Participatory Action Research in Health Promotion in the Philippines: A Scoping Review

Abstract

Background and Objectives

Health promotion necessitates a multifaceted approach, focusing on individual, social, and environmental factors. Participatory Action Research (PAR) offers a process for community-level knowledge to inform these approaches, but little is known about its actual utilization. This review was conducted to explore the implementation and effectiveness of PAR in health promotion in the Philippine context. The specific objectives are: 1) to systematically map and analyze the existing literature on PAR in health promotion within the Philippine context; 2) to identify and categorize the levels of community participation in PAR initiatives; and 3) to evaluate the spheres of influence of health equity principles in PAR methodologies in health promotion.

Methods

A scoping review was implemented following the protocol by Mak and Thomas (2022), guided by the Health Equity Framework and the New Economics Foundation’s Ladder of Participation, highlighting the empowerment and participation of communities in health research to produce relevant and sustainable outcomes. PubMed, HERDIN, and Google Scholar were searched to gather a comprehensive range of literature, then analyzed for themes relating to community engagement in health promotion through PAR.

Results

A total of 452 articles were obtained from the initial search. After applying inclusion and exclusion criteria, 12 articles were included for analysis. The results highlighted the importance of engaging community leaders and advocacy groups as entry points in engaging community members, which were seen to be more effective in collaborating with the community. PAR was able to effectively identify gaps in health systems, particularly in access to programs for vulnerable sectors. The studies also exhibited differing levels of participation of the researchers with diverse population groups. This diversity in participant engagement led to more tailored and communityspecific interventions, fostering social innovation and better community well-being.

Conclusion

The integration of PAR in health promotion demonstrates a robust approach to addressing health inequities, showcasing the potential for community-driven research to foster equitable health outcomes. PAR enabled communities to lead and shape interventions, making them more relevant and effective. The spectrum of participatory activities reveals the diversity of PAR as a research approach, and an opportunity to develop guidelines on what constitutes PAR in the global context. This approach is crucial in developing sustainable health strategies that are responsive to the needs of diverse communities, ultimately contributing to the global discourse on community-driven health promotion and equity.

INTRODUCTION

Participatory Action Research (PAR) is recognized as a powerful methodology for development, intervention, and transformation within communities. It maintains that members of the community are experts on their situation, and that research should aim to empower all community members to engage in decision-making processes.^1,2 O’Brien described PAR as “learning by doing,” a process where participants identify a problem, attempt solutions, observe the outcomes, and, if unsatisfied, repeat the cycle.³

PAR’s adaptability has allowed it to address a breadth of social issues, including health equity. The advent of health promotion strategies globally has underscored the critical role of participatory methods in enhancing health outcomes, particularly within vulnerable populations. In the Philippines, the Universal Health Care Act (Republic Act No. 11223) mandates the implementation of PAR on cost-effective and high-impact interventions for health promotion and social mobilization. The overall framework and guidelines for operationalization of PAR are outlined in Administrative Order 2021-0065.^4,5

With the operationalization of PAR for health promotion nationwide, there is a clear need to map the existing knowledge on PAR and how it utilizes social mobilization to improve health outcomes. Scoping reviews are beneficial for exploring growing evidence, especially when the research landscape has not been extensively reviewed, such as health promotion in the Philippines.⁶ A scoping review aims to outline the existing body of evidence and to gauge the breadth and depth of literature on a specific topic.⁷ It can also offer insights into the quantity and nature of available literature and studies, presenting either a broad or detailed synopsis of the main themes.

This scoping review aims to explore the implementation and effectiveness of PAR in health promotion within the Philippine context. This scoping review was guided by a central inquiry: “How do PAR methodological approaches in health promotion address multilevel influences on health outcomes and contribute to strategies for reducing health inequities in the Philippines?”

The specific objectives of this review are: (1) to systematically map and analyze the existing literature on PAR in health promotion within the Philippine context; (2) to identify and categorize the levels of community participation in PAR initiatives; and (3) to evaluate the spheres of influence of health equity principles in PAR methodologies in health promotion.

By conducting this scoping review, a picture of the current landscape of PAR in health promotion will emerge, enabling health promotion practitioners and participatory action researchers to identify areas where PAR is needed to improve health outcomes and achieve health promotion goals.

MATERIALS AND METHODS

Relevant literature was examined in four critical stages, as guided by the Mak and Thomas guidelines for scoping review: 1) identifying relevant studies, 2) screening and selection, 3) charting the data, and 4) data analysis and reporting of findings.⁸

Stage 1: Identifying Relevant Studies

A systematic search was done in PubMed, HERDIN, and Google Scholar from January 4 to 12, 2024 to retrieve health promotion studies conducted in the Philippines. The authors utilized the Population, Concept, Context framework to refine and ensure the relevance of the search terms based on the specific facets of the research topic.⁹

Boolean search strings were tailored to capture the specific syntax and capabilities of each database for efficiency and focus of the search. Additional sources were solicited from government agencies and field experts to broaden the study selection, ensuring comprehensive coverage of the topic (Table 1).

Table 1.

Search Keywords

Category	Target	Keywords
Population	vulnerable populations in the Philippines	(““Philippines””[MeSH Terms] OR ““Filipino””[MeSH Terms] OR Philippines[Title/Abstract] AND (““vulnerable populations””[MeSH Terms] OR ““disadvantaged””[Title/Abstract] OR ““low income””[Title/Abstract] OR ““underserved””[Title/Abstract])”
Concept	methodologies and outcomes of PAR specific to health promotion	((““Health Promotion””[MeSH Terms]) AND (““Community-Based Participatory Research””[MeSH Terms] OR ““participatory action research””[Title/Abstract]))
Context	health promotion activities conducted in the Philippines	Philippines[MeSH]

Stage 2: Screening and Selection

Studies conducted within the Philippines that: (1) specifically designed as PAR within health promotion or (2) displayed key features of PAR such as active community participation and collaborative decision-making were included. Peer-reviewed articles and Department of Health (DOH)-commissioned research spanning qualitative, quantitative, mixed-methods, case studies, and observational studies published within the last 20 years were also included. Studies not addressing the Philippine context or lacking relevance as well as research only tangentially related to health promotion or PAR were excluded. Studies without full-text documents and with incomplete or indecipherable data were also excluded. These criteria ensured that the review reflects the current practices and impact of PAR in health promotion in the Philippines.

