Narrative, Nature-Based Participatory Action Research (PAR) among Female Turkish Migrants in Denmark: Reflections on Methodological Benefits and Challenges

Abstract

Migrants of non-European origin tend to suffer more from diabetes, obesity and other chronic ailments compared to the native population. A group of female Turkish migrants in ill health, living in Denmark, were invited to join a session of eleven weekly meetings in natural surroundings, including yoga, bonfires and gathering fruits and herbs. The women were invited to suggest activities, and every meeting included dialogues focusing on their everyday life, interests and experiences. Two PAR researchers facilitated the meetings together with an interpreter. This article presents the methods and results of this PAR research and discusses the methodological ethnographic balance between approaching the migrants’ weaknesses in terms of their illness and migratory challenges on the one hand and, on the other, their transnational resources as workers, household keepers and kin keepers.

1. Introduction

Participatory action research (PAR) represent various perspectives and approaches, including cooperation between different groups of active participants. The term ‘action research’ was coined in 1946 by Kurt Lewin [1], who emphasized the practical aspect of interventions, meaning that the distinct quality is ‘action’ in practice. Some decades later, the participatory aspect of PAR became highlighted, focusing on collaborative processes of research, education and action, with transformative processes as a goal [2]. Within ethnography, interactions between academic researchers and ‘the natives’ have always been at the center, particularly since Bronislaw Malinowski, in 1922, reported on his Ethnography from Melanesian New Guinea, where he lived among the Argonauts:

“…in this type of work, it is good for the Ethnographer sometimes to put aside the camera, notebook and pencil, and to join in himself in what is going on. He can take part in the natives’ games, he can follow them on their visits and walks, sit down and listen and share in their conversation”

[3] (p. 10).

For Malinowski, participation was neither a goal nor a way of transforming the lives of the people he studied; it was a means by which to dig out knowledge pertaining to cultures and “the science of Man [3]” as a broader aim. More than half a century later, many ethnographic researchers and anthropologists, as well as action-researchers, have, with inspiration from Marxist ideology, applied a motivation with which to work toward transformation through and via ‘the native’s point of view’, in solidarity with and for the benefit of the ‘natives’ or for ‘the people’ [4]. However, a wave of reflexivity then questioned the role of scholars in the realm of ethnographic interaction and their impact as participants in the field [5]. These new considerations from activist research and ethnography induced important ethical questions regarding ‘voices’: Who speaks for whom, who has the right to the interpretations of other people’s voices, and what are the opportunities regarding whether these people can speak for themselves in any way [6,7,8]? From post-structural literary criticism and Derrida’s theory of deconstruction [9,10], critical voices of non-Western origin have emerged, pointing out the positionality of researchers representing broader, hegemonic structures of power and/or wealth on local, national or global levels deriving from colonial history, especially construing the ‘Occident’ (the Western world) as the logo-center, where discourses of power were inherent, as opposed to the subordination of the ‘Orient’ [11,12,13].

Today, participatory action research involves embedding democratic ideas and striving to support collaboration between researchers and non-researchers; including marginalized or vulnerable participants [2,14], and new terms such as ‘user-driven innovation’, ‘co-production’ or ‘co-creation’ are merging into the dialogue, primarily influenced by methodologies from design studies and digital technology [15]. Common in these approaches is the incentive for the co-creation of knowledge based on non-hegemonic participation from different kinds of actors who add expertise from each of their own fields. The group of participants may comprise users, citizens or other groups of persons who work together with academics toward transformations with the potential to empower the people engaged.

However, the challenges concerning the ethics, positionality and relics from cultural and historical inventories are still actual dilemmas necessary to reflect upon when using PAR or similar methods. In this article, we describe and discuss some of the issues experienced in a PAR nature-based intervention study involving the co-creation of knowledge regarding health in everyday life, together with a group of aging Turkish migrant women living in Denmark, all of them suffering from more than two diseases.

Turkish Migrants in Denmark

Migrants comprised 281 million people worldwide in 2020 [16] (p. 3), and, in January 2022, 23.8 million non-EU-member citizens resided in the EU (5.33% of the population) [17]. In Denmark, the total number of migrants (from the EU and outside the EU), including their children born in Denmark, comprised 15.4% in January 2023, and Turkish migrants represented the largest national group [18]. Immigrants from non-EU countries are, by political discourse and demographic science in Denmark, categorized as ‘non-Western’, leading back to associations with Edward Said’s considerations regarding ‘the Orient’ and ‘the Occident’ [11]. Until 2023, few registers and studies existed in Denmark with a focus on the health situation among non-Western migrants. This reveals a lack of knowledge pertaining to the health of Turkish migrants as a specific population group. However, analyses of self-reported health document significantly poorer health among non-Western migrants than among the Western population [19,20,21,22]. Furthermore, compared to migrant men, as well as to the majority population, older migrant women experience higher risks of ill health, including anxiety, depression and diabetes [23,24].

