Community Incentives and Capacity Building for CBPR: Successfully Promoting Community Interests through Research

Rebeca Ramos, M.A., M.P.H., U.S.-Mexico Border Health Association

The Importance of the Community as an Equal Partner

Ms. Ramos remarked that community-based organizations (CBOs) want to ensure that investigators transfer knowledge generated by CBPR back to the community and integrate it into practical programs as directly and immediately as possible. CBPR can be a powerful approach to advance practice, support CBO sustainability, and build community capacity at every level. However, the power of CBPR depends on the extent to which the community is intimately integrated in the planning, implementation and utilization of the research. That is, the community must be an equal partner at all stages of CBPR. One must operate from the premise that the community and CBOs implement strategies. Therefore, those involved in CBPR must consider how research coincides with the interests of the community.

Barriers to Community Participation

Ms. Ramos identified the following impediments to the full participation of the CBO:

• The community does not own or have rights to data.
• The community perspective was secondary to scientific methods and theories.
• Antagonism between academics and seasoned community-organizing practitioners.
• Inter-organizational competition for limited resources.
• Lack of consensus on goals.
• Inadequate resources to advance identified goals.
• An overemphasis on high-level policymakers, rather than mid-level implementers.

Conditions for Community Capacity Building

Ms. Ramos identified the following necessary conditions for successful community capacity building:

• Participation must extend beyond the CBO executive level.
• Traditional and non-technology transfer mechanisms to enhance learning of community members.
• Augmentation of the response to specific community needs.
• Respecting, valuing, and working with all groups in the community.
• Expansion of data collection possibilities and inclusion of new methods and settings.

Overcoming Barriers

She listed the following specific mechanisms that facilitate the full participation of CBOs:

• The ability of the CBO to choose research partners (this is a very powerful motivator).
• Establishing ground rules and formal contracts with clear descriptions of roles and expectations.
• Establishing a method for decision-making.
• Building a climate of mutual trust and respect and recognizing the different skills of team members.

She emphasized that the research-to-action approach involves close collaboration of researchers with the community and focuses on gaining and sustaining positive outcomes in the community. This approach strengthens the community with the intervention design, implementation, evaluation, and resource acquisition. In the research-to-action approach, community-based workers are offered professional development opportunities as part of the project. Both the academic and the community at large receive the project findings, and the team acknowledges the contributions of all stakeholders. The team applies the principles of parity, inclusion, and representation in project planning and implementation to achieve full participation by clients, academics, casework managers, and clinicians. The team shares data collection responsibilities, which facilitates understanding of the community perspective. Stakeholders validate findings and indicate whether the project recommendations would actually work in the community.

Two Examples of Initiatives with Full Community Participation

Ms. Ramos provided two examples of community-driven initiatives with full community participation. Taking the research-to action approach, the initiatives resulted in the transfer of programmatic innovations (programs, interventions, services, and practices) to minority communities.

• The first example, Programa Companeros, illustrates capacity building within a CBO through research. This is a CBO-based program in Ciudad Juarez on the United States-Mexico border, near El Paso, TX. Companeros has collaborated with Federal, State, and academic institutions for over 15 years to gain knowledge and skills to better deliver services to the community. The CBO has gained knowledge and improved practice by the successive implementation of research projects. Programa Companeros exhibited characteristics that facilitated research-to-action. The CBO selected researchers interested in drug use and HIV prevention so that those involved had a desire to work as part of a team. Researchers committed to working with the CBO on the project for as long as possible. The research process provided technical assistance to improve existing interventions and professional development opportunities for the CBO staff. These critical facilitators of community participation were negotiated at the beginning of the project.

• The second example, the AIDS Behavioral and Epidemiological Study Training Program (AIDS BEST-Program), used a community-oriented process for building capacity among community-based researchers. The AIDS BEST-Program was a collaboration of the University of New Mexico, University of Texas School of Public Health, and United States-Mexico Border Health Association funded by the World AIDS Foundation and the John E. Fogarty International Center for Advanced Study in the Health Sciences. Its primary goal was to involve minority community-based researchers in the conduct of prevention studies in their communities. AIDS BEST had an epidemiological research training track focused on the principles of modern epidemiology, study design considerations, data management, data analysis, and program quality assurance. The behavioral research training track focused on the principles of individual and community behavioral theories in HIV prevention, and the design and evaluation of behavioral intervention research projects.

