Participatory action research: considerations for ethical review

A framework for building research partnerships with first nations communities

Solutions to complex health and environmental issues experienced by First Nations communities in Canada require the adoption of collaborative modes of research. The traditional "helicopter" approach to research applied in communities has led to disenchantment on the part of First Nations people and has impeded their willingness to participate in research. University researchers have tended to develop projects without community input and to adopt short term approaches to the entire process, perhaps a reflection of granting and publication cycles and other realities of academia. Researchers often enter communities, collect data without respect for local culture, and then exit, having had little or no community interaction or consideration of how results generated could benefit communities or lead to sustainable solutions. Community-based participatory research (CBPR) has emerged as an alternative to the helicopter approach and is promoted here as a method to research that will meet the objectives of both First Nations and research communities. CBPR is a collaborative approach that equitably involves all partners in the research process. Although the benefits of CBPR have been recognized by segments of the University research community, there exists a need for comprehensive changes in approaches to First Nations centered research, and additional guidance to researchers on how to establish respectful and productive partnerships with First Nations communities beyond a single funded research project. This article provides a brief overview of ethical guidelines developed for researchers planning studies involving Aboriginal people as well as the historical context and principles of CBPR. A framework for building research partnerships with First Nations communities that incorporates and builds upon the guidelines and principles of CBPR is then presented. The framework was based on 10 years' experience working with First Nations communities in Saskatchewan. The framework for research partnership is composed of five phases. They are categorized as the pre-research, community consultation, community entry, research and research dissemination phases. These phases are cyclical, non-linear and interconnected. Elements of, and opportunities for, exploration, discussion, engagement, consultation, relationship building, partnership development, community involvement, and information sharing are key components of the five phases within the framework. The phases and elements within this proposed framework have been utilized to build and implement sustainable collaborative environmental health research projects with Saskatchewan First Nations communities.

Ethical community-engaged research: a literature review

Health research has relied on ethical principles, such as those of the Belmont Report, to protect the rights and well-being of research participants. Community-based participatory research (CBPR), however, must also consider the rights and well-being of communities. This requires additional ethical considerations that have been extensively discussed but not synthesized in the CBPR literature. We conducted a comprehensive thematic literature review and summarized empirically grounded discussions of ethics in CBPR, with a focus on the value of the Belmont principles in CBPR, additional essential components of ethical CBPR, the ethical challenges CBPR practitioners face, and strategies to ensure that CBPR meets ethical standards. Our study provides a foundation for developing a working definition and a conceptual model of ethical CBPR.

Variation in the interpretation of scientific integrity in community-based participatory health research

Community-based participatory research (CBPR) has become essential in health disparities and environmental justice research; however, the scientific integrity of CBPR projects has become a concern. Some concerns, such as appropriate research training, lack of access to resources and finances, have been discussed as possibly limiting the scientific integrity of a project. Prior to understanding what threatens scientific integrity in CBPR, it is vital to understand what scientific integrity means for the professional and community investigators who are involved in CBPR. This analysis explores the interpretation of scientific integrity in CBPR among 74 professional and community research team members from of 25 CBPR projects in nine states in the southeastern United States in 2012. It describes the basic definition for scientific integrity and then explores variations in the interpretation of scientific integrity in CBPR. Variations in the interpretations were associated with team member identity as professional or community investigators. Professional investigators understood scientific integrity in CBPR as either conceptually or logistically flexible, as challenging to balance with community needs, or no different than traditional scientific integrity. Community investigators interpret other factors as important in scientific integrity, such as trust, accountability, and overall benefit to the community. This research demonstrates that the variations in the interpretation of scientific integrity in CBPR call for a new definition of scientific integrity in CBPR that takes into account the understanding and needs of all investigators.

Ethical challenges and opportunities for nurses in HIV and AIDS community-based participatory research in Jamaica

As part of a multinational program of research, we undertook a community-based participatory research project in Jamaica to strengthen nurses' engagement in HIV and AIDS policy. Three leadership hubs were purposefully convened and included small groups of people (6-10) from diverse HIV and AIDS stakeholder groups in Jamaica: frontline nurses and nurse managers in primary and secondary care settings; researchers; health care decision makers; and other community members. People living with HIV or AIDS were among the hub members. Using a relational public health ethics framework, we outline some of the ethical challenges and opportunities experienced by the research team and the leadership hubs. Data included research assistant field notes and hub progress reports. Emerging ethical concerns were associated with relational personhood, social justice, relational autonomy, relational solidarity, and sustainability of the hub activities.