Because Turkish migrants comprise the largest group of migrants in Denmark, and because of the scant focus on and documentation of ill health among this group, including aging women, we decided to investigate using a mixed intervention and PAR study together with a group of Turkish women from a smaller city in Denmark.

The aim of this study was bifurcated as a practical (health) intervention study and a PAR study. In the following, we present the intervention and the PAR experiences and reflections from the intervention as a methodological experiment, identifying methodological benefits and challenges. What can we learn from an experimental research method like narrative nature-based PAR, carried out with and among marginalized female migrants living in the triple jeopardy of bad health, related to migrant status, age and gender?

2. Intervention and Research Approach

This study is based upon new ideas and knowledge about health interventions in green environments as well as a specific PAR methodology related to our intervention. In the first part, (2.1), we will shortly introduce how we developed the ‘narrative, nature-based intervention’ as an emerging health intervention. In the second part, (2.2), we present the planning, recruitment, and execution of the practical intervention, including informed consent, and the stock of collected research data. In the third part, (2.3), we will describe some of the activities and reactions during the process of the intervention as well as how this part fed into the research project. We will then focus on what we can learn about PAR and marginalized populations from this case, and we will discuss balances between weaknesses and resources in participants as important issues to include in reflexive considerations of PAR studies with marginalized and vulnerable populations.

2.1. Emerging Health Interventions

Within health promotion science, alternative methods of healing from arts and nature have been brought forward in recent years. The role of arts in improving health and well-being is documented by WHO [25], inspiring the Danish health authorities to recommend ‘Culture prescriptions’ for patients [26]. Nature prescriptions, too, are found to be effective especially for mental health, but also for cardiometabolic health [27,28]. In fact, distance from nature may be a threat to human health [29]. We created the idea of a ‘narrative, nature-based health intervention’ for and with aging, female, Turkish migrants with inspirations from narrative rehabilitation [30,31] and from eco-therapy [32]. One of the researchers (ALB) is also a nature therapist [33] and a yoga teacher, and these skills were applied in the project’s activities. In the following, the activities will be outlined further alongside considerations about the interrelationship with the research methodology.

2.2. Planning, Recruitment and Execution of the Intervention and Research Method

In the planning process, we decided to arrange eleven meetings in green environments, each lasting 2.5 h on a weekly basis. We also intended to carry out life course interviews with the participants to learn about the personal context and background of the participants’ current everyday life and health practices [34]. Only women were invited, because we intended to create a trustful environment for the participants, demanding a homogeneous gender representation, in line with the (female) gender of the researchers as well. The content of the meetings included invitations for input from the participating women, and we aimed at creating space for dialogues and feedback all along the process. This would encourage everyone to join in with wishes and suggestions.

Because of the bifurcated model of this study, the health intervention included physical activities, enjoyment of nature, picking berries and herbs, doing light yoga, breathing exercises and meditation, making fires, and enjoying home-/nature-based meals together, whereas the research-oriented part included dialogues about the participants’ health issues, daily life in Denmark, past and present notions about health, food, nature, and other subjects occurring spontaneously. Obviously, these two parts intertwined along the way, each fertilizing the other for further input or ideas, and we would tape the dialogues and interviews, write fieldnotes from the conversations, and document the activities with photographs.

Recruitment of especially vulnerable migrants as research participants represents a difficult part of qualitative migration research [35,36], due to linguistic problems, culture gaps and vulnerable life situations. Our research protocol (and funding) indicated collaboration with aging, female, Turkish migrants who suffered from, or were at risk of suffering from type 2 diabetes. For recruitment, we contacted a local Muslim association who invited a group of eleven Turkish female members aged 41–65 with interest in joining the nature-based meetings.

The participants all had physical and mental health challenges; type 2 diabetes or risk of developing diabetes mixed with other chronic diseases such as high blood pressure, osteoarthritis, anxiety, mental stress, fibromyalgia, pain in back and legs, and for all of them, low to severe obesity. Due to these health challenges, between four and ten women participated in each meeting in the natural surroundings over the course of fall 2021, and the number of participants decreased, along with the onset of fall and winter temperatures. We offered transportation to the natural environment, a clear prerequisite for their participation. Another prerequisite was the attendance of a Danish-Turkish interpreter. One of the Turkish women was born in Denmark and spoke Danish fluently, the other women spoke little or no Danish.

