Building capacity in community health action research - SAGE Journals

Action Research Volume 2(4): 389–408 Copyright© 2004 SAGE Publications London, Thousand Oaks CA, New Delhi www.sagepublications.com DOI: 10.1177/1476750304047982

ARTICLE

Building capacity in community health action research Towards a praxis framework for graduate education Geoffrey Nelson Wilfrid Laurier University Blake Poland University of Toronto Michael Murray Memorial University of Newfoundland Eleanor Maticka-Tyndale University of Windsor

ABSTRACT

KEY WORDS •

action

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education

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health promotion

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liberation

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participation

Community-based action research has received increased attention in health research as an important vehicle for both knowledge creation and community capacity-building. This approach to research is value-driven, attuned to power issues, committed to stakeholder participation, and action-oriented. Efforts to build capacity within the health research community to engage collaboratively with communities in action research projects must be predicated on a framework that delineates the preferred knowledge base/core concepts, skill sets, and the combination of classroom-based, academic learning, and supervised field learning that is required. In this article we propose a praxis framework that integrates the core concepts, core competencies, and training processes for graduate education in community health action research. We review current opportunities for training in this approach in Canada and illustrate how two graduate programs in different disciplines currently operationalize the elements of the proposed framework.

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Views about health and health interventions have changed considerably over the past 30 years. Whereas health was previously viewed as the absence of disease, more recent views define health as wellness: an optimal state of development that entails physical, cultural, psychosocial, economic, and spiritual attributes (Marks, Murray, Evans & Willig, 2000). With this shifting view of health have come alternative health interventions. Several influential reports in the 1970s and 1980s called for a shift in health policy and practice from an exclusively biomedical focus on the treatment of disease to the inclusion of population and community-wide approaches to health promotion (Epp, 1986; Lalonde, 1974; World Health Organization, 1986). Since the publication of these reports, a variety of health promotion programs have been established, most of which focus on lifestyle factors that contribute to poor health and strive to promote behavior change for healthier lifestyles related to smoking, diet, and exercise. Recently, several limitations of this lifestyle approach to health promotion have become evident. First, health promotion remains micro-centered, reflecting an ideology of individualism (Lupton, 1994). Psychological components, such as health-related attitudes, cognitions, and behaviors are emphasized, while social determinants, particularly socioeconomic inequality and social capital (Hofrichter, 2003; Wilkinson, 1996), receive little attention. Second, programs are typically conceived by ‘expert’ health care professionals and researchers, with little to no consultation with the people who are the intended beneficiaries of the programs (Boutilier, Cleverly & Labonté, 2000). Such programs may not be what people want or need, and they may perpetuate the power imbalance between health care professionals and community members. Third, health promotion research has retained an almost exclusive reliance on positivist, quantitative research methods that is typically done ‘on’ people rather than ‘with’ people. As the limitations of both the biomedical and lifestyle approaches to health have become more apparent, more critical perspectives on health research and action have emerged (e.g. Murray, 2004; Murray & Campbell, 2004; Poland, Coburn, Robertson & Eakin, 1998; Prilleltensky & Prilleltensky, 2003). Indeed, professionals from different disciplines have argued that for health research to be relevant, it must take account of the broader sociopolitical context in which health is shaped. This must include attention to widening economic disparities, which are expressed in many ways, including the following: processes of economic globalization and its sociopolitical consequences regarding the flexibility of labour and ‘cultural imperialism’ (Galtung, 2000); the social and environmental impacts of wasteful consumerism; the social class bias and conservatism of many influential media; and the emergence of an ‘underclass’ of unemployed homeless people and the concurrent erosion of the social safety net (Barlow & Clarke, 2001). While this list is by no means complete, it does point to the need to articulate an alternative vision of health research and action and to develop forward-

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Building capacity in community health • 391

thinking curricula in the health sciences that integrate a concern for social justice with a rigorous and theoretically informed understanding of how society operates, how it is structured, and processes of social exclusion (Coburn, 2000). While there are currently several diverse strands of alternative approaches to health research and action that have emerged from different disciplines, a coherent framework that integrates these strands and provides clear direction for graduate education has yet to be articulated. In order to help fill this gap, the purpose of the article is to explicate and illustrate a praxis framework for graduate education in what we call ‘community health action research’. The article is divided into two main sections. In the first section, we sketch out the contours of such a praxis framework, while in the second section, we illustrate how this framework has been implemented in Canada, focusing specifically on two graduate programs.