Recognizability: a strategy for assessing external validity and for facilitating knowledge transfer in qualitative research

In this article, we argue in favor of quality assessment for qualitative studies and propose using a strategy we have labeled recognizability to assess external validity and facilitate knowledge transfer. To test our idea, we gathered data about recognizability in relation to a specific study on facial disfigurement. Four categories were identified: full recognition; partial recognition; recognition in others; and no recognition. In this article, we show how we used these categories both to evaluate the quality of our study and to assess its external validity. We also discuss the implications of recognizability for knowledge transfer.

Using participatory approaches with older people in a residential home in Guyana: challenges and tensions

Participatory approaches are a popular and entrenched strategy in community development, yet a number of unresolved issues and tensions persist regarding the definition, rationales, outcomes and ethics of participation. Despite its popularity there are relatively few examples of participatory projects with older people or in institutional settings so their potential with this group is poorly understood. This case study presents some of the practical and ethical challenges that arose over the course of a participatory project that aimed to analyse and improve quality of life in a residential home for older people in Guyana. Through a qualitative process evaluation it examines the degree of participation achieved, the determinants of the participatory process, the benefits the approach brought and the ethical dilemmas encountered. Although the degree of participation achieved was limited, beneficial outcomes were observed, notably the selection of appropriate and desirable interventions and the effect on the residents themselves, who valued their part in the project. The participatory process was unpredictable and complex, however, and key determinants of it included the organizational dynamics of the home and the skills, actions and attitudes of the researcher. Adopting a participatory approach brought valuable benefits in a residential home, but others adopting the approach should ensure they critically consider at the outset the ethical and practical dilemmas the setting and approach may produce and have realistic expectations of participation.

Community-based participatory research and the ethics review process

THIS EXPLORATORY STUDY EXAMINES the experiences of community-based participatory researchers' (CBPR) with the IRB. CBPR is oftentimes applied to non-clinical questions where academic researchers collaborate with community partners to address local concerns. Constant Comparative Method guided the analysis of ten CBPR interviews. The interview questions included: How does your conceptualization of research coincide with the regulations' definition? How are community partners involved in the IRB process? What are the benefits/challenges of the IRB process? And, what recommendations do you have to strengthen the IRB process? The article concludes with suggestions for IRB reviewers and CBPR partners on how to facilitate the review of CBPR projects.

A realist-constructionist perspective on participatory research in health promotion

Clarifying the contours of research in health promotion (HP) is an ongoing challenge. Research in this action-oriented field has traditionally been developed based on values such as participation and empowerment. Consequently, many forms of participatory research have emerged throughout the years, and participatory research has positioned itself as a core competency of HP and public health. This paper argues that participation as a normative stance guiding methodology, or as value, is a fragile posture upon which to position research practices. The argument is based on a realist-constructionist perspective of science and specifically uses Law and Latour's notion of inscription device and Callon's actor-network theory to suggest that participation is an epistemological necessity and that participatory research practices may be considered as inscription devices. These theoretical notions help clarify the consequences of participation on knowledge production. Finally, the article refers to Stengers's work to propose an ecology of research practices that defines obligations and exigencies for HP with respect to knowledge production and that are more consistent with the field's values of social justice and equity.

Research ethics education for community-engaged research: a review and research agenda

Community engagement is increasingly becoming an integral part of research. "Community-engaged research" (CEnR) introduces new stakeholders as well as unique challenges to the protection of participants and the integrity of the research process. We--a group of representatives of CTSA-funded institutions and others who share expertise in research ethics and CEnR--have identified gaps in the literature regarding (1) ethical issues unique to CEnR; (2) the particular instructional needs of academic investigators, community research partners, and IRB members; and (3) best practices for teaching research ethics. This paper presents what we know, as well as what we still need to learn, in order to develop quality research ethics educational materials tailored to the full range of stakeholder groups in CEnR.

The politics of action research: "if you don't like the way things are going, get off the bus"

Participatory action research is lauded for its emancipatory potential and practice relevance. Little research has focused on the ethical and political dimensions of power relations between management gatekeepers and staff in large organizations in the negotiation of action research. To illuminate the dynamics of this engagement, this paper is informed by Aristotle's practical ethics of phronesis, arguing that ethics emerge through human interaction. The paper reports on a multi-method study and intervention in inter-professional learning and collaboration, conducted between 2008 and 2010, across an Australian health system. It draws on results from researchers' progress notes, 139 semi-structured interviews and focus groups (492 participants), more than 200 h of organizational document analysis, and more than 200 h of ethnographic observation. From conventional thematic analysis, we note that the project had considerable support from senior managers who were gatekeepers for the research. Such support stemmed from managerialist tendencies, with senior managers explicitly aligning inter-professionalism with prospective health reforms and improvements to quality of care and patient safety. Senior managers were also enthusiastic about standardized processes. Many frontline staff were less supportive, and some were suspicious of or hostile towards management-led processes to improve and evaluate care. Some senior managers' self perceived alignment with and support for the research process changed to resistance once this finding was presented. This paradox in the interplay of research findings and research process evinces the inherent tension between organizational politics and conducting action research that reflexive researchers need to negotiate in knowledge translation, exchange or mobilization exercises.

