Critical Reflexivity of Communities on Their Experience to Improve Population Health

Abstract

Although community capacity has been prominent in the public health literature for nearly 20 years, the field has only operationalized a few dimensions. An intriguing dimension of capacity is a community’s ability to critically reflect.

On the basis of previous research as well as theoretical and practical insights from management and organizational learning literature, we offer a process framework for critical reflexivity practice in community. The framework draws on ideas regarding cognition and agency, praxis, as well as the transformative learning model to conceptualize how reflexivity happens as an emergent community process.

The implication is that reflexivity is a community-level process of making meaning of experiences that drive a common narrative. Inclusivity and establishing consensus are paramount, and can be difficult in light of power dynamics and consideration of dissenting voices and different experiences; enlightened self-interest and creating conducive spaces for dialogue are key in this process. Strengthening communities’ ability to gain and employ collective wisdom from their experience will also build their overall capacity for population health improvement.

The term “community capacity” describes characteristics within communities that enable them to meet their needs and address issues. Within public health, capacity is a necessary condition for the development, implementation, and maintenance of effective health improvement initiatives.¹ Community capacity acts as a mediator between public health interventions and population health changes and is mobilized when a community acts as an agent to improve its health status.²

Early work on community capacity defined 10 dimensions:

1. citizen participation,

2. leadership,

3. skills,

4. resources,

5. social and interorganizational networks,

6. sense of community,

7. understanding of community history,

8. community power,

9. community values, and

10. critical reflection.¹

Our understanding of these dimensions is derived largely from other social science disciplines and is not specific to public health. Although community capacity has been prominent in the public health literature for nearly 20 years, the field has only operationalized and studied a few dimensions; leadership, networks, and sense of community are relatively well-understood, whereas community history, values, and critical reflection are acknowledged as important but skimmed over in the research.³

An elusive yet intriguing dimension of capacity is a community’s ability to critically reflect. Described in the literature as critical reflection,¹ learning culture,⁴ dialectical thinking,⁵ and praxis,⁶ the process by which communities assess their processes, actions, and results, and determine how to proceed to reach an intended outcome, is paramount to their success. Goodman et al. refer to reflexivity as critical reflection, which is a “lived activity and reflection within one’s community for the purpose of challenging assumptions and creating change toward the core public health values of democratic participation and equity.”^1(p273) However, this area is largely unexplored at the community level. We therefore offer a framework for operationalizing and understanding the practice of critical reflexivity at the community level.

BACKGROUND

The concept of reflexivity dates back more than a century and is applied to individuals and groups of people in various contexts.^7–10 Psychology, social work, education, and organizational management have advanced thinking and practice around critical reflexivity and adaptive learning at the individual and organizational levels; this provides valuable insight for broader application. Psychologists Cooley and Mead asserted that reflexivity “among human beings is rooted in the social process, particularly the process of taking the role of the other and of seeing the self from the other’s perspective.”^11(p3) At the individual level, the concepts and practice of reflexivity naturally fit into disciplines aimed at individual problem solving or self-improvement. Whether targeting the client, as in motivational interviewing,¹² or promoted in the practitioner, such as social workers mitigating power imbalances,¹³ this practice involves intentional introspection for the purpose of improving a behavior or process to achieve a desired outcome. Mezirow’s model of transformative learning in adult education emphasizes critical reflection as individuals alter the cognitive schema underlying their perspective on a specific subject, ultimately leading to a change in behavior and thus in outcomes.¹⁴

Contrasted with critical reflexivity at the individual level being rooted in the social process, reflexivity practiced collectively is a social process and context dependent. The literature on organization-level reflexivity provides insight on the added complexities of moving through this process as a group as opposed to an individual. Reflexivity in organizations examines processes and structures within organizations that foster individual and collective learning. Senge describes learning organizations as those “where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.”^15(p3) Thus, even while individuals are prepared and positioned to learn, organizational structures or systems must promote or facilitate the reflection or engagement necessary for learning to occur.¹⁶ In this context, both success and failure have the potential to breed wisdom, which can lead to increased capacity for both processes and achieving outcomes.

