Practitioners research their own practice - Health Policy and Planning

HEALTH POLICY AND PLANNING; 11(1): 72-83 © Oxford University Press 1996

Practitioners research their own practice:collaborative research in family planningJUDI AUBEL1 AND AMINATA NIANG2,'Independent Consultant, Dakar, Senegal, and 2Sante Familiale, Dakar, Senegal

A recurring problem in many African countries is that the results of research carried out in public healthprogrammes are often not used by programme planners and managers. Collaborative research, whichinvolves programme practitioners in applied research projects with social scientists, can strengthen thelink between programme research and its application in programme implementation. In this paper, therationale for a collaborative research approach is discussed. The article illustrates use of this approachin a study conducted in Senegal of midwives' interpersonal communication behaviour during familyplanning consultations. Once the practitioner-researcher team had summarized the study findings, theydeveloped detailed recommendations for key aspects of family planning service delivery. This experiencesuggests that a collaborative research approach can be beneficial insofar as it can generate practicalrecommendations for improving health programmes, strengthen programme staff's applied researchskills and increase their motivation to use research results. Several constraints associated with the use

. of a collaborative research approach are also identified. Based on this experience, suggestions for in-creasing the effectiveness of social scientists' involvement in research activities in collaboration withprogramme practitioners are formulated.

IntroductionIt is often assumed that the results of applied researchcarried out in the context of public health programmeswill be used to improve programme policies andstrategies. In developing countries, where resourcesare usually limited, rational allocation of availableresources presupposes that investments in programmeresearch should yield results which programmeplanners can readily use. There is increasing recogni-tion, however, that there is often a gap between healthsector research and the application of research find-ings to the development and implementation of healthprogramme strategies (WHO 1991; Mosely 1992;Cook et al. 1993). In a review carried out for WHOon the utilization of social science research by healthprogramme managers, Ambrose (1986) concludedthat under-utilization is a widespread problem.Evidence of the gap between research and its applica-tion is, to a great extent, anecdotal given the fact thatfew social scientists have been interested in empir-cally investigating the issue of research utilization(Cernada 1982; Crosswaite and Curtice 1994).

In an important collection of writings on the contribu-tion of social science research to improving health

in developing countries, one of the main issues dealtwith is the extent to which such research is used toinform health policies and programmes (Chen et al.1992). In this recent volume, Lincoln Chen advocatesthat there is an urgent need to strengthen 'research-to-action linkages' (ibid. 211).1

Several factors have been identified which can poten-tially contribute to the under-utilization of healthresearch results: in some cases researchers do notfully understand either the nature of the existent pro-gramme intervention or practitioners' expectations ofthe research* researchers often have their ownresearch agendas which do not correspond with pro-gramme managers' priorities; researchers oftenemploy sophisticated methods which mystify both theresearch process and results and, consequently,alienate programme planners and managers (Mosley1992).

Traditionally, responsibility for conducting pro-gramme research has been delegated to social scien-tists who have worked independently of programmestaff. Some social scientists continue to defend suchautonomy on the grounds that involving programme

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Collaborative research 73

staff in programme research requires unacceptablecompromises in terms of scientific rigour. In addi-tion to the potential constraints identified by Mosley(1992) associated with research conducted exclusivelyby the 'experts', such an approach does not promotea sense of ownership of the research on the part ofprogramme staff.

Two factors related to the use of social scienceresearch results, and which appear to contribute tothe utilization of research findings in public healthprogrammes, are: 1) the involvement of programmestaff and decision-makers in the research process(Patton 1978; Argyris et al. 1987; Ayers 1987; Lin-coln and Guba 1985), and 2) the formulation ofcomprehensive and specific recommendations basedupon research results (Kar 1977; Weiss andBucuvalas 1980; Argyris 1993). Both of these fac-tors are germane to Chen's call for stronger linkagesbetween health sector research and public healthaction programmes. Related to the first issue, res-ponsibility for carrying out health sector research,Findley (in Chen et al. 1992) underscores 'the needfor a close partnership between researchers and (pro-gramme) implementors' (p. 15). With regard to theproduct of health sector research, Mosely contendsthat research results must not only be comprehensibleto programme managers but also provide them withpractical guidelines on how to improve programmeperformance (in Chen et al. ibid). In a collaborativeresearch approach these two elements are priorityconsiderations.

Before describing the collaborative research projectcarried out in Senegal, this paper will review the prin-ciples underlying the collaborative research approach,and the family planning (FP) programme context inSenegal in which the research was carried out.