"The midwifery two-step": a study on evidence-based midwifery practice

INTRODUCTION

To date, there has been little documentation of how practice-based midwifery networks in the United States might influence the transfer and development of knowledge in childbearing and women's health care. The first phase of this participatory action research project was to conduct a qualitative study with a community of midwifery practices to understand their perspectives on evidence-based practice and how an organized network could facilitate their work.

METHODS

Midwives within the community of interest were invited by letter or e-mail to participate in individual or small group interviews about knowledge transfer, primary concerns of evidence-based practice, and potential for a midwifery practice-based research network. Participatory action research strategies and organizational ethnographic approaches to data collection were used to guide qualitative interviews.

RESULTS

Eight midwifery practices enrolled in the study with 23 midwives participating in interviews. They attended births at 2 hospitals in the community. Two broad areas of discourse about evidence-based practice were identified: 1) challenges from influential persons, finances and resources, and the cultural perception of midwifery, and 2) strategies to foster best practice in the face of those challenges. The midwives believed a research network could be useful in learning collectively about their practices and in the support of their work.

DISCUSSION

Evidence-based practice is a goal but also has many challenges in everyday implementation. Practice-based research networks hold promise to support clinicians to examine the evidence and form strong coalitions to foster best clinical practice. The second phase of this study will work with this community of midwives to explore collective strategies to examine and improve practice.

Creating community-based participatory research in a diverse community: a case study

Communities struggle to create research guidelines for ethical collaborative research within their locale. In Lawrence, Massachusetts (USA) a collaborative group of community members and academic researchers, known as the Mayor's Health Task Force Research Initiative Working Group, took on the challenge of creating guidelines for ethical community-based research. This case study of the Task Force's work addresses questions of research ethics in a diverse community where families struggle with few resources and face many health disparities, under the often-intrusive and unhelpful scrutiny of researchers from the many nearby major research universities. Representatives from the city, community organizations, and research universities developed a set of core ethical principles for research partnerships, a list of criteria for agreements between partners, and a model to help guide researchers and community members toward equitable and mutually beneficial research. This model can be generalized to similar other communities.

Understanding community-based processes for research ethics review: a national study

OBJECTIVES

Institutional review boards (IRBs), designed to protect individual study participants, do not routinely assess community consent, risks, and benefits. Community groups are establishing ethics review processes to determine whether and how research is conducted in their communities. To strengthen the ethics review of community-engaged research, we sought to identify and describe these processes.

METHODS

In 2008 we conducted an online survey of US-based community groups and community-institutional partnerships involved in human-participants research. We identified 109 respondents who met participation criteria and had ethics review processes in place.

RESULTS

The respondents' processes mainly functioned through community-institutional partnerships, community-based organizations, community health centers, and tribal organizations. These processes had been created primarily to ensure that the involved communities were engaged in and directly benefited from research and were protected from research harms. The primary process benefits included giving communities a voice in determining which studies were conducted and ensuring that studies were relevant and feasible, and that they built community capacity. The primary process challenges were the time and resources needed to support the process.

CONCLUSIONS

Community-based processes for ethics review consider community-level ethical issues that institution-based IRBs often do not.

Review of procedures for approval of health studies in northern Canada

OBJECTIVES

This article describes the review processes required for research being conducted in Canada's 3 northern territories. When conducting research involving human subjects in northern Canada, researchers must go through a 2-step process by submitting protocols to both their university or hospital ethics review boards as well as to northern research institutions. Canada's northern territorial governments have requirements for attaining licensure before any research can be conducted.

METHODS

A document review was the method used to gather data, and an Internet search of the literature and documents was conducted to gather information.

RESULTS

Generally, university and hospital-based ethics review boards have been concerned with the rights of individuals in research. Northern Canadian research protocols require review by territorial government institutions and communities with respect to community rights.

CONCLUSIONS

The 3 territorial governments of northern Canada take the concept of community and individual participation in research seriously and have enacted processes so that opportunities for such approaches to research are ensured.

