Balancing empiricism and local cultural knowledge in the design of prevention research

Lifestyle Interventions through Participatory Research: A Mixed-Methods Systematic Review of Alcohol and Other Breast Cancer Behavioural Risk Factors

Breast cancer is one of the most frequently diagnosed cancers in women globally. Sex and advancing age represent the dominant risk factors, with strong evidence of alcohol as a modifiable risk factor. The carcinogenic nature of alcohol has been known for over twenty years; however, this has failed to translate into significant behavioural, practice, or policy change. As a result, women have not benefitted from this research and, by extension, have been exposed to unnecessary breast cancer risk. Participatory research presents a solution to research translation in public health through the collaboration of impacted populations with academics in research. This systematic review examines peer-reviewed research studies where participants were involved in the research process and the outcomes related to breast cancer prevention (either alcohol or broader lifestyle modification). Seven of the eight studies reported positive effects, and the collaboration between academic researchers and impacted populations may have supported positive outcomes. Women were receptive and responsive to participatory approaches, and their participation is important to address socially entrenched behaviours such as alcohol consumption. Participatory research presents opportunities for future interventions to improve (or address) modifiable risk factors for breast cancer.

Adapting PC CARES to Continue Suicide Prevention in Rural Alaska During the COVID-19 Pandemic: Narrative Overview of an In-Person Community-Based Suicide Prevention Program Moving Online

This paper presents how a community mobilization program to prevent suicide was adapted to an online format to accommodate the impossibility of in-person delivery in Alaska Native communities during the COVID-19 pandemic. The intervention, Promoting Community Conversations About Research to End Suicide (PC CARES), was created collaboratively by researchers and Alaska Native communities with the goal of bringing community members together to create research-informed and community-led suicide prevention activities in their communities. To continue our work during the COVID-19 pandemic and restrictions, we adapted the PC CARES model to a synchronous remote delivery format. This shift included moving from predominantly Alaska Native participants to one of a mainly non-Native school staff audience. This required a pivot from Alaska Native self-determination toward cultural humility and community collaboration for school-based staff, with multilevel youth suicide prevention remaining the primary aim. This reorientation can offer important insight into how to build more responsive programs for those who are not from the communities they serve. Here, we provide a narrative overview of our collaborative adaptation process, illustrated by data collected during synchronous remote facilitation of the program, and reflect on how the shift in format and audience impacted program delivery and content. The adaptation process strove to maintain the core animating features of self-determination for Alaska Native communities and people as well as the translation of scientific knowledge to practice for greater impact.

Technology-driven methodologies to collect qualitative data among youth to inform HIV prevention and care interventions

The use of technology as a platform for delivering HIV prevention interventions provides an efficient opportunity to reach those at risk for HIV with targeted and timely prevention and treatment messages. Technology-delivered HIV interventions are becoming increasingly popular and include interventions that use mobile text messaging and mobile phone apps or deliver prevention messages through telehealth platforms. Community-centered approaches of intervention development can help address the potential gap between science and practice by ensuring that interventions are appropriate and driven by community needs and desires. Common approaches to gaining community input rely on qualitative data gathered through in-person focus group discussions (FGD), in-depth interviews (IDI) and youth advisory boards (YABs). While these proven methodologies have strengths, youth engagement can be limited by structural barriers (e.g., lack of transportation, inconvenient timing) and reluctance to participate due to stigma or discomfort with group settings. This results in a number of biases that limit the quality of face-to-face qualitative data collection, i.e., social desirability bias or selection biases created by differential likelihood of recruitment and attendance. As an increasing number of HIV prevention and care interventions are successfully delivered online, innovative approaches to youth engagement in virtual spaces can also be applied across the intervention lifespan to increase the quality and validity of formative data. In this paper, we describe a range of qualitative data collection techniques that can be used via online platforms to collect qualitative data, and we outline their relative advantages over face-to-face FGD or IDI. We use four case studies to highlight the methodologies and findings and provide recommendations for researchers moving forward.