Conceptual foundation of thecollaborative research approachIn the research discussed in this paper, a 'col-laborative research approach' was used. A discretebody of literature does not exist on the collaborativeapproach, as such. Rather, the conceptual andmethodological underpinnings of this approach drawon several different but related bodies of literature,all from outside the health field, namely, organiza-tion development (Varney 1977; French and Bell1978; Margulies and Raia 1978); organizationallearning (Argyris et al. 1987; Senge 1992; Preskill1994); action research (Corey 1953; Lewin 1948;

Cunningham 1993; Adelman 1993); process consulta-tion (Schein 1969; Lippitt and Lippitt 1978); and par-ticipatory programme evaluation (Patton 1978, 1982;Guba and Lincoln 1989). The critical characteristicsof each of these perspectives embodied in the col-laborative research approach are summarized below.Other research modes share common elements withthe collaborative research model but are not discussedhere, including operations research (Fisher et al.1992; Seidman and Horn 1991), health systemsresearch (WHO 1991; Cook et al. 1993), action learn-ing (Revans 1982), action science (Argyris et al.1987) and participatory research (Maguire 1987; FalsBorda 1991).

Organization developmentThe field of organization development (OD) isprimarily concerned with how change can most ef-fectively be introduced into organizational settings(French and Bell 1978; Varney 1977). Key elementsin OD of relevance to applied programme researchin health include the concept of organizational culturechange (Gagliardi 1986; Nordstrom and Allen 1987)and the steps in the institutional adoption of innova-tions (Zaltman and Duncan 1977; Beyer and Trice1978). A critical facet of both is the role whichorganizational teams or groups play either to perpetu-ate or to modify the existing institutional culture. Theorganization development perspective on institutionalchange supports the need for the substantive involve-ment of teams of key institutional 'actors' in theresearch process.

Organizational learningRelated to the previous field, from the world ofbusiness and organizational behaviour, a new con-cept and literature has recently emerged in the workof Senge (1992) and others on organizational learn-ing. According to Cousins and Earl (1992): 'Organi-zational learning occurs when actions within theorganization are improved through better understand-ing' (p. 401). Effective learning organizations areskilled at five main activities: systematic problemsolving; experimentation with new approaches; learn-ing from their own experiences and past history;learning from the experiences of others; and trans-ferring knowledge quickly and efficiently throughoutthe organization (Garvin 1993: 81).

Action researchIn action research a systematic research process isused to solve practical problems in programmes ororganizations. 'Action research is an attempt to help

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74 Judi Aubel and Aminata Niang

the practitioners develop scientific ways of thinkingand acting and to seek actions that will result in theimprovement of practices' (Pareek and Khanna 1992:249). Action research grew out of concern for thediscrepancy between the research priorities of socialscientists and the practical needs of social action pro-grammes. Precursors of action research, Dewey(1938) and Lewin (1948), contended that social scien-tists should be involved with practitioners in the studyof social practice. Since the early 1980s, interest inaction research has grown, particularly in the fieldof education (Oja and Smulyan 1989; Elliott 1993;Walker 1993), and to some extent in public health(Israel et al. 1989; Barnett and Ndeki 1992; Titchenand Binnie 1993).

An action research approach is characterized by anumber of salient features: the use of a systemsapproach to programme analysis; primarily inductive-qualitative research methods are used (Cunningham1993); organizational members work with researchersin a collaborative process; organizational staff acquireskills in analyzing and solving organizational pro-blems in a process of staff and institutional develop-ment; and it can constitute an empowering processfor organizational staff as they increase their senseof control over their own programmes and lives(Israel et al. 1989: 139-40). To date the systematicuse of an action research approach in public healthprogrammes in Africa has been relatively limited.

Process consultationAnother body of literature concerning how socialscientists work with teams of practitioner-researchersis process consultation (Schein 1969; Lippitt and Lip-pitt 1978). In Schein's (1969) seminal book entitledProcess consultation: its role in organization develop-ment, he presents a typology of consultant styleswhich contrasts the traditional 'directive' mode withthe more participatory, 'facilitative' mode. The pro-cess consultation model embraces the facilitativemode of consultation, in which problems are jointlydiagnosed and solutions collectively developed by theconsultant in close collaboration with organizationalmanagers. This model provides useful principles andsteps for social scientists working with organizationalteams in applied health research activities.