Ethical Review of Action Research: The Challenges for Researchers and Research Ethics Committees

Action research has repeatedly demonstrated how it can facilitate problem solving and change in many settings through a process of collaboration which is driven by the community at the heart of the research. The ethical review of action research can be challenging for action researchers and research ethics committees. This paper explores how seven ethical principles can be used by action researchers and research ethics committees as the basis for ethical review. This paper concludes by offering some suggestions for a way forward for both action researchers and research ethics committees.

Finding middle ground: negotiating university and tribal community interests in community-based participatory research

Community-based participatory research (CBPR) has been hailed as an alternative approach to one-sided research endeavors that have traditionally been conducted on communities as opposed to with them. Although CBPR engenders numerous relationship strengths, through its emphasis on co-sharing, mutual benefit, and community capacity building, it is often challenging as well. In this article, we describe some of the challenges of implementing CBPR in a research project designed to prevent cardiovascular disease among an indigenous community in the Pacific Northwest of the United States and how we addressed them. Specifically, we highlight the process of collaboratively constructing a Research Protocol/Data Sharing Agreement and qualitative interview guide that addressed the concerns of both university and tribal community constituents. Establishing these two items was a process of negotiation that required: (i) balancing of individual, occupational, research, and community interests; (ii) definition of terminology (e.g., ownership of data); and (iii) extensive consideration of how to best protect research participants. Finding middle ground in CBPR requires research partners to examine and articulate their own assumptions and expectations, and nurture a relationship based on compromise to effectively meet the needs of each group.

The research ethics committee is not the enemy: oversight of community-based participatory research

Researchers conducting community-based participatory research (CBPR) often complain about research ethics committee (REC) oversight of their research. RECs may contribute to researchers' frustrations by seemingly focusing on form over substance and by failing to communicate effectively with researchers about their mission and their specific concerns. UCSF CBPR researchers presented their views of the UCSF REC's review of its tobacco use study in "It's Like Tuskegee in Reverse: A Case Study of Ethical Tensions in Institutional Review Board Review of Community-Based Participatory Research." This article builds on that case study by providing some perspectives from the REC side, identifying how the researchers and the REC came to be at odds, and seeking to bridge the gap between the CBPR and REC worlds. In particular, the article explores the different perspectives on who are human subjects under the federal regulations in CBPR research, who counts as the community, and the purpose of REC oversight. It offers concrete suggestions for improving the relationship between CBPR researchers and RECs.

Researchers' perspectives on collective/community co-authorship in community-based participatory indigenous research

Ethical tensions exist regarding the value and practice of acknowledging Indigenous contributions in community-based participatory research (CBPR). Semistructured phone interviews with researchers documented their perspectives on authorship in the scholarly dissemination of their community-based participatory Indigenous research. Thematic analysis resulted in four key ideas: (1) current practices regarding methods of acknowledging community contributions; (2) requirements for shared authorship with individual versus collective/community partners; (3) benefits to sharing authorship with collective/community partners; and (4) risks to sharing authorship with collective/community partners. Findings suggest an emerging but inconsistent practice.

A Practical Framework for Navigating Ethical Challenges in Collaborative Community Research

To effectively mobilize community-based organizations (CBOs) and international non-governmental organizations (NGOs) in research, important ethical issues must be addressed. A memorandum of understanding (MOU), providing a framework and a tool to be used for establishing effective community-research partnerships, was developed by the Community Collaboration Core (CCC) of the HIV Center for Clinical and Behavioral Studies. Aims of the CCC include: (1) Initiating and sustaining successful partnerships in HIV prevention research in areas of sexuality, gender, mental health, and of mutual benefit to communities; (2) Advancing the science of collaboration among researchers, practitioners, and government in HIV prevention. Developed and assessed over a two-year period by researchers, CBO/NGO and public health representatives, this MOU can be used by potential research and community partners to address the most important issues early in a collaborative research project. Clarifying essential roles, responsibilities, and relationships, establishing trust and transparency in that process, can guide collaborators in planning the important steps for beginning and sustaining an ethical and successful research project.

