Empowering community partners in health disparities research: Refining a community-based participatory research (CBPR) training curriculum

Abstract

The adoption of Community-Based Participatory Research (CBPR) approaches has increased due to its potential to reduce health disparities through Community-Academic Partnerships (CAP). Providing community members (CM) capacity-building opportunities is a way of empowering communities and promoting social change. To support the development of CAPs, the Community Training Institute for Health Disparities (CTIHD) was created in southern Puerto Rico to capacitate community leaders in the CBPR approach and basic research knowledge through the CTIHD-Community Research Program (CRP). In 2019, six syllabi-led courses were developed and implemented utilizing a problem-based curriculum design and competency-based learning model, with 12 community members enrolled. A mixed methodology assessed satisfaction, acceptance, feasibility, retention rate, and knowledge change from cognitive debriefing with semi-structured questions (qualitative), course evaluations, attendance, program documents, and pre-and post-tests (quantitative). Results indicate high levels of satisfaction from courses and retention rates of 100% and 91%, respectively. Post-course evaluation scores exceeded 70% in five (5) of six (6) courses, with two courses demonstrating statistically significant results (p < 0.05). Cognitive debriefing results indicate the feasibility and acceptability of the curriculum with suggested modifications in practical applications, itinerary of courses, and research proposal development. The outcomes of the program include the formation of four partnerships and the development of three research proposals. Capacity-building efforts, such as those of the CTIHD-CRP, are essential to increase community participation in health research, foster the formation of Community-Academic Partnerships (CAPs), and support the development of research on health disparities in the long-term.

Introduction

Capacitating and empowering community members (CM) in research is not just about promoting social change (Allen et al., 2011) but is vital in enhancing trust building between the community and academia, improving participation in research, facilitating knowledge translation and uptake, and fostering sustainable community-academic partnerships to increase the development of relevant health disparities research (Shah et al., 2023; Krishamurthi et al., 2016; Boyd & Patel, 2014; Robbins & Royer, 2015). Community-based participatory research (CBPR) is an equitable research approach involving collaboration between researchers, organizations, and community members throughout all stages of the research process. This collaborative approach addresses health disparities and promotes social change by combining scientific inquiry with community engagement and action (Kreider, 2018; Lachowycz & Jones, 2011). CBPR is founded on the principles of collaborative and participatory involvement of all members that form a Community-Academic Partnership (CAP).

Facilitating CM’s access to CBPR-based community research capacitation programs promotes community empowerment, shared power, and mutual benefits of CAP members (Andrews et al., 2013). Additionally, it reduces barriers to CAP formation, such as cultural and communication challenges (e.g., differences in terminology and communication styles, mutual presumptions) and power dynamics and equity issues (e.g., decision-making authority, equitable participation, a legacy of historical mistrust) (University of North Carolina, 2023). Among the principles that guide CBPR, we identify that training community partners is critical for the integration and equal participation of all community partners during the research process for balancing power dynamics, fostering sustainable partnerships, promoting actionable health improvements, and reducing disparities through research development (Wallerstein & Duran, 2006; Hacker et al., 2012; Jiménez et al., 2018).

CBPR curricula and programs for and between community members and academic researchers have previously been developed to support the integration of community members into research and the development of community-academic partnerships. For example, Canfield et al. (2016) piloted a CBPR curriculum focusing on environmental health research between community-based organizations and academic researchers, whereas Andrews et al. (2013) created a community-academic partnerships (CAP) training initiative for various health projects. Despite efforts to enhance community capacity building in CBPR for community members, to our knowledge, few capacitation programs have incorporated core competencies in health disparities research and are focused on Hispanic populations. Competencies associated to the CBPR approach are based on the nine key principles, which rest in the concept of cultural humility, which include recognizing the community as a unit of identity, facilitating collaborative partnerships in all phases of research, and promoting a co-learning and empowering process that attends to social inequalities. Although no competencies have been developed for community members, a study among professional counselors identified key areas which include knowledge (e.g., understanding key CBPR concepts), skills (e.g., listening, group and facilitating skills), attitudes (e.g., cultural humility, flexibility, persistence), and activities (e.g., community experiences) (Dari et al., 2019).

In the United States (USA), racial and ethnic health disparities have persisted for chronic diseases from 2017–2019. This period saw a notable 15% increase in chronic diseases compared to 2011–2013, affecting six out of ten adults with at least one chronic illness and four out of ten with two or more. Involving the community proactively in health promotion or disease prevention has proven to be an effective strategy for detecting, understanding, and reducing health disparities (Kilbourne et al., 2006; Ahmed & Palermo, 2010; Minkler & Wallerstein, 2011). Evidence has demonstrated the benefits of active community participation in health research and promotion to address problems related to social and structural inequities that affect health outcomes in under-resourced sectors of the population (Banna & Bersamin, 2018; Harris et al., 2018). CBPR is recognized as a key approach to improving community health outcomes and reducing health inequities (Tucker et al., 2018; Tucker et al., 2019; Parajón et al., 2021; Oetzel et al., 2018; Sanchez-Johnsen et al., 2015). Engaging community members as co-researchers enhances health equity, research literacy, and community research dissemination (Salimi et al., 2012).

