Closer to Home: The Case for Experiential Participation in Health Reform
Higgins, Joan Wharf, Canadian Journal of Public Health
A B S T R A C T
This article describes partial results from a case study of community participation in "New Directions for a Healthy B.C.", a nowabandoned health reform policy. For this study, focus groups were conducted to explore the perspectives of traditionally under-represented citizens in understanding reasons for nonparticipation and to identify strategies for fostering participation in the health reform process. The findings indicate that participating in traditional ways - committee meetings, public fora, completing surveys - was not relevant to the realities of these individuals. Yet, rather than merely refusing to be involved, focus group members extended an invitation for health planning group members to experience their daily lives; an idea that is referred to in the literature as `experiential participation.' In order to foster broad-based participation in community health initiatives, the findings from this study argue for a new understanding of, and appreciation for what actually constitutes participation.
The concept of public participation, or citizen involvement, in planning and implementing health programs, has been articulated and supported in various national and international documents for many years1-4 and is a core element of both health promotion and community development.5-7 The concept is considered to be the bedrock of practice,8 one that is integral to the "health" of a democratic community and is significant to governance and management issues in regionalized health services.9 Yet it is also a concept that has been realized only in a limited sense.'o
The literature on citizen participation contains demographic and psychological profiles of participants, and accounts of their activities, most often committee or public meetings.10-14 Despite the eclectic assortment of research in the field,15-24 the conclusions to be drawn are profoundly similar: the difficulty of enlisting participants from a broad base of citizens. Participants in community endeavours are characterized by their skill in public speaking, ability to understand policy and technical language, familiarity with meeting etiquette and by discretionary resources (education, income, previous experience) and professional status that motivates and enables them to become involved.25-29
Academics and professionals have criticized the design flaws of traditional participation techniques, including the economic and sociocultural barriers that make public fora inconvenient and inaccessible, citizen advisory meetings that require educational and financial resources, and an overreliance on superficial opinion surveys.14,30-32 The deficiency of such methods, then, is that they are exclusionary and fail to represent those who they are supposed to represent.25,33 These impediments are beyond the citizens' control, yet contribute to keeping the traditionally voiceless silent.34 Those unemployed, or who are stereotyped because of youth or old age, gender, physical or mental impairment, low income or ethnicity, are the politically and socially marginalized, and comprise the traditionally voiceless ranks of Canadian society.35-40
Why is it difficult for community initiatives seeking public participation to achieve inclusive, broad-based involvement? Are there alternatives to committee meetings and public fora that may be more accessible and inviting, particularly to and by under-represented segments of the community? Scholars of participation in community association and health promotion have called for research which would further identify feasible strategies for fostering broad-based participation.2641-45 The purpose of this paper is to begin to address the gap between the promise and reality of participation. This article presents some of the findings from a case study documenting the community development experience of local health planning groups as they implemented the now-abandoned health reform initiative "New Directions for a Healthy B. …