Mining the Challenges of CBPR for Improvements in Urban Health

The public health literature has broadly established that urban settings have complex impacts on the health and well-being of their residents.¹ With large numbers of people living in close proximity in urban settings, there is increased likelihood that they will affect, positively or negatively, the health of communities that reside there.² Low-income city residents, and in particular, persons of color, bear a disproportionate burden of chronic diseases such as asthma, HIV/AIDS, diabetes, heart conditions, and cancer.^2,3 The additional convergence of social, environmental, political, economic, and structural factors exacerbate conditions that in turn, influence behaviors and circumstances resulting in poor health outcomes.^1,4 With the proportion of people living in urban areas expanding worldwide,² attention to methods that address causes of disease, and concurrently, preserve and maximize health, is as critical as ever.⁵

In the past two decades, public health research has altered its approach to be more collaborative with communities in which diseases, disparities, and structural problems persist. With increased awareness of how multiple forces impact health and disease in cities, there is growing recognition that traditional methods of “outside expert” driven research are insufficient to define and address them.⁵ Community-based participatory research (CBPR) is increasingly viewed as an essential approach to understanding and addressing social determinants of health.^5,6 Essential principles of CBPR involve capacity building, shared vision, equitable involvement, ownership and trust, and immediate and long term gains resulting in improved and relevant research.^7,8 For community and institutional partners, CBPR involves their active participation, mutual benefit and co-education, and sustained commitment to a process beyond studying an area of concern, to applying findings to achieve social change.^5,9

While advantages of CBPR have been well documented, partnerships increasingly seek explication about the challenges inherent in this approach.⁵ Racial and ethnic discrimination, power and privilege, community definition and consent, and using research for social change are a few examples of recognizable tensions that affect CBPR partnerships.^5,7,9 Although these challenges are acknowledged, it is rarely made explicit how to address and resolve conflicts. Even less common is written testament by partnerships whose challenges are dire enough to threaten their sustainability—or those that do not continue as a result.

In July 2005, a stream of comments on the CBPR listserv co-sponsored by Community–Campus Partnerships for Health and the Wellesley Institute reflected these concerns.¹⁰ At the time, the listserv had approximately 1,900 subscribers, including 60% from higher educational institutions, 14% from community-based organizations and 11% from government.¹¹ Listserv members discussed a paucity of CBPR literature that explicitly portrays challenges of CBPR processes, defines “failures,” and draws upon these lessons. Neither institutional nor community partners, however, would normally wish to characterize their CBPR efforts as having “failed,” or even to admit to seemingly intractable challenges. In addition to compromising morale and community–institutional relationships, doing so might jeopardize future funding in an already competitive climate. This said, listserv members described potential benefits of well-written CBPR processes that may yield broader lessons for emerging and established partnerships, as well as those beginning to consider such an approach. One member referred to an unsuccessful partnership project as having

“...plenty of blame to go around for the failure of the project...from the state funders not inquiring at all about the capacity of the individual seeking the funding...to the academic researcher who didn’t understand why we needed to get IRB approval, to the executive director of the agency who...[frequently forgot] what the purpose of the organization [was] and who he was supposed to serve...There were so many lessons learned, for me at least, that I thought the story should be published...”

Another member wrote,

“Thank you for the interesting discussion about the relevance of ‘failed’ initiatives. Evidence-based policies and programming need to be informed by an understanding what works, what doesn’t, and why from the full spectrum of CBPR outcomes and processes. Actually, from all research initiatives—e.g., there has been criticism of how limited publication about ‘failed’ randomized controlled trials (those that fail to show a statistically significant difference from a given intervention) leads to skewed findings from systematic reviews, which are relied on as the evidence base.”

An exchange of possible explanations for the lack of published articles on challenges, or lessons learned from CBPR “failures,” followed. These included “the extent to which a manuscript contributes to reflective discussion on a topic,” and, for “research-oriented journals with very high standards,” articles on CBPR process might not meet those standards. It was generally agreed that to effectively enhance the practice and literature of CBPR, a “manuscript [must be] of broad interest to the readership” beyond “describing a single program’s trials and tribulations.” Finally, and without prompting, listserv members mentioned journals that might be receptive to articles that highlighted CBPR challenges. The Journal of Urban Health topped the list. Their instincts proved to be right, as we subsequently sought and received approval from the journal editor to co-edit the theme section of this issue.

This theme section is one modest attempt to close the gap in our understanding of challenges encountered in CBPR and strategies for overcoming them. Four papers comprise this section, and candidly report on the trials and tensions faced by their CBPR partnerships and steps they took to mitigate these effects.

The section begins with a paper authored by a collaborative of nine partner organizations across the U.S. that report on their collective knowledge of factors that facilitate and impede successful CBPR partnerships.¹² The themes and practical recommendations that emerge offer guidance for avoiding common pitfalls and maximizing the potential for success in CBPR and provide the basis for an evidence-based curriculum now available online.¹³ The next paper, written by a team of authors from the three Urban Research Centers whose core funding from the CDC was eliminated in 2003, serves to broaden our understanding of, and ability to prepare for, sustainability. The paper makes a strong case for the critical role that centers can play in sustaining CBPR, including translating findings into practice and policy.¹⁴ The final two papers provide in-depth perspectives from CBPR partnerships that are grappling with very real imbalances of power and resources as they seek to “stay true” to the principles of CBPR. Two case studies of major research projects in Boston, MA reveal stereotypes, generalizations, and conflicting goals and expectations held by both community and academic partners that require constant negotiation.¹⁵ In the final paper, a CBPR partnership in North Carolina presents in exquisite detail the processes they followed to form their partnership and develop an application for federal funding.¹⁶ In so doing, they reveal conflicts that arose and the explicit attention to undoing racism that is central both to partnership functioning and the research proposed.

Taken together, these papers reveal the promise of CBPR as a strategy for improving urban health. Their explicit acknowledgment and focus on challenges faced should inspire other CBPR partnerships to similarly step forward and report on their individual and collective experiences. By providing windows into the reality of what “doing” CBPR entails, and how traditional funding mechanisms can pose direct conflicts, these papers also serve as a call to action for funders that seek to improve urban health. While this work is not easy, it is essential to understanding and solving persistent health challenges facing urban communities today.