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Embracing complexity in community-based health promotion : inclusion, power, and women's health Ponic, Pamela Lynn 2007

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EMBRACING COMPLEXITY IN COMMUNITY-BASED HEALTH PROMOTION: INCLUSION, POWER, AND WOMEN'S HEALTH by Pamela Lynn Ponic B.H.K., The University of Windsor, 1992 M.H.K., The University of Windsor, 1995 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in The Faculty of Graduate Studies (Human Kinetics) THE UNIVERSITY OF BRITISH COLUMBIA August 2007 © Pamela Lynn Ponic, 2007 Abstract Inclusion is increasingly being positioned by health promoters as a way of alleviating exclusion and related health inequities experienced by marginalized women (Shookner, 2002; Reid, 2004). Yet assumptions about inclusion are rarely investigated, especially from the perspectives of the individuals it is meant to benefit. The purpose of this research was to critically examine inclusion as a health promotion strategy from the standpoints of 14 diverse women who were involved in a 5-year community-based health promotion (CBHP) project called Women Organizing Activities for Women (WOAW). This qualitative feminist participatory action research (FPAR) project developed from my 4-year stint as research manager of WOAW, which was designed to improve poor women's health through a cornmunity development approach to recreation (Frisby, Reid & Ponic, 2007). Participants reflected on their varied experiences through interviews, writing, and collaborative analysis. Through my critical feminist lens, the findings reveal that inclusion was a multifaceted and dynamic process produced by the interplay between individual, psychosocial, relational, local/organizational, and socio-political factors. Inclusion and exclusion existed in a fluid relationship that was shaped by contradictory and internalized understandings of power across axes of difference mcluding gender, class, race/ethnicity, age, and (dis)ability. These tensions resulted in significant conflict through issues of leadership, sub-group loyalties, fear, and resistance. Amidst the inclusion-exclusion fluidity, participants' physical and mental health was both enhanced and hindered through psychosocial pathways. Their capacity, confidence, and sense of identity improved through participation, community connections, and consciousness-raising. Although the conflicts produced stress and anxiety, participants continually made health promoting choices to alleviate the effects. These findings do not measure health outcomes or inclusion processes; rather, they illustrate how coupling FPAR with critical theorizing can inform CBHP (Kesby, 2005; Poland, 1998). Exploring CBHP projects across this length of time and at this depth is rare, but doing so importantly explicates inclusion, participation, exclusion, and marginalization as contestable concepts that must be critically examined if they are to be useful. In the end, I offer an 'Inclusion Tool' designed to cultivate critical dialogues amongst CBHP participants, practitioners, and researchers who seek to embrace and utilize the complexity inherent within inclusion processes. Table of Contents Abstract » Table of Contents m List of Tables vi List of Figures vii Acknowledgements vm Chapter 1: Introduction 1 The Inspiration for this Inquiry 1 Research purpose & questions 6 Dissertation Outline 7 Chapter 2: Review of Literature 10 Feminist Approaches to Community-based Health Promotion 11 What determines women's health? 14 The status of women's health in Canada 17 Defining community as a multidimensional & relational construct 19 Feminist approaches to power 20 Power-to, power-with, power-for & power-over 21 The Impetus for Inclusion in Community-based Health Promotion 25 Defining inclusion as a social justice process 26 Exclusion, marginalization & 'Othering' 28 Inclusion/exclusion dialectic 30 Conceptualizing the Complexity of Community-based Health Promotion 32 Women's agency, health, & lived realities 36 Psychosocial sphere: Internalization & conscientization 39 Relational sphere: Group work, conflict & growth 45 Local sphere: Feminist community organizing & municipal recreation 49 Broader socio-political sphere: Neoliberal ideology & social-collectivism 53 Intersectionality: A web of power, privilege & oppression 56 Embracing Complexity in Community-based Health Promotion 59 Chapter 3: A Story of WO AW 61 Authorship of this Story 61 W O A W ' s Creation: The Socio-Political Context 61 The People : 65 W O A W members 65 W O A W service providers 66 W O A W researchers 68 W O A W ' s Structure 70 The sub-groups ^ 70 W O A W as Recreation " 73 The project team 74 The Research Component 74 Research parties 77 The research team 78 Envisioning W O A W : The Development of a Collective Organization 79 W O A W ' s Sustainability 82 iii Chapter 4: Research Methods 84 Participant Introductions 85 Involvement in W O A W 88 Demographic profile of participant group 89 Confidentiality & anonymity 91 Feminist Participatory Action Research: Theory, Methodology & Epistemology 92 Participatory Research & Unfolding Realities 97 Ethical recruitment, fostering inclusion & existing research relationships 98 Data collection decision-making • 102 Feminist interviewing 108 Lived realities & the balance of power 112 Collective analysis & action 114 The research party 114 The action meeting 116 Data Analysis & Making Meaning 120 Coding themes 120 Writing-up' the data 122 Tabling : 123 Representation & trustworthiness 124 Positioning Myself as Researcher, Author & Activist 126 Representing the 'Other': Social locations & insider/outsider relationships 127 M y Reflexive Practice 130 Reflexive field notes 131 Peer debriefing 133 Power & Inclusion in Feminist Participatory Action Research 135 Chapter 5: Inclusion as a Multi-faceted & Negotiated Process 137 The Relevance of Inclusion in W O A W 138 Women's Meanings & Experiences of Inclusion 140 Psychosocial dimension 142 Acceptance 143 Safety & trust 144 Recognition 146 Relational dimension 147 Being welcomed 148 Support 149 Respect • 151 Local/organizational dimension 152 Addressing barriers 153 Access to resources 155 Ethic of care 157 Participatory dimension 159 Sharing 160 Contributing 161 Participating in recreational activities 163 Having a voice 164 The Fluidity of Inclusion & Exclusion 166 Kate's story of inclusion & exclusion in W O A W 167 Multidimensionality & Dynamic Nature of Inclusion Processes 169 IV Chapter 6: Power, Difference & Conflict in WOAW ,. 173 Conceptions of Power & Difference 175 Participants' understandings & enactments of power 176 Participants' understandings of & relationships across difference 181 Unravelling the Conflicts 185 The 'big blow out' 186 The entanglement of leadership & power 187 Tense sub-group relations 193 Lack of trust& respect 195 A conflict resolution strategy 199 Sub-group loyalties & an abandoned process 202 Fear of blame & resistance to self-reflection 204 Sustaining W O A W post-conflict: A strategic planning process 207 Re-envisioning W O A W ' s organizational structure 210 Maintaining hope in the face of crisis and transition 217 Negotiating Power, Difference & Conflict within Community-based Health Promotion 218 Chapter 7: WO AW's Influence on Women's Health 221 Participants' Health Status: A Determinants Perspective 222 Physical ailments & chronic conditions 222 Psychosocial health problems: Social Isolation & depression 224 Women's ecological health 227 The Health Promoting Conditions of W O A W 228 Facilitating community connections, social support, & recreational opportunities 229 Enhancing capacity, confidence & self-esteem 233 Expanding practical consciousness through new knowledge & personal growth 238 Making Health Promoting Choices in the Face of Conflict 244 The health consequences of conflict, stress & anxiety '. 244 Choosing to 'stick with' or 'walk away' from W O A W 246 Sticking with W O A W 247 Walking away 249 Broadening What Counts as Health Promotion 250 Chapter 8: Conclusions & Implications 253 What have I Learned?: A Summary of Findings 253 Theoretical Implications 257 Methodological Reflections 261 Practical Implications 263 A n 'Inclusion Too l ' 264 Suggestions for Future Research 268 Possibilities for Transformation: Inclusion, Power & Women's Health 270 References 273 Appendices 298 Appendix I: Ethics Letter of Consent & Consent Form 298 Appendix II: Initial Letter of Invitation 301 Appendix III: Face Sheet 304 Appendix IV: Interview Guide 306 Appendix V : Final Codebook : 308 Appendix V I : Behavioural Research Ethics Board Certificate of Approval 312 V List of Tables Table 3.1: Recreational activities organized by WOAW members 73 Table 3.2: Collective organizing workshops 81 Table 4.1: Brief description of participants 86 Table 4.2: Participant involvement in WOAW 88 Table 4.3: Particpants'ages 89 Table 4.4: Participants' economic status 89 Table 4.5: Participants' education 90 Table 4.6: Participants' domestic & parenting statuses 90 Table 4.7: Participants' race/ethnicity and immigration 90 Table 4.8: Participation options 102 Table 4.9: Summary of responses to my invitation to participate 103 Table 4.10: Summary of participation options chosen 104 Table 4.11: Summary of primary data collected 107 Table 5.1: Dimensions & elements of inclusion 141 Table 5.2: Psychosocial elements of inclusion 142 Table 5.3: Relational elements of inclusion 148 Table 5.4: Local/organizational elements of inclusion 153 Table 5.5: Participatory elements of inclusion 159 Table 5.6: Dimensions & element of exclusion 166 Table 6.1: Participant-identified conflict dynamics 175 Table 6.2: Levels of involvement in conflict, conflict resolution & strategic planning 185 Table 6.3: Participation at strategic planning sessions 209 Table 7.1: Self-reported physical health problems 223 Table 7.2: Self-reported psychosocial health problems 224 Table 7.3: Health promoting conditions as identified by participants 229 Table 7.4: Participants' involvement choices in WOAW during conflicts 246 Table 7.5: Participant-identified conditions for sticky with WOAW during conflicts 246 Table 7.6: Participant-identified conditions for walking away from WOAW during conflicts.246 Table 8.1: Part 1 of the Inclusion Tool: Mapping the terrain 266 Table 8.2: Part 2 of the Inclusion Tool: Negotiating the nuances 267 vi List of Figures Figure 2.1: Theoretical framework of inclusion in community-based health promotion 34 Figure 3.1: W O A W ' s organizing structure 80 Figure 8.1: Theoretical framework of inclusion in community-based health promotion 265 v i i Acknowledgements Completing my PhD has been a transformative journey that would not have been possible without the support and wisdom of coundess people. I deeply admire the courage and strength of all the women who participated in WOAW and I am sincerely thankful that I had the opportunity to work, eat, and laugh with you over the years. I would especially like to thank Ana, Diane, Elaine, Kate, Maria Manuel, Mary Elizabeth, Marylu, Pat, Patricia, Tara, Sandra, Selah, Sydney, and Vicky for participating in my study. Your willingness to share your reflections, insights and experiences with me enormously enriched my learning and brought this dissertation to life. I will be forever grateful for your generosity. I would also like to acknowledge the commitment made by all the service providers who supported WOAW, often in the face of overwhelming workloads and competing pressures. Dr. Wendy Frisby, my research advisor, provided me with the life-changing opportunity to work with WOAW. Over the years she has encouraged and challenged me with critical comments and uncompromising compassion. Her enthusiasm for her work has inspired me and I will be forever grateful for her guidance and patience as I found my feminist voice and vision. I would like to thank Dr. Lorraine Greaves for her acute insights and consistent presence as an invaluable cornmittee member. Dr. Allison Tom's analytic ability and caring presence played a significant role in the early stages of my PhD experience and were deeply missed as a completed my research. Finally, I would like to thank Dr. Brian Wilson and Dr. Paule McNicoll for joining my cornmittee in the midst of this journey and for their helpful feedback and encouragement. I have been blessed with an amazing community of support, who have been by my side through the moments of pain and celebration. I would like to thank the members of the WOAW working group mcluding Beth, Sydney, JoAnn & Janna for their dedication to and thoughtful reflections about our experiences 'in the field.' It was a privilege to work with you all. I would especially like to thank Colleen and Tammy who were my peer debriefers and confidants, and most fmportandy, two of my dearest friends. Your critical minds and open hearts helped make this work possible. I am also deeply appreciative of my network of friends, especially Andrew, Holly, Jane, K Louise, Lisa, Vicky, and Victoria, who helped sustain my spirit through this often gruelling process and who will undoubtedly toast its successful completion with me over a glass or two of wine. To mom and dad, thank you for your unconditional support and love, even when you didn't really understand what it was I was doing or if it would ever be complete. I love you both more than words can express. To my brother Mike, I always feel your strength and presence, even as our lives have developed in different directions. I am proud to have you as a friend and sibling. And last but not least, I want to thank my beloved husband Ricky, who has never known me as non-PhD student. Well babe, the year and a half are finally over. My life was forever altered the day I met you and for that I am deeply grateful. viii CHAPTER 1 Introduction WOAW made life worth living. (Mary Elizabeth's interview) The Inspiration for this Inquiry If health promotion is defined as "the process of enabling people to increase control over, and to improve, their health" (WHO, 1986, p.l), is inclusion in a community-based project an appropriate strategy for obtaining this goal? This question lies at the heart of this dissertation and emerged from my experiences as a feminist participatory action researcher in a community based health promotion (CBHP) project guided by the value of inclusion. During my time with the project, I heard more than one woman living in poverty say that her involvement in the project, 'made live worth living', as Mary Elizabeth articulated above, by connecting her to a community of support, thus reducing her social isolation, depression, and stress. I also heard women reveal that conflicts and power dynamics that developed within the project created feelings of disrespect, stress, and exclusion, which in turn reflected the challenges of their daily lives, exacerbated existing medical conditions, and compromised their health. These contradictions, juxtaposed against assumptions embedded in the inclusion and health promotion literature I was reading at the time, led me to conduct this critical examination of inclusion, power, and women's health in CBHP. The project that was the site of my dissertation research was called Women Organizing Activities for Women (WOAW, pronounced 'whoa'). Prior to my study, a long-term feminist participatory action research (FPAR) grant, funded by Social Sciences and Humanities Research Council of Canada (SSHRC), was acquired by my advisor, Dr. Wendy Frisby, to study and work with WOAW. For nearly three years I held the privileged position of Project Manager of the 1 SSHRC-funded grant, a role that significantly shaped my PhD research. WOAW was designed to promote the health of women on low income through a cornrnunity development approach to recreation (Frisby, Reid, & Ponic, 2007). Community members, who were primarily women living near or below the poverty line, collectively decided what recreational activities they were interested in and worked with a group of local service providers and university researchers to organize them. WOAW's organizing and research practices were based on a vision of inclusion, participation, and respect for diversity, ideals which are commonly advocated in the CBHP literature (Donnelly & Coakley, 2002; Laverack, 2004; O'Connor, Denton, Hadjukowski-Ahmed, Zeytinoglu, & Williams, 1999; Shookner, 2002). For example, members, service providers, and researchers collectively attempted to foster inclusion by creating a welcoming environment, providing choice in types and^  levels of participation, developing shared leadership and decision-making strategies, and facilitating collaborative research processes. During my early involvement in WOAW I witnessed and experienced the value of feminist and health promotion practices that I previously had only read about in the literature. I was overwhelmed by the stories I regularly heard from members, including the depths of their despair while living in poverty and isolation and about the ways in which involvement in WOAW changed their lives and improved their health - they spoke passionately about the significance of feeling empowered and heard, developing skills and knowledge, and alleviating their isolation and depression. Over time, however, as the honeymoon ended, I began to recognize some contradictions and challenges within WOAW's inclusion processes. For example, WOAW adopted a consensus decision-making model because it was presumed to be more inclusive than a majority rules approach. In the consensus model that was used, an issue was discussed until members agreed that all voices had been heard and a decision could be made. Someone in the 2 room offered a decision (e.g., 'I would like to test the decision to go with strategy A for consensus.') and asked if anyone would like to block this decision. If an individual blocked a decision, it was her responsibility to offer an alternative. If a decision was blocked, the discussion continued until another decision by consensus was offered. A decision stood if no one blocked it. The intention behind this model was to promote collaborative discussions and agreements. However, I began to suspect that many WOAW members were feeling unheard and disempowered because they did not have the confidence, skill, or energy required to fully engage in this demanding process. The model also seemed to privilege the voices of those with power, mcluding the service providers, researchers, and a small group of members who tended to dominate discussions. As I witnessed many members struggle to find the courage to speak up in front of 20-30 people or to clearly articulate their position if they did speak, I began to wonder if the consensus model was resulting in more frustration, silence, and exclusion than voice, respect, and inclusion. The challenge of implementing collaborative and presumably inclusive organizing and research processes was compounded over time, as a number of conflicts and power struggles emerged between WOAW members. Despite the vision of inclusion, it seemed that some members were experiencing a sense of exclusion from decisions, activities, and even moments of celebration. A number of members quit or threatened to quit WOAW because the stress associated with the conflicts was negatively affecting their health. While bearing witness to these tensions, and struggling with the decision of if and how I might act to help rectify them, I began to reflect on the value of inclusion as a health promotion strategy in WOAW. I questioned whether or not it was possible to foster inclusion in a group such as WOAW given the complexity of negotiating power and conflict amongst a diverse group of community members, service providers, and researchers. I wondered what inclusion really meant to the various members and if the organization had adopted uncritically the 3 rhetoric of inclusion without considering its ambiguities and complexities. I was also concerned about what the implications might be for women living in poverty if involvement in a project designed to foster health promoting conditions ended up replicating their daily experiences of exclusion and stress, despite the accompanying health benefits. At the same time that I was experiencing and questioning the value of inclusion in WOAW, I recognized that the notion of inclusion was becoming increasingly heralded by health promotion researchers, programmers, and policy-makers as an important strategy to address exclusion and other related health inequities (Donnelly & Coakley, 2002; Labonte, 2004; Raphael, 2002; Reid, Frisby, & Ponic, 2002a). For example, the Atlantic Region of the Population and Public Health Branch of Health Canada produced a document called A.n inclusion lens: Workbook for looking a social and economic exclusion and inclusion (2002). This workbook suggests that: Inclusion reflects the need to address poverty and exclusion by mcluding the voiceless and powerless in shaping the policies that affect their lives. It welcomes these individuals and groups into the planning, decision-making, and policy-development processes in their community. And it empowers them by offering the opportunities, resources, and support they need to participate. (Shookner, 2002, p. 16) While the idea of facilitating the participation of individuals and groups in the health prograrnming and policy-making that directly affects their lives is promising, I certainly did not experience the women involved in the WOAW project to be 'voiceless' or 'powerless' and was concerned about the ramifications of positioning them in this way. This document seemed to be assuming that it was up to privileged professionals and researchers to 'include' those living on the margins into current structures, without necessarily considering whether or not these structures might be problematic in the first place (Hall, 2005; Labonte, 2004). And although the language of empowerment and participation was used throughout, there appeared to be little consideration for how the agency and choices of 'included individuals' would be utilized in a 4 system that inherently privileged the perspectives of those with resources and other forms of legitimized power. A tiiird ttoubling assumption underpmning this document was that fostering inclusion would necessarily alleviate the effects of exclusion. Yet inclusion and exclusion are complex and ever-shifting processes and inclusion in one realm of life would not necessarily address exclusion in another (O'Reilly, 2005). This type of compensatory inclusion within an existing oppressive system would likely only help individuals cope with their experiences of marginalization without necessarily addressing them at their root. Feminist approaches to CBHP were similarly espousing the inclusion of women in knowledge-making and programming practices (Minkler, 1997b; O'Connor et al, 1999; Reid, 2004). Despite its grounding in relevant and important theories of power and difference, this literature was also embedded with assumptions about inclusion and its apphcability to women's health issues. For example, health promoters seemed to assume that there were clear and consistent meanings of inclusion amongst project participants, that it was possible to facilitate inclusion given the complexity of negotiating power and difference, and that inclusion in CBHP projects could foster health promoting conditions for women who had been chronically oppressed. Yet there was scant evidence that either questioned or supported these assumptions and it appeared that the sustainabihty of many projects had been undermined because such assumptions and complexities were not adequately addressed (Frankish, Kwan, Rattier, Wharf Higgins, & Larsen, 2002; Guldan, 1996; Minkler, 1997a; Zakus & Lysack, 1998). A final critique I uncovered in reading of literature during my early days with WOAW was exemplified in the Laidlaw Foundation's (2002) series of "Workingpapers: Perspectives on social inclusion?' The Laidlaw Foundation is an Ontario-based organization that supports research and prograrnming designed to foster inclusive communities and enhance health and citizenship. The working papers were written to theorize and reflect upon the notion of social inclusion and 5 importantly recognized that "social inclusion is not, however, just a response to exclusion" and that structural forces needed to be addressed in order to facilitate inclusion and well-being (Laidlaw Foundation, 2002, p. viii). Yet, as with most inclusion theorizing, these papers tended to focus on the broader dimensions of exclusion at national and economic policy levels (Long & Bramham, 2006; O'Reilly, 2005; Shakir, 2005; Stewart, 2000), largely ignoring the micro and community-level power dynamics within inclusion processes that play out in individuals' lives on a daily basis. The perspectives of women who experienced exclusion and other forms of marginalization were curiously absent from this body of work given both the relevance of their experiences (Bryant, 2002; Milburn, 1996; Reutter et al., 2005) and, ironically, a commitment to their inclusion in CBHP. Overall, it seemed that the notion of inclusion had been under-examined and over-idealized in the CBHP literature, a critique that could also be applied to WOAW's vision and unfolding dynamics, as my experiences and reflections corroborated. This juxtaposition led to me the following research purpose and questions that explore the complexity inherent within CBHP inclusion processes. Research purpose & questions The overall purpose of my study was to critically examine the assumptions underlying inclusion in CBHP as a strategy to promote the health of a diverse group of women who had experienced various levels of poverty, exclusion, and isolation. I explored 14 participants' perspectives on their experiences within WOAW, as guided by the following questions: 1) What were the meanings and experiences of inclusion in this CBHP project and how did they shift over time? 2) How did the complexity of negotiating power and conflict amongst diverse community members, service providers, and researchers in this CBHP project affect possibilities for promoting inclusion? 3) Did involvement in this CBHP project create health promoting conditions for its members? Why and/or why not and in what ways? 6 Dissertation Outline The ways in which I answer the research questions in this dissertation are, of course, partial and socially situated (Naples, 2003). Feminist theorists have long grappled with the 'crisis of representation,' since all knowledge is generated from a range of contextualized perspectives that are embedded in inequitable power relationships (Fine, Weis, Weseen, & Wong, 2000; Harding, 1991). Rather than claim that the findings here articulate truths, I offer a 'rendered account' of WOAW that is based on the combined perspectives of me and the 14 women who participated in this study. The critical lens that shaped my analysis and write-up of this account was mutually informed by FPAR and contemporary material feminist theories. These issues of representation and authorship will be explored more deeply in Chapter 4. Each chapter serves to meet the purpose of this dissertation in particular ways. As you have already read, Chapter 1 provides a story that illustrates the impetus for my research purpose and questions and outlines the context of this document. Chapter 2 is the review of literature, whereby I draw on the divergent but mutually informative fields of feminist theory, health promotion, determinants of health, critical social-psychology, social group work, recreation, and feminist community organizing to provide a theoretical framework that positions CBHP, inclusion, and women's health as inherendy connected to social processes. In merging these perspectives, I outline a theoretical framework that contextualizes my analysis throughout the findings chapters. Chapter 2 also identifies key gaps in the literature that my research begins to fill. In Chapter 3,1 tell a story of WOAW's development, including the conditions under which it was created, who partnered in its creation, and the recreation, organizing, and research activities that unfolded. This chapter does not report findings per se, but provides a more detailed portrayal of the context witiiin which my research unfolded, based on my experiences 7 and perspectives. My methodology and methods are presented in Chapter 4, where I describe and reflect on how attempting to conduct FPAR required me to continually recognize and negotiate my own power with the power of participants. I also illustrate how my commitment to a participatory research design that emerged over time provided a template from which I could strive to foster inclusion by responding to the ever-shifting realities of participants' lives against the backdrop of my own academic imperatives. My fmdings in relation to the three research questions are presented in Chapters 5 , 6 , and 7 , respectively. Chapter 5 outlines participants' meanings and experiences of inclusion as a multidimensional process that shifted over time and was largely influenced by their agency in a range of forms and capacities. Their experiences of inclusion were also in a constant flux with those of exclusion, rendering unitary and binary depictions of inclusion and exclusion problematic. Chapter 6 explores the troubling conflicts that emerged in WOAW and contributed to its demise. By examining the ways in which participants related to one another across power and difference, this chapter further illustrates the complexity and contradictions embedded within CBHP inclusion processes. Chapter 7 illustrates how participants' involvement in WOAW, and their subsequent experiences of inclusion and exclusion, created conditions that promoted their health and agency through psychosocial pathways, via means that typically go unrecognized in CBHP. Within each chapter and throughout the dissertation, I have attempted to write-in the messiness and complexity of CBHP processes. Inherently, the knowledge offered in each chapter is connected to the other. I use the theoretical model depicted in Chapter 2 to map these connections and this then becomes the basis for the 'Inclusion Tool' I offer in Chapter 8. The Inclusion Tool consists of a series of 'conversation starters' that are built on the premise that there is no single recipe for conducting CBHP. Rather, the Tool provides participants, 8 practitioners, researchers, and policy-makers with a guide for the reflective development of inclusion processes amidst its inherent complexity, unavoidable power dynamics, and specific contexts, as a way to create projects and policies that begin to address women's diverse and multi-faceted health issues. In this final chapter, I also reflect on theoretical and methodological implications of this study and offer ideas for future research. 9 CHAPTER 2 Review of Literature I believe in the idea of WOAW. But it is a process, a tiling that every member needs to put a litde into, how can I say this, litde things that make a bigger tiling together. You know, so it's not only one person working for everybody together and then all the other people just enjoying it. I drink we have to work as a team together to arrive to a certain point and everybody is at this level of understanding. (Marylu's interview) In this chapter, I review divergent literatures to create a theoretical framework for exploring the complexity of inclusion processes in CBHP projects'designed to address women's health issues. Integrating critical feminist theories with those of CBHP, the determinants of women's health, and social inclusion is mutually informative to those working in the field of health promotion and to theorists seeking more nuanced understandings of how community dynamics shape and are shaped by social processes. According to Coburn (2000), health and health promotion are not separate from social processes but rather, they are embedded witiun them. "This is important for health promoters because a great deal of our health is determined by the power that we experience and our control over resources" (Laverack, 2004, p. 13). Yet attempts to promote women's health through a critical feminist lens are surprisingly rare, given the apparent synchronicity in values and goals. For those trying to make a difference in women's health disparities, focussing research and practice through this lens may help avoid inadvertendy rephcating the social and power dynamics that are being addressed (Poland, 1998; Porvin, Gendron, Bilodeau, & Chabot, 2005). The goal of integrating critical feminist theories with community-based initiatives is social change (Fine & Weis, 2005), which means striving to find new ways of relating to one another across our differences, to redress systemic inequities, and to enable individual autonomy. In other words, theory is a tool for critical thought and thus a breeding ground for social justice (Fraser & Naples, 2004; Smith, 1987). 10 Feminist Approaches to Community-based Health Promotion Feminist approaches to health promotion seek to uncover, actively negotiate, and shift the imbalances in power that contribute to determiriing health (Naidoo & Wills, 1994; O'Connor et al., 1999; Reid, 2004). As such, feminist CBHP practices are also those of social justice and thus require attention to the ways in which systemic inequities, cultural ideologies, and individual agency shape women's health (Cartwright & Allotey, 2006; Keleher, 2004; Minkler, 1999; Wallerstein & Freudenberg, 1998). The 1986 Ottawa Charter provided a promising template, based on an ecological health framework, for ferninist approaches to CBHP. In its goal "of enabling people to increase control over, and improve their health" (WHO, 1986), the Charter outlined 5 action strategies in the following areas: 1) healthy public policy; 2) supportive environments; 3) community action; 4) personal skill development; and 5) re-orientation of health services. The Charter also named social justice as a prerequisite, a commitment which is bolstered by naming the interconnected structural, community, and individual points of intervention to improve health. Redressing unbalanced power relations in CBHP requires a commitment to process, rather than a focus on outcome. For feminists this typically means fostering inclusive, participatory, and egalitarian ways of relating to one another, producing new knowledge, and taking action across power and privilege differences, even though these ideals are never fully attainable (Lykes & CoquiUon, 2006; O'Connor et al., 1999). The range of CBHP activities from a feminist perspective therefore can include activities across the individual-societal continuum. For example, initiatives have included health education about HIV/AIDS and sexual health choices (Kesby, 2005), community development in recreation initiatives aimed at reducing isolation (Frisby et al., 2007), and social action for employment policy changes(Tau Lee, Krause, & Goetchius, 2003). 