There are a number of buzz words and trending ideas being used in public health at the moment.
Community ownership, stakeholder engagement, participatory processes, sustainability and empowerment are just a number that are floating around.
In this blog post I’m also going to be jumping on the bandwagon. I’m going to explain why my field is currently fascinated with them and some of what I’ve been working on the past few weeks.
So what is a stakeholder? What is Theory of Change? And as my father says “What is a Machakos?”
Well for my Dad and everyone else who is interested, Machakos is a town in Kenya just southeast of Nairobi. My first week on site a number of Africa Mental Health Foundation staff and I left Nairobi and drove to Machakos to run a Theory of Change workshop with a number of the stakeholders for both of AMHF’s Grand Challenges Canada projects (e-DATA K and KIDS). It takes about an hour to get there depending on traffic. Why were we going there? Well Machakos and Makindu are the two rural districts that are the grounds for both e-DATA K and KIDS projects. We were going there to complete a process called Theory of Change with a number of the projects’ stakeholders (i.e. community and ministry leaders of the communities who will be affected by these projects).
Now before I explain Theory of Change I think it’s important to give you some context and go back to those trending ideas in public health.
The ideas of community ownership, stakeholder engagement, participatory processes, sustainability and empowerment are all wrapped up in a process called community based participatory research (CBPR). CBPR is based on the ideas of Paulo Freire and the idea that traditionally there is a significant power imbalance and inequitable transfer of benefits in research between individuals doing the research and those being researched (especially in marginalized communities and populations).
In research, traditionally information is passed from those being researched to the researcher. That information is then typically ‘owned’ and disseminated by the researcher from their perspective. Despite claims in background and justification sections of publications traditionally the results of that research typically only benefit the career of the researcher. Sometimes this is due to the fact the project was designed for the sake of science and objectivity rather than action. However, without input from the community the results cannot generally be integrated into any meaningful changes in the community. Traditionally, more often than not research information that could empower and strengthen communities is lost in academic journals accessible only by subscription to the academic elite and resource rich and/or communities are provided with summary copies of the information that are full of jargon and provides hypothetical solutions to problems they may not even think are important. Fortunately, these things are changing, research ethics are being updated and fields specializing in translating research into practice are emerging (Knowledge Translation).
For clarification, I am not saying there is not a place for basic research and knowledge for knowledge sake (sorry for the double negative). I have a background in philosophy. I love asking absurd questions for the sake of the intellectual journey. However, I think it’s hypocritical and a little egocentric for outside academics to claim their research is for the good of community and then fail to translate that research into any meaningful changes in that community, or strengthen that community with the information collected and/or tools that:
- Are made meaningful and presented in a way that can be easily understood (i.e. accessible) and
- Can be used to tackle problems identified as important by that community.
A foundation to these ideas is the respect for a community’s autonomy and the idea that they are the experts of their own lives and problems and therefore any action looking for meaningful and effective solutions demands their participation and involvement. This idea runs parallel to ideas in counselling psychology, client focused perspectives in addictions and mental health recovery and is something that I strongly believe; people are experts in their own lives, experiences and problems. It is not my place or anyone else’s to tell anyone else what is best for them. People often may not have all the information, resources or tools to make the ‘healthiest’ decisions or ‘best’ solution. It is my belief that it is our jobs as health professionals to provide people with all the information and tools that we can. It is then up to the individual to make informed decisions on what they think will work best for their lives.
The line between advice and suggestion is tricky. However, there is a difference between asking “do you know about this resource/tool/strategy? Do you think this may work for you?” and “You should do this”. The difference is that advice is disempowering and can even be perceived as disrespectful. What I mean by this is that advice does not provide any ‘ownership’ or responsibility for a decision or course of action. So if that decision/action results in success it is due to the advice giver and does nothing to strengthen the capacity of the advice taker. Alternatively, if the decision/action fails then that too is due to the advice giver. The people receiving the advice are less responsible for their own decisions/actions and often the only thing that can be learnt is, “maybe I shouldn’t take advice from that person.” You take something away from someone when giving advice. It is the opposite of supporting individuals in making their own decisions.
As a proud independent female (maybe too proud) with these beliefs, I often feel disrespected by unsolicited advice and especially if the person giving it does not know me well. Even though I know advice typically comes from a warm and caring place, I understand advice to be saying “I know more about your life and situation then you and here is a solution that I don’t think you could come up with.” This is something called ‘meta-communication’ or what is also communicated by what you do or do not say. Men who have responded with silence or too slowly to the question “Does this make me look fat?” know what I am talking about. In conversations and interactions, there is more to what is being said than the words or phrases being said. Different people and different cultures all respond and interpret things and advice differently. In social interactions there is not one correct meaning or interception to a single phrase (I do think there are interpretations that are contextually ‘healthier’ than others); meaning is negotiated between those involved in that interaction and coloured by their perspective and world views. I believe that every response makes sense given that person’s culture and personal history, it might just not be apparent to an outsider or anyone else. When this happens there is simply a need for more negotiation and open communication in order for both parties to get on the same page.
The idea of advice giving that I have just outlined refers to interactions that occur between single individuals. Now re-frame this idea and think about how this disempowerment or empowerment can happen with communities and larger groups or populations of individuals. This is why these traditional approaches to research, social programming for marginalized populations and international aid can be seen as being paternalistic, disempowering and also can explain their ineffectiveness and inability to bring about positive meaningful change. For those of us from privileged backgrounds, can you imagine a complete stranger suddenly coming into to your life (without asking for your perspective) who then proceeds to outline what they think all your problems are and then what the best and only solutions are? What is the meta-communication in this situation? Possibly:
- “Your perspective, problems, solutions, and input have no value.”
- “You are wrong. Those problems that you think are problem aren’t actually the problem.”
- “Everything you’ve done before to make your life better, any decisions and problem solving you’ve done up to this point aren’t going to work.”
Now add that these messages are explained in words and a language that you cannot quite understand with an underlying expectation that you do understand. Then without providing you any tools to undertake these foreign “solutions” this stranger leaves (and is potentially replace with a new stranger who repeats this process).
To be first told that the knowledge and perspective you have is not valuable and won’t solve your problems and then to be provided with nothing meaningful to change the situation is what I mean by disempowerment. This sows hopelessness and the idea that people need experts and others to solve their problems. Empowerment is the opposite. It is done by providing individuals and communities the information and tools they need to make informed decisions as well as strengthening their capacity to make meaningful change in their lives and situations. They are the owners of their problems and therefore are also responsible for any solutions. When this happens the solutions that are developed are generally more meaningful to the affected communities and individuals, which in turn makes them more effective as well as more sustainable and long lasting.
SOooo how does this all fit into what I was doing in Machakos? Theory of Change is a process which involves stakeholders (so those affected by the project) in creating a unique theory or story (specific to that community and project) about how to make the changes they want to see in the world happen. After providing a workshop on how to create these Theories of Change, (ToC) our research team, with our stakeholders, created specific ToCs for both of our projects. These ToCs will affect how the project is implemented, measured and hopefully be sustained by the communities once the research team leaves. Basically, by using ToC we hope to break out of those traditional disempowering patterns of research that I have been going on about. To use all those buzz words I listed in the begin of my post; this Theory of Change process hopes to increases community ownership and project sustainability through an empowering participatory process of stakeholder engagement.
I hope that all made sense. As always thanks for reading.
Until next time,