Fostering Ethical, Legal, and Social Implications Research in Tribal Communities: The Center for the Ethics of Indigenous Genomic Research

Genomic research raises unique ethical concerns among Alaska Native and American Indian (AN/AI) people and their communities. The Center for the Ethics of Indigenous Genomic Research (CEIGR) was created to foster research that takes these concerns into account while considering the sovereign status of AN/AI tribal nations. Relationships developed within CEIGR have allowed for effective, collaborative research among individuals who come from diverse cultures, political and historical backgrounds, and academic disciplines, and who work for organizations with varying resources, capacities, and expectations. The CEIGR framework may inform other groups seeking to conduct social science research related to genomic research with tribal people and their communities.

Community Protections in American Indian and Alaska Native Participatory Research-A Scoping Review

Experiences with unethical research practices have caused some American Indian and Alaska Native (AIAN) individuals, organizations, and tribes to mistrust health research. To build trust and repair relationships, current research with AIAN peoples often involves participatory research (PR) approaches. This article assesses community-level protections described in the scientific literature on PR involving AIAN communities. A scoping review search in PubMed and PsychInfo for articles published between January 2000 and June 2017 yielded an AIAN PR article dataset. Of 178 articles, a subset of 23 articles that described aspects of community protections were analyzed for descriptions of community-level protection practices. We identified the presence or absence of a description of four community protection measures in each article: a tribal research department, the development of community-level mechanisms for research regulation if not present, community collaboration throughout the research process, and project employment of a community member. The development of community-level mechanisms for research regulation was described in 39% of the articles. Ninety-one percent of these articles described community collaboration during the research process. Seventeen percent included descriptions of all four community-level protection measures. The extent and consistency to which community-level protections are described is variable; the current literature lacks reporting on community-level protection practices specific to tribal communities.

He Pikinga Waiora: supporting Māori health organisations to respond to pre-diabetes

BACKGROUND

Type 2 Diabetes (T2D) is a common long-term condition affecting the health and wellbeing of New Zealanders; one in every four New Zealanders is pre-diabetic. Māori, the Indigenous people of New Zealand, are at an increased risk of developing pre-diabetes and T2D and there are significant inequities between Māori and non-Māori for T2D complications. The purpose of this study was to explore the questions of how the strengths of Māori heath organisations may be leveraged, and how the barriers and constraints experienced by Māori health organisations may be negotiated, for the benefit of Māori; and from a systems perspective, to identify strategic opportunities that may be considered and applied by Māori health organisations, funders and policy makers to respond more effectively to pre-diabetes and reduce health inequities between Māori and non-Māori.

METHODS

Utilising case study methodology, a range of data sources were triangulated including nine semi-structured interviews, documents, and a diabetes system map to identify possible strategic opportunities for key stakeholders to respond more effectively to pre-diabetes.

RESULTS

Key themes and possible actions to improve health outcomes for Māori with pre-diabetes include: (1) Recognising Māori health organisations as conduits for the community voice and influential partners in the community to effect change; (2) Strengthened partnerships with Māori health organisations for community benefit and to support measurable, evidence-based change and service delivery, particularly when Māori knowledge systems are viewed alongside a Western scientific approach; and (3) Intersectoral integration of health and social services to support provision of whānau-centred care and influence the social determinants of health and local environment.

CONCLUSIONS

Māori health organisations are important actors in systems seeking to improve outcomes and eliminate health inequities. Support from funders and policy makers will be required to build on the strengths of these organisations and to overcome system challenges. To realise improved health outcomes for Māori, the value placed on whānau and community perspectives not only needs to be acknowledged in the implementation of health interventions, health and social policies and funding arrangements, but performance measures, service design and delivery must evolve to accommodate these perspectives in practice.

