthodox science inquiries and is relied on as the sole way to search for the "truth". In community-based research, propositional knowing is seen as interdependent with the other three ways of knowing.
Practical Knowing. Practical knowing has primacy in community-based research. Practical knowing is knowing how to do something it is knowledge in action. "Practical knowledge, knowing how, is the consummation, the fulfilment, of the knowledge quest" (Heron, 1996, p.34). This form of knowing synthesizes our conceptualizations and experiences into action (practice).
Each form of knowing is to some degree autonomous and can be understood and can function on its own. However, of interest in this paper, is the interdependent nature of these four ways of knowing. Practical knowing, knowledge-in-action, is grounded in propositional, presentational and experiential knowing (Heron, 1996). Intentional action or change is practical knowing. Consequently change can be thought of as being based on evidence from all four ways of knowing. In community-base research, as the inquiry group cycles through action and reflection, it builds theory (propositional knowing) from practice about what constitutes "good" practice. The group members test this theory in the real world of their practice and reflect on their experiences in relation to propositional knowing. The more congruent the four ways of knowing are, the more valid the evidence for practice.
Before turning to a discussion of axiology it is pertinent to further consider this relationship of theory to practice as it is critical in understanding evidence-based practice for communities.
Praxis - The Relationship of Theory to Practice in Community-Based Research
Theory is often talked about as if it belongs in the world of the academy; some form of abstraction that is separate from our day to day lives. Simply defined, theory is an explanation of phenomena. It is our contention that theory is implicit in all human action and is critical in developing evidence for community-based practice. "Only theory can give us access to the unexpected questions and ways of changing situations from within" (Schratz & Walker, p. 107). It is the relationship of theory to practice that is key in community-based research. As Lewin (1947) declared many years ago "there is nothing so practical as a good theory and the best place to find a good theory is by investigating interesting problems in everyday life" (p. 149).
In contrast to orthodox science, community-based research does not see theory as something that is known and that "informs" practice. As van Manen (1990) suggests "practice (or life ) comes first and theory comes later as a result of reflection" (p. 15). In community-based research, it is the cycling through the iterations of action and reflection in which experiential knowing and propositional knowing are considered in relation to practical knowing that creates praxis and that generates evidence for future practice. This process grounds practice in theory rather than applying theory to practice.
This notion of praxis is a fundamental concept in Freires work and is fundamental to creating evidence-based practice in communities. Praxis does not involve a linear relationship between theory and practice wherein the former determines the latter; rather it is a reflexive relationship in which both action and reflection build on one another. "The act of knowing involves a dialectical movement which goes from action to reflection and from reflection to new action" (Freire, 1972, p.31). Through critical dialogue, people become "masters of their thinking by discussing the thinking and views of the world explicitly or implicitly manifest in their own suggestions and those of their comrades"(p.95). Praxis, therefore, is constituted by both a theoretical and an experience component and is mediated by dialogue. As Wallerstein (1988) explains " the goal of group dialogue is critical thinking by posing problems in such a way as to have participates uncover root causes of their place in society the socio-economic, political cultural, and historical contexts of peoples lives (p. 382). It is through this emancipatory dialogue that people are liberated to act in ways that enhance society. Conceptualizing the relationship between theory and practice this way reorients our thinking about research from searching for understanding and explanation to ethical action toward societal good (Hills, 1999).
In addition to considering the three defining characteristics of a research paradigm suggested by Guba and Lincoln ontology, epistemology and methodology, - Heron and Reason argue that an inquiry paradigm also must consider a fourth factor axiology.
Axiology deals with the nature of value and captures the value question of what is intrinsically worthwhile? The fourth defining characteristics of a research paradigm, axiology, puts in issue "values of being, about what human states are to be valued simply because of what they are" (Heron & Reason, 1997, p. 287). The participatory paradigm addresses this axiological question in terms of human flourishing. Human flourishing is viewed as a "process of social participation in which there is a mutually enabling balance, within and between people, of autonomy, co-operation and hierarchy. It is conceived as interdependent with the flourishing of the planet ecosystem" (Heron, 1996, p. 11). Human flourishing is valued as intrinsically worthwhile and participatory decision-making and is seen as a means to an end "which enables people to be involved in the making of decisions, in every social context, which affect their flourishing in any way" Heron, 1996, p. 11).
In this way, human flourishing is tied to practical knowing, knowing how to choose, how to be, and how to practice in ways that are not only personally fulfilling but that also enhance and transform the human condition. This is similar to Frieres (1987) notion of conscientization. As he explains, "Even when you individually feel yourself most free, if this is not a social feeling, if you are not able to use your freedom to help others to be free by transforming the totality of society, then you are only exercising an individualistic attitude towards empowerment and freedom" (p.109). This valuing of human flourishing reconnects individuals to human communities and recognizes the "truth" in our actions and practices. It means that in community-based research what is of interest is more than the usual research outcome. The utility of the outcome is judged based on the difference it makes to transforming the health and wellbeing of the community.
