Transforming the field: the role of academic health centers in promoting and sustaining equity based community engaged research

Community-based participatory research (CBPR) and community engaged research (CEnR) are key to promoting community and patient engagement in actionable evidence-based strategies to improve research for health equity. Rapid growth of CBPR/CEnR research projects have led to the broad adoption of partnering principles in community-academic partnerships and among some health and academic organizations. Yet, transformation of principles into best practices that foster trust, shared power, and equity outcomes still remain fragmented, are dependent on individuals with long term projects, or are non-existent. This paper describes how we designed our Engage for Equity PLUS intervention that leverages the leadership and membership of champion teams (including community-engaged faculty, community partners and patient advocates) to improve organizational policies and practices to support equity based CBPR/CEnR. This article describes the feasibility and preliminary findings from engaging champion teams from three very different academic health centers. We reflect on the learnings from Engage for Equity PLUS; the adaptation of the intervention design and implementation, including the development of a new institutional assessment using mixed research methods; and our organizational theory of change. In summary, our design and preliminary data from the three academic health centers provide support for new attention to the role of institutional practices and processes needed to sustain equity-based patient and community-engaged research and CBPR and transform the field.

Exploring theoretical mechanisms of community-engaged research: a multilevel cross-sectional national study of structural and relational practices in community-academic partnerships

Background

Community-Based Participatory Research (CBPR) is often used to address health inequities due to structural racism. However, much of the existing literature emphasizes relationships and synergy rather than structural components of CBPR. This study introduces and tests new theoretical mechanisms of the CBPR Conceptual Model to address this limitation.

Methods

Three-stage online cross-sectional survey administered from 2016 to 2018 with 165 community-engaged research projects identified through federal databases or training grants. Participants (N = 453) were principal investigators and project team members (both academic and community partners) who provided project-level details and perceived contexts, processes, and outcomes. Data were analyzed through structural equation modeling and fuzzy-set qualitative comparison analysis.

Results

Commitment to Collective Empowerment was a key mediating variable between context and intervention activities. Synergy and Community Engagement in Research Actions were mediating variables between context/partnership process and outcomes. Collective Empowerment was most strongly aligned with Synergy, while higher levels of Structural Governance and lower levels of Relationships were most consistent with higher Community Engagement in Research Actions.

Conclusions

The CBPR Conceptual Model identifies key theoretical mechanisms for explaining health equity and health outcomes in community-academic partnerships. The scholarly literature’s preoccupation with synergy and relationships overlooks two promising practices—Structural Governance and Collective Empowerment—that interact from contexts through mechanisms to influence outcomes. These results also expand expectations beyond a “one size fits all” for reliably producing positive outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01663-y.

Structural Community Governance: Importance for Community-Academic Research Partnerships

Community based participatory research (CBPR) emphasizes democratic knowledge production and joint action between academics and communities to promote health equity through multilevel interventions. While much scholarship has expressed a commitment to collaboration between researchers and communities, effective methods of structural governance between community and academic stakeholders is under explored. We fill this gap by presenting a conceptual and empirical analysis describing multiple dimensions of structural governance in CBPR partnerships. First, we integrate public policy evidence on effective collaborative governance designs with the emerging literature in CBPR to create a conceptual model. Next, we utilize internet surveys of 179 federally funded community engaged research projects to construct and assess a measure of structural governance across multiple dimensions using confirmatory factor analysis. We explore whether antecedent factors such as the stage of the partnership and ethnic composition are associated with these dimensions and we examine associations for each of these components on positive perceptions of community involvement of research and collective empowerment. We develop a robust multidimensional measure of structural governance that is positively associated with perceptions of increased community involvement in research and collective empowerment.

CBPR Implementation Framework for Community-Academic Partnerships

The Engage for Equity (E2) study is an intervention trial for community-academic research partnerships that seeks to improve partnering practices and health equity outcomes by providing community and academic partners with tools to enhance and advance power sharing and health equity. Twenty-five community/academic research teams completed a two-day training intervention where they were introduced to the CBPR Conceptual Model and corresponding applied tools to their partnerships. We report on team interviews conducted immediately after the training, where teams discussed opportunities and challenges using the CBPR Model as an implementation framework as they considered their own contexts, their partnering processes/practices, actions, and their desired outcomes. We applied Diffusion of Innovation theory to guide data collection and analysis; augmented by intent to use and collective reflection. Results pointed to the flexibility of the CBPR model, concrete use of tools (e.g., planning/evaluation), and broader use in inspiring collective reflection to improve partnering practices and inform equity values. As an implementation framework, the CBPR model incorporates collaborative processes and strategies to mitigate power differentials into key phases of implementation studies, adding factors central to health equity work, not existing in previous implementation frameworks.

