Considerations for Community-Based Research With African American Women

Abstract

Although community-based research is intended to be culturally sensitive, more advanced consideration of the impact of race, gender, and class is needed for health disparity research involving women of color. Research processes must permit the simultaneous disclosures of the racial, gender, and class identities among women of color that are assumed and imposed.

The authoritative knowledge that women of color have about their lives and their health should form the basis for collaboration between researchers and study participants. The dissemination of research findings to study participants, and dialogue on those findings, is imperative for the development of sustainable interventions.

THE GOAL OF ELIMINATING health disparities among women of color has implications for the formulation of research questions and the selection of methodologies to be used. Reexaminations of the impact of race/ethnicity and oppression on health and of the unfolding associations between gender and health are producing new pathways of inquiry.1,2 Specifically, the conceptual and theoretical models emerging from women's and gender studies (and from race and ethnic studies) have become a catalyst for more advanced considerations for conducting health research with women of color.3–5 Therefore, the implementation of research approaches informed by critical analysis of the multiplicative impact of race, class, and gender on health offers a valuable conceptual framework for locating causal factors for the disparate health outcomes seen among women of color.6

The exploratory status of women's health generally and of the health of women of color in particular forms the impetus for reexaminations of conceptual frameworks, methodologies, and measures to assess determinants for adverse health. There is an expansive body of literature on reproductive health, but numerous questions remain unanswered.7,8 Researchers are vexed by the persistence of disproportionate rates of preterm delivery and low birth rates among African American women across socioeconomic categories.9,10 The better birth outcomes experienced by African and Caribbean women, compared with African American women, challenge genetic explanations for the poor birth outcomes.11

In contrast to the considerable body of literature on reproductive health, less is understood about the determinants for chronic disease (e.g., heart disease, hypertension, cancer) among women.12 What has been documented is that women of color, especially African American women, have disproportionate rates of morbidity and mortality as a consequence of chronic health conditions.13,14

The identification of determinants of the health of women of color is impeded by the absence of explanatory frameworks. In this commentary, I examine the complexities of conducting health research with women of color, in particularly considerations for conducting research with African American women. Drawing on the experience gained from implementing a series of studies on stress and reproductive outcomes among African American women, I examine the conceptualization and applications of a culturally sensitive, race/ethnicity–specific, and gender-specific approach to conducting research within the context of community-based efforts.15

The series of studies on stress and reproductive health that I refer to were designed to focus on the stressors and supports in the lives of African American women and to facilitate the development of a race- and genderspecific stress measure informed by what women said about their lives.16 The final phase of these studies focused directly on stressors and supports for African American women during pregnancy and birth. Because the women were representative of diverse educational and employment categories but were mainly collegeeducated, we also sought to explore the impact of socioeconomic factors on health outcomes.

This community-based research involved 545 African American women living in the metropolitan Atlanta, Ga, area. The aims of the research were accomplished through an iterative process, combining qualitative and quantitative methods, that included focus groups, interviews, jury exercises, the administration of a pilot stress measure, and postmeasure focus groups and interviews.15 In conjunction with the objective of gathering empirical data on stress, the focus of the research evolved to include the development of evidence-based, communityimplemented stress interventions.

CULTURAL SENSITIVITY: THROUGH THE LENSES OF RACE, GENDER, AND CLASS

Over the past decade, investigators have promoted the benefits of community-based approaches for conducting health research. The endorsement of community-based research methodologies stems from advocacy of a participatory model of research intended to empower community participants to make decisions about their health and well-being.17 That is, community-based research is designed to engage study participants in the conceptualization of research questions, the implementation of research procedures, and, most importantly, the sustained application of research findings to health promotion and intervention. Those goals are best met through collaborations between researchers and study participants that are undergirded by the tenets of community-based research: cultural sensitivity, reciprocity, and accountability.18

Adherence to cultural sensitivity is a core component of community-based endeavors, yet its utility can be circumvented by the superficial infusion of symbols, language, and rituals. Essential to a better understanding of why women of color experience poor health outcomes is a process guided by a deep-structure form of cultural sensitivity. Deep-structure sensitivity, which seeks to incorporate ideas of “peoplehood” (i.e., group identification), history, social factors, and geographic dimensions, enables researchers to devise strategies aimed at providing contexts for perspectives, behaviors, and experiences that impair or mediate health outcomes.19