Towards a praxis framework for education in community health action research In this section, we elaborate on six core concepts and the related competencies that constitute the outcomes of education in community health action research and key educational activities and processes that can be used to build these competencies in students in training. We selected these concepts based on our reading of the emerging literature on critical and community perspectives on health research and action. These interrelated concepts are the anchor points that begin to define the emerging perspective of community health action research, address the limitations of mainstream approaches to health promotion, and provide a foundation for competency-based training in this approach.

Values Core concept Whereas traditional health science research claims to be objective and valueneutral, such research can nonetheless be shown to be deeply value-laden, beginning with what topics and methods are deemed to be suitable for research and how problems are framed. Such claims of value-neutrality often camouflage research that supports the societal status quo (Nelson & Prilleltensky, 2004; Prilleltensky & Nelson, 2002). Prilleltensky (2001) has formulated a set of personal, relational, and collective values that provides direction for community health action research. These include self-determination, empowerment, inclusion, respect for diversity, and social justice (for definitions, see Murray, Nelson, Poland, Maticka-Tyndale & Ferris, 2004).


Core competencies Students need to be literate with respect to values so that they can critically analyse and challenge the values that underlie health research and action. They also need to be able to articulate the values that they deem important and to translate guiding values into action in practical ways (Nelson, Ochocka, Griffin & Lord, 1998). For example, the value of self-determination leads to research that should enhance the power of disadvantaged people; begin with their experiences through sharing personal stories; and maximize their participation in community health action research (Nelson et al., 1998; Tolman & Brydon-Miller, 2000). The value of inclusion suggests that community health action researchers should develop supportive relationships among all those involved in the research and be respectful of differences in ethno-racial background, gender, and sexual orientation (Adrien et al., 1996), while the values of social justice and accountability to oppressed groups mean that opportunities for employment and education of disadvantaged people need to be created and that research findings should be used to catalyse social change (Nelson & Prilleltensky, 2004). Key training activities and processes Developing these core competencies related to values requires several training activities, which should permeate all course and program activities. First, faculty needs to raise students’ awareness through readings and discussion about the value-laden nature of community health action research. Second, it is valuable to have class and program-wide discussions about the values and vision that should underlie the training program. Finally, it is important to create a safe space in training programs in which students and faculty can talk freely about value dilemmas, conflicts, and gaps between stated values and current practices.

Assumptions Core concept The nature of the questions that researchers ask about the world embodies a number of assumptions that fundamentally drive community health action research. These questions are framed in the context of assumptions about what constitutes ‘evidence’, the purpose of research, how we ‘do’ science; many of which are codified in methodological prescriptions. Critical social analysis is informed by historical perspective/analysis; moves back and forth from the micro to the macro to show the dialectical relationship between the two; and looks for root causes of health problems embedded in social structures and practices. According to Davies, Swift and Clarke (2003), key aspects of society that social analysis focuses on include inequalities in health and what they point towards

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and inequitable distribution of prerequisites to health (e.g. income, employment, housing). The search for root causes and deepening the social analysis reflects a particular world view called critical realism (e.g. Bhaskar, 1979). Unlike other paradigms of inquiry, critical realism is distinguished by its commitment to social justice and to socially relevant research. Core competencies Reflexivity about presuppositions enables community health action researchers to learn how to openly negotiate with community groups the perspectives that inform the research and action. Key skills for unpacking hidden assumptions that drive research include critical thinking and an awareness of basic paradigms of inquiry. Students need to understand how society operates, how resources and power are distributed, and specifically who benefits from prevailing sociopolitical arrangements. It is also essential that students become thoroughly familiar with competing paradigms and decide which paradigm is consistent with her/his own ontological, axiological, and epistemological orientation. Students must understand different ontological and epistemological stances, their implications for research methodology, and relation to communities, as rival paradigms lead to asking different research questions of the same phenomena and using different research approaches Key training activities and processes In classroom and practicum training, students should be encouraged to engage in critical thinking. Such thinking involves deepening the social analysis, including: questioning our assumptions about the world around us; going beyond surface understandings/appearances; and questioning popular beliefs, official truths, and so-called ‘expert’ opinions. Students must also learn how to reframe problems and generate alternative intervention strategies that address the root causes of health problems. Theory courses need to include material on social analysis and intervention, and practicum courses should provide students with practical examples and assistance in ‘doing’ social analysis and intervention. Additionally, students need to be exposed to different research paradigms and learn about their assumptions and implications, as well as research tools associated with each paradigm (Lincoln & Guba, 2000).


