Getting started in CBPR- Lessons in building community partnerships for new researchers

Abstract

Background

There is a growing interest in community based participatory research (CBPR) methods to address issues of health disparities. Although the success of CBPR is dependent upon the formation of community-researcher partnerships, new researchers as well as seasoned investigators who are transitioning to CBPR often lack the skills needed to develop and maintain these partnerships.

Objectives

The purpose of the article is to discuss the competencies needed by new researchers to form successful CBPR partnerships.

Methods and Lessons learned

The author presents a series of strategic steps that are useful in establishing academic-community partnerships and in initiating, maintaining and sustaining CBPR projects. These steps include suggestions regarding community engagement, selection of Community Advisory Board members, outreach, the community’s role in problem identification, selection of research methodologies, considerations related to the community setting, need for flexibility and patience, “insider vs. outsider” conflicts, commitment and training issues, timing concerns for tenure-track faculty and the process of community empowerment.

Conclusions

CBPR is both rewarding and time consuming, for both the researcher and members of the community. Given its promise to address health disparities, it is imperative that researchers acquire the skills needed to develop and cultivate durable community-researcher partnerships.

Over the past decade, there has been a burgeoning interest in community based participatory research (CBPR) methods. Driven by a need to address health disparities, more communities and funding agencies are demanding alternatives to conventional research to address complex health and social problems. CBPR has been defined as “a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings.” (Kellogg Foundation 2001). Inasmuch as the success of CBPR studies is so heavily dependent upon the formation of community-researcher partnerships, it is unfortunate that the skills needed to develop and maintain these requisite partnerships are not often taught or explored in an academic setting (Wallerstein, Duran, Minkler and Foley 2006).

The purpose of the article is to discuss the competencies needed by new researchers and those investigators transitioning to CBPR during the formation of these partnerships. These competencies, which can be considered strategic steps, address the “pre-research period” (including community engagement, selection of Community Advisory Board members, outreach, and the community’s role in problem identification), the conduct of the research project itself (including CBPR research methodologies, considerations related to the community setting, need for flexibility and patience, “insider vs. outsider” conflicts, commitment and training concerns and “post-research issues” (such as timing concerns for tenure-track faculty and the process of community empowerment.

The situations and strategies discussed are based upon the author’s experience with several CBPR projects involving groups of Latino immigrants in two New Jersey urban communities. Although every geopolitical community is unique and each researcher will face his/her own set of unique circumstances, these “lessons learned” can be applied to many researchers as they embark on CBPR projects.

The “pre-research” period- Community engagement

New CBPR researchers are often faced with the task of selecting a community with which to partner for research. How does one go about doing this? The most effective CBPR projects are often a natural extension of an evolutionary process of community engagement. Minkler and Hancock (2003) suggest that the best CBPR projects build upon existing relationships and efforts within the community. The author’s first experience with CBPR began while doing volunteer clinical work at a local community based organization (CBO) near her university. The author approached the directors of the CBO and asked them what she could offer them. Her volunteer work there led to requests from community members for health education sessions, blood pressure and cholesterol screenings and health fairs. The author and her nursing students became frequent visitors to the CBO and participated in invited social activities there. Three years later, the author approached the CBO about initiating a small qualitative Photovoice study at the site (D’Alonzo and Sharma in press). By that time, she was familiar with the community’s assets and needs and had taken the time to establish trust and credibility among community members who were familiar with the CBO. Likewise, these same residents had become more attuned to issues of health promotion and had expressed an interest in participating in a research project. To avoid being labeled as a “helicopter researcher”(Deloria 1992) who flies in to conduct a quick study and abruptly leaves the community, an academic researcher who is contemplating a CBPR study should plan for a sufficiently long period of engagement in the community. There are no hard and fast rules about how long this period of engagement should be. Based upon the framework of the Community Readiness Model, there are tools available to help the researcher get a feel of the community’s readiness to engage in research (Lawson et al 2007; Plested et al 1998).

Community Advisory Board (CAB)

An important initial step is the selection of community partners and the formation of a Community Advisory Board (CAB). A CAB is composed of representatives of community based-organizations (CBOs) who serve as community partners, along with community residents and other consultants. Some CBPR researchers prefer to use the term “steering committee” in place of CAB, to reflect both the advisory as well as the decision-making capacities of the group. Depending upon the tasks at hand, there may be multiple subcommittees or “work groups” within the CAB.

Researcher-community partnerships vary tremendously in their structure and the allocation of power(Green et al 2003). Selection of CAB members will be one of the first major decisions a researcher will need to make, so it is wise to begin by asking key informants for the names of individuals who would be good choices. If the same names come up from different sources, these are people to approach. Potential CAB members should be well known in the community; if possible, they should have an interest in and even a history of involvement in university affairs. Think about contacting persons who have the background, interest, time and energy to commit to the process. The author found that once she identified and recruited 1–2 key individuals who were well respected within the Latino community, it was much easier to convince others to join the CAB.