11 Given the scope of feminist initiatives, the community is the ideal site for health promotion because it is the fulcrum between individuals and societies (Raeburn, 2000). Women live and take action in their communities and experience the structural conditions that shape their lives in large part through community-based institutions and relationships. As such, "women's health resides in communities" (Ruzek, Clarke, & Olesen, 1997a, p. 21) and so too should their health promotion initiatives. Creating projects in communities can also work to alleviate the isolation experienced by many women living in poverty. That said, it is important to remain mindful of the women who are not being reached through CBHP efforts and who remain deeply isolated. Additionally, in light of the tendency for neoliberal governments to off-load responsibilities to local individuals and groups, fostering CBHP projects should not absolve policy-makers from making changes to the structural conditions that hamper women's health (Arai & Reid, 2003; Thibault, Frisby, & Kikulas, 2002). Despite theoretical understandings that strategies for addressing women's health issues require attention to both structural and individual dynamics, a polar, rather than integrated, approach has manifested in much CBHP practice and research. This polarity is underpinned by competing perspectives on who holds responsibility for fostering good health. The social responsibility approach resides in the societal end of the spectrum and is based in the social determinants of health perspective (Raphael, 2004a). At the other end of the continuum, the individual responsibility approach is in line with both neoliberal and medical discourses, which emphasize the role of individual behaviours in determining health (Buchanan, 2006). While there are some examples in which social and individual perspectives are well-integrated (e.g., Amaratunga, 2006; Minkler, Vasquez, Warner, Steussey, & Facente, 2006; Varcoe, 2006), much CBHP practice and research remains deeply embedded in the neoliberal individuahst model (Merzel & D'Afflitti, 2003; Raphael & Bryant, 2006). For example, the 12 Bangkok Charter for Health Promotion was recently confirmed as a way to build upon the foundations set by the Ottawa Charter (WHO, 2005). While its focus on global economic structures that determine health may seem well-placed, according to Porter (2006) the document illustrates a shift in the language of health promotion from a socio-ecological framework to a new capitalist one. Although its directives towards redressing global inequities may seem to fall in the social responsibility model of health promotion, its capitalist focus is actually more in line with neoliberal economic ideologies (Porter, 2006). In seeking to alleviate the myriad of women's health concerns, feminist approaches to CBHP must move beyond the tendency to polarize individual and societal approaches and recognize more fully that they can be mutually reinforcing. Participants in CBHP are neither completely determined by structural circumstances nor are they mindless recipients of behaviour-control interventions (Buchanan, 2006; Porter, 2006). In both of these extremes, the autonomy and agency of people is under-estimated and under-valued. Minkler (1999) suggests that "too exclusive an emphasis on social responsibility for health ignores human agency and may, as a consequence, downplay the important role of individuals in ... making important lifestyle changes" (Minkler, 1999, p. 130). Nevertheless, it is undeniable that people's agency and health are shaped by structural determinants (Raphael, 2004a; Williams, 2003). The challenge then for community-based health promoters is to return to Ottawa's focus on "enabling people to increase control over, and improve their health" (WHO, 1986, p. 1) and seek processes that address structural determinants for the primary purpose of facilitating individual agency and power (Laverack, 2004). Or in Porter's (2006) words: I prefer Ottawa's socio-ecology, which tasks health promoters with asking communities what kind of worlds we should build and supporting the bunding, over Bangkok's task of coping with the messes we are making without stopping to question their sources, (p. 78) 13 Her comment brings this discuss full circle to the relevance of community and power in addressing women's health issues. What determines women's health? A review of literature suggests that health inequities emerge from the dynamic intersections of the demands of multiple gender roles, environment exposures, the threats and consequences of gender violence, workplace hazards, economic disparities, the cost of poverty, social marginalization, and racism, aging, health conditions and interactions with health services and health behaviours. Psychosocial factors, whether positive, such as social networks and systems of support, or negative, such as stress and its physiological expressions, also mediate embodied expressions of inequality. (Spitzer, 2005, p. S80) How women's health is understood and determined is central to how it might be enhanced through CBHP efforts. Women know that their health is a complex mix of biological, psychological, social, and spiritual factors (Barnett, 2000; Cohen, 1998; Polakoff & Gregory, 2002; Rootman & Raeburn, 1994). Yet there is a dearth of CBHP research that adequately conceptualizes women's health from this ecological perspective. In keeping with traditional and dorriinant medical discourses, most research is built on overly-narrow conceptions that tend to conflate women's health entirely with their biology (Inhorn, 2006; Johnson, Greaves, & Repta, 2007; Krieger, 2003). At the other end of the spectrum, there has been a surge in epidemiological and qualitative research over the last few decades that illustrate how women's health is determined by social forces such as socioeconomic status, racism, social exclusion, and neoliberal policy-making (Anderson, 2000; Raphael & Bryant, 2004; Reid, 2007; Wilkinson, 1996a). While this body of work is invaluable in offsetting the dominance of the medical model, women's bodies seem to have gone missing in the fervour to position health within social processes. In this light, there have been increasing calls for women's health researchers to incorporate biological and social determinants - or in other words, sex and gender - into their investigations and analyses (Greaves et al., 1999; Krieger, 2003). Johnson, Greaves, and Repta (2007) have 14 constructed an extremely useful primer that clearly distinguishes between sex and gender research and illustrates how researchers can develop more thorough understandings of women's health by uniting sex and gender analyses. Sex, in this vein, refers to "a multidimensional biological construct that encompasses anatomy, physiology, genes, and hormones that together create a human 'package' that affects how we are labelled" (Johnson et al., 2007, p. 4) as male or female. Gender, on the other hand, "refers to the socially prescribed and experienced dimensions of 'femaleness' and 'maleness' in a society" (Johnson et al., 2007, p. 5), which play out in the roles and identities taken up by individuals, the relations between men and women and boys and girls, and in the ways power is distributed institutionally and culturally. Although the nuances go beyond this scope of this study, it is important to mention that biological sex characteristics and gendered identities are not simple male/female or woman/man dichotomies, but incorporate a continuum of possibilities mcluding, but certainly not limited to, intersexed, transsexual, and two-spirited individuals. In their primer, Johnson et al. (2007) draw on Kuehner's (2003) research on depression to exemplify the utility of sex and gender analysis. Biologically, women's increased susceptibility to depression, in comparison to men's, can be attributed to sex-specific physiological and hormonal reactions to stress (Kuehner, 2003). From a gender perspective, women are also increasingly at risk of stress and depression because they are more likely to live poverty, be socially isolated, and/or be responsible for multiple care giving roles. The example of depression also points to the significance of psychosocial factors in the determination of women's health. Psychosocial factors refer to the interplay between psychological and social behaviours and experiences such as "stress ... depression, anxiety, helplessness, hostility, isolation, insecurity, and a lack of a sense of control" (Wilkinson, 2005, p. 13). Psychosocial pathways mediate between embodied responses and social experiences, and also play a 15 significant role in influencing health behaviours (Brunner & Marmot, 1999; Ho, Davidson, & Ghea, 2005; Raphael, 2001). For example, the social experiences of poverty, homelessness, or domestic violence, each of which are significant social determinants of women's health, can perpetuate socially isolation, shame, and low self-esteem (Farris & Fenaughty, 2002; Greaves, Chabot, Jategaonkar, Poole, & McCullough, 2006; Mann, Hosman, Schaalma, & de Vries, 2004; Morrow, Hankivsky, & Varcoe, 2004; Reid, 2004; Scheff, 2001). Women who live in material and social scarcity also incur immense stress on a daily basis (Collins, 2005). In turn, such depleted psychosocial states tend to inhibit women's ability to engage in health promoting behaviours such as physical activity and may foster health damaging addictions like smoking, drugs, or alcohol to cope with the suffering (Greaves, 1996; Lyons & Langille, 2000). Psychosocial factors also affect the ways in which women experience and perceive their daily lives, including their self-reported health status (Mann et al, 2004; Svedberg, Bardage, Sandin, & Pedersen, 2006). Based on this multilevel analysis, a CBHP project seeking to address women's depression might be well-served to both alleviate the stress that perpetuates the biological and psychosocial pathways to depression and take actions that counter the systemic forces that induce stress. Increasingly, CBHP is being positioned as an appropriate research and intervention strategy to address the social determinants of women's health (Minkler & Wallerstein, 2003; Reid, 2004). Yet within this social framework, it is important to remain attentive to the interconnections between sex and gender in order to keep women's bodies present in such investigations, even if a sex-based analysis is not the focus of study. Furthermore, as the upcoming section on feminist intersectionality theory will further explore, understanding the determinants of women's health must go beyond sex and gender analyses and more fully encompass women's diversity within 16 interconnected systems of inequality based on social categories tied to gender, race/ethnicity, class, age, sexualities, and abilities (Hankivsky, 2005; Weber, 2006). The status of women's health in Canada Despite Canada's relatively advanced social and economic circumstances, Canadian women continue to suffer extreme health disparities (Hankivsky, 2005; Raphael & Bryant, 2006). Although women live longer than men, they are more likely to have chronic illnesses and inequitable access to health promoting resources (Amaratunga, 2000; Spitzer, 2005). Increasingly, women have become susceptible to infertility and other hormonal problems, to viral pandemics such as HIV/AIDS, and to debilitating ailments such as arthritis, fibromyalgia, and cancer (Inhorn, 2006; Orfila et al., 2006; Parry, 2004; Raheim & Haland, 2006). Psychosocial^, mental health disorders, depression, anxiety, stress, social isolation, addiction, and violence are also of increasing concern for women (Fioto, 2002; Greaves & Pederson, 2007; Morrow et al., 2004; Sandanger, Nygard, Sorensen, & Mourn, 2004; Scheff, 2001). Gendered, classed, racialized and other oppressive systems tend to render women more susceptible to chronic ailments, more dependent upon failing and exclusionary health systems, and less able to draw on health promoting resources such as access to local recreation services, affordable healthy food, and preventative health care (Amaratunga, 2000; Anderson, 2000; Raphael & Bryant, 2004). As the gap between rich and poor escalates in the current neoliberal era, so too do the health disparities within Western countries (Auger, Raynault, Lessard, & Choiniere, 2004; Coburn, 2004; Williamson et al., 2006). Wilkinson's (1996; 2005) landmark epidemiological research illustrates that the greater the economic differences between the rich and the poor, regardless of overall national wealth, the larger the health inequities. Recent research has also deduced that cumulative economic hardship is a strong predictor of women's ill health 17 (Ahnquist, Predlund, & Wamala, 2007). In Canada, the feminization of poverty has deepened in the last 20 years as a result of neoliberal policy shifts that continue to dismantle its welfare state (Brodie, 2005) and the 'colour' of poverty is shifting as new immigrants are becoming increasingly impoverished (TCazemipur & Halli, 2001). Women across the board earn 35% less than men, and women living with disabilities, single mothers, older women, and newly irnrnigrated women are most likely to live below the poverty line (Statistics Canada, 2005). Statistics also show that women are highly dependent on social services in Canada, which makes them even more vulnerable to the depletion of the social safety net (Brodie, 2005; Statistics Canada, 2005; Raphael & Bryant, 2004). Although the majority of Canada's health policy documents recognize such social determinants, these directives continue to be under-utilized in health promotion and public health practice, and women's health remains at risk (Hankivsky, 2005; Raphael & Bryant, 2006). In order to more fully incorporate the interplay between sex, gender, and other social categories of social analysis into CBHP, feminist researchers have increasingly positioned women's health within broader social justice goals (e.g., Amaratunga, 2006; Cornish & Ghosh, 2007; Minkler et al., 2006; Potvin, Cargo, McComber, Delormier, & Macaulay, 2003). Linking women's health to social justice, means acknowledging that women and their bodies can only be healthy when intersecting systems of oppression and domination are replaced by those promoting sound psychosocial health, self-determination, and self-development (Hankivsky, 2005; VanderPlaat & Teles, 2005; Young, 1990). In this light, it remains increasingly important for women be active participants in defining and addressing their own their health concerns and the community-based initiatives and therefore communities continue to be appropriate locations for fostering feminist agendas of inclusion in health promotion (Keleher, 2004; O'Connor et al, 1999; Ruzek, 1993). 18 Defining community as a multidimensional & relational construct The notion of community is contestable (Labonte, 2005). In much feminist and CBHP literature, community remains m-defined and is at times invoked "to describe anydiing that falls within the rather large gap between individual and society" (Boutilier, Cleverly, & Labonte, 2000, p. 250). The notion of community can be idealized, a trend which veils the complexity inherent to inclusion and participation processes in CBHP. Furthermore, the rhetoric of community is often used by neoliberal governments to dismande social services by placing responsibilities at a local level, often without appropriate resources (Labonte, 2005; Thibault et al., 2002). However, Raeburn (2000) has emphasized that: the power of community itself remains strong. Regardless of external or structural circumstances, people have to go on living their lives, and there are ' tremendous psychological and health benefits to be gained by the power of community, (pp. 280-281) To invoke the power of CBHP, it is essential that community be clearly defined and critically conceptualized. Rather than label community with static categories of identity, geography, or social cause, Walter (2005) depicts it as "multidimensional to describe the way in which the various dimensions that characterize community - such as people and organizations, consciousness, actions, and context — are integrally related with one another forming the whole that is community" (p. 68). Cornish and Ghosh (2007) extend this perspective by asserting that communities should be defined by "interdependences rather than likeness" (p. 498). Along these lines, then, CBHP does not simply 'happen' in a particular community setting, rather it refers to the process of 'building' contextualized community relationships that provide the meaning and context for the work of health promotion (Labonte, 2005; Walter, 2005). From a feminist perspective, building such relationships requires alternative means of working together across our differences and is especially important for women who have been excluded, isolated, and otherwise disconnected from community support systems (Mizrahi, 2007; Reid et al., 19 2002a). Diversity within relationships is inherent to this concept of community, thus requiring that issues of power and privilege be constandy negotiated (Boutilier, Mason, & Rootman, 1997; Cornish & Ghosh, 2007). Feminist approaches to power Community-based health promotion is primarily about transforming power relationships (Laverack, 2004). This focus is based on the feminist assumption that poor health and health inequities are largely determined by power imbalances and oppressive enactments of power (Ruzek, Clarke, & Olesen, 1997b; VanderPlaat & Teles, 2005). Despite a growing recognition of the centrality of power dynamics to CBHP, most people involved have superficial understandings of power (Lavarack, 2004). Further, in the face of dominant ideologies and social structures, it is easy to slip into traditionally oppressive power relationships despite good intentions (Mizrahi, 2007). Because "power cannot be avoided ... it must be worked with" (Kesby, 2005, p. 2038), it is imperative that CBHP participants, practitioners, and researchers thoroughly and reflexively investigate their understandings of power if the desire is to transform social structures and individual behaviours that determine health. In this section, I offer a feminist critique of traditional and hierarchical enactments of power and envision how power can operate in a more productive and collaborative light. Importandy, this conception is built upon the premise that power is an intention and action that we are all capable of, albeit at different degrees. Enactments of power are both facilitated and hindered by what I term the 'power tools' of society (Ponic, 2000). For example, knowledge, discourse, and material resources are not power per se, rather they are social constructed structures that privilege the power of some individuals over others (Fraser, 1997; Giddens, 1984). From a feminist perspective, then, all forms of CBHP practice and research, regardless of where they fall in the lifestyle-social structure continuum, should be underpinned 20 by a desire to utilize power responsibly, creatively, and/ or resistandy, in order to redress systems of oppression. Power-to. power-with. power-for & power-over Feminist theorists offer a view of power that can move all those involved in CBHP beyond traditionally oppressive enactments. Based on interpretations of Foucault's body of work (although his was not distinctly feminist), poststructurahst feminists envision power as a relational force, rather than a fixed entity (Kesby, 2005; Ristock & Pennell, 1996). Foucault (1977) has best articulated a ... perspective on power as productive and relational. Rather than repressive power being monokthic or a resource to be possessed, he conceptualizes power as built into a web of discourses and practices found in institutions, communities, and families that are exercised through actions in a multiplicity of relationships. These power relationships are inherendy unstable and therefore open to challenge. (Wallerstein & Duran, 2003, p. 38) Given its inherent instability, power is developed in and through social relations and is an always present, structural feature of society whether or not we are conscious of it (Dorninelli, 2005; Weedon, 1999). From this perspective, the focus is on how power operates in local situations, including how it circulates between and links individuals and groups as active subjects who experience and exercise it (English, 2006). This view of power is consistent with the idea that power resides in action through a range of dynamic, contradictory and at times reinforcing manners, for example, through practices of domination and resistance. In order to utilize the potential, albeit at times contradictory or stxucmraUy-lirnited forms of power that promote health and social justice, many feminist theorists seek and embrace enactments of power-with, power-to, and power-for rather than those of power-over (hooks, 2000a; Laverack, 2004; Ristock & Pennell, 1996; Teske & Tetreault, 2000). The dominant conception of power in Western societies is predicated on the notion of power-over. This definition is based in patriarchical, hierarchical, colonialist, and other oppressive 21 understandings of how individuals relate to one another. According to Kesby (2005), such enactments of power emanate "from the top-down and from the centre outward" (p. 2040) in order to maintain relations of control and domination. Power is understood to be a limited commodity that you either have or don't have and "thinking is dichotomous — you win or you lose" (Teske, 2000, p. 108). In this model, the power of those with gendered, racialized, classed and otherwise privileged social locations is hegemonically maintained through material, authoritative, and ideological structures (Giddens, 1984; McCall, 2005). Mohanty (2004) suggests that "the major problem with such a definition of power is that it locks all revolutionary struggles into binary structures — possessing power versus being powerless" (p. 39). It is important to note that power-over strategies are needed at times when an individual's safety or well-being is in danger, for example when a parent enacts power-over a child to prevent her from being struck by a car. With this in mind, however, I use the notion of power-over throughout this dissertation in reference to actions that seek to dominate and oppress rather than protect, as illustrated in the parent-child example. In CBHP, power-over strategies often dominate research and practice because they are built upon the assumption that those living on the margins are 'powerless' and in need of help from those with power to intervene (Buchanan, 2006; Cornish & Ghosh, 2007). Yet Aboriginal organizer Lily Walker succinctly challenges such authority by saying: "If you are here to help me, then you are wasting my time. But if you come because your liberation is bound up in mine, then let us begin (in Valvarde, 1991)" (Lavarack, 2004, p. 138). In this light, critical feminist perspectives that situate power as relational, cumulative, and expansive through power-with, power-for, and power-to strategies offer a potential framework for the co-creation of more socially just and mutually beneficial relationships, and therefore better health. 22 Although women's power is unequally facilitated by dominant material and ideological structures, we still have the capacity to utilize power in enabling rather than controlling or dominating manners (hooks, 2000a; Ristock & Pennell, 1996). By working in collective and mutually supportive partnerships, power can be created with one another, a process which can aid women's power-to take action and initiate change (Teske, 2000; Tett, 2005). These critical feminist notions of power are fuelled by creative and hfe-affkming intentions, that can support alternative or more egalitarian relationships and resist practices of oppression and domination (Collins, 2000a; hooks, 2000a). Power-with and power-to strategies have both individual and collective ramifications. For example, in CBHP, naming, contributing, and valuing the diverse resources that participants, service providers, and researchers bring to the table provides a grounding from which power can be shared in ways that joindy benefit and facilitate women's capacity to resist, redefine, and recreate their life circumstances (Dominelli, 2002b; Pmnington, 2001; Reid, Tom, & Frisby, 2006). Importandy, the notion of power-to does not imply that power is somediing that one can give to another, a common assumption in empowerment processes (Rappaport, 1987; 1995). Rather, the sense of our individual power-to create and act emerges through relationship and collective learning, as VanderPlaat's (1999) discussion of relational empowerment suggests: In a relational approach to empowerment, everyone involved, regardless of position of power and privilege, recognizes that he or she is both an agent and a subject in the empowerment process. The ability to be empowering or to support someone else's capacity to be empowering grows out of the mutual recognition that all of us can contribute to the construction of knowledge and social change but that, in that process, all of us have a lot to learn. In a truly empowering process, everyone changes. Empowerment is always mutual, (p. 778) Yet it is important to remember that power-with, power-to, and even relational empowerment concepts are not solely dependent upon individual or collective actions. The capacity to enact power is always shaped by structural conditions that differentially privilege the power of some 23 over others, especially across gendered, classed, racialized, and other oppressive systems (Bunjun et al., 2006; Fraser, 1997; Young, 1990). Many researchers and activists intentionally utilize power-for strategies to resist, destabilize, and transform dominant social relationships and structures (London Feminist Salon Collective, 2004; Fraser, 1997; Hartsock, 1990). The process of doing so, for example throughpower-with and power-to strategies, also holds the potential for personal transformation and the development of a critical consciousness about the systemic nature of one's oppression (Freire, 1970; Lykes & Coquillon, 2006). "Feminism's insistence that the personal is political has provided a rich resource for theorizing; not as a way of reducing the politics to the personal but as a way of interrogating both" (Clegg, 2006, p. 320). Power-for strategies therefore require that all involved in CBHP, especially individuals with access to legitimized community resources, question their own uses of power and seek to utilize their resources in ways that promote social justice goals and avoid recreating oppressive power-over systems (Ristock & Pennell, 1996). However, the positive and responsible use of power and privilege is a fine line to negotiate especially in the context of power-with strategies of grassroots CBHP projects and hegemonically reinforced power-over approaches. Critical feminist practitioners and researchers are commonly torn between not wanting to dominate processes yet desiring to 'make a difference' by facilitating inclusive and participatory processes (Frisby, Reid, Millar, & Hoeber, 2005; Varcoe, 2006) and working to reflexively interrogate their own uses of power and privilege (Pillow, 2003; Shope, 2006; Wasserfall, 1997). Despite these efforts, those with relative privilege in CBHP projects might be called to task, if participants perceive that the responsibilities associated with that privilege are inadequately fulfilled (Varcoe, 2006). This tension highlights Foucault's perspective "that power is not inherent witiun powerful subjects but that power is dispersed through complex networks of discourse, practice, and relationships" (Kesby, 2005, p. 2040). It is therefore important to 24 remember that the relative power and privilege of all participants, practitioners, researchers and policy-makers involved in CBHP projects are inherendy connected and must be negotiated from this perspective if improved health through social justice is the goal (Anzaldua, 2002; Barcinski & Kalia, 2005; Cornish & Ghosh, 2007). This is particularly so for feminist approaches to CBHP which aim to foster inclusion. The Impetus for Inclusion in Community-based Health Promotion Inclusion is central to CBHP practice and research, especially from a ferrrinist perspective, such that women play a role in determining their own health and the structures that affect it: A ferrrinist model would include women in the activities of knowledge making. It would create knowledge and theories, which present women as embodied, social and historically situated in social structures and discourses. And it would eliminate structures and discourses, which are oppressive in order to improve women's daily lives, the lives of their family members, and to create healthier neighbourhoods and communities. (O'Connor et al., 1999, p. 17) Inclusion means creating spaces for diverse women to work together to create supportive environments that foster women's opportunities to make choices about how and when to give voice to their perspectives, to contribute to knowledge development, and to take action in their communities. Such efforts are important given the degree to which exclusion compromises women's health. According to Galabuzi (2004), social exclusion is a crucial mediating factor between ill-health and poverty, racism, sexism, and other forms of prejudice. Reid (2004) suggests that poor women's experiences of material, institutional, and cultural exclusion compromise their psychosocial health, limit their access to health care, and perpetuate unhealthy behaviours. Furthermore, systemic exclusion has hrnited women's ability to participate in health promoting activities and research, since much of this work continues to be blind to the effects of gender, race, class, and other dimensions of power and privilege (Keleher, 2004; Ruzek et al., 1997a). However, the terms inclusion and exclusion are inherendy 25 problematic and require thorough scrutiny before they can be productively utilized (Shakir, 2005). In the following sections, I define the terms inclusion and exclusion from a critical feminist perspective, which informs the ways in which I apply them throughout this dissertation, unpacks common assumptions made about inclusion theoretically and practically, and positions these terms firmly widiin an ideology of social justice. Defining inclusion as a social justice process Inclusion must be understood as a multifaceted and dynamic process that has the potential to foster socially just outcomes (Lister, 2000; Stewart, 2000; Wotherspoon, 2002). Yet rarely do those involved in CBHP envision inclusion as long-term dynamic process, because it is often assumed to be an endpoint or project outcome (e.g. Allison & Hibbler, 2004; Doveston & Keenaghan, 2006; Turner & Martin, 2004). According to Shakir (2005), this is especially true in Canada where most programs and policies tend to 'water-down' inclusion processes. For example, if participants are invited to participate in action research or if government policy-makers make attempts to alleviate barriers to employment, many assume that the work of inclusion is complete. However, experiences of inclusion are fleeting, in large part because of the multitude of dynamics that influence them (O'Reilly, 2005). Conceptualizing inclusion as a process in CBHP, therefore, highlights the understanding that individuals have varying life circumstances that are shaped by inequitable power relations (Luxton, 2005). The interplay between structural determinants and individual agency lies at the heart of inclusion processes. Luxton (2005) suggests that an inclusion model "assumes that individuals play a role in shaping their lives" (p.84), while Mitchell and Shillington (2005) recognize that individuals play a role in fostering and/or inhibiting the inclusion of themselves and others. According to Kershaw (2005), citizens not only have an entitlement to be included in the decisions that shape their lives, they also have a responsibility, at some level, for their own 26 inclusion. Defirutions of inclusion that employ agency are able to consider "how individuals transcend structural limitations to create resources that promote inclusivity" (TJorninelli, 2005, p. 16). However, assumptions about individual agency in CBHP tend to be unilateral, such that those who hold relative privilege and power are expected to 'include' those with less, which negates the agency and power of marginalized social groups. While health promoters and researchers who have greater access to resources certainly have a responsibility to facilitate conditions for inclusion, community members who have been disenfranchised and excluded are also active players, rather than passive recipients, who also hold power and responsibility for their own inclusion (Kershaw, 2005; Shookner, 2002). While the centeality of agents in inclusion processes is important, the structural and relational elements that shape individuals' ability to take action should not be under-emphasized. To do so might serve to 'blame the victim' for her exclusion (Crawford, 1977; David, 2002; Morrow et al., 2004). If efforts to redress the ideological, material, and political structures that unequally benefit some and disadvantage others are not at the heart of inclusive processes, then they run the risk of assimilation, whereby the agency of the less powerful becomes stifled, consumed, or assimilated by the mainstream (Lister, 2000). Therefore, the multiple, overlapping, and dynamic dimensions of inclusion processes must be fully considered both in terms of their interplay with individual agents and to the degree that they shape the systems and structures individuals are to be included within. Inclusion theorists working from a critical perspective increasingly acknowledge the structural dimensions that shape inclusion processes (Donnelly & Coakley, 2002; Shookner, 2002). Early poHcy-making and research on social inclusion focused its attention on addressing broader social issues such as poverty and exclusion and called for the reduction of barriers that limit access to employment, education, and other material spheres of life (Mitchell & 27 Shillington, 2005). More recently, social psychologists have named the psychological, emotional, and relational dimensions of inclusion (such as acceptance, respect, and hope) and of exclusion (such as shame, anger, and alienation) (Abrams, Hogg, & Marques, 2005). Shakir (2005) illustrated that inclusion within community-based organizations is based in collaborative and cooperative relationships, the open negotiation of power and conflict, and flexible and responsive organizing structures. Certainly, all of these macro, micro, and meso elements are critical to understanding inclusion dynamics across power differences, particularly as they influence women's health. Yet few CBHP documents or projects identify inclusion across this range, and those that do, often fail to fully consider the complexity of interactions between them, and between these structural dynamics and human agency. This is a significant gap in the CBHP literature that my research begins to fill. Exclusion, marginalization & 'Othering' Fundamentally, inclusion strategies were developed to counter exclusion (Mitchell & Shillington, 2005; Reid, 2004; Shookner, 2002). Exclusion is the social process of being marginalized, powerless, and essentialized as 'Other' (Young, 1990). According to Young (1990), marginalization refers to the process whereby "a whole category of people is expelled from useful participation in social life and thus potentially subjected to severe material deprivation and even extermination'' (p. 53) and "involves the deprivation of cultural, practical, and institutionalized conditions for exercising capacities in a context of recognition and interaction" (p. 55). In this vein, marginalization refers to both social conditions and possibilities for taking action, and about material issues of distribution and cultural issues of recognition (Fraser, 1997; Giddens, 1984). Exclusion and marginalization are two forms of oppression, which refers to "institutional constraint of self-development" (Young, 1990, p. 37) 28 through experiences such as material scarcity and a sense of unworthiness or 'Otherness' (Reid, 2004). 'Othering' results from sexist, racist, classist, and homophobic (among other) ideologies that are underpinned by a fear and intolerance of differences (Lerner, 1993; Lorde, 1984; Moraga & Anzaldua, 2002). According to Young (1990), cultural imperialism results in exclusion and marginahzation when dominant cultural practices and individual experiences are universalized and normalized, such that any cultural practices or experiences that are different from the norm are deemed deviant. Members of 'Othered' social groups are stereotyped by essentializing assumptions such that their social experiences, meanings, and identities go unrecognized by dominant groups and are marked as inferior. As such, "exclusion is not about difference; it is about our responses to difference" (Sapon-Shevin, 2003, p. 26), which is especially relevant when negotiating power and diversity widiin CBHP projects. The hegemonic ideologies that teach us to fear difference and mark 'Others' also serve to legitimize institutional and material inequities that compromise women's health and their ability to participate in CBHP. Exclusion is institutionaUzed through discriminatory policies and practices in both public and private bureaucracies, which can lead to experiences of material deprivation and social isolation (Reid, 2004). The excluded are also held powerless in social institutions, such that at times they lack authority, status, respectability, and a sense of self (Young, 1990). The effects of exclusion include cultural and material deprivation, marginahzation from social practices, reduced access to public resources, denial of human rights, alienation from decision-making and civic participation, and isolation from community (Galabuzi, 2004). Given the centrality of these effects on women's health, remedying exclusion, to whatever extent possible, certainly is central to CBHP practice and research (Raphael & Bryant, 2004; Reid, 2004). 2 9 Inclusion/exclusion dialectic While the concepts of inclusion and exclusion are inherently connected, the connection is not dualistic because inclusion is not simply the flip side of exclusion and nor do inclusionary efforts necessarily address exclusion in all of its forms and outcomes. Given the complexity of social life, individuals are never fully 'included' or 'excluded.' Experiences of inclusion and exclusion are fleeting and related to variable social contexts that shift from moment to moment, across time and space (O'Reilly, 2005). As Hall (2005) understands it, "social inclusion and exclusion are fragmentary and relational, 'entangled' within each other in particular ways and in particular contexts" (p. 108). Understanding inclusion and/or exclusion then, requires understanding both concepts and their 'entangled' relationship. For example, it is important to consider how specific health promotion strategies or definitions of community may include some individuals, while simultaneously, and perhaps inadvertendy, excluding others (PomineUi, 2002a; Reid, 2004). Also, an individual may experience inclusion in one realm of life or moment in time, but experience exclusion in another. Again, the context is imperative, as are the numerous variables that construct experiences of inclusion and exclusion. O'Reilly (2005) suggests that the concepts are mutually dependent and "only if the question of what constitutes inclusion is addressed can the question of what constitutes exclusion be posed" (p. 84). Hall (2005) argues that negotiating inclusion/exclusion dialects requires a critical re-imagining of inclusion as social justice. According to Young (1990), social justice requires the elimination of institutionaUzed domination and oppression in order to foster self-determination and self-development. In this vein, inclusion as social justice is primarily about power and difference (Shakir, 2005). The key consideration here is who and what are required to shift for inclusion to occur. Failing to "unmask" the cultural, material, and institutional facets of power differentials runs the risk of perpetuating oppression under the "guise of inclusion" (Shakir, 30 2005, p. 207). Simply opposing exclusion runs the risk of assimilation such that the inherently inequitable centre does not change (Labonte, 2004; Lister, 2000). Critically advancing inclusion, on the other hand, means transforming mainstream social structures in order to promote the individual agency of all (Mitchell & Shillington, 2005). According to Young (2000): Inclusion ought not to mean simply the formal and abstract equality of all members of the polity as citizens. It means expKcitly acknowledging social differentiations and division and encouraging differently situated groups to give voice to their needs, interest, and perspectives, (p. 119) Yet acknowledging diversity in CBHP does not in and of itself promote social justice or inclusion. Rather it is the socially constructed ways in which differences are ideologically, materially, politically, and culturally negotiated that serve to resist and perpetuate exclusion (Juteau, 2000; Silver, 1994). Fraser (1997) contends that in order to address the layers of inequity that perpetuate exclusion, inclusion as social justice requires both the socialist redistribution of material resources and relations of production and the deconstruction of relations of recognition that re-structure the ways in which we conceptualize differences. The challenge, however, is that these strategies are at odds with one another because redistribution strategies serve to ameliorate group differences (e.g., treat everyone equally), while recognition strategies seek to specify and affirm group difference (e.g., treat everyone differently) (Fraser, 1997; Labonte, 2004). This inherent tension is based on the premise that a coherent social centre that 'includes' is possible and desirable. Yet, as Shakir (2005) ponders, "surely the whole point of 'diversity' is accepting the lack of a universal point of reference?" (p. 206). Fraser's (1997) concept of subaltern counterpublics is helpful in this regard: ... parallel discursive arenas [are created] where members of subordinated social groups invent and circulate counter-discourses, which in turn permit them to formulate oppositional interpretations of their identities, interests, and needs, (p. 81) 31 While this theory speaks specifically to the resistance of socially marginalized social groups against a dominant mainstream, Fraser's vision of a multiplicity of publics provokes mteresting possibilities for inclusion. If any universal point of reference can be rejected, as Shakir (2005) suggested, perhaps what we are left with is the absence of a centre, replaced by overlapping public spheres where individuals and groups can negotiate their own inclusion without privileging or normalizing one way of being over another. Idealistically, in such an inclusion scenario, the 'Other' is not feared, power relations may be minimized, and differences are respected and celebrated (Anzaldua & Keating, 2002). The consideration of inclusion in terms of a multiplicity of publics thus calls into question the notions of marginalization and marginalized social groups, since both are steadfastly connected to the notion of a dominant centre. For those of us committed to conducting CBHP in inclusive and socially just ways, we must aim to create projects - or counterpublics - that resist traditionally oppressive systems of power and domination harmful to women's health and that offer new ways of relating to one across our differences. Such projects could be well-informed by a theoretical framework that captures the complexity of dimensions that simultaneously infiltrate inclusion processes, CBHP projects, and women's health. In the following section, I offer such a theoretical framework and highlight the various ways that multiple spheres of structural influence and individual actions can shape CBHP, particularly as they applied to my analysis of WOAW. Conceptualizing the Complexity of Community-based Health Promotion CBHP processes, such as fostering inclusion across power and difference, and women's health are each intricately shaped by the interplay between structural conditions and individual agency. Williams (2003) has suggested that although there are growing bodies of literature exploring issues of structure and health and agency/behaviour and health, there is little health research that captures "the complex intersection of structure and agency within the material 32 world of everyday life" (p. 139). I suggest that his argument also rings true for the CBHP literature, which continually fails to capture the multi-layered micro, meso, and macro dimensions that women must negotiate in projects designed to promote their health. In particular, the ways in which psychosocial and relational dimensions impact CBHP practice and research is often overlooked. These dimensions are meaningful because they play a crucial role in mediating and are significantiy shaped by the interplay between broader social conditions and women's agency. And despite a tendency to over-emphasize individual behaviour or lifestyle factors in health promotion (Buchanan, 2006), the choices made and actions taken by women within CBHP processes remain mostiy invisible. Women's agency, bodies, psychosocial constitution, and relational patterns, are not only essential dimensions of women's health, they also play a significant role in how women engage in CBHP inclusion processes and therefore influence the benefits that may be gained. Importantiy, our understandings of these more personal dimensions must remain contextualized by broader structural conditions in order to avoid the dangerous possibility of blaming the individual for not taking 'appropriate' actions to overcome her oppressive life circumstances (David, 2002). The theoretical framework in Figure 2.1 offers a means through which CBHP inclusion processes, in all their complexity, can be conceptualized. This framework provides those of us working in the field with a way to more fully understand the scope of dimensions that impact women's health and CBHP in order to navigate them productively. Certainly, all of the dimensions outlined cannot be tackled witliin a single project. Yet it is crucial that the point of entry that participants, practitioners, researchers and policy-makers decide upon and the ongoing dynamics that unfold are informed by an understanding of CBHP as multifaceted and dynamic. 