While notions of peoplehood are inclusive of racial and ethnic identity, deliberate articulation of the experiences associated with race and ethnicity is warranted for research with women of color. Research findings indicate that race is both an imposed identifier and a self-identification that is embraced by African Americans.15 Sensitivity to the racialized experiences of study participants must inform the research process to permit dialogue on the polarized components of race as an embraced and devalued identity. It is from this vantage point that research processes can advance to further disaggregate the components of race and oppression and then reassemble those components to offer a valid, comprehensive analysis of the impact of race on health.

Single-risk explanations for health disparities obscure discoveries of the complexities of day-to-day existence that imperil health.7 Limiting the focus to race precludes crucial assessment of the impact of gender and class and thus is a major impediment to understanding health disparities among women of color. The dearth of research on women's health suggests that the articulation of gender has not necessarily materialized within the context of adherence to cultural sensitivity.

Gender as a social construct is embodied in the roles, obligations, and relationships of women; gender is shaped by region, class, and sexuality. Gender oppression, like racism, is a consequence of the multiple identities imposed on women. Cultural sensitivity linked to gender and applied to research methodology should foster interactions and direct research processes that permit expressions of the gendered identities, roles, and experiences of oppression among women of color.

The link between poverty and adverse health is well established, and since women of color are overrepresented among the poor, a lack of resources has been the prevailing explanation for their disparate health outcomes.20,21 There is no doubt that the conditions that accompany poverty imperil health. However, the inability to recognize status and access to resources within the context of how communities of color evaluate poverty and wealth hinders identification of the mechanisms by which poverty affects health.

Assumptions that racial or ethnic membership is automatically indicative of poverty are flawed, as they disregard socioeconomic diversity within communities of color. That inability to take notice, to substantively integrate socioeconomic diversity, hampers the discovery of the convergent (and divergent) experiences—despite or because of education, income, and employment—of women within communities of color. The conceptualization and measurement of class as a proxy for education, income, and employment remain unclear. Encouraging women to validate their lived experience within and across the boundaries of presumed socioeconomic categories offers an approach for identifying the impacts of class on health in communities of color.

Disaggregating the components of race, gender, and class may appear to be working against the aim of coalescing the identities assumed by women of color. But, as previously indicated, this course is desirable in the presence of unknowns regarding lived experiences and health outcomes. Ultimately the goal is to reassemble the details of the separate identities, focusing on the intersection of race, gender, and class as an authentic representation of the lives of women of color. The validity of this approach was seen in the responses of 2 of our research participants:

I voiced this to my son's assistant principal not too long ago, that some of the things that I have been concerned about with my children she will never have to worry about, because my children are Black and her children are White. You know, she will never have to go—like once I was in [a store] and this man was watching my children and I know that he thought that they were going to steal, you see? And we were talking about some things and I told her to be glad you don't have—you have to worry for your children, but you don't have what I have to worry about.

(S. E., married, with a household income exceeding $90 000)

One of the absolutely biggest problems on my job . . . is dealing with racial and sexual issues. I mean in a lot of ways it was easier because I was the only woman in the group, I could say, well, I don't have a wife to do the clothes. All you need to do is jump into the shower and comb your hair. . . . So there were issues that I could deal with. But in terms of racial issues, it was difficult for me to talk about this because they didn't have a clue as to what I was talking about.

(L. M, single, working in a corporate setting)

These women revealed stressors associated with their gendered roles as nurturer and employee, respectively, and their stories show how race—or more precisely, racism—exacerbated the stress they experienced as women. The interaction of race and gender, as described by these women, is gendered racism. Cultural sensitivity framed by considerations of race, class, and gender permits the articulation of these and other lived experiences among African American women.15

RECIPROCITY, ACCOUNTABILITY, AND AUTHORITATIVE VOICES

Cultural sensitivity promotes communication of the experiences of women of color that is facilitated by reciprocal interactions between researchers and study participants. The exchange between researchers and study participants recasts the identities of all involved, promotes critiquing of the research questions, and stimulates ongoing reassessment of the research process.