Most of the women were born in the countryside in Turkey, and, in general, they had five years of education. Migration to Denmark was either due to work or marriage. As migrants, they obtained low-paid jobs in Denmark such as industrial production, cleaning, or food preparation. Following years of paid work along with caring for the family they all experienced severe health problems. Except for one woman, who became ill after a pregnancy by the age of 20, they all blamed their health problems on the physical and mental exhaustion from their working life in Denmark. At the time of this study, the participating women had lived most of their lives in Denmark, now aging there with adult children and grandchildren. Socially, their everyday life had become very isolated due to poverty, health problems, and limited social networks.

The research material collected comprised transcriptions and field notes from dialogues during the meetings in the green environments, and documentary photographs1. One researcher (ALB) was primarily engaged in facilitating the activities in green environments, while the other researcher (KC) took part in the activities while she currently made fieldnotes on sight. After each meeting both researchers wrote extensive fieldnotes based on memory; this resulted in two sets of fieldnotes from each meeting. Furthermore, dialogues were taped during the meetings. The quality of the sound was unfortunately too low to include this material in the analysis, but we could use the notes taken on sight by KC. After the end of the course of the nature meetings, six of the women accepted being interviewed; each interview lasting 1–1.5 h and giving insight into their migration, life course and current life situation. These interviews were also transcribed, and furthermore, the two researchers wrote evaluating notes from the impressions at every interview. Finally, we arranged a workshop for evaluation and photo session together with the participants. This was held almost two months after finalizing the meetings in nature, and we also produced notes from this event. Summing up, the textual material for the research analysis comprises 511 pages transcribed in Danish and approximately one hundred photos from the meetings.

When analyzing this material both researchers read and executed content analysis based on meaningful utterances regarding health practices, value of the intervention, foodways, impressions of the nature, reflections about past and present time, daily family life, and experiences as a transnational migrant. For this article, topics regarding the value of the intervention has been selected related to nature and well-being.

Informed consent was executed. The participating women signed a sheet requesting their informed consent, promising anonymity. Their names and locality are not provided, and the transcriptions are not available outside the project. Some of the women had to sign with a cross, due to illiteracy. They were also asked for permission to use the photos, which most of the women did give.

2.3. Activities

Since this study involves two parts, a health intervention and a PAR project, we will, correspondingly, divide this section into two parts: One part will present the activities in the natural surroundings, including some of the reactions from the participants and the role of the interpreter. The other part will present the activities as research methodologies with comments about their impact on the research process and options for gaining more knowledge about the people studied. However, these two parts are intertwined in a mutual process, which will be explained.

Some of the activities offered to the participants in the intervention were light yoga exercises, breathing exercises, and practical knowledge about edible berries and herbs available in the Danish countryside. These activities took place in the forest at two different places near the small town where the women lived, and transportation to the spot was provided for the participants. The activities were received with positive responses. The women said they could feel the benefits of doing a little yoga for their sore muscles, and the breathing exercises calmed mental or cognitive distress. They also seemed to expect information and advice in top-down formats more familiar to them from previous experiences, as they asked for advice from a dietary expert. Then, we invited a dietary expert who came to present a lecture about type 2 diabetes in the nature. After a few meetings the women sensed the informal PAR-ideals of the project and our invitations to participate more actively, also in the organization of the meetings. Then, they asked for more yoga, more knowledge about edible herbs, and they brought more foods, because they enjoyed our social connectedness. The trust which was built even encouraged one of the Turkish women to present her own experiences with weight loss when guided by a cognitive therapist. She, therefore, requested a model of a brain for her presentation about how to “trick” the brain to lose weight. (See illustration, Figure 1).

An important participatory element was social gathering and partaking of food. At the very first meeting, the women were welcomed by “mercimek” in a pot on the fire, a traditional Turkish lentil soup to make them feel at home, and to signal that we had knowledge about and respect for their traditional foodways. We also wanted to signal that we did not intend to drench them in dietary advice from a Western-oriented diabetes recipe book. Serving a small snack or meal was used as a basis for dialogues about healthy eating habits, and the Turkish women quickly embraced this idea and brought along a variety of foods to share—and discuss.