33 Figure 2.1: Theoretical Framework for Inclusion in Community-based Health Promotion Gender Race/ethnicity Sexual identity Dis / ability 34 A framework can be defined as a set of assumptions, values, and practices that describe a social concept and create a structure for written work (American Heritage Dictionaries, 2006). The iterative development of this framework has been mutually informed by my reading and analysis of divergent literatures and my co-created data set. At this stage, I demonstrate the utility of the framework by reviewing relevant literatures that explain its various dimensions and exemplify their interconnections. That said the framework is data-driven, rather than theory-driven: I developed it initially from Maria Manuel's quote that opens Chapter 5 and expanded upon to organize my analysis in all three findings chapters, before I 'pulled it back' into this chapter. Finally, I also draw on this framework as the basis for the tool I offer to CBHP participants, practitioners, researchers, and policy-makers in Chapter 8. While I recognize that the circular diagram is not particularly original or innovative (see Dominelli 2002a for a similar structure), I did utilize it in a unique way to organize and explain the intricacies of my literature review, data set, and subsequent analysis. The circles in this framework represent what I call the spheres of influence on CBHP processes. Beginning at the centre and moving outwards, these spheres include women's agency and health and their lived realities, the psychosocial sphere, the relational sphere, the local/community sphere, and the broader social-political sphere. The lines in the circles are perforated to illustrate that each sphere is connected to each other sphere, through a range of pathways. The connections between spheres are mutually dependent, such that each is influenced by and influences the other to certain degrees and in varying ways that shift over time. The arrows that run across the spheres represent the ways in which ideological and material structures cut through them, creating unbalanced power relations. Additionally, the actions that women take also have the potential to impact other spheres and, of course, are impacted by them. As such, the interactions between spheres are shaped by the systemic 35 patterns of power that privilege some individuals, ways of being, cultural values, organizational practices, and political structures over others. A web of power relations encompasses the entire framework to illustrate the intersectionaHty of gender, race/ethnicity, class, physical and mental ability, sexual identity, and age as systems of power, privilege, and inequaUty (McCall, 2005). This logic of interconnections in this framework is based on my feminist reading of Giddens' (1984) duality of structure theory, which suggests that the structure/agency relationship is dualistic and self-perpetuating. Social structures shape women's agency, which in turn shapes social structures (Giddens, 1984). From this perspective, both structure and agency play pivotal roles in recreating, reinforcing, destabilizing, facilitating, and/or inhibiting one another, and also serve to influence the determination of women's health and the ways in which CBHP initiatives unfold. Yet, as critical feminist theorists point out, this dynamic does not equitably affect all individuals because dominant power relationships and social structures that have been created and reinforced to differentially privilege members of some social groups over others pervade the structure-agency duality (Fraser, 1997; Young, 1990). In the following sections, I will further describe these spheres of influence by drawing on seemingly divergent, yet deeply connected bodies of literature. My description of each sphere cannot capture the breadth of all elements that might be encapsulated within it, for that would be an impossible task. Rather, it provides examples of the elements that pertain particularly to the CBHP project that was the focus of this dissertation and iUuminates my findings and analyses in Chapters 5, 6, 7, and 8. Women's agency, health, & lived realities Women and their lived realities are at the heart of this framework for three reasons: 1) the intent of CBHP processes such as inclusion is to enhance their lives and health, 2) the ways in which women understand and experience CBHP gives evidence to the meanmgfulness of these 36 processes, and 3) women make everyday decisions about if, how, and when to engage in CBHP. As such, I envision individual women as embodied and active social agents embedded in particular lived realities that may or may not facilitate their action and health. Women's agency refers to the intentional ability to act, or refrain from acting in the social world (Giddens, 1984). Agency is inherendy intertwined with power and social structures since agency presumes power and is only realized through interaction with social structures at micro, meso, and macro levels (Clegg, 2006). Giddens (1984) goes as far to say that "power is all action" (p. 15) and structures are the primary means through which individuals exercise agency. This vision of power and agency is in keeping with the ideas of power-to and power-for, which presume that we all have capacity at some level to make a difference in our lives (hooks, 2000a; Lykes & Coquillon, 2006). As his duality of structure framework explicates, structural conditions or systems of privilege and power inequitably shape women's ability to enact their agency; "as collective and individual agents we have choices about how we intervene, not necessarily about the conditions of our successful actions" (Clegg, 2006, p. 320). The tendency in feminist theorizing has been to focus on how structural and power relations serve to oppress the agency of members of socially marginalized groups across axes such as gender, race/ethnicity, class, nation, sexualities and abilities (Bunjun et al, 2006; McCall, 2005; Young, 1990). This focus remains important because the structural realities of our social world have served to privilege few while oppressing many. However, in light of the mutually exclusive relationships between structure, agency, and power, feminist theorists have recently suggested that more attention be paid to feminist visions of agency in social change efforts (Clegg, 2006; London Feminist Salon Collective, 2004). They suggest that a deeper understanding of women's agency is needed to more fully explore the possibilities of enacting power-to, power-for, and power-with strategies in order to resist the dominating social circumstances 37 and create new structures that foster social justice. Importandy, the London Feminist Salon Collective (2004) have identified the need to consider how women's emotional, psychosocial, and internalized response to oppressive conditions influences their ability to see themselves as active agents witliin, rather than passive victims of, inherendy oppressive systems. Intentionally positioning women as active and reflective agents witiun the theoretical framework on page 34, acknowledges their capacity to make decisions and take actions, based upon their best ability to negotiate their social realities within multiple spheres of influence. Highkghting women's agency in this way, intentionally points to their power and desire to make a difference, albeit often in challenging social circumstances. Dorninelli (2005) suggests that: Marginalized individuals draw on a whole range of strategies and knowledge in everyday interactions to empower themselves and highhght subject agency in negotiating social inclusion and exclusion, (p. 15) Women who experience chronic marginahzation seldom have their agency and power recognized (Reid et al, 2006), a tendency which is often perpetuated by relatively privileged practitioners, researchers, and policy-makers in CBHP (Porter, 2006; VanderPlaat, 1999). Yet, despite their social status, women continually make decisions about how to participate in such projects in the attempt to control their own lives and health. This reality must be embraced by all involved in CBHP if our projects are to be successful. As the earlier section on health determinants begins to articulate, women's health is embodied and experienced through biological, psychosocial, and broader social, political, and economic pathways (Ho et al., 2005; Johnson et al., 2007; Krieger, 2003). I place women's health at the centre of the theoretical framework, and alongside women's agency, to illustrate the inherent and mutually informative connection between women's health and well-being and their ability to take action. Women can take actions that enhance their health, yet, at times, women's poor health at physical or psychosocial levels, can impair their ability to adopt health 38 promoting behaviours or to engage in their communities at any level (Greaves, 1996; Lyons & Langille, 2000). Similarly, women's health and agency are also shaped, and serve to shape, the micro to macro spheres of influence identified in the framework (Giddens, 1984; Ponic, 2000). Since women's health and agency are so closely intertwined, the ability to enact change at individual, community, or broader social levels remains affixed to their embodied and psychosocial beings. Finally, women's lived realities are often a reflection and manifestation of their locations within broader socio-political conditions, systems of power and privilege, and of the decisions they make within them. As such, their realities are mutually informed by the spheres of influence articulated in the theoretical model as well as women's health and agency. For women who live in chronically oppressed conditions, the realities that they must negotiate on a daily basis include material deprivation, inadequate shelter, lack of transportation and childcare, violence, cultural insensitivity, un- or under-employment, dependency on social services, extreme stress, and ill health (Bryant, 2004; Collins, 2005; Frisby & Hoeber, 2002; Morrow et al., 2004; Moss, 2002; Reid & Golden, 2005; Stewart et al, 2006). These realities have a significant impact on women's daily decisions and therefore must be accounted for in CBHP. The challenge in this regard is not to overly focus on women's lived realities in isolation of the structural conditions that create and perpetuate them or through victim-blaming tendencies that de-value the decisions and actions women take to negotiate them. Psychosocial sphere: Internalization & conscientization The psychosocial sphere of influence refers to the deeply embedded ways that individuals understand their social worlds and their places within them. Giddens (1984) refers to this process as the development of a 'practical consciousness' such that the assumptions that individuals make about what is appropriate and possible become internalized and normalized. 39 In this section, I explore the ways in which the internaUzation of oppression and domination implicate and limit CBHP processes in different ways for different women. Given the fluid and multifaceted nature of individual and collective experiences, our practical consciousness is not fixed. I thus draw on Freire's (1970) notion of conscientization to explore how collective and critical analysis of our assumptions about social life can serve CBHP processes dedicated to social justice. Developing a sense of self occurs as individuals navigate relationships in their social worlds and come to understand their place in them (Tappan, 2005). Experiences of oppression and domination are commonplace witliin individual and collective relationships, given the degree to which patterns of power-over' have been naturalized in Western society (Dominelli, 2002a). The accumulated experiences of such systemic power imbalances over time can become internalized by individuals (Prilleltensky & Nelson, 2002), as described by Pheterson (1990): Internalized oppression is the incorporation and acceptance by individuals witliin an oppressed group of prejudices against them within the dominant society. Internalized oppression is likely to consist of self-hatred, self-concealment, fear of violence, and feelings of inferiority, resignation, isolation, powerlessness, and gratefulness for being allowed to survive. Internalized oppression is the mechanism witliin an oppressive system for perpetuating domination not only by external control but also by building subservience into the minds of the oppressed groups, (p. 35) The psychological manifestation of internalized oppression refers then to a developed sense of self as negative, inferior, and powerless. At a social level, those who experience chronic oppression learn to adopt patterns of helplessness, obedience, fear, and/or anger (Prilleltensky & Nelson, 2002). Thus, women who have internalized their oppression become complicit in the oppression process through internally regulated self-denigration (Freire, 1970; Hertzberg, 1996). For example, Russell (1996) explores how the internaUzation of classism manifested in shame, grief, and a sense of being 'Othered' for her female clients in psychological therapy. Importandy, the internaUzation of oppression is not the result of an isolated incident, but of 40 reoccurring patterns over time and across contexts. Living in poverty therefore consists of the accumulated and perpetuating experiences of material deprivation and being stereotyped, which can reinforce low self-esteem and a sense of powerlessness (Reid, 2004; Russell, 1996). Not surprisingly, negative mental and physical health outcomes are similarly compounded by the often-interconnected experiences of exclusion, economic hardship, racism and other forms of oppression (Ahnquist et al, 2007; Anderson, 2000; Ryff & Singer, 2001). Some of the psychosocial effects of exclusion that researchers have identified include anger, frustration, hostility, a high need for control, withdrawal, compliance and/or emotional denial (Abrams et al., 2005). CBHP projects that engage women living in poverty, women of colour, or other members of marginalized groups must certainly be affected by the psychosocial effects of internalized oppression and exclusion. Yet there is little evidence that this level of analysis has been taken into consideration in the planning or ongoing negotiation of CBHP inclusion processes. It may be unreasonable to expect that women who have been chronically excluded and harmed by oppressive social relations would be able to participate in projects in positive, cooperative, and egalitarian ways without first addressing their deeper psychosocial wounds, (Anzuldua, 2002; Nelson & Prilleltensky, 2005; Young, 1990). While this recognition is embraced in some social work group practice (Brandler & Roman, 1999; Lee, 2001; Mullender & Cohen, 2003), it is a significant gap in CBHP and most researchers and practitioners lack the skill to facilitate such healing. In fact, the tendency to overlook the effects of internalized oppression may help explain why the positive impact of CBHP remains difficult to evaluate (Butterfoss, 2006; O'Neill, Pederson, & Rootman, 2000; Zakus & Lysack, 1998). For practitioners and researchers working in CBHP, it is important to remember that the effects of internalizing systemic social patterns are not limited to those who are oppressed. Patterns of domination also become internalized, as Pheterson (1990) describes: 41 Internalized domination is the incorporation and acceptance by individuals witliin a dominant group of prejudices against others. Internalized domination is likely to consist of feelings of superiority, normalcy, and self-righteousness, together with guilt, fear, projection, denial of reality, and alienation from one's body and from nature. Internalized domination perpetuates oppression of others and alienation of oneself by either denying or degrading all but a narrow range of human possibilities, (p. 35) Those with structural power develop feelings of elitism that serve not only to mark those who do not fit into the mainstream as 'Other,' but also to justify the devaluing of such others (Hertzberg, 1996; Prilleltensky, 2003; Young, 1990). Because the narrow and dualistic natures of patriarchal, classist, racist, and other oppressive systems hrnit the breadth of ways people can live, internalizing domination creates litde boxes within which our 'privileged' selves must fit in order to maintain our privilege. Furthermore, for those who recognize the unearned and inherendy unjust nature of privilege, feelings of guilt and fear manifest for the roles that perpetuate systems of oppression and domination and, the albeit contradictory, possibilities of losing privilege (Brydon-Miller, 2004; Leondar-Wright, 2005; Lykes, 2005; Mulvey et al, 2000). The varying effects of the internalized domination have important repercussions for those with relative social privilege working in CBHP, especially if socially just outcomes are our goal. We must continually interrogate the assumptions made about participants and about our respective roles in the process (Mauthner & Doucet, 2003; Shope, 2006; Tom & Herbert, 2002). It is a delicate balance to utilize our privilege responsibly and productively, without overshadowing the contributions that can be made by women who have experienced chronic oppression (Frisby et al, 2005; Varcoe, 2006). Certainly, the internalization of oppression and domination are related to our social positions. Yet, as critical feminist theories stress, these positions are inherendy unstable, relative, and contextual (McCall, 2005; Mohanty, 2004). Our fluid positions amongst axes of power and privilege mean that most of us will have experienced, resisted, and internalized 42 oppression and domination along a continuum of possibilities. The ways in which these multiple and at times contradictory senses of self unfold are contextualized such that our psychosocial interactions are in a constant state of flux (Barcinski & Kalia, 2005). Again, there are implications for CBHP. Since all individuals involved will move along a continuum of internalized oppressed and/or dominating selves throughout the processes, then nobody can be firmly placed in the binary categories of 'recipient' or 'provider.' Seeking social justice through CBHP means that despite or perhaps because of relative privileges, those involved must be open to individual and collective transformation (Leondar-Wright, 2005; Lykes, 2005; VanderPlaat, 1999). The connected experiences of internalizing oppression and domination mutually serve to maintain and perpetuate our current systems of inequity and injustice. Yet, power relations are ever-evolving since individuals are capable of exerting agency to resist and recreate our social worlds (Barcinski & Kalia, 2005). Freire (1970) believes that systematic resistance requires the process of 'conscientization,' whereby members of oppressed social groups come to understand the political and social nature of their oppression. This notion resonates with feminist consciousness-raising groups associated with the second wave of feminism that occurred in the 1960s, 1970s and 1980s (Maguire, 2001). The basic premise of conscientization is that becoming critically aware of the systemic power imbalances that shape one's life is the first step in taking action to resist, rectify, and/or re-imagine these systems (Carlson, Engebretson, & Chamberlain, 2006; Champeau & Shaw, 2002; Lee, 2001). Developing a critical consciousness expands one's practical consciousness, such that once an individual sees her social world from a broader and more critical perspective, what she believes to be possible will also expand (Buchanan, 2006; Paraschak, 1997). 43 Similarly, relatively privileged individuals also require a form of 'conscientization,' in order to recognize the systemic power inequities and utilize this power to recreate a more socially just system. While this may make the privileged temporarily vulnerable, in the end a system based on feminist, social justice ideals will create a 'freer' existence for all involved. Regardless of an individual's social status, current systems that are based on binary ideals (e.g., good/bad, body/mind, poor/wealthy) limit our ability to be our whole and true selves. In a way, we are all oppressed because the diversity of who we are and who we can be is contained in narrowly framed social norms (Anzaldua, 2002). Social justice, then, is somediing that all individuals might seek as the freedom from external and internal sources of oppression and freedom to pursue personal well-being, self-determination, and self-development in all their various forms (Prilleltensky, 2003; Young, 1990). There are numerous examples of how Freire's notion of conscientization has been applied in CBHP (e.g., Carlson et al., 2006; Champeau & Shaw, 2002; Kearney, 2006). Certainly, it is an important component in collectively promoting the health of individuals who experience and internalize oppression. Freire's work focuses on critical consciousness as the basis for political action and social transformation. Yet, as Nelson & Prilleltensky (2005) ask: Is it fair to expect community members wounded by interpersonal and social oppression to change society while they are hurting? At what point do we expect people who have been damaged emotionally and socially to turn their attention to the plight of others? If we expect them to do so too soon they may not be ready or it may not even be fair. After all, they may need some time and space to nurse their wounds and recover, spiritually and psychologically, from experiences of subjugation and minimization. On the other hand, if we don't connect their plight to the plight of others, in some form of solidarity, we may end up isolating them and their source of discomfort even further, (p. 212) Their mquiry points back to the necessity of conducting CBHP in a way that constantly connects the work to both individuals and social contexts (Nelson & Prilleltensky, 2005). Conscientization is only one aspect of the process of addressing the health repercussions of 44 internalized oppression and domination. Critical community psychologists and social workers offer important contributions on group work, conflict, and personal growth that could well-serve community-based health promoters, as the following section explores. Relational sphere: Group work, conflict & growth The relational sphere of the theoretical model refers to the relationships between individuals and groups, particularly in terms of how they engage and behave with one another. Most CBHP projects that work from a premise of inclusion involve the formulation and development of groups that require individuals to relate to one another across their differences. However, there is litde evidence that attention is being paid to the intricate relationships within group processes. This is of particular concern because the ways in which group members relate to one another can have considerable influence on the evolution of the group and the potential health promoting outcomes. Drawing on the notion of group work, a common practice in community psychology and social work practice, will be highly beneficial to all involved in CBHP by iUustrating how negotiating conflict in groups can be useful in addressing the internalization of oppression and related mental health issues experienced by many women (Mullender & Cohen, 2003). I suggest, in fact, that engaging in relational group work from the outset of CBHP projects may be the necessary precursor for CBHP projects that aim to support individuals who have been historically marginalized. Group work refers to the active negotiation of social dynamics within groups in order to promote individual and collective growth, development, and healing (Mullender & Cohen, 2003; Sullivan, 2001). Nelson and Prilleltensky (2005) suggest that group work in communities is a necessity for women who have been oppressed to heal from internalized effects, as well as a stepping stone for action. Community-based and anti-oppressive group work can provide a safe space in which individuals can be supported to cope with their daily circumstances and 45 strengthen their personal resources and can thus lead to transformation at individual, relational, and collective levels (Dominelh, 2002a; Nelson & Prilleltensky, 2005). For example, group work processes can enhance individual resilience, voice, respect for diversity, caring and compassion, and egalitarian understandings of power and help women develop what Patricia Hill Collins (1993) refers to as an 'ethic of care'. McLeod (2003) believes that group work is especially important for women who have been isolated and excluded, because it provides them with a space for deep connection and support where they can give voice to their realities and find solidarity through commonality while also respecting their differences. While fmding common ground is an essential component in early group process, conflict is also seen as a vital aspect of group functioning and development, particularly as it manifests as an expression of difference (Northern & Kurland, 2001; Schiller, 2003; Sullivan, 2001). Often times, those in conflict can help each other develop personally and as a group (Steinberg, 2004). In fact, many theorists view conflict as a positive sign of inclusion (Shakir, 2005; Sharp, Pollock, & Paddison, 2005; Sullivan, 2001; Young, 2000), because it may seem that diverse voices and perspectives are being vocalized, heard, and negotiated. Yet the development of groups, especially when organized around common identities and causes, necessarily perpetuates exclusionary dynamics. For example, a specific group identity can exclude those who do not 'fit,' certain criteria (Reid, 2004) or when adequate space is not given for different voices to be heard widiin group dynamics (TJominelli, 2002a). Labonte (2004) suggests that "we need to retain a healthy scepticism of concepts that direct us towards a wishful desire for social harmony" (p. 116). For example, seeking social harmony through consensus may result in the assimilation of difference and the coercion of the less powerful (Greenwood & Levin, 1998). At the group level, conflict may lead to enhanced understanding and consequent strengthening of relationships between members because differences are aired and not allowed to remain irritatingly under the surface. Conflict provides stimulation and a basis for interaction. Only through the 46 expression of differences is it possible for a group to delineate its common values and interests. (Northern & Kurland, 2001, pp. 214-215) Conflict often signifies that individuals within a group feel safe enough to openly voice their perspectives, even when such expressions make them vulnerable or provoke anger from other members (Sullivan, 2001). This is significant work for women who have been chronically oppressed because typically the "ability to comfortably hold power and to engage in conflict are the cutting edges for growth for many women" (Schiller, 2003, p. 21). Certainly, this recognition is of the utmost importance to those working towards feminist and anti-oppressive goals of inclusion and positive enactments of power-with, power-to, and power-for vs\ CBHP. We cannot take for granted that those who have internalized oppression and dominant patterns of power-over can easily shift into new ways of being without first attending to their psychosocial wounds. To do so requires that conflict be embraced in CBHP processes and framed as offering the potential for growth and inspiring positive social interactions, which in turn can result in health benefits (Ryff & Singer, 2001; Sullivan, 2001). It also provides an oudet for expressing negative emotions, which if stifled can fester to hinder relationships and health. Yet, conflict in Western society is most often seen as a negative and destructive force, particularly for women who have been chronically oppressed and socially trained to be submissive, 'make nice' or 'not rock the boat.' Many women tend to be afraid of conflict and its consequences, see it as bad, scary, and anxiety-provoking, and thus tend to avoid it (Schiller, 2003). Certainly, conflict can be destructive, yet it is not inherendy so. The negative connotations and fears associated with conflict typically come from the ways in which conflict is negotiated or, more specifically, how power is negotiated during conflict. When the dominant power-over strategies prevail, conflict resolutions result in a win-lose situation. Typically, those with more power utilize it to oppress and dominate those with less power in order to get their way and, as they understand it, resolve the conflict. Therefore, the ways in which "members of 47 groups recognize, resolve, and manage conflict [and power] is crucial to the very survival of the group" (Northern & Kurland, 2001, p. 215). A key step to managing conflict is to rename it as an important aspect in embracing differences, identifying self, and creating opportunities for deeper connection. This approach can "offer a powerful antidote to the forces of shame, oppression, and silencing that many women experience, and help members to regain their true voice" (Schiller, 2003, p. 29). Attention to anti-oppressive process is of the essence here (Dominelli, 2002a). The integration of conflict resolution strategies into emerging CBHP processes may provide a path through which group members can map new and alternative means of working together that builds collaborative, rather than competitive or avoidance-based, resolution strategies by utilizing their collective power to create win-win situations (Chinn, 2001; Northern & Kurland, 2001; Northouse & Northouse, 1998). However, a significant gap in CBHP practice is that most participants, practitioners, and researchers do not have the adequate skills to adequately facilitate effective conflict negotiations. Developing these skills seems to be a reasonable prerequisite for those with relative privilege in order to use power positively and responsibly, rather than to expect women who have been psychologically and socially harmed by oppressive systems to do this work without adequate support (Nelson & Prilleltensky, 2005; Steinberg, 2006; Young, 1990). This is not to orminish the contributions that all women bring to group work and CBHP processes, as certainly the strengths and experiences of those who have been marginalized are central to the development of feminist practice (Pollio, 2000). Rather, it opens the doors for the development of mutually beneficial partnerships between social workers, critical community psychologists, and CBHP practitioners and researchers. By combining collective resources, training, and visions, all involved may be better able to manage the nuances of working in groups (McNicoll, 2001). Not only will those in CBHP learn about anti-48 oppressive group work, social workers, critical community psychologists, and health researchers who tend to be subsumed by medically-driven approaches that pathologize the effects of internalized oppression, could also benefit from the inclusive, participatory, and ecological perspectives of CBHP (Lykes & Mersky, 2006; McNicoll, 2001). Finally, the development of anti-oppressive group work that facilitates inclusion and actively negotiates conflict for personal growth and social transformation requires a setting and structural environment that provides a sense of comfort or relative safety for participants amidst their diverse backgrounds and needs (Brown & Mistry, 2005; Schiller, 2003). Creating such a space requires all involved to contribute to the development of content, group rules, and organizing processes that are based in anti-oppressive and feminist principles of openness, compassion, non-blame, and responsibility (Brown & Mistry, 2005; Chinn, 2001; Leondar-Wright, 2005). Importantly, the processes within the group must be grounded by a broader understanding of the social contexts within which the group operates and by which women are typically oppressed (Dominelli, 2002a; Nelson & Prilleltensky, 2005). With this in mind, those working in CBHP may find that adopting feminist community organizing principles is useful in fostering health promoting group processes and environments. Local sphere: Feminist community organizing & municipal recreation The local or community sphere of influence refers to the organizations, institutions, and other public spaces within which CBHP occurs and women live out their daily lives. The notion of community organizing has become a mainstay in CBHP and is defined as "the process by which community groups are helped to identify common problems or goals, mobilize resources, and in other ways develop and implement strategies for reaching the goals they collectively have set" (Minkler & Wallerstein, 1997, p. 31). Minkler's (1997c; 2005) editions of the book "Community Organising and Buildingfor Health"'thoroughly reveal the usefulness of 4 9 community organizing processes for addressing health issues, particularly for members of marginalized populations. Yet, as I have argued thus far, the inclusion processes within CBHP groups and organizations are insufficiendy considered in terms of how they impact the outcome of projects and how they might create health promoting conditions in their own right. Feminist community organizing (FCO) processes pay deliberate attention to the internal functioning of groups and organizations and therefore have much to offer those involved in CBHP. In this section, I outline the possibilities and tensions of FCO for health, particularly as they relate to women's inclusion in municipally-funded recreation as a CBHP strategy. In intentional opposition to hierarchical, bureaucratic, and otherwise oppressive organizing strategies that dominate Western societies, FCO ideals "embrace collectivist decision-making, member empowerment, and a political agenda of ending women's oppression" (Feree & Martin, 1995, p. 5). In her extensive review of the literature, Mizrahi (2007) suggests that FCO is explicitly based in a humanist and democratic framework that values women's strength, dignity, agency, and power and views the 'personal as political.' Furthermore, cooperation rather than competition is considered the desired way of relating to one another based on the assumption that we are all deeply interconnected (Mizrahi, 2007). In order to live these visions, internal anti-oppressive and inclusive organizing processes are critical (Dominelli, 2002a). Mizrahi (2007) lists a series of FCO strategies in this regard: 1) community involvement; 2) collective problem solving; 3) process as part of the product or goal; 4) consciousness-raising; 5) cooperation, consensus, and collaboration; and 6) reflexive- and praxis-oriented evaluation. More specifically, FCO in practice commonly entails consensus decision-making, flexible and contextual organizational development, shared leadership and responsibility, intentional conflict resolution tactics, and a willingness to embrace and accommodate differences and women's lived realities (Chinn, 2001; Gutierrez & Lewis, 2005; Ponic & Frisby, 2005; Shakir, 2005). 