Participatory programme evaluation (PPE)There is a quickly expanding body of literature onPPE, primarily from the field of education. Majorcontributions to the conceptual and methodologicaldevelopment of PPE have been made by Guba and

Lincoln (1989), Patton (1978, 1982, 1987), Cousinsand Earl (1992) and Greene (1988). While theseauthors deal specifically with evaluation, much oftheir work is applicable to applied programmeresearch.

A key element in all of the work on participatoryevaluation is the assumption made regarding the par-ticipation of programme stakeholders in the evalua-tion or research process.

"The 'stakeholder assumption' is the idea that keypeople who have a stake in an evaluation shouldbe actively and meaningfully involved in shapingthat evaluation so as to focus the evaluation onmeaningful and appropriate issues, increasing thelikelihood of utilization.' (Patton 1982: 59).

Based on this assumption Patton (1982) formulatedmethodological guidelines for 'collaborative evalua-tions' which specify how programme staff can be in-volved at each step in planning and carrying out anevaluation or research activity. Guba and Lincoln(1989) refute the conventional belief that evaluationsshould be carried out exclusively by 'objective' out-siders. They deny that an objective reality exists andmaintain that the perceptions of both outsiders andinsiders are subjective 'social constructions of themind' (ibid: 43).

A critical facet of PPE is the social scientist-facilitators role in the evaluation process. In a par-ticipatory or collaborative evaluation the role is thatof a. facilitator who provides a structure within whichstakeholders can participate in the process. The roleof the evaluator-facilitator is that of collaborator,change agent, learner and teacher, and active partici-pant. The meaningful involvement of practitioners incollaborative research projects requires social scien-tists who are also adept facilitators.

It is noteworthy that these five areas of conceptualand methodological thought reviewed above arelargely ignored in the public health literature onresearch and evaluation.

Key methodological features ofcollaborative research

Based on the conceptual and methodological para-meters discussed above, four key features of col-laborative research are identified, all of which areof relevance to applied health research: a focus on

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practical concerns of programme staff; contributionto staff development; demystification of the researchprocess; and collaboration between social scientistsand practitioners. All of these features are illustratedin the case study from Senegal presented below.

The research context: the SenegaleseFamily Planning ProgrammeFamily planning (FP) services have been providedin Senegal since 1980. For many years, the emphasisin the national programme has been on establishinga network of services with necessary staff, equipmentand supplies. Concern with 'quality of care' (Bruce1989) has been articulated only recently (Huntingtonet al. 1991; Diop 1992).

The impetus for the collaborative research projectcame from national FP programme staff. In 1992,in an informal discussion, they articulated their con-cern with the quality of the interaction between mid-wives and their FP clients. Based upon numerousanecdotes about midwives' negative attitudes andpoor communication skills, they insisted that suchattitudes are counterproductive to FP service delivery.We decided to carry out a study on midwives' inter-personal communication attitudes and skills duringFP consultations. We subsequently prepared a pro-posal for the study and a small amount of fundingwas obtained from the national programme in orderto carry it out.

In keeping with a collaborative research approach,it was agreed that FP programme staff would beinvolved in all phases of the research project. A groupcomprising 6 of the national FP programme staff wasconstituted, heretofore referred to as the'coordinatinggroup'. The members of this group included fourmidwives, a social worker and a communication-education specialist. They were expected to par-ticipate in developing the study methodology and totake primary responsibility for coordinating theimplementation and completion of the research.

The research methodologyWe proposed to the coordinating group a sequenceof 7 steps as a framework for the researchmethodology (Table 1). These steps draw primarilyon Patton's work on collaborative evaluation withorganizational groups (1982). While the steps aresimilar to those commonly used in research projects,a critical distinction in a collaborative research pro-

cess relates to who is involved in each of the steps.Each step in the methodology is described in termsof the process followed and secondly, the outcomeor product of each step.

Step 1: Identify research team membersIn a collaborative research approach, the researchteam should be made up of staff from different levelsof the programme. The rationale for this is that thosewho work at different levels of the programme havedistinct perspectives and that it is valuable to incor-porate the different perspectives when developing thestudy content, interpreting the results and formulatingrecommendations.

It was decided that the research team would include:the central level coordinating group, to coordinateand be directly involved in all aspects of the study;the FP supervisor from each of the 10 regions of thecountry, to carry out the data collection and par-ticipate in formulating study conclusions and recom-mendations; and the social scientist (principalresearcher, JA), referred to as the 'methodologycoordinator'. The role of the methodology coord-inator was to provide a methodological frameworkfor the study, to facilitate the different steps in theprocess and also to participate as an active memberof the research team.