The size of the CAB will depend upon the size of the study, but 5–10 members are usually adequate. The CAB should be comprised of formal and informal community leaders as well as representatives from a few CBOs. This arrangement will provide a rich perspective on the assets and needs of the community and be a tremendous benefit in the event there are unforeseen changes in one or more of the CBOs. When scheduling CAB or subcommittee meetings, it is useful to rotate meeting sites. This helps to establish a sense of equity among the members and prevents any one organization from bearing the burden of hosting a meeting. The author learned this lesson during the formation of the CAB for the PAIL (Physical Activity Intervention for Latinas) Study (publication in progress). After she assembled the CAB, the author perceived it would a sign of hospitality to host the first CAB meeting on the university campus. In reality, she learned the campus was an intimidating venue for some community residents, who had to pay prohibitive bus or taxi fares to travel there. For researchers contemplating CBPR projects, alternatives to the use of campus facilities include town libraries, community centers or local restaurants which are within walking distance for many area residents. Since that first CAB meeting, the author has occasionally held meetings at members’ homes, reducing the need for transportation costs and childcare. To ensure that everyone has input into the decision-making process, it is prudent for the Principal Investigator (PI) to draft an agenda prior to the meeting and give all community partners the opportunity to add to it. This helps to create a sense of equity among members. Active CAB members are crucial to the success of the project. They can guide the researcher, provide timely suggestions and help the researcher to avoid costly mistakes.

Outreach

Prospective CBPR researchers would do well to avoid becoming a victim of the “town and gown” mentality. It is important to “be a good neighbor” by participating in community projects and events beyond the research project, such as cultural programs and seasonal festivities. The community needs to see that the PI is interested in them beyond the research project. Too often, residents of the neighborhoods surrounding the university may have limited contact with faculty and students (except perhaps for the occasional unruly football fan). Authentic community-academic partnerships help to create a vision for “what can be” among community residents, particularly youth. The author always makes a point of encouraging undergraduate nursing students from minority or traditionally underrepresented backgrounds or those who are economically disadvantaged, to come with her to health fairs and community events. At such gatherings, there are inevitably high school students present from similar backgrounds, who want to talk to them about career opportunities in nursing. Likewise, many of the immigrant Latino parents who work in CBPR projects with the author are proud to tell her, “Someday my children will go to your school.”

In many universities, faculty members communicate primarily through e-mail; it is convenient and time-effective. However, there is no substitute for “face time”- meeting personally with staff and community partners to discuss issues surrounding the project. In the Latino community for example, most people expect this and see it as a sign of genuineness and respect. The author has found that she needs to be flexible in planning such meetings around the work schedules of those community persons involved. Unlike her colleagues who conduct research in a laboratory or clinical setting, this frequently means scheduling meetings in the evening, after a long day of teaching on another campus. For the academic researcher, face time is frequently more time consuming, but in the long run, it is time well spent.

The community’s role in problem identification

An unequivocal aspect of the CBPR process is its emphasis on what Ansley and Gaventa (1997) have called “…the deconstruction of power and the democratization of knowledge”. Unlike traditional research approaches, topics for CBPR projects ideally should originate from within the community itself (Minkler and Hancock 2003; Mosavel, Simon, van Stade and Buchbinder 2005). For most academic researchers, this represents a major paradigm shift. In reality, many CBPR projects are initiated by the PI, who has the time, the expertise and the funding to carry out the research study. If this is the case, at the very least it is essential for the PI to determine early on if the proposed project is a priority for the community (Sullivan et al. 2001. Prior to initiating her first CBPR project, the author met with community members and discussed her concerns about rising levels of obesity and sedentary lifestyles in Latinos following immigration to the US. She was surprised to learn that many residents shared her concerns and looked forward to partnering with her to address these issues. Later on, once her community partners were “bitten by the research bug”, many enthusiastically came to her with their own ideas for future projects.