Ponce Health Sciences University’s (PHSU) Specialized Center in Health Disparities (Ponce Research Institute, n.d.) includes the Community Engagement Core (CEC), a unit within Research Centers in Minority Institutions (RCMI) that fosters partnerships between academic researchers and local communities to address health disparities. Within this framework, the Community Training Institute for Health Disparities (CTIHD) operates under the RCMI-CEC. The CTIHD’s primary goal is to increase health disparity research and improve community health outcomes in underserved Hispanic populations. This is achieved by fostering CAPs and providing health education to address identified community health needs.

To accomplish this goal, the CTIHD developed a program to capacitate and empower community members to address health disparities through research. This article outlines the development, refinement, and implementation of a problem-based curriculum with a competency-based learning model for the first cohort of the CTIHD-Community Research Program (CRP).

Methodology

Background: Pre-pilot CBPR Workshops

The CTIHD - Community Research Program utilized as a base a series of six one-session CBPR training workshops developed by the research team between 2016 and 2017 for community members. It was facilitated by academics in their respective fields and included topics such as community-based participatory research principles, health disparities, social determinants of health, translational research, ethics in community-based participatory research, and fundamentals of research methodology. These workshops aimed to increase community members’ knowledge and skills to support their integration and collaboration with academic researchers in research activities. Once the workshops were completed, an assessment of acceptability, feasibility, and preliminary effectiveness was conducted through a mixed-method design (e.g., pre-post test, evaluation forms, cognitive debriefing [realized at the end of the workshop series]). Results indicated that the workshops could support the active integration of community members in research activities. Nonetheless, feedback suggested increasing the length for more in-depth exploration of the topics offered and adding practical activities to apply what has been learned. Based on the results obtained from the pre-pilot CBPR workshops, the subsequent process was conducted to refine and develop the curriculum for the first cohort of the CTIHD-Community Research Program (Jiménez et al., 2018). Please see more details on developing and assessing the pre-pilot workshops here.

Phase 1: Literature review and additional resources.

An in-depth literature review of peer-reviewed journal articles, website materials, and grey literature centered on community members’ capacitation on CBPR, and research was conducted to support the curriculum refinement process. PubMed, PsycINFO, Social Sciences Full Text, and Google Scholar databases were searched with terms commonly used to identify capacity-building programs for community members in CBPR (e.g., “community capacity building AND CBPR,” “community capacity-building AND CBPR AND curriculum,” “community training AND CBPR”) This review aimed to support the research team’s informed decision-making on curriculum design and instructional strategies, identify key areas related to capacity-building programs for community members in CBPR, and contextualize the curriculum within the current landscape of similar programs (Allen at al., 2011; CCPH, n.d.; Detroit Community-Academic Urban Research Center, n.d.; Canfield et al., 2016; Highfield et al., 2011, 2013; Israel et al., 2010, n.d.; Masuda et al., 2010; Plumb et al., 2019; UofSC, n.d.).

During the literature review, the research team (See Phase 2 for description of team members) identified engaging teaching strategies and resources suitable for Puerto Rican/Hispanic community trainees and considered integrating them into the new curriculum to support knowledge retention and engagement. The recommended application activities included small projects, group discussions, presentations, role-playing, brainstorming, literature review, topic conceptualization, library visits, and writing documents to apply learned concepts. For example, sections from the University of Kansas’ ‘Community Toolbox’ were included due to its accessibility in terms of language (Spanish) and detailed guidance, such as ‘Toolkit #1 – Creating and Maintaining Coalitions and Partnerships,’ ‘Toolkit #2 – Assessing Community Needs and Resources,’ and ‘Toolkit #10: Advocating for Change’ (Community Toolbox, n.d.-a, n.d.-b, n.d.-c).

Phase 2: Curricular Refinement: Syllabi Development, Learning Model, Curricular Design, and Core Competencies

A multidisciplinary research team comprising experts in CBPR, public health, epidemiology, health disparities research, curriculum development, quantitative research methodology design, and clinical and translational research refined the curriculum and developed syllabi over approximately ten months. The team ensured the curriculum aligned with the objective of the CTIHD-CRP through collaborative and iterative meetings. Through these meetings, based on the pilot program workshop’s initial topics, the research team developed, reviewed, and discussed the course descriptions, course objectives, course content, and activities to be integrated into each ten-session course syllabus based on the literature review and expertise of each team member. The courses aimed to enhance participants’ knowledge and skills in key areas: CBPR, research ethics, fundamental research principles, social determinants of health, health disparities, and translational research. During these meetings, the course policies, conditions, and evaluation criteria were discussed. See Table 1 for details on the main objectives per course.

Table 1:

Course Tittles and General Objectives

Course	General Objective
Fundamentals of Community-Based Participatory Research	Enhance knowledge and understanding of how CBPR research approaches provide a foundation for establishing partnerships between researchers and community members.
Fundamental of Research Methodology	Enhance knowledge and understanding of research methodology fundamentals and develop basic research skills to contribute to a community-academic research project.
Social Determinants of Health – Part 1 & 2	Enhance knowledge and understanding of how social determinants are interconnected with health disparities and how they can impact individual and community health.
Introduction to Clinical and Translational Research	Provide basic knowledge and understanding of the how knowledge moves through various stages in the translational science continuum.
Ethics in Community-Based Participatory Research	Enhance knowledge and understanding of research ethics, as well as to provide an in-depth understanding of the Institutional Review Board (IRB) process.

