Improving a Swedish health practice for refugees through participatory action research: potentials and constraints

ABSTRACT

This paper reports on a two-year project focusing on health communicators working with refugees in Sweden. By employing participatory action research and the theory of practice architectures, the study examines a health information practice for newly arrived refugees and highlights its potentials and constraints. The joint meetings that occurred between the participating researcher and the health communicators during the project were the primary source for collaboration, development, and data collection. The findings show that perceptions of limitations due to existing power structures initially hindered the group from experimenting with new activities for the groups of refugees. However, as the communicators gained experience, the conversations in the joint meeting practice changed, which facilitated the action research process. By challenging common working methods, which were initially perceived as causes for concern, the communicators recognised that the concretisation of the health information they wanted to convey could also function as a useful pedagogical tool. The analysis shows that, despite constraints during the working process, the participatory action research practice created a democratic work process which empowered all participants. Collective talks in the communicative space nurtured an architecture that generated new ideas and made it possible to leave the classroom-based teaching situation for new ways of learning about health and physical activity. The findings also show that participatory action research made the communicators aware of their capacity to implement change by offering various movement-based activities that benefited the participating refugees and increased their agency and empowerment.

KEYWORDS:

• Empowerment, health promotion
• participatory action research
• practice architectures
• refugees

Integration and health – an interplay

Sweden has long welcomed large numbers of refugees, but this reached record levels in 2015. As a result, several projects have been established in recent years to support the integration of newcomers into Swedish society (Löthberg et al. 2012; Svanholm et al. 2020). One way to support integration is by working with health issues, as integration studies show that health, as a resource, plays a key role in enhancing newcomers’ opportunities for integration (Helgesson et al. 2019; Hjern 2009).

Newly arrived refugees in Sweden, and elsewhere, are in a vulnerable situation, generating the need for special efforts to be made at different societal levels (Burström, Rostila, and Toivanen 2018). While there is a consensus regarding the importance of health for this group, studies have shown that the health of newly arrived refugees tends to deteriorate during the initial period of their resettlement in Sweden (see Figure 1). This is related to the challenges and struggles that refugees encounter, both during the migration process and as they try to establish themselves in their new country of residence (Rostila et al. 2018). These challenges draw their attention away from physical and leisure activities, even though the refugees acknowledge the importance of good health. Although their health eventually improves, this happens much too late for newly arrived refugees, causing problematic situations at both individual and societal levels.

Figure 1. Societal health curves with or without support.

Different health promotion projects have been launched to support refugees (Björngren Cuadra and Carlzen 2015; Bäärnhielm et al. 2013; Bergenfeldt Fabri 2019) and address this troubling interplay between health status and integration. For example, in Skåne, a large county in the south of Sweden, the local County Administrative Board set out to create a ‘health-promoting introduction’ for new arrivals (Björngren Cuadra and Carlzen 2015, 10). This included a project where newly arrived refugees were offered health information in their own mother tongues by health communicators who had refugee backgrounds themselves and personal knowledge of the difficulties associated with the migration process (Al Adhami 2015; Bäärnhielm et al. 2013). The idea of providing health information in this way was first realised as a labour market project in 2001, with the intention of both influencing the health of the new arrivals and creating jobs for established immigrants with knowledge in the health care field. Since then, the project has expanded and become part of the information service that newly arrived refugees receive in Skåne (Länsstyrelsen 2020); this includes health communicators lecturing on health and societal themes, such as nutritious food and healthy lifestyles, in a Swedish context.

However, despite the overall success of the initiative, the communicators in this study experienced a lack of response and engagement with health issues among the refugees they were working with. They attributed this to two factors: a) despite the communicators’ cultural understanding, they had no influence over the content or design of the information they were expected to convey, and b) the fact that the information was offered in a ‘one size fits all’ format, which took no account of the newcomers’ levels of education, backgrounds, or ages, etc. The origin of the present study arose from the desire of a group of seven health communicators at the County Administrative Board in Malmö, Skåne, to enhance classroom practice and better promote health among newly arrived refugees by a) aligning the information provided with their needs more closely, b) by integrating physical activity into their teaching and learning (Björngren Cuadra and Carlzen 2015) and c) striving for greater empowerment throughout the process.