Scales of Practices and Outcomes for Community-Engaged Research

Despite the growth of research on community-engaged research (CEnR), recent reviews suggest there has been limited development of validated scales to measure key contexts, mechanisms, and outcomes, impairing testing and refinement of theoretical models. The purpose of this study is to present the psychometric properties of scales from the Engage for Equity (E2) project, stemming from a long-term research partnership examining community-engaged research projects. This study used a three-stage, cross-sectional format: (a) a sampling frame of 413 CEnR projects was identified; (b) 210 principal investigators completed a project-level survey and nominated partners for another survey; (c) 457 investigators and partners completed a survey about project contexts, processes, interventions, and outcomes. Factorial validity was established through confirmatory factor analysis supporting seven scales: contextual capacity, commitment to collective empowerment, relationships, community engagement in research actions, synergy, partner and partnership transformation, and projected outcomes. Convergent validity was established through examining covariances among the scales. This study largely yielded results consistent with a previous psychometric study of related measures, while demonstrating improved ceiling effects of the items and refined conceptualization of core theoretical constructs.

Engage for Equity: A Long-Term Study of Community-Based Participatory Research and Community-Engaged Research Practices and Outcomes

Community-based participatory research (CBPR) and community-engaged research have been established in the past 25 years as valued research approaches within health education, public health, and other health and social sciences for their effectiveness in reducing inequities. While early literature focused on partnering principles and processes, within the past decade, individual studies, as well as systematic reviews, have increasingly documented outcomes in community support and empowerment, sustained partnerships, healthier behaviors, policy changes, and health improvements. Despite enhanced focus on research and health outcomes, the science lags behind the practice. CBPR partnering pathways that result in outcomes remain little understood, with few studies documenting best practices. Since 2006, the University of New Mexico Center for Participatory Research with the University of Washington's Indigenous Wellness Research Institute and partners across the country has engaged in targeted investigations to fill this gap in the science. Our inquiry, spanning three stages of National Institutes of Health funding, has sought to identify which partnering practices, under which contexts and conditions, have capacity to contribute to health, research, and community outcomes. This article presents the research design of our current grant, Engage for Equity, including its history, social justice principles, theoretical bases, measures, intervention tools and resources, and preliminary findings about collective empowerment as our middle range theory of change. We end with lessons learned and recommendations for partnerships to engage in collective reflexive practice to strengthen internal power-sharing and capacity to reach health and social equity outcomes.

Engage for Equity: Development of Community-Based Participatory Research Tools

We developed a set of four community-based participatory research (CBPR) partnership tools aimed at supporting community-academic research partnerships in strengthening their research processes, with the ultimate goal of improving research outcomes. The aim of this article is to describe the tools we developed to accomplish this goal: (1) the River of Life Exercise; (2) a Partnership Visioning Exercise; (3) a personalized Partnership Data Report of data from academic and community research partners; and (4) a Promising Practices Guide with aggregated survey data analyses on promising CBPR practices associated with CBPR and health outcomes from two national samples of CBPR projects that completed a series of two online surveys. Relying on Paulo Freire's philosophy of praxis, or the cycles of collective reflection and action, we developed a set of tools designed to support research teams in holding discussions aimed at strengthening research partnership capacity, aligning research partnership efforts to achieve grant aims, and recalling and operationalizing larger social justice goals. This article describes the theoretical framework and process for tool development and provides preliminary data from small teams representing 25 partnerships who attended face-to-face workshops and provided their perceptions of tool accessibility and intended future use.