Following the deduplication of the search results, the review process employed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews framework, which involved an initial screening of titles and abstracts followed by a detailed fulltext review.¹⁰ Conflicts were resolved to achieve a minimum of 70% agreement among reviewers. This process was facilitated by Rayyan QCRI, a tool that semi-automated the screening process and ensured methodological rigor and consistency.¹¹ These procedures were performed by three independent assessors, all of whom are authors of this paper.

Stage 3: Charting the Data

Data extraction was systematically conducted using Google Sheets by three independent assessors (one of whom is the lead author), with disagreements resolved through consensus as well as a third-party assessor. Aside from the publication details, the researchers abstracted the following data:

• Health promotion key strategies based on the Health Promotion Strategic Framework (HPSF) 2023-2028 of the DOH,

• New Economics Foundation’s (NEF) Ladder of Participation, and

• Health Equity Framework (HEF).

Health Promotion Strategic Framework

The HPSF refers to a 10-year national roadmap on health promotion, which shall be the basis of implementation of health promotion in the country, nationwide and locally with a mission statement of making healthy behaviors the easier choice for everyone, every time, everywhere. This framework addresses the social determinants of health, people’s behaviors, and the physical environment with three key strategies that include health literacy, healthy settings, and health governance. These strategies aim to establish health-seeking individuals, health-enabling settings, and health-supporting governance, all of which are essential for achieving HPSF’s vision of a Healthy Pilipinas.

Ladder of Participation

A foundational model by Arnstein categorizes community participation into a “ladder” of engagement, ranging from non-participatory actions to full citizen control, highlighting a spectrum of involvement from manipulation to genuine empowerment.¹² In this scoping review, the authors utilized the NEF’s participation ladder to assess the level of community participation in each PAR study:

• Doing to: This initial stage is characterized by a coercive approach where services are imposed on recipients without their input. The focus is on conforming to predefined norms and standards, with no invitation for the recipients to participate in the design or delivery of the service

• Doing for: Progressing along the pathway, this stage involves shallow involvement with greater participation, yet within limits set by professionals. Services are designed with the recipient’s interests in mind, but their role is restricted to providing feedback or opinions, which may not necessarily influence decision-making.

• Doing with: The most advanced stage signifies a deep level of user involvement, shifting power towards service users. It requires a fundamental change in the relationship between service workers and users, emphasizing codesign and co-production.

Spheres of Influence

Education, Training, and Research (ETR), a non-profit organization committed to improving health outcomes and advancing health equity, established the HEF to illustrate how health outcomes are influenced by complex interactions between people and their environment. The framework emphasizes the importance of equity at the core of health outcomes. It recognizes that an equitable distribution of resources and opportunities is often hindered by various forms of bias, such as racism, sexism, classism, homophobia, and ableism. This skewed distribution leads to health inequities, defined as systematic, preventable differences in health outcomes closely linked to social, economic, and environmental conditions.¹³

HEF introduces the concept of multiple, interacting spheres of influence that represent both the risk and protective factors for health outcomes. These spheres are as follows:

• Systems of Power - encompass policies, processes, and practices that dictate the distribution and accessibility of resources and opportunities

• Relationships and Networks - a myriad of connections and support systems encompassing family, friends, and community members

• Individual Factors - personal attitudes, skills, and behaviors that are shaped by personal experiences and relationships

• Physiological Pathways – the biological and psychological aspects of health, acknowledging their significant yet complex role in overall well-being

In this scoping review, ETR’s HEF was used to examine how health outcomes are influenced by complex interactions between people and their environment, specifically in the context of PAR in health promotion.

The integration of the HEF and NEF’s participation ladder enabled a thorough examination of how PAR in health promotion addresses equity issues in the Philippines. By exploring the interplay between participatory approaches and health equity, this dual-framework approach presents a thorough examination of both the participatory processes and their impact on health equity.

Stage 4: Data Analysis and Reporting of Findings

The authors conducted a numerical analysis of the included articles, identifying characteristics such as year published, the topic tackled by the research, and whether the research was empirical or conceptual in nature. Articles that clearly identified the use of PAR as a methodology in addressing health promotion concerns were also identified.

Thematic analysis was conducted to identify common themes across the PAR methodologies used in the included papers. Using the ladder of participation framework, the authors also identified which studies had similar entry points into their target communities and how the level of involvement of community members contributed to the relevance and appropriateness of the proposed interventions. The spheres of participation framework were also used to identify which spheres mainly influenced health outcomes, as well as protective factors and risk factors that either positively or negatively influenced health seeking behaviors.

The ethics review clearance was provided by the Single Joint Research Ethics Board with protocol number SJREB-2023-109.

RESULTS

Characteristics of Included Papers

The comprehensive search yielded 452 articles from various sources. After deduplication, title, and abstract screening, 26 articles were deemed eligible for full-text review. Of these, 14 were excluded due to inaccessible fulltext document, lack of relevance to health promotion, or being outside the Philippine scope. A total of 12 articles met the inclusion criteria for in-depth analysis (Figure 1).

Figure 1.

PRISMA flow diagram.

The 12 articles included for analysis were published in the following years: (2004-2010), n= 5; after 2010 (2012-2017), n=4; and 2020 up to the most recent article (2020-2022), n= 3. Most papers included vulnerable groups across different regions in the Philippines. There are four general topic categories: sexual and reproductive health (SRH) (n=5), indigenous health (n=3), and health service delivery improvement (n=4). Ten papers were empirical in nature, while two were conceptual such as white papers and evaluation reports (Table 2).

Table 2.