Impacts of alcohol availability on Tribal lands where alcohol is prohibited: A community-partnered qualitative investigation

On a Northern Plains reservation where alcohol was prohibited, we investigated community members' views on the impacts of alcohol availability. Our methods combined elements of Tribal community participatory research with qualitative inquiry to elicit these perspectives. We used rapid appraisal techniques to conduct confidential interviews with 31 key leaders representing 7 relevant major community systems, and representing a variety of perspectives. Topics included respondents' understandings of the current systems of alcohol availability and use on the reservation, the impacts of these systems on reservation residents, and possible ways to measure these impacts. Respondents reported impacts on individuals, families, and the tribe overall. Alcohol-related problems shaped and were shaped by a constellation of social-ecological conditions: kinship, housing, employment, public/social service capacity, and the supply of alcohol in nearby off-reservation areas, as well as inter-governmental relationships and the spiritual life of reservation residents. A variety of social-structural determinants magnified alcohol impacts, so that the problem drinking of a small number of individuals could have broad effects on their families and the entire community. Our participatory qualitative methods enabled us to directly include the voices as well as the personal experiences and expertise of community members in this presentation. These methods may be broadly applied within policy analysis to identify ways to reduce harms related to alcohol and other drugs for Indigenous communities.

Cross-Jurisdictional Sharing for Emergency Management-Related Public Health: Exploring the Experiences of Tribes and Counties in California

Each American Indian tribe is unique in several ways, including in its relationships with local governments and risk for emergencies. Cross-jurisdictional sharing (CJS) arrangements are encouraged between tribes and counties for emergency management-related population health, but researchers have not yet explored CJS experiences of tribes and counties for emergency management. This investigation used collaboration theory and a CJS spectrum framework to assess the scope and prevalence of tribe-county CJS arrangements for emergency management in California as well as preconditions to CJS. Mixed-methods survey results indicate that tribes and counties have varied CJS arrangements, but many are informal or customary. Preconditions to CJS include tribe-county agreement about having CJS, views of the CJS relationship, barriers to CJS, and jurisdictional strengths and weaknesses in developing CJS arrangements. Areas for public health intervention include funding programs that build tribal capacity in emergency management, reduce cross-jurisdictional disagreement, and promote ongoing tribe-county relationships as a precursor to formal CJS arrangements. Study strengths, limitations, and future directions are also discussed.

American Indian and Alaska Native Cancer Patients' Perceptions of a Culturally Specific Patient Navigator Program

Lack of access to care, funding limitations, cultural, and social barriers are challenges specific to tribal communities that have led to adverse cancer outcomes among American Indians/Alaska Natives (AI/AN). While the cancer navigator model has been shown to be effective in other underserved communities, it has not been widely implemented in Indian Country. We conducted in-depth interviews with 40 AI/AN patients at tribal clinics in Idaho and Oregon. We developed the survey instrument in partnership with community members to ensure a culturally appropriate semi-structured questionnaire. Questions explored barriers to accessing care, perceptions of the navigator program, satisfaction, and recommendations. AI/AN cancer patients reported physical, emotional, financial, and transportation barriers to care, but most did not feel there were any cultural barriers to receiving care. Navigator services most commonly used included decision making, referrals, transportation, scheduling appointments, and communication. Satisfaction with the program was high. Our study provides a template to develop a culturally appropriate survey instrument for use with an AI/AN population, which could be adapted for use with other indigenous patient populations. Although our sample was small, our qualitative analysis facilitated a deeper understanding of the barriers faced by this population and how a navigator program may best address them. The results reveal the strengths and weakness of this program, and provide baseline patient satisfaction numbers which will allow future patient navigator programs to better create evaluation benchmarks.