Are we asking the right questions? A review of Canadian REB practices in relation to community-based participatory research

Access barriers to effective ethics review continue to be a significant challenge for researchers and community-based organizations undertaking community-based participatory research (CBPR). This article reports on findings from a content analysis of select (Behavioural, Biomedical, Social Sciences, Humanities) research ethics boards (REBs) in the Canadian research context (n = 86). Existing ethics review documentation was evaluated using 30 CBPR related criteria for their sensitivity to relevant approaches, processes, and outcomes. A linear regression was conducted to determine whether specific organizational characteristics have an impact on the CBPR sensitivity: (1) region of Canada, (2) type of institution (university or a healthcare organization), (3) primary institutional language (English or French) and (4) national ranking with respect to research intensiveness. While only research intensiveness proved statistically significant (p = .001), we recognize REB protocol forms may not actually reflect how CBPR is reviewed. Despite using a single guiding ethical framework, REBs across Canada employ a variety of techniques to review research studies. We report on these differences and varying levels of sensitivity to CBPR. Finally, we highlight best practices and make recommendations for integrating CBPR principles into existing ethics review.

An Expansion and Modification of the Information, Motivation, and Behavioral Skills Model: Implications from a Study with African American Girls and Their Mothers

African American females make up a disproportionate number of adolescent HIV cases. Focus groups were conducted to investigate sexual communication between 11- to 14-year-old girls and their mothers. Twenty-eight African American mother-daughter dyads from inner-city community centers participated. Implementing an intervention for families with children requires the use of a framework that is amenable to the development of intervention strategies as well as taking a family approach. The focus of the study was to adapt a leading theory used in interventions for HIV risk reduction at the individual level to be employed with a dyadic relationship between mother and daughter. Following qualitative analysis, data were reexamined according to an expanded and modified version of the Information, Motivation, and Behavioral Skills (IMB) Model. Each of the constructs was represented in the data, and insights for intervention strategies were obtained. However, the IMB model restricted an understanding of the dynamic relationship and the mother-daughter interactions with the community.

Participant observation of time allocation, direct patient contact and simultaneous activities in hospital physicians

BACKGROUND

Hospital physicians' time is a critical resource in medical care. Two aspects are of interest. First, the time spent in direct patient contact - a key principle of effective medical care. Second, simultaneous task performance ('multitasking') which may contribute to medical error, impaired safety behaviour, and stress. There is a call for instruments to assess these aspects. A preliminary study to gain insight into activity patterns, time allocation and simultaneous activities of hospital physicians was carried out. Therefore an observation instrument for time-motion-studies in hospital settings was developed and tested.

METHODS

35 participant observations of internists and surgeons of a German municipal 300-bed hospital were conducted. Complete day shifts of hospital physicians on wards, emergency ward, intensive care unit, and operating room were continuously observed. Assessed variables of interest were time allocation, share of direct patient contact, and simultaneous activities. Inter-rater agreement of Kappa = .71 points to good reliability of the instrument.

RESULTS

Hospital physicians spent 25.5% of their time at work in direct contact with patients. Most time was allocated to documentation and conversation with colleagues and nursing staff. Physicians performed parallel simultaneous activities for 17-20% of their work time. Communication with patients, documentation, and conversation with colleagues and nursing staff were the most frequently observed simultaneous activities. Applying logit-linear analyses, specific primary activities increase the probability of particular simultaneous activities.

CONCLUSION

Patient-related working time in hospitals is limited. The potential detrimental effects of frequently observed simultaneous activities on performance outcomes need further consideration.

Augmenting frameworks for appraising the practices of community-based health interventions

This paper aims at augmenting the frameworks proposed by Rifkin in 1996 to distinguish between target-oriented and empowerment approaches to participation in community-based health interventions. In her paper, Rifkin defined three criteria: who makes decisions on resource allocation, expected outcome and outcome assessment. We propose five additional criteria: the definition of community, the characteristics of the capacity-building process, the leadership characteristics, the documentation process, and ethical issues regarding participation. Derived from our analysis of a community-based project, the proposed criteria are discussed in the light of the principles of Popular Education and other literature on community participation. The augmented frameworks are intended to assist health professionals and planners interested in the empowerment approach of community participation to consciously sharpen their practice.

Placing ethics in the centre: negotiating new spaces for ethical research in conflict situations

Issues of power and consent, confidentiality, trust, and benefit, risks to researchers, and potential harm to participants, are all contested when working with different cultures and within environments marked by violence and insecurity. Difficulty resolving these dilemmas may paralyse ethics committees, may fail to give the guidance sought by researchers, and will not help populations who are among the world's most vulnerable. Even where efforts are made to respond to ethical guidelines and to improve practice, considerable impediments are present in many developing countries, including lack of formal ethical review structures in unstable settings, lack of required skills, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice (Elsayed 2004, Macklin 2004). In conflict settings, these limitations are more marked, and the responsibilities of the researcher for ethical practice are greater, but the mechanisms for oversight are weaker. Moreover, the constant focus on vulnerabilities and problems, and the often almost total lack of recognition of strengths and resilience, can further disempower already exploited groups and individuals. The capacity of refugees and communities in conflict to take an active role in the research process is seldom acknowledged, and undermines the potential for more innovative research which can help generate the evidence for better policy and practice.

