Evidence, Power, and Policy Change in Community-Based Participatory Research

Abstract

Meaningful improvements in health require modifying the social determinants of health. As policies are often underlying causes of the living conditions that shape health, policy change becomes a health goal.

This focus on policy has led to increasing interest in expanding the focus of community-based participatory research (CBPR) to change not only communities but also policies. To best realize this potential, the relationship between evidence and power in policy change must be more fully explored.

Effective action to promote policies that improve population health requires a deeper understanding of the roles of scientific evidence and political power in bringing about policy change; the appropriate scales for policy change, from community to global; and the participatory processes that best acknowledge the interplay between power and evidence.

In recent years, public health researchers and advocates have recognized that meaningful improvements in health and health equity require modifying the social determinants of health, the fundamental drivers of a population’s health and disease.^1–3 Public health researchers seek to identify such modifiable determinants of health and use this evidence to make the case for change. Because policies, being defined as the actions of public or private organizations that allocate resources and set courses of action, are often underlying causes of health enhancing or damaging conditions, policy change becomes a public health goal.^4–6

This renewed focus on policy change has also led to changes in the discourse on community-based participatory research (CBPR). CBPR, influenced by a variety of earlier research traditions,^7–9 emerged in the 1980s and 1990s to engage those most affected by a problem. The goals of CBPR are to ensure that a community’s health needs are assessed and interventions to address these needs are implemented in partnership with community residents and leaders.^10,11 In the last decade, CBPR practitioners have expanded their focus to work to change policies as well as community environments and behaviors, strategically diversifying their methods and approaches.^12–14 In so doing, they have helped to lay the foundation for a range of participatory policy successes.^15,16

In this commentary, we argue that to best realize CPBR’s potential for significantly improving population health, the relationship between evidence and power in policy change must be more fully explored. Policy changes that improve population health and reduce health inequality do not typically come about solely as a result of strong scientific evidence, the mobilization of a few communities, or the convictions of a few politicians. Instead, these changes result from multiple actions in many domains. Effective action to promote health-enhancing policies requires a deep understanding of the respective roles of scientific evidence and political power in bringing about policy change. By calling attention to this need, we hope to encourage community-, policy-, and academically based CBPR participants and the researchers and policymakers from other research traditions with whom they interact to focus more attention on the complex relationships between power and evidence.

Public health researchers and advocates describe a variety of approaches to balancing the relationship between evidence and power.^17–19 In this discussion, we define evidence as data on the nature and magnitude of a problem and the efficacy of various methods to reduce that problem. Although many disciplines have proposed definitions of power,²⁰ we consider power simply as the ability to influence allocation of resources, engage players, and shape policy. Because policy decisions are made at the local, state and national levels in both the public and private sectors, we are interested in the dynamic interplay between evidence and power within and across these domains.

Among the approaches that have examined the relationship between evidence and power in the literature in recent years are participatory action research,²¹ media advocacy,²² legal advocacy,²³ knowledge synthesis,²⁴ policy analysis and advocacy,^25,26 and community-based participatory research.^10–12 These approaches are usefully defined and critiqued elsewhere.^19,27,28

In this commentary, we highlight ways that power dynamics and structures are woven throughout participatory policy efforts to improve health. Our critique of CBPR and similar approaches takes the concept’s primary elements—community, participation, and research—as points of departure. We ask:

1. What are the benefits and limits of the scale of community as a focus of policy change and when are other scales more appropriate venues for policy work?

2. Who are the appropriate participants in policy change initiatives? What are appropriate roles for various players in the policy change process? What are the procedures that allow meaningful participation by necessary constituencies?

3. What is the role of research (or scientific evidence) in policy change? In what circumstances does evidence drive policy change and when are other levers of change needed?

By exploring the role of political power in bringing about policy change, we seek to develop a more useful understanding of how power shapes the evidence researchers uncover, the communities in which policy change takes place, and the participation of various constituencies in the processes of CBPR. To answer these questions, we propose and discuss four hypotheses on the characteristics of effective partnerships for policy change, drawn from our own policy work^29–31 and our interpretation of the recent literature on CBPR.^10–15 In the box on the next page, we illustrate these hypotheses with selected vignettes from policy change case studies.