More specifically, three activities were discussed in the process when the study started. These were chosen by the communicators and consisted of a) testing pedometers, b) visiting a training centre, and, finally, c) taking a bus trip to a nature area, including walks and information about Swedish nature. These three activities form the case that was the point of departure for the present research study which originates from a larger doctoral project (Bergenfeldt Fabri 2019) conducted by the first author of this paper. This paper therefore builds upon this doctoral project¹ and aims to further understand and analyse what enables or constrains efforts to improve a health promotion practice for refugees in a Swedish context from an empowerment perspective. This health practice, and its potentials and constraints, is used as a critical case to answer the following overarching question: What changes took place within the framework of the participatory action research project regarding a health information practice in general and regarding empowerment processes in particular?

The Swedish context

The present study is set in a Swedish context, and this influenced the research process and its findings in two significant ways. First, like other Nordic countries, Sweden is characterised by a lifestyle that highly values active outdoor recreation. This is facilitated by the right of public access, which is important for a large proportion of the Swedish population (Bell et al. 2007). There is also a common belief among Swedes that nature benefits social, psychological, and physical well-being (Björk et al. 2008; Mygind et al. 2019). Health and a healthy lifestyle are important in Swedish tradition (Eurobarometer 2018) and are underpinned in multiple ways by governmental structures, such as the Public Health Agency of Sweden (2018). In addition, evidence suggests that Swedes are more physically active than citizens in other European countries. For example, according to Eurobarometer (2018), 67% of the Swedish population are physically active at least once a week, compared to 40% in the rest of Europe. Therefore, health activities and participation in sport activities becomes intertwined with possibilities for (or obstacles to) integration into Swedish society. In light of this, this paper adopts a broad perspective on health, which accepts that there are many components in a person’s life that affect their health and well-being. Some factors are lifestyle-dependent, while others can be linked to social and societal circumstances that are often beyond the scope of the individual’s influence (Rostila and Toivanen 2018). Considering this, however, it is important to point out that this project is not based on a normative Swedish health discourse; rather, it is based on the communicators’ own understanding of being newcomers and their own wish to change the existing health practice.

Second, since the beginning of 2000, approximately 30,000 individuals have sought asylum in Sweden annually. However, during the height of the Syrian crisis in 2015, these numbers increased to 160,000. After 2015, the Swedish parliament sought to even out the distribution of refugees among the European countries; however, when this failed, Swedish refugee policy was tightened, nurtured by a change in public opinion, causing a rapid reduction in the number of refugees coming to Sweden (Ghersetti and Andersson Odén 2018). Although numbers dropped to 22,000 asylum seekers in 2019, Sweden remains one of the countries in Europe that is most welcoming to refugees (SCB 2020), enhancing the importance of understanding how health and health issues interplay with integration processes.

Methodological and theoretical frameworks

This study is built on a critical action research tradition called participatory action research (PAR) which originates from ideas about research as socially changing and emancipatory (Carr and Kemmis 1986). The research strategy is based on the principle that it is the collective work process and the joint reflection that forms the foundation for developing knowledge to bring about change by developing new ways of thinking, acting, and relating to each other within a practice (Kemmis, McTaggart, and Nixon 2014). In accordance with PAR, this project was implemented on equal terms between the first researcher and the communicators. All the ideas in the project were initiated by the communicators themselves and all the empirical material used in this study has been examined and approved by the communicators. This is considered important for creating commitment to the collaborative work process (Cook et al. 2017) and shapes a democratic dimension in which all participants have agency and can develop their own practice (Carr and Kemmis 1986; Kemmis, McTaggart, and Nixon 2014).

As mentioned earlier, this paper originates from a doctoral study (Bergenfeldt Fabri 2019) where the researcher’s role was as a critical friend and facilitator during the ongoing work process e.g. by booking meetings, keeping track of the working process by recurrently summarizing the work at meetings and providing feedback. The second author became involved when the doctoral study was finalised, working on this paper, contributing to the analysis, discussing and presenting the results, and, as such, deepening the shared knowledge and giving new perspectives.