As no curricular design or learning models were established in the pre-pilot workshops, the research team identified that employing a problem-centered and competency-based learning model rooted in CBPR principles, emphasizing real-world problem-solving, critical thinking, and practical skills development would be fundamental to achieving the objectives of the program (Universidad EIA, 2020; Universitat et al., 2013). All pre-pilot CBPR workshop feedback was considered for refining the curriculum and syllabi development, including the length of the courses, and more practical application during courses (See Course Structure and Resources for details).

Aligned with the program’s objectives, ‘Core Competencies’ were identified, selected, and adapted by the research team during the iterative meetings and guided the course content development for the knowledge and skills community trainees were to achieve the expected outcomes and the tools needed to support learning. These core competencies were based on the established Core Competencies for Public Health Professionals by the Public Health Foundation, which provides a foundational framework for public health practice (Public Health Foundation, n.d.). The research team adapted the competencies most relevant to the program’s objectives, design, and learning model, thus developing the syllabi for each course in the new curriculum. A competency matrix was developed to align the specific learning objectives of the courses with the competencies they met. This approach ensured that the program’s content was grounded in recognized public health standards while being tailored to the community trainees’ specific needs in community-based research to codevelop the research proposals in a CAP. The eight (8) competencies identified for the CTIHD-CRP curriculum are analysis/assessment, policy development/program planning, communications skills, cultural competency, community dimensions, public health sciences, financial planning and management skills, and leadership and system thinking (Table 2).

Table 2:

Core Competencies of the CTIHD-Community Research Program

Core Competency Domains and Skills	Courses
	CBPR	FRM	HD	SDH	TR	ETHICS
Analysis/Assessment	X	X	X/F	X	X	X
Policy Development/Program Planning	F			X
Communications Skills				X
Cultural Competency			X/F	X/F		F
Community Dimensions	X/F		X	X
Public Health Sciences		X	F	X
Financial Planning and Management Skills	X/F			X	X
Leadership and Systems Thinking	F	X				X

Note: CBPR: Fundamentals of Community-Based Participatory Research; FRM: Fundamental of Research Methodology; HD: Health Disparities; SDH: Social Determinants of Health; TR: Translational Research; ETHICS: Ethics in Community-Based Participatory Research.; F: Future Course Iterations; X: Accepted in current program. This is an adaptation based on the combination of different sources of information on competencies in public health for community-based research (Public Health Foundation, n.d.)

Once the initial syllabi were developed, external experts (six instructors with years of experience and a background in community-level research, such as CBPR and social determinants of health) reviewed, analyzed, and further refined the syllabi to obtain the final version. This process of expert review helped to validate the alignment of the course objectives, competencies, and content.

Following this, the Community Scientific Advisory Committee (CSAC), composed of eight community representatives trained in basic research principles, evaluated the curriculum. The CSAC’s main role is to assess the comprehensibility of educational or research materials and to confirm that they embody cultural humility and ethical appropriateness for the target audience. The committee reviewed and approved the final version of the curriculum for implementation.

CTIHD: Community Research Program Description

The CTIHD-CRP aims to capacitate community members with the basic knowledge and skills to actively participate as community partners in research projects and support the development of novel research proposals through CAPSs to reduce health disparities relevant to the community. The CTIHD-CRP has eight core competencies based on the basic knowledge and skills identified that community trainees need to participate actively in CAPs and research projects. The program curriculum was organized into six virtual courses (due to the COVID-19 pandemic), with ten three-hour sessions in a trimester system (two courses per trimester).

Course Structure and Resources

The structure of the CTIHD-CRP was organized so that the instructors had three (3) hours of contact per session with the trainees, with two (2) hours of teaching theory and one (1) hour of practical applications of the theoretical content. To guarantee uniformity and comparability between all courses in the curriculum, instructors were provided a course rubric, which included a breakdown of topics with a list of resources, the course objectives, the period duration of the course, the modality, the didactic content, the possible application activities, and a guide on how to develop the evaluation test of the trainee’s knowledge (number of questions, topics, format of questions, considerations). The community trainees were provided with educational materials, brochures, and references related to the course content. They had access to ‘Moodle,’ a learning management system (LMS) platform for easy access to their course material, which was monitored to ensure everyone had access to it.

The research team identified 48 active learning strategies that instructors could choose from, ranging from 4 to 17 per course to accommodate different learning styles and support equal opportunities for trainee success. These strategies included art techniques, completing a Know/Wants to know/Learned graph (a tool to keep track of gathered information during the course), role-playing, group discussions, concept maps, and brainstorming.

Phase 3: Recruitment and Selection of First Cohort

Recruitment for the first cohort of the CTIHD – CRP began in April 2020. The research team disseminated information through participation in virtual ‘open houses;’ sharing promotions in community-based and nonprofit organizations with community partners (CSAC and CTW) and through collaborators (external entities that support the objectives of the project); social networks and community educational activities (e.g., health fairs, talks, conferences). Promotional flyers and pamphlets were given to community leaders and strategically placed in the community (e.g., churches, pharmacies, community bulletins). Potential candidates were given orientations of the program, including overall description, program length, and requirements for completion, among others.

