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Volume 20 Supplement 1

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• Research article
• Open access
• Published: 11 September 2020

Connecting communities to primary care: a qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines

• Eunice Mallari 1 ,
• Gideon Lasco 2 ,
• Don Jervis Sayman 1 ,
• Arianna Maever L. Amit 1 ,
• Dina Balabanova 3 ,
• Martin McKee 3 ,
• Jhaki Mendoza 1 ,
• Lia Palileo-Villanueva 1 ,
• Alicia Renedo 3 ,
• Maureen Seguin 3 &
• Benjamin Palafox   ORCID: orcid.org/0000-0003-3775-4415 3  

BMC Health Services Research volume  20 , Article number:  860 ( 2020 ) Cite this article

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Community health workers (CHWs) are an important cadre of the primary health care (PHC) workforce in many low- and middle-income countries (LMICs). The Philippines was an early adopter of the CHW model for the delivery of PHC, launching the Barangay (village) Health Worker (BHW) programme in the early 1980s, yet little is known about the factors that motivate and sustain BHWs’ largely voluntary involvement. This study aims to address this gap by examining the lived experiences and roles of BHWs in urban and rural sites in the Philippines.

This cross-sectional qualitative study draws on 23 semi-structured interviews held with BHWs from barangays in Valenzuela City (urban) and Quezon province (rural). A mixed inductive/ deductive approach was taken to generate themes, which were interpreted according to a theoretical framework of community mobilisation to understand how characteristics of the social context in which the BHW programme operates act as facilitators or barriers for community members to volunteer as BHWs.

Interviewees identified a range of motivating factors to seek and sustain their BHW roles, including a variety of financial and non-financial incentives, gaining technical knowledge and skill, improving the health and wellbeing of community members, and increasing one’s social position. Furthermore, ensuring BHWs have adequate support and resources (e.g. allowances, medicine stocks) to execute their duties, and can contribute to decisions on their role in delivering community health services could increase both community participation and the overall impact of the BHW programme.

Conclusions

These findings underscore the importance of the symbolic, material and relational factors that influence community members to participate in CHW programmes. The lessons drawn could help to improve the impact and sustainability of similar programmes in other parts of the Philippines and that are currently being developed or strengthened in other LMICs.

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Community health workers (CHWs) are an important cadre on the frontline of health systems in many low- and middle-income countries (LMICs). The 1979 Alma Ata Declaration on Primary Health Care (PHC), with its call for both more health workers and greater community participation [ 1 ], paved the way for CHWs to assume a greater range of functions, from health promotion to case management, with growing evidence of their increasing role which they have been shown to execute effectively and with good value for money [ 2 ].

In many parts of the world, CHWs are seen as a means to deliver culturally appropriate health services to the community, serving as liaisons between community members and health care providers [ 3 ]. To achieve this, health systems and programmes typically enlist lay individuals with in-depth understanding of the culture and language of the communities from which they are drawn, with the expectation that they will require only minimal education and in-service training, although this will depend on their scope of work [ 4 ]. In 1981, the Philippines was one of the first countries to implement at scale the Alma Alta recommendation of PHC based on community participation (Fig.  1 ) [ 5 ].

Timeline on the development of the Barangay Health Worker role in the Philippines (1978–2020). This figure illustrates the key events related to the introduction and developing role of Barangay Health Workers in the Philippines, since their introduction in the late 1970s to the present day. BHW Barangay Health Worker; CHW community health worker; LGU local government unit; NCD non-communicable disease; NGO non-governmental organisation; PHC primary health care

Operating at the level of barangays or villages, the smallest unit of governance in the Philippines, volunteer Barangay Health Workers (BHWs) have evolved to become an essential component of the nation’s healthcare workforce [ 6 , 7 , 8 ] and have been key to the success of PHC in the country [ 5 , 8 ]. In recognition of their contribution, the Philippine Congress passed the BHWs’ Benefits and Incentives Act (Republic Act 7883) in 1995 (Fig. 1 ), which is the most recent major reform to the BHW role. The law aimed to empower BHWs to self-organise, to strengthen and systematise their services to communities, and to create a forum for sharing experiences and recommending policies and guidelines [ 9 ]. The law also required local governments to offer benefits and allowances to BHWs, as well as scholarships for their children. The only constraint imposed by the law was that the number of BHWs could not exceed 1% of the community’s population. In practice, however, the number of BHWs, along with the scope of their responsibilities and the size of their allowances, are determined by the budget of the decentralised local government health board covering the barangay to which BHWs are assigned.

BHWs have now existed in the Philippines for almost four decades and have often been commended in evaluations of local health systems and community participation [ 6 , 10 , 11 ]. Yet, we lack a good understanding of what motivates and sustains their involvement on a largely voluntary basis. This understanding is crucial as the programme’s continued success and sustainability relies on its ability to motivate and mobilise community members to act as peer health advocates – and the difficulty of realising such community mobilisation has been noted [ 12 ]. The longevity of the Philippine BHW programme, especially when compared with more recent CHW models elsewhere, provides an excellent case study to explore these topics in depth.

This study aims to address this gap by documenting the experiences and roles of BHWs in selected urban and rural sites in the Philippines. We follow Campbell and Cornish’s approach that draws attention to relational and material aspects of the social context of participation, enhancing understanding of facilitators to community mobilisation to improve health [ 12 ]. This helps identify contextual dimensions often neglected in the literature that undermine or support community members’ motivation to participate in the BHW programme and sustain their involvement over time [ 12 , 13 ]. As many countries are in the process of implementing new CHW programmes or strengthening existing ones, the findings from this study could inform ‘task shifting’ programmes and policies that seek to empower and mobilise communities to take more control over their health by means of CHWs [ 14 ], both in the Philippines and in other LMICs.

This study was conducted as part of the Responsive and Equitable Health Systems-Partnership on Non-Communicable Disease (RESPOND) project, which uses longitudinal mixed-methods to better understand health system barriers to care for hypertension as a tracer condition for non-communicable diseases (NCD) in the Philippines [ 15 ]. The study was conducted in purposefully selected urban barangays in the City of Valenzuela and rural barangays in Quezon province, and data for this analysis was collected via semi-structured interviews with BHWs as part of the facilities assessment component of the RESPOND project.

Data collection and management

A senior in-country, bilingual, social scientist researcher led the data collection and supervised two in-country, bilingual, trained research assistants (one male, one female) with relevant experience and backgrounds in communication and public health in administering semi-structured interviews in pairs in Filipino. A total of 23 BHWs were purposefully recruited, 13 from Valenzuela City and 10 from Quezon province, to maximize diversity of experience in terms of length of service, education and age, across the participating barangays. All BHWs in the study sites were women and those agreeing to participate in the study varied in age from 35 to 75 years. All but one were married. Their lengths of service ranged from 1 to 38 years, with 8 possessing 11 or more years of experience. Two participants reported recently returning to their duties following periods undertaking parental and household duties. The educational background of participants ranged from primary school to undergraduate degree. None received formal training as a health professional prior to starting their roles as BHWs.

The interview guide focused on their motivations for becoming a BHW, their day-to-day experiences of developing their role and responsibilities in the community, and their understanding of hypertension (Supplementary File 1). As BHWs in RESPOND project communities were engaged in the sampling of the household survey component, they were approached directly and oriented to the nature of the BHW study. Written informed consent was acquired from those who wished to participate, and interviews with each were arranged and conducted by the two research assistants in Filipino as the mutually shared language. Because all interviewees were women, it was considered important to include a female and male interviewer who could work flexibly to minimise response bias. Interviews were conducted and audio recorded in a secure place selected by participants between September 2018 and October 2019, lasting 30–60 min. After 15 interviews, data saturation was reached and subsequent interviews were conducted to ensure no new data was generated and to maximise sampling diversity.

Following each interview, written notes were reviewed jointly by the research assistants and BHWs to ensure accurate representation and interpretation. The two research assistants transcribed each interview recording verbatim in Filipino, and the fidelity transcriptions was assessed by the senior researcher against the recording. Anonymised transcripts were produced by removing all personal identifiers and attributes, and participants were assigned a pseudonym, which have been applied throughout this report. Research notes and signed consent forms were stored in locked cabinets accessible only to the research team. All digital audio recordings, digitised research notes, and original and anonymised transcript files were stored separately on secure, encrypted and password protected servers or laptops. All non-anonymised research material (e.g. audio recordings, original transcripts, notes) will be destroyed at project end, while consent forms and anonymised transcripts will be kept securely for 7 years thereafter.

Data analysis and rigour

Verbatim transcriptions in Filipino were analysed using NVivo 12 software [ 16 ]. The senior social scientist led the open reading of the Filipino transcripts and several rounds of coding using a thematic approach [ 17 ] with the research assistants. The coding frame emerged, in part, inductively through multiple, iterative readings of the interview transcripts, but was also informed from our a priori interest in motivations and experiences of BHWs, drawing on Campbell and Cornish’s approach to examining how a “health enabling social environment” affects community mobilisation and participation [ 12 ]. After several rounds of coding, analytical memos of emerging and recurring themes were shared with the broader research team, who have expertise in primary health care, health system strengthening in LMICs and the local context, to conduct interpretation and contextualisation via regular discussions in English, ensuring the relevance and transferability of the results both locally and globally. This also included critical assessments of the findings’ plausibility, consistency with other research of findings, and in light of researchers’ own biases, preconceptions, preferences, and dynamic with the respondent (i.e. researchers were health professionals and/or staff of well-known universities) to ensure validity. Key themes, supporting quotations and statements included in memos (and subsequently in the manuscript) were extracted from interview transcripts and translated to English by the bilingual research assistants; and the quality of translations was assessed by bilingual senior researchers by checking and rechecking transcripts against the translated interpretations [ 18 ].

Informed consent and ethical approval

Ethical approval for the research was obtained from the local research ethics board of the University of the Philippines Manila Panel 1. We obtained written informed consent from BHWs prior to the interview, ensuring that their anonymity, privacy and confidentiality would be maintained. BHWs were advised of their right to withdraw their participation at any time, although none of the participating BHWs did so.

In this section, we summarise the lived experiences of community members who volunteer as BHWs in our urban and rural study locations. We also describe the salient themes from these accounts that relate to factors that influenced their initial motivation to volunteer and that determine their continuing involvement.

Becoming a BHW: the role of socio-political positioning and technical knowledge

The social relationships and political positioning of BHWs played an important role in their pathway to participation in the local health system (i.e. recruitment, appointment, and continuing inclusion). Recruitment was largely dependent on having these socio-political connections rather than on having the right skills or technical knowledge to deliver health services. The barangay captain, the leader of the village administration, holds the power to appoint BHWs, and with no formal guidelines to follow, appointments are arbitrary. Some BHWs recalled that they or their peers were appointed by the captain as a result of personal or political relationships, or following a recommendation from other barangay officials, including current BHWs or health staff. Some of the reasons cited for these endorsements included a history of active involvement in barangay activities, such as programmes on feeding, family planning, and fitness. For example, Amy (1 year in service) shared:

I volunteered myself and I said to [the barangay councillor] that if he wins, [allot me a position]. I’ve been applying since before, but I was not given the opportunity. I only volunteer. When he won a seat, I finally got a position at the [health] centre. [The councillor] is my husband’s buddy .

Importantly, however, there need not be any reason for the endorsement other than the prospective BHW’s need for a job, as Ellen (2 years in service) recalled:

My livelihood then was to wash and iron clothes and take to care of children. But when I had a grandchild I could no longer do those tasks, so I asked the barangay treasurer (who happens to be my co-godmother) for any available jobs in the barangay. She told me that they can make me a BHW, so I suddenly became one.

Ellen’s example points to the informality of the application process to become a BHW, something supported by most respondents’ accounts. Cea (11 years in service) recalled that she was interviewed by the local doctor and simply asked (not assessed) about her capacity to work in health centre: “I was interviewed and she asked, ‘Can you do community area activities? Can you do duties in the health centre? Can you do all of this?’” Skills and professional qualification, while useful, are largely secondary to personal connections.

Given that barangay captains are elected every 3 years and their power to appoint (or remove) BHWs, one’s position may not be secure when administrations change. Many BHWs recalled instances when they or their former peers were dismissed because they were not allied politically with the newly elected captain’s party. Luisa (5 years in service) shared that she was dismissed because her religious values did not permit her to vote; while Catherine (6 years in service) recalled that she was dismissed unexpectedly at an earlier point in her career:

We thought that they would not remove anyone, including BHW positions. I was confident. I did not even vote and had no involvement in the political system. After the election on July 1, I went to the barangay office and my name was not included on the list of BHWs.

While a connection to barangay officials appears to be a common route to becoming a BHW, involvement with the wrong politician or non-involvement in politics can also be liability, underscoring the political nature of the position. However, several examples of more merit-based appointments were noted, such as where applicants had previously volunteered for other community activities or programmes (e.g. in the barangay day care centre) or assisted existing BHWs.

Mediating health: bridging and linking community members to services

In general, the activities performed by BHWs involved two roles: serving as frontline health centre staff and acting as community health mobilisers. However, the balance of activities depended on the priorities of the health centre manager to which the BHW was assigned. BHWs were commonly involved in various health centre programmes, including immunisation, maternal care, family planning and hypertension management. Their weekly schedules varied from barangay to barangay, but they typically spent the whole day in health centres 2–3 times a week.

As frontline staff at local health centres, BHWs are often the first point of contact for patients. They welcome patients and perform a range of specific tasks, including admitting and interviewing patients and recording patient information and/or vital signs (e.g. blood pressure), before being seen by a doctor or nurse, if available. BHWs confirmed that their role did not involve diagnosing or prescribing.

As community health mobilisers, BHWs serve as a bridge between the community and their local health centre, promoting health and engagement with existing services, often working house-to-house. They particularly encourage uptake of programmes such as child feeding and NCD prevention and screening at health centres. While they are not allowed to dispense medicines, administer vaccines, or provide direct patient care, they play a supportive role, which includes assisting midwives, blood pressure monitoring, and talking to and motivating patients to adopt appropriate health behaviours. Gina ( 38 years in service) shared:

We encourage them. This is our job: to encourage them that we have a health centre and to seek help if they feel something.

BHWs also assist patients in the community with self-management of their chronic conditions. For instance, they measure the blood pressure of those with hypertension at both the health centre and during house-to-house visits, take the opportunity to remind patients of upcoming follow-up appointments, advise them if medicines are available at the health centre for prescription refills, and educate community members. Ruby (22 years in service) shared:

I remind them that they should not be confident if they don’t feel anything [symptoms]. We don’t know if we have hypertension.

BHWs’ role as community health mobilisers also includes a public health surveillance component, following up on non-adherence and surveying prevailing health conditions in the community. April (8 years in service) described:

If we are not in the health centre, we visit our assigned area. We ask who is pregnant. We ask who is sick. We ask who has tuberculosis. We also do lectures on tuberculosis.

Denden (10 years in service) also described:

We visit them. We knock on their doors and ask why they don’t visit the centre. We remind them to finish the programme. If they give us a chance, we explain the need to continue the programme. It’s like the patient and I are a tandem.

BHWs’ local knowledge and position in the community are useful assets in their role as health mediators, helping them to identify health needs and engage with community members to link them to services . Maria (2 years in service) talked about using her local knowledge and position in the community to achieve this:

We know for example in our community who has tuberculosis. We always research them, so that we encourage them to undergo treatment. During immunisation, we notify parents to bring their child to the health centre.

BHWs also mentioned that they are often approached by patients before they have reached the health centre, which suggests that they enjoy a high level of trust among community members as intermediaries of the health system. Lili (11 years in service) told us about being contacted often by patients asking for medicines and using this opportunity to remind then about the importance of engaging with services to “ consult the doctor before taking medicine. It’s just not about taking medicine.”

Contracting arrangements and compensation

BHWs are considered part-time, volunteer workers and not government employees. Hence, they do not receive a regular salary. However, BHWs from rural areas reported being given honoraria and allowances of PhP 1150 (USD24) each month; in urban communities honoraria were also paid but their size, and that of any other allowances, varied depending on whether they were contracted by city or barangay administrations, with the latter having smaller budgets. Although urban BHWs all perform similar duties and report to local health centres, the financial incentives, in the form of honoraria to acknowledge their voluntary contributions and allowances to cover the incidental costs of carrying out their assignments (e.g. transport), varied by location. For barangay-funded BHWs, the combined lump sum was reported as PhP 2300 (USD 50) per month distributed in cash by barangay offices, and PhP 3000 (USD 60) for city-funded BHWs paid through a designated local bank. In addition to honoraria and allowances, city-funded BHWs are provided with PhilHealth membership, the national social health insurance programme.

Other non-monetary incentives that BHWs reported receiving included free medicines from the health centre, free health services, and groceries at Christmas from local or barangay administrations. Since the honoraria received by both rural and urban BHWs is insufficient to support themselves and their families, most respondents reported also having part-time jobs, mostly in the service industry, alongside their BHW duties.

Beyond economic empowerment: social positioning and common good

We now describe how relational dimensions of BHWs’ work play an important role in their initial motivations and in sustaining participation over time. Interviewees described a range of motivations for volunteering as BHWs, with the desire to serve the community and improve its health as the most frequently mentioned factor. Gina (38 years in service) described this motivation to contribute to the common good of the community:

I observed the lack of health [knowledge] in our barangay. Parents are not aware of what to do for their child’s fever. They only cover them with [wet towels]. It's just like a cold. I want to know why, why they lack attention and knowledge.

Sisa (1 year in service) cited similar motivation and particularly wanted to improve health-seeking behaviour of the community: “I want the community to be aware that if they are sick, they should consult a doctor. I advise them to go to the doctor.” Jhoanne (4 years in service) derived pleasure from serving the community: “I’m happy to serve my fellow community members. You will be happy if you do it with you heart. You will learn a lot [from being a BHW].”

