You will have noticed that the term participatory approaches is broad and can be applied to a range of different activities. We have suggested that an approach can be defined in relation to ways of doing, ways of knowing, and ways of changing. But not all participatory approaches and studies achieve the same level of participation. In fact, each public health activity will need to be looked at individually to decide what level of participation is appropriate and possible. In this lecture, you'll be introduced to frameworks for categorizing and assessing participatory approaches in order to critique specific examples. In 1969, Sherry Arnstein published an influential article called A Ladder of Citizen Participation. She was working in the US Department of Housing, Education, and Welfare. While her work focused on planning and the role of public participation in decision-making, her model can also be relevant to public health. She described a hierarchy starting at the lowest levels of non-participation, such as manipulation through tokenism, such as consultation, and placating up to various degrees of power, partnership, delegated power, and citizen control. In this interesting article, she provides examples of each rung of the ladder. For example, manipulation might include an advisory committee designed to rubberstamp government decisions after a public relations exercise. By therapy, she means, for example, public housing programs where tenants groups are used as vehicles for delivering local cleanup campaigns. The tenants are brought together to help them adjust their values and attitudes to those of larger society. The next rungs of the ladder progressed degrees of tokenism. Informing and consultation allow citizens to hear and to have a voice, but they generally lack any power to ensure that their views will be taken into account. The exercise might be a one-way flow of information from officials to citizens with no possibility for feedback and no power to negotiate or influence the planning decision. Arnstein also places consultation at this level, which you might think is a bit unfair. However, consultation is frequently about getting local people to choose between a set of options decided by those with power, none of which might be appropriate and with no opportunity to suggest an alternative. Policymakers can then say, for example, that 80 percent of people supported option A. But that's only because option B was even worse. Towards the top of Arnstein's ladder, citizen power increases with citizens having the increased ability to make decisions, whether in a partnership model, through delegated power. For example, by having a few elected citizen representatives. At the top of the ladder, she describes citizen control, where, for example, residents run their housing association with autonomy and democratic structures. There are limitations to Arnstein's ladder, including the suggestion that there is a necessary progression from the bottom of the ladder to the top, implying that citizen control is always the goal. Also, the ladder does not allow for more than one type of participatory approach to happen at the same time, which may be required, for example, using informing, consultation, and partnership together. Various iterations of participation ladders have been proposed and one that is commonly cited includes the concepts of co-design and co-production. This version produced by the New Economics Foundation refers to doing to, doing for and doing with which can be a useful framework. At the lowest level of doing to is coercion. An example of this is discussed in the case study on the Sonagachi Project in India. Dr. Jana refers to three other HIV prevention projects with sex workers that failed and they all shared a model of mandatory testing and registration. Those three projects were clearly at the coercing end of the ladder. At the other end is co-production, where people affected by HIV would work together to deliver appropriate services. The Sonagachi Project itself is a good example of this, with peer workers helping design and deliver sex worker services. Indeed, I would argue that with the establishment of sex worker leadership, the Sonagachi Project takes the level of participation one step further than co-production to user control of the service, which you'll see at the top of Arnstein's ladder. Clearly, these frameworks are simplifications of the real world, but they do provide a way of categorizing the different levels of citizen participation. Being aware of these different levels helps you to understand the demands for participation from citizens, as well as the breadth of responses from the power holders. It also allows you to consider what level or levels of participation may be appropriate and possible for your public health activity. If you'd like to read more about Arnstein's Ladder of Participation, please go to the Resources page. You'll be asked to use one or more participation frameworks to assess different examples of participation later on.