COMMUNITY-LEVEL REFLEXIVITY

The conceptualization of reflexivity at the individual and organizational levels provides a foundation for examining community reflexivity. It is important to recognize here that “community” can be defined countless ways, and how it is defined has implications for who is included (and thus also who is excluded). In defining community for a population health improvement effort, stakeholders must attend to the collective attributes, interests, and resources of the community. The more broadly community is defined and the more inclusive an endeavor, the greater the likelihood of introducing competing agendas, complicated histories, entrenched ways of thinking, and power dynamics. However, inclusivity also increases the opportunity for building strong consensus that benefits the community as a whole, and the likelihood of just and equitable outcomes. Inclusivity also brings in additional capital—intellectual, social, financial, material, and political; if consensus can be reached regarding goals and definitions of success, that capital increases resources available for achieving success. For our purposes, the definition by MacQueen et al. is useful: “a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings.”^17(p1929)

Although the definition of community may include many individuals, all members—even those with a vested interest—do not engage in every community initiative. In community-based practice, a subset of individuals or organizations with some specific tie to a distinct issue are typically identified or self-select to carry out planned activities. Although a larger group may have input in setting an agenda or developing action plans, implementation frequently relies on the subset as the planned actions align in some way with their focus and resources. In practicing reflexivity, it is important that the group tasked with operationalizing the plan represents the diverse interests of the community. Achieving this representation is a fundamental challenge and is critical to equitable processes and outcomes.

At the community level, reflexivity has been referred to as learning culture.¹⁸ Wendel et al. define learning culture as a concept in which a community has the ability to think critically and reflect on assumptions underlying its ideas and actions, to consider alternative ways of thinking and doing, and to mine lessons from its actions.⁴ The community must be able to frame successes as building blocks to continuously improve and translate processes and frame errors and failures as resources for learning and moving forward as opposed to excuses and barriers. Others have characterized reflexivity as a community “asking why.”^19,20 Laverack describes “asking why” as the community’s ability to “critically assess the social, political, economic, and other contextual causes that contribute to their level of disempowerment.”^19(p140) Essentially, communities become subjects of their own learning through this process.¹⁹ The community addresses root causes of the issue(s), and the target population is actively involved in the process of “asking why.”²¹

Analogs of this process exist at the individual and organizational levels, from mindfulness techniques to continuous quality improvement models, each with its own strengths and challenges. At the individual level, the adaptive learning process engendered through critical reflexivity is conceptualized as a behavior model through which a person learns through iterations of a particular action, progressively adjusting one’s actions to achieve an intended outcome.²² Applying this model at the organizational level increases complexity because learning occurs at different paces, feedback can be interpreted from multiple perspectives, and the parties involved may not share the same goals or agree on how to reach them.²³ Van de Ven et al. assert that reflexivity at the organizational level, compared with individual reflexivity, is complicated by differences in definition of outcomes and in power.²³ This is an important consideration for understanding critical reflexivity at the community level, as the opportunity for introducing varying agendas, politics, and dynamics of leadership can influence whether and how reflexivity is practiced, and whether learning occurs. The driving questions, then, are specifically how do communities engage in reflexive practice, what does it look like, and how does it work?

COMMUNITY REFLEXIVITY FRAMEWORK

On the basis of our previous research,²⁴ as well as theoretical and practical insights from education, management, and organizational learning literature, we offer a framework for critical reflexivity at the community level. Table 1 outlines this 4-step cycle.

TABLE 1—

Four-Step Process Framework for Critical Reflexivity at Community Level

Step	Function	Key Questions	Key Challenges
Step 1: Reflect.	Intentionally, systematically examine outcomes in context related to shared goals and of processes and representation of diverse perspectives.	Outcomes: What did we set out to accomplish? What did we accomplish? What do the data tell us? Are there areas where we did not achieve intended outcomes? What were unintended or anticipated outcomes from our efforts? Processes: What did we do collectively? What did each of us do in the process? Are there voices missing from the process that should be included?	Multiple perspectives and experiences Competing agendas Interpretation of evaluation data Reaching consensus on assessment of the experience thus far
Step 2: Assess.	Collectively make meaning of the process and determine why certain processes or actions led to success or failure.	Outcomes: Were our outcomes what we want(ed)? Processes: What specific actions or processes led to our outcomes? If something worked well, why did it work? If something did not work, what assumptions were we making that we need to change? Are there structures in place that are inhibiting success?	Different levels of understanding of the process and underlying theory of change Reaching consensus on attribution of success or failure to specific processes or actions Tendency to blame rather than take ownership for negative outcomes Politics and power imbalance
Step 3: Specify changes.	Explore feasible options for strengthening successful processes and altering unsuccessful ones; document specific plan of action.	Outcomes: How do we need to modify our actions to achieve the desired outcome(s)? Processes: What options are feasible given our resources? What changes do we need to make to processes and actions? Are there broader structures that need to change? What are the specific actions that need to be taken? Who is going to do them, when, and with what resources?	Differing perspectives and agendas influencing potential strategies considered Consensus regarding how to modify processes and actions
Step 4: Implement and evaluate.	Implement and evaluate the planned changes; cycle back to step 1.	Outcomes: Is there evidence that our changes are having the intended effect(s)? Processes: How are we doing? Are changes being implemented as planned? Are we communicating regularly? Are we being accountable to the community for our efforts?	Historical relationships and experiences Entrenched mental models and processes Lack of adequate resources, supports, and authority to change what needs to change