The dual role of the action researcher

This article aims to provide more insight into advantages and challenges of conducting action research with the intention to improve health care. Action research is distinctive in the sense that the researcher has a dual role as both researcher and implementer of the program studied. The article is based on two Norwegian action-oriented studies that aimed to explore the potential role of online self-help groups for breast cancer patients and adolescents with mentally ill parents respectively. We argue that action research can contribute both to the generation of knowledge, as well as a greater sense of ownership to the program among those who are intended to use it. Nonetheless, a potential conflict between the researcher's pursuit of data, and ethical considerations became apparent in the contexts studied here. Bearing these challenges in mind, we still conclude that action research offers an important contribution for the further development of health care services.

A model for community representation and participation in HIV prevention trials among women who engage in transactional sex in Africa

Actively engaging communities in effective partnerships for the design and implementation of HIV prevention research is vital to the successful conduct of ethically robust, locally-appropriate clinical trials in developing countries. This is especially true in vulnerable at-risk sub-populations, where definitions of "community", "participation" and "representation" can be difficult to apply. This study was conducted to investigate the feasibility of a participatory model of community liaison among an occupational cohort of women at high-risk of HIV and sexually-transmitted infections in Mwanza City, northwest Tanzania in preparation for a Phase III vaginal microbicide trial. This approach was rooted in participatory action-orientated research and used tools adapted from participatory learning and action techniques. During the feasibility study, a mobile community-based sexual and reproductive health service for women working as informal food vendors or in traditional and modern bars, restaurants, hotels and guesthouses was established in 10 city wards. Participatory mapping was carried out by project fieldworkers and wards divided into 78 geographical clusters of facilities in consultation with community members and study participants. Representatives at cluster and ward level were elected in a process facilitated by the site Community Liaison Officer and a site-level Community Advisory Committee established. A logical framework was used to guide the implementation, monitoring and evaluation of the community liaison system (CLS) within the broader feasibility study. The CLS was essential to the successful conduct of the feasibility study and has now been consolidated and expanded as part of the on-going MDP301 Phase III microbicide trial in Mwanza. The participatory model presented in this paper is likely to be generalisable to other vulnerable, stigmatised, at-risk study populations in resource-limited settings.

The rise of 'recruitmentology': clinical research, racial knowledge, and the politics of inclusion and difference

Recent debates concerning the biomedical meaning and significance of race have paid relatively little attention to the practical implications of new policies in the US mandating the inclusion of racial and ethnic minorities (along with other 'underrepresented groups') as research subjects in clinical studies. I argue that pressures to enroll underrepresented groups have stimulated the development in the US of an auxiliary science I term 'recruitmentology': an empirical body of studies scientifically evaluating the efficacy of various social, cultural, psychological, technological, and economic means of convincing people (especially members of 'hard-to-recruit populations') that they want to become, and remain, human subjects. Via the filtering of social scientific frameworks into the clinical research domain, recruitmentology has promoted hybrid ways of thinking about race--awkward encounters in which depictions of race as a bounded, quasi-biological medical and administrative category sit uneasily alongside an interest in understanding racial identities and communities as sociocultural phenomena. I analyze how recruitmentologists, in addressing the mandate to recruit racially diverse subject populations, conceptualize race while simultaneously grappling with problems of trust, collective memory, and participation. I also examine how the increasingly transnational character of biomedical research is intensifying the exploitative dimensions of recruitment while further transforming the racialized character of human experimentation. This analysis highlights the tensions underlying projects to eliminate health disparities by race.

Involving people affected by cancer in research: a review of literature

The purpose of the literature review was to find out why people affected by cancer have been involved in research; how they have been involved and the impact of their involvement. We used systematic methods to search for literature, applied inclusion and exclusion criteria, conducted a quality appraisal, selected relevant data from the included articles for analysis, and provided a narrative summary of these data. The literature shows that people affected by cancer, particularly women with breast cancer, have been involved in a range of research programmes, projects and initiatives especially in the USA, UK, Canada and Australia. Their involvement has impacted upon research design, accrual and response rates. There is increasing recognition of the need for an infrastructure, including formal recruitment procedures, training and mentoring, to support an agenda of involvement and a need to challenge the ethos of traditional research, which does not easily lend itself to this agenda. Further critique of the role of 'experiential knowledge' in research is required so that researchers and people affected by cancer can work in partnership.