Supporting the community required some BHWs to contribute their own money, for example to purchase medicines for patients who could not afford them, and to cover costs to travel to their assigned areas. April (8 years in service) described the honorarium and allowances provided as insufficient to shoulder such expenses:

During our areas of assignment, it’s our own-pocket expenses. It’s fortunate if the barangay can provide a transportation service. What if none? We will walk and of course, we will eat and drink. Not all households can provide drinks. Our PhP 3000 honorarium [and allowance] is really not enough.

Gina (38 years in service), said that it was inevitable that she would use her own funds:

I visited a patient and he had no food. I gave my own money. I also arrived when he was sick. He had no money for medicine and I gave him money. I accompanied a patient to the hospital. It’s my own pocket expense.

Mell (5 years in service) described how a provincial governor promised to increase the financial incentives given to BHWs.

Our governor’s term is about to end, but he promised that we, the BHWs, will become counterparts of nurses, doctors and midwives. We need salary. We need honorarium.

Although some BHWs reported struggling financially as a consequence of the low honorarium and allowances, they still expressed contentment with what they were doing. The opportunity to serve the community gave them a sense of fulfilment, through the relational aspects of their involvement in the programme. Their relationships with other BHWs, patients, and the wider community, as well as the new knowledge they gained, compensated for the relative lack of financial and non-financial incentives. Denden (10 years in service) expressed that it was not about how high her compensation was:

If feels good to help. Sometimes [patients] comfortably share their stories. That’s the best part. After they are treated, they go again to you and say thank you. That’s the best part to us. A simple thank you means a lot and it makes us smile. It’s not about how high is our compensation. If you enjoy your work, it’s the best feeling. It’s feels good to give service to the community.

Enhancing one’s social position, particularly through establishing new relationships in the community, gaining respect, and acquiring technical knowledge, played an important role in sustaining participation. Amy (1 year in service) echoed: “Patients trust us. One of my neighbours visited my house and asked if I can take her blood pressure or when I will next be on duty. [I feel] they trust me. They wait for me to be on duty.”

Cherry (12 years in service) shared that she gained respect (‘ respeto ’) from being a BHW:

Interviewer: What do you feel being a BHW? Are you happy?

Cherry: “I’m happy that they address me as ‘Ma’am’. If I was not a BHW, they would not address me as ‘Ma’am’. I’m happy with that. They respect me. I gain respect.”

Many BHWs spoke of the opportunities to travel outside of their localities, develop camaraderie with fellow BHWs, and acquire health knowledge as rewards in themselves, pointing to the role conferring a multiplicity of benefits. As Lili (11 years in service) said:

Being a BHW is difficult, but fun, because you are able to visit places you don't get to visit for seminars, out of town activities, and the like. And then of course the ‘bonding’ here in the health centre. It’s also fun because we learn a lot.

This camaraderie also appeared to be developed and reinforced through the model of BHW training, which was similar in both urban and rural study locations. New recruits typically shadowed more experienced BHWs and other health workers to familiarise themselves with health centre workflows. This was followed by brief training on basic procedures, such as blood pressure monitoring and first-aid. BHWs gained further knowledge and skills through participating in occasional activities organised by national and/or local government agencies, including workshops on immunisation, tuberculosis management and monitoring, and basic life support, among others. While BHWs found such activities useful, many claimed that the most valuable sources of knowledge and skills came from their interactions with experienced BHWs and from their own experiences on the job.

Finally, since the BHWs interviewed were typically mothers and wives, they also found the additional income and, as mentioned above, the opportunity to gain health knowledge and skills as attractive incentives. As Sisa (1 year in service) recalled:

I’m a mother and for my children, it’s good that I have [health] knowledge. I have no husband and I mainly guide my children. I need [health] knowledge in case of emergency. I can use what [I learn] as a BHW and apply it to my family.

This paper examines the experiences of local women in urban and rural locations of the Philippines involved in the delivery of primary care as part of the national BHW programme, a four-decade-long experiment in community participation. By focussing on the socio-political and material conditions that facilitate and sustain their involvement in the programme, as advocated by Campbell and Cornish [ 12 ], the findings from this case study identify factors that contribute to the continued success and longevity the BHW programme in these settings. Such findings may improve the impact and sustainability of similar programmes in other parts of the Philippines and other LMICs. Below, we use the concepts suggested by Campbell and Cornish to contextualise our results [ 12 ].

Symbolic context

Regarding the symbolic context, which refers to relevant meanings, ideologies or worldviews that shape community perceptions of the BHW programme, the participants’ accounts indicate that the BHW role is respected by community members and confers social status, which are two widely recognised factors known to motivate individual CHWs [ 19 ]. Those interviewed in both rural and urban locations noted that community members valued them as resource persons for health, and as peer supporters who assisted others to navigate the health system and manage their health conditions. These symbolic meanings attached to the BHW role are also formally acknowledged and reinforced in several ways. First, the BHW role is defined in national law, which recognises them as essential components of the national health workforce with specific rights and responsibilities [ 9 ]. Also, the value of BHW contributions to primary care service delivery is embodied in the monetary compensation (i.e. honorarium) mandated by the law and the various non-monetary incentives provided to them. That many of the interviewees became BHWs through appointment by community officials further signals the perceived status attached to the role.

While the respect conferred by each of the symbolic factors noted above motivated many participants to initially seek and maintain their BHW appointment, the same factors were also found to have certain stigmas attached, which could discourage community members from becoming BHWs. The commonly held view that BHW appointments are politicised or require personal connections to local officials poses a barrier to wider community participation, leading to an inequitable distribution throughout the community of the health and social benefits derived from the BHW programme. The resulting turnover of BHW staff at each electoral cycle also negatively affects the sustainability and effectiveness of the programme, as resources invested into training BHWs and building rapport within the community are lost with each new round of appointments. This also negatively impacts the ‘embeddedness’ of BHWs in the community and their integration into local health systems, which are recognised enablers to CHW programme success [ 2 ]. It is notable that reforming the BHW appointment process was recommended as far back as the early 1990s [ 20 ]. Furthermore, the national BHW law codifies the role as ‘voluntary’, despite the recognition of the essential contributions that they make to the health system [ 9 ]. While not explicitly mentioned by any participants during interviews, some may question why such an essential role is only voluntary, rather than salaried.

Our observation that the BHWs engaged in all of our study sites were exclusively female points to yet another symbolic factor that may limit wider participation and the impact of the programme: the persistent effect of cultural patriarchy on women’s labour force participation in the Philippines. Despite the country’s world-leading performance on several key indicators of gender equality, the most recent figures for 2019 indicate that just under half of all Filipinas above 15 years of age are economically active, placing them in bottom third of over 180 nations [ 21 ]. Moreover, these women’s jobs are largely restricted to those considered as extensions of the mothering, caring and educating roles defined by a patriarchal worldview [ 22 , 23 ]. The descriptions of the BHW role and factors motivating women to seek BHW appointments are consistent with this worldview, which likely explains the absence of male participation and the role’s categorisation as voluntary, as has been observed in numerous CHW programmes in both lower and higher income country settings [ 24 ]. While BHWs felt respected by community members, those who adhere to patriarchal views may not consider BHWs as sufficiently authoritative to trust or follow any health advice given, further eroding BHW’s embeddedness in the community and their impact of community health [ 2 ].

Material context

Participants in both rural and urban communities unanimously valued the various resources they were able to access as BHWs. These resources comprise Campbell and Cornish’s material context, which empowers community members to put themselves forward for appointment as BHWs [ 12 ]. Several described how the health knowledge and skills acquired as BHWs not only allowed them to perform their assigned tasks effectively, but also enhanced their roles as the carers and educators of family and friends. And while many protested the paltry level of monthly honorarium and allowances given to BHWs, this financial benefit was still considered a useful source of primary or secondary income; however, we acknowledge that this may be due to the fact that our participants were assigned to and drawn from low-income communities. These findings align closely with existing evidence, which also demonstrates clear positive links between incentive levels (both monetary and non-monetary) and CHW motivation, performance and retention [ 2 , 19 , 25 ].

The decentralisation of decision-making powers for the delivery of health care from national down to provincial, city/municipal and even barangay administrative levels [ 26 ] also appears to influence the material context of the BHW’s daily working conditions. This is most evident in the incentive packages that varied depending on the governance level to which the BHW was attached. Such decentralisation means that the amounts of local government budgets allocated to health, and primary care specifically, depends largely on the priorities of locally elected officials, which likely varies from jurisdiction to jurisdiction and administration to administration. This, in turn, is known to directly affect CHW’s scopes of work, remuneration and incentive levels, training and supervision, and logistical and material support (e.g. transport, medicines, equipment, etc.) needed for them to perform their duties – all of which impact their motivation, performance and retention, ultimately determining the effectiveness of CHW programmes [ 2 , 7 , 20 , 27 , 28 ]. Our findings suggest that BHW monetary incentives should be reviewed periodically by decentralised decision-makers to ensure that their levels are appropriate for their specific contexts and scopes of work, as has been advocated by several studies [ 29 , 30 ]. Also, ensuring health centres are continuously stocked with medicines and supplies will support BHW activities and foster the trust and confidence that community members have both in BHWs and in local health services.

Finally, while it is acknowledged that CHWs in LMICs can effectively support a range community-based programmes targeting NCDs, including tobacco cessation, diabetes and hypertension control [ 31 ], evidence emerging from mainly high-income settings also suggests that, with sufficient training, supervision and definition in roles, they may also be effectively integrated into the provision of other primary care services, including mental health and drug rehabilitation [ 2 , 32 ]. These issues have been prioritised by national government as reflected in several key reforms since 2012 that have mandated the involvement of BHWs in community services for mental health, hypertension, diabetes and addiction (Fig. 1 ) [ 33 , 34 , 35 ]. However, CHWs should not be used as a remedy for reducing the burden of other health workers or other symptoms of a weak health system [ 36 ]. Also, when broadening CHW responsibilities, careful consideration must be given to the education, training, remuneration and commitment required from CHWs to deliver such services, as such parameters vary from programme to programme, even within countries as described above. Importantly, programmes must ensure that such expansion does not result in task overload, which could reduce productivity and worsen health population health outcomes [ 37 ].

Relational context

Perhaps the factors that have contributed most to the success and longevity of the BHW programme in the Philippines pertain to the Campbell and Cornish’s relational context, which are the features that encourage community participation through the prospect of being involved in leadership, decision-making, and the building of social capital [ 12 ]. As above, the respect from community members that the BHW role confers is derived not only from the symbolic, but also from other features that mark out these individuals as community leaders. In our study communities, BHWs viewed themselves as ‘local’ health experts, peer mentors and trainers, and brokers and facilitators of patient care and access to the local health system, particularly for the underserved and marginalised in their communities, all of which are well documented nonmonetary CHW incentives [ 19 ]. These functions appeared to underlay the profound satisfaction they derived from their position, despite the perceived inadequacy of material remuneration. It is also evident that these leadership functions succeed by fostering the development of social capital in both its bonding form (by helping community members to “get by” and benefit from existing health services), and its bridging form (by helping other BHWs to “get ahead” and succeed in the role) [ 38 ].

Recent research has, indeed, clarified the significance of social capital for the CHW role. One review concludes that the CHW’s ability to affect positive health behaviour change rests largely on the bonding and bridging social capital existing between them and community members [ 39 ]. Others have discussed how the social capital wielded by CHWs in these forms is crucial to facilitating access to care in poor and marginalised communities [ 40 ]. Again, these notions resonate clearly with the experiences and motivations mentioned by respondents in both rural and urban study locations. With continuing urban migration, the rising burden of NCDs, and the immense strain these trends are placing on the health system both in the Philippines and beyond, the value CHWs and the social capital that they bring is only likely to grow in importance [ 41 ].

However, our findings suggest that more attention could be given to BHW involvement in decision-making about their role and primary care more generally, which itself constitutes a form of linking social capital as a means of spanning power divisions between community members and those who design and fund community health services [ 38 ]. Despite being explicitly mandated by Republic Act 7883 [ 9 ], the participant accounts from our study locations provided little evidence that such involvement occurred in any institutionalised form. Meaningful participation of BHWs in decision making represents yet another means of integrating and embedding them further into the local health system [ 2 , 40 ]. In the decentralised Philippine context, this could be readily achieved, for example, through the inclusion of BHWs as ‘local’ health experts in multi-stakeholder consultations administered by local governments on the planning, financing, implementation, management and monitoring of community health services [ 42 ]. With the ongoing implementation of the Universal Health Care Act in the Philippines [ 43 ], and the renewed commitment to strengthen primary health care [ 44 ], a formidable cadre of BHWs stand ready to dedicate their time, energy and expertise to help realise these goals for the nation.

The Philippine experience of integrating CHWs in the delivery of effective PHC over nearly four decades provides an important, yet under-reported, case study of community participation and people-centred care. As many countries work to develop and strengthen CHW programmes in their effort to achieve universal health care and the health-related sustainable development goals, the lessons drawn from the Philippines could help to ensure that such programmes achieve optimal impact and sustainability.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to the presence of information that could compromise research participant privacy and confidentiality.

Abbreviations

Barangay (village) Health Worker

community health worker

local government unit

low- and middle-income country

non-communicable disease

non-governmental organisation

primary health care

Philippine Peso

Responsive and Equitable Health Systems – Partnership for NCDs

United States Dollar

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Acknowledgements

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The authors would like to thank the Wellcome Trust/Newton Fund-MRC Humanities & Social Science Collaborative Award scheme (200346/Z/15/Z) for providing funding for this research. The funders had no role in the design of the study, or in the collection, analysis or interpretation of the data.

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GL, DB, MM, LPV, AR, MS, BP designed the overall RESPOND project; and GL, BP conceptualised the component described in this manuscript. EM, GL, DJS, AMA, JM, LPV, BP contributed to the development of study design, data collection and analysis. EM, GL, DJS, LPV, BP produced the first draft. All authors interpreted the data, critically revised and approved the final version.

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Mallari, E., Lasco, G., Sayman, D.J. et al. Connecting communities to primary care: a qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines. BMC Health Serv Res 20 , 860 (2020). https://doi.org/10.1186/s12913-020-05699-0

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Jean McIntosh

Using research in community nursing

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Evidence-based health visiting — the utilisation of research for effective practice

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SYSTEMATIC REVIEW article

Community health nursing in iran: a review of challenges and solutions (an integrative review).

• 1 Student Research Committee, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
• 2 Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
• 3 Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Background and Objective: In recent decades, nursing has witnessed many changes in Iran. Despite the numerous advances in nursing, the health system faces many challenges in community health nursing. This study aims to review the challenges in community health nursing in Iran and provide an evidence-based solution as well.

Materials and Methods: This article is an integrated review of the literature regarding the challenges in community health nursing published between 2000 and 2021 in the databases Scopus, Medline, Cochrane Database of Systematic Reviews, Science Direct, Google Scholar, Scientific Information Database (SID). After performing searches, 20 articles were selected and studied. Data analysis was done using Russell approach (2005).

Findings: The results of this study were summarized in 6 themes consisting of challenges in community health nursing education, practical challenges in community health nursing, policy-making challenges in community health nursing, management challenges in community health nursing, and infrastructural and cultural challenges. Solutions were also proposed to address each of the above issue.

Conclusions: The results of the study showed that diverse challenges exist in community health nursing in Iran, considering that community health nurses play an important role in providing primary health care and community-based care. In order to solve these challenges, the authors have some recommendations: modifying the structure of the health system with the aim of moving toward a community-oriented approach from a treatment-oriented one, developing laws to support community health nurses, creating an organizational chart for nurses at the community level, modifying nursing students' training through a community-based approach, and covering community-based services and care under insurance.

Introduction

An examination of nurses' status and position in the service provision system around the world shows that nurses constitute the largest group of health care workers ( 1 , 2 ). Community health nurses are a major link between the community and health institutions. They are able to understand and interpret the needs of the society and the objectives of health policymakers ( 3 , 4 ). In addition, community health nurses have an excellent position and status for addressing many challenges in the health system including immigration, bioterrorism, homelessness, unemployment, violence, obesity epidemic, etc. ( 1 , 2 , 5 ). From the perspective of the World Health Organization (WHO) and the American Nursing Association, community health nursing is a special area of nursing that combines nursing skills, public health, and a part of social activities with the aim of promoting health, improving physical and social condition, and rehabilitation and recovery from diseases and disabilities ( 6 , 7 ). Considering the importance of nursing services in the health service provision system and their role in universal health coverage, in the 66th Session of the health ministers of WHO Regional Office for the Eastern Mediterranean, much attention was devoted to developing plans for improving and strengthening community health nursing ( 8 ).

In all developed countries, community health nursing has had a significant growth in the health care system ( 9 ). In Canada, the community-based community health nursing has been established in 1978, aiming to maintain and promote the health of individuals, families, and communities. It also participates in the family physician and primary health care delivery ( 10 ). In some European countries, including Norway, Finland, the United Kingdom, Ireland, Sweden, and France, community health nurses have replaced physician-centered and hospital-centered approaches, providing health services for the members of the community ( 4 , 9 , 11 – 13 ). A study conducted by WHO on community health nursing's status in some less developed and developing countries (Bangladesh, Indonesia, Nepal, Cameroon, Senegal, Uganda, Guyana, Trinidad and Tobago) shows a lack of commitment and the low capacity of the policymakers to implement global and regional political tools regarding community health nursing, although most of the countries under study had a basic and operational framework for the optimal activity of community health nurses. On the other hand, only 6% of the community health nurses in these countries worked in the field of health promotion, disease prevention, and rehabilitation care, while this sector is supposed to be their main field of activity. The existing barriers preventing community health nurses from playing their role in developing countries include the lack of consensus in the realm of community health nursing practice, the lack of necessary coordination for inter-professional activities, few job opportunities for community health nurses, insufficient recognition of community health nursing, and great emphasis on clinical care in health centers ( 6 ). In Asian countries, including Japan, China, and Malaysia, community health nurses play a key role, too, focusing on the assessment of community health needs, health care delivery, and health promotion ( 9 , 14 , 15 ).

