CBPR

1. Bonnie Duran DrPH, Associate Professor,
University of Washington School of SocialWork
Director, Center for Indigenous Health Research
IndigenousWellness Research Institute www.iwri.org
University of Massachusetts, Lowell
October 29, 2015
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2. 1. Define and describe community-based
participatory research (CBPR) for health
2. Rationale for CBPR
3. Explore the history and theory of CBPR
4. How can we train for equity in community
engagement?
2

3. “ CBPR refers to a partnership approach to
research that equitably involves
community members, organization
representatives, and researchers in all
aspects of the research process.”*
Israel BA, Eng E, Schulz AJ, et al., eds. Methods in Community-Based
Participatory Research for Health. San Francisco, Calif: Jossey-Bass; 2005
3

4. Participatory Research is an Umbrella Term:
Action Research
Participatory Action Research
Emancipatory Research
COMMUNITY-BASED PARTICIPATORY RESEARCH
popular epidemiology
cooperative inquiry
empowerment evaluation
Practice Based Research Networks
Patient Centered Outcomes Research
PARTICIPATORY RESEARCH

5. 5
 “Systematic inquiry, with the participation of those
affected by an issue for the purpose of education and
action or effecting change.” Green et al., 1994, 2003
 “ A collaborative research approach that is designed to
ensure and establish structures for participation by
communities affected by the issue being studied,
representatives of organizations, and researchers in all
aspects of the research process to improve health and
well-being through taking action, including social
change.” AHRQ Report, 2004

6.  Emphasizes local relevance and ecological perspective
that recognizes multiple determinants
 Involves system development through cyclical and
iterative process
 Disseminates findings and knowledge to all
 Involves long-term process and commitment
Israel, Schulz, Parker, Becker, Allen, Guzman, “Critical Issues in developing and following CBPR principles,”
Community-Based Participatory Research in Health, Minkler and Wallerstein, Jossey Bass, 2000.
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7.  Recognizes community as a unit of identity
 Builds on strengths and resources
 Facilitates partnership in all research phases
 Promotes co-learning and capacity building
 Seeks balance between research and action
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8. University Control Community Control
CBPR
Spectrum of CBPR
Relationships
Shared University/Community Control
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9.  Don’t plan about us without us
 All tribal systems shall be respected and honored,
emphasizing policy building and bridging, not a policy wall
 Policies shall not bypassTribal government review and
approval prior to implementation
 Tribally specific data shall not be published without prior
consultation
 Data belongs to tribe
Turning Point Collaboration for a New Century of Public Health, Spring Forum 2001, NACCHO,W.K.K Kellogg,
Robert Wood Johnson Foundations
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10.  CBPR is an orientation to research
 changes the role of researcher and researched
 CBPR is not a method or set of methods
 Typically thought of as qualitative
 Fewer epidemiologic examples, but promising
 CBPR is an applied approach
 Goal is to influence change in community health, systems,
programs, or policies
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11.  Who chose the
problem to be studied?
 How is the budget
divided?
 What is the theory of
etiology or causal
theory?
 Is there an intervention
or service component?
 Where are the results
disseminated?
 Who designed the
intervention?
 Who made the
research policy
decisions? (e.g. is there
a control group?)
 Who writes
papers/makes
presentations? Who
owns the data?
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12. Models are “an idealized representation
of reality that highlights some aspects
and ignores others.”*
“Models, of course, are never true, but
fortunately it is only necessary that
they be useful”**
12
* Pearl, J. (2000). Causality: Models, reasoning, and inference.
Cambridge, England:Cambridge University Press.
** Box, G. E. P. (1979). Some problems of statistics and everyday
life. Journal of the American Statistical Association, 74, 1–4

13. 13

14. 14

15. University Control Community Control
CBPR
Spectrum of CBPR
Relationships
Shared University/Community Control
15

16. Spectrum of Participation:
(Cornwall 2008)
Compliance
Co-option
Consultation
Co-operation
Co-learning
Collective action
Cornwall, A (2008) Unpacking “Participation” Models, Meanings and Practices. Community
Development Journal; 43(3): 269–283.
“Token” involvement of
knowledge users
Possible “Token”
involvement of
academic researchers
Equitable
Co-governance

