In Sync with the Community: Applying CBPR Principles and Methods

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In Sync with the CommunityApplying CBPR
Principles and Methods
Part 2 of the series Community Engagement and
Research Sponsored by The Division of
Community Engagement, The Institute for Women's
Health and The Center for Clinical and
Translational Research
Judith Bradford, PhD Director of Community-Based
Research Institute for Womens Health
Cornelia Ramsey, PhD, MSPH Community Research
Liaison Center for Clinical and Translational
Research
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An Overview of Community-Based Participatory
Research
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Workshop Outline

• Introduction to Community-Based Participatory
  Research (CBPR)
• Study example of CBPR
• Application of study example to key elements in
  successful CBPR initiatives

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Getting Started

• What is CBPR?
• community based, community placed, community
  focused, community centered, community
  engagement, participatory
• Key strategies of CBPR
• Active engagement and shared decision-making of
  community members, academic researchers and
  funders,
• Integrated sources of knowledge (e.g., formal
  informal),
• Iterative data collection and analysis using
  multiple methods (e.g., qualitative and
  quantitative etc.)
• Utilization of multiple channels for knowledge
  dissemination,
• Achievement of common goals social change,
  improved health and well-being etc.

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Traditional Research CBPR
Advance Knowledge

• Goal of research
• Source of
• research
• question
• Designer of research
• Role of researcher
• Role of community
• Relationship of
• researcher
• to participants
• Value of research

Theoretical work
Collaborator, learner
Contribution to community
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Comparison of Traditional Academic Research and
Community-Based Research
Strand K, et al. Community-Based Research and
Higher Education Principles and Practices. San
Francisco Jossey-Bass Co., 2003.
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5 Phases of CBPR Process

• Partnership formation and maintenance
• Community assessment and diagnosis
• Definition of the issue (s) strategies
• Documentation and evaluation of the partnership
  process
• Research initiation
• Feedback, interpretation, dissemination and
  application of results

Israel B, et al (Eds.). Methods in
Community-Based Participatory Research for
Health. San Francisco Jossey-Bass Co., 2005.
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Study ExampleUsing Community-Based Participatory
Research to ImproveBirth Outcomes in Richmond,
Virginia
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Basic AssumptionCommunities cannot be usefully
studied without their own participation, through
partnership and with mutual accountability.
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Characteristics of a CBPR Project

• Recognizes community as a unit of identity.
• Builds on strengths and resources within the
  community.
• Facilitates collaborative, equitable partnership
  in all phases of the research.
• Promotes co-learning and capacity building among
  all partners.
• Integrates and achieves a balance between
  research and action for the mutual benefit of all
  partners.
• Minkler M, Wallerstein N (Eds.). Community Based
  Participatory Research for Health. San Francisco
  Jossey-Bass Co., 2003.

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Characteristics of CBPR, cont.

• Emphasizes local relevance of public health
  problems and ecological perspectives that
  recognize and attend to the multiple determinants
  of health and disease.
• Involves systems development through a cyclical
  and iterative process.
• Disseminates findings and knowledge gained to all
  partners and involves all partners in the
  dissemination process.
• Involves a long-term process and commitment.
• Minkler M, Wallerstein N (Eds.). Community Based
  Participatory Research for Health. San Francisco
  Jossey-Bass Co., 2003.

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Major Challenges

• Acknowledging disparities within underserved
  communities.
• Placing higher priority on least understood
  areas.
• Recognizing the power and implications of
  cultural context for health.
• Finding common cause and forming strong
  affiliations to work across dividing lines.

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HP2010 Goal 2 Eliminate Health Disparities

• gender
• race and ethnicity
• income and education
• disability
• rural localities
• sexual orientation

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• The black / white gap in birth outcomes is not
  just what happened during pregnancy but a
  consequence of what happens over the life course
  of the woman.
• Dr. Michael Lu

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Its not just an individual matter

• McElroy KR, Bibeau D, Steckler A, Glanz . An
  ecological perspective on health promotion
  programs. Health Education Quarterly 15351-377,
  1988.

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Richmond Healthy Start Initiative Mission and
Purpose

• Mission achieve a reduction in infant mortality,
  low birth weight and racial disparities in
  perinatal outcomes for African American women who
  reside in the City of Richmond.
• Purpose establish a comprehensive, coordinated
  and community-based approach to address
  significant disparities in perinatal health such
  as infant mortality, low birth weight and other
  perinatal outcomes for women and infants living
  in high-risk situations throughout the city.

