ALAR
Journal, 11(1), 29-39.
This paper will combine information from these systematic reviews and other sources, to
invite discussion of the quality of action research reported in the health related literature, and
the criteria used to judge the quality of action research in healthcare settings.
Since the 1990’s health care new systems known as evidence based practice, evidence
based medicine and evidence-based healthcare have been developed to support health
professionals in providing the best available care.
Evidence based medicine has been defined as ‘the conscientious, explicit, judicious
use of current best evidence in making decisions about the care of individual patients’
(Sackett, et al, 1996). From medicine, these principles have expanded into the care of
patients or clients by other health professions as evidence based practice (EBP) and
more recently, to include service development and management in evidence based
health care . Evidence based practice asserts that making clinical decisions based on
best evidence, either from the research literature or clinical expertise, improves the
quality of care and the patient's quality of life. In this framework, clinicians may
utilizing the best evidence available from the same sources, may still apply this
knowledge differently, and outcomes may vary depending upon the patients' values,
preferences, concerns, or expectations.
Most texts on evidence based practice present a set of identified levels or hierarchies
of evidence which were established initially within evidence based medicine. (see, for
example, . Although wording may differ slightly, the constructions are similar to the
following table:
The work of Hampshire and her colleagues demonstrates that it is possible to apply
the randomised controlled trials to action research. Some would ask whether this is
appropriate, and whether we should buy into the idea that randomised controlled trials
are a ‘gold standard’ of healthcare knowledge, but that is outside the scope of this
paper. The difficulties of making statistical measures of the effectiveness of
interventions to improve the quality of care is well recognised, and by no means
limited to action research. This work illustrates one way of generalising action
research findings, but combing the results of several case studies.
Elizabeth Hart and Meg Bond {Hart, 1995 #77} identify four types of action research
in healthcare. They call these ‘experimental, organisational, professionalising and
empowering action research, and arrange them on a continuum from top-down control
to bottom-up participation in decision making. This typology includes research
approaches which are designed and controlled by the researcher, with the dual aims of
increasing knowledge and contributing to improved practice, as well as others which
could be described as a ‘participatory, democratic process concerned with developing
practical knowing in the pursuit of worthwhile human purposes, grounded in a
participatory worldview’, which is the definition of action research proposed by
Reason and Bradbury {Reason, 2001 #73, p. 1}.
The largest and most systematic review was prepared by the RTI Evidence-based
Practice Center at University of North Carolina for the US Agency for Healthcare
Research and Quality. Their full report is available on the open Web. They defined
Community-Based Participatory Research (CBPR) as ‘a collaborative research
approach is designed to ensure and establish structures for participation by
communities affected by the issue being studies, representatives of organizations, and
researchers in all aspects of the research process to improve health and well-being
through taking action, including social change’. They identified 1408 published
articles which satisfied at least one of their inclusion criteria, and after systematically
applying exclusion criteria, reviewed 185. Several reports claiming to be Community-
Based Participatory Research did not fit their systematic definition, reflecting well
known difficulties in defining action research.
The systematic literature search illustrates the increase in the number of CBPR
studies, especially after 1996. The identified a total of 11 studies in all years prior to
1996, and 24 in the three years from 2001 to 2003 {Viswanathan, 2004 #66, p. 59}.
Viswanathan and her colleagues asked two key questions that relate to the quality of
action research and health. They systematically reviewed each article with regard to
the quality of research method and the quality of community involvement. They also
asked whether CBPR projects achieved their intended to outcomes.
Table 1: Publication dates of CBPR articles
35
30
Number of Studies
25
20
15
10
0
Before 1980-1985 1986-1990 1991-1995 1996-2000 2001-2005
1980
Year (2003-2005 projected)
To assess the equality of research methods, Viswanathan and her colleagues reviewed
four randomized controlled trials, four quasi experimental studies, two single group
pretest and posttests and one non- experimental design, all of which were considered
CBPR. There is an inherent difficulty in systematic the judgment of the quality of
CBPR. Whereas we might consider a randomized trial in which studies were allocated
between a CBPR approach and traditional research methods, because CBPR requires
that the community identify the health problem to be addressed, and be involved in
designing and conducting the research, the two approaches would almost certainly
yield very different interventions and recruitment strategies, leaving little for
comparison other than the final outcome measure.
