Panel Discussion: Academic Incentives and Capacity Building for CBPR

Eric Bass, M.D., M.P.H., Journal of General Internal Medicine and Johns Hopkins School of Medicine
David Korn, M.D., Association of American Medical Colleges
Tony Whitehead, Ph.D., University of Maryland

Dr. Eric Bass, editor of the Journal of General Internal Medicine, shared from his perspective as a general internist in a traditional academic medical center. CBPR and other types of "non-traditional" research approaches face the same barriers—i.e., the perception that the science is "soft" and difficulties in obtaining funding and publication. He focused on specific actions that could facilitate funding and publishing and bring attention to CBPR successes.

Overcoming Funding Barriers

To overcome funding barriers, Dr. Bass recommended that the field:

• Develop, maintain, and publicize a directory of agencies that are willing to fund CBPR.
• Convene workshops in grant writing for researchers who use the CBPR approach.
• Identify opportunities to direct institutional resources to CBPR (e.g., advocate for community health indicators in the academic plan of your institution; support the career development of CBPR investigators; recruit and train people interested in CBPR taking advantage of existing fellowships).
• Identify opportunities to influence policymakers to direct money to CBPR.

Overcoming Publication Barriers

To overcome publication barriers, Dr. Bass recommended that the field:

• Identify clinical and public health journals interested in publishing CBPR, especially qualitative research.
• Take advantage of opportunities for CBPR experts to serve on journal editorial boards.
• Convene workshops to help researchers write better papers with community partners and to inform them of the different types of scholarly articles.
• Submit original research to the special issue of the Journal of General Internal Medicine that will emerge from this conference.
• Develop and disseminate better methods of measuring CBPR's impact.

He emphasized that actions that enhance the ability to obtain funding and publish will help faculty who conduct CBPR gain promotion and tenure. He encouraged participants to expand CBPR networks to share information and facilitate dissemination.

A Perspective from Academic Medical Centers

Dr. David Korn shared the perspective of medical schools and centers. His goal was to make observations that might assist strategy and planning efforts. Participants should keep in mind that academic medical centers represent a diverse set of social institutions, so it is not useful to make generalizations about "medical schools" as if they were all similar. Various medical schools have very different missions, prestige levels, histories, and relationships with communities. Some institutions have a mission to advance local/regional concerns, while others see the world as their community.

There are some common themes, however. All institutions of higher education expect faculty to demonstrate excellence in some combination of teaching and research, and some require service to the community. Dr. Korn emphasized that in the academic setting, evaluation is paramount. The focus of academic evaluation is the individual, so the system has difficulty assessing achievement for individuals involved in interdisciplinary research. This problem has to be solved before CBPR and other types of interdisciplinary research can fully establish themselves in academic institutions. Fortunately, there is increasing recognition that most scientific problems are so complex that they require interdisciplinary research. Unfortunately, a well-established value hierarchy exists in academic institutions. That is, academic institutions place higher value on some types of research and journals. Most research universities rely heavily on external funding as their fluid pool of resources since institutional resources are limited and allocated for specific purposes. Therefore, investigators must persuade institutional leaders to allocate resources to their research program or win external funding from an organization that has integrity and rigorous selection criteria. He thought it would be productive for CBPR to train investigators to conduct rigorous research and champion the work. A focus on patient empowerment as part of CBPR might be of interest to academic medical centers.

A Perspective from Anthropology

As an anthropologist, Dr. Tony Whitehead shared from the cultural framework perspective. When there is tension between two communities, it is necessary to address the unconscious paradigms that individuals carry into situations. All cultures, including academic disciplines, socialize and influence the views and values of their members. Academics are trained to view issues with a high degree of precision and reduce phenomena to a small set of variables. In contrast, communities emphasize context, process, appropriateness, and relevancy. Science is a language and tends to be the language of those in power. Community members can see that researchers have been socialized to see themselves as more important than others so tension results. Community-researcher relations are complicated when the community involved is diverse and complex. In developing such relationships, cultural translation is necessary for the communities to have a better understanding of each other.

Community partners can provide a translation of the culture/community, yet researchers have to be open to the emergent characteristics of cultures and relationships. Overall, understanding the community enhances the meaningfulness of the research and positive relationships with the community facilitates the research process. Often the community struggles with the same questions as researchers. He encouraged those involved with CBPR to develop a "project culture" and establish common objectives and goals from the beginning. Relationship monitoring and process and formative evaluation can help researchers develop a project culture.