  The AIDS BEST project emphasized capacity building goals. It involved community-based researchers to conduct effective community prevention studies. The program supported community-based researchers to implement projects in their own localities independently or in cooperation with academic institutions. Research projects often do not transfer adequate resources to support the community as it collects data, even though data collection is often a heavy burden to communities. However, the AIDS BEST project augmented local resources to carry out effective and creative studies that responded to community need. Ms. Ramos emphasized that augmenting community resources is a critical aspect of CBPR.

Capacity-building activities (CBAs) consisted of problem-based learning tutorials, workshops, and a followup consultation by faculty via telephone and E-mail. Working in small groups with a faculty mentor, trainees were presented with a learning challenge and sought a solution to that problem in these small groups. Other sessions consisted of faculty presentations followed by active involvement by the trainees in exploring a topic of relevance to their communities. CBAs were successful because the training program provided a foundation to address issues that were relevant to particular communities. The activities made new and cost-effective tools available to meet the challenges faced by local-level researchers. There are now a few community-friendly outlets for the results of capacity building activities and community-based projects.

Reasons Underlying Full Community Participation

Ms. Ramos emphasized that these initiatives were successful for the following reasons:

• The community had full ownership and participation in the research process.
• There were mechanisms and systems (policies, staff development, and service delivery design) in place to ensure participation.
• Stakeholders had a specified role in the design, execution, and utilization of research findings. CBOs mandated the role of stakeholders.
• These projects involved an explicit and previously negotiated transfer of technology, a process of learning and adapting the different conceptualizations of research, and research outcomes (data) linked to the sustainability of CBO programs.
• There was a consensus that the community collaboration was as important as the findings.

Summary and Conclusion

CBPR builds capacity for all partners. To build capacity, one must identify a genuine concern across multiple communities, select partners working in nonacademic institutions, and provide training to researchers on rules for working with communities. Because capacity building is a process rather than an event, there must be incentives for all participants throughout the process. From the community perspective, incentives for participation in the research-to-action-approach include access to state-of-the-art interventions, the possibility of obtaining funding or employing stakeholders through research grants, and enhancing organizational skills and status through work with research institutions.

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Panel Discussion: Community Incentives and Capacity Building for CBPR

Barbara Major, St. Thomas Health Services
Mary Northridge, Ph.D., M.P.H., American Journal of Public Health and Harlem Health Promotion Center
Clifton Poodrey, Ph.D., National Institute of General Medical Sciences, National Institutes of Health

Ms. Barbara Major commented that CBOs have to reconsider their mission. CBOs tend to become very involved in service provision, but they should also work for change in institutions and a health care system that was not designed to serve communities of color. In her community, race is an independent health risk, and people face systemic, institutional racism. Health care research and evaluation is not race neutral. She wondered if participants meant building capacity for service provision or institutional change when they spoke of "building capacity for communities." She stressed the need for communities to hold CBOs accountable for advancing institutional change.

Dr. Clifton Poodrey remarked that like many participants, he feels connected to at least two communities. He wondered what people mean when they use the term "community." He challenged participants to reach out to a broad range of communities with vastly different interests, awareness levels, problems, and issues. It would be especially challenging to reach communities that are not looking for information. He focused participants on training individuals to conduct CBPR and stressed the need to find alternative, cost-effective training models. He mentioned the need to examine NIH review criteria for applications submitted by CBOs, the impact of not getting funded on CBOs, and characteristics of CBOs that obtain funding. He thought it would be a challenge to balance provision of long-term funding and offering opportunities to many researchers.

Dr. Mary Northridge encouraged participants to contribute to CBPR from their own expertise and experiences of effective practices. She stressed the importance of adding committed experts to a CBPR team. Often, one can train committed individuals to have the necessary skills for CBPR. She also encouraged participants to use a variety of existing mechanisms for dissemination.

Open Discussion

Participants discussed community issues and capacity building. They stressed the overall cultural context of racism and discrimination that exists in institutions and systems. Until this context shifts toward an equitable state, participants stated that it will be challenging to create CBPR that reflects balanced power and a true partnership. Some community members remember inequitable relationships with researchers, which seemed to be established only for the benefit of the investigator or a large institution. They noted some progress, and these participants looked forward to better relationships with investigators and using research to bring positive changes to their communities. Participants from many communities emphasized capacity building—enhancing the economic and human resources present in communities so they can further develop their resources—as a key action that will promote greater equity. Participants called for those in positions of power to share that power and build long-term relationships and truly get to know the community. To community members, part of power sharing involves co-ownership of data from the community, publishing, and working with researchers to obtain funding from large institutions.