50 Despite such powerful anti-oppression sentiments and strategies, FCO has historically been riddled with challenges that stem from the constant negotiation of power amongst organizational members, especially amidst dominant and contradictory ideologies (Angeles, 2003; Angeles & Gurstein, 2000; Mizrahi, 2007; Staggenborg, 1995; Teske & Tetreault, 2000). In fact, Mizrahi (2007) found that conflict was to be expected within feminist organizations, especially in contexts framed by women's experiences of trauma and oppression. Internalized experiences of oppression and domination can manifest in behaviours that serve to perpetuate oppressive relationships, despite FCO ideals, unless conflict resolution strategies that focus on compassion, non-blame, and individual and collective healing are embraced (Chinn, 2001; Nelson & Prilleltensky, 2005; Northern & Kurland, 2001). Attempting to build trust across difference and historically oppressive relationships is an essential quality of inclusive FCO and CBHP processes intended to productively navigate power imbalances (Roberts, 2004). Power dynamics also infiltrate ongoing organizing practices such as consensus decision-making and shared leadership. Such approaches are usually designed to include the voices and perspectives of all involved, find agreement, and share responsibility. Yet considerable power is attached to decision-making and leadership within organizations, and the skills required to assertively articulate one's position in a consensus process privilege middle-class and educated women (Ponic & Frisby, 2005). In this vein, consensus decision-making can serve to stifle and assimilate the perspectives of members who hold less social power and fewer legitimized skills (Greenwood & Levin, 1998). Division of labour has been documented as another challenge in FCO. Appreciating the complexities of women's lives and resisting top-down accountability structures has often resulted in work not being completed within feminist organizations if members are overwrought with other life responsibilities and non-authoritarian values can make it difficult to ensure accountability (Staggenborg, 1995). Frustration about getting the 51 work done and managing complexities between organizing members has at times led some women to be hard on one another and retreat to traditional power-over tendencies, thus leading to internal conflict (TVIizrahi, 2007; Reid, 2004). Despite its challenges, FCO still has considerable potential for anti-oppressive practices in the face of dominant and hierarchical forces. This holds especially true for those working in CBHP who seek inclusion and social justice. Municipal recreation is a fruitful site for CBHP that could be well-informed by FCO processes. There is considerable evidence illustrating the health benefits associated with recreation (Caldwell, 2005; Frisby et al., 2007; Petryshen, Hawkins, & Fronchak, 2001; Ponde & Caroso, 2003). Most publicly-funded municipal recreation organizations hold mandates of 'recreation for all' in order to 'promote the health and well-being of citizens.' In fact, community recreation and leisure are regularly being positioned as ideal locations for promoting inclusion, citizenship, and social relationships (Arai & Pedlar, 2003; Donnelly & Coakley, 2002; Glover, 2004; Reid & Golden, 2005). Nevertheless, two-tiered approaches to local recreation programming that offer inconsistent levels of service across class differences and limited perspectives on the value and entitlement of leisure activities, continually hamper the participation of poor, non- English speaking, people of color, and otherwise oppressed citizens (Reid et al., 2002a; Reid & Golden, 2005). Further, many low-income individuals and families are excluded from recreation because of the neoliberal shift to user-pay public services (Allison & Hibbler, 2004; Donnelly & Coakley, 2002; Thibault et al., 2002). Top-down organizing and policy-development practices within municipal recreation exclude community involvement in the determination of programs made available to them and fail to fully consider the realities of women's lives, mcluding more invisible barriers such as a lack of transportation, childcare, or appropriate clothing (Frisby & Hoeber, 2002; 52 Frisby et al., 2007). Labonte (2004) has in fact questioned the degree to which inclusion is possible in institutions that have systemically excluded the most vulnerable citizens. Despite these incongruities, participation in recreation activities remains especially important for marginalized women who may experience isolation, depression, and other chronic ailments. CBHP projects designed to enhance women's participation in recreation, within or outside traditional municipal systems, would be well-served by FCO principles that create more meaningful experiences of inclusion and participation in the decisions that affect women's lives, in promoting empowerment and healing through the process itself, and by incorporating women's lived realities and connecting them to broader social inequaUties (Mizrahi, 2007). It may also offer a more integrated service approach such that a variety of local providers partner to offer their services, rather than the more typical fragmented approach where women's lives are compartmentalized via bureaucratic structures and power-over program delivery strategies. Each of these collective benefits is especially important in CBHP and social justice processes that seek to resist dominant neoliberal ideologies of individuaHsm, consumerism, and personal entidements, which are inherendy gendered, classed, racialized, and otherwise oppressive (Brodie, 2005). Broader socio-political sphere: Neoliberal ideology & social-collectivism The socio-political sphere of influence refers to political climates, government policy, and public discourses, all of which have the capacity to shape understandings of health and, subsequendy, CBHP strategies (Langille, 2004; O'Neill et al., 2000; Raphael & Bryant, 2006). In Canada, understandings of health and health promotion practice and research tend to be influenced by two contradictory ideological positions: neoliberalism and social collectivism. Neoliberalism is based on the assumptions that autonomous individuals are primarily responsible for their own welfare and that the state's role is to adequately regulate the capitalist 53 markets (Brodie, 2005; Coburn, 2000; 2004). From this perspective, it is the responsibility of individuals to utilize the system for their own financial and social benefits, under the guise of equality of opportunity and the need to downsize government. Yet the inherent inequity and oppressive power relations embedded within this system are typically ignored, such that those who do not benefit from the system are seen as failures. Social collectivism, on the other hand, is based on the premise that all citizens should be inherendy connected and mutually responsible for each other's welfare (Morrow et al., 2004). From this perspective, the state's responsibility is to create policies and economic structures that support and sustain all citizens, regardless of their social standing, through social welfare programs. Since the early 1990s, neoliberal policy-making and discourse have dominated the Canadian political landscape and have had the effect of dismantling the social welfare system and therefore the social safety net. Research has shown that this trend has resulted in an ever-developing gap between rich and poor, a reduction in social networks and trust, and a decrease in public health status and services (Anderson, 2000; Coburn, 2004; Wilkinson, 2005). Furthermore, neoliberal policies create an environment of competition for limited resources and therefore perpetuate a climate of fear, 'Othering,' and oppression (Anderson, 2000; Young, 1990) to the point where "many Canadians now accept the notion of a smaller welfare state where social spending needs to be targeted and strategic" (Morrow et al, 2004, p. 361). Chronic poverty and exclusion are some of the harmful effects of such a system (Galabuzi, 2004). The effect has been particularly devastating for women and women's health, particularly across class, race, and other social differences (Anderson, 2000; Brodie, 2005; Coburn, 2004). For example, Morrow, Hankivsky, and Varcoe (2004) argue that social welfare cuts have undermined women's ability to leave violent relationships by elimmating or severely diminishing social assistance, legal aid, and other crisis-based services. Women's access to health promoting 54 community resources such as publicly-funded recreation have been compromised by the trend of local governments to off-load social responsibilities to citizens and community groups amidst a climate of fiscal restraint and revenue generating mandates (Arai & Reid, 2003; Thibault et al, 2002). Neoliberal ideology has also begun to re-shape healthcare reforms toward privatization in Canada in that: All the provinces have moved to shift health care costs to individuals, to shift care delivery to for-profit concerns, to shift managerial practices to for-profit approaches, to shift care responsibility to households and care to unpaid caregivers. (Armstrong et al., 2001, p. 307) These reforms are making health care services increasingly unavailable to people living on low income (Williamson et al, 2006). Poor and racialized women are particularly harmed by such trends since they tend to occupy the lower wage service jobs that bear the brunt of cost-reduction strategies, while their caretaking burdens are simultaneously increased as access to public health systems decreases and these responsibilities shift to domestic arenas (Anderson, 2000; Brodie, 2005; Raphael & Bryant, 2004). The effects of neoliberal reform are also evident in CHBP. In Canada, a tendency toward population health that emphasizes science and economics over a broader social determinants perspective has displaced most health promotion programs (O'Neill et al, 2000). This has led to a focus on individual, biomedical, lifestyle, and behavioural approaches to CBHP, which fail to adequately address broader health determinants such as poverty, housing, service provision, and exclusion (Buchanan, 2006; Raphael & Bryant, 2006). Yet, as I have emphasized throughout this chapter, there remains a pocket of socially-minded practitioners and researchers, who continue to espouse the virtues of a collectivist and feminist CBHP that emphasizes inclusion, social justice, and social determinants approaches to addressing women's health issues across its diversity (e.g. Amaratunga, 2006; Frisby et al, 2007; Hankivsky, 2005; Raphael & Bryant, 2004; Varcoe, 2006). This work, however, remains difficult to enact productively against the 55 overwhelming domination of neoliberal ideologies and aligned material distributions. Witiiin the broader complexity of CBHP, this socio-political environment makes it challenging to create and maintain FCO practices, to develop relationships that offer positive social support and an ability to resolve conflict productively, and to overcome the psychosocial effects of oppression and domination. In this light, some CBHP programs tend to be reactionary, rather than preventative or facilitative, such that women are supported to cope with their difficult circumstances and ill-health rather than alleviating these issues at their core (Amaratunga & Hockney, 2003; Porter, 2006; Raphael, 2006). Given these challenges and the harm they inflict on women who have been chronically oppressed, those who espouse collectivist ideologies need to continue to swim against the tide of neoliberalism to promote inclusion, social justice, and health, now more than ever. Intersectionality: A web of power, privilege & oppression The outer web of intersectionality in Figure 2.1 posits each of the model's spheres of influence amidst complex systems of power and privilege that shape social relations, identity formations, and therefore, women's health and CBHP (McCall, 2005). Intersectionality theory was initiated by feminist women of colour who felt excluded from and thus resisted the second wave of ferninism in the 1970s (hooks, 1981; Lorde, 1984; Moraga & Anzaldua, 2002). This wave, which was dominated by white, middle-class women, tended to homogenize women's experiences and assimilated all women into a single gender-based category of power and oppression (Brah & Pheonix, 2004; Mohanty, 2004). Early theorizing by women of colour referred to 'interlocking' oppressions that examined how systems of gender, race/ethnicity, and class connected to shape women's lived realities (Collins, 1993; Zinn & Thorton, 1996). In the last 10 years, the term intersectionality has replaced the term interlocking to capture the dynamic range of "social categories such as race, class, gender, sexualities, abilities, citizenship, 56 and Aboriginality among others, [which] operate relationally; these categories do not stand on their own, but rather gain meaning and power by reinforcing and referencing each other" (Bunjun et al., 2006, p. 8). An important aspect of intersectionality theory is the recognition that women's social identities and locations are not fixed, but are in a constant flux amidst a web of intersections and thus produce a multiplicity of realities across time and context (Brah & Pheonix, 2004; McCall, 2005). Intersectionality theory moves feminist theorizing beyond the gender focus that captures only one relationship of power (e.g., patriarchy), in order to more fully uncover and account for the complexity of systems that shape the diversity of women's lived realities (Bunjun et al., 2006). Women's social locations, material circumstances, and ideological identities are woven together by the strands of intersecting systems of power and oppression at a range of micro, meso, and macro levels, as depicted by the theoretical model on page 34. Yet most policy-makers, practitioners, and researchers tend to examine women's lives through narrowly-defined lenses. For example, the experience of new immigrant women are often analyzed through one-dimensional categories of race or gender (Mullings & Schulz, 2006). Such strategies simplify women's realities and are often applied without a critical analysis of power. Case in point, the gender-based analyses that dominate Canadian policy-making remain blind to the mixed effects of immigration, colonization, language oUscrimination, and poverty (Bunjun et al, 2006; Weber, 2006). Alternatively, when race becomes the only category of analysis, it is often simplified to mean individual characteristics and is only associated with women of colour, both of which have the effect of masking the relational nature of systemic racism mcluding white women's compliancy within it (Frankenburg, 1993; Mohanty, 2004; Mullings & Schulz, 2006). Yet research increasingly shows that the health of new immigrant women is compromised by the combined strain of women's care giving roles, culturally insensitive social service programs, and 57 material deprivation associated with being unable to obtain work because of language barriers and systemic racism (Beiser, 2005; Oxman-Martinez, Abdool, & Loiselle-Leonard, 2000; Stewart et al., 2006). From an intersectional theory perspective, however, the lived realities of newly immigrated women can only be understood and improved when the complexity of historically created and dominant systems of power and oppression are more fully taken into account. Along these lines, researchers are begmning to call for the application of feminist theories of intersectionahty to women's health research and methodologies (Brydon-Miller, 2004; Hankivsky, 2005; Reid & Frisby, forthcoming). Weber (2006) suggests that such an approach is necessary because dominant biomedical and epidemiological frameworks tend to homogenize the diversity of women by separating social systems into discrete categories, which has the effect of disconnecting women's health disparities from the socio-historical, political, and economic conditions within which they occur. From an intersectional approach then, "the challenge is how to understand the ways in which gender, race, and class relations [among others] intertwine and are expressed in disparate chances for health, illness, and well-being" (Mullings & Schulz, 2006, p. 6). Yet to do so is extremely complicated since no single theoretical framework or methodology approach can adequately capture the complexity of social life and its diverse effects of women's health (Reid, 2002). That said, however, applying a lens of intersectionaHty can aid researchers in deepening the ways in which social theorizing can inform empirical research, bridge gaps between theory and practice, and ascertain more appropriate points of entry for CBHP interventions (Mullings & Schulz, 2006). Examples of how intersectionaHty theory can muminate understandings of the ways in which health is socially determined are becoming slowly evident in women's health research. For example, it has been used to analyse HIV/AIDS discourse and poHcy-making (Bredstrom, 58 2006; Dworkin, 2005) and women's experiences of health and aging (Dressel, Minkler, & Yen, 1997). However, this level of analysis is scarce in CBHP research (for an exception, see Gutierrez & Lewis, 2005), yet women's multiple and ever-shifting social locations not only influence the health issues that need to be addressed, they also impact the ways in which women participate in health promotion processes. Therefore, positioning the spheres of influence within the web in the theoretical model on page 34 makes an important contribution in extending the analysis of how a feminist intersectional analysis can inform and transform CBHP practice and research. Embracing Complexity in Community-based Health Promotion In this review of literature, my intention has been to illustrate the complexity of facilitating inclusion and CBHP from a feminist perspective. Exploring this depth of complexity is rare in CBHP literature, which tends to focus on individuahst and narrowly-defined programs that are embedded with assumptions about the individuals involved in and the social processes that contextualize this work. Yet processes of inclusion, exclusion, and marginahzation are contestable and complicated theoretical concepts that must be critically explored and reformulated if they are to be useful tools for understanding ever-changing social relations and the actions that people take within them. Navigating and mtermpting dominant understandings and enactments of power are central to facilitating CBHP that promotes social justice and addresses the oppressive systems witliin which women's health is determined. In this chapter, I have offered a theoretical framework that conceptualizes the individual, psychosocial, relational, local, and socio-political dimensions that shape CBHP and inclusion and position them as complex social processes. Framing the intricacies in this way is not meant to overwhelm participants, practitioners, researchers or policy-makers. Rather, I suggest that there are advantages in understanding this complexity to more productively define, 59 contextualize, navigate, and evaluate CBHP projects designed to enhance women's health, as the findings in chapters 5, 6, 7, and 8 will demonstrate. In order to more fully contextualize my findings, I now present more information about the research site in Chapter 3 and about my research process in Chapter 4. 60 C H A P T E R 3 A Story of WOAW Women Organising Activities for Women (WOAW) is diverse women working together to enhance quality of life and create positive and sustainable change. Women are empowered, respected, and connected to their communities. All thoughts and feelings are valued and important, and women are treated with dignity. (WOAW vision statement, collectively written in May 2000) Authorship of this Story I wrote this story based on my experiences, perspectives, and knowledge of WOAW. It is not a dissertation 'fmding' and I have not attempted to include the voices of study participants or make connections to relevant literatures. Such stories portray partial realties from the standpoint of the person Writing them; they are not necessarily fact-based, because every story-teller carries her own subjective truths (e.g. Frank, 2000; Marx, 1934; Ponic, 1994). With this in mind, the purposes of this story are threefold. First, it provides important contextual information and terminology to frame the rest of this dissertation, and second, it provides insight into the issues with which I grappled during my involvement in WOAW that instigated my research questions. Third, I tell this story for its own sake, as a way of documenting and honouring the effort of the women (and two men) who contributed to this community-based organization that changed each of our lives. WOAW's Creation: The Socio-Political Context Women Organizing Activities for Women was a community-based organization originally designed to improve poor women's access to local recreation as a form of health promotion. Recreation was provided through a community-development and grassroots strategy whereby the women involved in WOAW, with the support of local service providers and a group of academic researchers, decided upon and organized the activities their desired activities. This 61 approach stands in contrast to traditional top-down and user-pay public recreation programrning. As the above vision articulates, WOAW strove to organize itself such that women were 'empowered, respected, and connected' across their diversity. In these ways, and others, WOAW operated as a feminist collective. WOAW was also the site of a 4-year, federally funded feminist participatory action research grant and 4 graduate student research projects, mcluding my own. WOAW existed in different forms from 1999-2005, however, the research grant was only active from 2000-2004. Three distinct yet related forces converged to create WOAW; within each force, specific individuals were taking action in response to their social, political, and/or economic environments. The first key player in WOAW's development was a municipal recreation service provider named Jim1. In 1999, the municipahty that he worked for was sued for gender discrimination by a local family whose daughter faced unequal access to a local recreation facility. As a consequence of the legal decision favouring the family, city council required their departments to develop gender equity initiatives for girls and women. This imperative became Jim's responsibility in his role as Leisure Access coordinator, a job designed to facilitate access to recreation services, and he thus sought out applicable programs. Louise, a coordinator at the local women's centre, was the second key player. Louise repeatedly heard stories of exclusion, isolation, and ill-health from women she served. Although they knew that recreation could help address these core concerns, her clients found that local recreation services were inaccessible to them and that often their attempts to apply for reduced fees through Leisure Access programs were shaming invasions of their privacy. For example, if 1 I will be naming the service providers and researchers involved in WOAW by first name only, which is consistent with the way that study participants are named. I sought each service provider's and researcher's permission to use their names in this way. The lone exception is my PhD advisor, Dr. Wendy Frisby. I provide her full name in order to be transparent about her dual relationship to WOAW and my dissertation. 62 a woman was interested in participating in a recreation program but was unable to afford the program costs, she was forced to prove her poverty to recreation administrators by providing a copy of her tax forms. In her efforts to support the women in her community, Louise was seeking to understand and advocate against women's exclusion from public recreation services that were meant to be accessible to all citizens. Both Jim and Louise came upon a workbook entitled "Leisure Access: Enhancing Recreation Opportunities for those Living in Poverty" (Frisby & Fenton, 1998). The interactive workbook was designed by Dr. Wendy Frisby to help municipalities evaluate and improve their recreation accessibility for low income populations. The content of the workbook was based on a participatory action research project that she had conducted in the BC interior. In this study, local recreation, health, and social service providers partnered with women living on low income to create a community development model of recreation provision. The project was initiated when a local public health nurse called Wendy for support, in response to a political outcry about the lack of accessible recreation for low income families. A group of women involved in a Healthy Community Initiative were lobbying against the costly construction of a new ice rink because they felt that this form of recreation provision would not meet their needs or those of their children. Wendy and a former graduate student, Jennifer Fenton, wrote the workbook as part of a knowledge transfer strategy to communicate the results to other communities interested in promoting health and social change, which became a driving force in WOAW's creation. This overlapping series of events resulted in the development of a community-based workshop for women living in poverty to discuss and improve their access to recreation in a BC Lower Mainland area. Following their discovery of the Leisure Access workbook, Jim and Louise met and decided to invite Wendy to be involved in the development of a community 63 initiative. At the same time, other mutually-concerned recreation, health, and social service providers were called upon to join this effort. When this group came together for the first time, they realized that many of the women they were serving faced similar dilemmas and that they shared similar values about working 'with' rather than 'for' women to collectively address the issues that they faced. They felt a synergy in the room and agreed to pool their resources for the workshop. The workshop was advertised through posters, newspaper articles, and mailed invitations. Each service provider spread the word amongst her/his clientele and contributed resources to provide space, office supplies, childcare, food, and transportation. They expected a dozen or so citizens to attend the event and were completely overwhelmed when more than 85 women and children showed up. One service provider made an emergency trip to the grocery store for additional food, as others frantically pulled out more chairs and supplies, made extra sandwiches, and put cookies on plates. Those in attendance described the energy in the room as kinetic; each participant recognized that she was involved in something different and special. Wendy facilitated the workshop using her workbook as the guide. She asked participants to work in small groups to discuss their barriers to good health, how recreation could address these barriers, and their access to municipal and publicly funded recreation systems. The participants broke into lively discussion groups and in this process they began to learn that their individual experiences of poverty, isolation, exclusion, and ill-health overlapped to create a collective story. Those who attended the workshop felt energized by the experiences of sharing their stories and being listened to by people in their community who had access to resources. As the workshop wound down, Wendy asked if anyone was interested in contmuing these discussions and building on them. It was in that moment, when hand after hand after hand rose eagerly into 64 the air, that WOAW was born. This group of diverse women, service providers, and researchers was ready to take action. The People WOAW was made up of three partnering constituent groups that I refer to as WOAW members, WOAW service providers, and WOAW researchers. WOAW members WOAW 'members' are the women who lived in a tri-city area and who joined WOAW to improve their health and their lives. Over the 6 years of WOAW's existence, more than 100 women became members. These members occupied unique yet overlapping social locations and life circumstances. While they were all women and most of them lived at or below the poverty line, they differed across other social axes and life circumstances. Within WOAW's membership there were mothers and non-mothers who were single, married, and/or divorced; some members were heterosexual, while others were queer. WOAW members ranged in age from their early twenties to late seventies and had various levels of physical dis/ability and health. The membership included white women and women of colour. Some were new immigrants from Latin America, the Middle East and Asia, whose first language was not English, while others were Canadian born and spoke primarily English and some French. They had diverse work and educational experiences, family histories, and community involvement. The members who lived in or on the" edge of poverty were on social and disability assistance, partially employed at minimum or low wage, and/or financially dependent upon spouses. Members joined WOAW primarily to connect with other women and to participate in recreation activities in order to address their health concerns. Nearly every WOAW member was socially isolated and for many this experience funnelled into cycles of ill-health that included depression, stress, and physical inactivity. Many members found WOAW at points of 65 transition in their lives, mcluding loss of home, family, employment, and health. Most sought WOAW to develop a place of belonging in their communities, where they could contribute their skills and make a difference in their worlds. They also wanted to find a supportive environment where they could have fun, learn, and be exposed to other opportunities. The need to develop friendly and supportive relationships was central for members who had experienced extreme and chronic isolation. WOAW members participated for varying amounts of time and at a variety of levels. While some members were involved from the first workshop to the final meeting, others only participated for a few months or years. During their membership, some women participated regularly, attending meetings and activities each week; others did so sporadically, only partaking in events that were of particular interest, that fit into their schedules, or that they were well enough to attend. Additionally, some members left WOAW after a period of involvement only to return at another time. While the degree to which members could choose their level of involvement was appealing and honoured different levels of participation, the variable amount of work and energy that members contributed to WOAW also developed into a source of frustration and conflict. WOAW service providers WOAW received support from local service providers who represented a variety of organizations. Nine providers worked for three municipal leisure and recreation departments, while one provider each was involved from a local women's center, a family and community service organization, a community school, and a neighbourhood child support centre. Some of the service providers were involved in WOAW because it fell within their job descriptions, others remained committed because of the benefits they saw, even though it was outside of their organization's mandate, and a few even had to hide their involvement from their 66 organizations. All but two of the service providers were women and all but one of them was white. They all had post-secondary educations and professional employment, were able-bodied, and spoke English. One provider spoke openly about the financial challenges she had faced as a single mother prior to obtaining her current job. Although their domestic status and sexual orientation were never specifically considered in the scope of their work with WOAW, most providers spoke freely about their relationships, marriages, and children which implied that they were straight. As a group, the service providers held social locations that were relatively more privileged then most WOAW members. The service providers connected WOAW members to community resources. They supplied gathering spaces and local information; they addressed barriers for participation by providing childcare and assistance with transportation; and they facilitated the development of the organizational structures and processes. WOAW service providers attended meetings, taught activities, facilitated workshops, coordinated functions, and offered social support to WOAW members. They were the foundation that held up the rest of WOAW and often did so in the face of declining resources and downloading within their organizations. During the first two years, 10-12 service providers supported WOAW. Over the course of WOAW's 6-year existence, this number slowly dwindled until only one provider remained connected to the organization. Even then, however, in the final months she was only able to provide arms-length logistical support and was not allowed to attend meetings or contribute substantial time to WOAW functions. The decline in support occurred at a time of social, economic, and political upheaval in our province. In 2001 a neoliberal government was elected and drastic cuts were made to social services. In the ensuing three years, funding cutbacks, organizational down-sizing, mounting job demands, and stress-related ill-health contributed to the decline in service provider support. Simultaneously, the municipal recreation departments 67 that originally sponsored the WOAW project began to realign their backing. Those from one department, whose ideologies around low income and entidement to services were often in conflict with WOAW's principles, gradually removed themselves from the project. In another department, recreation managers increasingly questioned the value of WOAW and whether or not supporting it was an efficient use of their workers' time, given their other responsibilities and pressures to meet financial imperatives. Furthermore, as the service providers with expertise in group process and social work — these were the ones who felt the cutbacks most severely — left the organization there was no one remaining at the table with the skills or training to manage the escalating and debmtating group dynamics. The remaining recreation providers were consistentiy challenged, confused, and frustrated by conflicts and power struggles and, as these dynamics ensued and deepened over a two year period, they grew weary of the work and became less dedicated to the cause. Over the years, WOAW's foundation became increasingly fractured. W O A W r e s e a r c h e r s The group of researchers from UBC who worked with and studied WOAW consisted of one UBC professor, 4 doctoral students, and 4 masters' students. Wendy Frisby was the principal investigator of a SSHRC-funded research grant that will be described later in more detail. One Ph.D. student, Colleen, was project manager of the grant from 1999-2001 and conducted her doctoral research with WOAW. I took over from Colleen as project manager from 2001-2004 during my doctoral studies. The grant was complete by the time I began my Ph.D. research. Beth and Sydney were research assistants who completed their master's research with WOAW. Finally, 4 other students also acted as research assistants on the grant, although they did not conduct their graduate work with WOAW. All 9 researchers were white, well-educated, able-bodied, and middle-class women. Two researchers were openly queer in long-term relationships, 5 of us were married to men, two had children, and two were single. We were all Canadian-born and spoke English or French as our first language. One researcher had experienced the struggle of being a single mother living on welfare, prior to remrning to university. Similar to the service providers, the researchers also held positions of relative power and privilege. As feminist participatory action researchers, we not only conducted research activities in WOAW, we were also active participants in its ongoing development and events. In our 'research' roles we were participant observers and field note-takers; we also conducted interviews and focus groups and facilitated 6-monthly evaluation meetings. We coordinated the budget and honoraria, transcribed and analyzed data, co-wrote research reports written in lay language for community members, and cusseminated our findings through a variety of academic and professional channels. In our 'action' roles with WOAW, we facilitated and participated in organizational meetings, provided photocopying and similar logistical services, helped write newsletters, contributed to poducks, participated in policy making discussions with recreational service providers, and attempted to help resolve organizational conflicts. Since we did not live in the area, we all travelled considerable distances to fulfill these roles. Our team of researchers met regularly to critically reflect on our role and emotions within the project. We became feminist allies in the journey of understanding oppression, health, and community organizing. Although we were each in very different stages of our lives and our learning, we connected through our commitment to WOAW; we were dedicated to supporting its members and to exploring how organizations like WOAW could make a difference in recreational organizations, local communities, and women's lives. We each approached our commitment from different angles, offered support in our own ways, and asked unique, although mutually informative, questions. Individually and as a team, we explored research 6 9 areas such as: 1) how community development could improve women's access to local recreation and address their social isolation; 2) the depth of resources brought to WOAW through its diverse membership; 3) how poverty and/or exclusion impacted women's health and sense of identity; 4) divergent and at times contradictory community development discourses; and 5) women's experiences of inclusion, power, and health. Each researcher had her own time span for involvement in the project. While most of us remained committed in principle, our life realities compromised the degree to which we actively participated in WOAW. Most of us left WOAW once our research projects or assistant jobs were complete, although on occasion a few attended events as volunteers. I continued to volunteer my time to WOAW functions up until the action phase of my doctoral project. However, the energy in WOAW was depleted by this time and my decreasing involvement coincided with the eventual demise of the organization. This is not to say that WOAW ended with my involvement, rather, that as WOAW was dying I became less able and inspired to be involved. My involvement will be more deeply considered in upcoming chapters. WOAW's Structure WOAW's structure took subdy different shapes over its lifespan, although the basic framework remained the same. In general, WOAW consisted of sub-groups, a project team, and a research team. The sub-groups Given the extensive number of members who showed up at the initial workshop and were involved in WOAW over the years, the sub-groups evolved as a way for smaller groups of women in similar life circumstances to work together. The sub-groups typically consisted of 10-30 members and 2-4 service providers. It was within the sub-groups that the majority of WOAW activities were planned. Each sub-group charted its own courses of action depending 70 on the needs and interests of its membership. The service providers and researchers provided resources and support for these groups. The sub-group formation emerged over the years. The initial sub-groups formed as a natural extension of the discussion groups at the initial workshop, at which time women gathered around their commonalities including age, ethnicity, and geographic location. Over time, some sub-groups disbanded, others were formed, and the make-up witliin the groups was transformed. For most of its existence, WOAW consisted of 4 sub-groups named ATP, CoPoMo, PoCo, and SWCo and each sub-group developed its own 'flavour' of recreational activities. ATP consisted primarily of older women many of whom had significant health and disability concerns. Their group typically had 10-30 active members supported by one or two service providers. In general, ATP organized fun, creative social outings for its members. Within ATP there was also a group of dedicated activists who initiated political action and who contributed their energy and talent to community causes. CoPoMo was made up of mosdy middle-aged women between 40 and 55, however there were a few younger women involved. Typically, this group had 15-40 members and was supported by two service providers. These members tended to be single without young or dependent children. Over the years, a large percentage of new CoPoMo members were recent immigrants, giving the sub-group a dynamic cultural diversity. For a period of time, this group was extremely active organizing two to three activities per week. In general, CoPoMo members chose activities that built on their cultural diversity and catered to their collective desire for learning in supportive social environments. The PoCo group, over time, became comprised of primarily young mothers. Since these women faced the layered barriers of transportation and childcare, the sub-group's membership 71 consisted of only 3-10 members, who received variable support from three to four service providers. Most often PoCo members organized activities that either involved their children or intentionally gave them a break from parenting. They organized a number of physical activities, coupled with fundraising events to help cover the costs of childcare. The fourth sub-group, SWCo, developed as a sort of 'catch all' group for members who didn't necessarily 'fit' well widiin any of the other sub-groups. The 10-20 SWCo members tended to live in a specific geographical area and were supported by three service providers. These members ranged in age from their early twenties to late forties and had various domestic statuses. Some had dependent children, some were partnered, while others were single. Additionally, this group had the most employed members, which made arranging mutually convenient meeting times across various schedules a constant challenge. In general, this group engaged in informal social gatherings and outings. While these 4 sub-groups were the mainstays of WOAW between 2000 and 2003, there were some shifts in the sub-group composition over time. The initial, post-workshop sub-groups included a primarily Persian, Farsi-speaking group and did not include the CoPoMo group. The Persian group dissolved within the first months of WOAW's existence due to limited service provider support and challenging cross-cultural and language differences. The CoPoMo sub-group was created late in the first year by some members who were originally affiliated with the PoCo group. They created this group because transportation to the PoCo location was complicated and they felt their needs might be better served in a new group that did not consist primarily of young mothers. It was not unusual for members to move between sub-groups in order to find the place within WOAW that best met their needs and interests. In the final years of WOAW, the PoCo and SWCo sub-groups ended. The PoCo group struggled to maintain adequate membership to sustain the group, primarily because of childcare 72 costs. Over the final months of its existence there were only three active members, who eventually were unable to hold the group together. Two of these members decided to leave WOAW and the third joined another sub-group. SWCo also struggled to maintain an active membership and those members who remained involved gradually affiliated themselves with the ATP sub-group. Eventually, these two sub-groups amalgamated leaving WOAW with two primary groups, ATP and CoPoMo. WOAW as Recreation Within its community development framework, WOAW ascribed to a broad definition of recreation. Table 3.1 provides examples of the types of activities that WOAW sub-groups organized in 4 general categories: social, physical, educational, and political. These recreational activities provided a platform from which members were able to choose activities they wanted to be involved in that would improve the quality of their lives and their health, albeit to varying degrees. Table 3.1: Recreational activities organized by WOAW members Ii fi! ii i ii i K ii h \ i l ^ ^ ^ ^ ^ K A l l ' C o P o M o PoCo SWCo Social Anti-fashion show, trips to local attractions, quilting, potlucks Crafts, reader/writers club, movie nights, potlucks, picnics Social nights, holiday events, picnics Informal gatherings, group outings Physical Belly dancing, Tai Chi Aquatics, dance & exercise classes Swimming, yoga, and Tai K w o n D o Walking group, aquatic exercise classes Educational ISM ^ !