Research project itself- Methodological issues

CBPR is considered an orientation to research, but it is not a research method per se. There are numerous examples of qualitative, quantitative and mixed methods CBPR studies in the literature (Viswanathan et al 2004). Whichever methods are chosen, community members must be comfortable with the study design, data collection methods, and reimbursement policies. If the researcher is planning an intervention, it is important to consider utilizing a design that maximizes the number of community members who will actually receive the intervention, rather than simply assigning them to a control group (Wallerstein, Duran, Minkler and Foley 2005). For this reason, crossover and non-equivalent (attention) control group designs can be particularly effective (Shadis, Cook and Campbell 2002). In the crossover design, half of the group will receive the intervention first, while the other group serves as a control. After the first experimental group has finished, the control group becomes the second experimental group. In the non-equivalent control design, the control group receives a different type of intervention than the experimental group, but one that can ultimately have benefits for them as well. Similar methodological concerns arose in the author’s Photovoice study. Although the use of Photovoice can itself be seen as a type of empowerment intervention (D’Alonzo and Sharma in press), the author was concerned about the subjects’ acceptance of the camera as a data collection method among immigrants. As a result, preparatory sessions were held with the subjects to address ethical issues associated with the use of Photovoice, including what and who to photograph and measures to minimize invasion of privacy. Similarly, when the author pilot-tested a group of Spanish language questionnaires to prepare for the PAIL Study, she found the immigrant women experienced great difficulty with the restrictive nature of the Likert- format questions. Major revisions were needed to improve the validity of the tools for use in the intervention (a separate publication detailing this process is in progress).

Considerations with research in the community setting

Academic researchers who are making the transition to the community setting will discover they need to address a host of different issues in their budgets. Since CAB and staff meetings often take place early in the evening, it is helpful to provide light refreshments for participants who may be coming directly from work. This is more than simple hospitality; it is an acknowledgement that research assistants and study subjects are sacrificing their dinner time (and often the interaction with family that accompanies mealtimes) to assist you with your research. The dietary preferences of community members are important considerations. Pizza and soda may seem like logical choices if you are working with college students, but will not likely be as popular among elderly members of the community. In the course of conducting training programs for community health workers (promotoras) in the Latino community, the author found that some of her trainees were excellent cooks who preferred to prepare their own ethnic dishes for these gatherings. Similarly, the author has found that babysitting arrangements can take on a life of their own when working with young women with small children. In such cases, it is important early in the planning phase to develop a pool of persons who can baby-sit and to draw up a flexible schedule that allows for contingency plans. It is advisable to consult in advance with risk management officials at the university as well as the Institutional Review Board (IRB) to discuss potential liability issues associated with babysitters. Although it is tempting to rely on nursing students or other healthcare majors (their training in CPR and first-aid is a plus), consider older teenagers from the community or relatives of subjects for CBPR studies. It is wise to have a variety of activities available for children of different ages, including homework sessions for school age children. The PI should also find out what the women expect of babysitters. It is the author’s experience that some women would prefer their children were given crafts or quiet projects to do or a DVD to watch in an adjacent room rather than have their children participate in active games outdoors. The PI should also plan for have healthy snacks available for the children if the event will last more than an hour or so.

Flexibility and patience

CBPR projects require a great deal of flexibility. Unforeseen events often occur, causing the PI to reconsider what seem to have been well constructed plans and resort to a “Plan B” (or Plan C, D, etc). The author began LIP (Latina Interview Project) (publication in progress), a qualitative study of the attitudes and beliefs of immigrant Latinas with regard to physical activity, as a partnership with a faith-based organization. The pastor of the organization and his wife assigned a staff member to assist the PI and they themselves were enthusiastic supporters of the research project. A year into the study, the pastor and his wife were transferred and replaced with another couple who had different priorities for their congregation. Without the support of the couple, interest in the project among the congregation waned to the point where the author consulted with the CAB and moved the study to another site.

“Insider” vs “Outsider” issues

The popularity of CBPR methods has undoubtedly been influenced by criticism of traditional “outsider” research. Community residents may erroneously assume that a researcher has “singled them out” for study in a pejorative manner because of their race or ethnicity. Within many low income minority communities, health-care providers and health-care systems may in fact be seen as contributors to the existence of health disparities. Many minority CBOs are inundated with requests from majority researchers to conduct studies that ultimately provide no benefit to the community and further strain the CBO’s limited resources. It is often a challenge to convince such persons that you have a different approach, one that is built on collaboration. As a researcher, even if you live within the community, you are what is often called the “outsider within” (Minkler 2003). It is vital that the PI partner with persons who are “boundary spanners,” (Kelly, Mock and Tandon. 2002) individuals who live and work in the community who can provide the researcher with valuable insight into how to handle issues of mistrust. As an “outsider” in the Latino community, the author relies on members of her research team to let their neighbors know, “She is buena gente (a good person).”

Early in the engagement process, the researcher must think long and hard about why he or she wants to work with a community and what he/she expects to gain from CBPR. As Cornel West has observed, “You can not lead the people if you do not love the people, and you can not save the people if you do not serve the people.”

Commitment and training issues

The prospective CBPR researcher must be very clear about his/her temporal expectations for community members as research assistants and subjects. A CBO may find that the time needed for staff members/research assistants to plan and carryout a research study is interfering with the day to day operation of the organization. Because work is an economic necessity in low-income communities, the PI should consider the time and salary requirements of potential staff members early in the planning process. The working poor may hold several part-time jobs or may work jobs with undesirable hours, leaving them little time to work as research assistants. It may be useful to assign such persons tasks that can be completed in off-hours, e.g. data entry. Community women who are stay-at-home moms, for example, may make phone calls to potential study subjects while their children are napping or at school.