Characteristics of Included Articles

Author	Title	Location	Type
Morisky et al., 200414	A model HIV/AIDS risk reduction programme in the Philippines: A comprehensive community-based approach through participatory action research	Lapu-Lapu and Mandaue City, Cebu, Region VII Legazpi City and Daraga, Albay, Region V Cagayan de Oro, Misamis Oriental, Region X Cavite City, Cavite, Region IV-A	Empirical
Estacio and Marks, 200715	Health inequity and social injustice for the Aytas in the Philippines: Critical psychology in action	Floridablanca, Pampanga, Region III	Empirical
Paterno, 200716	Lessons from a local government unit - health academic partnership	Unspecified	Conceptual
Estacio and Marks, 20101	Critical reflections on social injustice and participatory action research: The case of the indigenous Ayta community in the Philippines	Samal, Davao del Norte, Region XI	Empirical
Morisky et al., 201017	Reducing alcohol use, sex risk behaviors, and sexually transmitted infections among Filipina female bar workers: effects of an ecological intervention	Legazpi City, Albay, Region V Cebu City, Region VII Cagayan de Oro, Misamis Oriental, Region X Iloilo, Region VI	Empirical
Salvador et al., 201218	Validation of the selection process of PhilHealth sponsored members in 4 barangays in a municipality in Batangas using the participatory action research	Batangas, Region IV-A	Empirical
Castro-Palaganas and Perez-Molintas, 201419	Learning with communities: Structures and mechanisms for reproductive health programs among indigenous peoples of the Cordilleras	Cordillera Administrative Region	Empirical
Lee et al., 201520	Sexual and reproductive health services for women with disability: A qualitative study with service providers in the Philippines	Quezon City, Metro Manila, National Capital Region Ligao, Albay, Region V	Empirical
Devine et al., 201721	“Freedom to go where I want”: Improving access to sexual and reproductive health for women with disabilities in the Philippines	Quezon City, Metro Manila, National Capital Region Ligao, Albay, Region V	Empirical
Vaughan et al., 202022	Enabling action: Reflections upon inclusive participatory research on health with women with disabilities in the Philippines	Quezon City, Metro Manila, National Capital Region Ligao, Albay, Region V	Empirical
Nisay et al., 202023	Lessons learned from healthy Balangueno 2020: A participatory approach to health improvement in rural Philippines	Balanga, Bataan, Region III	Conceptual
Tomas, 202224	Evaluation of the effectiveness of community involvement program of education and nursing students	Matangtubig, Bulacan, Region III	Empirical

PAR Approaches in Health Promotion (n= 5)

Table 3 presents articles that clearly explained the rationale of using PAR as study methodology.

Table 3.

Rationale for Utilizing PAR as a Methodology

Source	Rationale for utilizing PAR
Morisky et al., 2004	To empower the high-risk target population (heterosexual male clients of commercial sex workers); to co-create knowledge and solutions that reflect the real-world complexities of a sensitive topic (HIV/AIDS)
Estacio and Marks, 2007	To understand factors influencing health inequity by generating knowledge with an indigenous community
Salvador et al., 2012	To co-develop a poverty grading tool with community members that were best equipped to define socioeconomic status in their community, in contrast to standard criteria used by the local government
Castro-Palaganas and Perez-Molintas, 2014	To ensure health interventions are relevant and culturally sensitive by involving an indigenous community in decision-making, planning, and project implementation
Vaughan et al., 2020	To empower women with disabilities to identify and propose solutions to the challenges affecting their reproductive health

The five articles noted the relevance of PAR in supporting and empowering the needs of the sector they partnered with. Thomas et al. has provided a comprehensive summary of PAR’s principles in which as a research approach, PAR embodies an emancipatory agenda and seeks to work with community members as co-researchers in building knowledge and guiding change.^25–27 PAR is distinct from other research methods – on knowledge creation and social change – emphasizing equitable partnerships between researcher and communities, and a commitment to positive social change.^28,29 Despite this diversity in methods, the overarching goals remained consistent: to enhance community well-being and implement effective health promotion initiatives.

In this review, the rationales provided by some authors for utilizing PAR were explicitly mentioned. For instance, Morisky et al. aimed to empower high-risk populations by cocreating knowledge and solutions that resonate with their lived experiences, particularly concerning sensitive topics like HIV/ AIDS.¹⁴ Similarly, Estacio and Marks used PAR to generate knowledge on the factors influencing health inequity, directly involving indigenous communities to understand and address these issues. The objective was to leverage local knowledge to inform interventions that are both relevant and sustainable.^1,15 In contrast, other studies, such as those by Salvador et al., Castro-Palagnas and Perez-Molintas, and Vaughan et al., clearly articulate how PAR was employed to ensure that health interventions are culturally sensitive and contextually appropriate by actively involving the community in decisionmaking, planning, and implementation processes.^18,19,22 These studies highlight that PAR’s focus on co-creating knowledge with community members is vital to developing tools, like a poverty grading tool, or to identifying and proposing solutions to challenges in areas such as reproductive health.

However, the remaining seven studies in this review mentioned the rationale for utilizing PAR (n=2) and do not explicitly describe why PAR was chosen (n=5) beyond mentioning research objectives. While they involve community engagement elements, such as empowering the local community members (i.e., youth leaders, community health service providers, support groups), the specific goals of cocreating knowledge and fostering transformation as central tenets of PAR are not clearly articulated. The distinction suggests that while PAR’s methodological flexibility allows it to be adapted to various contexts, clarity on its foundational objectives – generating locally relevant knowledge, making knowledge accessible, and promoting transformation – is essential to understanding its full impact and potential.

Methodologies Used in PAR Papers (n = 12)

The articles included in this scoping review adapted their methodologies to meet specific community needs, contexts, and research objectives (Appendix). The themes identified in this section emerged from a thematic analysis conducted after the data extraction. The analysis highlighted several recurring themes, such as stakeholder engagement, methods development, implementation of project, data validation, monitoring and evaluation, and follow-up. These themes provide a framework for assessing the unique attributes and effectiveness of participatory action research as it relates to the broader context of health promotion and community engagement within the scoping review.

Preliminary Stakeholder Engagement

Eight studies emphasized establishing footholds in their respective communities. In a multi-year project that aimed to increase women with disabilities’ access to SRH services, authors Lee et al., Devine et al., and Vaughan et al., highlighted the critical role of Disabled People’s Organizations.^20–22 This project also collaborated with non-profit organizations specializing in SRH to recruit co-researchers and conduct research activities such as support groups of women with disability and Disabled People’s Organizations (Appendix).