This cycle echoes transformative learning within education. Although the transformative learning model focuses on individuals as learners, it is useful for understanding the role of critical reflexivity in how communities process and integrate their experiences to achieve their desired outcomes. Essentially, communities practicing collective reflexivity do the following:

1. Reflect on the experience—including their own actions within that context.

2. Identify which processes produced desirable outcomes and which did not and what underlying assumptions and structures were responsible.

3. Determine what alternatives exist within the constraints of available resources to make specific changes to their approach, processes, or activities.

4. Implement and evaluate the planned changes, and reiterate the cycle.

This means that when efforts are effective, the community examines why its actions were successful and how it can enhance those processes or translate them to other activities. It also means that when efforts are ineffective, the community uses available data to inform its actions rather than stopping at failure. The process itself is not novel; however, explication of how communities engage in the process—not just individuals within communities—extends our understanding of how it works and how it can be fostered. Each step is discussed in detail below.

Step 1: Reflect on the Experience

Step 1 entails intentional, systematic evaluation of what has occurred within a defined context of a particular community effort. This evaluation collectively examines both processes and outcomes, and seeks to determine aspects of success or failure as measured against some predetermined goals or objectives. Practically, this involves the engaged community members closely reviewing evaluation data as well as reflecting on their experiences in the process and coming to consensus on what the data mean. It also entails asking whose perspectives were not part of the preceding activities and who is missing from the reflection process that should subsequently be included. Reaching consensus is a critical step and may take time or may not be achieved at all. For some communities, reflecting on processes and outcomes and interpreting evaluation data becomes the stopping point because consensus cannot be reached. Engaging a neutral facilitator can assist in productive dialogue to ensure that all perspectives are heard and considered and assumptions are interrogated.

Ideally, the community has established predetermined goals or objectives prior to this step, as well as an operationalized definition of success. If not, this step provides the space to determine and articulate those as a foundation for moving forward. For this type of critical reflection to occur, the community must plan for evaluation from the start to ensure that adequate data are collected to allow for assessment of processes and outcomes. The data are more useful and easier to navigate if the evaluation of the effort is well designed and the data quality is reliable. Step 1 also requires that the community examine its efforts from a holistic perspective, analyzing what occurred in context, accounting for variables both within and out of its control, and acknowledging intended and unintended consequences; this requires it to incorporate data from multiple sources to get a comprehensive picture.

Engaging in critical reflection at the community level is considerably more challenging than individual or organizational reflexivity. Individuals enter this process with their own experiences and perspectives, and organizations at least have an overarching mission to guide definitions of success, which can facilitate consensus building, as well as mechanisms for accountability of members. At the community level, the number and types of people involved can exponentially increase the complexity and politics, as this adds multiple experiences, perspectives, agendas, missions, orientations, worldviews, resources, and power dynamics. Again, a neutral facilitator with appropriate expertise may assist in this process by asking critical questions, helping navigate data interpretation, providing perspective without an agenda, and guiding the consensus-building process.

Step 2: Assess What Is Working and Why

In step 2, the community assesses which processes or actions resulted in desirable outcomes, and also identifies unanticipated challenges. This assessment—the “meaning making” of the process—is specifically focused on zeroing in on factors facilitating success or leading to failure at different points in the effort. Practically, the community members would discuss what occurred and to what extent they succeeded, and would then work to identify specific processes or actions that worked well or did not. This reflects principles of participatory evaluation and developmental evaluation in the inclusion of stakeholders in the process²⁵ and the use of information to improve.²⁶ However, it goes beyond that by asking why.

