Reimagining Innovation in Health Equity: Making a Case for a Community-embedded Participatory Learning Site for Adivasi Health Research
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Abstract
Introduction: This paper explores the development of the Realist Implementation Action Research Lab (RIAL), a participatory learning site aimed at addressing health disparities among Adivasi communities in India. Despite national health improvements, Adivasis face significant health inequities. RIAL employs a realist-inspired, theory-driven design to co-create solutions with communities, fostering collaboration among diverse stakeholders. The paper discusses insights from the establishment of RIAL, focusing on strategies implemented, opportunities identified, challenges encountered, and lessons learned to inform public health research and practice for Adivasi populations.
Methods: We utilized processual analysis to examine the evolving dynamics of RIAL, combining historical and current documentation with collaborative team reflections. Context-Mechanism-Outcome (CMO) configurations were developed to tailor interventions to community needs and foster stakeholder engagement. These methods emphasized the contextual nature of health interventions, aligning with a systems-oriented, participatory approach. The establishment of RIAL involved consultations with community-based organizations, capacity-building workshops, and collaborative platforms to engage community leaders, healthcare providers, and policymakers, ensuring a participatory and contextually relevant foundation.
Results: RIAL’s implementation highlighted the importance of reconfiguring power dynamics and fostering participatory processes. Strategies included co-design workshops, town hall assemblies, and capacity-building sessions, which enhanced community ownership and engagement. Challenges such as gender norms, logistical barriers, and resistance from non-Adivasi stakeholders were encountered, but iterative adaptation allowed for overcoming these barriers. Key findings included improved intervention receptivity, such as the successful relocation of a deaddiction clinic to a community-trusted NGO hospital and the implementation of sports-based psychosocial interventions for Adivasi youth, which demonstrated increased mental health awareness and reduced stigma.
Conclusion: RIAL exemplifies the potential of participatory and context-aware methodologies in addressing health inequities among marginalized populations. Although scalability and resource availability pose limitations, this paper advocates for a shift from techno-centric solutions to those that are participatory, emphasizing sustained community engagement and co-creation of health interventions. The insights from RIAL's implementation offer potential implications for adapting similar models in other contexts, aiming to reduce health disparities through inclusive research practices.
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References
Xaxa V. Formation of Adivasi indigenous peoples’ identity in India. First Citizens: Studies on Adivasis, Tribals and Indigenous Peoples in India. Washington DC: Oxford India Studies in Contemporary Society; 2016: 33–52.
Ghosh P, Chaudhuri D. Adivasi, tribe or ST: The debate on the status of Adivasi livelihood; 2022 [cited 2023 Oct 29]. Available from: https://www.pradan.net/sampark/Adivasi-tribe-or-st-the-debate-on-the-status-of-Adivasi-livelihoods/
Census. Census of India 2011. Government of India; 2011 [cited 2016 Mar 17]. Available from: http://censusindia.gov.in/2011-prov-results/data_files/india/paper_contentsetc.pdf
Ambagudia J, Mohanty S. Adivasis, integration and the state in India: Experiences of incompatibilities. Int Rev Soc Res.2020;9:108–21.
Nilsen AG. Adivasis and the State: subalternity and citizenship in India’s Bhil Heartland. 1st ed. United Kingdom: Cambridge University Press; 2018: 247–263.
Chemmencheri SR. State, social policy and subaltern citizens in Adivasi India. Citizensh Stud. 2015;19(3–4):436–49.
Choudhury A. State, conflict and India’s North East. The Clarion-Int Multidiscip J.2012;1(2):182–8.
Muralidhar G. Livelihoods of Adivasis in India: Continuing marginalisation. In: Adivasi Rights and Exclusion in India. Routledge India; 2018.
Krishnan S, Mallick S. The forest rights act and Adivasi landlessness in Kerala. J Asian Afr Stud. 2024 Dec;59(8):2259–69.
Xaxa V. Isolation, inclusion and exclusion: the case of Adivasis in India. In: Adivasi Rights and Exclusion in India. Routledge India; 2018: 27–40. Available from: https://www.taylorfrancis.com/chapters/edit/10.4324/9780429437076-2/isolation-inclusion-exclusion-virginius-xaxa
Bang A, Jhalani M, Angami N, Beck H, Jain Y, Kujur JM. Tribal health in India: bridging the gap and a roadmap for the future. Executive Summary and Recommendations New Delhi: Ministry of Health and Family Welfare and Ministry of Tribal Affairs, Government of India; 2018.