Step 2: Develop research methodologyIn a collaborative research approach, the practitioner-researchers are involved, as much as possible, in thedevelopment of the methodology. Their involvementcan contribute to the relevance of the research, totheir sense of ownership of both the research processand product, and to their individual and collectivelearning.

In the FP study, the research methodology wasdeveloped by the coordinating group in collaborationwith the methodology coordinator. In this step,together we defined the research objectives, choseand developed the data collection instrument anddetermined the criteria with which the researchsample would be chosen.

First, the team carefully defined the overall objectiveof the research as: to identify the verbal and non-verbal behaviours of midwives during FP consult-ations which either inhibit or facilitate communica-tion with their clients. Based upon this objective, weconsidered alternative data collection techniques. Ina group exercise, the team members were asked to

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Table 1. Steps and responsibility in the family planning collaborative research study

Steps Persons involved

Step 1: Identify research team members

Step 2: Develop research methodology

Step 3: Train observers

Step 4: Conduct observations

Step 5: Tabulate and analyze data

Step 6: Formulate conclusions and programmerecommendations

Step 7: Develop plan to disseminateresearch results

Family planning (FP) programme managerand social scientist

Coordinating group and social scientist


Regional FP supervisors and coordinatinggroup

Coordinating group, regional FP supervisorsand social scientist

Coordinating group, regional FP supervisorsand social scientist


list the advantages and disadvantages of using eitherinterviews or observations. Based upon the discus-sion, they concluded that interviews of clients and/ormidwives would not provide detailed and accurate in-formation on the midwives' actual behaviour duringthe consultations. They decided that observationscould provide more reliable information, though theywere sceptical that the presence of an observer wouldinfluence the midwives' behaviour. Despite thesewell-founded concerns, there was a consensus thatthe observation was the best available data collectiontechnique. The methodology coordinator reinforcedthis decision and explained that while observationshave been used to only a limited extent in health sec-tor research, they are particularly useful for collec-ting information on actual behaviour in a given setting(Field and Morse 1985; Morrison et al. 1990).

In order to reduce the study costs and to integratethe data collection into the regional FP supervisors'normal work responsibilities, it was decided thatobservations would be conducted at a purposeful sam-ple of the FP centres in each region. In keeping withthe idea of integrating the research project into ongo-ing programme activities, the number of observationsto be conducted was determined based on the numberof centres in which the regional supervisors couldcarry out the data collection in a one-month periodin the course of their routine supervision visits. Basedon this pragmatic reasoning, it was planned that ineach region 6 to 8 midwives would be observed three

times each. As such, it was anticipated that between60 and 80 midwives would be observed in total.

Developing the data collection instrument, a checklistof verbal and non-verbal behaviours to be observed,was the next task. This proved to be both challeng-ing and instructive for the coordinating groupmembers. Prior to the study, the national FP pro-gramme had never clearly defined the optimumbehaviours (verbal and non-verbal) which midwivesshould exhibit at each step in the FP consultationprocess.

The methodology coordinator structured andfacilitated a process in which the coordinating groupmembers took the main responsibility for identifyingthe desired behaviours. This required them to reflecton their own experience working in FP clinics. Inaddition, based upon her own familiarity with the FPcounselling literature and with FP service deliveryprogrammes, the methodology coordinator suggestedcertain behaviours which she felt the other teammembers had overlooked. Once a draft observationchecklist was ready, it was presented at a nearbyclinic, and subsequently revised several times priorto its finalization.

The development of the observation checklist wasa time-consuming task but when it was completed theteam members concurred that it was an instructiveexercise. A statement by one of the participants

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seemed to reflect the sentiments of the group, 'Nowwe know exactly what we expect of midwives duringthe FP consultancy'.

Step 3: Train observersThe next step was to train the FP supervisors to con-duct the observations. While the training of datacollectors is obviously necessary, in a collaborativeresearch approach such training can also constitutea staff development exercise.

In many research projects, the training of data col-lectors is considered to be a perfunctory step in whichthe mechanics of data collection are to be masteredby outside 'enumerators', 'interviewers' or'observers' who are recruited for the task. In suchcases, time allotted for the training is often minimal.In the FP study, the justification for the trainingworkshop was indeed to prepare the supervisors tocollect the observational data. At the same time,however, it was viewed as an opportunity for FP stafffrom both the central and regional levels to sharpentheir understanding of one of the key facets of FPservice delivery, midwives' interpersonal com-munication skills. In addition, the training was ofvalue to the FP practitioners in that it expanded theirunderstanding of applied health research. Given thestaff development value of the training, three full dayswere allocated for the training workshop.