The “why” is uniquely important as the community examines its own assumptions and structures as a factor in the initiative. Hinging on the quality of step 1, step 2 relies on the community reaching some form of consensus on attributions of success or failure to specific points of implementation. In some cases, dissent will divide the effort into multiple efforts or lead the community to abort the initiative. Consensus can take the form of agreement or, minimally, consent to move forward a certain way. This step requires that the group involved collectively understands the processes in place and documents how those processes were enacted. Perhaps most important to the tenor of step 2, the community should take collective ownership of successes and failures; this can affect both consensus building as well as future engagement and investment of resources.

Challenges to step 2 include politics, differing levels of understanding, and multiple perspectives on why a specific activity resulted in success or failure. At the community level, individual stakeholders may be particularly invested in an organization or activity, making it difficult to critically examine effectiveness; this dynamic is further complicated when those who are invested hold substantial influence or resources that the community needs to move an effort forward. This underscores the importance of building relationships and trust and fostering an inclusive process from assessment to planning to implementation. Existing relationships can provide a foundation from which to address difficult issues; in contrast, historically negative relationships among individuals or organizations can contribute additional tension to these processes. Regardless, if those engaged have agreed to a collective goal, this can serve as a touchstone for keeping the community focused through the process.

Step 3: Determine Changes to Enact

Step 3 utilizes the identified factors of success or failure from step 2 to determine concrete changes to processes or actions that need to occur. On the basis of what was found effective or ineffective, the community explores feasible options within its resource constraints and develops a concrete action plan for moving forward. This process incorporates aspects of double-loop learning from systems thinking,²⁷ a dynamic learning model in which the outcome of reflection (first loop) is integrated into the mental model going forward (second loop), not just altering the procedures. Subsequent to assumptions and structures being interrogated in step 2, the process may call for macro-level changes that require considerable time and political will, which goes back to feasibility of options within the resources available. Practically, community members—equipped with insight from steps 1 and 2—articulate a plan of who is going to do what, when, and how. As with any action planning, those engaged must also identify what resources or supports are needed to determine how to marshal those resources and supports.

Although this step seems to be intuitive to implementation frameworks, the process of reflexivity offers a unique lens to taking action. As a community conducts steps 1 and 2, it is gathering and leveraging process and outcome data; however, it is also experiencing and reflecting on the context in which the initial action occurred. The context in which an initiative is implemented influences its results; therefore, by using reflexivity at the community level, these insights can be incorporated into the solutions.

As with other steps in this process, a primary challenge is consensus. Multiple perspectives, organizational missions, and agendas often bring differing strategies for improving on the approach. Step 3 hinges on what was accomplished in steps 1 and 2. Power brokers and resource holders in the community often have significant influence in this stage, especially when consensus cannot be reached. Continuing to point the community back to the shared goal or intentionally evolving the shared goal is critical in this decision-making process.

Step 4: Implement and Evaluate Changes

Step 4 requires the actual implementation and evaluation of planned changes. This seems relatively straightforward and simple; however, this step can be challenging. As with individuals and organizations, it is often easy to identify what needs to be done but very difficult to do it. Step 4 requires that those involved have the resources, supports, and authority to change what is necessary. For individuals and organizations involved at the community level, change also relies on humility. Where the action plan calls for multiple changes by multiple parties, building in mechanisms for communication and accountability is crucial to keeping the efforts in sync. This step assumes that there is substantial commitment to the community goal at multiple levels and by all parties engaged. Where this does not exist, efforts are often abandoned by the community or relegated to one or a few particularly invested parties.

Challenges to this step abound. In addition to those listed in preceding steps, making changes to processes and actions can also be impeded by history (e.g., organizations do not collaborate because of a past event), tradition (e.g., we have always done things this way), the way funding is allocated (e.g., a funding stream only allows an organization to do certain things), and policies across different sectors (e.g., organizational measures of success differ by sector and do not necessarily align). The entire process requires intentionality and tenacity. Clearly, each step requires collective work and is predicated on the work invested in the preceding step(s). Communities must proceed through all 4 steps of the cycle for them to benefit from critical reflexivity practice, and for the process to yield community learning.

It is also important to note that the process is intended to be iterative. The community should use evaluation data to identify successes and failures throughout its project, not just at the end. This allows early identification of issues and midcourse corrections. If a community waits to reflect on its experiences until the end of a project, valuable learning opportunities will be lost and it runs the risk of missing a vital chance to improve its initiative.