•'.'..'•: ^  rilf Wpflli! Wil l & tax workshops, computer classes Conflict resolution, cooking classes, language lessons, personal safety courses, career training Self-defence, computer courses, C P R Nutrition and cooking classes Political Bus-riders union, charity auctions, affordable housing and anti-poverty advocacy Fund raising Fund raising Anti-poverty advocacy 73 The project team The project team was the organizational body that coordinated the 'business' of WOAW. These meetings were open to all WOAW members, service providers, and researchers and had variable attendance. In general, however, project team meetings were primarily attended by unofficial representatives of each sub-group, meaning that the same members from various sub-groups typically participated at this level of WOAW. Although participation rates varied, the meetings usually involved 8-15 members, 5-8 service providers, and two to three researchers. The project team met approximately 6-10 times per year. The project team created WOAW's vision and directed ongoing logistics. For example, budgetary issues and overall communication structures were managed by the project team. Members, service providers, and researchers took turns chairing these meetings. Typical discussions at project team meetings included sub-group updates, information about local events, resources, and issues, and consideration of any overall issues affecting the organization. Each year, the project team organized WOAW events for the entire membership, including full-day outreach programs, a weekend retreat, and organizational visioning workshops. Additionally, the researchers shared information about upcoming research activities, and any concerns regarding the research aspect of WOAW were discussed with the project team. The Research Component Riding the wave of energy from the initial workshop, Wendy Frisby coordinated a research grant application in a competition entitled "Culture, Society & Health of Canadians." Wendy applied for the grant in collaboration with WOAW members and service providers. She facilitated meetings to discuss and determine the research questions and circulated a draft of the grant application for feedback. Six WOAW members and service providers contributed letters of support because they felt that a grant would bring legitimacy to the organization and they 74 saw value in having their efforts and experiences documented. In early 2000, Wendy successfully secured a three-year $265,000 federally funded grant from the Social Sciences and Humanities Research Council (SSHRC) entided "Addressing the Self-Determined Health Problems of Low-Income Women Through Participatory Community Interventions: Meanings, Process, and Evaluation Issues." This research was conducted through a feminist participatory action research framework, such that the diversity of women's lived experiences lay at the heart of the research purpose, participants' inclusion and participation was facilitated in all aspects of the process, and the researchers were actively involved in the project they were studying with the goal of initiating actions toward social justice. Over 50 WOAW members and 12 service providers actively participated in WOAW research projects. They attended meetings where researchers observed and took field notes, they engaged in one-on-one interviews and focus groups, and they participated in regular evaluation meetings called research parties. The data set for the SSHRC funded project included transcripts from 63 individual interviews with WOAW members and service providers, 4 focus groups sessions and 10 research parties, and over 100 sets of field notes from WOAW meetings and events. To date, WOAW researchers have published 16 peer-reviewed academic journal articles, two articles in non-refereed publications, two book chapters, and one book, and presented at one professional and 18 academic conferences. Additionally, the WOAW model was offered as an exemplar in Health Canada and the Canadian Park and Recreation Association's "Everyone Gets to Play," an initiative aimed at promoting access to recreation for those living in poverty. Three of the 4 graduate student research projects occurred in conjunction with the SSHRC grant. The fourth, mine, was conducted as a follow-up to it. 75 The SSHRC-funded research project was divided into 6 phases over three years. At the end of each phase, the researchers produced research reports written in lay language that were distributed to the WOAW membership, local service providers, and a national mailing list of interested organizations. These reports captured ongoing recreational, organizational, and research dynamics within the organization. More specifically, report 1 focussed on the early organizational development of WOAW, report 2 discussed initial research findings based on the first round of interviews with WOAW members, report 3 presented the elements of WOAW's functioning as a feminist collective based on the focus group discussions, and report 4 depicted WOAW members' interconnected and pervasive experiences of social isolation, including how WOAW alleviated this health concern. Report 5 was collaboratively written with WOAW members to illustrate the actions they had taken in the community and their lives through their involvement in WOAW and report 6 described the outcome of WOAW's 3-day strategic planning sessions. These reports were used as tools to evaluate the progress of the organization and to lobby local government for further support. They also helped the researchers conduct initial analysis on a very large data set on topics that were of particular interest to WOAW. In each phase, WOAW members were invited to participate in a range of research activities (e.g., interviews, focus groups, research parties), for which they were offered honoraria as a way of recognizing participants' contribution to the research process. One of the service providers negotiated an exemption on behalf of women who were living on social assistance that precluded them from receiving money from other sources without losing their benefits, so they could receive the honoraria without penalty. As researchers, we were aware of the possibility that offering honoraria to women living on minimal financial resources might result in their coercion into the research project. Yet it remained important to us that participants were 76 compensated for their time to some degree, especially since we were all being paid for our work on the project. In retrospect, this reasoning seems absurd given the discrepancies between the financial rewards received by participants and researchers, especially since they served to further reinforce our privilege differences. However, I take some solace in the memory of a number of participants telling me that they never chose to participate for the money; rather, they chose to participate because they felt valued for their contributions and understood WOAW and the research we were conducting could make a difference in their lives and those of other women. Research parties WOAW researchers hosted 'research parties' at the end of each phase. Typically, one was held with WOAW members while another was held with the service providers so that each group was able to identify their own topics of concern that they could speak about relatively openly. The purposes of the research parties were: 1) to present initial research fmdings to participants for their feedback, 2) to create a space for members and service providers to evaluate the progress of the organization, and 3) to celebrate WOAW's ongoing accomplishments. Typically, the researchers facilitated the discussions at the research party and provided food, childcare, and transportation. The context and direction of the research parties were primarily developed by the researchers, depending on what was happening in WOAW at the time and our research purposes. At times the researchers coordinated specific agendas for the parties. For example, over the course of our involvement in WOAW, we heard members talk about their experiences of social isolation at nearly every meeting and event. We wanted to learn more about the pervasiveness and nature of their isolation, so we organized a research party with the intention of creating the space to collaboratively analyze their experiences. Over 30 women attended and we facilitated a discussion on why women were isolated, what it felt like to be isolated, and in 77 what ways WOAW alleviated their isolation. On other occasions, we co-created the agenda with participants by opening the parties with a general question like 'is there anything in particular you would like to discuss today?' or 'how are things going in WOAW?' In both scenarios the discussions and energy at the research parties were quite lively and msightful, providing valuable feedback for organizational and research purposes. The research team The research team was created by Colleen as a space for members to discuss their diverse yet interconnected experiences of poverty and health. The research team served the dual purpose of providing a needed oudet within WOAW to discuss members' personal life issues and the 'politics of poverty,' which was the focus of Colleen's dissertation research. The research team met on a monthly basis between March 2000 and June 2001, at which time Colleen facilitated the meetings. Thirty WOAW members attended research team meetings, half of them on a regular basis. Colleen's Ph.D. work won the best dissertation award from the International Institute for Qualitative Methodology and was published as a book entided "The Wounds of Exclusion: Poverty, Women's Health <& Sodal Justice" (Reid, 2004). Although Colleen's research was completed in June 2001, the research team continued to exist until December 2002. The meetings occurred sporadically, when initiated by a researcher or member for a specific purpose. For example, Colleen and I organized one meeting to coordinate a conference abstract with interested members, a group of members requested a meeting when they were being deeply affected by provincial cuts to social welfare programs, and I initiated a meeting to present and get feedback on the research questions I was considering for my dissertation. Attendance at these meetings ranged from 4 to 30 members, depending upon the relevance of the issue and the overall energy within the organization. Almost exclusively, research team meetings were facilitated by the researchers and, as much as 78 possible, food, childcare, and transportation was provided with the assistance of the local service providers. Envisioning WOAW: The Development of a Collective Organization Most WOAW members, service providers, and researchers desired an organizing framework that facilitated a non-oppressive environment, since everyone involved had been harmed by traditional and hierarchical organizations in one way or another. With this broad understanding in mind, WOAW's collective organizing practices developed organically in formal and informal ways. While a number of service providers and researchers labelled these organizing strategies as feminist, not all members were comfortable with this term and preferred instead to call it collective or collaborative organizing. In general, our collective organizing strategies entailed shared leadership and responsibilities, consensus decision-making, and a non-hierarchical structure. We also pooled our resources in order to address barriers to involvement such as childcare, transportation, and language. Theoretically, there were to be no 'bosses' in WOAW and we were meant to report to each other as a collective and to share the responsibility of managing the ongoing functions. We took turns chairing project team meetings and the workload was distributed in an ad hoc fashion. Recreational activities were coordinated by members and service providers and we aimed to make decisions by consensus rather than majority rules. Finally, we attempted to adopt a flat structure such that no sub-groups were privileged over others. Rather, the three constituent groups overlapped to create the Project Team, Research Team, and sub-groups, as Figure 3.1 illustrates. 79 Figure 3.1: WOAW's organizing structure These organizing practices developed fluidly, yet over time (as I will delineate in considerable detail in the upcoming findings chapters), concerns about decision making, leadership, and power emerged. In response to these tensions, a series of workshops were facilitated by the service providers and researchers over the course of 4 years to investigate, develop skills for, and refine our organizing practices. Each of these workshops provided settings for members, service providers, and researchers to discuss and learn about alternative and feminist forms of organizing, and each in some ways enhanced our practices and fostered the levels of inclusion and participation identified in WOAW's vision. However, this information was inconsistently applied to WOAW's ongoing practices due to a range of challenges we encountered. Table 3.2 summarizes these events. 80 Table 3.2: Collective organizing workshops 1 '.van Date- Imcm Led b \ : U „t Pan apams Outcomes Visioning May 2000 To create a vision statement. Recreation provider 19 WO \W "s M M - . 1 1 statement. Collective Organizing January 2001 To learn how to organize as a collective. Two social service providers 20 The decision to make decisions through consensus. Re-visioning May 2001 To evaluate WOAW's vision and functioning. Social service provider 23 WOAW's vision still fit. Key organizational issues identified. Retreat: October 2001 To consider how power operates. Two social service providers 30-40 Members seemed to enjoy social component but most seemed relatively indifferent to the workshop topic. Strategic Planning June 2003 To evaluate and re-create WOAW's organizational structures & processes Researchers 14-25 A new organizational structure designed to address ongoing tensions. Given that WOAW members, service providers, and researchers had diverse backgrounds and occupied different social locations, there were also varying levels of interests, needs, and skills that affected our organizing practices. For example, not all members were interested in formalizing a structure because they wanted WOAW to remain more informal and flexible. Other members had trouble with the level of chaos that emerged from the fluid approach and preferred a tighter structure and more formal guidelines. Additionally, not all members had the language or organizing skills to comfortably participate in the decision-making and shared leadership processes and we made inconsistent efforts to work in a language other than English. Some members lacked the confidence to chair meetings or the capacity to communicate their ideas articulately, while others grew more comfortable doing so over time. In part because of this imbalance in skills, education and confidence, the service providers and researchers at times occupied what we saw as an unbalanced amount of power. On occasion, we took over work when members were unable to fulfill their commitments, we often stepped in to chair meetings when members were unwilling to do so, and we played a 81 significant role in dkecting the development of the organization through the series of workshops. This imbalance of power was a source of discomfort for many of us, since we shared a desire to facilitate a grassroots organization. In some respect, the roles that we played were examples of positive use of our power and resources. At other times, frustration or the paternalistic sense of 'knowing better' influenced our engagement and dominated the organizing dynamics. The line between using our privilege responsibly and not taking over the process was fine indeed, especially since some members continued to expect us to take over the leadership of WOAW in order to use our skills and resources to guide the process. Communication was another ongoing challenge in WOAW. Given the large number of members, the various sub-groups, and the somewhat variable attendance at Project Team meetings, it was difficult to effectively communicate the extensive number of activities that were occurring. Efforts to communicate across the membership were made through phone and email trees, a newsletter, and reports at Project Team and sub-group meetings. These efforts were often ineffective because members were unable to maintain the associated workloads and much information was lost or forgotten between meeting times, in part because many members did not have access to computers. Increasingly, the gap in communication left members feeling excluded from events and contributed to tense interpersonal and sub-group relations. As these relationships intensified, members' willingness to cooperate with one another declined, significant conflict developed, and our collective ability to sustain WOAW's vision and organizational practices was compromised. WOAW's Sustainability WOAW proved to be unsustainable and the organization dissolved in the latter half of 2005, shortiy after I finished collecting the data for this dissertation. Our lofty vision and organizing ideals became unmanageable across our significant differences in class and other 82 markers of privilege and power. Additionally, as funding and other institutional backing dwindled, addressing the members' extensive barriers to participation became impossible. In the face of a neoliberal political upheaval, service providers were less able to support WOAW, members' already impoverished lives became more challenging and complicated, and as such, intense dynamics amongst the membership resulted in a decrease of interest and willingness to do the work necessary to sustain the organization. Despite its demise and amidst its messiness, WOAW and its organizing practices served many of its membership well over the years. The upcoming chapters delve significandy deeper into this incongruity by mvestigating the ways in which inclusion was and was not facilitated, how issues of power and difference perpetuated conflict, and how members understood the impact of WOAW on their health. Before tmning to these findings however, I first describe and reflect upon the research methods and methodology that framed this investigation. 83 C H A P T E R 4 Research Methods Pam: Why did you agree to participate in my study? Sydney: Because it gave me a chance to talk about things that were happening in the group and it made me feel included. (Sydney's interview) Patricia: Because a lot of things have come out of the research, and when we are doing the research that it was shared, and it helped people know what was going on in the community. (Patricia's interview) Fourteen women who were current or former members of WOAW agreed to participate in my research project. This group of women occupied diverse social locations and had varied levels of involvement in the organization. The data that we co-created consisted of 12 face-to-face interviews, two telephone interviews, three written stories, one collaborative analysis research party, and one meeting to explore possible actions that we could take based on the knowledge produced. The data collection process was informed by our mutual experiences in WOAW and further documented through my reflexive field notes. My intention at the onset of this project was to create a research process that facilitated the inclusion of WOAW members. As such, and in keeping with FPAR tenets, I committed to a feminist participatory action research design that unfolded over time (Frisby & Reid, forthcoming; Tom, 1996; van der Wey, 2004). Participants and I continually made choices that directed and shifted the emerging process and responded to ever-shifting and, at times, competing lived realities and agendas. In this chapter, I describe and reflect upon the power dynamics the inevitably infiltrated our FPAR process, including the possibilities and challenges associated with remaining vulnerable to an open-ended plan. Before turning to the details of my methods and the theories that framed them, I begin by introducing the 14 women who made this work possible by sharing their stories, perspectives, and energy with me. 84 Participant Introductions During each data gathering session, I asked participants why they agreed to be involved in my study. As the quotes that open this chapter exemplify, participants chose to engage in this research process because they wanted the opportunity to give voice to their stories, they valued and trusted our existing research relationships, and they sought to make a difference in their lives and their communities by gathering and acting upon the knowledge we co-created. Importantly, each of these reasons fell in line with FPAR goals. Similarly, Peel, Odette, Douglas & Lawton (2006) found that people chose to participate in research when the subject matter was personally meaningful, when they thought the research could help them and others, and/or when they anticipated a therapeutic element to giving voice to their stories. Table 3.1 provides a glimpse into participants' backgrounds and identities and includes a quote to illustrate the role that WOAW played in each of their lives. Throughout this dissertation I have denoted participants' contributions using real names or pseudonyms of their choice, a topic I will explore later in this section. Yet I struggled with how to introduce them in a way that protects the confidentiality of those who sought it, while also describing them in ways that were not completely depersonalizing. Because these descriptions might easily reveal the identity of participants to WOAW insiders, I have chosen to name each woman by the colour of jewels in Table 4.1 and keep the information as broad as possible. This decision also prevents readers from connecting participants' descriptions to their quotes throughout this dissertation. 85 Table 4.1: Brief description of participants (at the time of this study) Pariiripsim 1 )emographic "description The impact of \\ ().\\\ on their U\«. Azure Azure was in her late 40s and immigrated to Canada in 2000 from a South Pacific nation. She was married with 3 teen-aged children. She completed post-secondary education and held professional employment with a national public profile employment in her home country. Since moving to Canada she has worked in primarily minimum wage jobs in the food service and retail industries and also received Unemployment Insurance for medical reasons. "[WOAW] touched the very core of my sense of being important, being somebody, being a woman and a career woman, so it started everything. And I finally got a job." Ruby Ruby was in her early 60s, Caucasian, and Canadian-born. She was married with 5 grown children. She completed post-secondary education. At the time of her involvement in W O A W she was supported by Canadian Pension Plan disability benefits due to her extensive health concerns. "Being able to get out of my house sometimes is the issue, because I just felt so isolated at one point in my Ufe, that it caused me a lot of depression and being with a group Uke WOAW, made me want to do more." Opal Opal was in her early 50s, Caucasian, and Canadian-born. She had never been married and had no children. Although she had earned a university degree, her employment history was sporadic and Uttered with experiences of harassment and conflict. She also lived on Social Assistance for a period to tend to ailing parents. "I had been involved with a women's group before and I knew the kind of emotional support Uke this is usuaUy available by being with other women.... And I was going through quite a reaUy chaUenging time doing the caregiver role, so I needed an outlet and some connection." Emerald Emerald was in her early 50s. She was born in Central America and immigrated to Canada in 2000 after marrying a Canadian man. She had no children. At the time of the study, she was unemployed and dependent upon her husband's income because she felt that her EngUsh skills were inadequate to secure a job. "I joined W O A W because I was recent immigrant and I felt very lonely. I thought it was a very good idea to interact with other women and women that talk in EngUsh because it is a problem for me and I wanted to be doing something in the community and to have friends." Pearl Pearl was in her 70s, Caucasian, and Canadian-born. She was separated from her husband and had 2 grown children. For most of her career, she worked in public service after completing her post-secondary education. After retirement, she developed a serious disorder of her nervous system that seriously compromised the quaUty of her Ufe. She was financially supported by her old-age pension. "I go to feel to be accepted, for what you are and who you are, which you know, the women give each other respect. And that's been a big part of it." Amber Amber was in her early 30s, Caucasian, Canadian-born, and had a high school education. She was married and had three young children that she cared for on a daily • basis. She was therefore dependent upon her husband's salary. "It's been my outlet, it's been my, it's my way to find out who I am and what I can do. I've met some of the most amazing women that I'll ever get to meet and done some of the most amazing things I'll ever get to do." 86 Onyx. Onyx was in her early 40s, born in Central America, and immigrated to Canada in 1997. She was a single mother with one dependent child. Since moving to North America, she earned a post-graduate degree and held full-time professional employment. She was temporarily unemployed during the time of her involvement in W O A W and this study, which she attributed to a shift in market forces. "It was like suddenly I was by myself, working at home trying to do my own litde things to look for work but it was boring, it was depressing and I found that just going to meet people and meet other women, just as a network opportunity was very good." Jade Jade was in her early 30s, Caucasian, and Canadian-born. She was single with no children and had a high school education. After a brief period of working in the retail sector, Jade became unable to work due to a physical disability. She was dependent upon Social Assistance disability benefits and family support. "The idea that there is a group in my area and a place to go on a regular basis. Meeting women who live in my community and being invited into their homes for social times, to learn something about everyone. My self-esteem heightened with participating in meetings and at activities. As my confidence grew, I tried to take on a leadership role and be more involved." Sapphire Sapphire was in her mid-40s, Caucasian, and Canadian-born. She was separated from her partner and had two dependent children. After completing her post-secondary education, she had obtained work in the health sector. Her career was often interrupted by a serious mental health issue. "Well, I had just moved to the neighbourhood and I was interested in meeting people. And, I came from the [another area] where I was involved in a single mom's group and it was really good for connecting with other women and getting to know people in your neighbourhood." Garnet Garnet was in her mid-30s, born in Central America, and an immigrant to Canada in 1999. She was married with 2 young children. She completed post-secondary education in her home country and held professional work there. After immigrating to Canada, she could not find similar work because her English was limited and she was not willing to work a rninimum-wage job while paying others to care for her children. She was therefore dependent upon her husband's income. "And I visited W O A W and listened at one meeting and saw one activity and I realized that it would help me, because I wouldn't feel so isolated. And I also can practice English. And I felt frustrated that something I had in my own country and I don't have it anymore. And I have economic oppression, and I realized I can have a distraction." Amethyst Amethyst was in her late 40s, Caucasian, and Canadian-born. She was separated from her partner and had no children. After creating and maintaining a successful small business, she developed a number of serious and debilitating ailments that forced her to close her business. She then became reliant on Social Assistance disability benefits. "WOAW was for me completely. I love the people that I'm with and when we had our little group and things happening, I was going to W O A W for me. Which was very different for me in my life - that had changed. Where before I was always doing for others, helping others. I had no self care. ... But I was being reminded that I needed to take care of myself first. Again that came from the mentorship of the older women." 87 Topaz Topaz was in her early 70s, Caucasian, and Canadian-born. She was single and had 3 grown children. After completing her post-secondary degree, she had a career in social services and retired on a government pension. "I'm in my glory in a group. It's very satisfying and rewarding to be in a group ... its wonderfully fulfilling and uplifting." Aquamarine Aquamarine was 50 years old, born in Central America, and immigrated to Canada in 1999 after marrying a Canadian man. She had one dependent teenaged child. After completing a post-secondary degree and holding professional employment in her home country, she was unable to secure comparable work in Canada because her qualifications were not recognized and her language skills were considered inadequate. She therefore held a minimum wage retail position. "I had a very bad depression when I get here. And one day they announced a conference about food, so I went only to have something to do and try to meet people. ... Some of the ladies from the group were there, and they told me about the group and the next week I started going to the meetings." Turquoise Turquoise was 70 years old, Caucasian, and Canadian born. She was divorced and had one grown child. After completing a post-secondary diploma, she held positions in the health care industry. Her career was interrupted by a series of physical and mental health concerns. She lived on old age pension. "Back in that basement suite, the children would come right up to the glass in my living room and peer in on me. I was in constant pain; did not know any of my neighbours; had difficulty getting to church; there were many days when Ufe did not seem worth Uving. W O A W changed aU of that. My beautiful brand new suite is indirectly due to W O A W too." Involvement in WOAW Table 4.2 illustrates participants' involvement in W O A W . Table 4.2: Participant involvement in WOAW Sub-group Affiliations N umber of participants (n=14) ATP 7 CoPoMo 6 PoCO 2 SWCo 5 Years of Involvement Less than 1 1 1-2 2 3-4 7 5 or more 4 T\pe:- of Invohement lllllililll 1 1 1 1 ! i ii B f S i l l 1 1 1 1 1 1 1 1 1 il^ ^^ B^UI 1 1 1 1 1 1 i^ ^KIl i ! ! I I 1 1 1 1 USt^ ^^ ^^ H^ilt 1 1 1 . 1 1 H l ^ ^ i l i : i : Social activities 14 Physical activities 5 Educational activities 11 PoUtical activities 4 Project team organizing 10 Sub-group organizing 11 Teaching 3 88 Every study participant was also involved in the SSHRC-funded research grant through interviews, focus groups, and/or research parties. Five of these women also voluntarily participated in research conducted by other graduate students. As Table 3.2 demonstrates, the participants were affiliated across WOAW sub-groups, tended to be involved for two or more years, and participated in a wide range of recreational and organizational activities. Demographic profile of participant group The 14 women who participated in my study occupied diverse social locations. They differed across intersections of class, race/ethnicity, age, domestic status, and physical ability. They also had varied education, employment, and personal histories. As a group, therefore, they comprised a diverse sample of women whose identities intersected across some social axes and diverged at others. Tables 4.3-4.7 summarize their demographic profiles as a group. Table 4.3: Participants' ages •V Number of panicip.uus m - l - l : 31-40 3 41-50 5 51-60 3 >70 3 Table 4.4: Participants' economic status *i I :inancial support Number of participants (n-14) Social assistance 1 Disability benefits 2 Seniors pension 3 Supported by husband 2 Unemployment insurance 1 Part-time employment 2 FuU-time employment 2 Unknown 1 Reason* for low income -Immigration 4 Disability or ill-health 6 Retirement 1 Unemployment 2 Parenting 1 89 Table 4.5: Participants' education 1 '.ducation level . - Number of participants (.1=14; High school 2 Post-secondary 11 Post-graduate 1 Table 4.6: Participants' domestic and parenting statuses Domestic status Number of participant in - 1 1 , Married 6 Single, separated, or divorced 8 Parenting Mothers with dependent children 6 Mothers with grown children 4 Women with no children 4 Table 4.7: Participants' race/ethnicity & immigration Self-identified Ethnicity • Year immigrated to Number of participants • Canada • n - i r . Caucasian Canadian-born 9 Filipino 2001 1 Hispanic 1999 1 Spanish 1997 1 Mexican 2000 2 As Tables 4.3-4.7 demonstrate, participants ranged in age from their 30s to their 70s, had various domestic and parenting situations, and received their relatively low incomes from diverse sources. Also, the majority of women were White and Canadian-born, while five were women of colour who immigrated to Canada less than eight years before the time of the study. One notable feature of these participants' collective demographics was their education level. Although nearly every woman lived below or near the poverty line, they had considerably high education levels with 11 of them having completed post-secondary education and one woman having completed post-graduate school. This feature is sttiking because it transcends typical socioeconomic status/education metrics, whereby individuals on low incomes tend to have lower levels of education in Canada (Ronson & Rootman, 2004; Ungerleider & Burns, 2004). 90 Certainly this was the case for the majority of WOAW members, as Reid's (2004) research has highlighted. This anomaly may be explained by the fact that 10 of 14 participants transitioned from middle-class backgrounds to more impoverished situations as a result of immigration, disability and ill-health, unemployment, and/or domestic care giving responsibilities. Confidentiality & anonymity Research Ethics Board requirements of confidentiality can create a double-edged sword. On one hand, they importandy seek to protect the identity and vrunerability of often-marginalized individuals in the research process (Brydon-Miller, Greenwood, & Eikeland, 2006). On the other hand, mamtaining confidentiality can compromise feminist analysis practices of contextualizing data within social, economic, and political dynamics that are in part provided by participants' identities and lived realities. Confidentiality requirements, especially those that are enforced by the academy, can also limit potential group actions that may serve to publicly identify members of vulnerable populations (Hegeland, 2005). However, as the participants' different choices around how they would like to be identified in this document revealed, we cannot assume that all participants desire confidentiality; in fact, some preferred to have their voices heard and validated (Giordano, O'Reilly, Taylor, & Dogra, 2007). Given that WOAW was a public, community-based organization, participants felt that the primary risk of being involved in my study was that their comments about sensitive topics, such as organizational conflict and power, could negatively impact their relationships with other members. Another less likely, although possibly of greater risk for some members was having their social assistance benefits compromised by disclosing their involvement in this community organization. For example, one participant's ability to receive her disability support was challenged because they saw her contributions to WOAW as Volunteer work,' which was not allowed since the government worked from the assumption that if an individual could do 91 volunteer work, she should also be able to hold employment. While she eventually won her challenge, the entire process was extremely stressful for her and she remains fearful of a reoccurrence. In order to clarify, minimize, and perhaps balance these risks against potential benefits, I discussed these issues with participants before they signed the ethical agreement forms. Following my analysis, I then mailed each participant copies of their quotes and other descriptive information that I intended to include in this dissertation. In a follow-up phone call I discussed the inherent risks with each participant and asked them to choose whether they would like to have their real names or pseudonyms attached to this information. Of the 14 participants, 6 chose to use their real names, 5 chose pseudonyms, and I assigned pseudonyms to the three who I was either unable to reach or who did not respond to my request. I reminded participants that anonymity through pseudonyms would not guarantee confidentiality within the organization because most individuals involved in WOAW would likely be able to identify the women involved in the study based on their personal profiles listed above, but would likely guard against outsiders being able to easily identify specific members. Those who chose to use their own names said that they had nothing to hide or they wanted to stand behind their words. Those who chose pseudonyms did so because they were concerned about the potential risks associated with being identified by people either within or external to WOAW, as discussed earlier. These choices provide one example of the ways in which participants reflected upon and directed their involvement in the research process in keeping with FPAR ideals. Feminist Participatory Action Research: Theory, Methodology & Epistemology As a fernimst participatory action researcher driven by a distinct social justice agenda, I was nourished in this work by my "commitment of caring to know and knowing to care" (Gunzenhauzer, 2006, p. 642). I believe that new knowledge and new ways of producing it are 92 central to the elimination of oppression and domination and the simultaneous facilitation of self-development and self-determination (Maguire, 2001; Reid & Frisby, forthcoming; Young, 1990). This is especially true for research aimed at addressing the roots of inequity that compromise women's health through CBHP and inclusion processes (Labonte, 2004; Raphael, 2002; Wallerstein & Freudenberg, 1998). Methodologically, participatory action research (PAR) has become a mainstay in the field of CBHP (Minkler & Wallerstein, 2003), in response to the positivist monopoly of truth, knowledge, and power and was seen as a process to be done 'with' community members rather than 'to,' 'for,' or 'on' research subjects (Lather, 1991). Researchers take on facilitative roles, rather than sitting back as the distant observer or attempting to control the entire process (Gibbon, 2002). PAR is explicitly political and action-oriented, striving for individual consciousness raising, empowerment, and social change (Frisby, Crawford, & Dorer, 1997). Maguire (2001) contends, however, that PAR is typically conducted under the assumption of gender-neutraHty or gender-equality and argues for a feminist lens to focus PAR methods and goals. She asks: "without a grounding in feminisms, what would action research liberate us from and transform our communities into?" (Maguire, 2001; p. 60). Maguire's concern continues to be applicable in CBHP. Although PAR methods have been wholeheartedly embraced by CBHP researchers and the principles of FPAR remain in line with those working to address women's health issues, it seems that with only a few exceptions, most involved in CBHP are tentative to expuciuy embrace the term 'feminist' (e.g., Clarke, 1992; Daykin & Naidoo, 1995; O'Connor et al., 1999; Ward-Griffin & Ploeg, 1997). Reid and Frisby (forthcoming) have responded to Maguire's (2001) call by creating a framework that integrates PAR principles with feminist theories and methodological concerns. From their perspective, FPAR: 1) centers gender and women's diverse experiences while challenging forms of patriarchy, 2) accounts for mtersecting oppressions, 3) honours voice and 93 difference through participatory processes, 4) explores new forms of representation, 5) requires reflexivity, and 6) legitimizes many forms of action towards social change (Reid & Frisby, forthcoming). Each of these dimensions points to the need to interrogate, redefine, and transform power relationships, tasks which remain central to feminist goals of social justice (Brydon-Miller, 2004; Lykes & Coquillon, 2006). FPAR, as a methodology, is a theory of how research can be conducted from an explicitiy feminist perspective (Harding, 1987). Yet given the diversity of feminist perspectives, it remains crucial for feminist participatory action researchers to be more explicit about the epistemological assumptions that inform our process and analysis (Maguire, 2001; Tong, 1998). Naples (2003) suggested that: The specific methods we choose, and how we employ those methods is profoundly shaped by our epistemological stance. Our epistemological assumptions also influence how we define our roles as researchers, what we consider ethical research practices, and how we interpret and implement informed consent or ensure the confidentiality of our research subjects, (p. 3) An epistemological stance refers to the assumption one makes about the nature of knowledge and how it is produced (Harding, 1991). My feminist belief system has been influenced by a variety of divergent yet complementary theories and political positions that recognize and problematize the connections between knowledge, power, and social justice; thus I am hesitant to apply a single label to it. However, to keep my perspective contained for the purpose of clarity within this document, I will loosely describe my work as 'contemporary materialist feminist' because of its amalgamated nature and its rooting in the material and ideological reality of women's lives (Naples, 2003). Contemporary materialist feminism developed from socialist feminist theory that was critically informed by standpoint, poststructuralist, critical race, and critical psychological feminist theories of meariing, subjectivity, and oppression (Collins, 2000a; Fraser, 1997; GiUigan, 1982; Naples, 2003; Smith, 1987; Weedon, 1999; Young, 1990). 