Participatory Action Participatory Action Research:Research:

Partnership With An Partnership With An Indigenous Guatemalan PHC Indigenous Guatemalan PHC

ProgramProgram

Southwest region

AcknowledgementAcknowledgement

Dr. Beverly McElmurry (chair)Dr. Beverly McElmurry (chair) Dr. Linda McCrearyDr. Linda McCreary Dr. Jerry NiedermanDr. Jerry Niederman Dr. Kathleen NorrDr. Kathleen Norr Dr. Chang ParkDr. Chang Park Dr. Susan SwiderDr. Susan Swider

Embajadores Medicos (LifeWind) Embajadores Medicos (LifeWind) GuatemalaGuatemala

DedicationDedication My God and Savior Jesus Christ. It is in Him that I My God and Savior Jesus Christ. It is in Him that I

live, and move, and have my being.live, and move, and have my being.

My loving parents who taught me to pursue My loving parents who taught me to pursue knowledge, wisdom, and truth.knowledge, wisdom, and truth.

Dr Hugo & Miriam Gomez and family, Betty, Dr Hugo & Miriam Gomez and family, Betty, Juven, and Juven, and

Hermanos: Chepe, Florentine, Marcitos, Marcos, Hermanos: Chepe, Florentine, Marcitos, Marcos, Felipe, Abel, Cirilo, Margarito, Apolinario, Obispo, Felipe, Abel, Cirilo, Margarito, Apolinario, Obispo, Mariano, Nazario, Pio, and Santiago. Thank you Mariano, Nazario, Pio, and Santiago. Thank you for putting “feet to your faith”, and for allowing for putting “feet to your faith”, and for allowing me to work with you.me to work with you.

BackgroundBackground

Guatemala, Central AmericaGuatemala, Central America• >7.6 million persons earn less than >7.6 million persons earn less than

$1/day$1/day• Under-five mortality 47/1000Under-five mortality 47/1000

Acute respiratory illness (40%)Acute respiratory illness (40%) Acute diarrheal illness (12%)Acute diarrheal illness (12%)

Coastal Village home

Background cont.Background cont.

Embajadores Medicos (Life Wind)Embajadores Medicos (Life Wind)• Guatemalan, faith-based, Primary Health Care Guatemalan, faith-based, Primary Health Care

organizationorganization• 25 yrs. of health-promotion in indigenous 25 yrs. of health-promotion in indigenous

villagesvillages• Participatory teaching and learning emphasisParticipatory teaching and learning emphasis• Curriculum foci: Curriculum foci:

spiritualspiritual physicalphysical environmental environmental economic economic and social well-being and social well-being

Community Health Educators & Training Team

Building Stove

Improved Stoves

PurposePurpose

The purpose of this PHC descriptive The purpose of this PHC descriptive case-study was to:case-study was to:• expand current understanding of PAR,expand current understanding of PAR,• highlight its key attributes, highlight its key attributes, • identify strengths, and identify strengths, and • discuss limitations of PAR methodology discuss limitations of PAR methodology

in the context of an indigenous in the context of an indigenous community setting. community setting.

Specific AimsSpecific Aims

Tool development for Tool development for program evaluationprogram evaluation

Pilot evaluation tool Pilot evaluation tool

Cross-sectional program Cross-sectional program evaluation evaluation

FrameworkFramework

Participatory Action Research:Participatory Action Research:• With & by the communityWith & by the community• Community as partnerCommunity as partner• Direct community benefitDirect community benefit• Shared powerShared power• Mutual learningMutual learning• Practice-based, action-orientedPractice-based, action-oriented• Dynamic processDynamic process

OverviewOverview

Lit. Review (1)- 45 articles- Developed a PAR guiding framework

Visit (1) 2 wks- Relationship building- Observation

Visit (2) 2 wks- Observation- Planning- Negotiation

Work in Guatemala

Work in the U.S.