Power Core concept Whereas power is typically ignored in mainstream views of health, power is central to critical perspectives on health. Power suffuses everything; there are many different types of power; power can be used for many different ends; and power consists of both agency and opportunity (Prilleltensky, in press). It is important for community health action researchers to recognize that there are power imbalances in most contexts, and that power inequality can have profound negative health consequences (McCubbin, 2001; Wallerstein 1992). Power inequality has been conceptualized as oppression, a relational concept that implies asymmetric power relations between individuals, groups, communities, or societies (Prilleltensky & Gonick, 1996). Oppression suggests that it is not just that some people lack power, but that there are dominant-subordinate relationships in which certain groups enjoy more power at the expense of others. Core competencies Core competencies that need to be fostered include the ability to understand health from the framework of power and oppression and to conceptualize alternative health interventions based on such an analysis. In addition, students need to learn to become reflexive researchers and practitioners. This involves connecting the personal and political in their identities as health professionals and becoming aware of their own power and privilege and the need to share power (Eakin, Robertson, Poland, Coburn & Edwards, 1996). Community health action researchers often have assumptions and prejudices of which they were unaware in working with disadvantaged people. Thus, it is important to approach empowerment practice with a spirit of humility and a willingness to learn about oneself. Finally, students need to learn how to work with disadvantaged groups through an empowerment approach to health promotion (Labonté, 1993; Lord & Hutchison, 1993). An empowerment approach to health promotion begins with listening to disadvantaged people and collaborating with them to address the unjust conditions that are oppressing them (Freire, 1970). Key training activities and processes To promote these competencies, students must be exposed to theory, research, and practice in health promotion from the perspective of critical theories of power and oppression. Particularly important for the practice of community health action research is the need to challenge the ‘professional as expert’ model and to learn how to work as facilitators and collaborators with disadvantaged people. To model power-sharing, faculty members need to share power with

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students in the classroom and the program. Concretely, this means negotiating the content and process of all courses, recognizing and valuing students’ experiences and strengths, and encouraging students to play an active role in the learning process (Freire, 1970; hooks, 1994).

Partnership Core concept Community health action research demands that researchers work in partnership with disadvantaged community members who are vulnerable to a variety of health-related problems by virtue of their social circumstances. However, it is not easy to work in partnership with disadvantaged people who are deeply mistrustful of health researchers because they have seldom benefited from research. Moreover, the concept of ‘partnership’ can be corrupted and used to manipulate disadvantaged people (Lord & Church, 1998). Therefore, partnership needs to be grounded in terms of the emancipatory values noted earlier (Nelson, Prilleltensky & MacGillivary, 2001). Partnership means that the researcher is committed to sharing power and reducing the power imbalance between professionals and disadvantaged community members, providing multiple mechanisms for participation of disadvantaged people in the research process, focusing on their strengths, and immersion of the researcher in the issues, needs, and context of disadvantaged people over the long-term (DeKonning & Martin, 1996; Rappaport, 1990). The partnership relationship that we are proposing has been described as one of accompaniment or solidarity with oppressed people (Baum, 1992; Lykes, 2001). Core competencies In addition to methodological skills, community health action researchers need to have skills in interpersonal relationships, including active listening and other communication skills, such as team work, group process facilitation, taking the perspective of the ‘other’, and bearing witness to oppression. Research cannot proceed without partnerships that are based on trust and mutual respect. It would be naïve, however, to think that relationships can always be ‘equalized’. It is preferable to acknowledge power imbalances than to pretend we can wish them away (Boutilier, Mason & Rootman, 1997). Nevertheless, in the context of acknowledged unequal power relations, one can work towards embodying active listening, the ceding of decision-making control, and the cultivation of solidarity around shared goals.


Key training activities and processes The skills of partnership are best learned from modeling and practicum experiences. Faculty needs to use highly participatory group processes in classroom instruction, in which they share power and build community with students. More explicitly, practicum courses need to provide structured activities and use experiential activities to build skills, such as active listening, group facilitation, and conflict resolution. These are important skills that students will need to use in their field placements.