Healing of the canoe: preliminary results of a culturally tailored intervention to prevent substance abuse and promote tribal identity for Native youth in two Pacific Northwest tribes

Using Community-based and Tribal Participatory Research (CBPR/TPR) approaches, an academic-tribal partnership between the University of Washington Alcohol and Drug Abuse Institute and the Suquamish and Port Gamble S'Klallam Tribes developed a culturally grounded social skills intervention to promote increased cultural belonging and prevent substance abuse among tribal youth. Participation in the intervention, which used the Canoe Journey as a metaphor for life, was associated with increased hope, optimism, and self-efficacy and with reduced substance use, as well as with higher levels of cultural identity and knowledge about alcohol and drugs among high school-age tribal youth. These results provide preliminary support for the intervention curricula in promoting positive youth development, an optimistic future orientation, and the reduction of substance use among Native youth.

The Community Pulling Together: A Tribal Community–University Partnership Project to Reduce Substance Abuse and Promote Good Health in a Reservation Tribal Community

Alcohol and drug abuse are major areas of concern for many American Indian=Alaska Native communities. Research on these problems has often been less than successful, in part because many researchers are not sensitive to the culture and traditions of the tribes and communities with which they are working. They alsooften fail to incorporate tribal customs, traditions, and values into the interventions developed to deal with substance abuse. The authors describe the use of community-based participatory research and tribal participatory research approaches to develop a culturally sensitive substance abuse prevention program for Native youth. This project, The Community Pulling Together: Healing of the Canoe, is a collaboration between the Suquamish Tribe and the Alcohol and Drug Abuse Institute at the University of Washington, Seattle, Washington.

Enhancing stewardship of community-engaged research through governance

OBJECTIVES

We explored the relationship of community-engaged research final approval type (tribal government, health board, or public health office (TG/HB); agency staff or advisory board; or individual or no community approval) with governance processes, productivity, and perceived outcomes.

METHODS

We identified 294 federally funded community-engaged research projects in 2009 from the National Institutes of Health's Research Portfolio Online Reporting Tools, Centers for Disease Control and Prevention's Prevention Research Centers, and Native American Research Centers for Health databases. Two hundred (68.0%) investigators completed a survey about governance processes and productivity measures; 312 partners (77.2% of 404 invited) and 138 investigators (69.0% of 200 invited) completed a survey about perceived outcomes.

RESULTS

Projects with TG/HB approval had increased likelihood of community control of resources (odds ratios [ORs] ≥ 4.80). Projects with other approvals had decreased likelihood of development or revision of institutional review board policies (ORs ≤ 0.37), having written agreements (ORs ≤ 0.17), and agreements about publishing (ORs ≤ 0.28), data use (ORs ≤ 0.17), and publishing approval (ORs ≤ 0.14).

CONCLUSIONS

Community-engaged research projects with TG/HB approval had strong stewardship of project resources and agreements. Governance as stewardship protects community interests; thus, is an ethical imperative for communities, especially native communities, to adopt.

Community perspectives on drug/alcohol use, concerns, needs, and resources in four Washington State Tribal communities

Community-university teams investigated substance use, abuse, and dependence (SUAD) and related concerns, needs, strengths, and resources in four Washington State Tribal communities. A total of 153 key community members shared their perspectives through 43 semi-structured interviews and 19 semi-structured focus groups. Qualitative data analysis revealed robust themes: prescription medications and alcohol were perceived as most prevalent and concerning; family and peer influences and emotional distress were prominent perceived risk factors; and SUAD intervention resources varied across communities. Findings may guide future research and the development of much needed strength-based, culturally appropriate, and effective SUAD interventions for American Indians, Alaska Natives, and their communities.

Navigating Between Rigour and Community-Based Research Partnerships: Building the Evaluation of the Uniting Our Nations Health Promotion Program for FNMI Youth

Our team has worked closely with First Nations, Métis, and Inuit (FNMI) community partners and our local school board over the past 9 years to develop a range of strengths-based health promotion programs for FNMI youth. This article begins with a brief description of our school-based programming to provide context. Next, we identify challenges in conducting rigorous program evaluation and highlight the requirements of community-based research partnerships. Finally, we identify a number of factors that have helped us achieve a balance between the frameworks of rigour and community-based research partnerships. Throughout the paper we use examples from our projects to illustrate issues.