2005 2006 2007 2008 2009

Tool Development- Key goal setting

Tool Development- Draft- Revisions- Training- Adaptation

Survey- Data collection- On-going analysis- Discussion- Adaptation

Preliminary Report- Jointly written- Translation- Dissemination

Lit. Review (2)- 36 articles- PAR methodology - Clarification- Recommendations

Tool DevelopmentTool Development

Developed jointly, based on Developed jointly, based on Embajadores Medicos’ curriculumEmbajadores Medicos’ curriculum• Picture basedPicture based

40% literacy 40% literacy Benitez, 2007Benitez, 2007

• Spanish languageSpanish language+ Mam and Quiche+ Mam and Quiche

• Nominal level dataNominal level data• Face validityFace validity

Goal: future Guatemalan program’s Goal: future Guatemalan program’s independent useindependent use

TrainingTraining

14 Guatemalan training team members14 Guatemalan training team members• Joint decision-making for tool developmentJoint decision-making for tool development• Scheduled trainings and survey visitsScheduled trainings and survey visits

8-45 community health educators per 8-45 community health educators per village (number varied)village (number varied)• Voluntary participationVoluntary participation• Return demonstration of correct tool useReturn demonstration of correct tool use• Independently chose number of households to Independently chose number of households to

survey survey

Training

Practice

EvaluationEvaluation Eleven indigenous villagesEleven indigenous villages

• 5 Coastal + 6 Mountain5 Coastal + 6 Mountain• Convenient sampleConvenient sample• Determined by Guatemalan Determined by Guatemalan

partnerspartners

Adult household Adult household representatives (n=1,188)representatives (n=1,188)• Verbal consentVerbal consent

Village Visit in the Rain

Findings (Coastal Villages)Findings (Coastal Villages)Reported Implementation of

Curriculum Foci (% ) Village

Name Phase

Number of

Households

(covered % ) BBooiilleedd wwaatteerr

II mmmmuu--nniizzeedd

NNuuttrrii-- ttiioonn

UUssee LLaattrriinnee

RReeaadd BBiibbllee

MMoonnttee

CCrriissttoo 1 111111 ((3300%% )) 5599 9977 11 44 4444

NNuueevvaa

CCaajjoollaa 2 115500 ((3300%% )) 7744 9933 1111 9999 3366

LLaa

GGoommeerraa 2 5500 ((8833%% )) 7700 9988 66 110000 5588

SSaann

MMaarrccooss 3 114444 ((8800%% )) 9977 9988 00 4455 4400

LLaa

VVeerrddee

Post-

program 8800 ((5533%% )) 110000 110000 5566 110000 1177

Running Water

LimitationsLimitations

Pilot studyPilot study

Cross-sectional designCross-sectional design• Unable to compare changes over timeUnable to compare changes over time

Nominal level dataNominal level data• PAR can use higher level data. This is PAR can use higher level data. This is

community-dependent.community-dependent.

StrengthsStrengths Addressed questions important to Addressed questions important to

community memberscommunity members

Large sample sizeLarge sample size

Direct Community BenefitDirect Community Benefit• Joint tool and data ownershipJoint tool and data ownership• Training and evaluation experienceTraining and evaluation experience• Final report ownership for dissemination to Final report ownership for dissemination to

donorsdonors

DiscussionDiscussion

Each phase of a PAR study must be Each phase of a PAR study must be accompanied by purposeful accompanied by purposeful examination of: examination of: • community members’ roles,community members’ roles,• dynamics of power, dynamics of power, • direction of knowledge flow, direction of knowledge flow, • whether the process retains dynamicity, whether the process retains dynamicity,

and and • whether a tangible benefit is identifiable whether a tangible benefit is identifiable

by the community partners. by the community partners.

DiscussionDiscussion Participatory Action Research partnership with communities Participatory Action Research partnership with communities

is one of the most significant developments in community is one of the most significant developments in community health-promotion research. health-promotion research.

Community members’ perspectives and life-experience are Community members’ perspectives and life-experience are incorporated.incorporated.

Research has face validity and practical value to Research has face validity and practical value to community members.community members.

Sustainability of health promotion efforts is greater due to Sustainability of health promotion efforts is greater due to community ownership.community ownership.

Participatory action research is a methodology with Participatory action research is a methodology with tremendous potential for bridging science with the tremendous potential for bridging science with the everyday lives and health behaviors of community everyday lives and health behaviors of community members. members.

THANK YOU!