Systems Core concept Community health action research is also characterized by an ecological analysis of health. Such a perspective views health within the context of characteristics of the individual (e.g. coping skills); micro-level analysis (e.g. family, peer group); meso-level settings that mediate between smaller systems and the larger society (e.g. work settings, schools) (Poland, Green & Rootman, 2000); and macro-level analysis (e.g. social policies, social class, social norms). The smaller systems are nested within the larger systems, and the various levels are interdependent (Kelly, 1986). Core competencies Systems thinking is important for two reasons. First, failure to think and practice systemically may inadvertently lead to ‘victim-blaming’. Mainstream health research and action is micro-centered and seldom takes into account more macrosocial determinants of health (Prilleltensky & Prilleltensky, 2003). Second, systems thinking is important for practice. An important step in any health action research project is to identify and organize the relevant stakeholders. Often times community health action researchers play a key role in the formation of coalitions and partnerships among multiple stakeholders that aim to improve population and community health (Israel, Schulz, Parker & Becker, 1998; Roussos & Fawcett, 2000). Key training activities and processes Theory courses need to familiarize students with ecological perspectives and systems theory, and research courses need to focus on multi-level analysis of health phenomena. An important component of this is how macro-social factors are related to meso- and micro-level factors in influencing health. Practicum training needs to provide students with experiences in working with diverse groups of stakeholders (e.g. health coalitions).

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Action Core concept While mainstream health research is concerned with the creation of new knowledge, community health action research is concerned with the development of new knowledge towards the goal of social justice and health promotion (Prilleltensky, 2001). In community health action research, action is derived not only from research but also in it. Unlike mainstream research, action is the selfconscious intent of community health action research from the beginning (Hart & Bond, 1995). Its purpose is the generation of knowledge that is strategically catalytic to the social change process, not as a ‘nice’ by-product of research, but as a fundamental non-negotiable animating life-force (Reason & Bradbury, 2001). Towards the goals of action and change, there is an emphasis on widespread communication of research findings. Researchers need to consider all the different audiences for the research and translate research findings into useful products. These products can include pamphlets, summary bulletins, and progress reports; programs, processes, and intervention strategies (e.g. Elkins, Kuyyakanond, Maticka-Tyndale, Rujkorakarn & Haswell-Elkins, 1996; Maticka-Tyndale, Haswell-Elkins, Kuyyakanond, Kiewying & Elkins, 1994); and videos, dramatic productions, and stories. Communicating research findings to multiple audiences can lead to a process of resource mobilization for change. Core competencies In addition to communicating findings, community health action researchers can work with community partners in using a wide range of strategies to create transformative social change (Prilleltensky & Nelson, 2002). First, there are skills in designing and implementing health promotion/prevention programs, including building a sound program model and community ownership for the project. Second, community health action researchers need to develop competencies in organization development, such as process consultation, leadership training, and team-building. Third, in community development, the community health action researcher must not only be able to form partnerships with disadvantaged groups, but she/he must also be able to engage numerous other stakeholders and systems. Fourth, training needs to build competencies in understanding the process of social policy formulation, analysing social policy issues and positions, and influencing social policy. Finally, community health action researchers must develop skills in social action, coalition-building, and political advocacy to create broader social change.


Key training activities and processes Action needs to be emphasized in all parts of training, both formal and informal and both academic and experiential. Students must be provided with a background in social analysis and intervention strategies. This should include both reading material and exposure to community health action research projects through field trips and guest speakers. Students also need practicum training in which they can gain experience in social intervention. Finally, action should be a key part of the ethos of training, with faculty and graduates serving as role models of social action and community development through their immersion in social justice issues.

Summary In summary, we have outlined core concepts and related core competencies and training processes that are a foundation for graduate education in community health action research. In the next section, we illustrate how this framework can be put into action.