Every prospective community trainee candidate went through the process of completing the application and submitting the required documents: a criminal record certificate, two (2) letters of recommendation, one (1) essay (indicating their motivation to participate in the program), and a resume or curriculum vitae. Additionally, prospective trainees had to be 21 years or older, have completed a high school degree (or equivalent), and be an active member of communities within the following municipalities located in the southern region of Puerto Rico: Guánica, Yauco, Guayanilla, Adjuntas, Peñuelas, Ponce, Jayuya, Juana Díaz, Villalba, Coamo, Santa Isabel, Salinas, Guayama, Arroyo, or Patillas. Selection criteria evaluated during the process were goals or objectives for participating in the programs, experiences working with communities, teamwork experience, and time availability. The Admission Committee, comprised of community partners and the research team, reviewed all documents from prospective trainees. After the documentation review, they were invited for an interview with the Admission Committee. Subsequently, the admissions committee analyzed the results and selected the cohort trainees based on the obtained scores and evaluation criteria (See Evaluation and Instrumentation section for details).

Accepted candidates, notified and confirmed by email, became CTIHD ‘community trainees’, and started the curriculum in October 2020. Community Trainees were informed that to receive the certification (total of 180 contact hours) granted by Ponce Health Sciences University (PHSU) and Ponce Research Institute (PRI), they must complete the requirements established by the program: active participation in courses, attending 70% or more of course sessions (no more than three (3) absences), and approve the research proposal with more than a 70% grade.

Participant consent was waived because this study was granted exemption from the IRB review and does not require consent documentation, although all participants received information about the study (IRB protocol #2201083931). No monetary compensation was provided for participating or completing the program.

Phase 4: Implementation of Curricular Sequence and Research Proposal Development

The curricular sequence was organized as follows: (a) First Trimester Courses: Fundamental of Community-Based Participatory Research and Ethics in CBPR; (b) Second Trimester Courses: Fundamental of Research Methodology and Social Determinants of Health Part 1; and (c) Third Trimester Courses: Translational Research and Social Determinants of Health Part 2. See Figure 1 for details.

Figure 1.

Flowchart of curriculum refinement, implementation and evaluation.

As a program requirement for completion of the program, a group of community trainees had to co-develop, with an academic researcher, a research proposal on a topic of interest as a final integrative project. It was recommended that trainees consider topics that affect their communities to be applied. The project quick-off meetings began during the third trimester and had a timeline of approximately six (6) months to be completed, equivalent to two (2) trimesters. During this period, trainees had an initial meeting with the CTIHD director and academic mentors, during which they were oriented on the research proposal. During the meeting, due dates for the proposal, an outline of the project’s sections, and an assignment for their academic mentor were provided. Academic mentors are experienced researchers in community-based research who provide guidance and feedback on community-academic partnerships during the proposal development process, including reviewing written research proposals, assuring academic standards, supporting literature review, assisting in visual presentation preparations, and applying for funding for the proposal’s implementation.

The project groups comprised two (2) to four (4) community trainees, a collaborating researcher, and an academic mentor. The trainees met, as needed, with their collaborating researchers who are early-, mid-, and senior researchers in their respective fields (e.g., Medicine, Psychology, and Public Health). As professionals with research experience and proposal development, they worked hand in hand with the trainees as research partners. The collaborating researchers were matched with groups based on their expertise, academic experience, and interest in specific health disparities. This matching process occurred through various activities throughout the academic year or during a Community Forum. The Forum, held between the second and third trimesters, serves multiple purposes: project groups present their preliminary research ideas, potential research collaborators engage in one-on-one conversations, and participants discuss preliminary areas of interest. The goal of the Forum is to facilitate the development of Community-Academic Partnerships.

Data Collection and Analysis

Recruitment and Selection Process of Trainees Evaluation:

The recruitment and selection process for the programs utilizes a comprehensive rubric method to evaluate candidates through document submission and interviews. The evaluation focused on various criteria, including academic background, work experience, community service, and personal goals.

During the document review phase, the admissions committee assessed submitted materials, assigning 1 point for meeting criteria and 0 points for not meeting them, with a maximum score of 65. The requirements included academics, work experience, community service, letters of recommendation, essays, and a criminal background check. Any criteria not evaluated through documents were addressed during the subsequent interview process.

The interview process employed a rubric divided into three main areas: academics, work experience/community service, and work aspects. These categories were further subdivided into 18 questions to facilitate the interview. Interviewers scored candidates on a scale of 0–4 points per question, with a maximum possible score of 133 points. The interviews, lasting up to 60 minutes, allowed for personalized questions based on the candidates’ submitted documents. If needed, interviewers were encouraged to review the previously submitted materials to create more tailored questions. The final selection of candidates was based on the combined scores and information gathered from the document review and interview process, with a total possible score of 198 points across both stages.

Course and Program Evaluation:

During the curriculum’s implementation, the CTIHD-CRP used a mixed methodological approach, utilizing a cognitive debriefing with semi-structured questions (qualitative), a sociodemographic survey, a course evaluation questionnaire, and pre-and post-tests (quantitative). Additionally, data was collected from program documentation.