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Richmond Healthy Start Initiative

• RHSI is a federally funded program designed to
  improve disparities in perinatal health such as
  infant mortality, low birth weight, and
  prematurity, for minority women and infants
  living in the city.
• The primary focus is on African American women
  and their families increasing focus on Latina
  women and families.
• Funded through HRSA (US Health Resources and
  Services Administration)
• Maternal and Child Health Bureau
• Division of Healthy Start and Perinatal Systems
  (DHSPS)

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History National Healthy Start

• In 1991 the time was right
• The US infant mortality rate was rising.
• Traditional strategies to combat infant mortality
  were not as successful as expected.
• Black infants and babies from other ethnic groups
  were dying at higher rates than white
  populations.
• There was a new focus on racial and ethnic
  disparities in health and health care.

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History contd

• In 1991, 15 sites with IMR of 1.5 2.5 times the
  national average were funded as HS
  Demonstration Projects.
• Now, National HS includes 99 communities in 38
  states, DC, and Puerto Rico.
• HS communities have large minority populations
  with high rates of unemployment, poverty and
  major crime.
• Each project is unique, uses local input to shape
  strategies, and all share the same core program
  goals.
• In 1994, Richmond received its first 4-year award
  and has been continuously funded ever since.

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History contd.

• Based on the premise that community-driven
  strategies are needed to address factors that
  contribute to infant mortality, low birth weight,
  and other adverse perinatal outcomes in high-risk
  populations.
• Focus on increasing access to and use of health
  services for women and their families.
• Strengthen local health systems.
• Increase consumer input into systems of local
  care.
• Hallmark of the program focus on developing and
  mobilizing strong community coalitions, local and
  State governments, the private sector, providers
  and neighborhood organizations.

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To address these multiple challenges, RHSI
supports 5 Core Services

• 1. Outreach To identify pregnant women living in
  high risk neighborhoods and enroll them in
  support programs and needed services.
• 2. Health Education To support healthy pregnancy
  and birth outcomes through knowledge sharing
  about
• Birth control and interconceptional care
• Importance of early and regular prenatal care
  breastfeeding
• Nutrition education (appropriate weight gain
  during pregnancy
• Smoking, alcohol, and drug use cessation
• Primary and preventive health care
• Depression and other mental health problems

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RHSI Core services contd

• 3. Case Management (home visiting) services to
  ensure mothers get health insurance, identify a
  doctor, keep their medical appointments
  (transportation), learn about pregnancy,
  childbirth, infant care and parenting skills, and
  increase self confidence and personal worth.
• Provide support services i.e., transportation,
  parenting skills/infant care
• Monitor client status
• Reassess and modify the service plan as needed
• Home visitation is key to success
• 4. Interconceptional Care - Birth Spacing and
  Family Planning
• 5. Depression Screening and Referral

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RHSI funds four organizations and programs to
address these concerns

• 1. Childrens Health Involving Parents (CHIP)
• A medical home visiting model that serves
  Southside and Northside.
• 2. Richmond Healthy Families
• A social home visiting model that serves families
  living in the East End.

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Funded RHSI organizations and programs contd

• 3. Richmond Behavioral Health Authority (RBHA)
• Provides substance abuse treatment services to
  women through intensive outpatient treatment
  services
• 4. Richmond Fetal Infant Mortality Review
  (FIMR)Conducts infant mortality case reviews and
  identifies contributing factors that may lead to
  infant deaths and make recommendations for
  intervention
• Health Education
• Bereavement Counseling

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Voices of the Community

• A Community Advisory Board gives a voice to
  program participants and to women and families in
  Healthy Start communities.
• Prioritize neighborhood needs
• Develop messages and services to improve access
  and care utilization
• Peer mentors are the core of the CAB.
• Conduct outreach to their neighbors
• Serve as advocates locally, within Virginia and
  at the national level

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Discussion Groups

• Common themes
• Services are fragmented.
• We need help to get services.
• You have to be in a program to know about a
  program.
• There are no programs to help the fathers and
  the ones that are available are so under-funded
  they should not exist anyway who is here to help
  the father?

