Using CommunityBased Participatory Research CBPR to Address Health Disparities

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Community-Based Participatory Research (CBPR) A
Strategy to Reduce Health Disparities?

• New Mexico Public Health Association
• April 5, 2007
• Nina Wallerstein Dr.P.H
• Thanks to Bonnie Duran, Dr.P.H.
• Thanks to Meredith Minkler, Dr.P.H.

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Outline

• What is CPBR?
• Why is CBPR important for health disparities?
• Challenging issues for CBPR
• CBPR case study of developing culturally-based
  intervention
• CBPR case study of policy change

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Definition of CBPR

• 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 Scholars Program (2001)

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CBPR Relevance

• Increasing understanding of importance of
  partnerships and participation to improve health
  outcomes and reduce disparities
• Foundations Kellogg, Ford, Annie E. Casey,
  Aspen, California Endowment
• Government NIEHS, AHRQ, NIH disparities grant,
  CDC, NCI, NIMH, NCMHD, recent Joint RFA
  http//grants2.nih.gov/grants/guide/pa-files/PAR-0
  5-026.html
• Academic Env. Health Pers., AJPH, AJPM, AJPHMP,
  HEB, JGIM
• IOM Report Who will keep the public healthy?
  Educating PH Professionals for the 21st Century,
  2002

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CBPR What it is and isnt.

• CBPR is a research orientation and overall
  research methodology
• changes the role of researcher/agency and
  researched
• CBPR is not a single method or set of methods
• Both qualitative and quantitative
• CBPR goal is to influence change in community
  norms, systems, practices, programs, policies and
  health status

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Origins of CBPR

• Northern Action Research Kurt Lewin 1940s
• Cycle of action, reflection, problem-solving and
  decision-making for new actions
• Organizational rational change
• Southern Participatory Research 1970s
• Radical critiques by social scientists from Asia,
  Africa, Latin America
• Critiques of structural underdevelopment and
  challenge to redistribute inequitable structures
• Challenge academic distance from communities and
  new academic discourse of feminism,
  post-colonialism, post structuralism

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Why is CBPR important for health disparities ?

• Existence of health disparities undisputed
  health status, access to care, and quality of
  care
• Top people live longer.
• They are healthier while doing so.
• Strong relationship between social status (SES)
  and health
• Hecklers 1985 DHHS Report on Black and Minority
  Health, Civil Rights Report, 1999 IOM Unequal
  Treatment, 2002 Healthy People 2010 Goal of
  Eliminating Racial and Ethnic Health Disparities

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Percentage of Adults who are Overweight by
Income New Mexico, 1998
Source NM BRFSS
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Percentage of Adults who are Overweight by
Education New Mexico, 1998
Source NM BRFSS
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Percentage of Adults who are Overweight by
Race/Ethnicity New Mexico, 1998
Source NM BRFSS
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Causes of Disparities
Physical and Social Risk Factors
Living in Poverty/Absolute Conditions Low in
Hierarchy High Demand versus Low Control
Physical/Psychological Chronic Stressors Low
Social Support/Social Capital Racism/Segregation R
elative Inequality Lack of Resources Stressors
disrupt neuroendocrine system/allostatic load
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Strategy to Reduce Disparities Empowerment

• Psychological Empowerment
• Self Efficacy to Act
• Political Efficacy
• Motivation to Act
• Collective Efficacy

Reduce Social Risk Factors
Sense of Community Participation
Critical Thinking/ Conscientization
Community Empowerment Increased Local
Action Transformed Conditions Improved Health
Policies Resource Access/Equity
Reduce Physical Risk Factors
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Challenges in Reducing Health Disparities

• Despite evidence, knowledge of disparities alone
  does not lead to action
• Challenge of developing effective strategies,
  ie., expanding actions beyond behavioral and
  health care targets to incorporate social
  determinants and policy changes
• Need framing of issue as problem caused by human
  action and therefore can be solved by human
  agency and action
• For policy change, need political will and civic
  engagement to move disparities agenda from low
  importance to forefront.