Following every meeting, the group was asked to provide an assessment of their impressions of the day. They praised most of the activities, and they especially appreciated the practical knowledge about ‘the edible nature’ in Denmark, which they had never known about before. Neither did they know about the local area in the nature where the meetings took place. The knowledge about ‘edible Danish nature’ reminded them of customs from their youth in the home-country. At almost every meeting, the women indicated that they really enjoyed the social benefits of coming together and having a good time in the green environment. They also enjoyed walking in the forest, and they often talked about how to implement this habit in their daily lives, walking together, for instance two women together, combining physical activity and friendship.

The activities were facilitated by the researchers as well as an interpreter. Due to the weakly developed Danish language knowledge among the Turkish women, it was crucial with an interpreter, who participated in all the activities herself. It was crucial too, that she had the same gender and that she in several ways lived a similar migrant life as a Turkish woman in Denmark, except for being a professional employed within social work. During the project time her role very much became a co-researcher role, where she strengthened the researcher–participant relationships.

Except for the life course interview, the research methodology applied in this project had never previously been tried out by the two researchers; its components were invented along the way as an iterative process, following the directions of the activities, wishes from the participants, and conditions provided by the weather. Regarding individual life course interviews, the two researchers have extensive experiences with this qualitative research method. During the eleven meetings and social gatherings, which were carried out prior to the life course interviews, we learned that the eleven meetings represented a foundational basis for background knowledge about the interviewees and their challenges in daily life, especially related to health. We had observed the women moving, talking, being in pain and in joy, we learned about physical and mental limits regarding their mobilities and capabilities, and we had all participated in group conversations about habits and values related to daily life concerning food, physical movement, things that “make us happy”, and the joy of green environments—only to mention some of the topics from our dialogues. All this knowledge was very beneficial for the conversation at the individual interview, since we had got closer to the daily lives of the women at the meetings.

Our knowledge base was further widened by the interviews. For instance, it was revealed through face-to-face conversation that the women would never go out for a walk together on their own, even though they had talked very positively about this at our meetings in the green environments. In the private conversations in their homes, we learned even more about the significance of the vulnerability in the lives of the women, including the barriers of going out for a walk on their own. This information enhanced our understanding of the importance of provision of transportation to the natural environments. It also widened our understanding of their actual, deep motivation to participate in the meetings because of joy, even though they sometimes had to cancel due to physical or mental problems.

3. Results: Experiences from Collaborative Research with Vulnerable, Female Migrants

In this section, we will present some of the results regarding the health intervention, the PAR methodology, the interrelatedness between these two parts, and the benefits and challenges entailed by this method.

3.1. The Unknown and Informal, but Successful Health Intervention

One result of the narrative nature-based health intervention was that the activities in the green environment clearly had a positive impact on the immediate well-being of the participating, vulnerable women and their health issues. We cannot conclude anything about long-term effects, as this would require a longer period and follow up activities related to a longitudinal research design, which was not possible within our funded framework.

Here is one example of a woman’s assessment after the third meeting, 21 September 2021:

“Before I came today, I was sad, angry, and had anxiety. I now see that it was the right decision to come. I now have positive energy. I am feeling good. I am happy after this meeting. I have never known the nature here as I do now. I am very happy to learn about the nature.”2

It was our clear impression that some of the women experienced a growing self-confidence during the sessions. As mentioned above, one woman decided to “give a presentation” about a complex topic; brainwork for dietary benefits, and another woman who suffered from many, severe illnesses, appeared to be the master of making pancakes on the fire, which made her shine for a day.

These effects are in line with documented research on benefits from interventions in green environments, which are proven to increase mental health problems like stress, depression, and anxiety (Hartig et al. 2014 [37]; Beyer et al. 2014 [38]; Bratman et al. 2015 [39]; Mcmahan et al. 2015 [40]; Schertz & Berman 2019 [41]).

However, at the very first meeting in the natural surroundings, the atmosphere was not very relaxed, which is revealed in some of the fieldnotes. The Turkish women had just arrived at the meeting for the first time, when one of them took the lead.

“She (G) indicated that they wanted to know the aim of the project and its uses. Her tone of voice was slightly aggressive (…). She made it clear that they wanted information. So (…) I presented us and the project shortly, and S. translated. They seemed satisfied with this information and with the knowledge that this is concurrently a health intervention and a research project. We emphasized that we did not have a fixed program, because we wanted to do this collaboratively with the women. (…) G. brought forward that they needed knowledge about weight loss and diet.”