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Its about Capacity Building

• Other Resources

• Funding

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Accomplished through 4 core systems efforts
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Strengthening Core Systems

• 1. Consortium
• A combination of service providers, health care
  organizations, consumers, businesses, government
  agencies and universities that engage in a joint
  effort to eradicate perinatal disparities.
• 2. Collaboration and Coordination Linkages with
  Title V and others
• Ensure that RHSI works collaboratively with
  others in the community, region state.
• 3. Local Health Systems Action Plan
• Work with partner organizations, within the
  community, and across the region to establish
  maintain a comprehensive system of coordinated
  perinatal care that is accessible and acceptable
  to all women.
• 4. Sustainability
• The bottomline promote, fund and increase
  utilization of programs shown to be effective in
  reducing infant mortality.
• Identify and encourage public, private and
  nonprofit organizations to adopt evidence-based
  interventions and to adapt existing models to
  populations in need.

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Community-University Partnership(14 years)

• Original RHSI grant partnership with VCU,
  continuous relationship with faculty and staff
  since 1994
• Results from community discussion groups
  indicated needs for change in VCUHS prenatal care
• Institute of Womens Health (IWH) Seed Grants
  Program
• RHSI membership on IWH Steering Committee
• VCU Center for Health Disparities
• P60 EXPORT Center Award to VCU School of
  Medicine, reduce infant mortality
• CDC 5-year award to conduct RCT with multiple
  strategies for increased adherence to prenatal
  care at Nelson Clinic

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Reflection Application of Example
Community-Based Participatory Research Skills
and Abilities for Researchers and Community
Members
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Example Study

• Roles Skills of Researcher

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Researcher Roles

• Initiator or Catalyst for change
• Consultant
• Collaborator/Partner
• Other Hybrid

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Example Study

• Roles of Community Partners

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Community Partner Roles

• Expert Collaborator
• Source of information and connections
• Troubleshooter
• Channels of communication
• Consultant
• Historian

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Benefits of CBPR

• Increases relevance of research to participants
• Improves quality and validity of research
• Power of knowledge is gained by all partners
• Creates theory grounded in social experience
• Increases possibility of overcoming communitys
  distrust of research/university community
• Has potential to bridge cultural gaps by
  involving particular communities

Israel A et al. Annual Review of Public Health.
1998 19173-202
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Operational Challenges in CBPR

• Time timing funding cycles, IRB cycles,
  community calendar, academic calendar, short-term
  vs. long term commitment
• Competing partnership priorities/assumptions -
  process vs. task, multiple community needs
  limited resources, who represents the community?
• Competing institutional demands - service
  delivery, procurement of grants and funding, etc.
• Mistrust of research overcoming negative
  experiences, clear community benefit, quality of
  results

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Evaluating CBPR Success

• Clear goals
• jointly defined, based on community needs,
  agreed upon common good
• Adequate Preparation
• scholars have CBPR skills, needs assets
  assessment using appropriate methods, scholars
  recognize utilize community expertise
• Appropriate Methods
• all partners engaged in all levels, partnerships
  built on proven frameworks, elements of
  sustainability included from the onset
• Sound Approach
• reflect culture of the community, innovative and
  original, emphasize sustainability

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Evaluating CBPR Success (continued)

• Significant results
• resulted in positive outcomes for community and
  university, are results judged effective by BOTH
  community and university, long-term partnership
  developed
• Effective presentation
• has work been reviewed and disseminated,
  publications at community and university level,
  results disseminated in variety of formats
• Ongoing reflective evaluation
• has evaluation occurred, will scholar work with
  community again, will community work with
  scholar/university again

Minkler M, Wallerstein N (Eds.). Community Based
Participatory Research for Health. San
Francisco Jossey-Bass Co., 2003
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Study example

• Study example criteria for success

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Key Funding Questions

• How do you get funding for CBPR?
• What are the issues to consider when seeking CBPR
  funding?
• What are the University resources?
• What are examples of CBPR funding?

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References

• Israel A et al. Review of Community-Based
  Research Assessing Partnership Approaches to
  Improve Public Health. Annual Review of Public
  Health. 1998 19173-202.
• Israel B, et al (Eds.). Methods in
  Community-Based Participatory Research for
  Health. San Francisco Jossey-Bass Co., 2005.
• Minkler M, Wallerstein N (Eds.). Community-Based
  Participatory Research for Health. San Francisco
  Jossey-Bass Co., 2003
• Strand K, et al. Community-Based Research and
  Higher Education Principles and Practices. San
  Francisco Jossey-Bass Co., 2003.