Five studies have underscored the involvement of Local Government Units (LGUs) and city health personnel.^{1,14,15,18,19} This collaboration with government entities was essential for mobilizing local resources and integrating research activities within existing health service frameworks. Moreover, it ensured that the interventions were feasible and effective within the local governance structures. This approach established a critical link between research activities and municipal support, potentially facilitating broader implications and sustainable improvements in community health.¹⁴

Five studies also emphasized the importance of rapport building.^{1,14,15,17,19} Initial interaction and baseline assessment were crucial in establishing community support and buy-in from the stakeholders on the ground. One of the essential methods employed by Castro-Palaganas and Perez-Molintas included community visits and interactive sessions such as “kwentuhan,” fostering informal yet profound exchanges of stories and ideas which enhanced the relational and community-oriented nature of the research.¹⁹

Through the process of engaging various stakeholders, Morisky et al., and Estacio and Marks established advisory committees and peer counselor associations, which were vital in sustaining initiatives even before research implementation.^1,15,17 This engagement aided in recruiting target collaborators for co-development of data collection tools and ensured the sustainability of the initiatives through continuous community engagement and support. The role of the collaborators also extends to integrating the PAR within city operations and health services, and the implementation of an action plan.

On the other hand, Paterno involved rural health midwives who were directly connected to the community as advisers in the development of the local health plan. This approach ensured that the research was grounded in everyday health practices and challenges, guaranteeing that the outcomes were immediately applicable and beneficial.¹⁶

Needs Assessment and Research Tools Development

Five studies involved community members in baseline or needs assessment activities and designing research tools.

Castro-Palagnas and Perez-Molintas emphasized the importance of community needs assessment and objective setting during the initial stages of the study. This experience highlighted the importance of establishing the research problem coming from the community members on the topic of integrating reproductive health program in the Cordilleras.¹⁹

Similarly, Morisky et al. engaged city health personnel, mayors, and other civic officials in conducting baseline assessments and training peer counselors for an expanded STI and HIV/AIDS prevention program.¹⁴ Lee et al., Devine et al., and Vaughan et al. contributed to a multi-year project (W-DARE) that evaluated various aspects of SRH of women with disabilities. Tools such as question guides for interviews and focus group discussions were developed with co-researchers with disabilities.^20–22

Furthermore, to determine indigent residents for inclusion in the PhilHealth Sponsored Members list, Salvador et al. designed a Sponsored Program and Participatory Action Research survey with Barangay Health Workers and midwives to reflect local perceptions of socioeconomic levels in the community. Compared to the ‘LGU list of Sponsored members’, the survey co-developed with community members was able to identify more “true” poor households that would benefit from the sponsorship program. This was achieved through classifying the households into poor, middle, and rich households in accordance with their consensus criteria based on their collective knowledge and experiences. Authors emphasized that inherent potential of communities in knowing their collective health and socioeconomic concerns include identifying poor within them.¹⁸

Implementation of Participatory Research

Five studies recruited community members in the implementation phase of the research. In the implementation of an integrated reproductive health program in the Cordilleras, Castro-Palaganas and Perez-Molintas worked with local non-government organizations (NGOs), community-based initiatives (CBIs) with local non-governmental and people’s organizations in the development of community based initiatives and reproductive health programs.¹⁹ Conversely, Tomas mentioned the involvement of community members in the research during the data collection stage. A researcher’s self-made questionnaire was administered to the barangay chairman and council, which in turn selected community members as additional respondents appropriate for the research objectives after encountering the types of questions asked.²⁴

As part of the W-DARE project, Lee et al., Devine et al., and Vaughan et al. established a Participatory Action Group (PAG) which involves community members of women with disabilities who joined the meetings and data collection activities. Results from these discussions were analyzed with co-researchers, other women and girls with disabilities, SRH service providers, and gender specialists.^20–22

Data Validation, Monitoring and Evaluation, and Follow-up

After data collection, Estacio and Marks, and Salvador et al. validated their results with community members through a workshop and barangay assembly, respectively.^1,15,18 Estacio and Marks, Castro-Palaganas and Perez-Molintas, and Devine et al. conducted monitoring and evaluation activities after research implementation such as post-surveys and follow up interviews.^1,15,19,21

Ladder of Participation

Most articles are categorized under Doing WITH (n=9), the most advanced stage of participation where there is deep involvement of the community members (Table 4).

Table 4.

Levels of Participation in PAR Papers

Level in Participation Ladder		Source	Rationale
Doing WITH	Co-Producing	Paterno, 2007	Family and community medicine residents and interns collaborated with the Municipal Health Office to assess community health needs and create a joint health plan.
Doing WITH	Co-Producing	Castro-Palaganas and Perez-Molintas, 2014	A local NGO and the LGU were involved in community needs assessment and action planning. Peoples’ organizations were involved in the development of community-based initiatives and reproductive health programs.
Doing WITH	Co-Designing	Morisky et al., 2004	City Health personnel and other city officials collaborated to integrate the research within city operations and health services. Peer counselors educated the target groups on STI/HIV/AIDS prevention using information, education, and communication materials that they developed.
Doing WITH	Co-Producing	Estacio and Marks, 2007, 2010	The Aytas identified issues impacting their health and co-developed an action plan, which included a literacy center and multi-purpose cooperative program. Ayta volunteers, local community members, NGOs, and the LGU collaborated to implement the action plan.
Doing WITH	Co-Designing	Morisky et al., 2010	Focused on the social preparation of the community with city health officers and local healthcare workers. Established an Advisory Committee, an Owners/Managers Association, and female bar worker Peer Counselors Association to facilitate structured support and intervention.
Doing WITH	Co-Designing	Lee et al., 2015	Data collection tools were informed by experiences of women with disabilities. Recruitment of participants were facilitated by City Health Offices and W-DARE partner networks. Women with disabilities, SRH service providers, and gender specialists identified key themes from interviews and focus group discussions.
Doing WITH	Co-Designing	Devine et al., 2017	Women with disabilities were engaged in PAGs as facilitators and co-researchers.
Doing WITH	Co-Designing	Vaughan et al., 2020	Disabled People’s Organizations sought out women with disabilities and recruited them as co-researchers. They were trained on data collection and analysis.
Doing FOR	Consulting	Salvador et al., 2012	The research was conceptualized by the authors. The PAR survey used was designed with community members to reflect perceptions of socioeconomic levels in the community.
Doing FOR	Consulting	Tomas, 2022	Researcher’s self-made questionnaire was first administered to the barangay chairman and council, who in turn selected residents to answer the questionnaire.
Doing TO	Educating	Nisay et al., 2020	Information was sourced from Healthy Balangueno 2020 records submitted by the internal evaluators for review.