Open Discussion

Participants discussed academic incentives and capacity building. They focused on academic culture, which values rigorous research methods, analysis and reduction of phenomena to a small set of variables, and the language of science. In contrast, the community perspective values context, process, appropriateness and relevancy. Because of the unbalanced power dynamic and differing cultures and languages, tension results when the two cultures meet. Academics who want to work with the community and understand the culture sometimes feel that they are "caught between two worlds, but part of neither." These investigators, as well as others from nontraditional research approaches, perceive a disadvantage in terms of how their institutions assess their work. Community members focused on the need for academic institutions, which have been traditionally isolated, to reach out to communities and build external relationships. Dr. Korn appreciated the issues identified by participants, but he advocated action rather than discussion of differences and perceptions held by one group about another. He encouraged participants to take specific steps that would advance the necessary changes that they have identified.

Need to Increase the Number of Faculty Members Conducting CBPR

Although CBPR is not the only valid research approach and is not suitable for all researchers, the CBPR approach needs more investigators.

Benchtop science and CBPR can be connected. Researchers should be creative and open minded about this possibility.

Funding Initiatives

Requests for Applications/Proposals should ask for projects that join benchtop science and CBPR, thereby targeting and facilitating collaboration.

Federal funding allocation and research agenda should be accountable to taxpayers.

Since the amount of commercial research and development funding is three times the Federal research budget, investigators using the CBPR approach should apply for private sector funds.

Academic-community Relationship

CBPR projects should include CBOs in their budgets.

Once a relationship with an academic institution is established, the community should leverage university resources (e.g., priority tuition reimbursement for students who are community partners and positions that are half time community and half time academic.

Students could pressure the university administration to improve the CBPR curriculum.

To foster a good academic-community relationship, partners need to discuss and agree upon intellectual property rights from the beginning. Universities have not typically dealt with intellectual property issues in the context of collaboration, but there is a great need for them to do so.

The Value of CBPR

CBPR offers a fresh approach to engaging disadvantaged populations in clinical research.

The methods for developing evidence-based guidelines could be applied to synthesizing evidence on the value of CBPR. Scholars should compile evidence on interventions that are only effective when implemented at the community level.

In communicating the value of CBPR, proponents need to balance the emphasis on process and products.

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Funding and Funding Priorities for CBPR

Angela Glover Blackwell, J.D., PolicyLink

Ms. Angela Glover Blackwell commented that she learned a great deal on the first day of the conference. She has used CBPR in her own work, although she did not use this term. She noted that others had pointed out the funding challenges, so she would try to elaborate on the deeper issues of CBPR funding.

An Example of Community-Based Work

She described her experience with several community-based projects. In one situation, the city of Oakland, CA, supported the Urban Strategies Council to bring various organizations together to prepare an application for empowerment zone funding. The team enacted the principles of CBPR and developed an excellent application. However, the project was not funded. She stressed that the organizations continued to work together for community change. The city demonstrated deep understanding of community needs by trusting community organizations with the application rather than automatically delegating it to an academic institution.

Community-Building Participatory Research

Ms. Blackwell expressed a strong preference for community-building participatory research because it advances solutions that improve quality of life for individuals and communities. She defined community-building participatory research as:

• Continuous, self-renewing efforts by residents and professionals to engage in collective actions aimed at problem solving initiatives to make life in the community better. This work improves lives and equity and creates new relationships, assets, standards, and expectations of life in the community.

The community-building perspective understands that historical racism has put individuals at an extreme disadvantage. This perspective also understands that racism continues every day because it permeates institutions regardless of leadership.

Recommendations for Funding Organizations

Funding for community-building participatory research must focus on achieving equitable outcomes and examining the process to reverse power dynamics. Funders must understand the following:

• The goal of community-building.
• The process of community-building.
• Power is concentrated in organizations and institutions.
• Communities need flexible mechanisms to solve complex problems.
• Evaluation of community-building is critical and many struggle with this issue.
• Funding/incentives must be connected to measures of authentic, deserving work.

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Panel Discussion: Funding and Funding Priorities for CBPR

Carolyn Clancy, M.D., Agency for Healthcare Research and Quality
Iris Farabee-Lewis, D.D., Centennial Caroline Street United Methodist Church
Raynard Kington, M.D., Ph.D., Office of Behavioral and Social Sciences Research, National Institutes of Health
Henrie Treadwell, Ph.D., W.K. Kellogg Foundation

Community Members Emphasize Infrastructure Development Needs

Dr. Iris Farabee-Lewis stressed that communities require financial support to develop infrastructure. They need technical assistance to sustain research projects. Funders could support the development of long-term relationships among diverse groups. Dr. Farabee-Lewis emphasized that there must be followup programs/interventions to address community problems identified by research. The community would like to see funding initiatives to train their own people to do research. Finally, communities deserve access to data collected by CBPR projects.

Increasing Acceptance of CBPR Among Funders

Dr. Raynard Kington commented that he is optimistic about CBPR's future based on recent indications and events. The National Academy of Sciences/Institute of Medicine released several reports relating to this type of research. Because such reports have tremendous influence on the scientific process, there is good reason to expect that funders will respond. These reports identified research questions that can only be addressed through community-based research. The Federal initiative to eliminate health disparities elevated the profile of these research questions. Therefore, research topics that are best addressed by the CBPR are now at the forefront.