94 A core principle of materialist feminism is that women's everyday lived realities and perspectives give insight into socially structured systems of oppression and domination and therefore that typically ignored and silenced voices provide alternative, legitimate, and valuable sources of knowledge for understanding and ttansforming our social world (Harding, 1997; Smith, 1997). Yet women's stories provide only partial and subjective information because there is no universal truth, but rather multiple ways of understanding the world based on one's social location within systems of power and privilege (Mohanty, 2004; Weedon, 1999). Women's diverse experiences of privilege and oppression are socially constructed by multiple and fluid systems of power such as gender, race/ethnicity, class, (dis)ability, and sexual orientation, which intersect uniquely to socially situate each of us (Collins, 2000b; McCall, 2005). Experiences of privilege and oppression also become internalized and embodied, in ways that deeply penetrate women's beliefs about what is possible and desirable (Barcinski & Kalia, 2005; Fonow & Cook, 2005; Mulvey et al., 2000). Material feminists assume that although gender, race, class and other social axes are socially created and unstable categories of analysis, they have real consequences for those living impoverished lives (Lather, 2001; McCall, 2005; Mohanty, 2004). Material deprivation and the disproportionate distribution of wealth are of central concern, under the recognition that mtersecting experiences of oppression are most often lived via class differences (Bettie, 2000; 2002). Ideologically, oppression plays out through shaming, stereotyping, and dehumanizing practices to which those deemed 'Other' are subjected on a daily basis (Reid, 2004; Young, 1990). These interconnected experiences typically serve to disempower women whose struggle for existence, legitimacy, quality of life, and good health is continually and systemically undermined. As such, material ferninists focus on women's agency and power as a site of 95 representation and struggle, witliin the broader context of producing knowledge for personal and systemic transformation (Hesford, 1999; Naples, 2003). The critical feminist lens that I use throughout this dissertation was shaped by my commitment to the theoretical and methodological ideals of FPAR as informed by contemporary material feminism. This lens provided a rich grounding for my unfolding methods and for the investigation of my research questions and situated my entire process within the broader context of social justice. As I found, however, the scope of such ideals can be overwhelming, especially for novice researchers (Gibbon, 2002; Maguire, 1993; Reid, 2004). Conducting FPAR is an inherendy complicated process because attempts to disrupt traditional research relations require researchers and participants to swim against the tide of patriarchal and otherwise oppressive ideologies and assumptions, hierarchical institutions and policies, and material mequalities (Greenwood, 2004). Yet the challenge of the process might just be the key to unravelling the deeply held assumptions that researchers and participants bring to research settings and thus holds the potential for fostering personal and collective growth (Varcoe, 2006). An elegant way of describing [feminist] PAR is that it is 'a natural process of growth.' In this definition, 'natural' means that nothing is forced in that the worker starts where people are and believes in the strengths of the members. Process is the never-ending succession of discovering, taking action, reflecting, and doing it again and again together. The final product is a spkalling cycle of 'growth' that happens at many levels: individual, group, social, and political. (McNicoll, 2003, p. 46) Williams and Lykes (2003) similarly refer to their PAR experiences as a 'reflexive cycle' of introspection, analysis, and (in)action that was mutually informed by theory and practice and worked to navigate the messiness of working against deeply embedded,power imbalances. In the following sections, I describe my unfolding FPAR methods and reflexive practice by naming, supporting, resisting, and/or legitimizing the varied sources and enactments of power 96 and agency that were central to the co-created knowledge in this dissertation. I sought to provide a humble, yet important, contribution to feminists' "long haul struggle to create a world in which the full range of human characteristics, resources, experiences, and dreams are available to all" (Maguire, 2001, p. 66). Participatory Research & Unfolding Realities Ferninist participatory action researchers' intention to destabilize traditional power relations requires them to relinquish some control of the research process. Participatory research that emerges over time means that researchers must respond to the diverse and unique ways in which participants' realities and perspectives infiltrate the research process (van der Wey, 2004). Rather than slicking to a rigid research design, researchers should be open to having their plans and strategies challenged, revisited, and altered based on participants decisions and actions within a project (Tom, 1996). This commitment often leaves researchers and their agendas relatively vulnerable to an ever-changing environment that requires constant reflection and negotiation. However, it can also help facilitate a process that remains relevant to participants' lives, true to collective research intentions, and therefore in line with FPAR values of inclusion, choice, and voice (van der Wey & Ponic, 2005). Inclusion and participation are critical elements of FPAR and, given their relevance to my research questions, they were also guiding forces in my research design. I created an innovative and open-ended strategy for inviting participation and for collecting and analyzing data that required my willingness to be flexible and responsive to participants' preferences, needs, and realities (van der Wey, 2004). I consistently faced ambiguous, challenging, and contradictory situations that inadvertently resulted in participants' exclusion and reinforced my power as researcher (Hall, 2005; Reid, 2004). However, there were also instances when participants enacted their power in ways that interrupted and enlivened the research processes, some of 97 which left me vulnerable to their decisions. As I describe my research process in the following sections, my aim is to provide insight into the situations I faced and the decisions I made amidst ever-shifting power relationships. Ethical recruitment, fostering inclusion & existing research relationships The relationships that develop between researchers and participants engaging in FPAR raise particular ethical concerns around coercion and voluntary consent (Brydon-Miller, Wadsworth, & Satiani, 2004b). At the onset of my research project I had an existing V/2 year relationship with WOAW and its members and had developed a variety of formal and informal relationships with those I invited to participate in my project. In my role as project manager of the SSHRC grant I carried significant power as I controlled the money that was offered to WOAW members as honoraria for research participation and that financed research-related activities, I conducted tape-recorded interviews with them and took field notes at meetings and activities, I facilitated research and evaluation meetings, and I wrote reports filled with recommendations for how to move WOAW forward. The practical conditions that fostered my power in WOAW through the SSHRC-funded grant formally ended by the time I began this research. However, I was aware that remnants of my power within WOAW might carry over, particularly as they were perpetuated by my roles as an academic researcher. Many members still looked to me for leadership within the organization and as someone with access to resources who could facilitate and support them as individuals and in WOAW processes. For example, I was regularly asked to chair meetings, write personal reference letters, and help with bureaucratic paperwork such as government application forms. In this light, WOAW members' ability to consent freely to my study was implicated by our existing relationship if members felt that not agreeing to participate might jeopardize my support of them personally or within the organization. 98 To contextualize these tensions, I turned to the notions of 'ethics in practice' and 'relational ethics' to guide my decisions. Ethics in practice refer to the ethical dilemmas that arise in daily research practices while relational ethics refer to the particular considerations that researchers must negotiate when working with participants that they know and care about, sometimes in deep and mtimate ways (Ellis, 2007; GuiUernin & Gillam, 2004). Underlying these combined strategies is the desire to "recognize and value mutual respect, dignity, and connectedness between researchers and the researched" (Ellis, 2007, p. 4). With these commitments in mind, I strove to make ethical decisions that were in keeping with the intentions of my research project, my relationships with participants, and university ethics requirements. The task of meeting these often-competing parameters was challenging. In order to facilitate voluntary consent and avoid coercion, the UBC Research Ethics Board required that I invite participation through a written letter rather than a face-to-face or telephone invitation (see Appendix I). This requirement made sense to me, as I understood that it would be easier for women to choose not to respond to my invitation through a letter than it would be during a phone or face-to-face encounter, especially at a WOAW meeting where my power was most apparent. I wanted WOAW members to agree freely to their involvement in my study because they valued our relationship and the potential benefits of involvement, rather than feel pressured. I also believed that their inclusion would be undermined if it was driven primarily by my power in the process, rather than their own (Shartrand & Brabeck, 2004). However, as I wrote the formal letter of invitation (see Appendix II), guided by UBC requirements, I realized this effort to avoid coercion might inadvertendy serve to exclude many WOAW members. The formality and academic language of the letter was not in keeping with my relationship with most WOAW members and might have been unreadable for women with literacy concerns and/or who spoke English as their second language. It served to highlight our 9 9 status and privilege differences as researcher and potential participant. Based on my experiences, I also knew that many WOAW members had a strong aversion to and distrust of bureaucracies and often refused to read formal letters. As I reflected in my field notes, I realized that "although there are good reasons for writing the letters, they may work to hurt, alienate, and/or exclude some women, which are in direct conflict with what I am trying to accomplish in my 'inclusive' methods" (Pam's field notes). When I contemplated who did and didn't respond to my letter of invitation, I suspected that the letter served dual purposes. In all likelihood, it provided a relatively easy out for WOAW members who did not want to participate, but that it also prevented some members from being involved because they resisted reading the formal letter. My desire to foster inclusion and avoid coercion, coupled with strict and formal ethical requirements, both destabilized and reinforced the power imbalances between me and my participants. Another example of this tension involved my persistence in interviewing a particular WOAW member. I saw her as being a key figure in the WOAW dynamics that I was interested in exploring and I knew from experience that she was a reflective and insightful interviewee. During our initial conversation she told me that she was learning to say no to invitations in order to make her life more manageable. This made it tenuous to invite her participation and I told her so. She reified her power and choice within the process when she assured me that this interview was important to her and that she wanted to do it. However, she proceeded to cancel three scheduled interviews due to ill-health. While I knew she suffered from chronic health issues and that her sporadic participation was a pattern in WOAW, I wondered whether or not her cancelling was indicative of an overall reluctance to participate and felt concerned that my persistence around interviewing her was bordering on coercion. On the other hand, my perseverance may have shown her that I valued and recognized her contributions in WOAW 100 and thus inspired her to remain engaged in our process. In line with my intention to foster voluntary participation, each time we spoke I reminded her that her participation, although desired, was optional and that it was fine for her to change her mind about participating. We eventually conducted the interview on our fourth attempt and, as I had hoped, it was rich and insightful. At the end of the interview, as my field notes below reflect, we discussed the issues of persistence and inclusion. We actually talked about this at the end of the interview, where we both said we appreciated the other's persistence in sticking with this interview. She said it's an example of what makes her feel valued in WOAW. I know that I kept trying because she's a good interview and she was an important informant for my work. How much was my persistence fuelled by my desire to be inclusive? I certainly haven't been as persistent with others. (Pam's field notes) This example may illustrate that I successfully managed to negotiate the balance between inclusion, exclusion, and coercion in this instance. However, because I was not as persistent with other members, my reflexive process forced me to consider that some of my choices might have been fuelled more by my own academic agenda then by my desire to foster inclusion (Brydon-Miller, 2004). On another note, my language in this field note also demonstrates how easy it is for researchers to inadvertendy objectify participants in their writing. Although I have attempted to represent all of the women in my study as active agents, my casual reference to this participant as a 'good interview' was both disrespectful and dehumanizing. In fact, as a feminist researcher acutely aware of the power of language, I was embarrassed to have members of my committee point out such oversights. I invited all WOAW members whose contact details I had access to and asked those members to extend my invitation to others who I may not have contacted. Because this number was substantial (n=46+) and I was cornrnitted to a qualitative framework, I needed to find creative ways to hear from a potentially large number of women. Additionally, I realized that potential participants might have different mclinations for how they shared their stories 101 depending on their comfort levels, talents, and/or communication skills. Reid and Frisby (formcoming) have noted that researchers are increasingly exploring 'counter-practices' such as poetry, photography, co-writing, and journaling to find alternative ways to communicate and investigate women's lived experiences (e.g. Baker & Wang, 2006; Lather, 2001; Williams & Lykes, 2003). With this notion of creative data gathering in mind, I developed a set of optional methods for participants to choose from as their preferred way of communicating their experiences. Table 4.8 outlines the options for participation that I devised based on my knowledge of the type of research activities WOAW members had chosen to participate in during earlier projects. Table 4.8: Participation options Option-presented Description of option Written story Participants could write a story in response to questions I posed Art form with description Participants could create a piece of art (e.g. a drawing) in response to questions I posed accompanied by a written or verbal explanation Telephone mini-interview Participants could be involved in a 30-minute telephone conversation and respond verbally to questions I posed Individual interviews Participants could engage in 1-1.5 hour face-to-face and semi-structured interviews verbally responding to questions I posed Self-selected focus group interview Participants could self-select small groups of 3-5 W O A W members for face-to-face 1-1.5 hour focus groups Large group meetings Participants could be involved in collaborative analysis and potential action-outcomes meetings The following section describes how WOAW members responded to my invitations and the complexity of my decision-making while striving to conduct emergent and inclusive FPAR. Data collection decision-making Fourteen of 46 invited WOAW members agreed to participate in my study. Ten participants agreed in response to my letter and 4 participants were interested but uncertain about their involvement. Three of these participants were hesitant because they were not sure whether or not they had sufficient involvement in WOAW to contribute in a meaningful way. The fourth 102 participant did not respond to my letter widiin the initial timeframe I had requested, but told another participant that she wanted to be involved. After I followed up with each of these participants, and assured them that they had valuable contributions to make to the research, they agreed to participate. Two other members who responded with initial interest did not answer my follow-up calls. Table 4.9 summarizes the responses I received. Table 4.9: Summary of responses to my invitation to participate Tvpc of response Number of participants (n=46) Agreed to participate 10 Declined to participate 2 Showed interest and/or uncertainty 6 Agreed to participate after I followed-up 4 Did not respond 29 Twenty-riine of 46 invitees did not respond to my letter and another two women declined my invitation. One woman who declined explained that she did not feel she had enough experience in WOAW to be involved in my research because she had only been involved for two weeks and had since moved from the area. The other woman did not provide an explanation. I did not follow up with either of these women because their responses clearly indicated a lack of interest in participating. Based on my experiences with them and the organization I can only speculate on why the other 29 members did not respond to my invitation. It is possible that some of these women felt 'over-researched' given their varied participation in the SSHRC project and in research conducted by three other graduate students. Some members may have declined because they were still recovering from the conflicts within the organization, that left many women exhausted and unwilling to delve back into these topics for my research. Since the energy in WOAW was low at the time, some members may have decided to move on from the organization and therefore my project may not have seemed relevant in their lives. A final possibility is that some members may not have felt comfortable discussing their stories with me, despite or perhaps because of my long-term involvement in the organization. In fact, it might 103 have been a combination of any of these possibilities that prevented the majority of WOAW members from participating. In my letter of invitation, I asked potential participants to indicate via a checklist which participation options they felt comfortable with. As Table 4.10 illustrates, most participants were open to more than one way of being involved. Their variety of preferences required that I choose which data collection tools I might proceed with and with which participants. For example I wondered: should I have a mixed-methods approach to my data collection, ensuring that I received data from across each of the options I provided? Should I focus on one or two forms of data collection in order to have the most comparable sources of data? Should I go with approaches I was most comfortable with or should I stretch outside of my comfort zone to new and more creative methods? And, importantiy, were there certain choices that would result in a more inclusive process and facilitate the power and voice of my participants? Table 4.10: Summary of participation options chosen Option foi im oh c m e i u Number of participants who marked this option :o^ .i4) Creating an art form 2 Writing a story 4 Telephone interview 6 Face-to-face interview 12 Small group interview 8 Large group session 9 I decided to employ a mixed-methods approach in large part to honour participants' desire to contribute creatively, but also because I was curious as to how this might unfold and contribute different perspectives for answering my research questions. I asked each participant who was willing to write a story or create an art form to do so and provided a series of questions that were in line with my research questions to guide them. I was working from the assumption that this approach would enhance participant control over data collection as they would be free to create their responses without the influence of my presence. I invited each of the others to 104 participate in telephone or face-to-face interviews as per their requests. I decided to leave the possibilities of self-selected small group and large group meetings to a second and perhaps more collaborative data collection phase. Who participated in which forms of data collection shifted over time. While initially I was open to a variety of data collection methods, what unfolded was a data set comprised primarily of interview transcripts. This may not be surprising given the verbal nature of our society and the level to which interviewing dominates qualitative research (Fontana & Frey, 2000), and the importance of giving voice that was apparent in WOAW. Additionally, participants had become comfortable with the interviewing process through their involvement in the SSHRC project. My attempts to collect stories and artwork were relatively ineffective, likely because of my lack of skill in these areas. I was unsure of how to ask appropriate guiding questions that would speak to the sensitivity and depth of my research questions. For example, I received three stories that were at times interesting and msightful and at other times partial and superficial. The stories left me wanting to probe participants' experiences, which I did through face-to-face interviews. The project of creating art forms never came to fruition. There was a lack of clarity between myself and the two participants who chose this option. In both cases, the task became too ambiguous and cumbersome, so we communicated instead through interviews. I learned that despite the possibilities around creating choice and inclusion, my partial skills as a qualitative researcher served to limit what was possible with the alternative methods. A few months into my process I received an email from a participant who suggested that some members of her WOAW sub-group might be willing to participate in my research in a focus group session. I later learned that her intention was to tell group members that it was happening at the next group meeting and to see who showed up. While I was grateful for her initiative, I was also uncertain about this set-up, as my field notes illustrate: 105 My first reaction ... was that it was not a good idea. I didn't like the idea of waiting to see who would show up because I wasn't sure that it would provide a space to have the conversations I want to have. I also have fears that it won't provide a safe space for the women who showed up and had no idea what type of questions I would be asking. I was also feeling that I shouldn't do it because I wouldn't have enough control over the situation and that it may not be a good use of my time. (Pam's field notes) At that time my primary concern was participant safety. My experience of the unbalanced power dynamics and communication structures within that sub-group left me uncertain about each member's ability to freely consent to the research and feel safe in answering my potentially sensitive questions in the small focus group setting. I also suspected that since I would be reluctant to ask sensitive questions about inclusion and power in this setting I would not gather useful data. I was concerned that this exercise would be an inefficient use of my limited data collection resources - a challenge which speaks to the reality of conducting FPAR as a graduate student confined by restrictive resource structures within academic institutions (Gibbon, 2002). Through a reflexive conversation with a peer WOAW researcher, I pondered whether or not my prior experiences in WOAW were limiting what I was open to in my research. I was anticipating that this process had the potential to be unsafe for members who did not trust each other enough to speak openly and therefore not useful for my purposes. This speculation was based on my assumptions about the power dynamics within this sub-group, which may or may not have been accurate. Perhaps my assumptions resulted in a missed opportunity to surrender some control of the research process. My desire to foster inclusion through the co-creation of the research process was being compromised by my desire to create an environment where participants felt free to voice their diverse perspectives and was further complicated by my personal history in WOAW. At the time, I felt that either decision would create what Hall (2005) refers to as entangled inclusion and exclusion. That is, if I chose to conduct that small group meeting, I would include the perspectives of a group of WOAW members but run the 106 risk of excluding the voices of those that felt unsafe in the situation. If I opted not to conduct it, I would exclude potential participants from my project, while simultaneously faciktating their need for safety as an instrumental source of inclusion within W O A W . In retrospect, I recognize that the situation need not have been so dichotomous. There may have been a way to organize the event that met both conditions of voice and comfort by emphasizing the participants' right to opt in or out of the conversation during the focus group and possibly by inviting individual participation for those who were quiet in the group setting. In my given circumstances at the time, I did not see this possibility and chose to err on the side of participant safety, based on the assumptions I was making about what they needed to be safe. While I do not regret this decision because I made a choice in which I felt like there was less potential for harm, I am aware that it served to reify my control over the research process and was less participatory in nature than depicted by F P A R ideals. Table 4.11 summarizes the data that informed this dissertation. I worked with 52 primary documents that were collected between March 25, 2004 & June 21, 2005. In the sections that follow I will describe some of the details and challenges I faced in my data collection process. Table 4.11: Summary of primary data collected Primary Data Sources Number of transcript* Written stories 3 Telephone interviews 2 Face-to-face interviews 12 Research party 1 Action meeting 1 Reflective field notes 35 Total # of primary transcripts A t the onset of my project I had intended to use interviews and field notes from the original SSHRC project, and had ethical approval to do so, to supplement my data set. However, as I moved through my data collection and analysis processes I realized that I had more than enough information in my primary sources and therefore did not draw this secondary source. I 107 did however use my existing knowledge of the SSHRC data, along with my years of experience as a WOAW researcher, to inform the story in Chapter 3 and the descriptions of events around the conflict and conflict resolution in Chapter 6. Feminist interviewing The interviews ranged from 45 minutes to two hours and 15 rriinutes and occurred between May 5, 2004 and February 2, 2005. The telephone interviews were conducted over speaker phone, with me at my home and the participants at their homes. For the face-to-face interviews I asked each participant to choose a location that was comfortable for her. All but one participant chose to be interviewed in their homes. The other interview was conducted as we moved between three locations: a fast-food restaurant, a parking lot, and a park bench. Most of our meetings began with some informal conversation, an offer of food or beverage, and a review of the ethical consent forms and personal history face sheets. The face sheets consisted of a number of questions about each participant's personal background and involvement in WOAW (see Appendix III). The interviews did not begin until each participant understood and signed the ethics form, including the consent to have the interview audio-taped. I specifically let the participants know when I was beginning the interview and that I was tarning the tape-recorder on. The notion of Teminist interviewing' refers to an intention by the researcher/interviewer to be empathetic rather than interrogative, in her approach and to create an environment where the interview and participant co-create the interview narrative in a mutual effort to produce new knowledge for social change (Fontana & Frey, 2005). With this in mind, I chose not to take notes during the interviews so that I could focus on my important role of interviewer as deep listener (Anderson & Jack, 1991). Bunding on the history of feminist approaches to interviewing and in keeping with my relationships with most of my participants, I wanted to 108 create a comfortable environment that felt more like a conversation than a hierarchical interview (Oakley, 1993; Rubin & Rubin, 1995). However, I also remained mindful of potential exploitation if this type of mtimate and conversational interview resulted in participants forgetting that the interview was for research purposes and answering my questions solely as friends (Finch, 1993). Our existing relationships may have provided environments where participants felt safe in sharing their thoughts and feelings with me. However, it is also possible that being too comfortable might have resulted in them communicating personal information that they might not otherwise share in a more formalized research setting. While I recognized that they had freely consented to this process, I attempted to maintain the research setting by fiddling with the tape recorder at regular intervals and remmding them that they did not need to answer any uncomfortable questions. I created a semi-structured interview guide based on my research questions on inclusion, power, and health (see Appendix IV). I offered participants advance copies of the interview questions and 4 of them requested the questions in order to prepare for the interviews. To avoid the formality of my grilling them with a list of questions to direct the conversation, I memorized my interview guide so that I had a strong knowledge of the ideas I wanted to talk about. Each interview followed its own path. I did not ask each participant each question in succession; rather I followed the flow of the conversation as it unfolded. Our collective knowledge of WOAW dynamics produced lively conversations about specific situations that spoke directiy to my research questions. I probed their understandings of WOAW events with questions specific to my interview guide and re-directed the conversation when it began to flow away from my research purposes. Through the flow of our conversations, the participants and I co-created and negotiated the interview text. 109 Fontana and Frey (2000) suggest that interviews are "persistendy slippery, unstable, and ambiguous from person to person, from situation to situation, from time to time" (p. 62), which certainly rings true to my experience of interviewing. While some interviewees were quite open and emotional, others remained detached and pragmatic. Some interviewees answered the questions with one sentence responses while others offered five minute anecdotes. In some instances, I found it challenging to get participants to focus on their own experiences and emotions in WOAW; instead I received speculations about other WOAW members' experiences or analyses of 'what went wrong' in WOAW. I reflected on this challenge in my field notes indicate: It was very challenging with her actually, getting her to talk about her experience, about how she felt, and really focusing on her experience. She has quite a strong and a sophisticated analysis of what happened in WOAW and talked a lot about where the other women were at and what happened between the other women But she didn't talk as much about her. I left with a sense of not understanding her any better in terms of what she felt during the group process. (Pam's field notes) There are a number of plausible reasons why each interview looked so different and why participants at times shied away from telling their own stories. Perhaps it was because each woman had a varying comfort level with me and with the sensitivity of my questions. Alternatively, the differing texture of each interview may have resulted because participants had different styles and skills in sharing her stories, especially those which may have left them emotionally vulnerable to my responses or interpretations. A third possibility is that the theoretical nature of some of the questions did not resonate with each woman's experiences. And finally, it might be a combination of each of these possibilities, which reflect the nature of the emergent conversations as they were shaped by our combined social and personal differences. Despite these possible tensions, the data set provided me with excellent 'snapshots' of participants' experiences as will be evident in the upcoming fmdings chapters. 