Imagining the flowers, but working the rich and heavy clay: participation and empowerment in action research for health

Abstract

Participation of the ‘target group’ is a key concept in working on empowerment in health education. However, it raises many questions and is not without struggle. I will discuss the findings from a study into the state of the art of empowerment in health education, which includes a literature review and the analysis of eight Dutch health‐promotion projects. An important finding is that participation is not an unequivocal concept. Professionals working in health education strongly disagree on the value, goals and meaning of participation. Moreover, in working on empowerment, a tension exists—between the ideal of participatory, ‘bottom‐up’ approaches on the one hand; and the ‘top‐down’ structure of health education programmes, on the other. I will argue for a ‘realistic approach’ in which the practice of health promotion is taken as the starting point to work on empowerment. After all, imagining the flowers is easy, but working the rich and heavy clay is the challenge.

Keywords:

• Action research
• Empowerment
• Health‐promotion practice
• Participation

Notes

1. The project was funded by ZonMw and the University for Humanistics. In this study, I took a relatively ‘outsider’ perspective by studying documents and speaking to colleagues in the field of health promotion, but I was struck by the correspondence between their experiences and mine in a project prior to this, which was a participative action research for health. To learn more about this project, see van den Ende and Jacobs (2005).

2. In a participative approach, ‘target group’ is not an appropriate term because it denotes top‐down determined goals for certain groups of people. In the absence of a more suitable term, we will use it between quotation marks.

3. A banking approach is characterised by a hierarchical relationship and one‐way transfer of knowledge from teacher to learners (Freire, 1971).

4. This is a strong ideological position and characteristic of the ‘empowering type’ of participative action research (Hart & Bond, 1995, p. 38). See also the principles of empowerment evaluation (Fetterman, 2002).

5. In this project, low‐educated and unemployed immigrant men are recruited by their social security institution to participate in training. The aim of the training is to learn to cope with their psychological problems and to improve their willingness to work, and thereby their job reintegration. These men are not involved in the development of this training, nor informed well about the goals. Moreover, the men probably perceive their participation as not ‘really’ voluntary.

6. An important reason is the dependence on grants. Fundraising not only takes a lot of time and energy of professionals in the preparatory phase, but professionals also feel that it is unethical to raise expectations in local communities that they perhaps cannot fulfil.

7. The Healthy Living programme of ZonMw, for example, covers four years until the end of this year and will probably not be continued.

8. For example, in Dutch health‐promotion practice we find the ideology of ‘personal responsibility’; that is, the idea that people can and should take responsibility and action for their own health. However, this may clash with the viewpoint of non‐western immigrant groups who accept their fate (and health) as it is beyond their control. This is also referred to as an internal respectively external health locus of control.

9. In a participative action research project (see also note 1) we found that participation can be seen either as an intrinsic value or goal in itself (the strong ideological position); as a strategy or instrument to improve the scientific validity of the results—the so‐called ‘member check’—or the effectiveness of a programme (the scientific position); or as a way to create a practicable programme (the practicable position).

10. The dynamic of ‘rooting’ and ‘shifting’ is introduced by Yuval‐Davis (1994) in the context of multicultural group work.

11. Co‐creation takes a different pace and specific skills: to give and take, looking for compromises without abandoning ones values and goals altogether; to be present and trustworthy; and to do things that seem not ‘professional’ at a first glance, such as baking pancakes on a community event or chatting and drinking coffee at informal meetings (ten Dam, 1998; Koelen & van der Ban, 2004).

12. In The Netherlands, the University for Humanistics and the National Institute for Health Promotion and Disease Prevention have started two projects for professional empowerment: the development of an action learning programme in participation and empowerment for professionals in health promotion, and the development of an empowerment quality instrument.