NFHS 5. National Family Health Survey 5. 2019 [cited 2023 Mar 1]. Available from: http://rchiips.org/nfhs/nfhs5.shtml.
Xaxa V. Report of the High-Level Committee on socioeconomic, health and educational status of tribal communities in India. Delhi: Ministry of Tribal Affairs Government of India; 2014 [cited 2016 Dec 9]. Available from: http://www.indiaenvironmentportal.org.in/content/403965/high-level-committee-report-on-social-economic-status-of-tribal-communities/.
Sabu KU, Basappa YC, Sangeetha VJ, Srinivas PN. An intersectional analysis of the composite index of anthropometric failures in India. Int J Equity Health.2021;20(1):1–11.
Sabu KU, Ravindran TS, Srinivas PN. Factors associated with inequality in composite index of anthropometric failure between the Paniya and kurichiya tribal communities in wayanad district of Kerala. Indian J Public Health.2020;64(3):258.
Sabu KU, Srinivas PN, Soman B. Social determinants of child undernutrition in Adivasi population in Northern Kerala: a study using syndemic framework. Indian J Pediatr.2023 Dec;90(Suppl 1):77-84.
Arya Krishna KG. Livelihood support for tribal population in Kerala through planned assistance: an evaluation of the tribal sub plan (TSP) in the agricultural sector (PhD Thesis). Department of Agricultural extension, College of Horticulture, Vellanikkara; 2020 27. Available from: http://14.139.185.57:8080/jspui/handle/123456789/10511.
Pujar SC. Socio-economic dimensions of education among the Betta Kuruba: anthropological insights from Mysuru District, Karnataka. Antrocom: Online J Anthropol.2023 [cited 2023 Oct 27];19(1).
Lukšaitė E. “Everything in India happens by Jugaad”: Dai-mas in Institutions in Rural Rajasthan. Med Anthropol.2021 Nov 17;40(8):703–17.
Gill K, Bhattacharya R, Bhattacharya S. The political economy of capitalism, development and resistance: The state and Adivasis of India. Oxfam India; 2015.
Ministry of tribal affairs. Statistical profile of scheduled tribes in India. 2018 [cited 2023 Aug 13]. Available from: https://tribal.nic.in/.
George MS, Davey R, Mohanty I, Upton P. “Everything is provided free, but they are still hesitant to access healthcare services”: why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare? Int J Equity Health.2020;19:1–15.
Mohindra KS, Narayana D, Haddad S. “My story is like a goat tied to a hook.” Views from a marginalised tribal group in Kerala (India) on the consequences of falling ill: a participatory poverty and health assessment. J Epidemiol Community Health.2010;64(6):488–94.
Gaitonde R. Research on inequities and inequalities in health in India: a mapping of the field. In: Ravindran TKS, Gaitonde R, editors. Health Inequities in India. Singapore: Springer Singapore; 2018 [cited 2023 Dec 19]:55–65. Available from: http://link.springer.com/10.1007/978-981-10-5089-3_3.
Freire P. Pedagogy of hope: reliving pedagogy of the oppressed. London: Bloomsbury Publishing; 2021: 251.
Campos FC, Anderson GL. Paulo Freire’s influence on participatory action research. The SAGE Handbook of Participatory Research and Inquiry.2021:41.
Glandon D, Paina L, Alonge O, Peters DH, Bennett S. 10 Best resources for community engagement in implementation research. Health Policy Plann.2017 Dec 1;32(10):1457–65.
Wallerstein N, Duran B, Oetzel JG, Minkler M. Community-based participatory research for health: Advancing social and health equity. New Jersey, USA: John Wiley & Sons; 2017.
Lin CY, Loyola-Sanchez A, Boyling E, Barnabe C. Community engagement approaches for Indigenous health research: recommendations based on an integrative review. BMJ Open.2020 Nov 1;10(11):e039736.
Mohindra KS, Narayana D, Harikrishnadas CK, Anushreedha SS, Haddad S. Paniya voices: a participatory poverty and health assessment among a marginalized South Indian tribal population. BMC Public Health.2010;10:1–9.
Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health. 2010;100(S1):S40–6.
Kelly J, Saggers S, Taylor K, Pearce G, Massey P, Bull J, et al. “Makes you proud to be black eh?”: Reflections on meaningful Indigenous research participation. Int J Equity Health.2012 Aug 8;11(1):40.
