Participatory action research in rural and vulnerable settings for community health: a systematic literature review

Community participation is a key strategy to reduce health inequities, particularly in rural or socially vulnerable settings. Participatory Action Research (PAR) provides methodological frameworks to actively engage communities across all phases of health interventions. However, systematic guidance on the concrete implementation of participatory action research is limited, and few studies explicitly evaluate the levels of community participation reached. To critically analyze qualitative studies implementing PAR in rural and vulnerable contexts by describing the participatory techniques employed, assessing the levels of community engagement achieved (based on the AdaptaGPS adaptation of the NICE NG44 guideline), and examining the utility and outcomes of these participatory approaches. A qualitative systematic review was conducted following the PRISMA 2020 guidelines. Six databases (PubMed, Web of Science, Scopus, SciELO, IBECS, and CUIDEN Plus) and additional sources were searched up to April 2025. Eligible studies were qualitative and demonstrated a community participation level of ≥ 3. Methodological quality was assessed using the CASP tool, and findings were thematically synthesized. A total of 43 studies were included, employing a range of PAR techniques such as Photovoice, Community Advisory Boards, intersectoral coalitions, co-creation methods, and Indigenous-led approaches. Techniques embedded within existing community structures were more effective in fostering network-building and sustainability. Expressive methods promoted critical reflection and political awareness. PAR techniques applied in rural and socially vulnerable contexts show strong potential for promoting empowerment and community-led transformation. Improving methodological rigor, systematizing participatory practices, and evaluating their structural impact on health equity are essential for advancing knowledge, informing policy, and strengthening practice in this field. PROSPERO 2025 CRD420251059871 (May 27, 2025).