The review rated the quality of reported research elements on a scale from 1 to 3, with
higher scores representing higher values. The researchers did not establish a cut-off
score for acceptable quality. On this 3-point scale, 50% of CBPR studies score more
than 2.5, 17% were between 2 and 2.5, 33% were between 1.5 and 2, and none were
rated below the half-way mark {Viswanathan, 2004 #66}. The reviewers commented
that some CBPR achieve high scores for research quality, but they found very few
complete and fully evaluated CBPR interventions, partly because page length
limitations in journals lead to incomplete documentation.
Of the same studies, only one third achieved quality ratings for participation higher
than 2.5. A quarter was between 2 and 2.5, 42% were between 1.5 and 2 and none
rated below the half-way mark for participation {Viswanathan, 2004 #66}. Studies
which rated high for research quality did not achieve such high scores for
participation, and from other data in the reviewers found evidence that high-quality
scores in community collaboration are associated with low-quality scores for research.
Despite this trend, the review uncovered several examples of outstanding research
combined withy collaborative community participation throughout the research
process {Webb, 2004 #89}. My conclusion is not that high levels of participation
produce poor quality research, but that more attention to quality of both research and
participation, and adequate resources are needed.
Overall, stronger or more consistent positive health outcomes were found in the better
quality research designs. CBPR can also lead to unintended positive health outcomes,
and positive outcomes not directly related to the measured intervention.
As Reason and Bradbury point out in their Introduction to the Handbook of Action
Research, ‘action research has been … promiscuous in its sources of theoretical
inspiration’ {Reason, 2001 #73, p. 3}. The Handbook includes chapters that draw on
pragmatic philosophy (Levin and Greenwood, Chapter 9), critical thinking (Kemmis,
Chapter 8), the practice of democracy (Gustavsen, Chapter 1), liberationist thought
(Fals Borda, Chapter 2), humanistic and transpersonal psychology (Rowan, Chapter
10; Heron and Reason, Chapter 16); constructionist theory (Lincoln, Chapter 11;
Ludema, Cooperrider and Barrett, Chapter 17), systems thinking (Flood, Chapter 12;
Pasmore Chapter 3) and complexity theory. While it is a mistake to claim that there is
one theoretical approach to action research, it is confusing and misleading to mix
models from different professional settings, paradigms and theoretical frameworks in
a single study, and Meyer and her colleagues do.
In their systematic review of 75 action research reports Meyer and her colleagues
Through an action research approach, what factors are identified as influencing
change in health care practice?'
Table 2: Systematic reviews
Reference No. articles Study design Aim or question
reviewed
{Viswanathan, 185 articles Community (1) What defined CBPR? (2) How has CBPR
2004 #66} (from 1408 based been implemented to date with regard to the
articles participatory quality of research methodology and
identified) research community involvement? (3) What is the
evidence that CBPR efforts have resulted in
the intended outcomes? (4) What criteria and
processes should be used for review of CBPR
in grant proposals?
{Meyer, 1999 75 articles Action Through an action research approach, what
#65} (from 333 research factors are identified as influencing change in
articles health care practice?'
identified)
{Waterman, 59 articles Action To examine the role of action research in UK
2001 #67} (from 285 research healthcare settings and to provide guidance for
articles funding agencies, policy makers, ethics
identified) committees, users and researchers for
assessing action research proposals and
reports
Background
Action research is employed in many healthcare settings in the UK but its scope and
role in this context is not clear. It is practised under a variety of names and has been
applied in many settings since Kurt Lewin coined the phrase in 1947. Its particular
strength lies in the coupling of participation and research to action and change.
Action research is a period of inquiry that describes, interprets and explains social
situations while executing a change intervention aimed at improvement and
involvement. It is problem- focused, context-specific and future-oriented. Action
research is a group activity with an explicit critical value basis and is founded on a
partnership between action researchers and participants, all of whom are involved in
the change process. The participatory process is educative and empowering, involving
a dynamic approach in which problem identification, planning, action and evaluation
are interlinked. Knowledge may be advanced through reflection and research, and
qualitative and quantitative research methods may be employed to collect data.
Different types of knowledge, including practical and prepositional, may be produced
by action research. Theory may be generated and refined, and its general application
explored through the cycles of the action research process.