In the present paper, the theory of practice architectures (Kemmis et al. 2008) is adopted as a theoretical lens. Rönnerman (2018) explains that this relatively new way of understanding a practice, in combination with critical action research, has contributed to development within the practice-based research field. For over a decade, researchers within pedagogy, education, and praxis networks have developed and used this theoretical perspective in different action research projects in order to improve local practices (Kemmis, Rönnerman, and Groves 2017). Regardless of their research tradition, there is a consensus among researchers that a practice is something that is situated and relational. That is, in a practice, social activities always take place with purposes in relation to a specific context (Green and Green 2009; Mahon et al. 2017). Thus, central to practice theories is ‘the emphasis upon the social and the organised nature of practice’ (Rapley 2018, 193). As such, practice theories contrast with research methods that emphasise objective researchers, the research process and its findings, or idealised accounts of findings and social actions.

The theory of practice architectures is based on the view of a practice as a situated and social phenomenon, where the dialectical interaction between the individual and the environment is expressed in distinctive ways of talking, acting, and relating to each other through specific practices (Kemmis et al. 2008). From this point of view, participating in a practice means meeting other participants in a social community (Kemmis et al. 2014) who are already shaped by the conditions that exist within the specific context in which the practice is located, while acknowledging that a practice is never static. A practice is continuously shaped and reshaped by both external and internal factors, which means that new practice architectures can arise or be added, which helps shape and reshape the practice (Mahon et al. 2017). The conversations, actions, and relationships that take place ‘hang together intersubjectively in the project of a practice’ (Kemmis et al. 2014, 33). In this context, a project means what is going on in practice and answers the question, What are you doing? Each practice has its own characteristic practice architectures (Mahon et al. 2017), and practices manifest in the following three arrangements, based on which spaces they arise in:

1. The cultural-discursive arrangements appear in the semantic space through the linguistic relations that arise between those who are part of a practice. These are expressed through specific ways of talking (sayings) to one other within a specific practice.

2. The material-economic arrangements are expressed in the physical space and refer to the physical, economic, and temporal conditions (doings) that form different patterns of action and activities within a practice.

3. The socio-political arrangements expressed in the social space consist of both formal and human relations. These conditions form rules and emotional relationships (relatings), where different opportunities for influence exist.

The arrangements are shaped over time by people both inside and outside the practice and stored as prominent conditions for a specific practice. According to this understanding, becoming part of a social practice means gradually learning to talk, act, and understand what is right and wrong within that community (Kemmis, 2009). These practices can be analysed as the unfolding of sayings, doings, and relatings in time and space. Importantly, it is not the practice that builds the architecture; rather, the architecture forms the practice.

Kemmis et al. (2008) conceptualisation offers a linguistic resource that is useful for zooming in (Nicolini 2012) and examining the design of a practice by studying the ongoing conversations, actions, and relationships. Their conceptualisation makes it possible to lead the analysis in different directions in order to gain knowledge of what is happening ‘in a site’ (Mahon et al. 2017, 9). In turn, this can help raise new questions and ideas that can lead to new practice architectures becoming a reality. For example, based on the social and political aspects of a practice, the participants can make visible and become aware of various power relations and injustices. As a result, the framework can function as both an analytical and a transformative resource, as new insights can create the conditions for bringing about changes that are beneficial to the work. By subsequently zooming out (Nicolini 2012), it is possible to broaden the analysis by tracking the practice’s relationships with other nearby practices and how they are mutually interdependent (Mahon et al. 2017).

The following section describes this collaborative work process in detail.

The collective work processes – carrying out participatory action research

Following the strong emphasis on a mutual relationship between researcher and practitioners, the working group in this project consisted of one participating researcher and seven social and health communicators, who met about once a month for two years. The study is based on empirical data collected during and through the conversations that took place in what Kemmis, McTaggart, and Nixon (2014) called a joint meeting practice, established by the working group during the project. Almost all the meetings took place in a conference room at the communicators’ workplace at the County Administrative Board in Malmö.