[Fieldnote by KC from the first meeting, 7 September 2021]

The fieldnotes from this day also include a reflexive note from the researcher:

“It is difficult to involve them; they seem surprised that we do not intend to provide them with health promotion advise. Clearly, we are creating a course on premises they do not know much about. We need to find good methods to involve them as active participants”.

[Fieldnote by KC]

Surprise is seen again in the fieldnotes from the next meeting:

“The atmosphere was clearly pessimistic when the women arrived. I was surprised, just as we had experienced a positive attitude last time. (…) They could not see the aim, and they did not see what they would benefit from this course. We just had to accept their responses and continue, so that we did.”

[Fieldnote by KC from 14 September 2021]

From these notes it is revealed that Participatory Activity in Research, and intervention projects, are not simple tasks. As researchers, we interpreted these challenges as deriving from the women’s experiences with conventional health interventions, which are often authoritatively one way-directed as top-down information from expert to lay-person/user/participant. We got the impression that the women did not have experience with informal projects where their own expertise and wishes were welcomed and wanted, and hence, from their perspective, this intervention may have seemed aimless and confusing in the beginning. As organizers we did not have an opportunity to explain the aim and methods of the project face to face for the participants prior to the first meeting because of the linguistic difference; and since most of the participants were illiterate, a written and translated introduction had not been an option.

However, along the way, our activities, experiences, and dialogues created a momentum of social interaction. Trust was established, not only between the group participants, but also between the researchers and the participants. This trust apparently evolved from a respectful attitude from the two researchers, who continuously expressed an intention to co-operate, and who met the women with kindness and invitations to bring along their own experiences and ideas. Laughter was always close to the surface, not the least when the yoga teacher (ALB) tried to name certain body parts in the Turkish language, which made everyone laugh, because she mispronounced. In this way, the Danish language was not always positioned as the hegemonic language, which is normally the case regarding the Turkish women’s lives in a Danish context, and the roles between the researcher and participants could be twisted for a while, because the Danish researcher obviously did not master their language, but she tried. Somehow, these episodes could establish a more equal position between the Turkish women, who normally struggle with the Danish language, and in this case, the researcher reversed the situation and took the role as a person who has not mastered their language as the ‘incompetent’ speaker in a foreign language.

The establishment of trust propelled us into a deeper level of information about the lives and daily challenges of the women in the group which was beneficial for the research part of the project. In this way, the women did also receive advice, inspiration, and health dialogues based on knowledge about edible plants, yoga, and nature therapy, and they appreciated this knowledge. Simultaneously, they also began to take part socially, to raise their voices and participate in the construction of knowledge concerning health in everyday life. They even shared certain experiences about difficulties of their family lives or health situations whish otherwise probably would have been kept a secret.

3.2. Relational, Social Connectedness

In the presentation above, it is mentioned that a homogenous gender selection for participants was chosen for this project to fertilize a good and trustful connection between all participants, including the researchers. We succeeded to some extend in establishing personal and close relations between the two researchers and the small group of the four to seven participants who joined almost all the meetings. Gender similarity was a prerequisite for this, but also similar life situations paved the way for social connectedness, such as when the Turkish women learned that the two female researchers had three and four children each, plus grandchildren, which was quite in line with their own family situation. Food recipes, health awareness and knowledge about herbal medicine at a layman’s level also relates to the stock of traditional, female knowledge across the world, and provided us all with a sense of alliance in these interests. This alliance was furthermore strengthened through the ‘bridging role’ of the Turkish/Danish interpreter, as indicated earlier.

During the eleven meetings, the relationships became more trustful and open, which also resulted in a more liberated dialogue, fun and laughter. In the evaluation rounds, it was mentioned several times that the Turkish women found the Danish researchers to “be nice”, and fun was made with the name of one of the researchers (Anne Leonora), because “anne” in Turkish means “mother”, and because she was often in charge of the practical activities.

3.3. Research Skepticism

On one specific point, we experienced continuous challenges throughout the intervention, namely concerning our roles as researchers. This problem involves the need to document the activities, and it became specifically pertinent when we intended to tape, write fieldnotes, or take photos, because they became particularly anxious when we carried out this documentation work. At the very first meeting, we asked for informed consent from the participants. In the consent paper, we divided their acceptances into different spheres, so they could claim anonymity concerning fieldnotes and tapes, whereas consent for photographing was marked out separately, because photographs are difficult to anonymize. Three of the participants did not agree to photography, and many times during the meetings this issue popped up as a problem. Even though we did not photograph anybody who did not allow this, some of the women persistently expressed worries about photo documentation. It somehow indicated that they did not trust us on this issue. This subject became a continuous problem throughout the intervention. Simultaneously, the participants all carried a cell phone in their hand or close to their body, making phone calls and facetiming at our meetings, filming the group and the researchers in action, sometimes even transmitting our activities live to family or friends in Turkey. Some of the women also produced complex films and notifications from their experiences in the nature meetings via the service Whatsapp. No doubt, these women had digital competences and liked to share their experiences with third parties.