Graduate education in community health action research in Canada: overview and examples of two training programs Overview of educational opportunities in Canada The Royal Society of Canada commissioned a study (Green et al., 1995) of participatory research in health promotion which recommended greater attention to the inclusion of participatory research in educational programs in health promotion. As members of a Working Party on community health action research from 1999–2001, we scanned opportunities for graduate education in community health action research in Canada in psychology, medicine, and health promotion. Within psychology, we identified two francophone programs and one anglophone program that provide training in community psychology at both the MA and PhD levels (Walsh-Bowers, 1998). These programs emphasize prevention/ promotion and action research, but tend to focus on mental health rather than physical health. Moreover, there were no free-standing graduate training programs in health psychology in Canada at the time (Graff & Martin, 1996), although Carleton University is currently developing a Masters’ program in health psychology. We also found that few of the 16 Canadian medical schools offer anything resembling community health action research. Several attempts at a comprehensive survey of educational programs in health promotion have been made over the past 10 years (Hills & Green, 1999; Hills & O’Neill, 2000; Ontario Prevention Clearinghouse, 1994; Stirling &

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Church, 2004; Working Group on Health Promotion, Education and Training, 1997). The survey by Stirling and Church (2004) is the most comprehensive in scope, including an inventory of: a) b) c) d) e) f)

‘self-learning’ resources, workshops; forums, symposia, and conferences; summer schools, institutes and short courses; certificate and diploma programs; undergraduate and graduate university degree programs; and continuing education and distance education offerings.

Several recent resources also list centres and units specializing in communitybased and participatory research (see Appendix H in Minkler, Wallerstein & Hall, 2003). A recent survey of teachers of health promotion commissioned by the Consortium for Health Promotion Research identified 84 courses with significant or exclusive focus on health promotion in 23 of 36 universities in Canada (Hills & Green, 1999). Significantly, the role and importance of community-based learning emerged as a key theme in their report. While most educational offerings in health promotion address the broad social determinants of health, among the six graduate-level programs in health promotion in Canada (University of Alberta, Dalhousie, Université de Laval, Université de Montréal, University of Toronto, and UBC Collaborative Program in Nursing), the University of Toronto program is arguably unique in its sustained focus on critical social science perspectives on health and health promotion. This is perhaps because educational programs continue, by and large, to be influenced by what several observers (e.g. O’Neill, Rootman & Pederson, 1994) characterize as an historic and continuing emphasis on the lifestyle approach to health promotion. In the following sections, we explore graduate education in community health action research by profiling two different programs. We selected these programs because we believe that they closely adhere to the praxis framework that we elaborated in the first part of the article. After describing each program, we note common themes and links to the praxis framework.

The community psychology program at Wilfrid Laurier University The MA Program in Community Psychology (CP) at Wilfrid Laurier University formally began in 1976. In the fall of 2003, a PhD program in Psychology, with CP as one of the fields of study, was launched. Here we focus on the MA program.


The curriculum The curriculum devotes relatively equal attention to theory, research, and practice. In the first year of this two-year program, students typically complete the six required courses: two courses in community psychology and social intervention, two research courses, and two practicum courses. The courses in community psychology and social intervention introduce students to the values of community psychology, theoretical foundations (including all of those described as core concepts in the first part of this article), and areas of application (e.g. health, mental health, disabilities). One of the two research courses is in statistics, while the other course focuses on research in community settings. This latter course includes attention to research paradigms and their respective ontologies, epistemologies, and methodologies, and provides skill training in qualitative research methods, program evaluation, and participatory action research. For the two practicum courses, students work in a community placement for one day a week or 100 hours per term. Students have a rich array of placements from which to choose and are encouraged to carefully select the setting and to make a contract with setting contacts about the nature of the work and the students’ learning goals. The practicum is designed to provide a service to the community, a learning opportunity for the student, and the potential for research (Bennett & Hallman, 1987). The practicum also focuses on a variety of practical skills that students need to work in community settings, including active listening and community skills, small group facilitation skills, and consultation skills with individuals, organizations, and communities. The second year of the program is devoted to a thesis, which is typically a community action research project. Students typically become immersed in a setting and work with community stakeholders to formulate an action research project. The faculty and students The CP program has eight full-time faculty members from the Psychology Department, one member of the Department of Sociology and Anthropology whose research focuses on gender, health, and illness, and a full-time field placement and practicum coordinator. Each year, six to seven MA students are admitted to the program. Students are selected not only on the bases of traditional academic criteria, but also on their community experience and their identification with the values of the CP program. The program also strives to be inclusive and have a diverse student body. Over 150 students have graduated from the CP program. More than 75 percent of these students go on to work as managers, researchers, evaluators, and planners in health, education, and social services. The majority of recent graduates work in community health or mental health. The remaining 25 percent go on to doctoral training in psychology or health sciences.