A Methodology and Methods for Community Based Research
The terms "methodology" and "methods" are often confused. For our purposes, we define methodology as a conceptual framework for doing research that is grounded in theory. Methods are the techniques and procedures we use for collecting data.
One methodology that is particularly well suited to community-based research is co-operative inquiry (Heron, 1996; Reason, 1994). Co-operative inquiry is a participatory action methodology that does research with people not on to or about them. This methodology engages people in a transformative process of change by cycling through several iterations of action and reflection. Co-operative inquiry consists of a series of logical steps including; identifying the issues/questions to be researched, developing an explicit model/framework for practice, putting the model into practice and recording what happens and, reflecting on the experience and making sense out of the whole venture (Reason, 1988). Therefore, evidence about what constitutes "best practice" is generated by people examining their practices in practice and reflecting on these practices.
As stated earlier and as should now be obvious, community-based research is not and cannot be method driven. The methods used to collect information about people and the human condition derive from and are contained by the principles of community-based research, the preferred methodology (co-operative inquiry), and the research question.
In community-based research, the research questions are almost always focused on wanting to know something about people or the human condition. "At the heart of the critique about orthodox inquiry is that the methods are neither adequate nor appropriate for the study of persons because persons are to a significant degree self determining... Orthodox social science inquiry methods, as part of their rationale, exclude human subjects from all the thinking and decision-making that generates, designs, manages and draws conclusions from the research. Such exclusions treats the subject as less than self determining persons, alienates them from the inquiry process and from the knowledge that is its outcome, and thus invalidates any claim the methods have to a science of persons" (Reason, 1994, p. 325). To provide evidence for practice that involves people, those people themselves must be involved in deciding what the appropriate methods are for collecting evidence and how the evidence can be interpreted. "To generate knowledge about persons without their full participation in deciding how to generate it, is to misrepresent their personhood and to abuse by neglect their capacity for autonomous intentionally. It is fundamentally unethical" (Heron, 1996, p.21).
Gadamer (1975) argued that a preoccupation with objective methods or techniques is antithetical to the spirit of human science research scholarship. "The research questions themselves are the important starting point, not the methods as such" (van Manen, 1990, p. 1). An interesting dialectic exists between the researcher and the research question. It is this: How one chooses to frame the question influences how one chooses to investigate it. It seems reasonable to expect a certain harmony between the researcher (as a person), the research question and subsequently the method.
In community-based research, whichever method is chosen, it needs to accommodate the notion of full participation of those involved. As a result, qualitative methods such as interviewing, journal writing, taped interactions, critical incidents, narrative accounts, and focus groups are likely to be used. In our experience, this criterion of using appropriate methods has challenged community-based researchers to develop new and innovative strategies to access peoples experiences and understanding. This way of thinking about research and the resultant methods that are used provide convincing evidence upon which to practice and to be in the world.
Generating Evidence for Practice: Examples of Community-Based Research
In the following section, three examples of community-based research are provided to demonstrate how community-based research generates evidence from practice.
James Bay Midlife Project (Hills, Mullett and Burgess, in progress).
This project was generated by a local community health centre in order to create a program for women that would maximize their participation in and control of making health decision in their midlife. The inquiry group consists of two university researchers from the Community Health Promotion Coalition, University of Victoria (the authors of this paper), program planners and staff from the James Community Health Project, and women of the community, including a physician, a homeopath, a naturopathic physician, an editor, teachers, counsellors and social workers. This group is in the process of generating evidence about ways of being that are "women-centred". The group is exploring women-centred care in several different contexts such as education programs, support groups, physician/client interactions and informal groups. To date it has used a critical incident method to collect accounts from group members own experiences about what constitutes women centred care in midlife. Members subsequently conducted interviews, held focus groups or collected narrative accounts of their practice. The data is being analyzed, considered in light of former knowledge and new methods are being chosen to generate further evidence about how to practice in a way that is women-centred.
Making Connections: Nurturing Adolescent Girls' Strengths (Bannister, in process)
This community based research project, funded by the British Columbia Health Research Foundation (BCHRF), was created in direct response to concerns articulated by adolescent girls who identified the importance of peer support and mentoring relationships as a means to enhance their ability to handle relationships. Effective relationships were viewed as the focal point for building self-esteem and enhancing health. A participatory action research (PAR) framework is being used to understand adolescent girls' (ages 14-19) experiences of relationships and to facilitate action. Four groups of girls, each of which has direct links to an advisory committee, have been meeting weekly for 18 weeks. The advisory committee serves as a forum for the girls to present their health related concerns and to generate further action. The adolescent girls are involved in analyzing the data. The girls report that they are learning new ways of interacting, thereby enhancing their ability to handle relationships. In year two of the project, it is intended that the girls will use their learning and reflections to create action to influence policy-makers and practitioners who are working with adolescent girls.