Due to this worry about photographs among some of the participants, the two researchers had to reduce the collection of photo documentation. The photography, however, was not the only problem identified by the participants.

“She [ALB] asks everybody to respond to three questions about their experiences from today. (…) When the responses start, I [KC] diligently write notes. (…) A women (N) pulls a scarf above her head, so AL cannot see her, and they [some of the women) start a mutual, private discussion. It occurs that she thinks I understand Turkish; and this shortly creates some fuzz. I explain that I only write the Danish translation.”

[Fieldnote by KC from the third meeting, 21 September 2021]

What happened was that the woman felt suspicious towards the role of KC, who was writing notes as the women were talking. Did she [KC] understand Turkish and “spy” on the women, as they talked? Issues like this were repeated several times during the process, and even on the final day of the intervention, another fieldnote reveals:

“ALB explained that we intend to make a photobook, which raised a lot of questions, because the photos again were mentioned. (…) We ensured that we do not share photos which are not accepted [by the participants], and that the use of these photos is for remembrance, and that the book will only include photos that are accepted by the participants. (…) Suddenly one of the women (N) realized that the tape recorder was on the table, recording, and she wanted to know why. Again, ALB explained that this is also a research project, so we need to remember what is being said. As at all the other times, when this issue was raised, they calmed down again3.”

[Fieldnote by KC from the third meeting, 30 November 2021]

The latter notes about distrust in the writing of fieldnotes, to recordings and photography, reveal an ongoing, skeptical attitude to our documentation of the activities, or maybe a kind of distrust of the researchers, and of what we intended to do with our knowledge and material about the participants. We did not encounter these kinds of hesitations toward our roles as providers of the health promotion intervention. At the same meeting, the participants simultaneously expressed great satisfaction with the intervention, because it had been very good for their health, and they indicated that they would like to continue participating in this project, if this were possible.

These two, very different kinds of input expressed on the very same occasion, prompted these reflexive considerations in the notes:

“The final meeting revealed for me a dilemma in this project: We create a health intervention together with the Turkish women, which they like, because it responds to needs in their everyday life with ill-health in Denmark. As soon as they observe photos taken, or conversations recorded, they turn suspicious. All through the course of the intervention we continuously had to explain these kinds of documentation. It seems as if they do not really accept this part of the project. (…). On the one hand they like the intervention, but they are skeptical about the research part. Maybe this is because they are not able to understand what it is, and for what purpose even though we have explained this in various ways? Does this mean that the narrative, nature-based PAR represents a challenge as a research methodology? Or does it mean that we have not succeeded in explaining it? Or does it mean that we need to elaborate on the research-part of the project, i.e., try to incorporate it in better ways into the meetings?”

[Fieldnote by KC from the final meeting, 30 November 2021]

4. Discussion

In the following discussion, we will present some considerations emerging from the results of the intervention as a participatory action research which may be specifically important when working with vulnerable migrants.

4.1. Mutual Respect and Research Benefits

As PAR researchers, we made persistent efforts to establish an equal and participatory approach between the Turkish women and us, the researchers. Concerning the health intervention part, the Turkish women displayed some confusion about our participatory ideals and intentions. We clearly underestimated the fact that providing a health promotion intervention based on participatory principles contrasts with the types of patient–expert relationships many people, including migrants in vulnerable positions like the Turkish women in this project, have developed within the conventional healthcare system.

After a few meetings the Turkish women seemed to have acknowledged and appreciated that we really wanted them to be active participants at the meetings, because we met them and their knowledge, opinions, and experience with great respect, as we invited them to speak up and bring up ideas. They seemed more confident with us, and the social interactions provided a mutual respect and relationship among them and us, which was partly due to some common understandings and similarities in each of our lives, such as gender and family experiences, partly due to our joint activities in natural surroundings.