Iran is a populated country in the Eastern Mediterranean region, where health services are provided at public, private, and charity sectors ( 16 , 17 ). In Iran, since 1958, behavioral and social sciences have been included in the nursing program as a major part of its curriculum. Then, in 1986, the disciplines of community-based and community-oriented nursing were considered by educational policymakers, followed by the inclusion of community health nursing and epidemiology courses in the undergraduate curriculum. Community health nursing program is developed in line with health-oriented policies and focuses on community health. Graduates of this field work in different settings of community by combining the nursing science with other health-related sciences and evidence-based practice ( 18 , 19 ). Due to its focus on health promotion, the position of this discipline in the country's health system is very crucial, and is a major contributor to directing the community toward the 20-Year National Vision and in an ideal position to address the countless challenges against the health system ( 2 ). However, the role of nurses in Iran has not made significant progress and is limited to providing services in medical centers ( 20 ), because the viewpoint and the attitude of most Iranian health authorities is based on the employment of nurses in the secondary level of prevention, i.e., clinical care in hospitals ( 2 ). Therefore, hospitals are the most common setting for community health nurses' activities ( 21 ). Comprehensive health centers are also managed to provide health services by the workers with bachelor's and associate's degrees in family health, environmental health, occupational health, and disease control, as well as midwives. These services are provided sporadically in health service centers ( 18 ) and no effective strategies tailored to the needs of the community are adopted in order to provide care ( 22 ).

It is noteworthy and interesting that also in the family physician team, no position has been defined for community health nurses and most of the Iranian health authorities believe that nurses cannot provide significant health services ( 18 ). However, the community health nurse can be a complementary project in the family physician program and even make up for its shortcomings. This can help the government understand the health for all as a goal, the proof of which is the presence of nurses in blood pressure screening program in 2012 ( 23 ). On the other hand, numerous studies indicate community health nurses' abilities and their key role in identifying health needs and promoting community health ( 24 – 28 ). Although the education and training of community health nurses is costly for the government, their expertise is not utilized. At present, the services of community health nurses in Iran are mainly provided at the third level and at hospitals, because no position is defined for them in comprehensive health centers ( 18 , 29 ). In other words, they have no defined job position to work in this field, although in the curriculums, the future job status of this discipline is designed ( 30 ). Therefore, one of the most important infrastructural issues is to create a position and a job description in the organizational chart for community health nurses in comprehensive health centers ( 31 ).

A brief review shows that studies in Iran have mostly focused on the challenges of community health nursing education and barriers against home care ( 1 , 16 , 18 , 19 , 32 – 34 ) and other aspects of community health nursing have rarely been studied. In addition, no study has been conducted to offer solutions for addressing the challenges of community health nursing. Although other studies have been conducted in different cultures and contexts, an integrated review of them can help identify and eliminate present barriers with the aim of facilitating future planning and policymaking to enhance the status of community health nursing. Therefore, by conducting an integrated review, the present study aimed to identify the challenges of and barriers against community health nursing and the strategies to address them.

Methodology

This is an integrative review study on the challenges of community health nursing and the related solutions. The integrated review of literature is the summarization of previous studies by extracting the study results. This method is used to evaluate the strength of scientific evidence, identify gaps in current research, detect the needs for future research, create a research question, identify a theoretical or conceptual framework, and explore the research methods that have been successfully used. The integrative review study is based on Russell model which consists of 5 steps as follows: (1) formulating the research problem, objective, and question, (2) collecting data or searching through articles, (3) evaluating data, (4) data analysis, (5) interpreting and presenting the results ( 35 ).

Formulating the Research Problem, Objective, and Question

Considering the items discussed in the introduction, this study is conducted to determine the challenges of community health nursing in Iran and the related solutions. Two key questions guiding the review process include “What are the challenges of the community health nursing discipline in Iran?” and “What are the solutions to address these challenges?” Answering these two key questions will help detect the challenges of community health nursing, propose solutions to address them, and promote the community health nursing discipline.

Collecting Data or Searching Through Texts

In this study, the target population consisted of all the studies (articles and dissertations) that had been conducted in the field of community health nursing regarding its challenges, barriers, and solutions, the full texts of which were accessible. Available resources, including all the studies on the challenges of community health nursing, were reviewed in this study. A comprehensive search was done through the databases Medline, Scopus, Cochrane Database of Systematic Reviews, Science Direct, Google Scholar, and Scientific Information Database (SID) for the papers published between 2000 and 2021 in eligible English or Farsi journals.

The keywords that were searched consisted of community health nurse, community-based nursing, public health nurse, nursing challenges, nursing position, and primary health care. The keywords were investigated both separately and in combination with each other ( Table 1 ). Finally, after preforming the search, 142 published articles were identified.

Table 1 . Search strategy.

Data Evaluation

The relevant articles were evaluated based on the title, abstract, text, as well as the inclusion and the exclusion criteria. The inclusion criteria for the studies consisted of the following: (1) examining the challenges of and barriers against community health nurses and its position, (2) containing the keywords or their equivalent in the title or abstract of the article (3) Being written in either Farsi or English. The exclusion criteria included the following: (1) not accessing the original paper and the information on its methodology, (2) being written in other languages, (3) being irrelevant to the research question. It is noteworthy that in this study, there were no limitations in terms of research method, so that the results of various studies could be used.

Selecting Studies

After doing the systematic search, the studies related to the search keywords were found. After removing the duplicate titles (79 articles), the title, the abstract, and the full text of the studies were reviewed by the research team, and the inclusion and the exclusion criteria were applied. Twenty-four articles were excluded due to being irrelevant and 55 articles entered the screening stage, 20 of which were excluded. Then 35 articles were examined regarding eligibility and, finally, 20 articles were included in the study. The studies were selected by a research team consisting of two nursing professors (faculty members of Ahvaz Jundishapur University of Medical Sciences and Tehran's Shahid Beheshti University of Medical Sciences) and one nursing PhD student (Ahvaz Jundishapur University of Medical Sciences). Furthermore, the research team came to a consensus through more discussion regarding the points of disagreement.

Data Analysis

At this stage, the articles were reviewed separately. Finally, 20 articles related to the purpose of the study were reviewed and analyzed. Each article was read completely and the results of the studies were extracted from them. After extracting the results of the articles, their results and statistical analysis were compared. The results with the highest frequency in these articles were further interpreted in the next phase.

Interpreting the Data and Publishing Information

At this stage, according to the analysis of the related studies, their comparison, and the data frequency, the following items were extracted.

Search Results

After eliminating the duplicate articles ( n = 79), 55 studies entered the screening phase and their titles and abstracts were evaluated. In total, 35 studies were included in the selection phase, and 20 remained in the study ( Figure 1 ). Twenty articles met the inclusion criteria and were included in the final analysis. The details are displayed in Table 2 .

Figure 1 . PRISMA flowchart for search strategy and results.

Table 2 . A summary of the critical review of previous Iranian and foreign studies.

The 20 remaining studies were published between 2010 and 2021. Five of them were review studies (systematic, meta-synthesis and integrated reviews). Seven reviews were of qualitative type (grounded and content analysis), seven reviews were cross-sectional descriptive, and one was a comparative study. Eighteen reviews were published in English and two were published in Farsi. The majority of the reviews investigated the position and the role of community health nursing in the health service delivery system and its challenges. About 40% of the reviews are related to the studies on the situation of community health nursing and the barriers against its provision in Iran. Two reviews have studied community health nursing education in Iran, and seven reviews proposed strategies to solve the challenges of community health nursing.

By analyzing the reviews, six themes emerged in the field of community health nursing challenges, and six other themes concerned the strategies to overcome the challenges. The details are displayed in Table 3 .

Table 3 . The challenges of community health nursing and the identified solutions.

The Challenges of Community Health Nursing in Iran

There are several challenges regarding community health nursing in Iran, which have been addressed in previous studies ( Figure 2 )

Figure 2 . Community health nursing challenges in Iran.

Challenges of Community Health Nursing Education

Several challenges were mentioned in the literature in regard with the education, which were divided into the three areas input, process , and output .

Input. Students' poor understanding of community health nursing lessons, considering the community health nursing apprenticeship as futile, and, in some cases, even as a chance to rest, as well as their poor motivation for active participation were mentioned as important challenges ( 32 ). Moreover, nursing students' treatment-based and disease-based perspective and their poor community-based and holistic perspective is another challenge in this area ( 1 , 2 ).

Another challenge in this area is the insufficient skills and experience of nursing educators in the field of community-based educational planning, their inadequacy in conducting community health apprenticeship programs and the related evaluations, and ineffectiveness of community health apprenticeship ( 19 , 42 ). In another study, the low quality of community health nursing education, the use of traditional methods, reviewing theoretical topics during apprenticeship, and not implementing appropriate educational models were mentioned as challenges ( 1 , 19 ). Other studies have shown that the educational system of medical universities is not adjusted to PHC and the educational content is not tailored to the needs. Therefore, the university graduates do not have the required skills to deal with problems and academic education courses should be promoted and based on PHC ( 22 , 47 ).

The Process. The poor presence of community-based care in the nursing education and focusing on hospital care have been referred to as one of the most important challenges according to several studies. Nursing education in Iran is more focused on clinical education. Most nursing schools train their students to play the traditional nursing role, while community needs the training of nurses according to holistic perspectives ( 1 , 16 , 19 , 40 ). Limited community health credits and the hours of apprenticeship in health centers will lead to poor productivity of apprenticeship programs ( 2 , 31 ). The theory-practice gap, i.e., the inapplicability of some health theory content in the apprenticeship settings, and the lack of community-based education standards in nursing were mentioned as other challenges in this field ( 1 , 19 ).

Output. Recruiting nurses only in clinical settings such as hospitals and the absence of a particular and appropriate professional position for nursing and community health nursing graduates in health centers has prevented nursing graduates from acquiring the necessary skills to provide health care ( 31 , 42 ).

Practical Challenges of Community Health Nursing

One of the most important challenges in this field is not defining positions for the provision of nursing services in the community and various settings of the health system. Therefore, in hospitals, which are considered as the main position of nurses, appropriate roles are not defined for them with the aim of health promotion ( 21 ). Another challenge is hiring nurses and community health nurses in medical settings and hospitals. Nursing care in Iran focuses on the provision of care at the secondary level of prevention; therefore, the preventive role of nurses is overshadowed and nurses are not involved in health care homes and comprehensive health centers, which is the first level of people's contact with the health care system ( 16 , 31 , 40 ). The lack of adequate and proper health care in remote and rural areas is one of the biggest national concerns, and most of the health care workers in rural and remote areas are Behvarzes (rural health workers) and practical nurses, while no job opportunities exist for community-based nursing postgraduates in comprehensive health centers, prevention units, and health care homes ( 2 ). The lack of clear job descriptions for community health nurses and community-based nursing in the country is another challenge, as community health nursing is only a field for study, not suited for practice ( 18 ). Another important challenge will be the inadequate professional development of nursing compatible with the needs of community, the lack of competent staff in the field of community-based nursing, and the lack of nursing promotion in accordance with the pattern of diseases in the country ( 29 ).

One of the important areas of community health nursing is performing home visits and the provision of care and counseling in the home environment. A challenge that community health nurses face in this regard is the problems with ensuring their safety ( 16 ).

Policymaking Challenges in Community Health Nursing

The lack of mutual interaction between nursing and other institutions of the health system and nurses' lack of involvement in policymaking regarding their own field of study has resulted in neglecting the role and the position of nurses in the health system. On the other hand, health policy makers have not taken the nursing profession seriously because physicians are dominant in the health system. In other words, the nurse's role and position in the field of prevention and community-based services has been ignored. The chaos and the disorder in the health system, as another challenge, has prevented the fulfillment of one's actual

role ( 21 ). On the other hand, the absence of interaction between nursing managers and the policymakers of the Ministry of Health to identify community health nurses' potentials is another challenge ( 31 ).

Managerial Challenges in the Field of Community Health Nursing

In the field of management, several challenges have been mentioned in the articles, which were divided into two areas: managerial actions , and the lack of knowledge of the community health nursing profession .

Managerial Actions. The lack of an effective management system for the use of community health nursing services has been mentioned as one of the most important challenges, as health managers have to make appropriate strategic plans ( 18 ). Another important challenge mentioned in the studies is the existence of specialty and subspecialty service providers in the health system, which has hindered the establishment and the development of health promotion centers; in other words, community-based care has no place in the Iranian health system ( 16 ). The managers' not using motivational mechanisms to encourage community health nurses to work in health centers is referred to as another challenge. One of the major motivating factors is the allocation of salaries and financial benefits, but since the health personnel's salaries are lower than those of the staff in treatment sectors, community health nurses are less motivated to work in the field of health ( 2 , 31 ).

The Lack of Knowledge of Community Health Nursing Profession . One of the important challenges is nursing institutions' lack of knowledge of nursing and its specialty disciplines ( 40 ). The health managers' lack of knowledge of the capabilities of nursing and community health nursing has resulted in their limited presence in community health service centers and the concept of community health nurse's role ( 2 , 31 , 40 ). In addition, Iranian health managers have not considered a position for community health nurses in the family physician team, because these authorities do not have any knowledge of the community health nursing profession ( 18 ).

Infrastructural Challenges

In regard with of infrastructure, several challenges were pointed to in the articles, which were divided into three areas: insurance coverage and funding, executive protocols , and interdisciplinary cooperation .

Insurance Coverage and Funding . Another challenge is the high cost of health service provision in the community in the form of home visits and the fact that they are not paid by insurance. Allocating less funds for providing community-based care than for treatment care and hospitalization is another challenge in the Iranian health system ( 16 , 17 , 31 , 33 ).

Executive Protocols . The absence of clear guidelines for making assessments, classifying patients and care seekers, wages and salaries, allocating funds and determining personnel adequacy and competency in the community-based care and home care system is another important challenge in this regard ( 16 ).

Interdisciplinary Cooperation . There is no interdisciplinary cooperation and coordination among different sectors of community such as health centers, municipalities, and the police to provide community-based care by community health nurses ( 16 ). While the desirable future of the community health nursing profession requires cooperation and communication with other institutions such as the Welfare Organization, the municipality, and the Broadcasting Corporation ( 29 ). On the other hand, Iranian health system is governed through unionism and tribalism. Therefore, as long as there is unionism, no interdisciplinary cooperation and partnership should be expected ( 31 ).

Cultural Challenges

Public distrust of and negative attitude toward the capabilities of non-physician experts in providing prevention and health services is another challenge in Iran ( 2 , 16 ).

In previous studies, several strategies were mentioned for each group of community health nursing challenges.

Appropriate Solutions to the Challenges of Community Health Nursing Education

Input . In order to solve the challenges in this area, the following strategies can be used:

1. A solution to instructors' challenges: one strategy is to hold training courses for community health instructors so that they can provide and train quality nursing services outside the hospital. It is also possible to provide information on new educational strategies, novel learning opportunities in the field of community health, new tools, and new methods of student assessment to the community health nursing instructors in workshops. In addition, qualified instructors should be hired to teach community health, and short-term training programs should be developed and prepared in the field of geriatric nursing, school nursing, occupational nursing, community-based rehabilitation, and behavioral disease counseling for senior community health nursing professionals in order to promote nurses' position and role in the educational, treatment, and health care teams ( 1 , 2 , 19 , 43 , 44 ).

2. A solution to students' challenges: the strategy is to hold pre-teaching workshops in various fields of community health with the aim of preparing students to share their apprenticeship goals and motivate them. Furthermore, to train nursing students for community health nursing discipline, participatory processes with key stakeholders such as health centers and deputies, regional hospitals, clinics and schools as well as specialty nursing programs should be used to empower nurses, instead of providing conventional and routine clinical trainings ( 1 , 6 , 16 ).

Process . Modifying nursing curriculums with the aim of focusing on community-based education, developing evidence-based curriculums based on the health needs of different regions of the country, and considering community health nursing practice is an effective strategy ( 1 , 2 , 29 ). Measures can be taken to overcome challenges in this area through changing teaching methods in apprenticeships (considering working with the community and family instead of the individual) and using nursing theories, including Betty Neuman's theory in community health education, the main purpose of which is comprehensive and continuous patient care and, accordingly, the actual position of nurses in care is all the three levels of prevention. We can take steps to address the challenges in this area ( 1 , 42 ). Using multiple approaches, and a combination of different methods in community health nursing apprenticeships has been effective in increasing nursing students' competence. Training courses in the field of community-based visits (home, schools, factories, and stores) had a positive effect on changing students' attitudes toward community services ( 34 ).

Appropriate Solutions to the Practical Challenges of Community Health Nursing

This group of challenges can be addressed by reviewing and reforming the process of hiring community health nurses and creating an organizational title for hiring community health nurses in schools, factories, prisons, and comprehensive health centers ( 1 ). In other words, this challenge can be overcome by shifting the health care delivery setting to the community, integrating nursing services into primary health care and focusing on health promotion and disease management ( 29 , 38 ). In addition, reviewing the educational needs of community health nursing graduates to provide ongoing responses to public health needs, especially plans to improve the skills and the abilities of nurses, is one of the effective solutions to this group of challenges ( 46 ). At large scale, nursing managers should formulate the job descriptions, roles, and responsibilities of community health nurses ( 6 , 9 , 16 ).

Solutions to Policymaking Challenges in Community Health Nursing

This challenge is possible to be solved by involving community health nurses, as professionals in this field, in health-related issues at large scale. Policymakers should also publicize laws and policies in support of community health nurses and develop guidelines that align community health nurses' roles with their skills and areas of practice ( 1 , 2 , 6 , 26 ). It is suggested that legislators prioritize accountability principles based on community, justice, and accessibility. In addition, policymakers need to develop a strategy to reform policies in order to lay the ground for the development of nursing at the community level ( 33 ).

Solutions to Managerial Challenges in Community Health Nursing

Health and treatment managers should support community health nurses in establishing community health clinics ( 1 , 6 , 21 , 30 ). Nursing managers should also take action to set up home visit centers using a health promotion approach with the help of community health nurses ( 33 , 46 ). Nursing managers should take the necessary measures to explain and promote the concept of community health nurse and its capabilities ( 46 ). Furthermore, health system managers should use motivational strategies to attract and retain competent community health nurses ( 6 , 9 , 45 ).

