While principles are a useful guide, they should not be imposed upon a project or partnership, and that theyshould be allowed to continually evolve to reflect changes in the research context, purpose and participants.The process of developing principles and making decisions about the partnership's characteristics isessential to building the infrastructure of the partnership.
They are willing and committed – for example, they are willing to get involved, open to creating a partnership, understanding of and committed to the long-term nature of the process.• Their organizational mission is in alignment – the partner organization’s mission, culture and priorities encourage, support and/or understand and recognize the value of community-based participatory approaches tolearning, research, evaluation and partnerships.• They have trust and a history of engagement in the community – for example, they are well respected in the communities involved in the partnership, are “in” and “of” the community and knowledgeable about and close tothe grass roots communities in which their organizations work.• They have staff and/or volunteer capacity to participate – for example, having staff and/or volunteers who can work with “outsiders” to accomplish their goals, see the value of research to the organization and community, and willing to navigate research processes and procedures (e.g., the human subjects review process).• They have engaged, competent researchers and research staff – who, for example, can maintain meaningful relationships with the community on multiple levels, are competent to facilitate partnerships and follow participatory approaches to research, and are willing to learn from their partners.• They have support and involvement from leaders at all levels – for example, they have active and visible support and involvement of both top leadership (i.e., a university department chair or dean, public health officer, agency executive director) and “front line” staff who have authority to make decisions, know about theorganization’s daily operations and strategic directions, and have ready access to top leadership. To be mosteffective, individuals involved in CBPR partnerships ideally hold positions of authority and/or leadership withintheir organizations. Ideally these functions are part of the point person’s job description.• They are knowledgeable about the community – for example, having the ability to obtain resources, highdegree of political knowledge, access to decision-makers within the community, have connections with or activein other networks or consortiums.• They strive for cultural competency – CBPR partnerships are likely to involve partners from diverse culturalbackgrounds, with respect to ethnicity or race, gender, social class, sexual orientation, community or academicroles, and academic discipline. It is important for partners to be striving for cultural competency.• They have skills in collaboration – for example, they are able to negotiate, problem-solve, resolve conflict and foster collaboration among partners.• They have interpersonal and facilitation skills – for example, they are sensitive to community needs, have goodlistening skills, are trustworthy, are capable of understanding and appreciating diverse groups, can communicatein a ways that keep partners motivated and informed, are able to understand and feel comfortable in bothacademic, governmental and community settings or translating between them, and are able to transfer knowledgeand skills to others.• They have technical skills – for example, skills in planning and organizing, evaluation, writing, using computer software programs, speaking and/or writing in multiple languages, conducting outreach and managing programs.• They have commitment and connections to the community – for example, placing a high value on community perspectives, knowing the community resources, being known and trusted in the community, being savvy about leveraging community resources, being committed to recognizing and striving to understand community issues, dynamics, and political ‘hot buttons.’• They are committed to the partnership process and the substantive issues being addressed by thepartnership – for example, they pay attention to both partnership process and outcomes, have a desire to see the partnership grow, are deeply committed to community health, community capacity building and social justice, andare knowledgeable about community-based public health.It is important to remember that despite the difference in the settings, mission and culture of their respectiveorganizations, community and institution-based partners share many similarities. They:• Are often over-worked and under-resourced• Have unique skills and experience• Work in complicated and stressful environments• Have their own productivity levels, accountability structures, timelines, calendars and bottom lines• Have very specific jargon• Are often not used to working with the other (communities or institutions) on a daily and ongoing basis• Above all, they care about the health and well being of local communities
Community based participatory research (cbpr)
Community-based Participatory Research (CBPR) Thira Woratanarat MD Department of Preventive and Social Medicine Faculty of Medicine, Chulalongkorn University
“The real challenge lies not in debating whether disparities exist, but in developing and implementing strategies to reduce and eliminate them.” —IOM Committee Chair Social Healthdeterminants ? outcomesof health