During the session, participants were involved in aseries of learning activities, in both classroom andclinic, which allowed them to discuss, observe andanalyze the various verbal and non-verbal com-munication behaviours defined as priorities in effec-tive FP consultations and included in the observationchecklist. By the end of the three-day session, thepractitioners appeared to be prepared to conduct theplanned observations. Furthermore, over the courseof the three days an improvement in the programmestaff's ability to discern the various verbal and non-verbal behaviours was observed.

Step 4: Conduct observationsSimilar to the previous step, in a collaborativeresearch approach, the rationale for substantivelyinvolving programme practitioners in the data col-lection phase relates to the potential for staff learningand ownership of the research process.

In the Senegal study, regional FP supervisors had fullresponsibility for conducting observations of mid-

wives in their routine catchment areas. It wasrecognized that the involvement of regional staffcould introduce several sources of bias to the validityof data collected. During the training workshop thesepotential problems were discussed in an attempt tolimit them as much as possible. In our opinion, inthe collaborative research mode the potential forlearning and ownership on the part of programmestaff, which can accrue from their participation,outweighs the disadvantages. In the traditionalresearch mode, which uses supposedly objective out-siders, there is no potential for staff development.

The regional FP supervisors were expected to carryout the observations in the two months following theirtraining. In most cases this was done, although in afew instances logistical constraints made the deadlineimpossible to meet. A total of 142 observations of51 midwives were carried out; an average of 2.78per midwife observed, slightly less than the 3 obser-vations per midwife which had been anticipated atthe outset.

Step 5: Tabulate and analyze dataInvolvement of practitioner-researchers in the dataanalysis phase of the research can contributesignificantly to the demystification of the researchprocess, and to programme staffs sense of owner-ship of the research project. It can also reinforce theirskills in basic data tabulation and analysis.

Once the observations were completed in all 10regions, the data were manually tabulated by severalof the working group members. The team members,none of whom were computer literate themselves, hadplanned the data tabulation to be done by a computertechnician, but the proposed cost for this was sub-stantial and the alternative was manual tabulation.From the authors' perspective, this alternative was,in fact, preferable, not only because it was less ex-pensive but also because the practitioners were notrequired to depend on the expertise of a computertechnician. While we live in an era of universalfascination with computers, the collaborative researchperspective compels us to favour methodologicaloptions which demystify the research process, ratherthan the opposite. In this case, with calculators inhand the FP practitioners completed the data tabula-tion. It is hoped this experience convinced them thatcomputer support is not indispensable and that it gavethem the confidence and skills necessary to conductsimple research activities on their own in future.

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Table 2. Results by categories of communication behaviour

Category of behaviour % yes % no

1. Efforts made to make the client feel comfortable

2. Explanations given regarding procedures carriedout and expectations of client

3. Discretion shown by midwife

4. Midwife is acceptably attired

5. Appropriate manner of talking to the client

6. Efforts made to involve the client inconsultation process

7. Appropriate manner of listening to the client

8. Adequate information given on contraceptivemethods

9. Reinforcement of client's choice of familyplanning method

64

53

77

98

84

43

70

46

36

47

23

2

16

57

30

54

83 17

We worked with the other team members to groupthe tabulated results into 9 categories of verbal andnon-verbal communication behaviours. Theyprepared a simple table summarizing these findings(see Table 2). While more sophisticated analyses ofthe data were possible, such as correlations betweenbehavioural categories, this level of analysis was suf-ficient for the purposes of the working group andsubsequent decision-makers. More elaborate dataanalysis is not necessarily advantageous insofar as ittends to mystify and alienate practitioner-researchers.

Step 6: Formulate conclusions and programmerecommendationsIn most health sector research projects, based onresearch results, conclusions and recommendationsare formulated by 'expert' researchers. There areseveral limitations associated with conferring respon-sibility for developing research recommendations on'outsiders'. On the one hand, if not intimately familiarwith the organization and programme in which theresearch was conducted, they tend to develop verygeneral results which subsequently are of limited useto programme staff. On the other hand, recommen-dations formulated by outsiders can be misunderstoodby programme managers or unfeasible in the institu-tional and/or programme context. In the collaborativeresearch approach these constraints can largely be

overcome through the involvement of programmestaff in the development of research conclusions andrecommendations.