Solutions to Infrastructural Challenges in Community Health Nursing

Nursing managers should provide appropriate guidelines and instructions for community-based care and its management and the insurance coverage of home and community based care and services, as is done in developed countries, which results in more people seeking this type of service from community health nurses ( 6 , 9 , 16 , 45 ). Necessary measures should be taken to increase inter-sectoral cooperation between the nursing profession and different fields of community in order to progress, address global health objectives, and strengthen interdisciplinary cooperation ( 46 ).

Solutions to the Cultural Challenges of Community Health Nursing

Strategies that are effective to address this challenge include informing the community and raising public awareness of the significance and the role of nurses in providing and offering community-based services through social media, as well as developing comprehensive supportive programs in collaboration with the Nursing Deputy of the Ministry of Health, Iranian Nursing Organization, and the National Broadcasting Corporation in order to raise public awareness and understanding of community health nursing ( 16 , 18 ). Moreover, some studies have proposed a research approach to address the challenges in various fields of community health nursing. Some examples are conducting research to evaluate the effectiveness of community health nursing approach and determine the position of nursing in the health care system, or doing more research on the services provided by community health nurses to make the other members of the health team acquainted with their activities ( 2 , 9 , 13 ).

The aim of this study was to investigate the challenges of community health nursing in Iran and the related solutions in an integrated manner. According to this study, the main challenges included the challenges of community health nursing education, practical challenges in community health nursing, policy-making challenges in community health nursing, managerial challenges in community health nursing, and infrastructural and cultural challenges.

It was discovered that the factors related to community health nursing education are among the challenges. Since health care delivery to people has shifted from hospitals to community centers, nursing students should be educated through community-based approaches. The results of a study on the experiences of nursing instructors showed that the practical training of students in the field of community health is not compatible with the needs of community and education is not community-oriented ( 48 ). According to other studies, although one of the goals of community health nursing education is community-based education, it is currently forgotten and ignored ( 1 , 49 ). The results of the study by Oros focused on education through community-based care models instead of using traditional health models ( 45 ). The results of a systematic review study also showed the impact of the effective training and the preparation of nurses in the practical fields of community health to overcome the challenges of community health nursing ( 24 ). In their study, Jarrín et al. ( 50 ) stated that launching a community health nursing education program in the form of lectures in the first months of university, introducing textbooks, and performing simulations regarding community and home care will significantly affect their attitudes toward and beliefs about community-based nursing because traditional curriculums has resulted in the students' considering community activities and home care unimportant.

The approach through which nurses have been educated during the 20th century is not tailored to the health care needs of the health system in the 21st century. Therefore, nursing educators and planners should constantly review the content of community health nursing education based on the needs assessment of community health students and graduates and according to the needs of the community ( 37 , 44 ). The study by the World Health Organization also considered the lack of educational standards for community health nursing as a challenge and referred to the need to develop programs in accordance with the educational needs of community health nurses ( 6 ). Kemppainen et al. ( 13 ) showed that continuing education in accordance with the needs of nurses is effective in their performance in the field of health promotion. Another challenge in this area is the community health nursing instructors' inadequate skills and experiences in providing effective education. In another study, Khorasani reported that the training and nursing courses for nursing students in the field of community health nursing are more focused on filling out care seekers' medical records and collecting health statistics and reports, which are usually done by midwifery or primary health technicians. However, it is less focused on issues such as establishing close relationships with the community and especially families in community health apprenticeship and pays more attention to reviewing theoretical content and superficial visits ( 51 ). In other studies, students considered community health apprenticeship futile and useless and believed that there is a relative relationship between theoretical education and the practical field of community health nursing ( 52 , 53 ).

Challenges related to the field of community health nursing practice are also very important. One of the challenges in this dimension is the lack of competent workforce in the field of community-based care. This finding is in line with the study of Kemppainen et al. ( 13 ). One of the reasons behind this is the lack of job opportunities for them to acquire the necessary skills and the lack of retraining courses, while in developed countries like Denmark, nursing graduates are able to make assessments and planning, perform prevention, treat all patients and provide community-based care ( 54 ). Another challenge in the practical field of community health nursing in Iran is the lack of a clear job description for community health nurses. In the study by the World Health Organization, disagreement on community health nursing performance was mentioned as one of the important challenges ( 6 ). In their study, Kemppainen et al. ( 13 ) considered the lack of clarity in the nurses' job descriptions and activities in the field of health promotion as a barrier. In another systematic review study, the lack of a clear definition of the nurses' role in PHC has been mentioned as an important challenge in achieving universal health coverage ( 24 ).

Another challenge lies in the field of community health nursing policymaking. What was mentioned in the studies shows the impact of the structure and policies of the health system on not creating an appropriate position for community health nurses in the field of community-based and community-oriented health services. Many countries have given nurses the opportunity to provide primary health care to develop the quantity and the quality of health care in their communities. At present, in the Iranian health system, changes are taking place without considering the needs of care seekers and the costs of health care increase with the rise in the elderly population and the higher percentage of chronic diseases in the community ( 23 ). A study conducted in Oman also showed that community health nursing is not considered as much important as hospital-based nursing by the policymakers ( 55 ). In the study by Yuan, the lack of community health nurses' participation in health policymaking and planning is one of the major challenges in providing community health nursing services ( 9 ). According to the WHO, one of the most important challenges is the lack of public commitment and the policymakers' incapability to execute regional and global policies for community health nurses ( 6 ).

Another important challenge is management. One of the challenges in this area is the lack of motivational mechanisms for encouraging community health nurses. In a WHO study, the environment and the non-supportive conditions of community health nurses are stated as challenges and the use of motivational strategies to attract and retain competent community health nurses is regarded as a solution ( 6 ). The study of Kemppainen et al. ( 13 ) showed that in the organizational culture, the presence of health managers who support nurses in providing health services is an effective factor in nurses' health promotion practice. Another challenge in this area is the health system managers' lack of knowledge of community health nursing, which is consistent with the study conducted by WHO ( 6 ). Therefore, considering the emergence of global health threats, it seems necessary to clarify the concept of community health nursing.

Infrastructural challenges are another type of challenge according to this study. Currently, the focus of the health system on disease-oriented approaches rather than prevention is an important reason for the huge amount of money spent in the treatment sector, and causes issues in the allocation of resources to the community health nurses in the field of health promotion. The results of the study by Yuan also regarded the lack of sufficient funding for the provision of community-based nursing services as a significant challenge ( 9 ). Moreover, an Omani study reported community health nurses' limited access to equipment and lower funding for implementing the program ( 55 ), which is in line with the study of Kemppainen et al. ( 13 ). Other studies in other countries have shown that the amount of nurse salaries at the community level and in the society is lower than in medical centers, and these underpaid nurses who provide services at the community level are pushed to work in the treatment sector ( 56 , 57 ). Another challenge in this area is poor interdisciplinary cooperation. The World Health Organization also considers poor interdisciplinary cooperation with other professions as one of the major challenges of community health nursing ( 6 ). Investing in interdisciplinary teamwork is considered as a way to overcome the challenges of nursing in providing primary health care ( 24 ).

Cultural issues are regarded as another important challenge. People's distrust of non-physician experts' capabilities is a challenge in this area. A Chinese study also showed the lack of public trust in community health nursing services ( 9 ). However, according to the study by the WHO, non-physician staff are also able to provide similar care to patients ( 58 ). The findings of another systematic review study aimed at investigating the impact of replacing physicians with nurses in PHC in the care procedure, patient outcomes and cost analysis showed that the care provided by nurses had similar or better health outcomes compared to the care provided by physicians ( 36 ). According to the WHO, if the health system wants to address the health needs of the community, it must use nurses and midwives ( 59 ). The existence of a communication channel for community health nurses is essential to raise public awareness through the media ( 47 ). The study of Heydari et al. ( 18 ) also emphasized on preparing the community and raising public awareness in order for them to receive community-oriented nursing services. Therefore, it is necessary to explain the important role of nurses in providing health services to the public.

Considering that all the challenges mentioned in these studies can also be applied to Iranian community health nursing in Iran, it is possible to take an important step toward solving these challenges in the country's health system by implementing the proposed strategies.

Limitations

This integrated review has several limitations. The authors' knowledge of the challenges of community health nursing and the solutions is limited to the data documented in the articles. Therefore, if the challenges are not fully described or reported by the authors, they will not be reflected in the results. Only credible articles in English and Farsi were reviewed; as a result, the articles and the related data from initial research and gray literature published in other languages may have been omitted. The authors did not seek to evaluate the quality of the studies and did not compare them with similar ones. However, our integrated review is an attempt to combine the results of the studies and the research approaches. Finally, these results are more related to community health nursing challenges in Iran. Future research should address the challenges of community health nursing at a global level.

Considering the results of the present study, it can be concluded that the challenges of community health nursing in Iran, including the lack of an appropriate position for community health nursing, nursing education ignoring community-oriented care, and inappropriate infrastructure are inter-wound issues dependent on each other that affect community health nursing practice. Therefore, in order to solve these challenges, it is suggested that the policy makers and the managers of the health system modify the structure of the health system so as to move from a treatment-oriented approach toward a community-oriented one, develop supportive laws and job descriptions for community health nurses, and create an organizational chart for community health nurses at the community level. It is also recommended to use motivational strategies to attract community health nurses and support them in establishing community health clinics, and to cover community-based services and care under insurance. Moreover, nursing education administrators should modify nursing students' curriculum with the aim of focusing on community-based education. In addition, in order to solve the challenges in this field, community health nursing leaders should try to increase cross-sectoral and inter-professional cooperation, promote the profession, and make the capabilities of community health nurses recognized by other professions and the public.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author Contributions

The data analysis and manuscript were prepared by AH with support from SJ, MR. All authors critically reviewed and contributed to the manuscript and approved the final version.

This article was a part of a nursing PhD dissertation approved by Ahvaz Jundishapur University of Medical Sciences (No. 1398.874) which was financially supported by the Nursing Care Research Center in Chronic Diseases of Ahvaz Jundishapur University of Medical Sciences (NCRCCD-9837).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors thank the library staff of Ahvaz Jundishapur School of Nursing and Midwifery for their contribution to the study and their support in searching through resources and articles.

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Keywords: community health nursing, nursing problems, challenges, solutions, Iran

Citation: Hosseinnejad A, Rassouli M, Jahani S, Elahi N and Molavynejad S (2022) Community Health Nursing in Iran: A Review of Challenges and Solutions (An Integrative Review). Front. Public Health 10:899211. doi: 10.3389/fpubh.2022.899211

Received: 18 March 2022; Accepted: 06 June 2022; Published: 27 June 2022.

Reviewed by:

Copyright © 2022 Hosseinnejad, Rassouli, Jahani, Elahi and Molavynejad. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Simin Jahani, jahanisimin50@yahoo.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Community Partners and Students Benefit from Working Together on Clinical Problems

Are you interested in learning about the current scientific evidence to manage a clinical problem? An essential component of our RN to BSN research courses (BNURS 360 & 460) is having students work with community partners to identify a researchable question that students will answer by searching, appraising, and synthesizing the scientific literature. Students complete this work over two quarters and develop a practice change implementation and evaluation plan presented to community partners at the end of the BNURS 460 course. Having a real-life context for a clinical question and problem-solving is engaging for everyone. Ideally, what the students produce is extremely helpful to partners, and they do great work.  

We aim to keep student groups small (4-5 students/group), so we always need community partners. Community partners meet once with students by Zoom, answer questions by email throughout the two quarters, and are encouraged to attend the students’ presentations. If you have questions or want to be a community partner for the 2024 fall/2025 winter quarters, please contact Dr. Linda Eaton ( lineaton@uw.edu ).

Situating Care as Feminist Rhetorical Action in Two Community-Engaged Health Projects

Peitho Volume 22 Issue 1 Fall/Winter 2019

Author(s): Maria Novotny and Dawn S. Opel

Maria Novotny is an Assistant Professor of English at the University of Wisconsin-Milwaukee. Her research oscillates around the areas of health activism, reproductive rhetorics and technology, and feminist rhetorics. She is currently co-editing special issues for The Journal of Multimodal Rhetorics on “Curation: A Multimodal Practice for Socially-Engaged Action”, Computers and Composition on “Rhetorics of Data: Collection, Consent, & Critical Digital Literacies”, and Reflections on “Rhetorics of Reproductive Justice in Public and Civic Contexts”. Her work has been published in Communication Design Quarterly, Computers and Composition, Reflections, and Technical Communication Quarterly. You can also learn more about her work by visiting  The ART of Infertility , a community arts and infertility organization curating exhibits that portray patients’ lived experience with reproductive loss.

Dawn S. Opel is an Assistant Professor of Digital Media and User Experience in the Department of Writing, Rhetoric, and American Cultures at Michigan State University. She currently serves as a Policy Research Fellow at the Center for Health and Research Transformation at the University of Michigan. An action researcher, she works to improve the design of communication across healthcare, government, and nonprofit organizations for enhanced coordination of patient care. Her work is funded by the Michigan Health Endowment Fund and the U.S. Department of Health and Human Services’ Administration for Community Living. Recent published work appears in Written Communication, Literacy in Composition Studies, and Computers and Composition.

Abstract: This essay builds upon feminist rhetorical study of health and the body, connecting this work to a feminist ethic of care to support action-oriented feminist rhetorical research initiatives related to health care. We intentionally focus on “care” in health activism to situate rhetorical research as care for the communities in which we work—an iterative act of compassion that is demonstrated and committed to through process; through languaging, listening, laboring, and transforming. We then demonstrate in this essay care as situated rhetorical action by citing examples from two community-engaged health research projects. Utilizing a feminist participation action methodological framework, we articulate a collaborative, situated sense of care that offers new scenes for feminist rhetorical practices when working with communities for change.

Introduction: Rhetoricians as Activists in Health and Medical Contexts

Individuals’ access to health care inhabits a precarious position given the current political climate in the United States. With threats made by the current administration to defund Planned Parenthood, public suspect that the future Supreme Court may reverse Roe v. Wade, and opposition to the United Nation’s breastfeeding policy supported by the World Health Assembly, health care and, moreover, an individual’s right to care no longer appears fully secure. We take the stance in this essay that feminist rhetoricians are well situated to increase our involvement in the nation’s critically important discourses surrounding access, affordability, inequities and quality of American health care.

We recall that as a field feminist rhetorical scholarship has a history of interrogating, recovering, and creating rhetorical theory related to gendered experiences of health and the body. For example, feminist rhetoricians have examined a range of topics that implicate the gendering of health and bodies, including: technological implications regarding the female body (Balsamo), the performance of femininity through the body (Bordo), rhetorics of midwifery (Lay), legal implications of insurance coverage and fertility treatment (Britt), prenatal testing and the genetic model of medicine (Condit), rhetorical analyses of breastfeeding recommendations (Koerber, Breast or Bottle; “Rhetorical Agency”). More recently, contemporary feminist scholarship has assembled and identified new scenes of needed rhetorical inquiry including the visual and cultural critiques of the reliance on fetal (Gregory) and transvaginal ultrasounds (Haas and Frost), analysis of digital forums reinscribing experiences of childbirth (DeHertogh), the role of women’s birth plans (Owens), and a historiographic tracing of the evolution of “infertility” as a transformative word (Jensen). Such feminist rhetorical work has been crucial to calling attention to sociopolitical realms that have and continue to implicate the construction of health and bodies. Further, these scholarly foci have established an exigency for feminist rhetorical approaches to be applied to a range of health care contexts. We take up feminist rhetorical study of health and gender by offering activist and community-engaged approaches to not only building rhetorical theory but changing health practices as feminist rhetorician-activists.

In order to become feminist rhetorician-activists, this essay explores blended methodological and epistemological approaches to health care as a site of situated action. We particularly focus on building a framework for community-engaged rhetorical scholarship. Our understanding of community-engaged scholarship is rooted within the CCCC Statement on Community-Engaged Projects in Rhetoric and Composition, which defines community-engaged projects as “scholarly, teaching, or community-development activities that involve collaborations between one or more academic institutions and one or more local, regional, national, or international community group(s) and contribute to the public good. We use the word project to denote well-conceived activities pursued over time to provide reciprocal benefits to both academic and community participants.” The CCCC Statement poses the question, “Did the project take care to credit all participants and treat marginalized groups respectfully and fairly?”. We begin by focusing on the language of “care” to ponder how the methodological approaches we apply to our research might act as an extension (and be informed by Annemarie Mol’s concept) of care—care being an iterative act of compassion that is demonstrated and committed to through process, through languaging, listening, laboring, and transforming.

In what follows, we draw upon feminist theories to situate care as a feminist ethic and motion its discussion as a feminist rhetorical practice. Feminist participatory action research, we claim, is a methodology that supports care as response-making space for action in community-engaged rhetorical scholarship. It does not just allow for rhetorical theory to be built but allows for rhetorical response. We illustrate this by providing two scenes of feminist participatory action research as a methodology to enact feminist approach to care within health communities. Dawn discusses her work partnering with a federally-qualified health center to improve communication practices. This partnership originated through a combination of serendipity and alignment of needs of a community partner, a family medicine clinic. The research project design was co-constructed with clinic providers and administrators and culminated in collaborative scholarship and advocacy for family practice transformation and healthcare payment and service reform. Maria emphasizes her collaboration in the infertility community with a traveling patient-created art exhibit. This collaboration began as she sought out a community of patient-advocates, discovered others interested in research and advocacy, and began curating patient-artists’ work. Maria pivots between advocacy and academic research in the project alongside her community partners, grappling with ethical considerations such as patient-artist privacy. For each of us, we intentionally discuss our embedded positions within these collaborative projects as it situates how we, as rhetorical scholars, mobilize theories of care into community-engaged action.