Challenges for Bridging Science to Practice: Need for CBPR• Challenge of bringing evidence to practice Moving from efficacy to effectiveness trials Internal validity focus insufficient for translational research External validity: Contextualization/Implementation process• Challenge of what is evidence Practice and Culturally-based Evidence/Indigenous theories, norms, practices• Challenge of one-way translation orientation Assumes community tabula rasa
Tabula Rasa• Individuals are born without built-in mental content and that their knowledge comes from experience and perception.• “Blank slate” in computer science
CBPR Definition“ Collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities.” W.K. Kellogg Community Scholar’s Program (2001)
But, first we need to know the history …• 1940s – Action research (Kurt Lewin) as well as other European social scientists Behavior occurs within a historical/social context Behavior is determined by the totality of an individual’s situation Individuals interact in inter-connected groups as actors as well as authors of their own reality A fundamental premise of community-based action research is that it commences with an interest in the problems of a group, a community, or an organization. Its purpose is to assist people in extending their understanding of their situation and thus resolving problems that confront them…. (Stringer, 1999)
History• 1970 – Empowerment Model (Paulo Freire) Before community members address particular social change goals introduced from the outside, they must first be organized and empowered to address their own concerns and goals
History – Empowerment Model It begins with a true dialogue in which everyone participates equally to identify common problems and solutions Once the individual strengths and the shared responsibilities are identified, the group can work together toward a common goal – participatory process“Washing one’s hands from a conflict between the powerful and the powerless means to side withthe powerful, not be neutral” (Paulo Freire)
What it is and What it isn’t• CBPR is an orientation to research Changes the role of researcher and researched• CBPR is not a method or set of methods Qualitative and quantitative Epidemiology and intervention research• CBPR is an applied approach Goal is to influence change in community health, systems, programs, or policies
Principles of CBPR Recognizes community as a unit of identity Builds on strengths and resources within the community Facilitates collaborative partnerships in all phases of the research Integrates knowledge and action for mutual benefit of all partners Promotes a co-learning and empowering process that attends to social inequalities Involves a cyclical and incremental process Addresses health from both positive and ecological perspectives Disseminates findings and knowledge gained to all partnersIsrael et al, 1998 and 2003
• Don’t plan about us, without us• All tribal systems shall be respected and honored,• Tribal government review and approval prior to implementation• Tribally specific data shall not be published without prior consultation; data belongs to tribe• Core Values: trust, respect, self-determination, mutuality of interests, perspective taking, reciprocity Turning Point Collaboration for a New Century of Public Health, Spring Forum 2001, NACCHO,W.K.K Kellogg, Robert Wood Johnson Foundations; (1) Manson SM, Garroutte E, Goins RT, Nez Henderson, P.. 2004; Norton IM, Manson SM. 1996.
COMPARE RESEARCH APPROACHES: TRADITIONAL VERSUS CBPRHartwig K, Calleson D and Williams M. Unit 1: Community-Based Participatory Research: GettingGrounded. In: The Examining Community-Institutional Partnerships for Prevention ResearchGroup. Developing and Sustaining Community-Based Participatory Research Partnerships: A Skill-Building Curriculum. 2006. www.cbprcurriculum.info
Full participation of Community representatives Community representativesCBPR community in identifying involved with study design and provide guidance regarding issues of greatest proposal submission. recruitment and retention importance. strategies. Increased motivation to Increased acceptability of Enhanced recruitment and participate in research study approach, include funds retention. process. for community. Participant Identified Study design recruitment health and funding and retention concern(s) systemTraditional Issues identified based on Design based entirely on Approaches to recruitment epidemiologic data and scientific rigor and feasibility; and retention based on funding opportunities. funding requested primarily scientific issues and “best for research expenses. guesses” regarding reaching community members and keeping them involved in the study.
Measurement instruments Community members help guide Community members assist developed with community intervention development. researchers with interpretation, input and tested in similar dissemination, and translation of population. findings.CBPR Potentially sensitive issues Assures greater cultural and Assures greater sensitivity to handled better and increased social relevance to the cultural and social norms and reliability and validity of population served, increasing climate and potential group harm measures. the likelihood of producing and enhances potential for positive change. translation of findings into practice. Data analyzed Measurement Intervention and interpreted, instrument(s) design and findings designed and implemented disseminated and data collected translated Researchers design intervention Researchers report findings fromTraditional Measurement instruments adopted/adapted from other based on literature and theory. statistical analysis and publish in studies. Tested chiefly with peer-reviewed journals. psychometric analytic methods.