In the FP study, a two-day working session wasorganized during which the research coordinatinggroup members discussed the results and formulatedtheir own conclusions. Responsibility for this taskprimarily belonged to these group members. The roleof the methodology coordinator was to structure andfacilitate the involvement of the group members inthe deliberations while at the same time contributingto the process as a group member.

A structured two-step methodology was used in theworking session. On the first day of the session, foreach of the 9 categories of midwife behaviour studied(Table 2), the research findings were discussed andthe group formulated succinct conclusions. On thesecond day, the group developed recommendationsfor each of the categories, based upon their conclu-sions. A critical aspect of the facilitator's role wasto insist that the conclusions and recommendationsbe formulated in very simple and concise language.

Table 3 presents the chart used in the two-stepmethodology, along with an example of the con-clusions and recommendations developed for one ofthe research categories studied.

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Table 3. Conclusions and recommendations chart: Efforts to involve the client in the consultationprocess

Conclusions Recommendations

1. In more than half of the consultations observed(57%) the midwife did not make the necessary effortto elicit the participation of the client. This findingsuggests that the consultation is often conducted as adialogue. Examples of the inadequate behaviour on thepart of the midwife include: in very few cases (4%) didthe midwife inform the client that she could askquestions during the consultation: in only 49% of thecases where clients using a FP method returned for afollow-up visit did the midwife ask the client for feed-back on her experience with the method; in 63% of thecases the date for the client's follow-up visit was notset in consultation with the client.

1. From the beginning to the end ofthe family planning consultation themidwives should involve the client ina dialogue in which the client isencouraged to ask questions, and isasked her opinion in terms ofdecisions to be made and follow-upaction to be taken.

In addition to the conclusions and recommendationsdeveloped for each of the categories of behaviourstudied, the working group developed several generalconclusions and recommendations as well. At thisstage, the methodology coordinator reiterated theimportance of clearly formulating the conclusions andrecommendations and ensuring their feasibility in thecontext of the national FP programme. One of thegeneral conclusions was:

The study results suggest that in the 10 regionsof the country the quality of interpersonal com-munication during FP consultations is generallypoor. We believe that this weakness contributesto several of the problems which have been iden-tified in the national FP programme such as:dissatisfaction of clients with services; low atten-dance rates at FP centres; the number of inactiveFP clients; the number of clients who have discon-tinued use of a FP method.

The group formulated one global recommendationand a series of specific recommendations based onthe main research conclusions. The global recommen-dation states:

Given the importance of interpersonal communica-tion in FP service delivery, it is critical that greateremphasis be given to this key aspect of any suc-cessful FP programme.

To increase the likelihood of the recommendationsbeing put into practice, the coordinating group wasasked to formulate recommendations for four keyaspects of the national FP programme, namely:organization and management of FP services; super-

vision of FP clinics by regional coordinators; healthtraining schools' curriculum; and inservice trainingcontent. Based upon the group members' indepthfamiliarity with the national FP programme, theydeveloped specific programme recommendationswhich are both clearly worded and feasible, accor-ding to them. For example, one of the recommend-ations for the organization and management of FPclinics states:

At the service delivery level, other staff (besidesthe midwives) such as social workers and nursesmust be conscious of the importance of their roleas communciators with clients. Their communica-tion skills should be reinforced through training.

Step 7: Develop a plan to disseminate researchresultsA universal problem is that often research results arenot communicated to the individuals and institutionsto whom they can be of use. The development of acomprehensive plan for the dissemination of researchfindings can increase the extent to which the resultsare ultimately used.

As the last step in the FP study, the research teammembers identified firstly the individuals and institu-tions who would potentially be interested in theresearch results, and secondly, for each of these in-dividuals/organizations, a strategy and/or materialsfor informing and discussing the results with them.In terms of identifying potential strategies/materials,the facilitator encouraged the group to be as specificas possible. As an example, the group identified the

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'regional medical officers' as key recipients of theresearch findings and two mechanisms were proposedfor communicating with them. The team recommend-ed that: 1) the research results be presented to themduring one of the periodically-scheduled nationalcoordination meetings for medical officers; and 2)that they receive a 4-5 page re'sume' of the study. Foreach of the target groups, similar strategies were pro-posed. In addition to the list of recipients andstrategies/materials, the working group recommendedthat someone from the national FP programme beappointed to ensure that the dissemination activitiestake place.