Both of us identify as feminist, activist researchers, and see each other as peers that frequently provide a support system for research practices that can feel isolating and difficult. Although our work is far from solitary, as researchers we often feel as though our practices are not legible or understood to either academic or community stakeholders. As Royster and Kirsch discuss, academic research has historically largely privileged what is conceived of as “objective” knowledge that does not value lived experience, and the positionality of the researcher has historically remained hidden to foreground the objectivity of the research. Royster and Kirsch respond by arguing for the value of lived experience of both researcher and of those we study (18). For feminist researchers who choose to embed themselves in research communities as scholar-activists, our work may be seen as additionally far afield from rhetorical, theoretical, or interpretive study. This essay seeks to make visible how care not only builds rhetorical theory but as a rhetorical practice it can support scholar-activist research in the public sphere. We end this essay with a call to action shared by other community-engaged researchers in rhetoric and composition, urging further uptake by feminist scholars interested in and committed to changing how care is attended to in health care and beyond.

A Feminist Ethic of Care Care is a recurring theme in feminist ethics and feminist rhetorical scholarship. In 1996, Peter Mortensen and Gesa Kirsch saw the field of rhetoric and composition as taking an ethical turn, and Kirsch further articulated a feminist ethic of care for the field based in work by Sondra Harding and the theme of reflexivity in research relationships (Kirsch 256). This ethic of care is frequently discussed in the context of empirical research in composition studies and literacy studies (Kirsch; Kirsch and Ritchie). In rhetorical studies, the concept of care frequently guides and shapes feminist rhetorical theories that examine and critique unjust systems that often marginalize, devalue, or all together ignore scenes and experiences of health.That is, care frequently serves as an ideological lens to emphasize practices in which bodies are not being cared for—allowing for critiqueto emerge. Rather than situate care as a critique, we build on the work of Maria Puig de la Bellacasa to offer care as a methodological response that better supports and acknowledges the needs in these health scenes and communities. Annemarie Mol further elaborates on the notion of care as a process and not a product. In Logic of Care, Mol advocates against the logic that increased patient choices result in greater patient care. Refuting this logic Mol argues for the need to better attend to the concept of care, particularly in the midst of increasing healthcare practices concerned more with measured targeted outcomes than the process in which patients are cared for. We see feminist rhetoricians are well suited to take up Mol’s call to attend to care by reflectively considering methodological responses that may resituate how our rhetorical work cares. This sense of care—as feminist response—is informed through Jacqueline Royster and Gesa Kirsch’s explanation that “care encourages us to assume a more patient, receptive, quiet stance, to ‘sit with’ the text, to think about it—slowly, rather than to take a more aggressive stance in order to ‘do something to’ it as a mechanism for arriving at and acredditing its meaning” (146).

A feminist ethic of care is a concept that is discussed in the health and medical professional community in much the same way as the ethical turn Kirsch articulated for our own field of rhetoric and composition. Braiding together these bodies of ethics-related research is fruitful for community-engaged work in scenes of health and medical. Rosemarie Tong’s feminist virtue ethics of care for healthcare practitioners and Royster and Kirsch’s revision of rhetorical practices are based on an “ethics of care and hope” (Tong 135) to resituate care and its methodological potential to initiate rhetorical action in health communities. Tong, a feminist health philosopher, has called for healthcare practitioners to enact a more feminist ethics of care approach, as opposed to a justice ethics approach, in health and medicine. Drawing differences between the two approaches, Tong outlines care ethics in six points:

care ethics “takes a contextual approach”; it “begins with an assumption of human connectedness”; it “emphasizes communal relationships”; it “works best in the private realm”; it “stresses the role of emotions (or sentiments) in constituting good character”; and it is “female/feminine/feminist” (131-32). She contends that healthcare providers may do more moral good by enacting this ethics of care as it helps “to develop caring feelings as well as conscientious desires and empathic skills” (151).

This ethical framework, we argue, is applicable not only for healthcare professionals but for feminist rhetoricians concerned with health care practices and with patients. First, Tong’s framework reinforces community-centered scholarship practices articulated by Django Paris’s and Maisha Winn’s humanizing methodological stance, which emphasizes reciprocal “relationships of care and dignity and dialogic consciousness-raising for both researchers and participants” as an inherent practice of research that ignites social change and action (xvi). Second, as an ethical framework emphasizing relationships and conscientious aims, it creates an exigency to rhetorically listen (Ratcliffe, 1999, 2005), a guiding practice to practicing research as care. Tong’s feminist ethics of care frames research as care as a methodological approach demanding dialogue, reflexivity drawing upon feeling, sentiment and affect as well as stressing relationship-building between the researcher and the bodies being researched.

Tong’s ethical framework can inform the ways we as feminist researchers work with communities that are in need of care. We find that this framework informs care as an ideological framework through the following three tenets. First, care makes visible the bodies implicated by our rhetorical scholarship. This tenet speaks to the ethical exigency that participant bodies in research must be recognized and must be made visible. Doing so is a practice of caring for the bodies, the participants in our research. Reflecting on how we make bodies more visible in our rhetorical research forces researchers to strategically contemplate not only our methods but the aims of our research. We do well to ask, how do we care for the bodies that we represent in our rhetorical scholarship? How can the caring for bodies bridge private academic spaces with more public practices?

Second, care embraces participatory-centered methods to support the visibility of our participants. This tenet asks researchers to critically question how existing methods represent bodies in our research. Doing so may invite moments to revise, even invite, new methods that invite communities and bodies to participate in our research. Foregrounding care as a guiding research practice thus allows for a valuing of lived experience as a site of rhetorical research. This aim invokes Royster and Kirsch’s concept of “critical imagination, ” thereby rethinking the spaces and methods of research scenes and rhetorical inquiries. For example, how may methods that tack-in to feelings, sentiment and affect make space for addressing rhetorical embodiment? How may participatory methods and participant interpretations of their own texts assist in efforts that care for bodies?

Third, care accounts for the rhetorical researcher’s personal experiences and affect in the doing of this research. In fact, Diane Davis’s scholarship suggests that for the rhetor there is “intractable obligation, and ethical-rhetorical responsibility to respond” (12). Davis’s work aids in situating the preorgins of an affective need to rhetorically respond, which ultimately creates space in rhetorical scholarship to move towards theorizing rhetorical action. We see care as one rhetorical approach that affectively acts. Care, practiced in rhetorical research, thus demands accounting for researcher motivations, researcher positionality in our work on bodies. These three tenets, taken together, stress the importance of reflexive dialogue and relationship building, and responds to Eva Kahana and Boaz Kahana’s concern over “unresponsive care” in which real-life circumstances restrict “ethical ideals of advocacy to serve the best interests of their patients” (22). They advocate for “proactive involvement in health through building alliances” as an effective strategy to confront contemporary bureaucracies in healthcare “which deliver unresponsive care” (Kahana and Kahana 42). Care works in this frame as a responsive approach to rhetorical research. We find that positioning care as guiding methodological framework in rhetorical research, particularly in health communities, can reinforce rhetorical scholarship as extending care.

We build upon these feminist ethics of care to suggest that it may also inform practices for community-engaged research that both builds inclusive steps for action in the public sphere as well as build rhetorical theories for meaning-making. As two rhetorical scholars embedded in two health-related community projects, we seek to show in this essay that one such outcome of our participation and collaboration in these communities can be care—in and of itself. This notion is informed by a methodological stance that advocates for researchers to “work as scholar-allies and view practices and findings as outcomes that can promote a better sense of care for communities. This is the ultimate goal in research as care” (Novotny and Gagnon 74). In the section that follows, we pivot from the ethical framework of care to demonstrate how it evokes a series of rhetorical practices that translates care from theory towards action in health and medicine.

Care as Feminist Rhetorical Practice in Health and Medicine Care, we acknowledge, has been critiqued by some feminist scholars as reinforcing gendered “pathological masochism,” “fear of success,” or “passivity” (Houston 240). Puig de la Bellacasa’s notion of “matters of caring” offers a justification for a renewed uptake of care in feminist rhetorical research. Her work calls attention and resituates care in our scholarship, by suggesting that

while a critical stance can bring attention to such matters as who cares for whom, to what forms of care are prioritized at the expense of others, a politics of speculative thinking also is a commitment to seek what other worlds could be in the making through caring while staying with the trouble of our own complicities and implications.

(204) Care is then reflexive and responsive. It “thinks with” communities we care for while also “dissenting” from the complexities that arise in our work. Care, then for Puig de la Bellacasa, is “something we do as thinkers and knowledge creators” (41) in that there is a materiality to what we care for and “contributes to mattering in the world” (41). As such, Kelly Dombroski, in her review of Matters of Care, argues that “we must operate our academic analyses of care in such a way as to support, construct, and enact collective change” so as we move away from “piercing critique” towards thinking-with in order to enact more constructive dissent (263).

Puig de La Bellacasa and Dombroski’s discussion of the materiality of care is important for feminist scholars working in and alongside communities of patients and healthcare activists, especially as it acknowledges the multiple competing forces and voices (human and nonhuman) in the doing of this work. Their work addresses Kahana and Kahana’s concern over “unresponsive care” in which real-life circumstances restrict “ethical ideals of advocacy to serve the best interests of their patients” (22). Instead, they advocate for “proactive involvement in health through building alliances” as an effective strategy to confront contemporary bureaucracies in healthcare “which deliver unresponsive care” (42). As co-authors, we recognize the sentiment expressed by Kahana and Kahana, as we have shared our own stories with each other about the need to build a methodological approach that confronts and assists in careful navigation of the rhetorical messiness (Grabill and Pigg) when working in health and medical contexts.

In this essay, we seek to continue in this tradition while building upon this important work, by situating care as a methodological practice that reimagines sites of feminist inquiry—not just for rhetorical inquiry but rhetorical action. We draw attention to care as rhetorical action by reflecting upon our research in two separate community-engaged health projects. These reflections are situated in conversations that we shared as we engaged in care work in activist healthcare projects. As we shared, the two of us gained a greater understanding of this practice of care: interventional rhetorical action undertaken as activist rhetorical scholars and engaged with community partners.

Real, material conditions—human and non-human—impact the rhetorical work of how we care and collaborate with health-related communities and projects. Our experiences working in these scenes have led us to privately question how it is that we practice care in these communities, while negotiating with competing stakeholders, and academic and institutional reporting required of our work with these communities. Reflecting the dilemmas we face as feminist rhetorical researchers confronting the material complicities of the stakeholders involved in our research, we are reminded of Royster and Kirsch’s charting of a new course in feminist rhetorical research which advocates that our work must:

assess current situations, contexts, and institutional forces…to inhabit a sense of caring about the people and the processes involved in the use of language by immersing ourselves in the work, spending time thinking broadly and deeply about what is there, not there, and could be there instead. The effort is to think beyond the concrete in envisioning alternative possibilities in order that we might actually work, often collaboratively, toward enacting a better future.

(145) Responding to Royster and Kirsch, we suggest feminist participatory action research as one framework for enacting care in our research when confronted by the complexities of engagement with multiple human and non-human stakeholders.

Feminist Participatory Action Research as a Methodological Instantiation of Care We offer feminist participatory action research (FPAR) as a methodological frame to support engagement in participatory and transformative scholarship. FPAR emerged in response to participatory action research, defined as a collaborative approach between community partner and researcher to “to facilitate knowledge construction, education, collaborative learning, and transformative action” (Lykes and Hershberg 332). Like participatory action research (PAR), FPAR “aims to democratize knowledge production as a precursor to taking action to improve the quality of people’s lives” but incorporates “feminist theories of oppression, domination, power, and social justice with participatory methods” (Ponic et al. 325). In this manner, Diana Gustafson and Fern Brunger suggest that “feminist PAR explicitly subverts the traditional relationships of power that characterize other forms of health research” (1000). Specifically, applying a feminist lens to research in communities related to healthcare activism “means recognizing that academics are typically in an advantageous position of power and must be cognizant of this privilege” and feminist perspectives work to uphold researcher relationality by “challenging and disrupting dominant relations of power, including colonialism, and work to validate culturally-specific forms of knowledge” (Darroch and Giles 29).

For example, a researcher applying for research approval to work with a disabled community faces specific ethical scrutiny. Gustafson and Brunger explain how ethics boards reviewing research applications routinely constitute persons with disabilities as populations at risk, and hence, vulnerable. At surface level, researchers can take such ethics review questions as a proactive intention to protect marginalized community/ies. Yet, Gustafson and Brunger note that in taking such precautionary measures, the researcher and the research subject, in this case the disabled community, “become individually implicated in reproducing this problematic social category” (1003). As a result, a colonial mentality of researcher “saving” the disenfranchised research subject often develops, whether through practice or in the writing up of a research design and/or results. We point to Gustafson and Brunger’s example to underscore the various moments in which colonial power structures influence and guide much of our work with marginalized populations, many of which often appear in rhetorical studies concerned with health and medicine, given that sub-field’s commitment to “concern for the humane-and the distinctly human-dimension of health and medicine” (Keranen 105). We argue that it is only when we as rhetoricians engage to change these power differentials in partnerships in health and medicine that our work as rhetoricians will begin to effectuate real change for the communities we seek to improve. Further, care, as an outcome, should be prioritized as a value in rhetorical studies if we are to make arguments for our participation and collaboration in interdisciplinary health and medicine projects.

FPAR then works to account for power relations and incorporate interventions representative of both researcher and community insight. Specifically, FPAR as a methodology operates from the following framework (see, e.g., Frisby et al.; Gatenby and Humphries):

Both researchers and community groups initiate the project. Both researchers and community groups (emphasizing community perspectives) develop the research questions/s. Both researchers and community groups (emphasizing community perspectives) conduct the research. Both researchers and community groups (emphasizing community perspectives) analyze the data and develop research findings. The research becomes linked to advocacy through community and researcher participation. Participation in the research itself becomes an empowerment tool and mobilizes collaborative plans for intervention. In disseminating the data, results are communicated throughout the research process and both researcher and community share the findings and work collaboratively to publicize them. In this way, FPAR distinguishes itself from other participatory action research methodologies in its emphasis on researcher reflexivity and full participation throughout the studies with community members (Frisby et al.). FPAR as a methodology comes with a host of challenges, particularly because of its commitment to working with community stakeholders throughout the duration of the project. Further complicating FPAR as a community-centered approach is the reality that “academic researchers embedded in traditional and often patriarchal setting receive little training in how to facilitate power-with approaches that cultivate the collective resources that all partners bring to the table” (Ponic et al. 325). In turn, this leaves few, if any, guiding protocols for research support. An additional strain to FPAR is the need for the researcher to embed within the community, often for a lengthy duration of time. While some may argue that this poses difficulties for the practice of FPAR (particularly on a time-constrained tenure track of academic employment), we see value in the scholarship that results from this commitment to community-engaged work on this level, and point to the CCCC Statement on Community-Engaged Projects in Rhetoric and Composition for language to define and validate this time-consuming and often invisible work. Administrators can use the CCCC Statement to advocate for community-engaged scholars in their retention, promotion, and tenure. We point out these challenges of FPAR as a part of orienting feminist rhetorical research in health care beyond a relationality with a static object to rather a relationality with dynamic and complex individuals.

Approaches to Care in Two Community-Engaged Health Projects In what follows, we draw upon our own projects to illustrate FPAR as practicing care in community-engaged (and feminist rhetorical) health research projects. We offer a glimpse of the research process at several moments critical to this methodological framework. Specifically, we illustrate the extension of care through the methodological application of FPAR in the following moments:

initiating relationships; designing the project; researching the project; advocacy through and beyond scholarship. Throughout these four iterative moments of research, the researcher remains embedded in the community site. Such embeddedness we argue is of particular importance from a feminist framework as it allows for active researcher reflexivity throughout the research process. It is in this reflexivity, we argue, that research becomes oriented more closely as advocacy and less as academic, rhetorical scholarship—important for feminist rhetoricians engaged in community health work and practicing care as rhetorical research.

1. INITIATING RELATIONSHIPS: A researcher develops relationships with community members and other stakeholders with no expectation of a research collaboration. From a relationship, a research project may begin to take shape, based on shared interests, values, and community needs, rather than the research agenda of one researcher.

Maria’s example: In May of 2014, I traveled to Washington D.C. for an infertility advocacy event. At the time, I had just completed my first year in a rhetoric and composition PhD program at Michigan State University. Like many other first-year PhD students, I was in the very beginning stages of formulating my research trajectory. Wanting to focus on the intersections of feminism, infertility, and rhetoric—yet unsure how to do this work—I traveled to the east coast to meet other infertile women from around the country and listen to their stories and why they decided to attend this event. While I understood that participating in this event would inform my research, I also had a personal connection to this event, as someone with my own infertility diagnosis and (as a result) had recently begun running a local infertility support group. Interested in meeting others who ran support groups and wanting to share my own story and frustrations as an infertility patient, I saw myself attending the advocacy event as a “scholar-patient-advocate.” My motivation then for attending and working with this community was fueled by both lived experience as well as a need to engage in rhetorical research that would be a catalyst for greater community change.

At the event, I met Elizabeth, another infertile woman and professional photographer who began to make art as a method to process her own grief around an IVF cycle that resulted in the miscarriage of twins. Like me, Elizabeth lived in Michigan and shared that she had recently curated a local art exhibit featuring some the lived experiences of infertility patients. Spending the day together advocating for legislation that would improve access to alternative family-building treatments, I began to share with Elizabeth how I, too, had turned to creative activities to make sense of my infertility diagnosis. As we talked more and opened up about our experiences, the two of us decided to continue meeting upon our return home. To be clear, our intention in meeting was not to formalize our shared experiences into a formalized research project, but to cultivate a relationship and offer support to each other as we ran infertility support groups. Thus, it was through our emerging friendship that we began to see threads and openings for how our shared experiences could become a catalyst for a larger infertility advocacy and art project.