Jagosh J, Bush PL, Salsberg J, Macaulay AC, Greenhalgh T, Wong G, et al. A realist evaluation of community-based participatory research: partnership synergy, trust building and related ripple effects. BMC Public Health.2015;15(1):725.
Lines LA, Jardine CG, Yellowknives Dene First Nation Wellness Division. Connection to the land as a youth-identified social determinant of Indigenous Peoples’ health. BMC Public Health.2019 Feb 11;19(1):176.
Morton Ninomiya ME, Pollock NJ. Reconciling community-based Indigenous research and academic practices: Knowing principles is not always enough. Soc Sci Med.2017 Jan 1;172:28–36.
Wali S, Superina S, Mashford-Pringle A, Ross H, Cafazzo JA. What do you mean by engagement? – evaluating the use of community engagement in the design and implementation of chronic disease-based interventions for Indigenous populations – scoping review. Int J Equity Health.2021 Jan 6;20(1):8.
DeCamp M, Matandika L, Chinula L, Cañari-Casaño JL, Davis CH, Anderson E, et al. Decolonizing global health research: Perspectives from US and international global health trainees. Ann Glob Health.2023 Feb 6;89(1):9.
Madegowda C. Traditional knowledge and conservation. Econ Polit Wkly.2009;65–9.
Nakkeeran N, Sacks E, Srinivas PN, Juneja A, Gaitonde R, Garimella S, et al. Beyond behaviour as individual choice: A call to expand understandings around social science in health research. Wellcome Open Res.2021 Aug 23;6:212.
Greenwood DJ. Pragmatism: Linking systems, evolution, and democratization in participatory and action research. London: Sage; 2020 [cited 2023 Oct 27].
Bell K, Reed M. The tree of participation: a new model for inclusive decision-making. Community Dev J.2022 Oct 1;57(4):595–614.
Abildgaard JS, Nielsen K, Wåhlin-Jacobsen CD, Maltesen T, Christensen KB, Holtermann A. ‘Same, but different’: A mixed-methods realist evaluation of a cluster-randomized controlled participatory organizational intervention. Human Relations.2020 Oct 1;73(10):1339–65.
Tilley N, Pawson R. Realistic evaluation: an overview. In: Founding conference of the Danish Evaluation Society. Citeseer; 2000.
Greenhalgh J, Manzano A. Understanding ‘context’ in realist evaluation and synthesis. Int J Soc Res Methodol.2022 Sep 3;25(5):583–95.
Gaventa J. Finding the spaces for change: a power analysis. IDS Bulletin.2006 Nov;37(6):23–33.
Ansell C, Doberstein C, Henderson H, Siddiki S, ‘t Hart P. Understanding inclusion in collaborative governance: a mixed methods approach. Policy Soc.2020 Dec 1;39(4):570–91.
Van Belle S, Abejirinde IO, Ssennyonjo A, Srinivas PN, Hebbar P, Marchal B. How to develop a realist programme theory using Margaret Archer’s structure–agency–culture framework: The case of adolescent accountability for sexual and reproductive health in urban resource-constrained settings. Evaluation.2023 Jul 1;29(3):259–75.
Thresia CU, Srinivas PN, Mohindra KS, Jagadeesan CK. The health of Indigenous populations in South Asia: a critical review in a critical time. Int J Health Serv.2022 Jan 1;52(1):61–72.
Pratt B, Seshadri T, N Srinivas P. Overcoming structural barriers to sharing power with communities in global health research priority-setting: Lessons from the participation for Local Action project in Karnataka, India. Glob Public Health.2022 Mar 31;17:1–19.
Pratt B, Seshadri T, Srinivas PN. What should community organisations consider when deciding to partner with researchers? A critical reflection on the Zilla Budakattu Girijana Abhivrudhhi Sangha experience in Karnataka, India. Health Res Policy Sys.2020 Sep 11;18(1):101.
Pettigrew AM. What is a processual analysis? Scand J Manag.1997 Dec 1;13(4):337–48.
Seshadri T, Madegowda C, R Babu G, N S P. Implementation research with the Soliga Indigenous community in Southern India for local action on improving maternal health services. Rochester, NY; 2019 [cited 2023 Feb 23]. Available from: https://papers.ssrn.com/abstract=3483650.
Pratt B, Srinivas PN, Seshadri T. How is inclusiveness in health systems research priority-setting affected when community organizations lead the process? Health Policy Plann.2022 Aug 1;37(7):811–21.