The women who participated in the stress research were seen as collaborators, not subjects. That designation was not merely semantic but rather denoted the women's involvement and authority in all phases of an interactive research process. Reliance on the authoritative voices of women of color is crucial to establishing and implementing reciprocity within the context of a community-based research endeavor.

Ideally, interactions during the research process should be mutually beneficial for study participants and researchers. The benefits of research, for all involved, rest on assumptions about authority and knowledge concerning health and well-being. Whereas researchers are authorities on the theoretical and methodological processes involved in conducting research, study participants must be viewed as authorities on their lives and the conditions in those lives that affect health and sickness. The collaborative approach employed in our research on stress resulted in significant input from the women in ways that were unsolicited and unanticipated but nonetheless productive.

The way in which we entered communities of African American women participating in the research was crucial in obtaining their collaboration. We made presentations to groups of women on the disproportionate rates of chronic disease and adverse birth outcomes among African American women. My identity and status as an African American woman investigator were significant, but equally important were the presentation and the facilitation of dialogue on the health of African American women. Women who were skeptical about the data questioned the questions guiding inquiry on the health of African American women. Others, who sought to find their own explanations for poor health (in particular, adverse birth outcomes), examined their own health status. This way of disclosing the rationale for the research affected the data collection procedures and content. It also provided a framework for data analysis, interpretation, and application.

Collaborators in the research were compensated; however, their motivation for participating extended beyond the anticipation of payment. Rather, they were interested in the research because of the opportunity it provided to engage in dialogue with other women and to begin a process for promoting wellness in ways that reflected their lives as African American women.

Within the context of collaboration, the importance of compensation was also informed by the identities of the women linked to race, gender, and class. Organizational collaborators, that is, clubs, sororities, and church groups, sought to maximize the benefits of their involvement in the research; thus, they combined the compensation received by individual members to support their groups' community outreach efforts. Specifically, members of a sorority and a hospital auxiliary group elected to use the research compensation to support their programs for youth and programs to help pay the medical costs of poor children.

Those decisions emanated from how the collaborators (who were college-educated) viewed themselves as African Americans, as women, and as individuals with access to resources. The quantitative findings from the research confirmed that the women felt obligated to protect and provide for the needs of African American children, both kin and non-kin.15

Accountability in community-based research is associated with issues of reciprocity, protection of the rights of research participants, and dissemination of findings to participants. While the rights of research participants are paramount, the dissemination of findings to participants is equally significant. Unfortunately, because data analysis is timeconsuming, considerable momentum can be lost between the entry phase and the time when the findings are disseminated. Furthermore, in contrast to the publication and presentation of findings to the scientific community, the dissemination of findings to research participants is typically optional or overlooked.

Neglecting the dissemination of research findings to collaborators represents a breach in the researcher–collaborator relationship, a breach that often characterizes research endeavors. Distrust of scientific inquiry within communities of color has its genesis in a history of exploitative experimentation, and that distrust is perpetuated by the absence of accountability for disseminating findings to research participants.22,23

The aim of our research on stress was to amass empirical data, but the women's sharing of their lived experiences caused us to expand the project to include promotion and support of interventions for stress reduction. An applied, rather than theoretical, focus on stress resulted in a conference for research collaborators. The goal of the event was for research collaborators to hear the preliminary findings from the investigation and to be exposed to strategies for stress reduction. Conference participants continued the dialogue among themselves and with the research team about their experiences as African Americans, as women, and as individuals with expectations for their lives stemming from their education, employment, and income. Those interactions stimulated the development of questions that framed subsequent research and informed the interpretation of the data from the previous work.

Regardless of the method or objective of the research (biological or psychological, theoretical or applied), the importance of reporting the findings to the participants must always be considered at the outset. The analysis and interpretation of research data must include processes that ensure that findings are reported to communities of color. The dissemination of research findings to women from communities of color is a critical step in the creation of intervention approaches.

CONCLUSION

The construct of research that is collaborative and is informed by the lived experiences of women of color must be a primary part of efforts to eliminate health disparities. The opportunity, in the process, for collaborators to make immediate use of the findings constitutes an intervention. The utility of the findings, and their immediate and subsequent application, resides in collaborative data collection processes that must be attuned to the multiple identities associated with race, gender, and class assumed by women of color.