This atmosphere of connectedness and understanding was unquestionably very beneficial for our dialogues and conversations, and we learned many things from each other at the meetings. For us, the researchers, these conversations contributed a great deal to our understanding of the Turkish women; about their ill health and the consequences and conditions in their lives, following from their situation and life course. From a research point of view, such knowledge is difficult to access, and it is important to obtain, because there is scarce knowledge about the health situation and daily life of migrants in Denmark in a life course context—for migrants like the women in our study. This issue represents an important challenge for a welfare state like Denmark with the political goal of equity in health for all citizens [42].

4.2. Considerations of Structural Positionality

As the practical activities seemed to build up a kind of mutual relationship between us, our research interest in documenting the activities simultaneously seemed to counteract this emerging, trustful relationship, due to the skepticism from some of the Turkish women.

From our first impression, this could be due to a sense of privateness, indicating that the women did not want any photographic exposures of themselves in public, and they were perfectly aware of the possibilities for digital distribution. However, they did not refrain from facetiming and filming each other and us in action, distributing this material to whom and where? We do not know.

Another feasible option is that the women did not understand or accept our need for documentation due to our research protocol, even though we got the impression that they did, since we informed them several times about this.

A third possible explanation is that they did understand but did not accept participating as “research objects”, being aware of our positionalities, respectively.

The second option is feasible, since each of us researchers previously have experienced challenges in explaining the full content and consequences prior to interviewing people about their life course. It is not possible to predict the development of the conversation in an interview, the possible emotions that may be raised by the topics, nor the outcome of the research far later in the process. This represents circumstances for the researcher, which makes it challenging to explain, prior to the interview, such details for the person who is interviewed. The challenge is even more relevant if the research approach is very “qualitative”, indicating an open minded and iterative research protocol and research process, which may often be the case in PAR. This challenge is also one of the reasons why common research ethics demand that interviewees are given the option of withdrawing their consent at any time.

Even though we as researchers struggled to facilitate a space for confidence and trust in a co-construction of a health intervention, it would be an illusion to consider such equity to be the case, when well-paid, well- educated and healthy, Danish researchers cooperate with frail, aging migrant women, and when the object of this study is the health and lives of only one part of the group. This is the case when we talk about a health intervention, directed at these women, and it is even more salient when talking about a research project, where one part participates as the object of study, studied by the other part. In one way, we take after Malinowski when we “play” with the Turkish women; we enjoy and have fun together, but on the other hand, we as researchers have a goal of obtaining knowledge from and about them.

As PAR researchers, we cannot escape our inherent reality as representatives of hegemonic structures which position us and the Turkish women in quite different situations—as “them” and “us”. Such structures are, among others, the different living and life course conditions for each of us, on a personal and practical level, but this situation, importantly, points to larger structural levels in society and culture. As Danish researchers, we represent the logocentrism of the Occident, according to Edward Said, and the Turkish women, though living in Denmark, represent “the other”; the “Orient” or the “non-Western migrant” as they are termed in a Danish, political context, which further feeds into the hegemony of positionality in Denmark.

This personal and political reality, marking the lives of some migrants, and among them, the Turkish women in our study, may presumably influence their experiences as well as their own approaches and attitudes to “us”, the Danish Danes. In the case of our research, this may be a reason why we were met by suspicious skepticism by the Turkish women, even though they also “liked us”, as they said. Social and cultural structures, however, overrule social relations [43].

At the inception of our project, we had the intention to co-create an exhibition at the local museum with the Turkish women, following the ideals of doing PAR and trying to empower the participants in the project, giving a voice to them in a public space. What we did not know, before we met the women, was that they refrained from exposure, and they did not want to participate in any public appearance. The reasons for this may be found in the analyses above, which lead us to suggest three interpretations, representing three elements of consideration concerning structural positionality and PAR among vulnerable female migrants:

The first reason may be cultural background: A wish for privacy may be due to the familial and religious/cultural background of the Turkish women, where women are not supposed to “show off”, which was for instance revealed at one meeting, where we all danced to fight off the cold weather and rain, and the women were specifically insistent that no photos should be taken. Our interviews with the women indicated strong, patriarchal structures in their family lives.

A second reason may be absence of personal resources: Acceptance of exposing oneself, for instance in photos at a local exhibition, and being given a voice in public space, may be seen as an embodiment of empowerment. However, such an acceptance demands an already existent subjective feeling of personal resources and empowerment. Such a feeling was absent in the lives of these women, who are frail and suffering from several illnesses.