Quantitative evaluation (satisfaction, acceptability, knowledge change):

To assess satisfaction, acceptability, and knowledge change of the curriculum, the following were utilized: course evaluations (satisfaction), retention rate (acceptance), and pre-and post-test (knowledge change). Knowledge change evaluations were administered at the beginning and end of each course. Course instructors developed multiple-choice questions that encompassed the core content, which were then reviewed by the research team to ensure clarity, eliminate ambiguity, and confirm rubric fidelity. Quantitative data was analyzed using SPSSv28 for descriptives and inferential statistics.

Overall Research Program Metrics:

In this study, “retention” refers to attending 70% or more of course sessions (no more than three (3) absences). The retention rate formula is [(retained participants during the program implementation/n) x 10]. Completion refers to completing all the requirements to receive certification from the CTIHD-CRP. The completion formula follows: [(community trainees who met completion requirements of program/n) x 100].

Sociodemographic:

At the beginning of the program, the trainee group received a sociodemographic survey in questionnaire format. This survey aims to create a profile of the participants, including their sex, age, marital status, annual family income, level of education, Hispanic origin and race.

Course Evaluation:

At the end of each course, the trainee completes an evaluation in form that includes six (6) domains: Course Structure and Organization, Course Learning Experiences, Instructor Evaluation, Course Evaluation Criteria, Virtual Tools Used and Technologies, and General Satisfaction.

Evaluation of change in knowledge:

To identify changes in knowledge for each trainee, the trainee’s knowledge was evaluated through pre- and post-tests administered at the beginning and end of each course. The collected scores were analyzed by applying a Paired Sample T-test.

Evaluation of the Research Proposal:

The community trainees’ written proposal and presentation were evaluated by three (3) expert evaluators. They assessed each criterion and assigned the following scores using a Likert Scale: 4 for Excellent, 3 for Good, 2 for Average, 1 for Needs improvement, 0 for Bad, and N for No information. The score that the community trainees received was averaged from the sum of the total of all evaluators for the final grade. A sample of the criteria evaluated were the selection of the topic of interest, the identification of the health problem, the organization of how the topic is presented, the development of the research question, the writing of the objectives, compliance with the literature review, the methodology design being straightforward, all sections being provided, including the presentation of the data collection instrument, the statistical analysis that will be carried out, writing, spelling, and APA format.

Qualitative Evaluation (acceptability, feasibility):

Cognitive debriefings are used to actively test representatives of the target population to determine if the respondents understand the material. In this study, the cognitive debriefing session was used to assess the acceptability and feasibility of the curriculum courses to improve the program’s quality. A trained interviewer used semi-structured questions to conduct these at the end of each trimester. A final cognitive debriefing was conducted after completing the program to gather feedback on the overall program.

The virtual session of the final cognitive debriefing lasted 40–60 minutes, depending on the length of the discussion, with approximately 8 to 12 trainees in the session, which were recorded and subsequently transcribed. The questions explored the general opinion of the program, the content and relevance of the courses, the challenges in the teaching-learning process, potential ideas to impact the community, and factors that have been supportive in the process. Two (2) research team members independently reviewed and analyzed the recordings to classify the content. Along with the CTIHD director (principal investigator), they discussed the findings and resolved any conflicting themes.

Results

Overall Research Program Metrics: Applications, Acceptance Rate, Retention Rate, Completion Rate, and Attendance

The CTIHD-CRP’s recruitment efforts yielded 17 applications. After reviewing documentation and conducting interviews, 12 applicants were enrolled, resulting in a 71% acceptance rate. The first cohort completed their coursework from October 2020 to June 2021, excluding the research proposal phase. One trainee initially dropped out of the program (n =1) for personal reasons), resulting in a 91% retention rate. Of those retained, one obtained incomplete (n =1) in the research proposal development phase, resulting in an 83.3% completion rate. A high attendance percentage was obtained on the courses, ranging from 87% to 98%. (See Table 3).

Table 3:

Overall Research Program Metrics

Key Metrics	Research Program
Community Trainees (n)	12
Completions	10
Non-Completions	1
Drop-Out	1
Partnerships Formed*	4
Completion Rate (%)	83.3%
Retention Rate (%)	91%

^*Partnerships: We refer to the union of a group of people (community members and academic researchers) who have the same interest in solving a public health problem. They work as peers.

Quantitative:

Sociodemographic:

Most of the participants were female (91%), married or living with a partner (50%), and had an annual family income of $34,999 or less (60%) with an average age of 52.1 years. Additionally, 40% of participants’ highest educational degree was a associate degree. All participants (100%) were residents of municipalities in the south/southeast regions of Puerto Rico. Participants represented a diverse range of affiliations, including global health organizations like Doctors Without Borders, local professional associations such as nursing colleges, community-based and faith-based organizations, and municipal government entities. This diverse representation encompassed both international and local perspectives, as well as professional, community, and governmental sectors (See Table 4).