NGO – non-governmental organization; LGU – local government unit; W-DARE – Women with Disability taking Action on REproductive and Sexual Health; SRH – Sexual and Reproductive Health; PAG – Participatory Action Group

Castro-Palaganas and Perez-Molintas and both studies by Estacio and Marks coursed their interventions through the LGU and relevant NGOs to secure commitment to their projects.^1,15,19 Similarly, Paterno and Morisky et al. tapped the local health office and workers to gather on the ground insights that could inform their methodologies.^14,16,17

Five studies also heavily targeted local organizations as well as individuals embedded in their respective communities. Vaughan et al. consulted with Disabled People’s Organizations to recruit women with disabilities as co-researchers, who facilitated the PAGs described in Lee et al. and Devine et al.^20–22 The co-researchers were able to tackle the sensitive topics of SRH and violence concerning women with disabilities with nuance, not only minimizing potential harm but also enriching the data gathered. Likewise, Morisky et al. trained peer counselors (female bar workers and male clients of sex workers) to educate their peers on safe sexual practices and STI/HIV/AIDS prevention.^14,17

In the studies by Castro-Palaganas and Perez-Molintas, and Estacio and Marks, PAR facilitated the formation of equitable and collaborative partnerships with indigenous communities. Their contributions ensured that the interventions were context sensitive and responsive to their needs: the Aytas’ requests for a literacy center and multipurpose cooperative came to fruition, while indigenous people in the Cordilleras were able to implement community-based initiatives.^1,15,19

Spheres of Influence

Relationships and networks (such as family, friends, and community members) and systems of power (i.e., policies, processes, and practices affecting the distribution and accessibility of resources) were the main factors influencing health outcomes as reported by the authors in the studies (Table 5).

Table 5.

Spheres of Influence in PAR Papers

Source	HEF’s Spheres of Influence	Protective factors	Risk factors
Morisky, 2004	Relationships and Networks	Support system of peer counselors educated on STI/HIV/AIDS prevention	Reluctance to discuss sensitive topics such as HIV/AIDS with peers
Paterno, 2007	Systems of Power	Researchers’ (University of the Philippines) partnership with Municipal Health Office Mayor’s issuance of administrative order defining duties and functions of the Local Health Board
Estacio and Marks, 2007, 2010	Relationships and Networks	Aytas acknowledged importance of unity and self-empowerment	Lowlanders’ discrimination against Aytas
	Systems of Power	LGU and NGO support in project implementation	Aggression and violence of land owners towards the project team and Ayta community Economic exploitation by lowlanders Inaccessibility of health services
	Individual Factors	Aytas’ pride in their “kulot” identity
Morisky, 2010	Relationships and Networks	Support system of managers and peer counselors educated on STI/HIV/AIDS prevention
	Systems of Power	Network of LGU-funded social hygiene clinics providing STI screening and prescriptions Establishment offering classes on AIDS prevention to bar workers
Salvador et al., 2012	Systems of Power		LGU’s limited knowledge on socioeconomic status of the community
Castro-Palaganas and Perez-Molintas, 2014	Systems of Power	Researchers’ partnerships with barangay councils and barangay health stations LGU and NGO support in project implementation
Lee et al., 2015 Devine et al., 2017 Vaughan et al., 2020	Relationships and Networks	PAGs of women with disabilities	Family members preventing access to SRH services
	Systems of Power	W-DARE’s partnership with Disabled Peoples’ Organizations	Service providers’ negative attitude towards SRH and poor understanding of disabilities
Nisay et al., 2020	Systems of Power	Local health office and Sangguniang Kabataan were involved in implementing health programs
Tomas, 2022	Systems of Power	Researchers’ (St. Mary’s College of Baliuag) partnership with barangay

LGU – local government unit; NGO – non-governmental organization; PAG – Participatory Action Group; SRH – Sexual and Reproductive Health; W-DARE – Women with Disability taking Action on REproductive and Sexual Health

Relationships and Networks

A support system of peers was crucial in encouraging community members to seek health services and engage in healthy behaviors. Peer counselors educated on STI/HIV/AIDS significantly increased awareness and preventive behaviors in their peers.^14,17 PAGs in the W-DARE studies provided a safe space for women of disabilities to share their experiences, leading them to acknowledge and pursue their rights to sexual and reproductive health services.^20–22 Similarly, the Aytas recognized the importance of unity and self-empowerment in working towards their desired health outcomes.^1,15

Conversely, peers and family members can discourage health seeking behaviors. Some community members were hesitant to discuss sensitive topics such as sexual health with their peers.^14,17 In the W-DARE studies, the taboo of sexual health is compounded by a poor understanding of disabilities. Family members often withheld SRH services from women with disabilities due to shame. Believing that women with disabilities are unfit to procreate, some family members subjected them to forced sterilization, robbing them of the agency to decide on the SRH services they want to avail.^20–22

Discrimination of lowlanders against indigenous peoples directly affected their access to health services. Sick Aytas were often driven away from hospitals despite the severity of the health condition.¹⁵

Systems of Power

Partnerships between the researchers (and their institutions) and community members provided them with resources and opportunities that otherwise would not have been available. In Paterno’s paper, the University of the Philippines partnered with an LGU to draft their first municipal health plan. There was a palpable improvement in the delivery of health services targeted in the approved health plan: a dengue eradication program reduced dengue mortalities, five villages organized hypertension clubs that employ a hypertension specialist, and some villages set up drug stores, a nationwide health program that was not implemented in the municipality.¹⁶

Prior to the study by Estacio and Marks, the Aytas expressed their need for a literacy center to the LGU, which was only established during the course of the research.¹⁵ Researchers’ intervention also led to positive outcomes in Matangtubig, Batangas. Community members agreed that their knowledge, attitude, and skills on several health topics improved after St. Mary’s College of Baliuag implemented their community involvement program that provided health and education services.²⁴

In the case of Morisky et al., the researchers integrated a sexual health educational program into social hygiene clinics where sex establishment workers were registered, an initiative funded by the City Health Department. Sex workers were able to access STI screening and prescriptions through these clinics. Some sex establishments also offered classes on STI/HIV/AIDS prevention to their workers.¹⁷