Evaluating community-based participatory research to improve community-partnered science and community health

BACKGROUND

Since 2007, the National Congress of American Indians (NCAI) Policy Research Center (PRC) has partnered with the Universities of New Mexico and Washington to study the science of community-based participatory research (CBPR). Our goal is to identify facilitators and barriers to effective community-academic partnerships in American Indian and other communities, which face health disparities.

OBJECTIVES

We have described herein the scientific design of our National Institutes of Health (NIH)-funded study (2009-2013) and lessons learned by having a strong community partner leading the research efforts.

METHODS

The research team is implementing a mixed-methods study involving a survey of principal investigators (PIs) and partners across the nation and in-depth case studies of CBPR projects.

RESULTS

We present preliminary findings on methods and measures for community-engaged research and eight lessons learned thus far regarding partnership evaluation, advisory councils, historical trust, research capacity development of community partner, advocacy, honoring each other, messaging, and funding.

CONCLUSIONS

Study methodologies and lessons learned can help community-academic research partnerships translate research in communities.

"Oh No, We are Just Getting to Know You": The Relationship in Research with Children and Youth in Indigenous Communities

We describe important elements in the process of engagement with tribal communities in research with children and youth and their families. We believe it helpful to understand the research relationship with tribal communities through the lens of kinship relations. This calls for re-examination of the nature of research and researcher, with important implications for the research process, design and organization, recovery from errors, and dissemination of results. Implications include a re-examination of some of our canons of research methods and research ethics, along with a willingness to address new challenges, to share control of the research process, and to be open to new conceptual perspectives, including alternative research strategies. Its repercussions hold promise for a deepening of the research relationship, and the role of researcher in the community.

Theory and practice in participatory research: lessons from the Native Elder Care Study

Models for community-based participatory research (CBPR) urge academic investigators to collaborate with communities to identify and pursue research questions, processes, and outcomes valuable to both partners. The tribal participatory research (TPR) conceptual model suggests modifications to CBPR to fit the special needs of American Indian communities. This paper draws upon authors' collaboration with one American Indian tribe to recommend theoretical revision and practical strategies for conducting gerontological research in tribal communities. We rated the TPR model as a strong, specialized adaptation of participatory research principles. Although the need for some TPR mechanisms may vary, our experience recommends incorporating dissemination as a central TPR mechanism. Researchers and communities can expect well-crafted collaborative projects to generate particular types of positive project outcomes for both partners, but should prepare for both predictable and unique challenges.

A prospective randomized controlled trial of an interpersonal violence prevention program with a Mexican American community

Using methods of community-based participatory research, a prospective randomized controlled trial of a violence prevention program based on Latino cultural values was implemented with elementary school children in a Mexican American community. Community members participated in intervention program selection, implementation, and data collection. High-risk students who participated in the program had greater nonviolent self-efficacy and demonstrated greater endorsement of program values than did high-risk students in the control group. This collaborative partnership was able to combine community-based participatory research with a rigorous study design and provide sustained benefit to community partners.

Value of Community Partnership for Understanding Stress and Coping in Rural Yup'ik Communities: The CANHR Study

Stress and trauma can compromise physical and mental health. Rural Alaska Native communities have voiced concern about stressful and traumatic events and their effects on health. The goal of the Yup'ik Experiences of Stress and Coping Project is to develop an in-depth understanding of experiences of stress and ways of coping in Yup'ik communities. The long-range goal is to use project findings to develop and implement a community-informed and culturally grounded intervention to reduce stress and promote physical and mental health in rural Alaska Native communities. This paper introduces a long-standing partnership between the Yukon-Kuskokwim Regional Health Corporation, rural communities it serves, and the Center for Alaska Native Health Research at the University of Alaska Fairbanks. Within the context of the Stress and Coping project, we then discuss the value and challenges of taking a CBPR approach to advance science and address a priority community concern, and share strategies to respond to challenges. Focus groups were conducted to culturally adapt an existing structured interview and daily diary protocol to better fit Yup'ik ways of knowing. As modified, these interviews increased understanding of stress and coping particular to two Yup'ik communities. Challenges included the geographical nature of Yup'ik communities, communication barriers, competing priorities, and confidentiality issues. Community participation was central in the development of the study protocol, helped ensure that the research was culturally appropriate and relevant to the community, and facilitated access to participant knowledge and rich data to inform intervention development.