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CBPR Evidence

• Recent literature suggests that progress in
  eliminating racial and ethnic health disparities
  can be achieved by increased community engagement
• Participation of minority communities, those most
  affected by disparities, still largely missing
• CBPR generates research partnership with affected
  communities and policy stakeholders
• uncovers social, political and economic
  determinants
• engages in dynamic processes which strengthen
  community partners' capacities

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Principles of CBPR

• Recognizes community as a unit of identity
• Builds on strengths
• Shares resources
• Facilitates partnership in all research phases
• Promotes co-learning and capacity building
• Seeks balance between research and action
• 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
  (editors), San Francisco Jossey Bass, 2003.

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Shared Power
University Control
Community Control
CBPR
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Challenge of Participation in Community

• Minimal Consultative versus Comprehensive
  throughout Process
• Participation Questions
• Who is included? Who is excluded?
• Who is representing the community?
• Service providers vs. community members
• Hidden discourse (what will never be known)
• Scientific/Academic Time vs. Community Time

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Ethnic/Racial Challenges

• Institutional Racism
• Predominance of white academics/practitioners
  working in minority communities
• Historical helicopter research
• Social labeling of communities
• Reproduced inaccurate representations
• Resistance is seen as ignorance
• Academy norm of value-neutral research

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Privilege and Power Challenges

• Expert or Scientific knowledge can obscure or
  prevent community knowledge
• Empirically Supported Interventions (ESIs)
  privileged over Culturally/Community Supported
  Interventions (CSIs) (Gordon Hall)
• Who has power of knowledge?
• Knowledge defined by whom? About whom? For what
  purpose? Who makes the decision of what to study?
  
• Who has power to act and decide?

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Challenge of CBPR Actions

• Waiting to publish v. taking action
• Reluctance to associate with research that
  appears connected to broader political agenda
• Funding constraints on policy-level activity
• We dont do policy we just educate
  legislators! (Community Partner, Tillery,NC)

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Shared Control ExampleCDC Capacity Study
1999-2003

• Multi-site study on social capital and community
  capacity
• UNM team work with two tribal communities
• Conduct participatory research with tribes to
  uncover understandings and meanings of community
  capacity
• Develop strategies with tribes to strengthen
  capacities to improve health systems and health
  status

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Changed Model Tribal Community Capacity
Health

• Cultural Capacities
• Culture / Tradition / Spirituality / Language

• Social Capacities
• Personal Relationships
• Participation
• Education

• Economic/Environmental
• Capacities
• Economic Development
• Youth/Elder Facilities

• Leadership Politics
• Tribal Leadership
• Tribal Council
• Tribal Programs

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Family Listening Project NARCH III

• NARCH grant (2005-2009) to work with Jemez Pueblo
  and Ramah Navajo to co-develop culturally based
  elder/
• family/child program to reduce alcohol onset and
  abuse
• Work with advisory councils to review and adapt
  empirically successful research with Anishinabe
  people
• Partnership tribes, UNM, AAIHB
• Develop methodology and tools for translational
  research to enhance external validity

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The Partners Literacy for Environmental
Justice / SF DPH
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LEG Survey of Products Sold in 11 BV/HP Corner
Stores
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Economic Incentives

• Store Branding
• Free Marketing
• Energy Efficient Appliances
• Marketing Assistance
• Group Buying
• Building Improvements
• Personnel Training
• City Recognition

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Identifying potential partners

• Supervisor Maxwell
• SF Redevelopment
• Mayors Office of Economic Development
• DPH
• SF Environment
• LEJ
• SF Power Co-op

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• Change in Sales over 7 Months
• Produce 5 -15
• Alcohol 25 -15

Pilot Store
By Fall 06 Produce 15 Alcohol
10 Cigarettes 10 Profits 12
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From Local to State Policy

• AB 2384 Demonstration Project
• Assistance to mom and pop stores improving
  access to fresh fruits and vegetables
• Bonus fruit and vegetable dollars to food stamp
  recipients

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Impacting on policy through CBPR Success Factors

• Presence of strong autonomous community partner
  organizations prior to the development of
  partnership. ..the community partner has to be
  able to stand eye to eye, peer to peer with the
  academic partner
• Facility for building strong collaborations and
  alliances with numerous and diverse stakeholders
• Knowledge of and facility for attending to a
  variety of steps in the policy process
• Importance of data/scientific evidence

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• CBPR Balancing Act

Necessary Skepticism of Science
Action Imperative of the Community
- Price and Behrens, 2003
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Dont tell us how much you know until you show
us how much you care
Anonymous