Examples of Participatory Policy Change Work Supporting Hypotheses

Hypothesis	Example
1. Effective partnerships for policy change work on multiple levels and scales.	Case 1: Tribal Efforts Against Lead (TEAL) in the Tar Creek region of Ottawa County, OK, sought to address high blood lead levels and related problems among Native American children in the area. One of TEAL’s policy goals was to implement mandatory blood lead screening and reporting, which they knew would require both persuasive advocacy and strong community buy-in. They worked at the tribal, county, state, and federal levels to achieve this and other goals. Clan Mothers and Fathers who were part of the coalition visited each tribal government in the area, “to urge passage of resolutions supporting mandatory screening. They then used these resolutions to persuade the Indian Health Service (IHS) to fully implement IHS screening and reporting”16(p33). TEAL partners also shared data with and served as members of the Governor’s Task Force on Tar Creek, and worked with the Ottawa County Health Department and IHS to implement the mandatory screening policy.16
2. Effective partnerships for policy change recognize that political power plays a key role in policy change.	Case 2: The Southern California Environmental Justice Collaborative worked for years to change a rule that allowed toxic air emissions along the southern California coast at levels that were 100 times the level recommended by the Clean Air Act. They tracked this closely and when an opportunity to renegotiate the rule arose, they mobilized their partners, community members, and policymakers in part by helping to outline “the powerful institutional forces driving the outcomes of prior decision-making.”16(p27) As a result, the Collaborative was successful in lowering the allowable cancer risk from pollution in that area from 100 cases per million to 25 cases per million.16
3. Effective partnerships for policy change recognize that power influences what is considered acceptable evidence, what evidence is available, and what role evidence will play in driving policy.	Case 3: The Concerned Citizens of Tillery in North Carolina sought to ameliorate the public health effects of large-scale hog production in their region, and partnered with researchers to collect spatial and resident data on the location and nature of these health impacts. However, when the partnership released the data publicly, the state’s Pork Council challenged the findings, insisting on being granted access to confidential data, a demand that cost the partnership time and funds to negotiate. By releasing their findings to local and national media, the partnership was able to use another source of power, media coverage, to keep their evidence in the policy debates.16
4. Effective partnerships for policy change develop processes that reflect the differing roles of power and evidence.	Case 4: The Literacy for Environmental Justice Partnership (LEJ) in San Francisco, CA, demonstrates how processes that recognize the need for capacity building and colearning can move coalitions toward successful policy change. LEJ’s work ultimately led to the adoption of a voluntary municipal policy encouraging stores selling alcohol, tobacco, and processed foods to decrease the availability of these goods and increase access to healthy foods, and a state-level bill to establish a similar corner store conversion program. To achieve these goals, LEJ youths were trained by health department staff to collect data from their neighbors and in stores, and to use Geographic Information Systems mapping software to analyze store locations against neighborhood demographics. The youth partners also learned how to assess economic feasibility from a local business school student, and they collaborated with their neighborhood’s city-level elected official to learn about similar policies in other cities.16

EFFECTIVE PARTNERSHIPS FOR POLICY CHANGE

We propose the following four hypotheses on the characteristics of effective partnerships for policy change.

Power Dynamics Work on Multiple Levels and Scales

We hypothesize that partnerships need to work at multiple levels and scales to change policy because the power dynamics and forms of power that shape population health work at multiple levels and scales. Although CBPR proponents acknowledge the role of these other levels, they continue to privilege the community level, in part from a correct understanding of the role of neighborhoods and communities in shaping health and health equity.^32,33

However, the risk of focusing on community-level determinants of health is that community living conditions are often the result of factors–like municipal, regional, national and global policies and politics–that operate at higher levels of organization. Many communities, especially low income ones, lack the political power to bring about change at these higher levels. By mobilizing communities to tackle unhealthy influences that are readily visible and accessible at the community level, CBPR may encourage participants to fall into what some geographers and planners call the “local trap”, a tendency to assume that a particular scale—in this case, the community—is inherently more desirable than others, even if other (higher) levels are more influential determinants of health or more effective starting points for policy change.³⁴

Political Power Plays a Key Role

Another feature of effective participatory policy partnerships may be the relationships they cultivate with those who have political power. These relationships, some collaborative and others adversarial, may take time and effort to cultivate, and can sometimes make for surprising pairings, as case studies of CBPR policy work have demonstrated.^12,16 What seems key for partners to acknowledge is that assembling a coalition that has the political clout to win passage of its policy proposals is an explicit goal. These politically savvy partners may sway policymakers and other key stakeholders at critical junctures. They also play an important role in helping to narrate and interpret policy processes that may otherwise appear opaque and convoluted to coalition members with less policy experience. These forms of information can be critical in timing coalition activities. For advocacy campaigns that choose adversarial political strategies, mobilizing large and diverse constituencies that have limited power to challenge small but powerful special interests can sometimes lead to success (see the box on the next page).