The tools employed comprised participatory observations sound recordings and documentation in the form of field notes and logbook writing. On some occasions, semi-structured interviews were conducted with the communicators, both individually and in groups. All group meetings, conversations, and interviews were recorded and transcribed verbatim. The material was analysed repeatedly, searching for patterns and insights into how new experiences contribute to the next step in the ongoing action research process. In the initial phase, the working group discussed issues concerning physical activity for new arrivals and what activities might be suitable for the intended target group. Experiences gained during the project provided the basis for new discussions and planning in the joint meeting practice. Furthermore, the lessons learned formed the basis for new adjustments in practice, and so on. By continuously reflecting together, the participants had the opportunity to view themselves and their own practice from new standpoints. The analysis of the empirical material helped increase awareness and understanding of what took place in the joint meeting practice.

In the meeting practice, the participating researcher (i.e. the first author) had a parallel/double role (cf. Olin, Karlberg-Granlund, and Furu 2016), both as a group member and as a facilitator to support the communicators in developing their own working practice. In addition, the researcher’s position went through different phases, starting as an outsider in a foreign context. As Somekh (2006) highlighted, the outsider’s role can be valuable in bringing new perspectives that can help transform practice, despite their limited knowledge.

For this study and the particular processes that took place, it was useful to combine action research (AR) with the theory of practice architectures when investigating and deepening the understanding of what enables and constrains implementing change to a practice (Kemmis et al. 2014; Rönnerman 2018). Also, the theory of practice architectures offered an innovative language that was used in the present study to capture the complexity of the context in which the project was located (Mahon et al. 2017). By critically examining a practice in this way, the PAR process, in combination with the theory of practice architectures, helps make different problems visible (Kemmis et al. 2014; Mahon et al. 2017). As a result, it became possible to discuss and problematise the situation, which is an important prerequisite for achieving change.

The work process followed cyclical and repetitive steps (plan – act–observe – reflect), similar to the theoretical model that Lewin (1946) developed to visualise AR. However, due to various circumstances (such as the challenges the communicators faced in responding to the acute refuge situation 2015), the project became messy and difficult to negotiate. Refugee reception is a dynamic process, and the need for communicators’ services varied during the project period depending on the number of new arrivals. Therefore, the communicators’ engagement in the project occasionally chafed against their obligations towards the municipalities’ increasing need for their services. In addition, PAR is itself messy, with a high degree of reflexiveness and transformability, which also complicated the process (cf. McNiff 2013). The requirement for close collaboration in PAR created vulnerability in relation to the conditions that prevailed during the project period. However, the findings section is structured using steps, referred to here as ‘phases, aligned with Lewin (1946) for comprehensibility.

In the analysis, Kemmis et al. (2008) conceptualisation of a practice was used as a starting point in three different spaces: the semantic space (sayings), the physical space (doings), and the social space (relatings). With this as an analytical lens, the possibilities and limitations presented themselves in the material, and the communicators’ ability to achieve a changed health information practice became visible.

Even though the research followed the ethical requirements and steps set up by the Swedish Research Council (Vetenskapsrådet 2017), this AR posed several challenges. AR means that people are involved in the entire process: they are not mere ‘subjects’ or ‘participants’- they are key partners in the process. Importantly, the ethical terms and conditions are fundamentally collaborative processes in AR – with ongoing mutual understandings of the project goals and objectives continuously negotiated between all parties (Zeni and Zeni 2001). This negotiation must be kept alive because there are no ‘participants’ that need to be protected; rather, all partners must protect themselves and each other against potential risks by mitigating the negative consequences of their collaborative work and pursuing the welfare of all parties concerned.

Changing practice

As stated above, PAR strives towards transformation and change, which makes it dynamic and messy (cf. Wright et al. 2018) and it can be challenging to present the findings in a comprehensible manner. Even though this project, using theory of practice architectures (Kemmis et al. 2008) as a starting point, should be seen in a more three-dimensional, architectural way, the following section is structured chronologically, discussing the initial phase, the implementation phase, and then the concluding phase based on how the work progressed during the project. The findings are illustrated with quotes taken from interviews, conversations, and discussions in the joint meeting practice.