Pai M, Schumacher SG, Abimbola S. Surrogate endpoints in global health research: still searching for killer apps and silver bullets? BMJ Glob Health.2018 Mar 1;3(2):e000755.
Friedman EA, Gostin LO. From local adaptation to activism and global solidarity: framing a research and innovation agenda towards true health equity. Int J Equity Health. 2017;16(1):1–4.
Callahan K. Citizen participation: models and methods. Int J Public Admin.2007 Aug 28;30(11):1179–96.
Pratt B, Merritt M, Hyder AA. Towards deep inclusion for equity-oriented health research priority-setting: A working model. Soc Sci Med.2016 Feb 1;151:215–24.
Mouffe C. Deliberative democracy or agonistic pluralism? Soc Res.1999;66(3):745–58.
Seshadri T, Velho ND, Narasimhamurti NS, Srinivas PN. Examining fine-scale tribal health inequalities around three forested sites in India: Results of a cross-sectional survey. J Family Med Prim Care. 2020 Sep;9(9):4788-4796.
Gonzales KL, Jacob MM, Mercier A, Heater H, Nall Goes Behind L, Joseph J, et al. An indigenous framework of the cycle of fetal alcohol spectrum disorder risk and prevention across the generations: historical trauma, harm and healing. Ethn Health. 2021 Feb 17;26(2):280–98.
Nadkarni A, Weobong B, Weiss HA, McCambridge J, Bhat B, Katti B, et al. Counselling for alcohol problems (CAP), a lay counsellor-delivered brief psychological treatment for harmful drinking in men, in primary care in India: a randomised controlled trial. Lancet.2017;389(10065):186–95.
Bhandalkar D. Spoiled identity and stigma: A case of ex-criminal tribes of India. Fourth World J.2021;21(1):47–56.
Pal GC. Atrocities against Adivasis: the implicit dimension of social exclusion. In: Adivasi Rights and Exclusion in India. New Delhi: Routledge; 2018 [cited 2024 Jan 9]. p. 217–41.
Jose JP, Sabu KU. Conceptualising psychosocial model of social exclusion: a preliminary debate. Indian J Soc Work.2018;79(2):177–92.
Mathias K, Pant H, Marella M, Singh L, Murthy GVS, Grills N. Multiple barriers to participation for people with psychosocial disability in Dehradun district, North India: a cross-sectional study. BMJ Open.2018;8(2).
Sadath A, Jose K, Meethal ST, Mathai JK, Venugopal AP, Xavier N. Factors associated with alcohol misuse among indigenous tribal men in Wayanad: a qualitative study. Indian J Psychol Med. 2019;41(6):516–22.
Carson B, Dunbar T, Chenhall RD, Bailie R. Social determinants of Indigenous health. Oxfordshire, England: Routledge; 2020 [cited 2024 Apr 23].
Mezzina R, Gopikumar V, Jenkins J, Saraceno B, Sashidharan SP. Social vulnerability and mental health inequalities in the “Syndemic”: Call for action. Front Psychiatry.2022;13:894370.
Mathias K, Jain S, Fraser R, Davis M, Kimijima–Dennemeyer R, Pillai P, et al. Improving mental ill-health with psycho-social group interventions in South Asia: A scoping review using a realist lens. PLoS Glob Public Health.2023;3(8):e0001736.
Van Belle S, Srinivas PN, Cornu T, Hebbar P, Abejirinde IO, Marchal B. Realist interviews in global health research: Case studies and comparative analysis with similar interview approaches. In: Realist Evaluation. Oxfordshire, England: Routledge; 2024 [cited 2025 Jan 20];104–16. Available from: https://www.taylorfrancis.com/chapters/edit/10.4324/9781003457077-8/realist-interviews-global-health-research-sara-van-belle-prashanth-srinivas-tom-cornu-pragati-hebbar-ibukun-abejirinde-bruno-marchal.
Cleaver F. Institutions, agency and the limitations of participatory approaches to development. Participation: the new tyranny? 2001;36–55.
Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ.2021 Sep 30;374:n2061.
Baumann AA, Cabassa LJ. Reframing implementation science to address inequities in healthcare delivery. BMC Health Serv Res.2020 Mar 12;20(1):190.
Golden TL, Wendel ML. Public health’s next step in advancing equity: Re-evaluating epistemological assumptions to move social determinants from theory to practice. Front Public Health.2020;8.