This origin story of how research emerges through lived experiences and relations, an important aspect of practicing care. It emphasizes the need to embed in the community and with the people who identify as community members. It suggests that rather than try and find a site to do research, we turn inward and more reflective, to collaborate with members and initiate authentic relationships both parties (researcher and community member) are invested in. Further, we find that this story mirrors Royster and Kirsch’s feminist rhetorical practice of strategic contemplation, which urges feminist researchers to “pay attention to how lived experiences shape our perspectives as researchers and those of our research subjects” (22). Meaning, it was Maria’s orientation to her own lived experience with infertility that shaped not only how she found her research site, but how she developed a collaborative and community relationship with research subjects. As feminist scholars, we can draw on our rhetorical training to respond to the injustice we, as patients, have had to navigate. Nonetheless, such work requires us as researchers to self-disclose personal information that other scholars, not researching personal communities, can avoid. This is because “embodiment encourages a methodological approach that addresses the reflexive acknowledgement of the researcher from feminist traditions and conveys an awareness or consciousness about how bodies—our own and others’—figure in our work” (Johnson et al. 39). This embodied orientation to our research, we argue is an implication of FPAR that embraces the materiality of care as echoed by Puig de la Bellacasa. More importantly, attending to embodied orientations to possible sites of feminist rhetorical research in health communities, we argue and will illustrate further, shifts rhetorical scholarship toward public advocacy.

Dawn’s example: When I interviewed for my current position, I visited campus and gave a research talk on my postdoctoral research at Michigan State University. In the audience was an undergraduate student, whose aunt is a physician at a family medicine clinic (Dr. Cathy Abbott) who serves primarily under-resourced patients. My talk focused on my research on improvement of clinical service delivery through online education initiatives for providers of care to under-resourced patients. At the talk’s conclusion, I talked about next steps for the research that included a desire to work on service delivery reform alongside clinicians serving under-resourced patients and communities, rather than building resources from the perspective of those institutions funding that work (private foundations, networks, and consultancies). I was concerned about the lack of engagement on the project from the intended users of the resources, and my attempt to advocate for those users and their patients. Four months later, I received an email from Cathy through a colleague, Bill Hart-Davidson. Providers at the clinic reached out to meet, and in that meeting, expressed a hope that Bill and I might partner on a clinic transformation project, to study communicative practices in the clinic in order to suggest interventions for improved service delivery and patient experience. (These communicative practices are the subject of service delivery reform efforts that my postdoc’s online resource project was designed to address.) The family medicine providers had conducted some of their own research and were seeking out a partner to help them find ways to move forward.

Dawn’s example illustrates a situation where an identified research direction matched an identified need of a partner, the family medicine clinic. These interests met rather through serendipity, another key factor of feminist research methodology (Royster and Kirsch). While Dawn articulated suggestions for future research in a public forum, it was the relationships between the undergraduate student, the program in which the undergraduate student was enrolled (where Dawn and Bill teach), and then her aunt Cathy and her practice, developed through a shared interest and needs of the clinic, that led to the research project.

2. DESIGNING THE PROJECT: The parameters of the research project should be co-constructed by the researchers and research participants, as well as other stakeholders to the project. The design may illuminate tensions in power relationships among stakeholders.

Maria’s example: The origin story of how I met Elizabeth illustrates how The ART of Infertility organization emerged over time, through a relationship, and ultimately was slow. There was no imperative pushing us “to create a sustainable research project”. Instead, both of us spent time listening to the needs of ourselves as infertile women, the needs of patient-artists already creating pieces of art reflective of their infertility, and the needs of the infertility community writ-large. It was through this process of listening to each other and to the community that The ART of Infertility began to take shape and a “a research design” emerged. As we chatted and ate dinner in the Brody cafeteria on Michigan State’s campus, Elizabeth and I slowly began to identify the objective of the organization, what would count as our “data” sets, how we would gain participants, the methods in which they would circulate stories and artwork, and how to fund the project. Slowly, after several conversations, we found ourselves with the beginnings of a project.

Fast forward five years, much of what was first discussed and identified at these Brody cafeteria meetings has either changed or has needed to be revisited. Positioned in this work as both members of the infertility community and as researcher-advocates, we have an embodied orientation to the outcomes of this research project which has naturally led to a self-reflective process, interrogating what aspects of the project have been more and less successful. In doing so, and in learning from these experiences, we have had to grapple with new questions of ethics, methods and data analysis. For example, who owns the art? This question was not an issue until we discovered other researchers contacting the patient-artists to gain copyright for the artwork. One such example can be found on the cover of Robin Jensen’s book Infertility: Tracing the History of a Transformative Term. The artwork displayed on that cover is artwork that is part of the project’s permanent collection. Yet, the artist also gave Jensen permission to use this art for the book cover—without indicating a need to reference the project. This example raised new ethical and copyright issues for the project and, and Elizabeth and I as co-founders, to undertake. Neither the patient-artist nor Jensen sought to leave out a reference to The ART of Infertility organization, nor did Elizabeth and I plan for this artwork to be circulated beyond the project. Yet, as the project has grown, new issues like copyright, ownership, and circulation have emerged.

Such stories recounting how community-embedded research projects take shape and shift given the addition, and sometimes subtraction, of stakeholders is important to point out because it emphasizes the continuous cycle of reflexivity that occurs in a FPAR research design. As The ART of Infertility has grown and changed, Elizabeth and Maria have had to alter their methods and review their processes. New ethical dilemmas have emerged and new insights on how to analyze data have resulted. The process is recursive and, importantly, emotionally exhausting. When designing a project that you share experiences with, it impacts not only as a researcher but as a patient stakeholder in the project’s mission. This bodily tension of positioning oneself as “scholar-patient-advocate” is challenging as we must negotiate multiple stakeholders, positionalities, and objectives. Yet, methodologically tuning into and towards this tension “opens up spaces for observation and reflection, for new things to emerge, or rather, for us to notice things that may have been there all along but unnoticed” (Royster & Kirsch, 2012, p. 90). We heed Royster and Kirsch’s claim and seek to practice noticing what was previously unnoticed in order to practice better care for a community in a project that seeks to ultimately create sustainable change.

Dawn’s example: As mentioned above, the project design in the clinic transformation project was a co-constructed design based upon providers’ and administrators’ understandings of problems with patient experience in the clinic caused by communication practices. A research team, consisting of my research partner Bill and myself, providers in the clinic including Cathy, and administrators to the larger unit where the clinic is situated, was created to meet and determine the scope of the project and its design. All members of the team understood that some degree of empirical research was needed to assess what kinds of communication practices necessitated intervention. Bill and I provided some qualitative research methods frameworks to design the study, but we presented these in a meeting in which everyone discussed their ideas and interests in the research process. One theme that emerged early was a tension between the external administration unit that oversees the clinic, the teaching physicians that work in the clinic one day per week, and the staff that works in the clinic full-time. The staff has the most experience in the clinic yet is the most subordinate in terms of authority. These tensions begin to expose the power relationships that undergird clinical communicative practices. From a perspective of a FPAR researcher and advocate, it was important for me to recognize and draw attention to these tensions, rather than simply carry out the research aims of the most powerful on the project.

3. RESEARCHING THE PROJECT: Data collection is a transparent and embedded process in the environment that is the subject of the research. Active roles are taken by both researchers and participants.

Maria’s example: Those who participate in The ART of Infertility project are frequently patient-artists with an infertility diagnosis, and as a project that is more public-facing than research-focused, what resembles data and how it is collected may appear differently than more traditional academic projects. Data collected in this project resemble two forms—the visual piece of art and the accompanying narrative attached. To collect these pieces of data, we post calls for infertility-inspired art on art call websites, on The ART of Infertility social media pages and websites, and frequently collaborate with other community infertility organizations to circulate the calls on their networks. When pieces are submitted, we try to accept each piece and show at least one piece from each patient-artist. This decision is notable and important because we understand, from our personal experiences with making art about infertility, how the artwork itself functions as a piece of activism. As an invisible disease, art serves as a material marker calling for others to witness the lived experiences that so often are invisible and, as a result, misunderstood and stigmatized. Therefore, as co-curators we try to evoke a sense of care for those who choose to self-disclose about their lived experiences with infertility by publicly displaying their art.

Another component of the project that requires care is how participant identities shift and change as they “resolve” their infertility. That is, when patient-artists agree to participate in the project, they submit their artwork with a narrative label reflecting on the connections between their composition and their lived experiences with infertility. Release forms are signed and indicate how, where, and who owns the pieces of art. This is important as the artwork is then later shared in curated exhibits around the country. Nonetheless, this “data” is not static and as such not always reflective of how the participant currently identifies in the infertility community. For example, Elizabeth and I have found through their project a need to check-in with prior patient-artists and understand how they currently identify with the infertility community. Much of this is because infertility is not a stagnant identity. For many in the community, they seek to “resolve” their infertility by successfully building their families. For some patient-artists they no longer feel comfortable showing their piece of art as they no longer view themselves as infertile. For others, they may have built their family and are okay with their art being shown but want to revise their artist label which appears alongside their piece. For instance, when a patient-artist first submits their piece it may reflect their current point in their infertility journey, such as undergoing their first round of in-vitro fertilization. Yet, three years later, the same patient-artist may have suffered numerous failed rounds of IVF, discovered an additional factor impairing their fertility, and now are in need of using a donor embryo. As such, this patient-artist may now want to have their story—present in the exhibit—better reflect their current reality: coming to terms that they may not be able to have a biological child. While this may seem like a minor request, this is a patient-artist’s new identity and so, while it may seem that such details lack importance, it often matters personally to the participant.

As directors and curators of The ART of Infertility, Elizabeth and Maria have had to grapple with how to build in check-in moments with their patient-artists into the operation of the project. At the beginning of the design of the project, this was an issue undenounced to them. They did not anticipate the need or desire for patient-artists to revise their narratives as they continued on their infertility journey. How to curate and take care of the representation of their patient-artists is yet another instance of how FPAR serves as a model to support continual communication between participants and researchers. Further, Elizabeth and Maria have found that curation is not an objective practice but rather a rhetorical practice that requires trust and enacts an ethic of care. Many patient-artists are self-disclosing for the first time about their experiences of reproductive loss. Maria and Elizabeth view it as imperative to make sure every effort is made to protect the patient-artist and curate a show that makes them feel safe. As such, the project frequently features the use of pseudonyms to allow individuals to be anonymous. In this way, our work as researchers with our participants must be recursive, tending to issues of identity shifts and participation representation

Dawn’s example: In the months following the designing of the project and IRB approval, Bill and I collected data for the clinic transformation project by formal observation of the workflow in the clinic, and also met regularly with physicians, nurses, medical assistants, and administrators in the clinic. These are both formal and informal meetings, so that we continue to build understanding and trust amongst all participants to the study. We advocate on behalf of patients and staff based upon our research but also based upon the relationships that we have developed over the last several months. And we are still in the clinic, preparing to test interventions that we hope will improve quality of care for patients, in this clinic and in clinics across the country. Finally, we have engaged in collaborative scholarship with our provider partner Cathy, analyzing data and writing a research article for an interdisciplinary audience (Opel, Abbott, & Hart-Davidson, 2018).

4. ADVOCACY BEYOND SCHOLARSHIP: Publication venues are considered that are beyond traditional silos of academic research in order to extend the reach of the research and “take it public”: the public is engaged with research outcomes.

Dawn’s example: Healthcare service delivery reform is an issue with implications at the clinical practice, communication, and policy levels. For this reason, our research findings will be communicated through a three-fold strategy. We are first and foremost committed to presenting our findings at the level of the clinic itself, as well with its institutional and administrative managers who control resources for change in the clinic. These communications take the shape of presentations and memos designed to present possibilities for action within the clinic, as clinical practice service improvement and improved quality of care for underserved patients is the primary goal of the project. Caring for the clinic and its patients means, for this project, that our work in the clinic only begins after the conclusion of data collection and analysis. For scholars of communication, rhetoric, and user experience, we have communicated our work through scholarly publication outlets such as journals in our field and conferences with both researchers and practitioners (Opel, Abbott, and Hart-Davidson, 2018; Opel and Hart-Davidson, 2019).

Dawn also works to present the findings from this work as advocacy for service reform in FQHCs (federally-qualified health centers, or those that serve under-resourced patients and communities), in venues where policymakers and advocates for healthcare service delivery reform will convene. These include a research policy fellowship that includes discussions with policymakers, lobbyists, and policy analysts, as well as participation in community forums and televised roundtable policy discussions. Advocacy for healthcare payment and service reform is integral to broader legislative and policy efforts to protect the Affordable Care Act and Medicaid and Medicare expansion. This adds an increasingly political dimension to Dawn’s research, complicating her relationships with stakeholders to projects such as this clinic project, but also offering a policy-focused opportunity to impact the lives of people seeking healthcare access and improved quality of care.

Maria’s example: Using art as a method of health activism, my orientation to academic scholarship is perhaps flipped compared to Dawn’s orientation. The research I engage in with The ART of Infertility is, by its origin story and design, already oriented towards infertility education and advocacy. I theorize this work then back towards academy, as a process that asks researchers to listen to what can be learned from engaging in rhetorical methodologies outside of the academy. In this way, the outcomes of this research indicate that rhetoricians have already acquired skills that allow us to build communities that effectively intervene in unethical health practices. Using rhetorical and visual analysis in the coding of data, I draw upon that analysis to identify current infertility community needs that appear in the patient created artwork. In this way, the analysis is always returned, reused, and revised by the community of study.

Embedded as a scholar-patient-advocate in the community, Maria faces a series of challenges. For instance, it takes time to engage in this type of community work and can constrain those who have limits on their time, such as graduate students. She also situates The ART of Infertility as a public facing entity, one not always clearly linked to academia. This requires dedicating time to sustaining that public entity, including posting on the organization’s social media pages, hosting art exhibits, and managing the collection of art. Community-engaged rhetoricians are not always positioned so actively in the day-to-day management of such projects. As such, Maria’s example suggests to researchers interested in engaging in a similar line of organizational building that such work requires a long-term commitment to sustaining the developed projects. This nod to the time activism and community-engagement requires has been articulated by other folks in the rhetoric and writing studies. For instance, Malea Powell in her 4C4Equality interview shares “When I was younger I thought activism meant going out in the streets, carrying signs and yelling, or standing on a soapbox…Now I know that activism, real sustainable change, is a long road. A long set of roads” (n.p.). The practice care through an FPAR framework supports Powell’s frank discussion of the time and commitment required of true activism, acknowledging that change does not occur overnight. FPAR guides us to care for our community, listen to their needs, revise as needed, negotiate with those we may not agree, come back to the table with a new idea, and continue making progress to our end goals.

A Community of Care: Framing Future Feminist, Community-Engaged Rhetorical Interventions in Health and Medicine Although the term “care” may not be employed, per se, there are communities in the field of rhetoric and composition where the tenets we articulate for FPAR and our own projects are familiar. Our work in the aforementioned projects aligns closely with the CCCC Statement on Community-Engaged Projects in Rhetoric and Composition and the literature that is cited in the Statement, largely comprised of scholars in community-literacy studies and in literacy research, although it stresses that “effective community-engaged projects can take many forms, shaped by local resources and needs, and can yield a variety of outcomes, including interactions, events, or artifacts of public and intellectual value” (CCCC Statement). The Statement mentions several rhetorical historical projects, particularly partnering with members of marginalized communities. We see a community of care taking shape within the field of rhetoric and composition: those conducting community-engaged scholarship at the site of action of health and medicine. We close by aligning our projects discussed above with the embedded community action-oriented work already being deployed by engaged scholars in rhetoric and composition, and urging further uptake by feminist scholars interested in and committed to changing how care is situated in healthcare research. Several scholars of rhetoric and composition have recently published scholarship demonstrating participatory, community-engaged approaches to rhetorical study of health and medicine. Melanie Yergeau writes “in equal parts as a rhetorician and autistic activist” (5), using stories of autistic people to theorize neuroqueerness as an identity and an alternative autistic rhetoric that complicates and challenges notions of the rhetorical (Yergeau). Rachel Bloom-Pojar conducted an ethnographic study of a summer health program in the Dominican Republic, working alongside translators and community members and ultimately theorizing a framework for the rhetoric of translanguaging for improved healthcare delivery (Bloom-Pojar). Timothy Amidon works alongside firefighters and technologists to study literate practices in the field and improve health and safety conditions for the firefighting community (Amidon et al.).

These are but three examples of recent scholarship that engage with communities, care for them in many of the same ways we articulate in this essay, and make and use rhetorical theory to work for social change. Taken together, they offer a glimpse at how intention, method, and positionality affect the care we afford to our research participants and their communities in health-related research projects. In a time when American healthcare policy grows in uncertainty and complexity, and the most under-resourced consistently go without access to affordable, quality health care, rhetoricians are urgently needed to make this turn to engagement and activism. In this essay, we have laid out our individual approaches to care as well as included other rhetoric and composition scholars we view as taking up this approach. But more explicit discussions about care and how we as a field practice care—in our research sites, in our classrooms, in our departments, and in our communities—must be had, especially given contemporary politics that make efforts to not care. As feminist scholar-activists, it is our task to confront these injustices through not only our teaching but through our methodological design. FPAR is one such method we see as assisting in actively extending care to the populations we work with. As a research community, we can practice care as a feminist rhetorical act.

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Challenges in Nursing and How to Work Through Them

April 25, 2024

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The Challenges of Being a Nurse

Nursing is one of the most rewarding and challenging professions in health care. During a 12-hour shift, nurses may take on a demanding workload due to staffing shortages; endure workplace bullying; risk exposure to infection; and, despite all their professional experience, still lose patients.

These challenges were especially prevalent during the height COVID-19. A survey of health care workers, including nurses, during the pandemic reported that 93% felt stressed, 82% experienced emotional exhaustion, and 75% felt overwhelmed. Furthermore, more than 30% of nurses who left the profession cited burnout — mental and emotional exhaustion — as the cause.

Although these challenges in nursing may seem insurmountable, nurse leaders and other health care experts are focused on alleviating nursing stress. Doing so can help prevent burnout, reduce medical errors, and improve patient care.

Nurses compose the largest part of the health care workforce. More than 5 million people have active nursing licenses (registered nurses, or RNs) nationwide, with those practicing working mainly in hospitals and long-term care. Being on the front line in providing direct patient care, nurses are vulnerable to numerous stressors that impact their physical and emotional health. It’s no surprise that 50% of nurses treating COVID-19 patients have reported symptoms of depression.