The initial phase – planning the project

The communicative arena – that is, the joint meeting practice that was established during the project period – acted as a catalyst and initiator that promoted dialogues, reflections, and feedback during the work process. In the initial phase, the participating researcher posed questions from an outsider’s point of view, and this opened the way for the communicators to verbalise and explain their experiences and understandings of their own work. This helped to increase the researchers’ contextual understanding (Lave and Wenger 1991). One health communicator stated:

Our target group is not so easily motivated given that the families are split, so the energy goes in that direction. I have the impression that things like this come last. It is not so easy for newcomers to comprehend that physical activity is something they need. (Amin)

In the ‘semantic space’ (Kemmis et al. 2014, 4), it is initially possible to identify topics of conversation that are characterised by an understanding that physical activity is important and should be prioritised and offered to all newcomers within the establishment programme. However, several communicators described the group (of refugees) as difficult to motivate because its members have a low degree of interest in health issues. This can be explained by the fact that many of the refugees lack experience of health education work and that the health information presented appeared to have little relevance to them. For example, Ali, one of the health communicators, stated: ‘There are a lot of people in our groups who do not take it seriously when we tell them that it is important to move.’ In the joint discussions, the communicators’ own understanding of how they view the target group’s conditions for assimilating the information was made visible; they discussed the statistics on disease rates among immigrants compared with Swedes and saw their own important role in changing this situation. There was a consensus among the working group that their role as communicators and their own cultural understanding of the refugees were important resources; they act as a bridge into Swedish society for the newcomers, something also supported by earlier studies (Svederberg et al. 2001; Wieland et al. 2012).

Various circumstances linked to the material and economic arrangements initially manifested themselves in the physical space (Kemmis, McTaggart, and Nixon 2014). For example, one health communicator, Cherbel, mentioned the need to check things with the coordinator, stating, ‘Before we do anything, we need to talk to the coordinator and get her approval’. This illustrates how the health communicators perceived limitations arising due to power structures: the group found it difficult to add or elaborate new activities without approval from the coordinator. These conversations highlighted a practice that is part of a larger context. Kemmis, McTaggart, and Nixon (2014) conceptualised this practice as being part of an ‘ecological context’. The perceived space for action that emerges in the social space seems, at this stage, to be a limitation for the project.

Ali also put forward another limitation:

The problem is that it gets complicated because we have limited time to give [additional] information along with the [health] information, so we cannot take more time. If we have two themes, we must have time to inform [the group] about them within four hours.

Lack of time, traditional classrooms, established routines, and standardised work material were emphasised as factors that limited the communicators’ ability to increase interest in physical activities among the participants. Thus, decision-making elsewhere in the establishment programme affected each individual’s own work. Accordingly, we can deduce that the socio-political arrangements are established for the role of executor in a project where the working methods are mainly predetermined by others.

Nevertheless, the communicators clearly attribute importance to their role and have a lot of insider knowledge about the cultural conditions that they value highly. The AR process helped generate engagement in the group of communicators, and this became particularly visible when the conversations were about how they could achieve an inclusive practice that more clearly put the newcomers’ health at the centre. New ideas were verbalised and discussed in the joint meeting practice. The activities that the working group had agreed to try with participants were talked about in tentative terms. In the semantic space, it became obvious that familiar patterns prevented communicators from changing the structures, and the discussions became more about how new content could be accommodated in an already fully subscribed information session. Thinking patterns seemed to function as a resource that the communicators used to structure their understanding of the context and the opportunities to act (Mahon et al. 2017) formulated as a collective practice memory that gives shape to what is understandable to say and do in the role of communicator.