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The MHSc health promotion program at the University of Toronto This two-year program, which was founded in 1979, has an explicit social science emphasis on health promotion. Like the WLU program, students in the Graduate Department of Public Health Sciences at the University of Toronto (U of T) can also complete a doctoral degree. Again, we focus here primarily on the Masters level. The curriculum The curriculum of the Health Promotion (HP) program is different from that of the Laurier in that it focuses more explicitly on physical health and health promotion, and it is more course intensive (a thesis is not required). In the first year of studies, HP students are required to take courses in health promotion, public health sciences, community health appraisal methods, Canada’s health care system and health policy, health promotion strategies, and a 12-week, full-time, paid summer practicum placement. In the second year, students take required courses in program evaluation and critical issues in health promotion, two electives, and a 16-week, full-time, paid practicum (or five more courses in lieu of the second practicum). A key component of the second practicum is the ‘field inquiry’, a reflective, community-based, practice-oriented field research project that is supported by mentors in the field and in academe, usually involving problem conceptualization, data collection, analysis and interpretation, and write-up in the form of a research paper. The purpose of the practicum is to enable students to get ‘hands on’ experience in health promotion and to apply the theory and analytic skills acquired in the academic portion of the program. Students arrange their own practicum, although all placements have to be approved by faculty. Students establish their goals for the practicum in consultation with their academic supervisors and their on-site field practicum supervisors. A written contract for the practicum specifies the goals/objectives and the learning experiences for achieving these goals. Students have weekly supervision meetings with their field practicum supervisors. The faculty and students The HP program consists of an interdisciplinary faculty (e.g. education, geography, health policy, nursing, psychology, sociology). The four to five full-time faculty members most closely associated with this program have diverse research and action interests, including workplace health promotion, the health of street youth, children’s health, women’s health, and ethnicity and health, to name a few. Each year 10–14 students are admitted. Individuals who graduate from the HP program find employment in a variety of human services, though not


exclusively in the health promotion field, doing project management, program planning and evaluation, and applied research (Allison, McNally, Depape & Kilner, 1995).

Common themes in the process of training across the two programs In line with the praxis framework that we proposed in the first section of the article, the nature of training in both the CP program at Laurier and the HP program at the U of T is competency-based, process-oriented, and guided by several core concepts (Lykes & Hellstedt, 1987). Moreover, these core concepts and related competencies and training processes are emphasized in: a) b) c)

the academic content of the program; supervised practicum training in the community; and interpersonal, classroom, and program dynamics.

First, both programs have an explicit focus on values. An examination of the values that underlie health research and action and one’s own values is an important point of departure for both programs. The values on which the Laurier CP program is based are embodied in the program’s mission statement (a joint effort of students and faculty), which is prominently displayed on a poster board in the department. The core vision of the HP program includes taking the broad determinants of health into account, thinking critically and strategically, seeking to advance the field of health promotion, and applying health promotion theory to practice. In both programs, attention is paid to values clarification and developing a sense of community, team work, and supportive relationships among students through routine ‘check-ins’ in classes, group process activities, and personal reflection exercises. Second, both programs encourage students to examine and challenge hidden assumptions that underlie health research and action, with attention to the broad social determinants of health and the assumptions of different research paradigms. Third, power is an overarching theme in both programs. Within the two programs, students have a say in the course content and process, serve as facilitators of classroom discussions, and make classroom presentations. They are encouraged to connect the personal and the political in the formation of their professional identities, to bring their experiential knowledge into the classroom, to use their strengths, to examine their privilege, to challenge the ‘expert’ role of health professionals, and to analyse the power dynamics that suffuse health research and action. Fourth, the small nature of both programs lends itself to close and collegial working relationships among students and faculty that are a model of how to develop partnerships. Many opportunities are provided for students to partici-

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pate actively in the programs, including attending business meetings, selecting speakers for colloquium presentations, and participating in the hiring of faculty and the student admissions committee. Fifth, ecological and systemic thinking is a key component of both programs. Whereas clinical health training programs have a micro-focus, the CP and HP programs view health from a systems perspective, including micro-, meso-, and macro-determinants of health, and the interrelationships between these different levels of analysis. In practice, learning to work with a broad range of stakeholders is an important component of systems practice. Lastly, both programs have a strong action orientation. The faculty members in both the CP and HP programs have long-term ties with a variety of community settings. Moreover, practicum training is a key element in both programs. Both faculty and student research often has an action component tied to it, and faculty and students routinely become involved in activities that have a social justice focus. Finally, faculty and students in both programs periodically review the curriculum, evaluating the degree to which students acquire core competencies, the processes of training, adherence to the core concepts and values that guide training, and the long-term outcomes of training (e.g. employment after graduation) (Alcalde & Walsh-Bowers, 1996; Allison et al., 1995).