Many challenges of being a nurse can contribute to stress, burnout, and depression. Without the proper coping mechanisms, these challenges can lead to medical errors, risks to patient safety, and poorer health outcomes.

Patient Deaths

Nurses cite patient death as a leading cause of stress. Because nurses spend more time with patients and their families than other health care workers they often form an emotional connection with patients who die. Nurses grieve in many ways, harder for some patients than others. RNs have various tactics that help them to cope with patient death.

RNs who provide professional nursing care to patients also provide emotional support to them. They must have difficult conversations with patients and their families. This impacts nurses’ own emotional health.

Nursing Graduate Programs at a Glance

Nurses may also choose to earn postgraduate degrees, such as a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP). These degree programs can involve special areas of clinical focus, but they’re essentially comprehensive courses of study, with in-depth coverage of clinical practice, nursing ethics, nurse leadership, and more.

Earning a graduate degree can be an important way for nurses to take on positions of greater leadership and authority, as well as higher salaries. The downside is that nursing graduate programs are typically expensive. They’re also time-consuming: For nurses who already have a Bachelor of Science in Nursing (BSN), earning an MSN usually takes at least another two years.

Those who have concerns about scheduling flexibility and work-life balance may opt for an online graduate program, which offers more accommodation for an already busy life.

Communication Challenges

Effective communication with patients and other health care professionals is often challenging for nurses for several reasons. This can be especially true with cross-cultural patient communication. Language barriers or cultural nuances can result in miscommunication of vital health information among nurses and their patients.

Staff Shortages

Even before the COVID-19 pandemic, the health care industry suffered from a nurse shortage. As a result of staffing shortages, nurses may work double shifts or be responsible for more patients. Overwork can lead to fatigue, resulting in medical errors. The U.S. Bureau of Labor Statistics (BLS) states that about 194,500 RN open positions exist each year. Reasons for the shortage include:

• High turnover. Up to 57% of nurses leave the profession in the first three years; between 17% and 30% leave during their first year.
• Nurses nearing retirement. RNs begin to retire at an average of 51 years of age. Their departure puts more pressure on the profession.
• Shortage of nursing school faculty. A shortage of nursing school faculty limits the number of new nurses who can pursue training each year.
• Increased demand. The aging U.S. population and the COVID-19 pandemic are just two reasons for the increased demand for nurses.
• Specialization. Specialization of care and an experience-complexity gap are causing a shortage of nurses with the right technical training and experience.

High Patient Ratios

Staffing shortages can result in high patient ratios, a challenge in nursing that can lead to poor patient outcomes. For instance, intensive care unit (ICU) nurses may become responsible for three or more patients rather than just one or two. This increase in responsibility can result in missed care or medical errors.

Risk of Infection, Injury, and Death

The BLS states that RNs are at risk of various injuries. The most common are back injuries (from lifting patients); coming into contact with harmful substances (needlesticks, harmful chemicals); and contracting diseases, such as the coronavirus. An estimated 3,000 health care workers, including nurses, died of COVID-19 in 2020.

COVID-19 Fears

During the COVID-19 pandemic, many nurses feared they would transmit the coronavirus to their spouse, children, and other family members. Many nurses took extreme measures, such as washing their clothes as soon as returning home and showering before hugging their children, to avoid infecting their loved ones.

Workplace Violence

Nurses may experience workplace violence including bullying and verbal abuse from doctors, fellow nurses and health care workers, and patients and their families. At the extreme end, they may be victims of physical abuse. Workplace violence is often unreported, and can take an emotional and physical toll on sufferers.

Electronic Medical Records

Electronic medical records (EMRs) are a significant part of a nurse’s stress. Although the goal of this technology is to ensure that staff have the most up-to-date patient information, some nurses cite EMR data entry as a high-stress, laborious process that takes them away from patient care.

Moral Distress

Nurses experience moral distress, also known as moral injury, when performing a task that runs counter to their professional ethics or knowledge. During the COVID-19 pandemic, nurses suffered moral distress when not having sufficient resources, such as ventilators, to treat patients. Nurses also may be susceptible to moral distress when their workplace devalues their training and expertise.

Twelve-Hour Shifts

The 12-hour shift is standard for the nursing profession. However, it is linked to fatigue and medical errors, especially when nurses must work double shifts or cover too many patients. Experts are calling for a move to eight-hour shifts to alleviate nurses’ working conditions and improve patient care.

How Nurses Deal with Stress

Other challenges in nursing are the various physical and mental health symptoms experienced due to stress. Symptoms can range from mild to debilitating. To manage stress and its symptoms, nurses can seek support and find effective coping mechanisms. This can improve their mental health, reduce errors and burnout, and improve patient outcomes.

Several different methods for how nurses may deal with stress exist.

Symptoms of Stress

Physical symptoms of stress include headaches and stomachaches, changes in appetite, poor sleep quality, and exhaustion. Emotional symptoms include anxiety, dread, fear, and compassion fatigue.

Stress Awareness

Managing nurses’ stress is crucial to avoiding burnout and continuing to provide patient care. Fortunately, awareness of the problem grows in the health care community. Hospitals and other workplaces are increasing the availability of programs to help nurses manage stress and increase job satisfaction.

Mindfulness, Meditation, and Gratitude Journaling

Mindfulness, including the act of gratitude journaling, and meditation, including yoga and breathing exercises, can help people in challenging situations manage stress. Many mindfulness and meditation apps are available free online. Research supports gratitude journaling as an effective way to boost happiness and alleviate symptoms of depression.

Getting enough rest is critical to maintaining health and mental acuity. Nurses who make sleep a priority can improve their mental and emotional health. An RN who works a 12-hour night shift but also has family responsibilities may have to reestablish a good sleep schedule.

Nurses on short-staffed floors have little time to take a restroom break, let alone to sit down to a healthy lunch or dinner. Poor nutrition, too much caffeine, and not enough water can lead to adverse health effects. Eating right is one way to improve physical well-being, increase energy, and reduce stress.

Although nurses are on their feet all day, they often don’t have the time to exercise, which can clear the head and release endorphins. Making time for the gym, a walk in the fresh air, or yoga can help nurses destress and improve their outlook.

Workplace Support

Support from employers and co-workers can help nurses recognize they aren’t going it alone. Hospitals that provide nurses with safety initiatives, for example, can increase nursing job satisfaction. Emotional, mental, and physical wellness programs also can be successful.

Family Support

Reconnecting with loved ones and making family time a priority can help nurses destress and relax. Nurses can ask partners and spouses to take over family responsibilities during busy periods. Although caregiving comes naturally to nurses, having someone care for them may help relieve stress.

Talk Therapy

Nurses may endure high-stress experiences daily. Taking the time to talk with a mental health professional, such as a hospital chaplain or social worker, can help nurses cope better emotionally. Some hospitals and other workplaces have mental health support programs for their nursing and health care staff.

Professional Development

Continuing professional education is an excellent way to manage stress and other challenges in nursing. Upskilling and training can offer fresh perspectives to health care practices and new career opportunities. Nurses who learn new skills, or invest in their careers, are typically more engaged with their work. Hospitals that value continuing education for their nursing staff show that they recognize nursing’s professional contributions to medical care.

How Nurses Can Help Families Cope with Stress

Hospital patients and their families also may face high levels of stress. Patients may be in pain or discomfort, and fearful about hospital procedures. As a result, family members may feel protective and frightened on their loved one’s behalf.

Nurses can help families cope with stress by providing a professional presence to respond to questions and provide reassurances. Reducing stress also is a factor in how well patients and their families weather the recovery phase, which may help reduce post-intensive care syndrome, a condition that can cause PTSD in patients.

Nurses can help manage the distress of patients and their families in several ways.

Include the Families in Health Care Discussions

When patients and families are not updated on a patient’s diagnosis or treatment, their stress can worsen, causing distrust in health care providers. This distrust can lead to more nursing challenges and poor patient outcomes. Nurses who include families in health care discussions help everyone understand the patient’s condition and prepare them for the subsequent treatments. This matter-of-fact communication is crucial to alleviating stress and anxiety in patients and their families.

A Compassionate Ear

Patients see nurses more than doctors. They may establish a rapport with their nurse, and feel more open about asking questions and revealing anxieties. Nurses who listen to their patients’ grievances or fears can uncover insights that may help with the recovery process.

Coping Strategies

A component of nursing is helping patients cope with a serious or life-threatening diagnosis. Nurses help patients cope with medical conditions by being compassionate to their fears and recommending healthy coping strategies. They may help patients identify priorities, such as getting their affairs in order. Nurses also help families cope after hearing a loved one’s diagnosis by facilitating counseling with hospital social workers or chaplains.

Professional Insight

RNs use their training to understand what patients and their families aren’t saying. Careful observation can help prevent stress-related outcomes, such as anxiety and depression. Nurses can pass along their observations and recommendations to medical staff, which can become a part of the treatment plan.

Guidance Through Grief

Nurses can help guide families of recently-deceased patients through the grieving process. They may be the first to tell the family that their loved one has died. They can make sure that families have access to hospital counseling services and help them through a difficult period.

Patient and Family Advocacy

Nurses can help patients and families navigate the confusing, often stressful hospital experience. They coordinate with other members of the care team, preparing patients for their next medical procedure or through hospital discharge. They educate patients about medications, doctor’s orders, and other information needed for a successful recovery.

How Nurses Cope with the Death of Patients

Patient deaths are part of the nursing profession. Even so, coping with death is one of the most difficult challenges in nursing. Death can affect nurses in different ways. Some may feel the death of a child more deeply than that of an elderly patient. They may feel grief about the death of a patient with whom they had a rapport. Especially during the COVID-19 pandemic, nurses have dealt with the increasing burnout and fatigue associated with patient deaths.

Several different methods for how nurses may cope with the deaths of patients exist.

Some nurses compartmentalize or detach from their emotions. This may happen more when nurses have experienced more patient death, such as during the COVID pandemic. They also may compartmentalize their feelings during their shift, and, then, express their grief while on break or when driving home.

Adaptive Coping

Although many nurses practice detachment, experts report that a better method is adaptive coping. Experts urge nurses to practice adaptive coping, such as prayer or meditation, debriefing with colleagues, and taking a moment of silence or solitude to grieve and accept the patient’s death. Being comfortable with death and dying is essential to being a nurse.

Nurses may seek advice from the hospital chaplain or social workers after the death of a patient. Workplaces that provide emotional support for nurses can help them manage stress. These programs also can assure nurses that they value their professional experience.

Support from Loved Ones

Nurses often get close to patients in their care. When they lose a patient, it can feel like losing a friend or family member. Nurses who let their loved ones know about patient deaths can help relieve the grief. Families can provide emotional support by listening compassionately.

Some nurses practice self-care. They may treat themselves to a lighthearted movie or time with family and friends. They may practice gratitude or mindfulness, in recognition that they have a hard job and death comes with the territory.

Code Lavender and Tea for the Soul

Some hospitals and health care providers have a Code Lavender program. This program provides mental and emotional support for grieving health care professionals, including nurses, as well as patients and their families. Similarly, Tea for the Soul is a chaplain-led program for nurses and their specific professional challenges, such as moral distress and compassion fatigue.

Learning How to Manage Stress

Hospitals, long-term care facilities, and other medical facilities cannot function without nurses. However, many challenges in nursing can lead to stress and burnout. Nurses who have the support of their workplaces and who can successfully manage their stress are better positioned to provide high-quality care to their patients. They will make fewer errors due to fatigue and burnout. In short, stress management for nurses leads to better patient outcomes.

Nurses who understand what it takes to provide the best care to patients qualify to be leaders, and they can take on advanced roles with the right training. With a core curriculum that can prepare students for nursing leadership, evidence-based practice, and care quality improvement, Norwich University’s online Master of Science in Nursing and online Master of Science in Nursing: Nurse Practitioner programs can prepare students for professional success. Discover more of the program details and start pursuing a career in nursing today.

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Challenges and strategies for conducting research in primary health care practice: an integrative review

Daiana bonfim.

1 Hospital Israelita Albert Einstein - Albert Einstein Center for Studies, Research, and Practices in Primary Health Care and Networks, Sao Paulo, Brazil

Lorrayne Belotti

Leticia yamawaka de almeida, ilana eshriqui, sofia rafaela maito velasco, camila nascimento monteiro, adelson guaraci jantsch.

2 Executive Secretariat of Organization Open University of the Unified Health System (UNASUS), Brasilia, Brazil

Associated Data

All data generated or analyzed during this study are included in this published article.

Providing accessible and high-quality patient-centered healthcare remains a challenge in many countries, despite global efforts to strengthen primary health care (PHC). Research and knowledge management are integral to enhancing PHC, facilitating the implementation of successful strategies, and promoting the use of evidence-based practices. Practice-based research in primary care (PC-PBR) has emerged as a valuable approach, with its external validity to diverse PHC settings, making it an effective means of translating research findings into professional practice.

To identify challenges and strategies for conducting practice-based research in primary health care services.

An integrative literature review was conducted by searching the PubMed, Embase, Scopus, Web of Science, and Lilacs databases. The research question, guided by the PICo framework, directed the execution of study selection and data extraction. Data analysis followed the RAdAR method's three phases: pre-analysis, data analysis, and interpretation of results.

Out of 440 initially identified articles, 26 met the inclusion criteria. Most studies were conducted in high-income countries, primarily the United States. The challenges and strategies for PC-PBR were categorized into six themes: research planning, infrastructure, engagement of healthcare professionals, knowledge translation, the relationship between universities and health services, and international collaboration. Notable challenges included research planning complexities, lack of infrastructure, difficulties in engaging healthcare professionals, and barriers to knowledge translation. Strategies underscore the importance of adapting research agendas to local contexts, providing research training, fostering stakeholder engagement, and establishing practice-based research networks.

The challenges encountered in PC-PBR are consistent across various contexts, highlighting the need for systematic, long-term actions involving health managers, decision-makers, academics, diverse healthcare professionals, and patients. This approach is essential to transform primary care, especially in low- and middle-income countries, into an innovative, comprehensive, patient-centered, and accessible healthcare system. By addressing these challenges and implementing the strategies, PC-PBR can play a pivotal role in bridging the gap between research and practice, ultimately improving patient care and population health.

Introduction

Despite global efforts toward strengthening primary health care (PHC) in the last 40 years, providing accessible and good quality patient-centered health care is still a challenge to most countries. Recently, the report Operational Framework for Primary Health Care (2020) released by the World Health Organization reinforced the principles of the Astana Declaration highlighting 14 levers that must be simultaneously pulled to promote PHC across the world [ 1 ].

One of those 14 “operational levers” describes the importance of conducting research that is meaningful for PHC: “ Research and knowledge management, including dissemination of lessons learned, as well as the use of knowledge to accelerate the scale-up of successful strategies to strengthen PHC ” [ 1 ] . Although conducting research that meets these premises is not simple, primary care practice-based research (PC-PBR) has become an important vehicle for the development of science in the real world, because of its external validity to other PHC settings and contexts, making knowledge translation easier to put evidence into professional practice [ 2 ].

PC-PBR occurs in the context of patient health care in the community, according to Dolor et al. (2015), resulting in the research questions being primarily generated by the health services to respond to the needs of their territory [ 3 ]. PHC is responsible for serving as the first point of contact for patients, through which all health issues should be addressed. It serves as an ideal setting for conducting practice-based research, encompassing the implementation of innovations and studies aimed at enhancing the quality of care for various health conditions. These conditions span across diverse areas, including mental health [ 4 ] and chronic kidney disease [ 5 ]. Furthermore, it is also pertinent in the context of public health emergencies, such as the COVID-19 pandemic [ 6 ].

One solution to foster this type of research is creating practice-based research networks (PBRNs). Their aim is to bring healthcare professionals, researchers, health managers, and academic institutions together, facilitating partnerships, and providing structure and technical support to healthcare professionals to carry out research projects that are developed and conducted in PHC settings to tackle important aspects of PHC [ 7 , 8 ]. They also help on the job of acquiring funding, capacity building, organizing the necessary logistics to put a research project in place and all sorts of tasks from study design to publication [ 3 , 9 ]. In this way, PBRNs seek to promote a culture of scientific research in an environment originally dedicated to health care [ 10 ] and to answer relevant questions about the local health needs of PHC services. According to Bodenheimer et al. (2005), PBRNs are increasingly seen as institutions that can simultaneously conduct research efficiently and leverage changes in practice [ 11 ], serving as laboratories for approaching important challenges to PHC.

However, a preview study [ 9 ] developed in Canada described some lessons learned to engage PBRLNs present aspects related to the need for continuity in ethics, regular team meetings, enhancing levels of engagement with stakeholders, the need for structural support and recognizing differences in data sharing across provinces.

Even though the literature on PC-PBR is growing, “How to implement a PBRN and how to scale PC-PBR?” and “How can a healthcare service become a setting for knowledge and innovation production?” are two questions still unanswered. Moreover, scenarios with incipient PHC could benefit from evidence-oriented policies and practice-oriented research. To answer these two questions, available information from places that already run PC-PBR projects needs to be systematized around the challenges, obstacles and solutions found by other researchers. Aiming to help researchers from low- and middle-income countries that are willing to produce research in primary care, we performed an integrative review identifying the challenges and strategies for carrying out PC-PBR.

An integrative literature review was performed based on the methodology proposed by Whittemore & Knafl (2005) [ 12 ] that includes (a) identification of the problem, (b) literature search, (c) evaluation, (d) analysis and (e) presentation of results. Differently from a systematic review, the broader focus of an integrative review enables the inclusion of studies using different methodologies (qualitative, quantitative and mixed) in the analysis and supplies the methodological rigor necessary for a broader understanding of one specific phenomenon [ 13 , 14 ].

Literature search

The research question was developed using the PICo framework (Population, Interest and Context). The elements were organized by P - Primary health care (PHC); I - Challenges and Strategies; Co - Practice-based research (PBR); resulting in the guiding question: “What are the challenges and strategies to carry out PBR in PHC?”. Data were collected in February 2022 by a librarian affiliated with the authors' institution from the databases PubMed, Embase, Scopus, Web of Science, and Lilacs. The database selection was conducted to ensure comprehensive coverage of relevant literature, encompassing multidisciplinary and geographical perspectives related to practice-based research in primary care. The search utilized descriptions and keywords from the Medical Subject Headings (MeSH) and Health Science Descriptors (DeCS), combined with the Boolean operators 'AND' and 'OR' (Table ​ (Table1 1 ).