The support of LGUs and NGOs were also crucial in project implementation. Castro-Palaganas and Perez-Molintas emphasized in their study that collaboration with LGUs was needed for the effective sharing of expertise, resource allocation, support for activities, and active engagement in monitoring and evaluation. Through their networks, LGUs also ensured legitimate community representation and participation in development planning and economic programs.¹⁹ Similarly in Nisay et al., the Sangguniang Kabataan was involved in the implementation of health promotion programs geared towards high-risk youths.²³

Systems of power can also hinder communities from accessing otherwise available resources and health services. Salvador et al. acknowledged that the incomplete knowledge of the LGU on the socioeconomic status of the community prevented some indigent families from availing the benefits of the PhilHealth Sponsored Program.¹⁸

In particular, Lee et al. investigated service providers’ attitudes and practices, highlighting the need for better training and awareness to improve sexual and reproductive service delivery for women with disabilities.²⁰ Emphasizing the critical role of service providers in facilitating or hindering access to necessary health services, Vaughan et al. pointed out that ensuring sustained participation and overcoming systemic health service barriers remains a challenge.²²

Individual Factors

Estacio and Marks also touched on individual factors: the Aytas’ pride in their “kulot” identity helped them overcome feelings of helplessness. This self-empowerment also led to a focus on improving their literacy and numeracy, indicating an investment in personal capacity building alongside a desire for systemic intervention.^1,15

DISCUSSION

Summary of Evidence

The evidence gathered from the scoping review illustrates the impactful application of PAR within the health promotion landscape in the Philippines as a strategy for enhancing community engagement and health equity. The collected data, derived from a thorough analysis of 12 rigorously selected articles, reveals that PAR has been effectively utilized across diverse regions and community settings in the Philippines, addressing a broad spectrum of health-related issues.

The scoping review reveals that PAR in health promotion in the Philippines works across multiple levels of influence, aligning closely with the HEF: from addressing individual factors (e.g., health behaviours, knowledge, confidence), enhancing relationships and networks (e.g., peer counselors, participatory action groups), to intervening in systems of power (e.g., local government partnerships, policy integration). The methodological approaches observed in the studies, from co-design to full co-production, reflect varying levels of community participation as assessed through the NEF’s ladder of participations.

PAR embodies a collaborative approach where research is conducted with and by the community members rather than solely on them. This approach is rooted in the principles of empowerment, inclusivity, and sustained community engagement. In the context of health promotion in the Philippines, PAR served not only as a methodological framework but also as a catalyst for social change, facilitating the creation of interventions that are culturally sensitive and deeply integrated within the community’s social fabric.

Community Empowerment and Ownership

PAR as a methodological approach aims to redefine power dynamics by redistributing the control over knowledge creation from traditionally privileged groups to marginalized communities. This not only fosters new insights into power relations but also enhances understanding of injustices, facilitating the development of solidarity and transformative actions within systems and institutions.³⁰

Community-based participatory research (CBPR), a framework under the broader umbrella of participatory research, is not merely a method but an orientation to health research.³¹ This orientation emphasizes mutual respect and co-learning between partners, capacity building at individual and community levels, systemic change, and a balance between research and action.^32,33

Across all these studies, PAR served as a bridge between research and practical, community-centered action, fundamentally rooted in the principles of empowerment and active participation. By transforming community members from mere subjects into partners in the research process, PAR fostered a collaborative environment that enhanced both the relevance and impact of the research.

A common thread across the reviewed studies is the engagement of community leaders and advocacy groups as critical entry points into the community. Initial engagements facilitated broader community participation, explored the effectiveness of leadership in PAR initiatives, and drew out in-depth analyses of health system gaps. Furthermore, preliminary stakeholders in PAR also played a critical role in ensuring that the research was culturally sensitive, deeply embedded within the community, and sustainable.

The involvement of a diverse array of stakeholders from government units to grassroots organizations and individual community members provides a robust foundation for comprehensive, inclusive, and impactful research. However, it is also crucial to note that it is primarily the community leaders who facilitate this participation. Study participants are usually chosen through their discretion, and when sharing community experiences, their voices may be louder than others. This can potentially impact the dynamics and outcomes of PAR projects.^34,35

A compelling aspect of PAR highlighted in the review is the empowerment of communities to lead and shape health interventions. This empowerment was achieved through active and meaningful participation. This not only enhanced the relevance and effectiveness of health interventions, but also fostered a sense of ownership among community members. Furthermore, this review emphasizes that such community-driven research approaches can significantly improve community well-being and contribute to the sustainability of health interventions.

The studies analyzed in this scoping review show that PAR is deeply rooted in its potential to engage communities in meaningful ways, address complex social issues effectively, and empower individuals and groups by involving them actively in the research process. This makes PAR an ideal approach for health promotion projects that aim to achieve lasting change through collaborative and inclusive research practices.

However, as emphasized by Estacio and Marks in their paper on Aytas, the success and long-term stability of community development projects still hinges on the active participation and support of stakeholders in positions of power.¹ Those involved in the research process, including community members, representatives from health services, and funders, may find investigating these power relations uncomfortable. Highlighting power imbalances can introduce risks for all participants involved, necessitating careful consideration of how to address such issues in a sensitive and ethical manner.³⁰

Variability of PAR Methodologies

PAR methodologies have evolved to encompass a variety of tools and techniques that facilitate deeper community involvement. Today, PAR is applied across various sectors and disciplines, adapting to the specific contexts and needs of communities globally. It continues to integrate new technologies and address emerging social challenges while remaining true to its core principles of participation, empowerment, and systemic actionable change. PAR remains a dynamic and influential approach in the fields of social research and community development. Its historical pioneers, evolving methodologies, and ongoing examination of critical issues provide a robust framework for empowering communities and fostering equitable change.²

This scoping review reveals a noteworthy observation: implementation methods of PAR in health promotion within the Philippines vary significantly. This variability is consistent with the existing literature and reflects both the inherent flexibility of PAR and the lack of a standardized approach to its application in research settings. The diverse application of PAR across the studies underscore its flexibility and effectiveness in engaging communities in research that directly impacts its members, although the degree of participation and community integration varies across the studies.

The evidence from the review demonstrates that while all the selected studies identified as employing PAR, their approaches differed in the depth of community involvement, the stages of research in which communities were engaged, and the methods used to foster participation and collaboration. For instance, some studies might involve community members primarily in the data collection phase, while others engage them from the initial stages of defining the research questions to the final stages of disseminating results.