An HIV prevention protocol reviewed at 15 national sites: how do ethics committees protect communities?

To learn whether ethics committees reviewing community-based participatory research concentrate on the protection of communities, in addition to individual participants, data from 15 sites were analyzed. Eighty-two ethics committee concerns related to consent (35%), protocol procedures (49%), data collection (17%), and HIPAA (6%) were identified. Concerns generally involved individual level subject issues; only 17% were related to community issues. To improve community-level protections in research, the authors recommend that both ethics committee members and research staff receive education concerning protection and respect for communities, that a community member group be established to advise researchers throughout the planning and implementation of community-level studies and that local ethics committee boards include members with community-level experience.

Mental health service needs of a Latino population: a community-based participatory research project

Community-based participatory research bridges the gap between academic researchers and the real-life issues of communities and offers promise for addressing racial and ethnic disparities in mental health care. The purpose of this community-based participatory research was to identify factors that affect access, use, and perception of mental health services by a Latino population at individual, organizational, and community levels. Individual level factors included health beliefs about mental illness and care, suspicions of providers, financial concerns, and culturally determined gender roles. Organizational factors included problems with access to care related to cost, lack of bilingual providers, and culturally competent care; and community level factors included distance between resources and the need for services to be provided in community sites. Immigration status and acculturation were identified as factors at all levels.

Barriers to patient involvement in health service planning and evaluation: an exploratory study

OBJECTIVE

Patient involvement in health service planning and evaluation is considered important yet not widely practiced. This study explored stakeholder beliefs about patient participation in performance indicator selection to better understand hypothesized barriers.

METHODS

Interviews with 30 cancer patients and health professionals from two teaching hospitals were analyzed qualitatively.

RESULTS

All groups believed patients, not members of the public, should be involved in the selection of indicators. Ongoing, interactive methods such as committee involvement, rather than single, passive efforts such as surveys were preferred. Health professionals recommended patients assume a consultative, rather than decision-making role. Older patients agreed with this.

CONCLUSION

Variable patient interest, health professional attitudes, and a lack of insight on appropriate methods may be limiting patient involvement in this, and other service planning and evaluation activities. More research is required to validate expressed views among the populations these stakeholders represent, and to establish effective methods for engaging patients.

PRACTICE IMPLICATIONS

Efforts to encourage a change in health professional attitude may be required, along with dedicated organizational resources, coordinators and training. Methods to engage patients should involve deliberation, which can be achieved through modified Delphi panel or participatory research approaches.

"I spent nine years looking for a doctor": exploring access to health care among immigrants in Mississauga, Ontario, Canada

There is a growing body of research in Canada and from other countries acknowledging that immigrants face barriers in accessing health care services. As immigrants make up an increasing percentage of the population in many developed nations, a better understanding and eliminating these barriers is a major priority. This research contributes to current understandings of access among immigrant populations in Canada by exploring perceptions of access to care through focus groups with a diverse group of immigrants living in a Mississauga, Ontario neighbourhood. The results of eight focus groups reveal that immigrants face geographic, socio-cultural and economic barriers when attempting to access health care services in their community. This paper provides policy recommendations relevant to the federal, provincial and local levels for eliminating these barriers.

Solution-focused conversations: a new therapeutic strategy in well child health nursing telephone consultations

AIM

This paper is a report of a study to explore well child nurses' perceptions of outcomes resulting from the use of solution-focused conversations in their telephone consultations with clients.

BACKGROUND

Well child nurses (health visitors) in some services provide a separate telephone consultation service for parents who need immediate advice or are unable to visit the clinic. As well as purely physical issues suggesting infant pathology, these consultations address a range of other concerns relating to parenting and child behaviour. The standard problem-solving approach used to address physical issues is less effective for various non-physical concerns, where different communication strategies may be helpful.

METHOD

In this qualitative, action-oriented study, a small group of well child telenurses in New Zealand was introduced to a specific communication strategy, called 'solution-focused conversations', during 2005. They applied this approach in their practice and then reflected together on their experiences in focus groups.

FINDINGS

The nurses considered that the solution-focused conversations enabled clients to: recognize the nature of the parenting issue of concern that had motivated their call; identify more effective parenting practices to address specific issues with their child; increase their confidence in their own parenting capabilities.

CONCLUSION

This study suggested the value of learning a specific communication strategy for the practice of a group of well child telenurses. Solution-focused conversation is a suitable approach for the single, relatively short, interactions involved in telephone nursing. Other communication strategies could be appropriate for nurses in different clinical situations.