Search strategies, according to the database and Boolean operators

Study selection

Articles in English, Spanish and Portuguese were included, regardless of their publication year. Review studies, essays, letters to the editor, studies conducted in non-PHC settings (e.g., emergency services), and those focused on specific health problems were excluded.

Two researchers independently screened the articles by title and abstract (SRMV e AGJ), and the disagreements were resolved through discussion and mediation by a third author (LB). Following this stage, the studies were read in their entirety by the same two authors. During this phase, any remaining disagreements regarding the final inclusion were examined and decided by the authors. In the study selection phase, the software Rayyan was employed as a tool for managing and screening research articles.

Data extraction

Information was systematically extracted from the selected articles and organized using a custom-designed spreadsheet, enabling the identification of key aspects essential for addressing the research question. These included author names, publication year, study type, study location, research objectives, methodologies employed, study populations, primary internal and external challenges encountered in operationalizing research within primary healthcare, and strategies offered for its effective implementation.

Data synthesis

The review followed a deductive approach that prioritized the extraction and summarization of studies included as the primary objective of the review and synthesis [ 15 ]. This process entails extracting the results from each included paper and categorizing them according to common themes or meanings. These categories are subsequently further organized, allowing for a summary that yields synthesized findings: practical and actionable guidelines suitable for informing policy and formulating strategies [ 16 ].

To achieve this, the data analysis followed the steps established by the three distinct phases of the RADaR method: pre-analysis, data analysis, and interpretation of the results [ 17 ]. In the pre-analysis stage, each article was read, and its information was extracted and stored in a spreadsheet created to summarize all articles included in the study. In the data analysis stage, the content was categorized according to the similarities of the barriers and challenges identified. Finally, in the interpretation of the results, a reflective and critical analysis of the content was conducted, summarizing the content into themes for analysis [ 17 ].

A total of 440 publications were identified in the databases. After excluding duplicate studies ( n =120) and those that did not answer the guiding question ( n =283), 37 studies were read in their entirety. Out of these, 11 were excluded as they did not meet the eligibility criteria. The final sample consisted of 26 studies (Fig.  1 ), with the majority being published in the past two decades and conducted in high-income countries (HICs), primarily in the United States of America ( n =13). Furthermore, a significant proportion of these studies were case studies focused on the medical profession (Table ​ (Table2 2 ).

Flowchart of study selection

Description of the primary studies included in the integrative literature review according to the lead author, year, country, objective, population, and type of study

NR Not Reported

During the data analysis, six overarching themes and 15 subthemes related to the challenges of carrying out PC-PBR emerged. Among these challenges, difficulties regarding research planning were noteworthy, with issues ranging from excessive bureaucracy to challenges in planning and developing a research project. The Engagement of health professionals in research was recognized as one theme encompassing four different subthemes: lack of training and experience in scientific writing; difficulties with foreign languages; previous negative research experiences; and fears of negative impacts on the healthcare team, patients and productivity. Challenges regarding knowledge translation detail the difficulties in applying the knowledge acquired from one article to a change in daily work. Infrastructure issues are related to the location of the health services and how dispersed they can be in one area, the lack of technological tools and the little access to funding resources to sponsor more robust and long-term projects. Finally, a weak relationship between universities and health services can lead to little – or even no – collaboration between research institutes and PHC practices. The lack of international partnerships is finally presented as one main challenge for low- and middle-income countries (LMICs) since such collaborations could be helpful in building capacity for young research centers to address pressing issues in contexts where PHC is still very incipient (Table ​ (Table3 3 ).

Summary of findings on challenges for conducting PC-PBR

The strategies listed in the articles included in this review were organized according to the challenges described in the previous section. The following were highlighted: suggestions related to creating a research agenda adapted to each reality; training strategies to develop research skills; sharing the results with all stakeholders involved, from participants to health managers and decision-makers; and the importance of creating networks for practice-based research (Table ​ (Table4 4 ).

Strategies for conducting PC-PBR

Challenges and strategies for conducting PC-PBR

Research planning.

In this domain, a series of challenges related to designing a research plan are combined, such as developing and refining a research question, designing a strategy for data collection and data analysis, writing and submitting a proposal to the ethics board committee and the amount of time it takes to obtain the approval to start the project [ 8 , 9 , 11 , 18 , 30 , 32 , 35 ]. The time needed to carry out and conclude a study is often very different from the amount of time needed to make decisions in health care. Conducting a study with the length of time necessary to meet the needs for the transformation of health services is a difficult task, since managers and decision-makers may have more immediate expectations and hope for quick solutions to their problems [ 8 ]. To overcome this limitation, it is important that all stakeholders (managers, patients, health professionals, and researchers) are involved in the study, mainly to facilitate the understanding of the steps that one study needs to go through until its publication [ 9 , 18 , 38 ].

Engagement of health professionals in research

Some decision-makers and health managers fear that a research project can cause trouble in the way that a health facility is used to operate, impairing its productivity or even hindering the patients’ trust in the health service [ 8 , 18 , 21 , 30 , 31 , 35 , 36 ]. In addition, many managers see research projects as less important than practice, without acknowledging the possible benefits of research on patient care [ 28 ]. Researchers must bring these issues into debate with health managers and decision-makers so that barriers such as a lack of time dedicated to research, high caseloads limiting the time dedicated to research, and the need for institutional approval to allow professionals to participate in research projects can be overcome [ 26 ]. If this is not done, it will be difficult to create a routine of knowledge production and innovative research that integrates healthcare professionals, patients and researchers to create robust scientific evidence with an impact on the workplace, patient care and the quality of the services provided.

Knowledge translation

This theme, which is known as integrated knowledge translation in the current literature [ 39 ], involves the processes of generating, sharing, and applying knowledge, not necessarily in that specific order [ 8 , 32 ]. In theory, carrying out PC-PBR is a powerful resource to make knowledge translation happen, since research questions are created to answer local needs, relying on the participation of professionals – and sometimes the patients – in practice [ 32 ].

However, one of the barriers to knowledge translation lies in the difficulty of adapting the knowledge to contexts that are distinct from those where one study was held, e.g., results from HIC being translated to LMICs. This reinforces the need to involve all stakeholders in the stages of designing the project to describe the aspects of the context where the research will be held, outlining this information in the discussion section of the article as well, making it easier for the reader to understand its external validity [ 2 , 8 , 30 , 38 ].

The long time span for the publication of the study results in scientific journals, in addition to the high rejection rate, are factors that further delay the process of knowledge translation. Considering the dynamic nature of primary care services, studies should have a broad plan to disseminate results, to implement the evidence in a timely manner [ 30 ].

Infrastructure

Challenges related to infrastructure are frequently found in PC-PBR studies, from the distance between primary care services in rural settings and the difficulty of reaching some services to the often lack of technology resources, such as internet access, and patients’ electronic records [ 8 , 9 , 20 , 23 , 32 , 35 ].

The lack of reliable, sustainable, and systematic funding for PC-PBR research activities is the main obstacle to overcoming these infrastructure limitations and promoting the creation of PC-PBR [ 8 , 10 , 19 , 23 , 27 , 31 , 35 ]. Like every research initiative, PC-PBR needs to be supported with adequate and constant funding. For that reason, researchers must remain attentive and updated to identify funding opportunities [ 18 ].

Healthcare services produce a large volume of data every day. Information about healthcare procedures, prescriptions, patient profile, and all sorts of interactions between the patient and their healthcare providers. However, the quality of the information input and the way it is stored can limit its use [ 9 ]. It is essential for managers and stakeholders to verify how these data have been used, not only how practitioners use them for patient management but also for research, surveillance, and accountability [ 19 , 23 ].

Confidential information should be strictly and safely handled so that no patient information becomes public, allowing its use for research with no harm to the patient or for the practice [ 34 ]. For this purpose, all parties using these data must agree to a common commitment across the PC-PBR network to develop and implement research programs. Ideally, the research priorities should be established by the researchers and managers, with a clear evaluation of the capabilities of each practice, the information systems available and the whole network. When used appropriately, these real-world data can generate new knowledge from practice to improve patient care [ 18 ].

Relationship between universities and health services

Some studies highlighted the strains of integrating universities and health services [ 8 , 18 , 21 ]. The distance between these two scenarios can be explained by several factors: (a) the fact that academic priorities may not reflect the needs of the communities [ 8 ]; (b) weak connections between academia and primary care services [ 19 ]; (c) the lack of a mutual agenda between them combining common interests [ 25 ]; (d) the distance between researchers and health professionals [ 8 ]; and (e) the restricted access to specific research training courses run by universities, apart from formal master’s and doctorate courses [ 21 ]. Such training courses are usually offered during workdays, which limits the participation of those who work full-time as health care providers. Offering postgraduate courses in research aimed at health professionals that take advantage of the students’ experience to generate relevant research questions and new knowledge for healthcare could be transformative both for universities and health services. However, gathering individuals who traditionally work in different sectors is not easy. In addition, creating organizational structures that support primary care-based studies can demand financial resources, time, and people, which are not easily available [ 29 ].

Among the strategies found in the articles to overcome this challenge, it is important that the research questions arise from practice and that the roles of researchers, academics and health professionals are well-defined within the group. In addition, it is important to select a coordinator responsible for managing the research project and the tasks that need to be executed [ 30 , 34 ].

Implementing PC-PBR can bring results both for practice and academia, bringing together different professionals to achieve a common goal of improving patient care. Strengthening the interaction between academia and primary care services can help to promote the sustainable development of research projects in which health professionals can develop innovations in health care that can be studied and tested, creating a virtuous cycle beginning with raising questions from practice, conducting experiments, finding results and producing evidence that can serve the purpose of improving patient care and the health of the population [ 19 ].

Partnerships between countries

Despite this being a topic addressed in only two of the articles under analysis, promoting international partnerships can be a solution to many of the challenges mentioned here. However, such collaborations are not yet a reality for many countries. There is a shortage of international initiatives to promote research courses and training to bring together mentors from HIC and young researchers from LMICs and provide direction for conducting studies in contexts with few resources [ 8 ].

In addition, many professionals from LMICs who are involved in studies or education abroad end up migrating to other countries, contributing to the so-called “brain drain” of skilled professionals and worsening the inequality in scientific production between HICs and LMICs.

Addressing research projects within the local context and exploring opportunities for international collaboration is important enough to foster PBR and guide health professionals in places where universities and research institutes are not yet established. Moreover, it is important to consider the epidemiological profile, cultural aspects, and social determinants of health in every scenario involved when an international collaboration is planned. The different contexts of practice can enrich the research and establish comparisons that can be decisive for international scientific advancement [ 8 ].

The challenges and strategies for the implementation of PC-PBR indicate operational, structural, and political issues. One of the key aspects learned about planning a PC-PBR study is to identify and include all stakeholders (patients, employees, doctors and administration) in the development phase of the project, allowing for discussions about the study design and its implementation phases. This approach must become an integral part of the study, being comprehensive to addressing barriers to participation, obtain data, analyze and interpret the results and, finally, discuss its findings and implications. Additionally, planning data collection that demands little effort from health professionals can strengthen the study’s realization and the involvement of everyone.

In this context, it is important to emphasize that all challenges are even more pronounced in LMICs. In this regard, efforts are being made towards decolonization [ 40 ], encouraging research that validates the context and perspectives of local thinkers, thereby expanding the discussion to generate and incorporate evidence into real scenarios that value the knowledge of communities, healthcare professionals, policymakers, and researchers in LMICs. Therefore, the present study aimed to synthesize the challenges and strategies that underlie this discussion, but a gap was identified in terms of the production of this discussion in LMICs.

To address the issue of limited international collaborations in LMICs, it is crucial to explore targeted implications and strategies to surmount this constraint. Some viable strategies involve providing training and education in cultural sensitivity, thereby enhancing the efficacy of these partnerships. While international collaboration typically prioritizes partnerships with high-income countries, LMICs can also explore collaborations with other LMICs. Sharing knowledge, best practices and resources with neighboring countries facing similar challenges can result in mutually advantageous outcomes.

PC-PBR only happens if the professionals who are directly involved in patient care and health service management are integrated as part of the team of researchers, not just as the subjects of the research [ 8 , 36 ]. Although it is a great challenge, training healthcare professionals to conduct research in primary care is fundamental for the success of these projects [ 23 , 24 ].

Alternative research approaches, such as implementation research, have advanced and grown as new strategies to reduce the gap between research and practice, mainly because they systematically approach the factors that contribute to this gap, understanding the context and identifying barriers and solutions for delivering sustainable and effective health care [ 41 ]. Thus, to make progress in overcoming these structural barriers it is important to understand the essential pieces of the research process, without which a project will likely die prematurely. One of these elements is the minimal infrastructure needed for PC-PBR research projects to be long-lasting and sustainable [ 9 , 23 ].

The studies under analysis point out that the most promising way for this to happen is through collaboration between primary care services, universities, and research institutes. In addition, these collaborations can provide training in research skills for health professionals, creating an environment conducive to exchanging experiences, ideas, and questions about the practice. All these suggestions will help to create a research agenda oriented toward solving real issues related to taking care of patients in primary care, which is the main objective of conducting PC-PBR [ 8 ].

The distance between universities and primary care settings is recurrently cited. This issue reinforces the idea that there is a place where knowledge is produced (universities and academia) that is different from the places where health care occurs. In other words, primary care is seen as a place where scientific evidence produced by academia is put into practice.

Conducting scientific research within primary care practices is innovative and can create ruptures and conflicts when it affects the way the job is done or when it takes people out of their comfort zones. By placing health professionals—and at times, patients—as agents of research production, PC-PBR can change the way new knowledge is produced. If knowledge is traditionally produced in academia and then taken as a truth by the place where patient care occurs, PC-PBR can not only generate new knowledge to change professional practice but also bring new evidence to change the way academia works, guiding new research that is better aligned with reality [ 34 ].

In some countries, a more horizontal construction of new evidence and knowledge translation can be seen between academia and healthcare practice. In Australia, for example, PBR protocols are designed to build a sustainable collaboration between a PBRN and an Advanced Center of Research and Translation in Health to build a research platform for planning, conducting and translating research evidence to improve care across the healthcare spectrum [ 42 ].

Aligned with the need for partnership between universities and practices, international collaborations are also an opportunity to guide professionals in places where universities and research institutes are not yet established. Cases such as Australia and New Zealand, where two PBR networks were established to encourage research in the area of osteopathy, show that PBRN has the potential to facilitate the access of professional researchers and clinics that are interested in collaborating with clinical tests and, thus, offer the scientific community an opportunity to conduct research with different methodologies in diverse contexts [ 42 ].

Regarding the difficulties in engaging health professionals in PC-PBR, some examples listed in the articles were little experience in scientific writing, difficulties reading articles in foreign languages, limited self-trust and lack of training to start and conduct studies. Thus, studies recommend that universities and research institutes organize training courses to develop research skills and exchange experiences to determine shared research priorities [ 8 ].

Although essential, the development of research skills is not enough for professionals to engage with and incorporate studies into their places of practice. For PC-PBR projects to advance, leadership is necessary to influence policymakers and managers and advocate for studies to be directly connected with the practice where health care happens.

The majority of the selected studies highlighted the medical category in the discussion about PBR. However, it is important to expand the professional composition of PC-PBR beyond and consider other categories to organize more participative and multidisciplinary studies. All health professionals must be invited to interact and collaborate with scientific activities and implement new projects. The inclusion of all health professionals, including community health workers, nursing assistants, and dental hygienists, who are commonly found in LMICs, can improve the development of research projects that will better take into consideration the patients’ and the territory’s needs [ 8 ].

Implementing PC-PBR goes beyond research production, since the results of the studies produced by researchers, health professionals, users and managers, in addition to the lessons learned, are shared with the health service where the study was held, bringing greater transparency to the entire process and motivating more health professionals to actively participate in future research projects [ 38 ].

Limitations

This review was limited to the literature that reported lessons learned and experiences conducting PC-PBR since few empirical studies with primary data from practice were found. Additionally, there is little representation from LMICs. This limits the conclusions of this review to the contexts described herein, i.e., HIC, where PHC already has a solid structure and a robust research production. Exploring studies performed in PC-PBR networks and identifying their strengths and weaknesses would be a step forward in this sense, but it would demand greater operational efforts. However, this is the first review that is necessary for the advancement of primary care research mainly in LMIC.

The challenges for implementing PBR are similar in the contexts analyzed, showing that turning one place that was originally designed for delivering primary care into a place of knowledge production is not a trivial task. The benefits depicted in the studies show that transforming the traditional methods of knowledge production and translation through PC-PBR can generate a virtuous cycle, providing criticism and reflection about the practice and generating innovations and new knowledge to improve healthcare and patients’ health and well-being.

Additionally, the found strategies point to the need for lasting and systemic actions involving health managers, decision-makers, academics, different types of health professionals and patients, aiming to transform PHC practice in the long term. Despite being more the exception than the rule, PC-PBR has the potential to transform a PHC system that is still under development into an innovative, socially accountable, more comprehensive, accessible, and patient-centered healthcare approach. Furthermore, recognizing the transformative potential of PC-PBR, it becomes imperative to explore strategies for scaling these practices and approaches, ultimately having a broader and more profound impact on the entire primary healthcare system.

Acknowledgment

Not applicable.

Authors’ contributions

Conception and planning of the study: DB and AGJ. Writing the main manuscript text: DB, LB, LYA, IEO, SRMV, CNM, AGJ. Analysis and interpretation: DB, LB, LYA, IEO, SRMV, CNM, AGJ. All the authors read and gave final approval for the final version to be published and agreed to be accountable for all aspects of the work.

The study received no funding.

Availability of data and materials

Declarations.

The authors declare no competing interests.

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