Table 4:

Community Trainees Sociodemographic Characteristics (n = 10)

Variable	Number of participants (n)	Percentage (%)
Sex
Female	9	90
Male	1	10
Age
24–34	1	10
35–44	2	20
45–54	2	20
55–64	2	20
65 or more	3	30
Marital Status
Married	3	30
Living with a partner	2	20
Widowed	4	40
Single	1	10
Annual Family Income
< $9,999	1	10
$10,000 - $14,999	3	30
$25,000 - $34,999	3	30
$35,000 - $49,999	1	10
$50,000 - $74,999	1	10
$75,000 - $99,999	1	10
Education
Complete HS	0	0
Technical Degree	0	0
Associate Degree	4	40
Bachelor’s Degree	3	30
Master’s Degree	2	20
Doctorate Degree	1	10
Hispanic Origin
Yes	10	100
Race
White	3	30
Hispanic/Latino/a	2	20
Black/African American	3	30
More than one race	2	20

Note: Data from two of the participants is not available.

Knowledge Change:

Results indicate that the post-course evaluation scores exceeded 70% in five (5) of six (6) courses: Community-based Participatory Research (73.48%), Ethics in CBPR (87.24%), Translational Research (70.93%), Social Determinants of Health & Health Disparities Part 1 (79.35%), and Part 2 (98.29%). An increase in scores (post-test scores minus pre-test scores) is evident in the following three courses: Ethics in CBPR (18.80%), Social Determinants of Health & Health Disparities Part 2 (20.80%), and Translational Research (17.84%). On the other hand, it was observed that the trainees had difficulties with the Fundaments of Research Methodology course, where the post-test scores were less than 70% (63.57%). Compared to a score close to 100% (98.29%) and demonstrating mastery are the Social Determinants of Health & Health Disparities Part 2 courses.

In the courses of Ethics in CBPR and Social Determinants of Health & Health Disparities Part 2 (p < 0.05), a statistically significant difference was observed in the change in knowledge. This is also evidenced by the increase in the averages of the pre-test and post-test of the Ethics in CBPR course, which increased from 6.8 (pre-test) to 8.7 (post-test). On the other hand, the Social Determinants of Health & Health Disparities Part 2 course increased from 7.7 (pre-test) to 9.8 (post-test).

In general, the average percentage of the post-test score in the curricular sequence was approximately 80% for the six (6) courses, where eight (8) of the twelve (12) trainees completed the curricular sequence with a score greater than 87%.

Outcomes - Research Proposals Developed:

Community trainees formed four groups to co-create and co-design the research proposals with a collaborating researcher as a final project, with one group member having an incomplete (n=1). The three (3) resulting groups completed the following proposals on mental health, cancer and communication, and overweight and obesity.

These projects were evaluated by three (3) individual judges by the academic mentors. The scores obtained in the proposals ranged from 72.6% to 93.85% (M = 86.60, SD = 2.59). In the individual evaluations, the three groups scored lowest using the eight (8) scientific articles in the proposal. In addition, one of the groups obtained a low score in the selection of subtopics (See Table 3).

Evaluation of Courses:

At the end of each course, the trainee completed the evaluation of their learning experience. The total percentage scores were highest in course general satisfaction (89.1%) and instructor effectiveness (87.6%). At the same time, the lowest was course learning experiences (83.2%). Please see Table 5 for details.

Table 5:

Course Evaluations by Domain: Model by Criteria and Courses.

Criteria	Percentage of Response Categories
	TD	D	N	A	TA
Good Course Structure and Organization
Community-based Participatory Research a			9.1	9.1	81.8
Fundaments of Research Methodology a				18.2	81.8
Ethics in CBPR a				9.1	90.9
Social Determinants of Health & Health Disparities 1a				9.1	90.9
Social Determinants of Health & Health Disparities 2b				10.0	90.0
Translational Research b				10.0	90.0
Total			1.5	10.9	87.6
Appropriate Course Learning Experiences
Community-based Participatory Research a				18.2	81.8
Fundaments of Research Methodology a				27.3	72.7
Ethics in CBPR a				27.3	72.7
Social Determinants of Health & Health Disparities 1a				18.2	81.8
Social Determinants of Health & Health Disparities 2b					100.0
Translational Research b				10.0	90.0
Total				16.8
Instructor Evaluation
Community-based Participatory Research a				18.2	81.8
Fundaments of Research Methodology a				18.2	81.8
Ethics in CBPR a				9.1	90.9
Social Determinants of Health & Health Disparities 1a				9.1	90.9
Social Determinants of Health & Health Disparities 2b					100.0
Translational Research b		10.0		10.0	80.0
Total		1.6		10.8	87.6
Course Evaluation and Instructor Feedback Criteria
Community-based Participatory Research a				9.1	90.9
Fundaments of Research Methodology a				18.2	81.8
Ethics in CBPR a				18.2	81.8
Social Determinants of Health & Health Disparities 1a				18.2	81.8
Social Determinants of Health & Health Disparities 2b				10.0	90.0
Translational Research b		10.0		10.0	80.0
Total		1.7		13.9	84.4
Satisfaction with Virtual Tools Used
Community-based Participatory Research a				9.1	90.9
Fundaments of Research Methodology a				9.1	90.9
Ethics in CBPR a				27.3	72.7
Social Determinants of Health & Health Disparities 1a				9.1	90.9
Social Determinants of Health & Health Disparities 2b				20.0	80.0
Translational Research b		10.0		10.0	80.0
Total		1.7		14.1	84.2
Course General Satisfaction
Community-based Participatory Research a				18.2	81.8
Fundaments of Research Methodology a				9.1	90.9
Ethics in CBPR a				9.1	90.9
Social Determinants of Health & Health Disparities 1a				9.1	90.9
Social Determinants of Health & Health Disparities 2b				10.0	90.0
Translational Research b				10.0	90.0
Total				10.9	89.1

Note: TD = Totally Disagree, D = Disagree, N = Neutral, A = Agree, TA = Totally Agree

^a= n= 11,

^b= n =10

Qualitative:

Post-training Cognitive Debriefing:

After all courses were finalized, a final cognitive debriefing was performed to gather the community trainees’ feedback. Opinions, suggestions, and comments were obtained from the participants and organized by identified themes and subthemes with summarized responses. Please see Table 6 for details.