DiscussionThe purpose of this article was to present the rationalefor the use of a collaborative research approach toapplied research in the health sector and to illustrateits use in a study conducted in the family planning(FP) programme in Senegal. The importance andcontent of each step in the collaborative researchmethodology has been described along with an illus-tration of how each step was operationalized in a FPstudy in Senegal. This article was not intended to pre-sent the findings of the FP study (see Aubel et al.1992 for details of the study).

Two key features of the methodology employed inthe FP study, which differ from conventional ap-proaches to health sector research, are of particularsignificance. First, there was close collaboration bet-ween the social scientist-researcher and the pro-gramme practitioners in all phases of the researchprocess. Secondly, the role of the social scientist-researcher was that of 'facilitator' and 'capacity-builder'. These characteristics are in keeping with theprinciples of action research, organizational learning,participatory programme evaluation, organizationaldevelopment and process consultation, which providethe conceptual underpinnings for the collaborativeresearch approach.

The FP research conducted in Senegal exemplifiesthe value of the collaborative research approach interms of: demystifying the research process for pro-gramme practitioners; contributing to staff develop-ment; linking research to programme implementation;the synergistic learning between social scientists andprogramme staff; and developing a sense of owner-ship of the research process and product on the partof the practitioner-researchers. Evidence of each ofthese outcomes in the FP study is summarized here.

Several characteristics of the study contributed todemystifying the research process for programmepractitioners: FP programme staff had substantiveresponsibility for developing and carrying out allsteps in the research process; an attempt was madeto simplify the research methodology at the data col-lection and data analysis stages. Whereas in manystudies programme staff are called upon to assist withprescribed aspects of data collection or analysis, inthis case the role of programme staff was moreimportant than that of the social scientist.

There is considerable evidence that in several respectsparticipation in the research process constituted a staffdevelopment exercise for those involved. Theirunderstanding of the steps and techniques involvedin conducting applied research increased during thecourse of the research. There was also an increasein their understanding of the programmatic issuestudied, namely midwives' communciationbehaviour. Whereas at the outset the research teammembers described in very vague terms the 'com-munication problem', by the end of the study theywere able to define the precise verbal and non-verbalbehaviours which should be exhibited by midwives.The study results provided them with concreteevidence of the status of the problem in the FP clinicsand this appears to have increased their commitmentto dealing with the problem.

From the outset to the conclusion of the study, severalaspects of the research methodology helped to linkthe research to programme implementation. Thegenesis of the study was a concern expressed by pro-gramme practitioners regarding a problematic aspectof programme implementation. At the end of thestudy, the practitioner-researchers, armed with anintimate knowledge of the organizational and pro-gramme context, formulated concise conclusions andpractical recommendations for the national FPprogramme.

The collaborative research methodology fostereda process of synergistic learning between socialscientists and programme practitioners. The socialscientist progressively learned about the national pro-gramme staffs expectations of midwives in the client-provider relationship while programme staff learnedhow to plan and conduct an applied research study.

The sense of ownership of the research process andproduct on the part of the practitioner-researcherswho were involved in that process is exemplified in

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the team's evaluation of the research methodologyitself:

The participation of programme staff in the entireresearch process was beneficial insofar as itallowed us to expand our knowledge in the fieldof interpersonal communications, to increase ourunderstanding of the action research method andto assume ownership of the research itself.

Constraints and caveatsWhile a number of advantageous facets of the col-laborative research approach are illustrated throughthe family planning case study, several constraintsand caveats related to the methodology are identifiedwhich are relevant to future applied research projects.

The use of an approach which depends on the substan-tive involvement of programme staff requires sup-port from programme management conceptually, interms of acknowledging the value of staff involve-ment, and practically, in terms of releasing staff fromother responsibilities. Such support does not alwaysexist in ministries of health where staff are pulled inmany directions at once.

In the FP study in Senegal, in spite of the enthusiasmof the Ministry of Health staff involved in the study,one year later the research recommendations have notbeen systematically put into practice. This is adecisive shortcoming of the research which meritscareful analysis. In the social science literature, twofactors have been shown to be related to the use ofresearch results: the specificity, comprehensibilityand applicability of research conclusions (Argyris etal. 1987); and the involvement of programme staffand decision-makers in the research process (Patton1978; Kar 1977).

In the FP study, the research conclusions and recom-mendations satisfy the first set of criteria, but asignificant flaw in the methodology can be identifiedregarding the involvement of programme staff anddecision-makers. While FP 'programme staff wereinvolved in all phases of the study, the two top-levelFP programme 'decision-makers' were not involvedin the process at all.

