Table 5

Actions and tools/techniques to address power inequities in participatory health research

Aims	Actions	Tools/techniques that can support actions within research partnerships
Micro level
Embed discussions about power and empowerment	Be explicit and prioritise discussions about power and empowerment within and beyond research partnerships	Explore assumptions about power using participatory tools such as Power Flower55, Chapati Diagram56or Power Line61
Demystify abstract concepts associated with ‘power’	Explore power and empowerment terms and principles, strengthening understanding of concepts such as positionality and reflexivity and how they relate to power, privilege, and empowerment	Rename and/or redefine CBPR principles so they are culturally appropriate, as done by the National Black Leadership Initiative62 Use metaphors, vignettes or alterative creative methods to demystify abstract concepts63
Ensure power is considered and addressed throughout each stage of the research process	Jointly decide key stages in the research process where power will be explored, reviewed and reflected on (eg, at the start of the project, after data collection and analysis, during advocacy or when taking action, throughout dissemination)	Integrative practice framework that provides a structured process for developing and maintaining PR partnerships64
Acknowledge deep-rooted power dynamics and understand what they mean for power sharing within research partnerships	Explore ‘identity’ within the research partnership, discussing how reflexivity, roles, responsibilities, knowledge exchange, capacity and choice of language can support shifts in power	The Tree of Life65 River of Life66 Metaphors to explore identity in relation to others67
Strengthen capacity of community and academic partners to, individually and collectively, pursue co-produced knowledge and take action for sustainable impact on research aspirations and beyond	Embed, measure and monitor capacity strengthening of soft and hard skills for community partners who are less experienced in research or social advocacy including confidence, self-esteem, effective leadership and communication, data collection and analysis, developing plans and constructing funding proposals	Bilateral training for ‘partnership readiness’42 68 Mentorships69 Social advocacy training70 Develop individual learning plans69 Value Creation Stories that collectively and individually generate immediate, applied and potential value of learning activities71
Meso level
Enable community partners to set the agenda for the research and choose which approaches to implement	Share knowledge of research methods, interpretations, perceptions and interventions from similar projects in different contexts, promote and support community partner decision-making on which options to use or adapt	Ranking exercises72 Participatory intervention mapping such as stepping stones to identify what steps are required to make change73 Training to become a peer educator74
Create safe communicative spaces for participants	Conduct research activities and discussions in settings that are familiar to co-researchers and provide opportunities to share experiences in safe spaces (eg, some marginalised groups feel more comfortable sharing stories with others who have similar experiences)	Jointly develop ground rules for communicative spaces75 Ensure that there is collective voice to protect from the risks of individual representation76 Assess who is present and the power dynamics that may be at play, considering intersection axis of inequities within group settings77.
Minimise ‘tokenistic’ participation in research	Employ mechanisms that ensure alignment with participatory research principles for participatory research,39 employ community governance structures to serve as a source of accountability in the partnership and provide structure to guide the partnership’s activities	CBPR evaluation framework78 Follow quality criteria for PHR79 External and/or community advisory boards where community partners can voice concerns and priorities that otherwise might not enter into the researchers’ agenda80
Protect communities from feeling coerced into participating in research	Ensure safeguarding principles are in place within the research partnership and consider how opportunities to participate in research are presented and by whom	Guidance on Safeguarding in International Development Research81
Shift decision-making to community partners early in the research process	Generate governance processes that are documented, shared and agreed by all members that clearly indicate decision-making roles and mechanisms of consensus and conflict management	Memorandum of Understanding/Terms of Reference82
Address hierarchies within and across stakeholder groups	Co-develop indicators that can be used to jointly monitor shifts in the internal dynamics and relational environment within research partnerships	Apply the ‘Dimensions of structural governance’ measures83
Maintain trust between different stakeholder groups	Manage expectations to balance research project limitations and community needs/priorities while supporting ideas and ways to expand beyond the project scope	Co-develop Terms of Reference to clearly define and communicate project limitations82 Conduct ranking exercises when multiple actions are suggested by communities72
Ensure appropriate reward for participation in research	Discuss reward systems as a partnership, explore what each partner wants to gain from the collaboration, what would incentivise and motivate them to continue, and what would be beneficial to all	Example incentives include monetary payment, educational/training opportunities, prestige, recognition in communities, becoming a peer educator and increased access to information or networks84
Examine the ethical risks associated with participatory health research	Have open transparent discussions that explore the impact of empowerment on individuals and groups within their sociopolitical environment	Participatory Health Research: A Guide to Ethical Principles and Practice53 Model for developing context-sensitive responses to vulnerability in research85
Promote inclusivity and facilitate mutual understanding	Use participatory tools that promote inclusivity such as creative and narrative techniques, drama, storytelling, song and others	Photovoice86 Participatory video87 Digital storytelling88 Participatory drawing89 Participatory creative writing90
Support documentation and community ownership of local knowledge	Prioritise the documentation of community knowledge that reflects local ways of knowing, ensuring that legal frameworks are in place to protect community rights and ownership of outputs to prevent exploitation for the gains of other more powerful partners	Establish intellectual property rights, shared authorship on publications, reports, blogs led by community; see co-researcher blogs from informal settlements in Bangladesh91
Manage the balance of gatekeeper involvement to minimise potential exclusion of the most marginalised	Engage gatekeepers in attaining access to communities early on in the research,52 while considering other avenues to work with diverse population groups that may not be reached through gatekeepers	Stakeholder mapping92 Social network analysis93 Social media analysis to identify supporting groups94
	Address ethical issues related to recruiting participants through gatekeepers by examining the complexities of human conduct	Phronesis to support researchers to make critical ethical decisions based on the specific characteristics of the research sites and subjects95
Understand the motives and intentions of gatekeepers	Evaluate gatekeepers’ motives, how routes of access affect research participation, and how the relationship between a gatekeeper and researcher is established and maintained	Establish trust and rapport with gatekeepers as members in the research process—raising issues of power and exclusion in research generally52
Macro
Ensure marginalised groups have equal opportunities for participation	Undertake social mapping and discursive activities to assess the distribution of power and resources across population groups	Governance diaries96 Transect walks97 Social mapping98 Community dialogue99
Recognise colonial legacies that generate power inequities within international partnerships	Have open conversations on the place of the ‘foreign gaze’, of local knowledge and of organic change in global health to help identify strategies to fundamentally undo colonial practices and attitudes100	Authorial reflexivity matrix, with combinations of local and foreign pose and gaze100

CBPR, community-based participatory research.