The Importance of True Power Sharing Among CBPR Partners

Participants stressed the importance of power sharing to eliminate racism and other forms of discrimination. Before they implement strategies to facilitate capacity building in a specific community, CBPR partners should have frank discussions about racism and power and the need for investigators to relinquish power. Researchers often rush to the outcome stage before they fully understand CBPR process. CBOs have to ensure that the CBPR process fulfills their needs. To build capacity, CBOs need people who serve as liaisons between the community and research environments.

A good model of power sharing between the community and academics exists—the Native American Research Centers on Health Initiative. Primary grant applicants are Tribal or Tribally-sanctioned communities, but secondary partners can also be research institutions. Grant applications are reviewed for scientific merit and relevance to the community. Other sponsors might find this different approach interesting or useful for building new models. For more information on this initiative, contact Dr. Spero Manson.

Training on systemic racism and the development of a culturally competent curriculum for clinicians have tremendous impact. It is critical to make changes in institutions that permit sustained improvements in racism and discrimination.

Funding for Capacity Building

Perhaps there should be three funding venues:

• Academic.
• Community-based.
• A mix of community and academic.

Communities struggle with obtaining funds through the complicated procedures in place at large institutions. They often perceive a cultural gap between their communities and these institutions. For example, institutions require applicants to explicitly define terms that community members understand intuitively (e.g., accountability and equity). Community representatives expressed a need for cultural translation so they can better understand how large institutions approach funding.

CBPR Products and Dissemination

Publishing by community partners is an essential adjunct to CBPR. Once community partners have published work, the relationship or dynamic with researchers and other partners changes. Individuals involved in CBPR should develop a process for authorship and convene a scientific writer's workshop to build capacity of community partners to publish. They need to recognize that submitting for publication involves understanding the language and culture of publishing. Community members have not been trained in this language and culture, but could learn.

The Importance of Knowing the Community

The relationship with the community is critical and determines the outcome of the work.

Even after one has worked with a community for many years, there is still a need to continually evaluate their needs. The community often enters a project with new interests and needs.

Individuals who work in both the academic and community settings are often not fully accepted in either environment, so they feel like outsiders in two communities. Both contexts have room for growth in terms of accepting these individuals and increasing their understanding of the other group.

Working with NIH

Researchers seek funding from NIH because of the high prestige and other advantages that NIH funding provides. However, grant reviewers with a purely academic background might not value research with community organizations as much as basic science.

Researchers seeking funding must recognize that funding agencies have agendas and try to find common ground to advance the project.

Participants perceived that the CBOs successful at obtaining NIH support might "speak the loudest." They were concerned that other groups with valuable contributions and good community representation do not attract attention and win funding. Dr. Poodry responded that NIH recognizes the need to hear from a variety of community voices. NIH convenes a series of focus and advisory groups to obtain good community representation. He acknowledged that it would be a challenge to establish targeted initiatives for CBPR at NIH.

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Academic Incentives and Capacity Building for CBPR

Two speakers summarized two different CBPR models. The models reflect experiences of researchers engaged in CBPR at three different types of academic institutions with wide CBPR experience—a small, private university, a large, public institution, and a private, research-focused institution. Dr. Phil Nyden emphasized that CBPR's main strength is that it produces knowledge for consumption rather than storage and has guaranteed impact. Mr. Toby Citrin focused on building academic capacity for the conduct of CBPR and indicated potential facilitators.

Incentives for Faculty Participation in Community-Based Participatory Research

Phil Nyden, Ph.D., Loyola University Chicago

Barriers to CBPR Participation from the Academic Perspective

Dr. Phil Nyden described some barriers to CBPR from the academic perspective. In the academic setting, the discipline defines research priorities. This is a barrier because university-based research focuses on furthering knowledge in the discipline rather than social change. Theoretical knowledge is favored over practical knowledge. As a result, applied research is not valued as highly as theoretical research and ideas tend to be kept within the academic setting.

The academic community views CBPR as biased because it involves "representatives" of the population to be studied in the research process, which raises potential bias in data collection. Academic researchers perceive that the data analysis might be manipulated to serve political ends because CBPR does not only involve unbiased, "outside" researchers. Academic researchers perceive CBPR as parochial because it is limited in scope and less powerful in its general application. Members of the academic community value "global" research and regional or national quantitative summary data, while CBPR offers highly-textured, local, and qualitative data.

Finally, tenure and promotion guidelines impede academic participation in CBPR. Tenure and promotion is not usually based on "demonstrated contributions to the improved quality of life in society"—a key principle of CBPR. Academic researchers often show indifference or even hostility to community engagement. A key aspect of this barrier is the emphasis that tenure and promotion committees place on publications and contributions to the field. Work with an impact on society does not tend to be valued as highly as contributions to the discipline.