Identifying Community Needs and Resources in a Native Community: A Research Partnership in the Pacific Northwest

Indigenous communities have engaged in needs and resources assessments for thousands of years. By blending CBPR/TPR approaches with community-driven assets and needs assessments, academic and community based researchers can work together to better understand and identify community strengths as well as issues of concern in Native communities. This best practice approach can set research agendas that are relevant to Native communities and result in interventions and health promotion programs that are respectful of Tribal sovereignty and that incorporate unique traditions and strengths of Native communities. A successful research partnership to develop and implement a needs and resources assessment using CBPR/TPR approaches is presented using a case study that can be used as a model for other research partnerships.

Building partnerships between indigenous communities and universities: lessons learned in HIV/AIDS and substance abuse prevention research

Many HIV/AIDS and substance abuse prevention studies in American Indian and Alaska Native communities have been directed by academic researchers with little community input. We examined the challenges in conducting HIV/AIDS-related research in American Indian and Alaska Native communities and the benefits of changing the research paradigm to a community-based participatory model. The lessons we learned illustrate that the research process should be a cyclical one with continual involvement by community members. Steps in the process include (1) building and sustaining collaborative relationships, (2) planning the program together, (3) implementing and evaluating the program in culturally acceptable ways, and (4) disseminating research findings from a tribal perspective. These steps can enhance the long-term capacity of the community to conduct HIV/AIDS and substance abuse prevention research.

Minority health and small numbers epidemiology: a case study of living conditions and the health of children in 5 foreign Romá camps in Italy

OBJECTIVE

We sought to test methods for generating epidemiological evidence on health conditions of small, dispersed minority communities.

METHODS

We used community-based mixed methods including a cross-sectional survey in 5 purposely selected settlements of Khorakané Romá (Gypsies of Muslim culture) in Italy to study the living conditions and health status of children aged from birth to 5 years.

RESULTS

In the 15 days prior to the survey, 32% of the children had suffered diarrhea and 55% had had a cough. Some 17% had experienced respiratory difficulties during the past year. Risk factors associated with these outcomes included years spent living at the camp, overcrowding, housing conditions, use of wood-burning stoves, presence of rats, and issues related to quality of sanitation and drains. Qualitative information helped define the approach and the design, and in the interpretation and consolidation of quantitative results.

CONCLUSIONS

Guided by the priorities expressed by dispersed minority communities, small studies with little resources can provide a solid base to advocate for evidence-based participatory planning. Exact intervals appeared to be robust and conservative enough compared with other intervals, conferring solidity to the results.

A cross-cultural and historical survey of tobacco use among various ethnic groups

This review of tobacco use in diverse historical and cultural contexts reveals a range of behaviors engaged in and perspectives held by members of respective ethnic groups, such as whether to consider tobacco as a medicine or as a problem. After its introduction to Western societies, many attributed tobacco with an array of medicinal uses, while condemning recreational use and identifying it as immoral. Tobacco has been used variously by respective ethnic groups at different times and places and these customs have flavored understandings of the relationships between tobacco and the body. Considerable ethnic variation exists not only in terms of tobacco use and abuse, but also with respect to pharmacogenetic factors that influences the consequences of tobacco exposure. There have also been different societal responses to the use of tobacco, including those related to the media, as well as to issues of treatment and prevention.