There is also increasing acceptance that the interdisciplinary approach is the only effective way to address complex problems. Although it can be difficult to effectively implement interdisciplinary teams, biomedicine provides a successful model. There is also an increasing interest in the social determinants of health, a topic very suitable for CBPR. With increasing interest in social determinants of health and health disparities, investigators need to make explicit to funders how CBPR will solve important health problems. Dr. Kington noted that there are multiple valid definitions of community. He suggested that CBPR investigators adopt the broadest definition possible to engage the maximum number of people.

Funders Require Education on CBPR

Dr. Kington spoke of the need to improve the grant review process. CBPR is not well understood by reviewers. Therefore, the field must define excellent CBPR and create specific criteria that reviewers can use in their assessment of grants. To educate funders and scientists about CBPR, members of the community should volunteer to be on institutional review boards or community advisory committees (for a university or NIH Institutes).

Dr. Carolyn Clancy commented on the current high interest in CBPR as a means of enrolling participants in large clinical trials. Although this interest is pragmatic, individuals invested in CBPR could build on this momentum to advance CBPR as a research model. She encouraged participants to define critical CBPR elements for funders. Funders need specific information on the following questions:

• What should funders expect from CBPR?
• How should funders evaluate CBPR?
• What are the characteristics of excellent CBPR?
• What are the predictors of CBPR success?
• What resource-sharing formula is most appropriate for CBPR partners?

Funders have resources that can act as a catalyst, but are challenged to build capacity in communities with multiple needs and few assets. They struggle with the need to balance unique insights into one community and knowledge that can be transferred to other communities. Funders need benchmarks for CBPR success and guidance as to suggestions to researchers when these benchmarks are not achieved. CBPR must demonstrate its value through clear metrics and clarify the types of research questions for which CBPR has the most value. The field must develop methods, especially for interaction assessment.

Dr. Clancy commented that community members might improve the grant review process by suggesting panelists and advising funders about the characteristics of a balanced CBPR portfolio.

Challenges

Dr. Henrie Treadwell noted the enormous challenges faced by those attempting to eliminate health and other disparities. Given the current policy and resource allocation, health status is declining. Change is clearly needed, and she hoped that the victims of inequities would not be blamed.

She stressed that taxpayer communities should have a voice in determining the Federal research agenda. Communities must discuss and clearly identify a worthwhile research agenda. Effective CBPR includes a policy component and community organization to inform policy and mobilize public funds.

The W.K. Kellogg Foundation supports pre- and post-doctoral training programs to increase the pool of CBPR investigators, especially those from minority and disadvantaged communities.

Open Discussion

Participants discussed funding and funding priorities for CBPR. Community members identified specific needs related to developing infrastructure and sustaining research projects. They stressed that it is not enough to identify problems in the community and conduct research studies examining such problems. Communities require followup programs to achieve social gains and improve overall health. Participants expressed a desire to be a part of the solution for identified problems, and they committed to being part of the solution by presenting various proposals to facilitate community advances.

Dealing with Finite Resources

Participants acknowledged limited funding for all research and discussed how to address this problem. Ms. Blackwell suggested that CBPR focus on influencing policy to obtain limited Federal resources. Community members could convince policymakers to address issues of interest to CBPR. Individuals engaged in CBPR should work with the media and political scientists, as this would help mobilize public opinion and reach policymakers. To engage the media and policymakers on an issue, CBPR investigators should provide rich, qualitative data (i.e., stories that put a "human face" on CBPR and show the positive effects of this approach). CBPR should also stress that the approach yields rich data and knowledge that can facilitate quality of life improvement. Policymakers tend to focus on practical outcomes, which CBPR has the potential to provide. It is critical for CBPR to be explicit about how evidence could be translated into policies and to indicate the worthiest research topics.

Dr. Kington suggested that CBPR investigators argue that the approach increases understanding of basic health processes and could be extended to all disadvantaged populations. He thought funders would respond favorably to the broadest possible impact of CBPR.

Community Health Indicators

Most community health indicators are deficit- and disease-oriented. Community members prefer to emphasize their assets and strengths. CBPR should define the attribute of a healthy community.

The Funding Process

The scientific paradigm dominates the grant review process. Reviewers require training on the CBPR approach. Funders should develop truly interdisciplinary review panels.

The CBPR field must find a way to reach funding organizations that have no interest in this research model.

Investigators should identify agencies whose interests are aligned with CBPR and support efforts by these organizations to enhance and better allocate resources.

Sustaining Gains in the Community

Communities must organize to sustain gains in equity.

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