The flexibility of PAR is beneficial in that it allows researchers to adapt methodologies to fit the specific cultural, social, political, and economic contexts of different communities. This adaptability is crucial in health promotion, where the effectiveness of interventions often depends on their relevance and acceptability to the target community. The ability to mold PAR approaches to specific settings enhances the potential for interventions to be more context-sensitive and culturally aligned with the partner community. This increases the likelihood of successful outcomes and sustained community engagement. Although diverse in approach, all studies supported co-created solutions to improve health equity.

Implications for Research and Policy

This scoping review demonstrates the potential of PAR as an approach to addressing health inequities through health promotion. By facilitating community-led research, PAR helped tailor health strategies to the diverse needs of communities, thereby enhancing the overall effectiveness of health promotion initiatives.

However, there is more work to be done in terms of aligning health promotion research to existing health promotion goals. Only five of the studies tackled SRH, one of seven priority areas in the national HPSF 2030.³⁶ Most research was also settings-based, focusing on small localities such as barangays or indigenous communities. As seen in the spheres of influence, this approach addresses social and environmental influences on health and health-seeking behaviors, but their impact on individual or physiological factors is limited.

Furthermore, the review suggests that there is a considerable opportunity to develop guidelines on what constitutes effective PAR. This framework would not aim to rigidify PAR, but rather to ensure that its core principles are consistently applied, thereby enhancing the integrity and effectiveness of PAR interventions in health research. The potential framework could outline key stages of community involvement, suggest methods for ensuring meaningful participation, and provide criteria for evaluating the impact of PAR on community empowerment and health outcomes. Moreover, it could help in training new researchers in PAR methodologies, ensuring a more uniform understanding and application of its principles.

This review makes a significant contribution to the existing literature by demonstrating how PAR can be strategically utilized to enhance health outcomes and equity by demonstrating an opportunity to align PAR with national health promotion goals. It also sets a foundation for future research to explore the scalability of such participatory approaches in other contexts and their long-term impacts on public health. This scholarly narrative affirms the transformative potential of PAR in health promotion, providing valuable insights for academics, practitioners, and policymakers engaged in community health initiatives.

Strengths and Limitations

While the studies reviewed provided valuable insights into the application of PAR in the Philippines, they also revealed several limitations, including the challenges of sustaining community engagement and the need for more rigorous methodologies to evaluate the impact of PAR. The review catalogs the existing body of evidence regarding PAR in health promotion but does not represent other PAR studies outside the scope of health promotion. However, this scoping review included a wide range of perspectives and methodological approaches that were applied in a variety of contexts having HEF and NEF’s participation ladder as valuable frameworks used for analysis. Furthermore, this review has demonstrated PAR’s ability to produce relevant and sustainable outcomes.

CONCLUSION

PAR has emerged as a transformative approach within the health promotion landscape of the Philippines. Filipino participatory action researchers empower communities to lead and shape interventions that they perceive to be relevant and effective, utilizing a variety of flexible and adaptable methods. This adaptability to diverse social and cultural contexts, without losing sight of overarching health equity goals, makes PAR an invaluable approach in a diverse setting like the Philippines.