And thirdly, cultural representation may be an explanation: In our interpretation, the migrant women reflect upon themselves as representatives of a marginalized population with negative experiences connected to positionality and “otherness” in the Danish culture. As described above, this was illustrated by their confusion and skepticism towards us; confusion, because they liked us and enjoyed the activities, we did together, but at the same time, they carried a skepticism all along the way, towards us as representatives of the Danish Danes.

These three considerations of structural positionality should be included in PAR-studies, especially regarding cooperation with vulnerable groups of migrants.

4.3. PAR and Research Structure

We have sketched benefits and critical considerations concerning a project like the narrative, nature-based health PAR, which is simultaneously a health intervention and a participatory action research project. The next level is to elaborate on methodological ways to overcome challenges for paving the way for more PAR among migrants, despite the impediments described.

Returning to the introduction and referring to classic ethnographic studies, it might be beneficial for PAR if the researchers had more insight into culture and language of the participants from the cooperation group, resembling the ethnographic notion of “going native” or “from the native’s point of view” [44,45]. However, such an ideal is probably not realistic for research and researchers, and, by the way, this topic represents a whole body of concerns and critical considerations from ethnographic science, i.e., [5].

Another issue is “time”, which is probably a general solution to several of the challenges described above. Our project could have benefitted significantly if we had had more time. Initially, we should have known the Turkish women prior to the meetings, and we should have had time to inform them in better ways about the project. This question also resembles classic ethnography, where the ethnographer often spent years together with the population of this study. In our case, and in present time and reality for most scholars, this is not achievable, but more time to build a foundational relationship between the researchers and migrants in this study would have been preferable. The period of the project should have been longer, and while onsite, the women also indicated that they wanted to continue the meetings in natural surroundings. However, the project had an end due to the funding. During the process, we as researchers applied to our funder for more time, which was unfortunately refused. Several months after the ending of the intervention and the life course interviews following, it appeared that we still were allowed a few months’ time for more meetings in natural surroundings, but by that time, our close connection to the women had been lost. The vulnerability of their lives, and of our relationship, was revealed in this weakness in reality.

While structural research conditions with a limited time period provide one explanation for some of these challenges, another and more substantial challenge relates to the methodological idea of realizing ‘participation’ in action research. The case of Turkish female migrants in Denmark gives insight into the point that there is no ‘participation’ before the term is operationalized based on interpretation and negotiation among the specific groups of people involved, and still then, participatory challenges may have to be solved. In the case of the vulnerable group of marginalized Turkish women in Denmark, this relates to the basic dilemma between wanting to protect and support participants carefully on one hand (particularly as they are suffering from ill-health), and simultaneously facilitating their active participation on the other hand. Bridging this protection and participation, which also includes bridging the ‘us’ (Occident) and ‘them’ (Orient) issue, requires a continuous process of methodological reflections, but also that the people involved are willing and ready to ‘move’ in a participatory sense [46]. PAR scholars need to reflect upon possible romantic views of “empowering” people who may not be ready or may not be in a position yet to go in that direction, and furthermore, there is a need for attention to the fact that co-production between scholars and participants is seldom expanded to the analytical work and dissemination of the research results [46]. It is very difficult to include all partners in all steps of a research process, and especially within applied health research where the term “co-production” has become a buzzword associated with participatory research in various forms and outcomes [47]. Our study with the Turkish women testifies that as PAR scholars we need to consider multiple perspectives, positionalities and structures, especially when working with vulnerable migrants.

5. Conclusions

By applying a bifurcated aim in this PAR project, including a practical health intervention along with an ethnographically inspired research study about the daily lives and health approaches among the participants, we acknowledged two different results, representing benefits as well as challenges. One result concerns the practical intervention which seemed successful, although too short in time. The research method was successful, because the combination of the practical health intervention and the ethnographic study provided a deeper understanding of the health and life situation of the participants, including knowledge about the impediments for developing a way to a more equal health situation, compared to the health situation of ethnic Danes. On the other hand, the research part also brought to the surface impediments concerning distrust and skepticism among the Turkish women who participated, and for whom our interest in their lives, and especially our need to document this as research material, for some of them seemed to be too intimidating, transgressing their intent to keep privacy.

This study illuminates that when working with PAR among frail and vulnerable persons, it is important to keep in mind that structural inequalities on a societal and cultural level are inherent in the interrelations between participants and researchers. This may be difficult, but not impossible to overcome in specific PAR studies. However, methodological reflexivity and considerations regarding deep, structural and cultural layers of us-and-them dichotomies are required. We suggest especially awareness in further PAR studies concerning cultural background, personal resources, and cultural representation.