Patton (1978) identifies the 'personal factor' as adecisive determinant of the utilization of evaluationor research results. He defines this factor as the in-volvement of 'an identifiable individual or group of

people who personally cared about the evaluation andthe information it generated' (p. 64). In the Senegalstudy, virtually all of the individuals involved artic-ulated their enthusiasm and commitment to seeing thatthe results were put into practice, but the keydecision-makers in the national programme were notpart of that group. The lesson to be learned from thisexperience is that involvement of programme prac-titione.s in a collaborative research activity shouldinclude top-level managers. Such individuals tend tobe extremely busy and it would be unrealistic to hopethat they could be involved in an entire research pro-cess. Rather, future studies could try to involve themat a few critical points in the hope that this wouldassure their commitment to the research results andto putting them into practice.

Some researchers would criticize the collaborativemethodology due to the involvement of programmestaff in the study of their own programme. While inconventional social science terms this constitutes athreat to validity, in our opinion the advantages ofhaving programme staff involved in the process, bothin terms of their contribution and their learning,clearly outweigh the disadvantages.

A requisite for the use of a participatory approachto research is the identification of researchers whohave the necessary attitudes and skills. In additionto skills in applied research methods, the collaborativeapproach requires a social scientist who values theinvolvement of programme personnel in the researchprocess and who has skills in group dynamics andfacilitation. Social scientists are not trained to begroup facilitators. Patton maintains that many socialscientists are not suited for such a task which requiresflexibility, creativity and the ability to work in part-nership with non-scientists (Patton 1982). Socialscientists who are primarily concerned with ensuringscientific rigour are neither comfortable nor effec-tive as facilitators of a collaborative research exer-cise (Guba and Lincoln 1989). The facilitator in thisstudy (JA) has encountered many social scientists inAfrica and Latin America who were either reticentor categorically opposed to involving programmestaff in an applied research exercise.

ConclusionsThe FP study illustrates the usefulness of the col-laborative research approach both in terms ofgenerating information and of promoting organiza-

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tional change. At the same time, several constraintsassociated with the methodology can be identified.

The rationale for the involvement of health practi-tioners along with social scientists in applied pro-gramme research is strongly supported by conceptsfrom organization development, action research,process consultation and participatory programmeevaluation. This literature has, however, been largely'ignored in the field of health sector research andevaluation.

From an organization development perspective,Argyris et al. (1985) have enunciated the need for'communities of practice' to become 'communitiesof inquiry' (p. 34). From a development planningperspective, Korten (1980, 1989) has articulated theimperative for social scientists to learn how to becomemore relevant to the needs of agency personnel bydemystifying traditional research methods and by in-volving programme practitioners in programme datacollection and problem-solving as part of an ongo-ing 'institutional learning process' (1989: 13). Froman international public health perspective, Chen et al.(1992) challenge social scientists to develop in-novative approaches to social research which con-tribute directly to 'social action for health' (p. x).They underscore the need for collaborative ap-proaches involving programme practitioners withsocial scientists in order 'to improve the linkages bet-ween research and action' (p. 214).

In most research projects, the focus is on theproduct of the research, i.e. the research findings andreport. There is a need to give more attention to theresearch process which can empower practitionersto carry out applied research as a critical element inan ongoing process of institutional learning. Mosleyargues: "The key to effecting institutional and socialchanges that will lead to health improvements lies notonly with the products of social science but also withthe research process' (1992: 202).

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AcknowledgementsThis research was supported by the Family Health and Popula-tion Project and the International Science & Technology Instituteunder a USAID-financed grant. In addition to the second author,other members of the research team include Caroline Mane\ Marie-Victoire Albis, Coumba Diarra and Fambaye Ndao, all of theMinistry of Health, Senegal.

BiographiesJudi Aubel has an MPH in Health Education from the Universityof North Carolina at Chapel Hill and a PhD from the Universityof Bristol in Adult Education and Anthropology. She has workedfor the past 15 years in MCH and community health programmesmainly in Africa but also in Latin America. She is primarilyinterested in developing methodologies for applied qualitativeresearch, participatory evaluation and participatory health educa-tion. She is an independent consultant based in Dakar, Senegal.

Aminata Niang is a trained midwife specialized in family planningservice delivery and training. At the time of the study she wasemployed by the Ministry of Health. She now works for aSenegalese non-governmental organization, Sant£ Familiale, inDakar, Senegal.

Correspondence: Dr Judi Aubel, B.P. 3746, c/o WTNROCKInternational, Dakar, Senegal

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Practitioners research their own practice - Health Policy and Planning