Table 6.

Final Cognitive Debriefing - Cohort 1 - Community Researcher Program

Topic Evaluated/Question	Thematic Domains	Quotes
Acceptance: General Recommendations for the Program include structure, Course Order, Educational-Practical activity, Schedules, Professors, Materials provided, and Selection Criteria.	Structure	• The order of the classes must be restructured. • To be better prepared for the research proposal, I think the research course should be at the end. • The Ethics course should be moved to the end for when we start with the research proposal project. • The research course should be divided in two parts.
	Course Improvement	• The program is novel, although some courses, such as the research course, need to be reviewed. Qualitative research needs to be included and focus groups and interviews should be discussed more.
	Schedule	• The schedule needs to include two more days but fewer hours. • Classes should begin at 6pm. It seems a little rushed to start at 5pm.
	Practical Activities	• We want more activities included in the course to make it more practical when working with the material. • The research course should have more practice and less reading.
	Modality: presential vs. virtual	• The research class should be face-to-face and with their mentors. • The hybrid modality (online) is ideal for people outside the area to participate in the program.
Acceptance: Process of Developing the Research Proposal: What do you think about the process of preparing the research proposal?	Adequate	• The experience of working with academic researchers was very good.
	Academic Stress	• It was stressful, as it was a lot to do but the academic investigators were helpful.
	Suggestions	• A review of the material should be done before starting the research proposal to be prepared. • …You should provide more time to identify the research topic.
Preparedness for Collaboration in Research Project: How prepared do you feel to collaborate on a research project as a community researcher?	Confirmation	• We are ready (reaffirmed by several colleagues).
Feasibility - Contribution to Community Situations/Problems: What is your opinion about the contribution that this program can give to community situations or problems?	Assure Continuity	• This is the medicine this country needs because there is a lot of misinformation, and we need to take the first step. We need to share this with everyone and explain more of what the program consists of so we can reach more people. The community leader is part of the social structure to aid in mobilizing needed changes. • Failing to support this program means losing an opportunity for the university to stop exposing a class program. • Novel and pioneering program with community leaders.
Acceptance Assure Continuity of Studies for Community Trainees: How could we ensure that students continue receiving classes and do not stop attending (retention)?	Adequate Support	• If we had any situations, the staff would call us to help us. • The program tried for all of us to complete this certification. • All the support you all have given me has aided me in staying and being able to finish the courses in my most difficult moments. • The support that they have given us.
	Recommendations	• Must be aware of the needs of the trainees so that they can be maintained in the group. • Dialogue one-on-one to see what obstacles they have.
Additional Comments: Anything else you would like to add? Comments? Suggestions?	Satisfaction	• I feel more prepared and learned a lot. I feel immensely proud of myself for completing this program. • I am very thankful for the program, and I suggest that all the other groups be as heterogeneous as we have been so they can nurture themselves from one another just as we have.

Discussion

Providing community members with knowledge and skills in research is essential for their integration, active participation, and sustainability in research initiatives and community-academic partnerships (Hacker et al., 2012). Through this integration, the relevance of the research to be co-constructed is amplified as it focuses on providing actionable knowledge that could be utilized for decision-making to modify current practices or governing policy to aid in reducing health disparities (Krishnan & Nongkynrih, 2020). The development and refinement of the CTIHD-CRP curriculum and subsequent implementation aim to provide its community trainees with the basic knowledge and skills to achieve this goal.

The results indicate that knowledge change increased for community trainees. The overall average percentage in the post-test scores was approximately 80% for all courses, suggesting a general understanding of the presented materials. Three courses demonstrated statistically significant change (p<0.05) in scores: Ethics in CBPR, Social Determinants of Health & Health Disparities Part 2, and Translational Research. Although most courses had increased knowledge, the Fundamental of Research Methodology course obtained the lowest score, demonstrating a need for further refinement and review. During the cognitive debriefing sessions, one participant expressed: “The research course should have more practice and less reading.” These indicators are essential to modify the course to aid better comprehensibility and ensure alignment with the needs of our trainees and future cohorts. Although difficulties in this course were identified, the course itself or lack of knowledge was not mentioned as a barrier for trainees to develop their research proposals with academic researchers co-jointly. A high retention rate (91%), the course overall satisfaction (89.1%), and the trainees’ expressions during the cognitive debriefing, such as “I feel more prepared, and I learned a lot” and “I feel immensely proud of myself for completing this program,” supports our inference of trainees’ satisfaction and acceptability of the program.