The interpretation at this phase was that everyday work routines were seldom abandoned for new forms of activities, if, as the researcher perceived it, the communicators did not really believe in them. The difficulties stemmed from the fact that new forms of work challenge existing routines that have developed over time to simplify work. The physical space is characterised by a culture of equality; the information is essentially a matter of justice based on the idea that all newcomers have the right to the same information. Thus, the information effort is characterised by an assembly-line principle and not by a pedagogically well-thought-out learning process.

In the social space, the powerlessness is obvious. This appears to be an obstacle to the planning of new activities. An example of the subordinate role of the communicators was the perception in the group that neither they nor the refugees were allowed to leave the premises. Although the project is well-communicated at a regional level (Björngren Cuadra and Carlzen 2015), there were no pre-given powers or dedicated resources or spaces to operate from during the project period. This means that any activities planned had to be negotiated with decision-makers before they could become a reality for the participants. The only exceptions were the experiments with the pedometers, as these could be carried out within the existing structures.

The implementation phase – carrying through the activities

During the first month of the project, the group took on various initiatives. Ali and Amin, two of the communicators, reflected on their experiences when introducing pedometers to some of the refugee groups as a first attempt to offer physical activity. Ali stated:

I told them that we will not start with a brisk walk, but we will walk a little slow in the beginning. We’ll just try. Then we looked at the pedometers. Everyone watched how many I had. How many do you have? So, they had already started talking about it. So, I think it will work. They were happy; we laughed and talked. It was good! (Ali)

Amin added, ‘Personally, I think they showed more interest than I personally thought; honestly, I thought they would not be interested in this, but they actually were!” Thus, the communicators shared and expressed enthusiasm about the participants’ curiosity. It was clear how this activity affected the social climate when the participants spontaneously began to interact with each other. The obstacles that initially occupied a large part of the semantic space were not part of the conversation at this stage.

By exploring pedometers, new positive insights were offered that were visible in the communicators’ commitment. They were hopeful that this way of working would also help when trying to increase the motivation for physical activity among the participants. As the communicators’ experiences expanded, the discussions in the conversations changed, and this seems to have promoted the AR process. Through self-reflection, and together with others in the group, knowledge is activated and becomes available, which helps increase one’s own self-understanding and makes new action alternatives visible (Somekh 2006). This was increasingly visible during the process. The material and financial arrangements were the main enablers for the development and formation of new practice architectures within the framework of the project. In connection with the planning of a visit to engage with the natural world, the working group met in a nature area together with a nature guide. Baizid, one of the communicators stated, ‘She [the nature guide] sees no obstacles with things. She is open – a fantastic person! It was like clearing the road. It feels much easier.’

Having the opportunity to twist and turn perspectives and discuss their own activities together with others, opened up new ways of looking at their everyday practice for the communicators – something perceived as stimulating. The shared conversations, both in the working group and together with other professionals, expressed in the semantic space, paved the way for abandoning old routines in favour of new ways of doing things.

The nature visit, which was carried out with some groups of newcomers, showed changes in the semantic space. Cherbel reflected on how the new activities created opportunities to guide the participants in a new learning practice:

I start with my own experience. There was a huge difference in the intake of information compared to sitting in the classroom. It affected the whole dynamics. I noticed it through the questions the participants asked and the dynamics of the group, and how they asked each other for certain things. Some started asking me questions. I felt that they were also more natural in their questions and behaviours. You know, you are often tired when you sit in the classroom, and that makes it difficult to concentrate. But here they were livelier; there were more questions, it was more social, and we were closer to each other. (Cherbel)

One goal in the study was to identify the changes that took place within the framework of the AR process and how these changes became noticeable in the meeting practice. Observations show how the experiences made together with the participants nurtured new communicative patterns in the semantic space. This was also visible in the participating researcher’s field notes: ‘The participants were curious and seemed interested in learning about nature. For most participants, it was the first time they went for a walk in nature. They asked many questions.’

Changes in the socio-political arrangements generated experiences, and the role of the communicator became different. The economic and material arrangements during the project also affected the social and political arrangements expressed in the form of changed relations in practice.