Sharing Resources To Alleviate Scarce Resources (Mullett, J., Hills, M., Hillman, L., in process)
Several non profit organizations asked a researcher to work with them because of their concern about current funding structures that have created a competitive situation for non-profit agencies in the community - agencies that previously had worked together to resolve issues in order to sustain a healthy community. The methodology of co-operative inquiry (Heron, 1996; Reason, 1988) is being used to develop a model of inter-agency collaboration, a transformative model for practice that will afford community agencies the ability to evolve together within new funding contexts. A critical incident technique was the initial method by which the current successful and unsuccessful collaborative relationships were examined. By reflecting on their current practice, the members of the inquiry group not only have begun to articulate the essential components of a collaborative model but also have reported that their relations with each other have improved. Their emergent model, which is based on the experiential, representational, propositional and practical knowledge of those engaged in living the model, is significantly different from theoretical models, which tend to be reduced to administrative models.
These projects have demonstrated that it is possible to collect useful, sound and "scientific" evidence for practice without the use of questionnaires, statistics, or experimental designs.
When working with people in communities, evidence-based practice must be based on the knowledge co-created by the community. Community-based research can make a significant contribution to debates about evidence-based practice. By using an extended epistemology, community-based research broadens the response to the question. "what constitutes evidence for community practice with people?" Community-based research acknowledges the value of multiple ways of knowing but, even more significantly, it recognizes the value of the knowledge that community members contribute to the co-creation of new knowledge. Its focus on practical issues, problem solving and change provides evidence for practice that is immediately useful and relevant to communities. By engaging all stakeholders in the research process it does not leave to chance the usefulness of the outcomes of the research. By full involvement of community groups and policy makers, decisions can be made throughout the process about how to use the information to bring about change.
The following checklist has been devised to help those interested in community-based research remain true to its philosophy and principles.
Checklist for Adherence to Philosophy and Principles of Community-Based Research
Systematic and Planned Process
- How does your research plan systematically address the research question?
- What is the logical relationship between the research question, methodology and methods?
- How does the research process incorporate the multiple ways of knowing?
Relevant to the Community
- Who generated the research issue?
- How is this a community issue?
- Requires Community Involvement
- What mechanisms are in place to include people in the planning, management and dissemination of the research?
- Are all the stakeholders who need to be involved, involved?
- How will decisions be made about the research process?
Problem Solving Focus
- What is the communitys practical problem or issue that is being addressed?
- How will researching this issue help the community?
Focuses on Societal Change
- What changes are anticipated?
- How is the research process structured to allow for reflection and iteration?
- Who will implement the changes?
- How is theory generated from and for practice?
- What will the community have at the end of the research?
- How does the research outcome enhance human flourishing?
Abram, D. (1996), The spell of the sensations. New York: Pantheon
Bannister, E. (unpublished manuscript). Making connections: Nurturing adolescent girls' strengths. Victoria, BC: Community Health Promotion Coalition, University of Victoria.
Freire, P. (1972) Pedagogy of the oppressed. London: Penguin Books
Gadamer, H. (1975). Truth and method. New York: Seabury.
(Guba E., & Lincoln, Y., (1994). Competing paradigms in qualitative research. In Denzin, N. & Lincoln, Y (Eds.) Handbook on qualitative research. Thousand Oaks, Ca: Sage. 105-118.
Heron, J. (1996) Co-operative inquiry. London: Sage.
Heron, J. & Reason, P. (1997). A participatory inquiry paradigm. Qualitative Inquiry. 3 (3) 274-294.
Hills, M., Mullett, J. & Burgess, J. (unpublished manuscript). Women-Centred Care: Choices and Voices in Midlife. Victoria, BC: Community Health Promotion Coalition, University of Victoria
Hills, M. & Mullett, J. (2000). Community-Based Research: Collaborative Action for Health and Social Change. Victoria, B.C.: Community Health Promotion Coalition, University of Victoria:
Lewin, K. (1947). Feedback Problems of social diagnosis in action. Human Relations. 1, 147-153.
Merleau-Ponty, M. (1962). Phenomenology of perception. London: Routledge & Kegan Paul.
Mullett, J., Hills, M., & Hillman, L. (unpublished manuscript) Victoria B.C. : Community Health promotion Coalition, University of Victoria.
Reason, P. (Ed). (1988) Human Inquiry in Action. London: Sage.
Reason, P. (Ed). (1994). Participation in Human Inquiry. London: Sage
Schratz, M. & Walker, R. (1995). Research as social change. London: Routledge.
Shor, I. & Friere, P. (1987). Pedagogy for liberation: Dialogues on transforming education. South Hadley, MA: Begin & Garvey.
Skolimowski, H. (1992). Living philosophy: Eco-philosophy as a tree of life. London: Arkana
van Manen, M. (1990). Researching lived experience. London, Ontario: Althouse Press.
Wallerstein, N. (1988). Empowerment education: Freires ideas adapted to health education. Health Education Quarterly, 15 (4), 379-394.