Traditional Research VS CBPRTraditional Research CBPR Community is a passive Involves the community being subject of study studied in the research Research Design – done a Research Design –done with priory by academic representatives from community institution & academic institution Needs assessment, data Needs assessment, data collection, implementation collection, implementation, & , and evaluation – evaluation – everyone’s academic institution’s responsibility responsibility Sustainability is priority that Usually sustainability plan begins at program’s inception is not included
Challenges in Researcher-community Relationships Nuances of participation Power and privilege: Who sets the research agenda? Historical and current research abuse/racism Specific university and research team reputation and community relationship Challenge of research team having necessary skills and values (cultural humility, listening, patience) Challenge of individual vs. community benefit Challenge of needs of academics (publishing) vs. community (immediate actions)
CBPR Conceptual Logic Model Contexts (adapted from: Wallerstein , Oetzel, Duran, Tafoya, Belone, Rae, “What Predicts Outcomes in CBPR,” in CBPR: From Process to Outcomes, Minkler and Wallerstein (eds). San Francisco, Jossey-Bass, 2008.) Socio-Economic, Cultural, Geography & Environment Group Dynamics National & Local Outcomes Policies/Trends/Governance Equitable Partnerships Intervention System & Capacity Changes Historic Collaboration: Community Fits Local /Cultural Beliefs, Norms & Practices Trust & Mistrust Structural Agencies Policies/Practices Dynamics Relational Sustained Interventions Reflects Reciprocal Learning Changes in Power Relations Community Capacity Dynamics Individual Cultural Renewal & Readiness CBO’s Appropriate Dynamics Research Design Improved Health University University Capacity & Readiness Disparities Social Justice Health Issue Importance Contexts Group Dynamics/Equitable Partnerships Intervention Outcomes Structural Dynamics: Relational Dynamics: CBPR System & Capacity Changes:•Social- • Diversity • Safety •Intervention adapted or created •Changes in policies /practices economic, cultural, geographic, political- • Complexity • Dialogue, listening & mutual within local culture -In universities and communities historical, environmental factors • Formal Agreements learning •Intervention informed by local •Culturally-based & sustainable•Policies/Trends: National/local • Real power/resource sharing • Leadership & stewardship settings and organizations interventions governance & political climate • Alignment with CBPR principles • Influence & power dynamics •Shared learning between •Changes in power relations•Historic degree of collaboration and trust • Length of time in partnership • Flexibility academic and community • Self & collective reflection knowledge •Empowerment: between university & community Individual Dynamics: -Community voices heard•Community: capacity, readiness & • Participatory decision-making •Research and evaluation design • Core values reflects partnership input -Capacities of advisory councils experience & negotiation • Motivations for participating -Critical thinking•University: capacity, readiness & • Integration of local beliefs to •Bidirectional translation, • Personal relationships implementation & dissemination •Cultural revitalization & renewal reputation group process • Cultural identities/humility•Perceived severity of health issues • Task roles and communication • Bridge people on research team Health Outcomes: • Individual beliefs, spirituality & meaning •Transformed social /econ conditions • Community reputation of PI •Reduced health disparities
Challenge of Translational Research How CBPR Addresses the Challenge* Wallerstein and Duran, AJPH, (Supplement) April, 2010.1) External validity Engages community stakeholders in adaptation within complex systems of organizational and cultural context and knowledge2) What is evidence: Privileging of Creates space for post-colonial and hybridacademic knowledge knowledge including culturally-supported interventions/indigenous theories and community advocacy3) Language: Incompatible discourse Broadens discourse to include “life world”between academia and community cultural and social meanings4) Business as usual within universities Shifts power through bi-directional learning, shared resources, collective decision-making, and outcomes beneficial to the community5) Non-sustainability of programs beyond Sustains programs though integration withresearch funding existing programs, local ownership, and capacity development6) Lack of trust Uses formal agreements and sustains long- term relationships to equalize partnership and promote mutual benefit
Benefits of CBPR• Enhances community relevance of research questions• Strengthens interventions within cultural and local context• Enhances reliability/validity of measurement tools• Improves response rates/recruitment & retention• Increases accurate and culturally sensitive interpretation of findings• Increases translation of evidence-based research into sustainable community change• Facilitates effective dissemination of findings to impact public health and policy• Increases research trust
Limitations• Threats to internal validity – it is difficult to account for all the factors that can play a role in the targeted behaviors• Difficulties with randomization• Highly motivated intervention groups• Expectations vs results – interpretation?• Interpersonal conflicts and individual “agendas”• Scientific publications
How do you begin?• Select the community “unit of identity”• Select your initial partners – individuals, representatives of organizations or both• True dialogue with partners (and others that should be at the table) before the proposal is written and throughout the process• Identification of WHAT, HOW, WHO, WHEN WHAT – research question HOW – research design WHO – who is responsible for what? WHEN - timeline• Sustainability plans from the beginning
Issues to keep in mind Willingness to truly “listen” – which applies to everyone (academics, community, etc) Willingness to share power – financial issues Trust is earned and it takes time Slow process Clash between community needs and funding restrictions (e.g., disease-focused; time limitations) Patience
IDENTIFYING & SELECTING PARTNERSSarah Flicker, Kirsten Senturia and Kristine Wong Unit 2 Developing a CBPR Partnership-GettingStarted. In: The Examining Community-Institutional Partnerships for Prevention ResearchGroup. Developing and Sustaining Community-Based Participatory Research Partnerships: A Skill-Building Curriculum. 2006. www.cbprcurriculum.info
Characteristics of Effective Partners• They are willing and committed• Their organizational mission is in alignment• They have trust and a history of engagement in the community• They have staff and/or volunteer capacity to participate• They have engaged, competent researchers and research staff• They have support and involvement from leaders at all levels• They are knowledgeable about the community
Characteristics of Effective Partners• They strive for cultural competency• They have skills in collaboration• They have interpersonal and facilitation skills• They have technical skills• They have commitment and connections to the community• They are committed to the partnership process and the substantive issues being addressed by the partnership
Incentives to Partner (Community)• Access resources• Advocate for policy change• Create jobs• Improve services• Protect the community• Solve a problem• Gain political capital
Incentives to Partner (Academics)• Attract and support students• Advance careers• Demonstrate/address inequities and injustices• Generate knowledge• Link personal and professional goals and values• Meet funding agency expectations• Obtain institutional funding