The participants also talked about the responsiveness of the staff at Skrylle [a nature area]. It was great. They were inclusive. They have never received such information before. They have never been respected in that way. The staff were helpful but at the same time part of the group. It was also for some an opportunity to speak Swedish with the staff. (Cherbel)

The changes were dressed in terms such as ‘meaningfulness’, ‘inclusion’, and ‘more equal relationships’ with the new arrivals. The phrase ‘doing things the right way’ became part of the social space at this stage. By challenging common working methods, which were initially perceived as difficult, the communicators recognised that the concretisation of the health information that they wanted could also function as a pedagogical tool. For example, Cherbel said:

I think based on the interest I saw in the target group to participate in various activities and based on what I have talked to the group about, I think it is very important. I do not think it is difficult to implement it, but I am thinking of transport costs. If you are going to plan this as part of your health information practice, it is possible to do so; the coordinators need to be a little more flexible. This is information in a different way than sitting and listening in the classroom. We need to work a little more on these issues. (Cherbel)

When new and untested forms of work were tested, a breakthrough took place in the conversations when the participants showed great interest in the new content.

The doubts and powerlessness that were initially formulated were replaced by thoughts about how existing resources could be redistributed to create new routines that would allow physical activity to be a natural part of the health information offered to newcomers participating in the programme. The changes that were being brought about at this stage gradually paved the way for the communicators to change the content within the agreed structures in order to facilitate new working methods. The hope was that incorporating physical activity could help raise the interest in health issues, which, in the long run, could become a way for the newcomers to approach Swedish society.

The concluding phase – evaluating the project

When examining the semantic space and looking at the working group’s conversations to capture perceptions and experiences during the work process, new ways of talking became a reality as the working process advanced.

We have started to think much more about physical activity. We have it as a theory in our health themes. Now we think much more about finding real physical activity so that it is not only theoretical but that it is just as important to make it practical with the target group. For me, it has changed my mindset. It is not enough to inform the target group to do this and that, but plan to offer them physical activity. (Amin)

The talks became permeated by pride in the initiative that the working group had taken to make the new working methods come true. The target group for the project was newly arrived refugees, and, on several occasions, the process contributed to the communicators being moved by the commitment shown by the participants. Ali said: ‘We have learned; for me there was no hope for the new arrivals, but when we handed out the pedometers and went out into nature and to the gym, it became clear that they want to progress!’

The arrangements that were formed during the AR project contributed to new activities becoming realities. Reflecting on their own activities stimulated the communicators’ self-perception and motivation for initiating the new activities. The AR project contributed to a democratic work process. At the same time, it became clear that certain pre-imposed structures were perceived as obstacles to a more permanent change in the working methods during the AR project. Muna said:

It is not only we who can decide this, but it is necessary that other authorities around us are also involved. Not just us. So, if you can find that time and that process and structure, then it is no problem that we add physical activity to our themes. (Muna)

At the end of the project period, the communicators demanded clearer collaboration on both structure and content issues in order to obtain permission for lasting changes. In the conversations, it emerged that others had interpretive precedence over their own practice and that their own position/role/capacity did not allow for any greater influence over content issues. The findings show that the process of change is complex and challenging. In the conversation, it is possible, from time to time, to identify moments when current structures were really questioned. This can be interpreted as a new understanding having been established as to how a motivating practice could be achieved if current rules and routines were to be changed. The conversations in the meeting practice are characterised by an openness that may be partly due to the fact that mutual trust had been built up within the working group, and partly as a result of new insights being gained during the work.

In AR, the shared responsibility and practitioners’ desire to drive change is in focus (cf. McNiff 2013). However, at different times during the project, the communicators’ work situation contributed to the AR project being an extra pressure that they did not really have room for. In the trial phase, Ali stated:

We have a lot, a lot to do. Therefore we do not have time for the project […]. It’s very difficult because we do not have time […]. I just want to explain that if we miss something, it does not mean that we are not involved in the project. (Ali)

At the same time, as the work process produced feelings of participation, it created frustration when it rubbed against the prevailing physical framework. There was an interest in participating in the project among the communicators, but conditions that they could not control limited their opportunities to work in the way that they wanted. This included the fact that the project coincided with the period when Sweden (and Europe as a whole) received the largest numbers of refugee since the Second World War, directly affecting the communicators’ work situation.