110 As the data collection unfolded, my reflections helped me to understand the role that my internalized social location played in co-creating the interviews and their inconsistencies (Nunkoosing, 2005). I realized that my decisions around what questions to ask, when and how deeply to probe, and how much to reveal of myself in the interview seemed to vary according to class, race, and education differences between me and my participants (although other differences that I am not aware of may have contributed to this dynamic as well). I was most comfortable with participants who I believed shared at least some strands of my social location, in particular class and education. Interestingly, race differences seemed less challenging for me to negotiate than class, as my comfort level was relatively high with the participants of colour. I attribute this level of comfort to our somewhat comparable backgrounds, since all of these participants were raised in middle-class families and had post-secondary education. In these instances, our mutual comfort levels resulted in engaging, deeply personal, and reciprocal dialogues, where I felt a freedom to explore their experiences and an ability to respect the boundaries they set for the interview. On the other hand, with participants who I understood to have a different class status and education than me, I found myself to be tentative and to retreat from deeper dialogue because I was afraid that it was inappropriate for a middle-class person to question their interpretations. Despite an inner desire to set aside stereotypical assumptions that the intellectual and emotional strength of these women was limited, I engaged in a manner that at best can be seen as protective and at worst condescending. I shied away from asking what I thought to be difficult questions that challenged their understandings or behaviours in WOAW. WTien a participant became emotional, for example, instead of exploring what lay under her tears, I quickly changed the subject or remained silent and allowed her to compose herself. In these moments I held tension in my belly and knew that my decisions echoed stereotypes that I abhorred but that lived in my body nonetheless. In these instances, I failed in my desire to 111 respect each woman's strength and diverse perspective and instead hid behind my guilt and privilege by staying detached from their deeper stories. While the variety, scope, and nature of my interviews was at times worrisome, in retrospect I believe that the interviews were a product of the particular relationships I had with each participant. In each scenario, we negotiated the power and social dynamics of our interview experience, as we chose what to say and not say to each other. We thus co-created what a growing number of qualitative researches refer to as a collective, contested, and contextual memory of a particular set of experiences (Fontana & Frey, 2005; Nunkoosing, 2005; Silverman, 2000). Within each interview setting, participants decided how make meaning of and share their experiences in response to the questions and comments I offered as interviewer (Cacioppo & Hawkley, 2003; Clegg, 2006; Maguire, 1993; Wahab, 2003). Rather than lament the comparability and authenticity of each interview, I have come to understand that "interviewing is inextricably and unavoidably historically, politically, and contextually-bound" (Fontana & Frey, 2005, p. 695) and therefore that each data gathering experience contributed unique, diverse, and socially contextualized ways to understand and create this particular picture of WOAW and participants' experiences within it. Lived realities & the balance of power My data collection process was littered with complicated circumstances, which were heightened by the fact that I live a considerable distance from participants and travelling to their neighbourhoods was a full-day event. For example, one participant cancelled three interviews on the day of each interview due to ill-health, another forgot about our scheduled interviews on two separate occasions because she was in the midst of some complicated negotiations with a local bureaucracy, and a third brought her young child along on the interview despite my understanding that she arranged childcare for which I offered to pay. In 112 each situation my initial reaction was to be angry and frustrated by how my participants' choices affected my data collection process and wasted my limited resources. A t the time, I did not fully consider the possibility that in each of these situations, the women's daily realities may have made participating in my study inconvenient for them. Reflecting on these emotional responses in my field notes I came to realize that these seeming inconveniences were "a practice in patience for me, I just kept remmding myself that it was part of the whole picture, this was her reality, she's always mothering" (Pam's field notes). Critically considering my emotional reactions as data sources gave evidence to the deeply embedded assumptions and realities associated with the class and other social differences between me and the women who participated in my study (Davis & Gremmen, 1998; Ponic, Reid, & Tom, 2002). This level of reflexivity also gave me insight into how participants' realities shaped the relevance of W O A W in their lives. During the most challenging of these situations, I briefly contemplated whether or not it was worth continuing to pursue these participants. In each case I quickly realized that I both wanted and needed their involvement and that, despite my frustrations, I was willing to put up with these inconveniences to include them. While I could position my decision to persevere as an example of my efforts at inclusion, it is more honest for me to admit that my persistence was often driven by my desire to create an academically credible data set. I felt like I needed to pursue these participants because they represented certain voices in W O A W and without them my findings would become increasingly partial. Brydon-Miller (2004) points out that this is a common tension for those of us attempting to engage in participatory and community-based relationships while mamtaining a foothold in the privileged location of academic researcher. In allowing participants to dictate the logistics of their interviews, I became vulnerable because, in the process of fostering a feminist and emergent research process, their exercises of power and 113 needs in the process had overshadowed my own (Nunkoosing, 2005). While I didn't realize it in the heat of these emotional moments, my vulnerability lay at the core of destabilizing traditional research and power relations (Maguire, Brydon-Miller, & Mclntyre, 2004). Collective analysis & action The research party The notion of a 'research party' had been established in WOAW as a regular practice whereby researchers would organize a gathering of members for research purposes. These three-hour parties were facilitated by the researchers and we typically found ways in conjunction with the community service providers to supply food, childcare, and transportation. One purpose of the research parties was for researchers to present initial findings to WOAW members to build on, analyze, and verify our understandings of their experiences, thus including them in the analysis portion of our FPAR process (Frisby et al., 2005). Herbert (1996) articulated the 7 C's of participation in order to assess and categorize the range of well- and ill-intentioned ways that researchers have engaged in participatory processes with communities. They are: collusion, co-opting, convincing, coercion, coordination, cooperation, and collaboration (Herbert, 1996). With an intention of facihtating 'collaboration' in the data analysis process, I invited participants to a research party after the interviews were complete and I had conducted some initial analysis. In preparation for the research party, I organized a location, cMabninding, food, and transportation and incurred the associated expenses myself. I asked Tammy, a colleague and former research assistant in WOAW, to assist me with the set-up and to take field notes while I facilitated. The purpose of her field notes was to document the details of the meeting, such as the tone, informal comments, and participants' body language, that would not be captured by the tape recorder and that I might miss while facilitating the meeting. I planned my agenda and 114 created flipcharts that outliried the themes I had identified in my early analysis of the interview and writing transcripts. My hope was to facilitate a discussion about the various themes, mcluding how they intersected and contradicted each other. The party was attended by 7 of 14 participants. Six of the seven participants who did not attend were unable to do so because of other cornmitments. The seventh was not willing to participate in a group discussion about WOAW. I mailed a copy of the handout I had prepared for the party to those who were not present and asked them to respond as they saw fit. One participant mailed back the handout with her comments written in the margins and another left me a phone message that said 'I agree with everything you wrote.' During the party, participants eagerly engaged in the conversations around the themes I identified, giving evidence to their interest and willingness to be involved in this participatory process. They offered additional stories that built on one another, verified the themes, added new themes, and with little prompting made connections between themes. This last contribution became evident as we moved through the flipcharts and realized that we had already covered much of the information on the later pages. The meeting was exhilarating for me as the participants were energetic, open, and willing to debate a variety of topics. In this moment I felt like we were 'collaborating' (Herbert, 1996). In retrospect, however, and similar to Reid (2004), the form of participation that we were engaged in can more adequately be described as 'cooperation,' since my role as primary researcher remained fixed. While I did not consciously 'choose' cooperative rather than collaborative strategies, it became increasingly clear that the possibility for collaborative analysis with research participants was limited by the decisions I made as a doctoral student. Facmtating collaboration, as per Herbert's (1996) model, would have required more extensive participant involvement in and control of the analysis process, mcluding theme development, cocling, and writing. This level of participation may have 115 resulted in a different and perhaps richer level of analysis, research ttaining for participants, and thus a more authentic version of FPAR. Yet it would also have required me to lengthen the rime of my process and over-extend my financial resources, two issues that were of significant consequence for a doctoral student limited by University timeframes and minimal funding. My decision-making around participation in analysis was also shaped by my perceived need to exhibit analytic competency as a PhD student. However, I now realize that facilitating collaborative rather than cooperative analysis may have demonstrated a more complex skill set in which I also relinquished my power as researcher. The action meeting At the end of the research party, I asked the participants if and how they thought we should act on the information we had co-created. I made some suggestions for action such as lobbying the City to reinstate their support of WOAW, writing a handbook for other groups like WOAW to learn from, or facilitating a series of meetings to support WOAW's growth. There was a sweeping consensus that the information should be acted upon and that it should be used to revitalize WOAW. I was excited by Diane's suggestion that we use our information to further explore "how to live WOAW's vision" (Diane, research party). Upon their request, I agreed to facilitate a follow-up meeting to continue this conversation. I felt a sense of responsibility and reciprocity to give something back as a feminist participatory action researcher so that our findings could be used to make a difference in the lives of women who participated in the study and who lived in their communities (Harrison, MacGibbon, & Morton, 2001; Wolf, 1996). In my initial euphoria, it seemed that the knowledge that we had co-created would actually be utilized to inform our action and transform WOAW. As my initial elation wore off, I became panicked about how I was going to facilitate such a meeting, especially in light of the complexities of inclusion, power, and conflict that we had 1 1 6 collectively uncovered. After reflexively working through my panic, I decided to facilitate a guided conversation about how to move WOAW forward, as a means to keep the women's wisdom as the driving force while also using my power and skills positively. This strategy provided what Vanderplaat (1999) refers to as relational empowerment, such that capacities of both the researcher and the participants are mutually utilized and extended. The action meeting was attended by 5 participants. I had expected larger attendance but there was a torrential downpour that evening that prevented at least 5 others from attending. I had organized the location and chddmmding with the local service provider and brought my food contribution for the poduck that had been suggested at the research party. As participants arrived, we shared food, chatted informally, and reviewed the flipchart notes from the research party that I had posted around the room. To begin the formal part of our meeting, I reminded the participants that we were there to decide how to use the information we had gathered together at the research party to move WOAW forward. I emphasized that I saw my role as facilitator of the discussion, but did not feel attached to any particular outcome. I asked the participants to check in by responding to two specific questions: How are you feeling about WOAW right now? What is the one most important step that we should take to move WOAW forward? I expected that the first question would provide some context and grounding for our action process and the second would create the springboard for what to do next. As the participants spoke I made notes on a chalkboard to summarize their check-ins. I reported back to them that I saw three main themes arise in terms of what they wanted from WOAW. They were fun, connection, and commitment, which were similar to the reasons that the organization was formed in the first place. In light of these themes and the challenges of shared work and leadership that participants identified in our data collection process, I asked 117 the participants to consider the following question: Would you be willing to commit to doing the work necessary to keep WOAW going in order to create some fun and connection? There was a definite lull in response to this question, which nobody answered directly. Perhaps they were uncertain as to whether or not they could commit to the organization. They may also have been speculating about who was responsible for sustaining WOAW and what commitment I might be willing to make. During the lull, I became concerned that I was pushing too hard or that I was not entided, in my privileged position, to ask this group to volunteer their limited resources to work for WOAW, and I thus became silent. In retrospect, I realize that contrary to my declaration otherwise, I was attached to members using the fmdrngs from our study to sustain and recreate WOAW. My attachment resulted in a desire to advance the ideals of FPAR and compromised the boundaries I had set in my role as researcher. Slowly, the conversation turned to communication and activity planning. One participant was particularly enthusiastic about the idea of developing a calendar of monthly fun events for WOAW members to plan and attend. As the participants brainstormed ideas, some members offered to take certain responsibilities to make things happen. Throughout this conversation, one long term WOAW member, who had lived through years of ups and downs with WOAW, pointed out the potential pitfalls of each plan. For example, she continually reminded the group of the potential barriers that some women might face to certain activities and of her concern that members would not fulfill the commitments they made to organize the activities. I found her contributions to be quite fmstirating, as her comments seemed to stifle the positive energy that the others were generating. However, I too was aware that the plans were proceeding with little attention being paid to the issues that we had collectively identified during interviews and at the research party. Basic components of inclusion such as location, childmmding, and cost were avoided, not to mention the more complicated aspects of inclusion and/or exclusion that 118 participants had identified, such as tense sub-group dynamics and distrust. While I tried to address some of these issues during the conversation, I realized that my comments also served to further stifle its flow; so I became silent once again. In retrospect, I realize that my chosen silences around the complexities of inclusion had repercussions. For example, withholding information such as one's own opinion does not just allow space for the other to speak, it can also be an act of power that forces the other to carry the burden of speaking or acting if the relationship is to be maintained. (Chataway, 1997, p. 758) At the time my silence felt appropriate because I did not want to stifle the positive energy around re-creating WOAW and I wanted to honour the participants' choices rather than take over the process. I also considered the possibility that the simpler approach they were considering might eliminate some of the challenges that had been identified through my research. However, I now see how my silence allowed me to abandon my role as facilitator of this discussion and the possibility of using the information from my study to help WOAW move forward. As I moved closer to becoming an 'objective researcher', as members and service providers at times assumed we were trying to be (Frisby et al., 2005), I did not use my power and resources positively. Rather, my silence may have allowed the women to recreate patterns of power and exclusion when they dismissed the concerns identified by me and the other discerning member. Despite how challenging her comments may have seemed, I now realize that she was making significant contributions by pointing to the issues and challenges when no one else would, which also risked her exclusion from the group. By failing to facilitate our counter-narratives during this meeting, I am left wondering how to balance my commitment to use my power positively while simultaneously honouring the contributions of participants. And yet, the tension regarding who gets to decide what a 'positive' use of power 119 might look like remains, especially given the diversity o f perspectives from w h i c h we each view each other's participation i n our collective processes. Data Analysis & Making Meaning M a k i n g meaning o f my data was an iterative process that happened to various degrees and through different strategies. Analysis reduces data into a story that researchers write through interpretation o f what the data 'means' (LeCompte & Schensul, 1999). I suggest that analysis begins before and during data collection since defining research questions, developing an interview guide, and wri t ing reflexive field notes each shape the researcher's interpretations. In each o f these early stages o f analysis I compared and contrasted my experiences o f W O A W and my participants against relevant literature. Decis ion-making is at the heart o f the inherently intertwined processes o f analysis and wri t ing i n qualitative research (Ellis & Bochner , 2000; F o n o w & Cook , 2005; Frank, 2004). Researchers make constant decisions about h o w to pul l apart, re-organize, pare down, and interpret a diverse collection o f stories, perspectives, and observations (Gilgun, 2005; L e C o m p t e & Schensul, 1999; Richardson, 2003). A l t h o u g h I present them i n discrete sections below, the process o f 'making meaning' placed me in a constant flow between the mutually informative exercises o f coding, writing-up, and tabling my data. Coding themes C o d i n g refers to the process o f identifying 'chunks' o f data into themes and sub-themes as they relate to the overall research purposes (LeCompte & Schensul, 1999; Ryan & Bernard, 2000). I used the computer software Atlas. t i to organize, code, and analyze my data. It is important to note that Atlas . t i does not do the analysis for the researcher; rather it provides a tool for the researcher to manage and analyze her data efficiently wi th in a single coherent system (Reid, 2004; Wei tzman, 2000). Transcribed data is loaded into a single computer file that 120 Atlas.ti terms a 'hermeneutic unit' (HU). Atlas.ti also provides researchers with 'windows' that help organize codes, memos and other notes into the HU. I created my initial codebook after my interview transcription was complete. The codebook consisted of themes and sub-themes that I created in relation to my research questions and my knowledge of the data set to date. This codebook was constantiy revisited throughout my coding process — codes were added, amalgamated, broken down, and deleted in relation to my interpretation of the data set. My final codebook is attached in Appendix V. The coding process involved reading through the transcripts, identifying 'chunks' of data into themes and sub-themes, then using the 'drop and drag' function within Adas.ti to connect the 'chunk' to the relevant code. Each 'chunk' of data was then termed a 'quote' by Adas.ti and each quote was categorized in accordance with the code that I connected it to. As such, Adas.ti helps researchers to compile all relevant chunks of data into discrete themes or codes. In order to contextualize each quote, I tended to chunk relatively large pieces of data that consisted of many sentences or paragraphs (rather than just one or two sentences). This strategy resulted in quotes having multiple codes attached to them, which had the advantage of allowing me to identify which codes regularly overlapped and therefore which themes held meaning to one another. I went through my data set three times in order to confirm my analysis and to rigorously compare and contrast the themes and quotes I had identified. My coding process took 6 months to complete. I drew on all 52 primary documents, mcluding my reflexive fieldnotes, in the thematic analysis. However, I purposefully chose quotes to illustrate themes in the three findings chapters from participant interviews, writing, and research party transcripts, rather than from my fieldnotes, to highlight their voices and perspectives. Quotes from my i fieldnotes were primarily used to illustrate the tensions I grappled with in this methods chapter. 121 Atlas.ti also provides tools for capturing descriptions and reflections of the coding process. These 'analytic memos' can be organized by date, code, or research topic. I used this function to define each code, to track my coding decisions, and to record my reflections and early interpretations of the data. Writing memos became a grounding process for me, as I ventured into the tenuous territory of frnding consistency and comparability within my interpretations. I reconciled my unease with the knowledge that I would return to this data repeatedly and the recognition that the decisions I made in order to 'make sense' of my data would result, at best, in a partial and subjective account. My memos also offered an invaluable entry point into the then seemingly overwhelming task of 'writing up' my data. 'Writing-up' the data "The role, meaning, and significance of writing are rarely problematized in the literature on qualitative human science methods" (van Manen, 2006, p. 713). Yet writing is, in and of itself, a method of inquiry and a means through which to interrogate and interpret data (Richardson, 2003). I learned as much or more about my data set while writing it up as I did when I coded it. Not only did my writing deepen my understanding of the data, it also intensified my sense of self as writer of the data (Gale & Wyatt, 2006). Writing forced me to consider my data in greater depth because I was forced to clarify how and why I was commumcating my fmdings. This reflective and iterative process sent me back to my coding regularly to further unpack and re-collate quotes and continually test the strength of my arguments. I began writing by using my codes and sub-codes to create chapter outlines. With the aid of Atias.ti, I printed out the list of quotes for relevant code. At this point, there were far too many codes and quotes to fit into one dissertation. My data set and research questions created mutually informative guides that framed my decision-making about which themes and quotes to 122 include. I moved between these parallel channels, as a means of keeping my decision-making contained by both my participants' stories and my research purposes. The first drafts of my findings chapters were primarily descriptive and evolved as I moved back and forth between the chapter outlines and the quotes. For each section, I read through the lists of quotes for each relevant code and identified the quotes that best captured the various themes and nuances within that section. I was also mindful of attempting to include quotes from all participants. I then copied and pasted the quotes from the list of quotes generated by Atlas.ti to the Word document that was my dissertation. Piecing together quotes into sections and themes required that I make constant decisions about whose words to include and whose words to set aside. The initial descriptive draft became the skeleton of the thesis and was primarily composed of the quotes organized in a coherent fashion and contextualized with relevant information about the participant, the WOAW organization, and/or the data gathering setting. In the proceeding drafts I gradually added my interpretations and links to the literature to further make meaning of the data and create the 'rendered accounts' in the upcoming chapters. Tabling The third embedded aspect of my meaning making process was tabling. At various stages of coding and writing I created tables to organize and verify my findings. For example, when I had completed my 14 interviews I wanted to confirm that the data collected would adequately speak to my research questions. I created a table that listed the key topic areas within each research question along the top and each participant's name along the left-hand side. I read through the transcripts and filled in the relevant boxes with words or short phrases to briefly describe how participants responded to a certain topic area. By completing this exercise I was able to confirm that I had adequate information to speak to each research question across my participant group 123 and to create the chapter themes and sub-themes from the data set. I also identified areas where more data would be helpful. This information became the starting point for my research party, at which time participants verified and expanded upon the existing themes and filled many gaps in my data set. For example, durmg the interviews a few participants mentioned that fear was a contributor to the conflict but I did not have enough information to make sense of it as a fmding. When I brought this up at the research party to see if this idea reverberated for others, an extensive discussion evolved whereby participants identified it as a major factor and offered a more in-depth understancling of how and why this was so. In order to further verify my findings, I also created tables to 'weigh' my data. In each of the upcoming chapters, I provide tables that illustrate how many participants spoke to the themes that I present. This exercise illustrated the relevance of each theme across the data set and guarded against any tendency I might have to over-extend particular arguments. For example, certain codes initially carried a great deal of weight because of the number of quotes contained in them. However, as I tallied the relevance of some codes, I realized that while the participants who spoke to these codes did so emphatically and repeatedly, it was only a small portion of them who did so. This weighing process also iUuminated that some codes contained relatively fewer quotes but were spoken to by a relatively high percentage of participants. I did not choose to write only about those with codes that had carried more 'weight,' however, I purposefully contextualized and justified those that I included that carried relatively less 'weight.' Representation & trustworthiness During my coding and writing processes I grappled with the legitimacy of my interpretations, a tension which is commonly called the 'crisis of representation' (Fine et al., 2000) . For example, I wondered whether the meanings I was assigning to their stories were 124 appropriate and accurate. What could I say about these women's stories that would represent their lives responsibly and with integrity? Was I reading too much into their experiences through the lens of my research questions? Or was this my job, as some critical feminist writers have suggested, to read through their stories and make sense of them in light of social, political, and economic processes and contexts (Cuadraz & Uttal, 1999; Power, 2004; Tom & Herbert, 2002)? Similarly, Fine and colleagues (2000) ask beginning and veteran qualitative researchers to interrogate their practices with the following questions: Have I connected the "voices" and "stories" of individuals back to the set of historic, structural, and economic relations in which they are situated? ... Have I deployed multiple methods so that very different kinds of analysis can be constructed? ... Have I described the mundane? ... Have some participants reviewed the material with me and interpreted, dissented, challenged my interpretations? And then how do I report on these departures/agreements in perspective? ... Where have I backed into the passive voice and decoupled my responsibility for my interpretations? ... Who am I afraid will see this analysis? ... To what extent has my analysis offered an alternative to the "commonsense" or dominant discourse? (pp. 126-127) In using these questions to guide my analyses and writing processes, I also created a sense of trustworthiness around my interpretations. By asking participants to co-operate in my data analysis at the research party and to comment on my interpretation and confirm the accuracy of their quotes, I created a sense of what Greenwood and Levin (1998) refer to as 'internal credibihty.' Credibility in "qualitative research has to do with the description and explanation and whether or not the explanation fits the description" (Janesick, 2000, p. 393). Furthermore, by describing the seemingly mundane aspects of participants' experiences of WOAW witliin social, political, and economic contexts, this case study provides transferable knowledge that legitimates, expands, and refines collective bodies of knowledge (Flyvberg, 2006; Rudden, 2006; Stake, 2000). Finally, I found Sykes' (2001) framework of 'understanding' and 'overstanding' the data useful. I aimed to 'understand' the stories the women told me as particular versions of their 125 truths. Simultaneously I also worked to 'overstand' the data through critical analysis of their collective stories in light of broader social conditions (Sykes, 2001). In this way, I believe that we have co-created knowledge and have each contributed significantly to the making of this dissertation. However, as researcher and author, I must take responsibility for its ultimate shape. I have listened to and mquired about their experiences, I have witnessed their participation, and I have worked alongside them at WOAW events. But their stories have been amalgamated and filtered through my critical ferninist lens (Maguire, 2001; Wahab, 2003). As the following section further reveals, I have attempted to represent participants' diverse perspectives and experiences through my own meaning-making process, as shaped by my social location, my personal history, my research intentions, my reading of relevant literature, and my long-term involvement in WOAW. Positioning Myself as Researcher, Author & Activist Researchers involved in CBHP projects often work from a PAR framework that involves developing deeper relationships with participants than traditional research methodologies entail (Frisby et al., 1997; Jackson et al, 2003; Potvin et al., 2003; Williams, Labonte, & O'Brien, 2003). Those conducting FPAR are acutely aware of the intricacies of negotiating such relationships across differences in power and privilege (Brydon-Miller, Maguire, & Mclntyre, 2004a; Frisby et al., 2005; Lykes & Coquillon, 2006; Maguire, 2001). As I mentioned earlier, the challenge of representing participants and their experiences is a common crisis for ferninist researchers, especially when researchers develop long-term and at times intimate relationships with those involved in FPAR projects (Fine et al., 2000; Reid & Frisby, forthcoming). In writing this dissertation, my 'crisis of representation' was confounded by the interconnecting ways that I understood participants' experiences as 'Other,' my social location and feminist orientations, and my insider/outsider position as a long-term researcher within WOAW. Importantly, and 126 witliin these tensions, I cannot claim that this dissertation is a complete depiction of all that occurred witiiin WOAW and all the ways of understanding these events across the diversity of possible perspectives (Lather, 2001). However, the importance of knowledge production and the relevance of women's lived realities cannot be denied (Harding, 1991). To address this dilemma, without being able to rectify it, my reflections situate this 'rendered account' firmly within my socially constructed position as feminist researcher and author and "[enable] me to question my authority without paralysis" (Reid, 2004, p. 7). Representing the 'Other': Social locations & insider/outsider relationships The researcher is in the potentially powerful position to specify what differences exist, what they mean, whether they matter, and how they should be represented in research fmdings. This power lies in the authority, or effective ability, to name difference and to specify the boundaries and meanings of relationships. (Ramazanoglu & Holland, 2002, p. 107) Inherent power and privilege differences infiltrated the entire research process, mcluding the lens through which I could understand and represent the experiences of the women who participated in the study. I am a feminist, middle-class, white, heterosexual, able-bodied, married, and well-educated Canadian woman, a social location embedded with considerable privilege. I was seeking to understand and write about the perspectives of women of colour who were newly immigrated to Canada, women with disabilities, single mothers, senior women with chronic health issues, and less educated women, most of whom lived below or at the poverty line. These women occupied social locations with relatively less privilege and in a range of ways they were the 'Other' to me. As Ramazanoglu and Holland (2002) point out, this relationship provided me with the power not only to name and represent our differences, but to decide how to represent the stories and perspectives they shared with me. I negotiated this tension by attempting to position this dissertation as being produced by a set of 'situated knowers' rather than by traditional positivist assumptions of the researcher as 127 the knower and participants as the known (Gunzenhauzer, 2006). Feminist theorists have convincingly argued that knowledge is subjectively and socially constructed; as such there are no universal narratives, but rather multiple ways of understanding the world (Tong, 1998; Weedon, 1999). Our diverse subjectivities and ways of knowing are produced in large part by our locations as refracted by axis of power associated with gender, race/ethnicity, class, age, (dis)ability, and sexuality (Anzaldua & Keating, 2002; Collins, 2000a; Lorde, 1984). As such, there is no one standpoint that can represent women's diversity. Rather, each of us is situated in multiple and fluid social locations that define and challenge our worldview. By keeping this perspective close at hand, I sought to recognize the diversity witliin the group of women and resist the tendency to categorize them as a homogenous group (Mohanty, 2004). I endeavoured to depict them as active agents, versus as powerless objects, in this knowledge-making practice. Rather than following patriarchal practices of privileging the voice of the researcher or attempting the impossible task of claiming to equally privilege the voices of all participants, Lykes and Coquillon (2006) refer to the process of writing-in a 'third voice' as a way to transgress traditional representations and integrate researchers' and participants' collective voices. In many ways, my attempt to write-in a diird voice served to create a collective and distinct set of knowledge that enabled me to address my research questions. My role in this co-creation was to explore, connect, and contextualize our diverse standpoints and subjectivities (Fine & Weis, 2005). And yet, I question the degree to which creating a diird voice was possible in the context of writing a doctoral dissertation given the imperative that I demonstrate my own knowledge, analysis, and voice to successfully climb the academic ranks (Brydon-Miller, 2004; Chrisp, 2004). I remain humbled by and grateful for the degree to which the women contributed to my completion of this document. 128 Insider/outsider debates in the feminist literature question the degree to which researchers who live outside the realm of the contexts we study can come to understand and depict the lives and experiences of the 'Other' (Harding, 1991; Shope, 2006). Certainly, there are limits to what I can know about the realities of being a new immigrant of colour, coping with a chronic disability, or living in material scarcity, and these limitations positioned me as an outsider. And yet, as a doctoral student and feminist participatory action researcher, I had the unique privilege of being involved with WOAW for over 5 years. I fulfilled many roles as Project Manager of the SSHRC-funded research grant and during my own doctoral research. I attended and facilitated meetings and strategic planning sessions, took field notes and conducted interviews and focus groups, managed the budget, analyzed data and wrote (or co-wrote) reports, papers, and conference presentations, assisted in the organization of WOAW events, and provided emotional and practical support to members, service providers, and co-researchers. This level of involvement placed me inside my research context and gave me a particular insight into participants' experiences within it. Yet my multiple and sometimes conflicting roles also complicated these power relationships. For example, at times my role as facilitator of a meeting conflicted with my role as researcher when I became attached to a particular outcome or exchange of ideas that may or may not have appropriately served the members and organization. At these times, my role as manager of the research budget reinforced my power and therefore my ability to facilitate a meeting in a direction that was in keeping with my academic agenda. Yet there were also times when my role as a researcher who required members' participation for the success of my project left me vulnerable to the power of participants to choose in or out of the research process. From this more vulnerable position, I occasionally extended myself in relationships with participants beyond comfortable boundaries, a tendency which at times compromised my role as manager of the project budget. These 129 conmcting roles and complicated relationships infused my insiderness/outsiderness with considerable ambiguity. Naples (2003) reminds feminist researchers that the insider/outsider debate is a created dichotomy, rather than a realistic interpretation of how researchers engage in, belong to, and know their research environments. Certainly, my reality reflected the notion of insider/outsider fluidity. When I spoke with participants about their experiences in WOAW, I knew about the situations that we were discussing because I had often been a part of them, yet I could not fully know how they had experienced them from their multiple and ever-shifting social realities. In this way, I constantly negotiated my insider/ outsider positions that shifted from moment to moment and at times occurred simultaneously. For example, there were times when my participation was central to WOAW activities we were planning, yet the appropriateness of the activities were curious to me because I could not understand their relevance to members' lived realities. By understanding that my position in the research process was never fully inside or outside, I aimed to transcend this debate by recognizing that I/we could only create knowledge that was partial and socially situated (Naples, 2003). The examination of my reflexive practice is an imperative step in understanding how this dissertation unfolded and what can be learned from it. My Reflexive Practice In keeping with the ferninist imperative to constantly interrogate how researchers' multiple and fluid identities inevitably shape their research processes (Naples, 2003; Reinharz, 1997), I regularly reflected on the impact of my 'brought selves' throughout the description of my methods. While this dissertation has left me open and, at times, academically vulnerable, it also contributes to a growing body of literature that is unveiling the messy reality and the deep 130 insights available through feminist research, and F P A R in particular (e.g. Ceglowski, 2000; Mauthner & Doucet, 2003; Reid, 2004; Williams & Lykes, 2003). I have attempted to critically explore my emotions, assumptions, and decisions within the social context that shaped them. I also investigated my enactments of power as researcher by considering the paths I did and did not take, my chosen silences, my privileges, and my relationships with participants. My reflexive practice also helped me to live more closely the commitment to a participatory design by providing a system through which I could verify that my decisions were aligned to with my research intentions (van der Wey, 2004). However, I also realize that this study could have been more participatory i f I relinquished more control during the initial stages of data collection and analysis. During those moments when my decisions were not in line with my research intentions, my reflexive practice helped me to grapple with the social, emotional, and power relations that shaped my decision-making. In the end, the value of reflexivity is not only in what I learned about the research process and its contexts. Importandy, it also taught me more about myself, my place in the world, and how I can learn to make a difference (Deutsch, 2004). While some of my insights were evident to me during my experience in field, the depth with which I came to understand them unfolded through my deliberately reflexive strategies of field note writing and peer debriefing. Reflexive field notes Field notes are "a record of one's reactions, a source of background information, and a preliminary stab at analysis" (Sanjek, 1990, p. 100). With the intent of capturing the tone and texture of research settings, field notes can be descriptive, reflective and/or analytic in nature. Similarly, journaling is a "powerful heuristic tool and research technique" (Janesick, 1999, p. 506) that aids researchers in rigorously refining their description and analysis of both research content and process through reflective writing (Janesick, 2000; Richardson, 2003). Journaling 131 can also provide researchers with an emotional oudet, particularly for those who are entrenched in the lives and communities of their participants (Sanjek, 1990). I began field note taking and journaling as discrete tasks, in relation to their proximity to the research setting. In other words, I took field notes after more direct and formal contact with participants and journaled after informal contact or in relation to research tasks that did not include participants (e.g. coding). Over time, however, I realized that both tasks served similar purposes: to describe, analyze, and reflect upon my research process. Thus, in my analysis and write-up I have named these interconnected productions into one category called 'reflexive field notes.' I wrote reflexive field notes after each data gathering exercise and after most transcribing and coding sessions. The field notes were written primarily by me except in the case of the research party when Tammy and I wrote them collaboratively. In this instance Tammy wrote her initial descriptions and reflections of the meeting, after which I added mine, clearly delmeating them from hers. I also wrote field notes after a significant event that occurred outside of the formal research process (e.g., a WOAW meeting or informal phone conversation) or when a certain set of ideas was pervacung my thoughts. The field notes served to describe and reflect upon the various stages of my research process. For example, the post-interview or post-meeting notes described the setting, the tone, and the events as they unfolded. My reflections also included the interrogation of assumptions I made about participants and their living situations, the usefulness of my methods, and how class and other power differences may have infiltrated the process. Finally, my field notes recorded the methodological decisions I made and their justifications, ideas for theorizing and making sense of my data, and my perceptions about how participants' experiences could be compared with and contrasted against one another and assumptions I was holding. 