Conclusion In this article, we have shown that there is an emerging trend of community health action research in the health sciences. This has been fuelled by critical perspectives on the larger sociopolitical context. In particular, the adverse impacts of increasing socioeconomic inequalities and declining social capital on health have been recognized. At the same time, health care has been commodified, privatized, and focused on the diseases or lifestyles of individuals, with no attention to macro determinants. One important implication of this social analysis for practice concerns the role of the community health action researcher as a social activist. Community health action research claims that research is value-laden and should be oriented towards the promotion of social justice. Thus, the stance of the researcher becomes one of partner with disadvantaged groups in society and advocate with these groups for social change. This stands in contrast to the role assumed by mainstream health researchers as detached scientists who avoid addressing the moral and political implications of their work. With the emergence of critical perspectives in health and community health action research, there is a need for educational programs to build capacity in this new approach. We presented a praxis framework for graduate education and suggested some broad skill sets that flow out of the key dimensions of this approach. We also illustrated how two Canadian graduate programs have been providing training in community health action research. We believe that the


framework that we have outlined and the illustrations of how this framework can be put into action provide a useful heuristic for graduate education in community health action research that can be used by other graduate programs in which faculty and students want to move beyond the lifestyle approach to health promotion to one that emphasizes social justice. In her commentary on practices for a liberation psychology, Moane (2003) distinguished between three levels of change. At the personal level, the challenge is to build individual strengths through promoting assertiveness and positive role models. At the interpersonal level, the challenge is to promote greater interconnectedness and solidarity, while action at the political level involves deepening the social analysis and developing a vision and strategy for promoting social change. These three levels are not distinct but can reinforce each other through a cycle of liberation. Through their training community health action researchers learn of the opportunities for action at these different levels. Such a process of working with can become an opportunity for what Freire has called conscientizacao – ‘learning to perceive social, political, and economic contradictions, and to take action against the oppressive elements of reality’ (1970, p. 17). This process can be one of substantial personal challenge for community health action research trainees. Disappointments and frustrations can be demoralizing and the trainees may need lots of support. On the other hand, successes can be personally transformative and need to be celebrated. It is through these processes that the trainees can develop a sense of themselves as scholar-activists.

Acknowledgements This article derives from a larger report entitled ‘Training in Community Health Psychology’ that was prepared by a working group composed of the authors together with Francine Lavoie, Roy Cameron, Lorraine Ferris, and Ken Prkachin. The preparation of that report was supported by the Canadian Institutes of Health Research Opportunity Program, Award Number COF 38230 [www.med.mun.ca/tchp]. Thanks to Nicole Nelson for her help editing the final draft of this article.

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Geoffrey Nelson is Professor of Psychology at Wilfrid Laurier University, Waterloo, Ontario, where he is University Research Professor for 2004–2005. He has served as Senior Editor of the Canadian Journal of Community Mental Health and was the recipient in 1999 of the Harry MacNeill award for innovation in community mental health from the American Psychological Foundation. Michael Murray is Professor of Social and Health Psychology in the Division of Community Health at Memorial University of Newfoundland, Canada. He is the editor of Qualitative health psychology (with Kerry Chamberlain; Sage, 1999) and of Critical health psychology (Palgrave, 2004). He also is the co-author of Health psychology (Sage, 2005). Blake Poland is Associate Professor and Director of the Masters Health Science Program in Health Promotion in the Department of Public Health Sciences at the University of Toronto. His work has included participatory action research with street-involved youth, as well as critical-interpretive research on community development as an arena of practice for health professionals. Eleanor Maticka-Tyndale is Professor of Sociology and Canada Research Chair in Social Justice and Sexual Health at the University of Windsor. Her research focuses on community understandings and influences on sexual health; she has partnered with communities in the development of sexual health programmes in Thailand, Kenya and Canada; and she has been a member of national and international expert working groups. Address: Correspondence should be directed to Geoffrey Nelson, Department of Psychology, Wilfrid Laurier University, Waterloo, ON, CANADA, N2L 3C5. [Email: [email protected]]