Overcoming Barriers

Dr. Nyden stressed that academic researchers can break through these barriers by emphasizing CBPR's strengths. CBPR can help universities establish and foster interdisciplinary initiatives. In theory, academic institutions value interdisciplinary approaches and recognize that "cutting-edge" work brings different disciplines/perspectives together. Because social problems are holistic and complex, they require an interdisciplinary approach. He stressed that academic institutions are under considerable pressure to establish their relevance to general society. This has been called the "age of engagement" in higher education, and advocates of CBPR could take advantage of this climate to form partnerships with universities. Advocates of CBPR could also engage students seeking practical experience during the course of their training. Since service learning and community-engagement are now recognized aspects of academic mission statements, CBPR could fit into these goals. Increasingly, people recognize that universities are not the only setting that generates and communicates knowledge. Academic institutions are therefore seeking partners in the non-academic world. CBOs are increasingly sophisticated centers of knowledge and have much to offer academic partners.

Motivating Investigators to Participation in CBPR

In terms of motivating faculty at a personal level to engage in CBPR, one can argue that CBPR is "traditional research plus"—i.e., it is knowledge for consumption rather than storage and has a guaranteed impact. Individual researchers might respond positively to CBPR's team approach because it connects faculty, other researchers, and practitioners with similar interests. They might be persuaded by the common tendency of faculty and CBOs to question the status quo. Faculty members would certainly be motivated by the opportunities that CBPR provides for significant new research avenues, funding sources, and publication outlets. The interactive, passionate nature of CBPR and the way that CBPR energizes teaching might motivate some faculty to participate in this approach.

Facilitators of Academic Participation

Dr. Nyden commented that changing the hiring and tenure and promotion procedures might be a slow or difficult process. However, he was optimistic that the academic community could encourage faculty to conduct CBPR by reducing the discipline-bound control of faculty personnel policies. They might increase university-wide incentives to promote engaged scholarship by setting aside interdisciplinary positions with an emphasis on community engagement and favoring community-engaged faculty departmental hires. The academic community might create a national network of peers to judge CBPR faculty. Finally, academics could make service a primary, not residual, evaluation category for tenure and promotion.

Models for Academic Participation in CBPR

Dr. Nyden described Portland State University as a working model that rewards community-engaged teaching and research. This institution emphasizes that research is an activity and views scholarship as discovery, integration, interpretation, and application. Portland State defines service in a way that supports CBPR—i.e., service is faculty engagement that solves social problems, facilitates organizational development, improves existing practices/programs, or enriches the cultural life of the community.

The Loyola University of Chicago Center for Urban Research and Learning (CURL) follows the CPBR model. In this model, projects are seen as research with the community, not research on the community. The model recognizes the knowledge in the community and offers research opportunities to members who have traditionally been excluded. The community is a partner at all stages of research, from conceptualization to dissemination of results. CURL engages in team-based research and action projects involving faculty, graduate students, undergraduate students, and community organization leaders, staff, and members. All team members are supported by the university's endowment and engage in co-learning.

These collaborative centers could serve multiple functions including institutional advocacy for CBPR, coordination of CBPR efforts, and as a repository of information and resources. Collaborative centers could also serve as technical assistance centers for CBPR projects, organizers of collaborative research meetings for discussion of ongoing projects, and alternative socialization venues for faculty and graduate students.

Conclusion and Broad Recommendations

In conclusion, Dr. Nyden suggested that funders and government organizations might support and promote CBPR through specific funding for CBPR initiatives, encouraging CBPR in all funding contexts, funding comprehensive CBPR centers, and financially supporting grassroots-based national policy-making. Although gains have been made in CBPR, substantial work remains.

Capacity Building for CBPR

Toby Citrin, J.D., and Lee R. Bone, M.P.H.

Mr. Toby Citrin acknowledged that his presentation was based on his experience with the Community Health Scholars Program at the University of Michigan (www.sph.umich.edu/chsp). He also recognized his collaborator, Ms. Lee Bone.

Definition of Academic Capacity for CBPR

Mr. Citrin described some reasons why academic institutions should support CBPR. CBPR furthers the ultimate missions of both the institution and schools of public health, strengthens research and teaching, relates research to community needs, strengthens the impact on community, and improves community support for the institutions. To support CBPR, academic institutions require faculty with a set of CBPR competencies. These faculty members understand the values and mission of community-based pubic health, the social and economic determinants of health, and have the knowledge and skills to apply CBPR principles. They especially understand that community-based public health is best practiced in a partnership mode. Faculty members with CBPR competencies are able to transfer these skills to the community and other scholars and are able to work effectively in and with diverse communities. A key characteristic of these individuals is that they enhance the capacity of the community to conduct CBPR. Faculty members who are successful at obtaining funding for CBPR must inform funders of the importance and relevance of this research model. Faculty members with CBPR competencies also understand the policy implications of CBPR and work with communities to translate CBPR into policy to sustain their work. These individuals balance academic tasks and CBPR work and are familiar with community-based teaching and learning approaches. They write grants that express CBPR principles and negotiate across community-academic groups.