APPENDIX

Summary of PAR papers

Objective	Methodology	Ladder of Participation	Sphere of Influence	Findings/Outcome
Morisky, 2004
To determine the feasibility and efficiency of an expanded STI and HIV/AIDS prevention program among diverse high-risk male heterosexual populations in the southern Philippines	City health personnel, mayors, and other city officials were engaged as collaborators Peer counselors were recruited to develop educational materials and educate peers on STI/HIV/AIDS prevention	Doing WITH – Co-Designing City Health personnel and other city officials collaborated to integrate the research within city operations and health services. Peer counselors educated the target groups on STI/HIV/AIDS prevention using information, education and communication materials that they developed.	Relationships and Networks	Increased condom usage Decreased STI incidence
Paterno, 2007
To provide learning opportunities for UPCM1 faculty, medical residents and students in community medicine To assist communities develop their health systems	A planning workshop was conducted jointly by the Municipal Health Office, UP professors, and family and community medicine residents	Doing WITH – Co-Producing Family and community medicine residents and interns collaborated with the Municipal Health Office to assess community health needs and create a joint health plan.	Systems of Power	Joint two-year health plan Strong partnership between municipality and UPCM
Estacio & Marks, 2007 and 2010
To engage the Ayta community in the development of a sustainable educational system that would integrate indigenous culture, livelihood, and health promotion into the curriculum through action research	Established rapport and planning: community visits, facilitators’ training/workshop, PAR orientation Knowledge generation: story-telling, interviews, workshops Data validation: community workshop Recommendations for action: community workshop Planning for action: stakeholders meeting Implementation Evaluation and follow-up	Doing WITH – Co-Producing The Aytas identified issues impacting their health and co-developed an action plan, which included a literacy center and multi-purpose cooperative program. Ayta volunteers, local community members, NGOs, and the LGU collaborated to implement the action plan.	Relationships and Networks Systems of Power Individual Factors	Increased social awareness and advocacy for Aytas Enhanced individual and community skills through community-driven literacy programmes and livelihood initiatives Encouraged space for critical thinking as part of the conscientization process of PAR
Morisky, 2010
To integrate successful components of an educational program into the healthcare processes of Social Hygiene Clinics (SHCs) and establishments employing FBWs2 To generate recommendations to the National AIDS Prevention Control Program for training and developing community-based AIDS prevention education in the Philippines	Social preparation of the community Established advisory committee, owners/managers association, and FBW peer counselors association ◦ Legaspi – FBWs received peer counseling ◦ Cagayan de Oro – trained by managers ◦ Cebu – trained by peers and managers ◦ Iloilo – control	Doing WITH – Co-Designing Focused on the social preparation of the community with city health officers and local healthcare workers. Established an Advisory Committee, an Owners/Managers Association, and female bar worker Peer Counselors Association to facilitate structured support and intervention.	Relationships and Networks Systems of Power	Combined group (Cebu) was more likely to consistently use condoms than all other groups
Salvador et al., 2012
To determine how the LGU list of PhilHealth Sponsored Members in a municipality of Batangas with the list of poor residents as identified by PAR methodology by: ◦ Describing the exact processes utilized by the LGU in determining PhilHealth beneficiaries and the PAR survey in identifying indigent families in a municipality in Batangas ◦ Comparing the list of beneficiaries of the PhilHealth Sponsored Program in that LGU with the list of indigent families identified through PAR	LGU protocol for identifying indigent families for inclusion in the PhilHealth Sponsored Program list was obtained ◦ Protocol was validated with local health and social workers PAR survey was obtained from College of Social Work and Community Development, University of the Philippines Diliman ◦ Designed with community members to reflect perceptions of socioeconomic levels in the community	Doing FOR – Consulting The research was conceptualized by the authors. The PAR survey used was designed with community members to reflect perceptions of socioeconomic levels in the community.	Systems of Power	PAR survey identified more “true” poor households for inclusion in the PhilHealth Sponsored Program
Castro-Palaganas & Perez-Molintas, 2014
To capture how the principles of PAR were put into life in the integrated reproductive health programme in the Cordilleras, Northern Philippines	Community needs assessment and objective setting Project development and start-up activities Implementation of CBI3 projects Group enhancement activities and municipal-level federation building of people’s organizations Group sustaining activities and beneficiary expansion of CBI projects Expansion of CBI projects and support network for reproductive health Monitoring and evaluation	Doing WITH – Co-Producing A local NGO1 and the LGU2 were involved in community needs assessment and action planning. Peoples’ organizations were involved in the development of community-based initiatives and reproductive health programs.	Systems of Power	Monitoring and evaluation results were used to improve project performance Improved awareness building and advocacy Strengthened reproductive health support networks Increased access to comprehensive, high quality reproductive health information and services
Lee et al., 2015
To investigate the knowledge, attitudes, and practices of service providers in relation to the SRH4 of women with disability To increase understanding about their experiences of providing SRH services to women with disability	Question guides developed with co-investigators, W-DARE5 partners, and women with disability Interviews and focus group discussions with SRH service providers Key themes identified with co-investigators, W-DARE partners, women with disability, SRH service providers, and gender specialists	Doing WITH – Co-Designing Data collection tools were informed by experiences of women with disabilities. Recruitment of participants were facilitated by City Health Offices and W-DARE3 partner networks. Women with disabilities, SRH service providers, and gender specialists identified key themes from interviews and focus group discussions.	Relationships and Networks Systems of Power	Identified factors that undermined provision of high quality SRH services to women with disability
Devine et al., 2017
Increase participants’ sexual and reproductive health knowledge Increase participants’ awareness of their rights in relation to sexual and reproductive health and disability Increase participants’ confidence to access and negotiate health services Support individual and/or collective action planning to further promote demand for sexual and reproductive health within the women’s communities (as can be achieved with participatory methods) Facilitate peer support amongst groups of women with disabilities	Developed and implemented a pilot intervention focused on peer-facilitated PAGs6 with women with disabilities ◦ Female W-DARE co-researchers with disabilities were engaged as PAG facilitators Evaluation of PAGs - pre- and post-rapid assessment of disability survey Stories of change: interview at the end of the PAG intervention Follow-up interviews nine months after the intervention	Doing WITH – Co-Designing Women with disabilities were engaged in PAGs5 as facilitators and co-researchers.	Relationships and Networks Systems of Power	Women’s stories ◦ Enhanced selfconfidence ◦ Increased knowledge on the rights of PWD ◦ Increased knowledge on SRH ◦ Increased knowledge on protection from violence for women and children with disability Follow-up interviews ◦ Increased access to SRH including protection from violence ◦ Sustained social inclusion ◦ Increased participation in communities
Vaughan et al., 2020
To reflect on the experience of implementing and evaluating W-DARE, a three-year program of disability inclusive CBPR7 aiming to increase access to SRH and violence-response services for women with disabilities in the Philippines	Women with disabilities were recruited as co-researchers and provided with extensive training to undertake data collection and analysis Conducted interviews with other women and girls with disabilities Facilitated peer-supported PAGs with women with disabilities and parents of children with disabilities Co-facilitated interventions with local health and violence response service providers and policy makers	Doing WITH – Co-Designing Disabled People’s Organizations sought out women with disabilities and recruited them as co-researchers. They were trained on data collection and analysis.	Relationships and Networks Systems of Power	Disability-inclusive CBPR approaches can contribute to the generation of high quality knowledge about the health inequalities experienced by people with disabilities Disability-inclusive research can contribute knowledge to the social and structural change required to redress inequalities and the capacities and attitudes of research teams Undertaking research with people with disabilities about the health inequalities and violence many experience comes with costs that are disproportionately born by co-researchers with disability and local allies
Nisay et al., 2020
To evaluate the context, conceptual basis, implementation strategy, and outcomes of Healthy Balangueño 2020, a model health promotion initiative implemented in the City of Balanga, Bataan, Philippines	Information was sourced from Healthy Balangueño 2020 records submitted by the internal evaluators for review ◦ Initiative was grounded in PAR	Doing TO – Educating Information was sourced from Healthy Balangueno 2020 records submitted by the internal evaluators for review.	Systems of Power	Authors determined that Healthy Balangueño 2020 was socially relevant, technically sound, novel, feasible, and reproducible
Tomas, 2022
To evaluate the effectiveness of the community involvement program in terms of health, literacy, and numeracy services rendered by nursing and education students in Matangtubig from 2015-2020	Researcher’s self-made questionnaire was administered to the community ◦ Barangay chairman and council ◦ Community members selected by barangay chairman and council	Doing FOR – Consulting Researcher’s self-made questionnaire was first administered to the barangay chairman and council, who in turn selected residents to answer the questionnaire.	Systems of Power	Community members recognized that their knowledge, attitudes, and skills on several health topics were enhanced through the program Community members positively acknowledged the environmental sanitation program organized by the students as teaching responsibility, collaboration, community service, and unity

¹University of the Philippines College of Medicine

²female bar workers

³community-based initiatives

⁴Sexual and reproductive health

⁵Women with Disability taking Action on REproductive and Sexual Health

⁶Participatory Action Group

⁷community-based participatory research

Statement of Authorship

All authors certified fulfillment of ICMJE authorship criteria.

Author Disclosure

All authors declared no conflicts of interest.