Nevertheless, through conversations and dialogue in the working group, a picture emerged of small but concrete changes that could also contribute to better resource utilisation. The changes that could be traced to the social and political arrangements that had become possible during the work process permeated the communicators’ understanding. At the end of the project period, there was a desire among the communicators to have the opportunity to leave the assigned informant role in favour of one with more power and decision-making regarding working methods and content:

If we are going to do this, I want a little more freedom. That we as communicators have more freedom to choose the day and theme without considering and asking the Swedish employment agency (arbetsförmedlingen) and so on. A few more opportunities to decide about activities and that could be outdoor activities nearby. (Amin)

I have a suggestion that we may teach outdoors. It is logical to talk about nature and leisure outdoors. There is a big difference from doing that in the classroom between four walls. It can be done in a park nearby. (Masoud)

The quotes from Ali and Masoud show that the group developed an understanding of how it could, by simple means, offer forms of work that are important for the participants’ motivation concerning health issues and physical activity without the need for additional resources. For example, Ali and Masoud proposed that the local environment could be used for educational purposes to strengthen the themes around nature and the environment. This also shows that the working group’s relationship building and discussions with other professionals had provided opportunities for learning. The study’s most important findings show that the AR practice created opportunities to create an architecture that differed from the one that shaped their everyday practice. This architecture promotes participation, collegial conversations, social relationships, and health-promoting activities that the participants perceive as motivating.

Ongoing change work for empowerment

This study aims to investigate what changes take place within the framework of a PAR project regarding a health information practices in general and empowerment processes in particular. In this section, we discuss the research process and its findings.

At the beginning of the study, the communicators’ work appeared to be tightly controlled by circumstances that can be traced to practice architectures that, figuratively speaking, were characterised by an assembly-line principle. Although the group members had both ideas and knowledge regarding content issues, they did not have an arena in which their understanding could be realised. In accordance with PAR (Carr and Kemmis 1986; McNiff 2013), the research approach gave the communicators influence over the design of the work process. The joint meeting practice functioned as a communicative space (Kemmis, McTaggart, and Nixon 2014) that promoted dialogue and collegial conversations about their own work and the researcher’s learning about the context and the communicators’ working conditions. More clearly than in earlier analyses (Bergenfeldt Fabri 2019), the analysis carried out in this study shows how this created a democratic work process including the newly arrived refugees, the communicators, and the participating researcher, which empowered all the partners in this project.

The reflective nature of the conversations enabled the communicators’ and the participating researcher’s professional knowledge to gradually become clear, and sometimes even be challenged. For example, it became evident that the architecture of the project sometimes chafed against existing structures on many levels, such as the general reception of refugees in Sweden at that time or the stressful work situation of the communicators. This constrained the possibilities for change but also showed what was needed and what could enable change. One such example was the collective talks in the communicative space, created during the project, which nurtured an architecture that generated new ideas and made it possible to leave the classroom-based teaching situation and try new ways of learning about health and physical activity. Moreover, the findings show that the leeway that arose during PAR made the communicators aware of their capacity to implement change by offering various physical activities that benefited the refugee groups. Once again, the analyses clearly showed that the democratic work process increased the communicators’ agency and commitment to the ongoing change work.

Despite the obstacles that arose during the work process, the analysis of the joint meeting practice shows that the AR practice provided opportunities for collegial conversations that favoured a changed practice. The findings show that the working group developed a greater awareness about the value of physical activity in health information. The work process also contributed to a gradual understanding of how physical activity could be offered to participants within the framework of health information. We also believe that the broad view on health and health practice used in this research project can create values that are useful for the individual in the integration process. Physical activities enable social contexts and a sense of coherence, factors that are of the utmost importance for health.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the European Refugee Fund (E86-302) during the period 1 January 2013 to 30 June 2015.

Notes

1. As such, some of the results in this paper are presented in a doctoral thesis (Bergenfeldt Fabri 2019) written in Swedish.