17.  Concurrent/Parallel
 Based onTheoreticalTransformative Model
▪ Interaction throughout Research Phases
▪ Qualitative and Quantitative = Equal Priority
▪ Sequential and ConcurrentTiming of Data Collection
▪ Current Mixed Methods Analyses
 Two Examples:
 Trust
 Governance/Approval Processes

18.  Key Informant (~15 minutes):
 Taken by Principal Investigator or Program
Director
 Community Engagement (~ 30 minutes)
 Taken by PI/PD, 2nd academic investigator,
and 2-4 community partners
 Conducted from 12/2011 – 8/2012

19.  Project Demographics and
Features (49)
 PI team and partners ethnicity,
position, gender, SO, etc.
 partnership dates, funding, type
of research,# of partners, staff
diversity, etc.
 Resource/Decision sharing (4)
 Who decides hiring/, budgets,
resources shared
 Research Integrity (4)
 Confidentiality/IRB training,
approval decisions
 Partner Research Roles
(13)
 Community Engaged
Research Index (CERI)
 Governance (15)
 Formal MOU’s & DSOA’s,
dissemination approvals, $,
conflict resolution
 FormalTraining (8)
▪ racism/sexism/privilege/cultur
al humility/CBPR-collective
reflection
▪ Contact info for Partners

20.  Context (10)
 Community Capacity, Project have what it
needs to work effectively towards its aims
 Social & Human Capital (3)
 Knowledge, skills, connections
 Alignment with CBPR
Principles (8)
▪ Builds on resources and strengths, equitable
partnerships in all phases of the research,
emphasizes what is important to the
community, etc.
 Core values (4)
 shared understanding of the missions and
the strategies
 Power dynamics (9)
 Power sharing, influence, decision making
 Dialogue, Listening, co-
learning
 Conflict resolution, emotional
intelligence
 Governance Mechanisms
 Competency of leadership in diversity,
communication, planning, efficiency,
financial management, etc.


21.  Partnership Synergy (5)
 Come together and work well
 Culture Centeredness (5)
 Community theories, ownership, etc.
 Concrete & Perceived Outcomes(8)
 Index of Perceived Community/Policy Level Outcomes (IPCPLO).
Improved services, policy change, health improvement, etc.
 Personal, Political, Professional Level
Outcomes (13)
 New knowledge, relationships, power, visibility, skills, etc.

22. Seven case studies:
 Diverse health issue, Geographic region, Populations:
 American Indian/other communities of color/social identity who face
disparities
 At least 3-year partnership history with projected research for at
least 2 years; successful
 Intervention, capacity-building or policy research
Methods:
 Focus Groups and Partnership meeting observation
 13-18 Interviews (university and community)
 Brief Partnership Survey: self-administered

23.  How do context/group processes/
individual issues shape facilitators and
barriers to effective CBPR?
 How do differing contextual
conditions and perceptions/meanings
interact with partnering processes to
produce differing outcomes?

24.  Healing of the Canoe:
 Youth Life Skills/Substance Abuse-Washington tribes
 Men on the Move:
 Cardio-Vascular/Sustainable Agriculture/Rural-AA
 Lay Health Worker Intervention:
 Colorectal Cancer Screening/San Francisco-Chinatown
 South Valley Partnership Environmental Justice
 Semi-urban, Southwest - Latino
 Cancer Coalition and Tribal Approval Processes
 Rural - Oglala Sioux Tribe
 Bronx Faith-Based Initiative
 Diabetes and Medical Apartheid
 Center for Deaf Health, Rochester

25. Quantitative Survey: Two scales
 Views on how trust has evolved (type/when)
 Level of trust between team members
◦ Trust of decisions, comfort asking others to take responsibility,
Qualitative Case Studies Questions:
 How do you describe trust in this partnership?
 Has it changed over the life of the partnership?
 How do people relate to the trust types in table?

27.  Multiple factors including, but not limited to:
◦ Who approves the project, Control of project resources, types of
formal or informal agreements, process of decision-making
 Quantitative questions:
◦ How are approval processes associated with control of project
resources?
 Qualitative questions:
◦ How are governance structures constructed and what are the
differences of governance for tribal and non-tribal communities?
Impact on outcomes?