CBPR is unique in that it integrates and achieves a balance between research and action for the mutual benefit of all partners (Israel et al 2003). This is why intervention studies are often popular in CBPR- the community receives something tangible in exchange for its efforts. However, because community members are often unfamiliar with the research process, interventions may be seen simply as educational programs. A prospective PI will need to plan extensive training for staff on the meaning of concepts such as experimental control and scientific rigor. The researcher will need to consider how to deal with IRB Human Subjects Certification for staff, a real challenge when working with low literacy individuals (Hatcher and Schoenberg 2007). Study participants also need to understand the importance of adherence and thorough completion of data collection tools.

Unlike other types of research, PIs of CBPR projects need to relinquish direct control of many aspects of the project, both for the good of the community and for their own sanity. Ideally the PI should hire assistants who are members of the community and let them take over responsibilities such as recruiting and contacting subjects, participating in training sessions and leading discussion groups. If staff members lack the skills to take on activities such as data entry and analysis, the PI can elect to train them in these responsibilities or send them to workshops for training. This is truly a win-win situation; the PI gains responsible assistance with the project, while the support staff members learn valuable life skills they can use in other areas. An added plus is that delegation of nonessential tasks frees up the academic researcher to focus on other responsibilities such as grant management, publications, teaching, or promotion and tenure issues.

Post research issues- Timing concerns for tenure track faculty

Rome was not built in a day and either are sustainable CBPR partnerships. A researcher’s personal timetable is likely to be significantly different than that of non-academicians within the community. Time constraints are particularly problematic for tenure-track faculty members who need to receive funding, conduct research and publish in a timely manner. Once a researcher begins a major CBPR project, it is useful to continue to pursue other smaller opportunities for community partnerships, knowing it will take 1–2 years of engagement before the researcher can determine if these will become potentially valuable sites for research. A successful clinical or educational partnership will not necessarily guarantee that members of the community will be interested in or have to the time to devote to research. Fortunately, most agencies who fund CBPR projects realize this. It is advisable for the researcher to have several small research projects in place along with the larger CBPR study; the PI should then be prepared to analyze the data and publish the results of the small studies rather quickly. All the while, the researcher is gaining expertise as well as building trust in the community

Community empowerment

The author’s approach to CBPR has been influenced by Paulo Friere’s model of empowerment (Freire 1970; Wallerstein and Bernstein. 1988). Freire was a Brazilian educator who work focused on aiding oppressed and marginalized communities to achieve liberation through literacy. Demmitt and Oldenski (1999) described Freire’s approach as “empowering the oppressed by transforming oppressors through reflection and action.” Gutierrez and Ortega (1991) expanded the meaning of empowerment to include personal, interpersonal and political forms. In this representation, each level of empowerment builds upon skills acquired at a previous level. An individual who is personally empowered influences activities within the community, leading to interpersonal and political empowerment, where the community advocates for social and political change.

Although the objective of CBPR studies is ultimately to effect social action and social change through political empowerment, these goals may not be easily achievable when working with groups who have little personal and interpersonal power. The author experienced just this when she found that none of the graduates of her first promotora program were ready to work or to recruit other women to participate in the research study. The 6- week promotora training process had been a personally empowering experience for many of the women; several of the participants enrolled in English (ESL) classes and returned to the work force. However, none of them felt ready to take the next step to work as promotoras, by influence others or advocating at the community level. This finding is not surprising as empowerment is a complex, long-term process. Stoecker (2003) reminds us that CBPR is not just a research project, but rather a social change project. One lesson the author learned from this experience was that progress toward empowerment can be measured in many different ways.

Conclusions

CBPR is a grass-roots approach to solving community health problems through community empowerment and social action. New researchers as well as seasoned investigators who are transitioning to community based methods often find that they lack the skills needed to be successful in CBPR. Philosophically, acceptance of the principles of community engagement that are the foundation for CBPR is likely to require a major paradigm shift for many academic researchers. Likewise, considerable time and effort is needed to initiate, maintain and sustain the requisite community relationships. Whitmore (1998) has noted that in addition to the skill of the research team, the parent institution must possess the desire, resources and infrastructure needed to make such CBPR successful. A remaining challenge for CBPR researchers is the need to disseminate the knowledge gained from CBPR to all partners in an understandable and respectful manner. This challenge is a crucial link in the process of community empowerment to address health disparities.

Building community partnerships is often like learning to dance the mambo; one step forward, then one step back. For the researcher, it requires a high level of commitment, flexibility and patience. Given its promise to address health disparities, it is imperative that researchers contemplating CBPR projects acquire the skills needed to develop and cultivate durable community-researcher partnerships.