Those with political power include not only those in government but also business and corporate leaders. Increasingly, decisions that influence health, lifestyle, living conditions and health inequalities are made not in legislatures or courts but rather in corporate board rooms, advertising agencies and lobbying firms.³⁵ In part because of public health’s origins in the public sector, public health professionals have focused more attention on the government’s role in policy, thus excluding from their purview important private sector influences on policy. Some CBPR partnerships have taken on corporate power,^36,37 but here too the community scale may not offer maximum opportunities for change. To better equip participatory policy coalitions in the face of expanded corporate power,³⁸ it may be necessary to develop stakeholder and power analysis processes that identify both the strengths and vulnerabilities of powerful players who hold opposing interests. In these situations, strategic political analysis and action may be more decisive than rigorous scientific evidence in achieving policy goals.

Power Influences the Role of Evidence

This hypothesis posits that political power and scientific evidence are not separate domains but are inextricably linked. Sometimes groups in power will insist that advocates for change must meet a standard of evidence that is difficult to achieve and higher than usually demanded in policy circles. The origin of this demand may be not a commitment to rigorous science but an effort to derail policy change. Acknowledging the reciprocal relationships between power and evidence increases the likelihood of finding the proper balance between the 2 in any given campaign for policy change, as illustrated in case 3 in the box on the next page.

In some cases partnerships might need to wield power to gain data, in others to use evidence to convince new players to join the coalition. For example, the environmental movement has helped to win legislation that forced companies to disclose the pollutants they release. This in turn provided community researchers with the evidence they needed to organize coalitions of community groups and labor unions to force individual facilities to reduce the pollutants they discharge.³⁹

Power and Evidence Have Differing Roles

Policy partnerships led by academic researchers often unintentionally create processes that value evidence more highly than power. A final hypothesis is that once the complex relationships between power and evidence are recognized, partnerships should create processes that enable the effective use of each of these resources to achieve policy goals. These include processes that:

1. bring into the partnership constituencies who can help to map the power and evidence domains and operate effectively in each (e.g., community residents, health and labor activists, sympathetic policymakers, researchers, and journalists),

2. promote colearning where all participants learn from each other the languages and skills of power and evidence and the ground rules for operating in each domain, and

3. develop the capacity to transcend scales, levels and sectors as windows of opportunity for policy change open or obstacles emerge.

A strategy for assisting policy partnerships to create these processes is capacity-building, a form of assistance that can reduce both the internal power differentials that often divide community leaders and members from academic researchers and policy decision-makers and the external differences between the partnership as a whole and the political interests that oppose its policy goals.^11,40 Internal conflicts may be resolved by specifying, discussing, and acknowledging the unique contributions that community and academic partners each bring to the effective deployment of evidence and power. In addition, partnerships with more experience in bringing about policy change may be able to share the lessons they have accumulated to assist less experienced groups to avoid common pitfalls, a form of organizational social support.⁴¹

CONCLUSIONS

Reflecting on how the mission of public health has shifted over time, Fairchild et al. urge public health workers to “integrate power and agency into our models” to “confront political and economic power in the name of the public’s health.”^42(p61) As we suggest here, by recognizing the appropriate roles of power and evidence, health professionals and researchers can use the emerging body of knowledge on CBPR to build more lasting partnerships with community members and work more effectively across the policy landscape. In some cases, this will require alliances with pro-health private interests; in others, partnerships will oppose those that seek to profit at the expense of public health.

The work of public health is inherently political^43,44; thus, we argue that all public health professionals and students, especially those who may encounter participatory policy change efforts in their professional practice, should be offered rigorous training in navigating the tensions between politics and science and in the tools of advocacy and participation. The idea that public health practitioners can be both scientists and activists is not new, as the work of Virchow,⁴⁵ Hamilton,⁴⁶ and others suggests. To build on these traditions, participatory researchers and advocates for healthier public policies need to develop the skills, theories and methodologies that allow them to function as effectively in the world of power as in the world of evidence. By doing so, they will expand their opportunities to make meaningful contributions to advancing population health and health equality.