For the academic programmatic structure, the trainees offered recommendations and contributions that are fundamental for the changes to be made in the general structure of the curriculum, including the order in which the courses will be taught, the balance between theoretical and practical activities, the schedule of the program, and materials provided. It is supported by what was expressed by one of the trainees: “A review of the material must be done before starting the research proposal to be prepared.” All these recommendations will be reviewed and analyzed before implementing the next cohort of trainees, combining them with a more in-person experience with the instructors and more practical activities for better comprehension of the teaching materials and information provided, particularly in courses that presented lower knowledge change.

According to the cognitive debriefing results from the research project development process, trainees felt ready to collaborate on research projects to benefit their communities. One trainee said, “The experience of working with academic researchers was very good.” The program’s initial outcomes include forming CAPs between community trainees and collaborating researchers and the successful co-development of three research proposals focused on current community health needs. Nonetheless, some participants expressed that the experience was stressful and suggested that there should be a review of the course content before starting this process.

The cognitive debriefing results imply that community trainees found the program acceptable and feasible. One community trainee stated, “This is the medicine this country needs because there is lots of misinformation, and we need to take the first step. We need to share this with everyone and explain more of what the program consists of so we can bring more people.” Another said, “Failing to support this program means losing an opportunity where the university could stop exposing a class program.”

This cohort of trainees completed their courses remotely due to the COVID-19 pandemic, potentially hindering effective communication between trainees and instructors (Central Office of Recovery, Reconstruction, and Resilience, 2023). The pandemic likely contributed to trainee burnout and exhaustion, affecting their interpersonal communication and cognitive efforts during the courses (Fauville et al., 2021; Salim et al., 2022). Furthermore, the social and emotional toll of COVID-19 may have left some trainees emotionally vulnerable, impacting their ability to concentrate and participate effectively. To address these challenges, the research team provided trainees with an academic advisor, a professor, and a licensed clinical psychologist, who evaluated individual situations and referred trainees to psychosocial and mental health services as needed.

The geographic location of this program, Puerto Rico, suffered the consequences of the great earthquakes that occurred in January 2020 (Almond, n.d.; Central Office of Recovery, Reconstruction and Resilience, 2023; Roble, 2020). Low literacy levels and limited access to technology among some trainees were identified as potential barriers to academic engagement. These factors created disparities in participation compared to other trainees. The research team offered basic training on the technologies required and provided computer equipment to address this issue. The situation was further complicated by trainees living in rural and remote areas, where weak and unstable internet signals caused interruptions in conference transmissions and trainee participation. As a solution, conferences were recorded to allow trainees to watch them later if needed and with follow-up from the instructors to ensure comprehensibility of the material.

Limitations for this study include (1) non-generalizability of results due to the non-probabilistic sampling method (purposive sampling); (2) the original programmatic structure was devised to be implemented in an in-person modality (notwithstanding modifications were realized to support a virtual environment); (3) trainees barriers in literacy and access to technology or internet; (4) participant burn-out from COVID-19 pandemic might have impacted trainees comprehensibility of material due to reduced engagement in courses (notwithstanding a counselor was provided and courses were recorded). Some of these limitations could have skewed the trainees’ change in knowledge by influencing their ability to participate fully in the courses.

The strengths of this study include the development and implementation of the program at PHSU, an academic institution focused on health sciences education, which proved advantageous. PHSU’s diverse academic offerings, including public health, clinical psychology, biomedical sciences, and medicine, facilitated the development of partnerships between academic researchers and community trainees. This multidisciplinary environment enhanced the program’s effectiveness and provided a rich context for community-based participatory research education.

Future directions for the CTIHD-CRP program involve several primary goals. First, we aim to enhance the current curriculum by incorporating feedback to benefit future cohorts. Additionally, we plan to evaluate the program’s impact on trainees’ ability to apply their skills within their community work and their confidence in conducting CBPR and research activities. Further assessment of future community-academic partnerships will provide insights into group dynamics and opportunities to strengthen collaborative practices. We also intend to identify supportive mechanisms for existing partnerships, focusing on implementing co-developed research proposals that address health disparities and promote health equity. Through these efforts, we strive to continually increase the program’s effectiveness in advancing community-based research and improving health outcomes.

Conclusion

Strengthening community capacity is essential for effectively integrating communities into health research activities, improving health outcomes, and ensuring the long-term sustainability of health initiatives. The CRP, developed by the CTIHD aims to empower community members with essential knowledge and skills to support the development of equitable partnerships and increase research on health disparities. The community trainees found the refined curriculum acceptable and feasible, demonstrating increased knowledge despite suggested modifications. The program’s outcomes include forming partnerships and co-developing three research proposals on community-identified needs.

Through this research capacity-building curriculum, the CTIHD aims to increase community participation in health research, foster the formation of CAPs, and support the development of research on health disparities. Additionally, the knowledge obtained through the development of these community-led research projects can evidence community health needs, which guides health promotion efforts to be tailored to specific community contexts and needs. This progress represents a positive step toward reducing health disparities and building healthier, more empowered communities in southern Puerto Rico. Ultimately, the long-term impacts of these efforts are directed toward improving health equity and reducing health disparities for and with the community. We anticipate that acknowledging the significance of community empowerment will guide others in developing research capacity-building programs to enhance community partner engagement. This approach will ensure that social determinants become fundamental in shaping future research initiatives, ultimately advancing community health equity through active participation and leadership within the community.