132 I often spoke my field notes into my tape-recorder immediately after a data gathering session. This typically happened in my vehicle as I left the site, but also took place in odd locations such as a public bathroom stall when time between interviews was scarce. I believed that the sooner I created the field notes the better, as the situation would be fresh in my mind. I transcribed these field notes in conjunction with .the transcription of the session as a whole. When it was not convenient for me to speak my field notes into the recorder, I wrote them out as soon as possible following the session. Upon analysis of these notes, I discovered that, despite the time lag, the field notes that I wrote out were more detailed and reflexive than the ones I tape-recorded despite my presumption that it would be the other way around because of the immediacy of the tape-recorded notes. I believe that this discovery speaks to the depth and value of writing as reflexive process. Marshall (2001) refers to reflexive writing as a means of engaging with one's 'inner arc of attention.' In this exploration, I delved inside myself to ask difficult albeit imperative questions about my role as researcher. She also purports the use of an 'outer arc of attention' as a way for researchers to look beyond themselves to test developing ideas and broaden their scope of understanding (Marshall, 2001). I developed an intentional outer arc strategy by creating a peer debriefing structure as part of my reflexive practice. Peer debriefing Brydon-Miller, Maguire, and Mclntyre (2004) remind feminist participatory action researchers that peer and community relationships are necessary to support and sustain us within the intensity of our research processes. At the onset of my data collection, I invited Colleen and Tammy to formally act as my peer debriefers since both worked with me on the SSHRC grant, understood the complexities of FPAR, and respected my concerns about confidentiality. Imperatively, I also trusted these women to gendy hold my experiences and 133 compassionately challenge my interpretations. We agreed to an informal structure such that I would call on their support as needed. The purpose of deliberately creating a peer debriefing structure was threefold. First, it provided me with support in what was often emotionally-taxing work. Second, it created a relatively informal and unthreatening setting where I could share and discuss my thoughts and feelings about my research experiences. And third, it allowed me to brainstorm ideas on how to manage and understand the inherent messiness of FPAR. Deliberately creating this peer debriefing structure was inspired by my experiences of working within the larger SSHRC-funded research project, where I found the connection to other researchers an invaluable source of learning and support (Ponic et al., 2002). As with most FPAR ideals and strategies, the reality of living them was complex (Reid, 2000). I did not engage in peer debriefing as consistently as I had anticipated because of logistical challenges. The most common use of my peer debriefers was to connect with them when I experienced intense feelings or difficult decisions about my research process or participants. What typically occurred during these conversations was that once I was able to express my emotions, we were then able to critically consider the implications to my research processes and relationships, especially as they related to issues of power and inclusion. In retrospect, I imagine that participants also experienced emotional reactions to their involvement and the co-creation of a peer debriefing structure could have been an important contribution to our participatory process and to their well-being within it. To document the conversations with my peer debriefers, I wrote about them in my reflexive field notes. As the following excerpt illustrates, this process allowed me to consider my emotions and power in a situation and reflect on the usefulness of peer debriefing in my reflexive process. 134 It felt so good to release these feelings and thoughts and by the end of the conversation my energy around the meeting felt less heightened and I could think about it more analytically. I moved from being angry with her to having more compassion for her and her place in the world. This is another good reminder of the importance of a peer debriefer, as both an oudet for feelings and a sounding board for ideas. (Pam's field notes) Coupled with the writing of my field notes, peer debriefing deepened my reflexive process. Our conversations grounded me when my emotions threatened to overwhelm my experiences and provided me with much needed support as I grappled with the power dynamics that danced amongst my research relationships. Power & Inclusion in Feminist Participatory Action Research Feminist methodology writers have brought to light the inherent power dynamics that privilege the researcher over the researched in most academic studies (Harding, 1987). This concern is being addressed by feminist participatory action researchers who seek to destabilize traditional research relations and utilize the collective sources of power, brought by both researchers and participants, to transform both individuals and social conditions (Lykes & Coquillon, 2006). Power, from this perspective, is a multidimensional and relational force (Brydon-Miller, 2004). Although differentially privileged, each woman has the capacity to draw on resources and enact her power accordingly. Feminist participatory action researchers attempt to create conditions that foster the positive and responsible use of power by all participants: we seek to enable strategies oi power-with, power-to, and power-for rather than power-over (Tetreault & Teske, 2000). Inclusion through a participatory research design in FPAR is one such strategy, such that participants are able to choose when, where, and how they participate in the research process (Reid & Frisby, forthcoming). Committing to an emerging and open-ended plan fosters inclusion because it provides a framework in which the researcher can respond to the needs and 135 demands of participants and adapt to the situations at hand (Tom, 1996; van der Wey & Ponic, 2005). This commitment, however, specifically requires the researcher to relinquish some control over research processes and outcomes, which can leave her vulnerable to the decisions, actions, and perceptions of participants, as well as academic imperatives (Brydon-Miller, 2004; Chrisp, 2004; Lykes, 2005). Destabilizing power relations in FPAR is inherently messy. A reflexive practice helps researchers make sense of and negotiate the uncertainty and complexity (Maguire, 2001; Naples, 2003). It is critically important that feminist participatory action researchers remember, especially in the thick of it, that when the work feels the most challenging is also when the most important contributions are being made. The unsettled territory that must be negotiated when traditional research power relations are destabilized is often the very ground where possibilities for action and change emerge. 136 CHAPTER 5 Inclusion as a Multi-faceted & Negotiated Process Inclusion in WOAW involved a process. It dealt with different stages. First stage was on structure, the existence of the group. Second stage involved getting to know the women, the physical stage. Third stage was the emotional stage. Identifying women's interests, concerns, challenges, hopes, dreams, etc. This was the most fascmating stage for me. I discovered similarities of concerns which made me identify myself in the group. (Maria Manuel's writing) In this first of my findings chapters, I describe and analyze the meanings and experiences of inclusion in WOAW from the perspective of the women who participated in my study. Maria Manuel's quote provided the starling point from which I came to understand and conceptualize inclusion. Her comment gives insight into the complexity of inclusion processes in CBHP and into the deeply personal meanings they hold. I gathered participants' perspectives by asking them to describe what inclusion meant to them and the ways in which they had and had not experienced it in WOAW. The range of participants' definitions, experiences, and reflections revealed that inclusion was a multidimensional and dynamic social process, which was shaped by the decisions that individual women made and the actions that they took in the context of multiple spheres of influence. Additionally, their experiences of inclusion were in a fluid relationship with those of exclusion. These fmdings begin to fill a gap in the inclusion literature by providing a community-based perspective. Most inclusion researchers and policy-makers have focused their work at broader political and economic levels (Askonas, 2000; Human Resources Development Canada, 2003; Richmond & Saloojee, 2005). While structural analyses of inclusion and exclusion are certainly necessary to redress systemic inequities (Galabuzi & Labonte, 2002), these approaches do not fully consider how members of marginalized communities experience, make meaning of, and benefit from inclusion strategies. Further, there is little evidence to indicate that inclusion 137 strategies in CBHP have proven effective, and rarely has their value and impact been evaluated from the perspectives of intended beneficiaries (Long & Bramham, 2006; Zakus & Lysack, 1998). In this chapter, I first explore the relevance of inclusion in WOAW. I then describe participants' meanings and experiences of inclusion in greater detail. Similar to the theoretical model described in Chapter 2, inclusion processes consisted of interconnected psychosocial, relational, and organizational dimensions that were in constant interplay with the women's participatory decisions and actions. Within each of these dimensions, participants identified a number of elements that gave meaning to their inclusion experiences. In the final section of this chapter, I explore participants' experiences of exclusion, which occurred in fluid relationship with those of inclusion. The Relevance of Inclusion in WOAW Inclusion was identified as a core value in WOAW when its members collectively developed its vision (Ponic & Frisby, 2005). However, deeply embedded assumptions about inclusion served to block much critical reflection about how it was fostered within the organization. Recognizing these assumptions opened the door to our deeper considerations and conversations about inclusion in WOAW. As a starting point for our conversations in each interview and in order to clarify whether inclusion was a significant aspect of WOAW, I asked about its relevance. Every participant emphasized that inclusion was deeply relevant and crucial to WOAW's creation and sustainabihty. When I posed this question again at the research party everyone in attendance nodded their heads in agreement. Kate said "yeah, because that's what WOAW is. It's not just one woman, it's every woman. And it's so diverse, that there are enough things [to do in WOAW] that it includes" (Kate, research party). Kate's comment confirmed 138 that inclusion was central to WOAW and her references to 'every woman,' 'diversity,' and multiple ways of being involved in the organization illustrated the personal meanings it held. Yet despite their declarations that inclusion was central to WOAW's vision, participants were challenged to define it in any clear fashion. During my data collection process, I grappled with the idea that the language of inclusion seemed to be letting me down, as this excerpt from my field note illustrates: What's become really clear to me is that there's really an assumption that everybody knows what you're talking about when you're talking about inclusion. And so unpacking it is quite difficult and I'm still not sure that I've found a way to ask about inclusion that gets people to really talk about what it looks like. (Pam's field notes) As I analyzed the transcripts, I realized that succinct and insightful descriptions were given less often when I asked participants to define inclusion and more often when we explored the instances when they felt included, strove to include others, or contrasted it with experiences of exclusion. Furthermore, a few participants admitted that they had not considered the relevance of inclusion in WOAW until I initiated the conversations. When I asked Selah if being included in WOAW was important to her, she said "um, included, mteresting word" (Selah's interview). Diane reflected on the idea that inclusion was both deeply relevant and rarely named when she remarked: So although I was aware that sometimes people weren't being included, I never really appreciated until you asked, [when you] sent me these questions that maybe this is one of the most important parts of WOAW. (laughter) I mean I understood, I guess I understood inclusion because, I know people on low income maybe get excluded. (Diane's interview) Their challenge in defining inclusion, their reflections about the word itself, and their deeper realizations about its relevance gave insight into the assumptions that were made about inclusion, assumptions that are also embedded in academic literature and that we all make every day. So entrenched are our assumptions about inclusion that we may fail to reflectively consider 139 what inclusion is, how it may or may not be manifested, and who does and does not benefit in the process. Once inclusion was named and described in their stories, participants were more often able to reflect on what it meant to them. The meaning of exclusion and inclusion does not derive from political actors' (or sociologists') definitions but from the people's interpretations. People's interpretations and their resulting actions must become the core subject of empirical research. (Vobruba, 2000, p. 609) Individuals make meaning from the ways in which they interpret their experiences, and it is in this source of lay knowledge that the deepest insight into inclusion processes are found (Williams, 2003). In keeping with this belief about the power of lay knowledge, I now turn to participants' meanings and experiences of inclusion in WOAW. This section purposefully highlights the positive and health promoting attributes of inclusion that participants identified. Yet their experiences were not universal or necessarily stable. They reflected on different forms of inclusion at various stages of their involvement and each participant also experienced moments of exclusion within the organization. The tensions associated with the fluctuations between experiences of inclusion and exclusion had consequences for their health as I will explore later in this chapter and in the ensuing ones. Women's Meanings & Experiences of Inclusion The most remarkable aspect of how participants made meaning of and experienced inclusion was its multi-dimensional nature. Participants spoke about 25 elements of inclusion that fell within the psychosocial, relational, local/organizational, and participatory dimensions that are in line with the spheres of influence and women's actions outlined in the theoretical model in Chapter 2. The entire list of elements discussed is reflected in my codebook in 140 Appendix V. In order to keep this section manageable, I have condensed the list to the 13 elements that were most prevalent as outlined in Table 5.1. Table 5.1: Dimensions & element of inclusion Dimension Elements Psychosocial Acceptance Safety & trust Recognition Relational Being welcomed Respect Support Organizational Addressing barriers Access to resources Ethic of care Participatory Sharing Contributing Having a voice Engaging in activities Participants shared their understandings and stories with me in response to questions such as: why did you join WOAW and/or what has kept you involved in WOAW over the years? What does it mean to have inclusion as a value of WOAW? Can you give me an example of when you felt included in WOAW? Was being included in WOAW important to you - and if so, why? What did you do to help make others feel included? I present these dimensions and elements by describing how the women expressed them individually and collectively. While I write about them in a somewhat distinct and linear fashion, it is important to remember that participants understood and experienced them in interconnected and dynamic ways. The breadth of participants' understandings and experiences contradicts all but the most critical of inclusion theory. For the most part, attefnpts to foster inclusion have held the embedded assumption that inclusion is a readily known, shared, and understood entity for all involved. For example, in their development of a 'social inclusion' interview schedule, a group of education researchers assumed that inclusion can be understood in the exploration of young people with disabilities' social networks (Pawson, Raghavan, & Small, 2005). Alternatively, the 141 Federation of Canadian Municipalities takes for granted that social inclusion can be equated with the economic security of its constituents (Canadian Federation of Municipalities, 2006). While social networks and economic security may be important aspects of inclusion, these approaches are one-dimensional. Critical perspectives of inclusion however, acknowledge the complexities and nuances, as O'Reilly (2005) articulates: There are, however, numerous variables that can be considered of importance in terms of inclusion and exclusion, and as all of these are potentially complex continua, a fully comprehensive model of inclusion and exclusion would need to be incredibly detailed, (pp. 84-85) His recognition that inclusion processes are inherently complex, often unfold in relation to those of exclusion, and need to be exceedingly detailed points to the gap in the literature that my fmdings begin to fill. Psychosocial dimension The psychosocial dimension of inclusion refers to participants' internal understandings about their relationships with other members of WOAW, which at times manifested emotionally. Table 5.2 outlines the elements of this dimension, which are acceptance, safety/trust, and recognition, as well as the number of participants who referred to them. Table 5.2: Psychosocial elements of inclusion Dimension Mlcmcni Number of participants who identified this clcmem i ' u — 1 f i Psycho-social Acceptance 11 Safety/trust 7 Recognition 8 Psychosocial aspects of inclusion are often overlooked when inclusion is theorized at broad social and political levels. However, they were central to how participants understood their places in WOAW. Fostering inclusion, especially as a means of addressing exclusion, requires that attention be paid to the internalized impacts of marginalization and exclusion (Prilleltensky & Nelson, 2002). Those who are chronically oppressed come to understand themselves as 142 unacceptable, unsafe, and de-valued members of society (Abrams et al., 2005). Fraser (1997) suggests that cultural recognition is necessary for individual well-being and social justice, such that all forms of identity are valued and celebrated. A culture of recognition is central to inclusion processes that seek to undo the effects of internalized oppression and exclusion while simultaneously fostering internal feelings of acceptance, safety/trust, and belonging. Acceptance Acceptance was identified as the most critical psychosocial element of inclusion. When I asked Elaine what aspect of WOAW had been most important to her she stated: "to be accepted for what you are and who you are" (Elaine's interview). Mary Elizabeth, an older woman who had often felt that her immediate family did not fully embrace her ways of being, said that one of the main benefits of WOAW was that "I have made new friends who accept me as I am" (Mary Elizabeth's writing). The notion of being accepted for who you are, which was prevalent for the majority of participants, implies that inclusion requires that differences are embraced, rather than feared or marginalized (Anzaldua, 2002). Yet most inclusion strategies seek to assimilate differences by fostering a sense of commonality that requires those who are different or 'Other' to 'fit' into existing structures (Shakir, 2005). This understanding of acceptance as inclusion flies in the face of typically oppressive practices that tend to exclude and marginalize people because of their differences. Participants explained that acceptance and inclusion in WOAW meant being willing to accommodate the differences. Patricia said that "being accepted when you have a physical impairment, or emotional, psychological, social, you know, anything like that, that was one the best things" (Patricia, research party). Each participant wanted to be accepted for the unique identities she brought to the group. This was particularly important for poor, unemployed, disabled and/or newly immigrated women who were often excluded because of their social 143 identity as 'Other' (Young, 1990). For Maria Manuel, who had recendy immigrated to Canada, the acceptance of cultural differences was imperative. She shared that "inclusion in WOAW was better felt when I am accepted as I am, my ideas, belief, religion, race and culture" (Maria Manuel's writing). Sydney specifically spoke of WOAW as a place where women felt accepted, despite the fact that they didn't have money to participate. So it was somewhere they felt they could come [even if] they didn't have the money, they couldn't afford to do it, so it was something where you could be accepted, you could do tilings even if you couldn't afford to do dungs. (Sydney's interview) In reference to her story about immigrating to a new country and a new culture, Marylu said "I think I needed the acceptance to survive" (Marylu's interview). Not feeling accepted would have jeopardized her participation in WOAW and she believed that her ability to 'survive' the transition into a new culture and community was significantly aided by experiencing inclusion. Safety & trust Over half of participants spoke about a sense of safety within WOAW as an important psychosocial aspect of inclusion. Feeling safe is a consequence of an individual's level of fear in a situation and is predicated on external events that may or may not be in that person's control. For example, over half of participants spoke of feeling generally unsafe in large groups, as they were in fear of being judged or verbally attacked. Such fears are typical reactions to persistent experiences of being impoverished and shamed (Russell, 1996). Sydney explained that "in the past I felt like I couldn't do or speak my mind in a group setting because I thought I'd be judged" (Sydney's writing). She went on to explain how she felt inclusion was possible in WOAW because members "are able to feel safe to say what they want to discuss" (Sydney's interview). Yet the notion of safety is slippery, since what makes one feel safe will vary from person to person and situation and to situation. Selah explained that what made her feel safe in WOAW was "the trust factor" (Selah, research party). While the notions of safety, fear, and 144 trust may be inherently related, trust results from the process of developing relationships in which individuals have faith that they will not be harmed. Safety is thus more a matter of external circumstances, while trust resides more fully in an individual's psyche and spiritual beliefs. Therefore, trust may more appropriately capture this psychosocial dimension of inclusion that relates specifically to fear in relationships. Trust in WOAW aided women in expressing their emotions about delicate social or health subjects such as alienation or depression. Diane explained she often found it difficult to speak openly about her depression during her mother's illness or about difficult times at work because she was afraid of negative ramifications. She experienced a sense of inclusion in WOAW because she trusted that she could express her emotions and challenges with other members in an open way: "I was dealing with depression on and off since the time I belonged. I always felt that it was okay to say that. It felt like a safe environment to talk about that" (Diane's interview).The creation of a space in WOAW for members to openly express themselves, allowed participants to feel supported during times of crisis. Leisure opportunities can create such a space within which women in health crises can access social support (Shannon & Bourque, 2005). Certainly, the value of sharing stories of oppression and ill-health as a mechanism for liberation and healing are central to feminist and participatory approaches to health promotion and research (Lykes & Mersky, 2006; Maguire, 2001; Prilleltensky, 2005). Trusting one another and feeling supported also allowed WOAW members to extend themselves beyond what they might normally do when bound by fear. Marylu shared that her experiences in WOAW helped her feel safe to participate in our interview despite her concerns about the quality of her English, which was her second language: WOAW helped me to be with a group of people that I felt comfortable to talk with, even with my mistakes. If other people ask me for an interview, I never give an interview about this type of thing. But with you [as part of WOAW] I 145 feel very comfortable that you are not going to hurt anybody. (Marylu's interview) She said she felt included, agreed to participate, and enjoyed the opportunity to share her experiences and insights with me because through our mutual involvement in WOAW, she had come to trust that my intentions were respectful and that I would not deliberately harm her or other WOAW members with my research. Ironically, the level of trust that was built in our relationship over time served to both facilitate participants' inclusion in the research while simultaneously making them vulnerable to my interpretations of their experiences. Recognition Being recognized for their presence, ideas, and feelings was a key psychosocial aspect of inclusion for over half of study participants. Patricia felt her presence was valued in the group because other members reached out to her when she fell ill. She explained that "when they found out I got hurt they sent me notes, which made me feel really close to the group, because I felt like I was wanted" (Patricia's interview). Ana spoke of how her connection with other WOAW members made a "difference in my life because I feel that my feelings are important" (Ana, research party). For both Ana and Patricia, they felt that they were being valued as women by other women and this was central to their sense of belonging and inclusion within the organization. WOAW members also felt valued when their participation and voices were requested and appreciated, as Marylu shared in this quote: [when] everybody phoned me and said 'come to this meeting, I would like you to participate in this or I like your ideas'. And sometimes if you hear a person ... say 'oh I love this because you give me another perspective or another idea,' it makes me feel good. (Marylu's interview) Inclusion was facilitated when participants felt recognized and valued for the skills, knowledge, and ideas that they offered to each other. This process also fostered their sense of self-worth. 146 Selah explained how important it was for her to be valued for her authentic contributions to WOAW and its members: I think the recognition was important for me. One of the biggest things I found over my years was that I was always recognized for what I did and I don't think I ever felt recognized for who I was. .. .Kate has said thank you for doing this or showing me that. And it's coming from me inside, so I feel recognized as Selah, as a peer, which is really nice. (Selah, research party) Feminist organizing structures encourage the participation and contribution of all members, seek to respect and foster each woman's contributions, and help set the stage for women to feel valued in the group (Dominelli, 1995; Mizrahi, 2007; Pmnington, 2001). By recognizing that, to some degree, most members wanted to feel appreciated for their contributions, participants attempted to help each other feel valued. This occurred at times even during conflict and disagreement, as Pat acknowledged when she said: "you can recognize and value somebody and still tell them they're wrong" (Pat's interview). By continuing to value each other in times of conflict, participants' sense of being accepted and safe deepened. It was in these moments of being recognized as important members who could contribute that they felt included. Relational dimension The relational dimension of inclusion refers to the relationships between members, particularly in terms of how they engaged and behaved with one another across power and other differences. Table 5.3 outlines the degree to which being welcomed, giving and receiving support, and respecting one another resonated for participants. These elements were central to the health benefits that participants experienced in WOAW, and when they weren't enacted, their absence typically fuelled the conflict that brewed in time. 147 Table 5.3: Relational elements of inclusion DimcnMun 1 Element " • - Number of participants uh<> identified tins eleinuu '11= 14'' Relational Being welcomed 12 Respect 9 Support 12 Being welcomed Nearly every participant identified being invited and welcomed into WOAW as an imperative first step in fostering their inclusion. Vicky described this aspect of inclusion as "everybody being invited to everything" (Vicky's interview). Ana commented that "everyone [in WOAW] opened their arms for me and my family and that was nice" (Ana, research party). While the notion of mcluding 'everyone in everything' was idealistic, the comments illustrate the importance of creating a welcoming environment. When I asked Sandra how long it took her to identify as being a member of WOAW, she explained that she immediately "felt welcomed and I became really an integral part of the group and I started going to all the meetings" (Sandra's interview). As Sandra's quote illustrates, the sense of feeling welcomed created a comfort within the group that facilitated members' ongoing participation and choices. Being consistently welcomed was equally important for long-term members whose personal lives prevented them from being consistently involved. As Diane explained: "even though I had a lot going on in my life with my parents and my focus would be completely separate for periods of time that when I came back [to WOAW], I always felt welcome" (Diane's interview). This level of openness absolved the guilt participants may have felt about their inactivity in the organization. Participants were aware of how important it was to keep the door open to women who had complicated lives and some went out of their way to continue to make members feel welcome, as Sydney described: 148 If they can't come every month we still let them know what's happening. Because we know that maybe they can't make it one time, that they still want to be involved and come and meet for socials or whatever we decide to do. (Sydney's interview) Patricia felt appreciated and included when other members made an effort to invite her to WOAW events because, even when she was sick or without transportation, she said that "I feel like I always get my email from Sydney" (Patricia, research party). Often the welcorning went beyond simply inviting someone to attend, to seeking out and valuing their participation. Marylu said that she felt appreciated and welcomed when another member "phoned me and said come to this meeting, I would like you to participate in this" (Marylu's interview). While this was often the first step to inclusion in WOAW, it continued to be important over the long term, such that women knew they remained included despite long absences and that they were welcomed not only for their attendance, but for their active and helpful contributions. Support All but two of the study participants emphasized that supporting one another was one of the most important elements of WOAW and central to their sense of inclusion. For many women who had lived in isolation, the friends they made through WOAW became, as Kate described, their "major support system" (Kate's interview). The women supported each other in emotional and practical ways and often during times of crisis. When Elaine fell ill and her ability to use her hands was extremely limited, she explained that WOAW members "supported me - they used to phone up and [one member] sent over some food when I wasn't able to prepare stuff (Elaine's interview). As Maria Manuel explained, support amongst members was typically mutual and carried significant meaning: When Diane's mom passed away we went there as a group [to] show our concern and showed that we care for her. And that means a lot for Diane. In the same manner that when I got sick they were with me. Diane and Caroline asked what would you like to do before you have your surgery. And then I 149 thought you know I'm a bowler back home, so let's go bowling. (Maria Manuel's interview) Feeling supported during times of transition was also extremely important to many WOAW members as they struggled to feel setded in their new life situations. As Ana explained, the support she received helped her to realize that her rmmigration to Canada could be successful and helped her to feel included in this new country. She remarked that it was "nice to have [WOAW] and I feel 'oh, I am here and it can work,' and this is good support I have ... in this country" (Ana's interview). Experiencing support from WOAW members also facilitated a sense of power for many participants. For some women, having power has been affiliated with a heightened sense of connectedness and self in ways that facilitated their action (Shields, 1995). Similarly, when participants felt supported by other WOAW members, they felt they could take risks and try to accomplish new things because they knew there were others to back them up if needed. Selah explained that "I feel like I can move forward in life because I don't feel alone anymore. There's always a phone call or something I can make" (Selah, research party). The support they received helped them feel included in their communities during times of crisis and transitions and provided a base from which they could move forward in their lives. Since nearly every participant had been socially isolated prior to joining WOAW, they were acutely aware of how important connection and support were in mamtaining their health (Reid, Ponic, & Frisby, 2002b). Experiences of social isolation are increasingly prevalent for marginalized women, including women who are addicted or homeless, older women, young girls at risk, women with disabilities, and blue collar workers (Farris & Fenaughty, 2002; Findlay, 2003; Havens, Hall, Sylvestre, & Jivan, 2004; Hazier & Denham, 2002; Nosek, Hughes, Swedlund, Taylor, & Swank, 2003; Vezina, Derriennic, & Monfort, 2004). Researchers continue to make links between social isolation and ill-health, mcluding depression, stress, suicide, 150 stigma, anxiety, elevated blood pressure, sleep deprivation, reduced self-esteem, and slower healing time (Cacioppo & Hawkley, 2003; Farris & Fenaughty, 2002; Findlay, 2003; Nosek et al., 2003). Alleviating social isolation through inclusion in CBHP, therefore, is critical to women's health. Respect During both the interviews and the research party, participants stressed the importance of treating each other with respect. When I asked about how inclusion was fostered in WOAW, Elaine said "the women give each other respect" (Elaine's interview). Patricia confirmed the importance of respect when she explained that a critical element of WOAW's vision was that "when we're together we respect each other" (Patricia, research party). When the women spoke of what it meant to respect each other, they talked about the importance of valuing each other's social, historical, and personal differences. Lorde (1984) makes the critical distinction between respecting and valuing difference versus simply tolerating them when she sug