IMPLICATIONS

Individual and organizational models are valuable in grounding a community-level conceptualization of critical reflexivity practice. In psychology, Rosenberg describes 2 types of individual reflexivity: cognition and agency.¹¹ Cognition speaks to the memory, perception, attention, evaluation, abstract reasoning, analysis, and synthesis capabilities that can be brought to bear on the self as an object. Agency refers to the experience of being an active cause in the production of some outcome. Freire’s notion of praxis extends this cognition and agency from the individual to the collective: the idea that oppressed people can develop critical consciousness—as individuals but together—and act for social change.^5,6 Both cognitive reflection and agency are central to community reflexivity; at the community level, however, we are talking about more than a collective of individuals engaging in this process simultaneously. The transformative learning model and double-loop learning may illuminate the emergent property, specifically related to making meaning of experience and then integrating that perspective into its schema for subsequent thinking.^14,27 Alternative views of transformative learning also focus on the role of emotion and how emotion and intuition affect rational critical reflection.^28,29 At the community level, this meaning-making process contributes to a community’s shared narrative and history as time progresses. That shared narrative, then, is invoked—consciously or not—in subsequent thinking and interpretation of experiences and becomes part of the context.

Given the power of the shared narrative, the issue of representation and consensus becomes increasingly critical. Without attention to marginalized voices who may not have the resources to participate in processes like community-level meaning making, the community risks simply reproducing dominant ideas by already powerful community actors. If not inclusive of diverse voices, a community process of making meaning can yield a narrative that reinforces inequity and injustice. How can communities include and attend to those voices? What happens when voices dissent? What happens when the dissenting voices are compounded by power dynamics in the community? Specific guidance exists to help groups through a consensus-building process in light of differing agendas and power imbalances, such as the U Process in management literature.³⁰ The U Process entails a stepped process called “presencing” that involves co-initiation of a common intent, co-observing with an open mind, letting emerging inspiration drive understanding, co-creating a new reality, and co-evolving as that new reality is experienced.³⁰ To some extent, this is reflected in the collective impact framework; however, collective impact does not specify processes around critical reflection.³¹ Other practices, such as World Café or Open Space, also provide guidance for ensuring that diverse voices are engaged and included.

Two critical themes connect these different practices: enlightened self-interest and a Habermasian notion of the ideal speech situation. Enlightened self-interest is an understanding that benefiting one’s self-interest does not have to be mutually exclusive from benefiting a common interest or the common good.³² In addition to this perspective, guidance for helping groups achieve consensus is also rooted in creating an ideal speech situation, governed by a specific set of rules:

1. Everyone is allowed to participate.

2. Everyone is allowed to question any assertion.

3. Everyone is allowed to make any assertion.

4. Everyone is allowed to express themselves.

5. No one may be prevented from their rights in 1 through 4.³³

These provide the environment for a constructive dialogue.

The public health literature demonstrates the importance of community capacity for health improvement and highlights the role of public health professionals in helping build local capacity. Our ethics guide us to equip communities—not just individuals or organizations—to do for themselves, and to recognize the assets of their members and the collective capacity that is bigger than the individuals who make up the community. This equipping requires community learning, which requires processes for critical reflection practice. Although the significance of reflexivity in communities is acknowledged, little conceptual development or practical research has been published on what it looks like or how it works.

The contribution of this article is in synthesizing concepts and models from various disciplines to inform a clearer conceptualization of critical reflexivity practice at the community level while illuminating and exploring emergent complexities beyond those observed at the individual and organizational levels. We provide a starting point; interrogation within public health and related disciplines will further develop our understanding of critical reflexivity at the community level. Examples abound of communities that continuously struggle because they are not equipped to evaluate their efforts, they stop short in the process, or they attempt one of the steps in isolation (e.g., they solely identify what did not work, or they attempt a new course of action without the insight of the other steps). If we recognize distinct steps in the process, can we help communities effectively navigate through them? Similar to community functions related to assessment, planning, and community development, the role of public health researchers and practitioners should be to articulate the skills and processes needed to practice reflexivity and develop tools and methods of assisting communities in building those processes and skills.

Finally, in looking at critical reflexivity from a community perspective, the commitment and tenacity to engage in this kind of learning must be supported by the community culture. This recontextualizes critical reflexivity within the larger construct of community capacity; in addition to skills and resources, there must be adequate leadership, mechanisms for engagement and dialogue, access to members of the community through social networks, a shared understanding of history and sense of community, and a way to utilize power within the community to work in alignment with community values. Reflexivity is a critical aspect of community capacity, but it must be understood and approached in relation to the other dimensions. Strengthening communities’ ability to gain and employ collective wisdom from their experience will also build their overall capacity for population health improvement.