29. 68.7% 70.5%
76.5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Key Informant Survey by
academic PI
Com Eng Survey by
academic PI
Com Eng Survey by
academic & community
partners
N = 200
N = 310
N = 141

30. What Predicts CBPR Outcomes? b SE p
Capacity: Project has what it needs to work effectively towards
its aims
.113 .059 .055
Alignment of CBPR Principles: Builds on resources and
strengths, equitable partnerships in all phases of the research
.230 .068 .001
Level of Involvement:Task roles and communication (CERI) .188 .046 .000
Communication Quality: Degree to which partners
cooperation to resolve disagreements
.059 .039 .137
Stewardship: Use of financial & in-kind resources .086 .048 .072
Partnership synergy: Partners ability to develop goals,
recognize challenges, respond to needs, work together
.249 .059 .000
Trust: Level of trust at the beginning of the partnership .113 .063 .073
R2: 0.467

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32. Mistrust of Research
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History is written
by people in power

33. 33

34.  The basket drum
 The drum stick
 The Plumed wands
 Kethawns
 Sacrificial
Cigarettes
Matthews, W. (1893). Some
Sacred Objects of the Navajo
Tribe. Archives of the International
Folklore Association 1, 227-254.

35.  Knowledge, race and social position
 Interpreter, health educator, health systems navigator, medicine person…
• …driver
Nursing outlook,
June 1961

36. 36
Schillinger, D. (2010). An Introduction to Effectiveness, Dissemination and Implementation Research. P. Fleisher and E. Goldstein University of California San Francisco.
http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf

37.  Challenge of bringing evidence to practice
• Moving from efficacy to effectiveness trials
• Internal validity insufficient for translational research
• External validity: Implementation/Role of context
 Challenge of community complexities
 Challenge of what is evidence
• Evidence-Based Practice vs. m Practice-/Indigenous-
/Community-Based Evidence
• Challenge of one-way orientation
 Challenge to translate action and policy

38. 38

39. 39
Wallerstein, Duran (April 2010) AJPH

40.  Implementation research is the study of
activities and strategies to successfully integrate
an evidence-based public health intervention
within specific settings (e.g., primary care clinic,
community center, school).
 Dissemination research is the study of the
distribution of information and intervention
materials to achieve greater use and impact of
the intervention.
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41. Furthermore, community-based prevention involves decisions
among groups of people about how to live in society, how the
physical environment is built, what food is served in schools, and
so on.Thus, the process by which interventions are decided upon
and undertaken needs to be treated as a valued outcome. If a
community decides to tell people what they can or cannot do, or
what they should or should not do, the decisions need to have the
legitimacy—the added value—that comes from an open
and inclusive group decision-making process.
41
IOM (Institute of Medicine). 2012. An integrated framework for
assessing the value of community-based prevention. Washington, DC: The National Academies Press.

42. 42
The California Endowment
Rodney Hopson, Ph.D.
Adapted from:

43. 1. The social location of the clinician /researcher
matters (intersectionality)
 Gender
 Race
 Class
 Ethnicity
 Education
 Privilege/target
 Sexual orientation
 Etc… What else?
43
Hankivsky, O., & Cormier, R. (2009). Intersectionality: MovingWomen’s Health Research and
Policy Forward.Vancouver:Women’s Health Research Network.
This publication is also available online at www.whrn.ca.

44. 2. Research plays a role in furthering social
change and social justice
 Ability and duty to recognize asymmetric power
relations and to
 challenge systems and mechanisms of inequity and
injustice
 in hope of dismantling oppression
Theoretical approaches: critical, feminist, cultural
humility, anti-racist, postcolonial, etc… What else?
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45. 3. Avoiding ethnocentrism means embracing
multiple cultural perspectives
 shift between diverse perspectives
 Recognizes ethnocentric standards and ideas
 HOW?
 Employ a team who can “translate” research from
multiple cultural contexts
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46. 4 Culture is central to the research process
 worldview, values and norms affect the uses of,
reactions to, and legitimacy of, any research
 multicultural validity - defining social problems
 norms will play out in the context of research
instruments and protocols.
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47. 5 Culturally and ethnically diverse
communities have contributions to make
in redefining the research field
 standards, guidelines, methods and paradigms of
the research field need to be rethought, and
underserved and marginalized culturally diverse
groups have an important role to play in this
process
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