The benefits of participatory methodologies to develop effective community dialogue in the context of a microbicide trial feasibility study in Mwanza, Tanzania

Background

During a microbicide trial feasibility study among women at high-risk of HIV and sexually transmitted infections in Mwanza, northern Tanzania we used participatory research tools to facilitate open dialogue and partnership between researchers and study participants.

Methods

A community-based sexual and reproductive health service was established in ten city wards. Wards were divided into seventy-eight geographical clusters, representatives at cluster and ward level elected and a city-level Community Advisory Committee (CAC) with representatives from each ward established. Workshops and community meetings at ward and city-level were conducted to explore project-related concerns using tools adapted from participatory learning and action techniques such as listing, scoring, ranking, chapatti diagrams and pair-wise matrices.

Results

Key issues identified included beliefs that blood specimens were being sold for witchcraft purposes; worries about specula not being clean; inadequacy of transport allowances; and delays in reporting laboratory test results to participants. To date, the project has responded by inviting members of the CAC to visit the laboratory to observe how blood and genital specimens are prepared; demonstrated the use of the autoclave to community representatives; raised reimbursement levels; introduced HIV rapid testing in the clinic; and streamlined laboratory reporting procedures.

Conclusion

Participatory techniques were instrumental in promoting meaningful dialogue between the research team, study participants and community representatives in Mwanza, allowing researchers and community representatives to gain a shared understanding of project-related priority areas for intervention.

Ethical dilemmas in community-based participatory research: recommendations for institutional review boards

National and international codes of research conduct have been established in most industrialized nations to ensure greater adherence to ethical research practices. Despite these safeguards, however, traditional research approaches often continue to stigmatize marginalized and vulnerable communities. Community-based participatory research (CBPR) has evolved as an effective new research paradigm that attempts to make research a more inclusive and democratic process by fostering the development of partnerships between communities and academics to address community-relevant research priorities. As such, it attempts to redress ethical concerns that have emerged out of more traditional paradigms. Nevertheless, new and emerging ethical dilemmas are commonly associated with CBPR and are rarely addressed in traditional ethical reviews. We conducted a content analysis of forms and guidelines commonly used by institutional review boards (IRBs) in the USA and research ethics boards (REBs) in Canada. Our intent was to see if the forms used by boards reflected common CBPR experience. We drew our sample from affiliated members of the US-based Association of Schools of Public Health and from Canadian universities that offered graduate public health training. This convenience sample (n = 30) was garnered from programs where application forms were available online for download between July and August, 2004. Results show that ethical review forms and guidelines overwhelmingly operate within a biomedical framework that rarely takes into account common CBPR experience. They are primarily focused on the principle of assessing risk to individuals and not to communities and continue to perpetuate the notion that the domain of "knowledge production" is the sole right of academic researchers. Consequently, IRBs and REBs may be unintentionally placing communities at risk by continuing to use procedures inappropriate or unsuitable for CBPR. IRB/REB procedures require a new framework more suitable for CBPR, and we propose alternative questions and procedures that may be utilized when assessing the ethical appropriateness of CBPR.

Community participation in Aedes aegypti control: a sociological perspective on five years of research in the health area ''26 de Julio'', Havana, Cuba

OBJECTIVE

Effective dengue prevention and Aedes aegypti control is a priority for the Cuban health authorities. To enhance effectiveness, strategies oriented towards a more active involvement of communities in control activities are being tested. This paper presents a sociological perspective on a pilot project conducted in the health area ''26 de Julio'' (La Havana) in 1999-2004.

METHODS

Instrumental case study based on an exhaustive content analysis of project documents and on observations of a sociologist.

RESULTS

The context and the pilot project are systematically described and an analysis of the evolution of the underlying concept of community participation is provided. The pilot experience was a dynamic process influenced by self-reflection of the research team, feedback from research partners and changes in the epidemiological context (provoked by two dengue outbreaks during the study period). Community participation evolved from being just one component in Aedes aegypti control directed by the health staff into a learning and empowering process for the people. This change in the concept of participation was reflected in different aspects of the pilot project such as the learning and evaluation processes.

CONCLUSION

Empirical evidence from 5 years of research in the particular context of Cuba showed that moves towards community-based Aedes aegypti control are feasible. However, in order to be successful, community-based dengue prevention should be a social learning process, implying a transfer of power and responsibilities to local people. Actions undertaken must be oriented towards creating local capabilities, strengthening existing structures and organizations and promoting group work for learning participation from participation itself.