An academic institution with CBPR capacity must have both academic and community mentors/advisors to coach students at various levels. CBPR mentors understand and have experience with CBPR, act as role models of academic or community success, and advocate on behalf of scholars conducting CBPR. Mentors advise on academic professional and career development and act as role models of success at combining community competency, CBPR and successful academic career development. Academic mentors advise students on the academic institution's culture, writing for publication and presentation, and techniques of community-service learning. Community mentors offer expertise in community leadership and the community's perspective on and prioritization of health issues and other challenges to community well-being. They advise scholars on community assets related to addressing health issues of interest, provide the community's insights on the culture of the community organization and the population it serves. Institutional capacity also includes having strong CBO partners with experience conducting CBPR, willingness to work with academics, potential CBPR projects, and leaders who can serve as mentors.

Barriers

Academic institutions must overcome barriers to enhance their capacity to conduct CBPR. One barrier is the extra time and expense needed to build trust and conduct CBPR. CBPR often involves travel and communication issues. The CBPR model is impeded by a lack of performance measures and the lack of credibility for research methods among some funders. Mr. Citrin emphasized the need to develop measures to hold organizations accountable and to distinguish credible and non-credible CPBR. Individuals conducting CPBR also have to face concerns about exploitation among some CBOs and confusion about terminology.

Solutions

Mr. Citrin described factors that facilitate academic capacity building for CBPR. Developing institutional capacity results in the ability to further enhance institutional capacity (e.g., those with a track record of success in CBPR have a greater chance of obtaining more resources to further CBPR work). Funding and institutional administration support for CBPR facilitates capacity building. Developing a support network within the institution and across other institutions enhances capacity. He stressed the importance of developing long-term community-academic partnerships because they strengthen research and teaching. Such relationships cannot be dependent on time-limited, individual grants. Institutions with support from their recruiting/admissions offices (i.e., those who mention CBPR opportunities to potential students and staff) can build capacity by attracting talented individuals. Postdoctoral training programs promote training and career development among scholars with an interest in CBPR. Finally, institutions that have strong relationships with national organizations that promote CBPR (e.g., the Loka Institute and the Community-Based Public Health Caucus) build capacity by sharing expertise and disseminating CBPR principles and methods.

Two Case Studies

Mr. Citrin described two case studies that illustrate the development of high capacity for the CBPR model. The University of Michigan School of Public Health (UM-SPH) used the principles of community organizing to mobilize efforts, facilitate projects, overcome barriers, and provide mentorship and encouragement in support of CBPR. UM-SPH built infrastructure that facilitates CBPR. For example, they created a staff position for a liaison to match academic and community partners based on research interest and established a CBPR resource room to support students working on these projects. UM-SPH developed long-term partnerships with multiple funding sources and established academic training programs from the masters to junior faculty levels.

The Johns Hopkins University Bloomberg School of Public Health is another example of an institution that built CBPR capacity. Key leaders, the president and governing board, were committed to community-based public health. They integrated this commitment into the University's strategic plan through the Urban Health Initiative. The Bloomberg School plans to create a concentration in CBPR and offer courses in CBPR competencies, thus integrating this research model into educational programs. A consortium of faculty members that interact and share information, advocates, and promotes CBPR across the public health school. The university offers incentives to support CBPR including seed funding and infrastructure to help faculty obtain external funding for CBPR projects.

Although these and other institutions have developed capacity for CBPR, many challenges remain. The field must develop a clear description of CBPR methods and establish a base of evidence demonstrating the impact of CBPR on institutions, CBOs, scholars, policy-making, and community health status. Mr. Citrin suggested that the ultimate goal for CBPR would be to strive for "excellence in scholarship through engagement." To achieve this goal, CBPR might fit into several existing frameworks including the "Boyer Model of Higher Education," the "Engaged Institution," and "Demonstrating Excellence in Academic Public Health Practice" (a document from the Practice Coordinators of Schools of Public Health). He stressed that CBPR is a promising model, but that it is not suited for all researchers. Such investigators might find a better fit with other valid research models.

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