Partnerships, Processes, and Outcomes: A Health Equity-Focused Scoping Meta-Review of Community-Engaged Scholarship

In recent decades, there has been remarkable growth in scholarship examining the usefulness of community-engaged research (CEnR) and community-based participatory research (CBPR) for eliminating health inequities.This article seeks to synthesize the extant literature of systematic reviews, scoping reviews, and other related reviews regarding the context, processes, and research designs and interventions underlying CEnR that optimize its effectiveness. Through a scoping review, we have utilized an empirically derived framework of CBPR to map this literature and identify key findings and priorities for future research. Our study found 100 reviews of CEnR that largely support the CBPR conceptual framework.

Power Dynamics in Community-Based Participatory Research: A Multiple-Case Study Analysis of Partnering Contexts, Histories, and Practices

Community-based participatory research has a long-term commitment to principles of equity and justice with decades of research showcasing the added value of power-sharing and participatory involvement of community members for achieving health, community capacity, policy, and social justice outcomes. Missing, however, has been a clear articulation of how power operates within partnership practices and the impact of these practices on outcomes. The National Institutes of Health-funded Research for Improved Health study (2009-2013), having surveyed 200 partnerships, then conducted seven in-depth case studies to better understand which partnership practices can best build from community histories of organizing to address inequities. The diverse case studies represented multiple ethnic-racial and other marginalized populations, health issues, and urban and rural areas and regions. Cross-cutting analyses of the qualitative results focus on how oppressive and emancipatory forms of power operate within partnerships in response to oppressive conditions or emancipatory histories of advocacy within communities. The analysis of power was conducted within each of the four domains of the community-based participatory research conceptual model, starting from how contexts shape partnering processes to impact short-term intervention and research outputs, and contribute to outcomes. Similarities and differences in how partnerships leveraged and addressed their unique contexts and histories are presented, with both structural and relational practices that intentionally addressed power relations. These results demonstrate how community members draw from their resilience and strengths to combat histories of injustice and oppression, using partnership principles and practices toward multilevel outcomes that honor community knowledge and leadership, and seek shared power, policy, and community transformation changes, thereby advancing health equity.

Advancing system and policy changes for social and racial justice: comparing a Rural and Urban Community-Based Participatory Research Partnership in the U.S

BACKGROUND

The paper examines the role of community-based participatory research (CBPR) within the context of social justice literature and practice.

METHODS

Two CBPR case studies addressing health inequities related to Type 2 Diabetes and Cardiovascular disease were selected from a national cross-site study assessing effective academic-community research partnerships. One CBPR partnership works with African Americans in rural Pemiscot County, Missouri and the other CBPR partnership works with African American and Latinos in urban South Bronx, New York City. Data collection included semi-structured key informant interviews and focus groups. Analysis focused on partnerships' context/history and their use of multiple justice-oriented strategies to achieve systemic and policy changes in order to address social determinants of health in their communities.

RESULTS

Community context and history shaped each partnership's strategies to address social determinants. Four social justice approaches (identity/recognition, procedural, distributive, and structural justice) used by both partnerships were identified. These social justice approaches were employed to address underlying causes of inequitable distribution of resources and power structures, while remaining within a scientific research framework.

CONCLUSION

CBPR can bridge the role of science with civic engagement and political participation, empowering community members to become political agents who integrate evidence into their social justice organizing strategies.

RACE AS LIVED EXPERIENCE: The Impact of Multi-Dimensional Measures of Race/Ethnicity on the Self-Reported Health Status of Latinos

A growing body of social science research has sought to conceptualize race as a multidimensional concept in which context, societal relations, and institutional dynamics are key components. Utilizing a specially designed survey, we develop and use multiple measures of race (skin color, ascribed race, and discrimination experiences) to capture race as "lived experience" and assess their impact on Latinos' self-rated health status. We model these measures of race as a lived experience to test the explanatory power of race, both independently and as an integrated scale with categorical regression, scaling, and dimensional analyses. Our analyses show that our multiple measures of race have significant and negative effects on Latinos' self-reported health. Skin color is a dominant factor that impacts self-reported health both directly and indirectly. We then advocate for the utilization of multiple measures of race, adding to those used in our analysis, and their application to other health and social outcomes. Our analysis provides important contributions across a wide range of health, illness, social, and political outcomes for communities of color.

“The Politics of the HealthCare Reform Debate: Public Support of Including Undocumented Immigrants and Their Children in Reform Efforts in the U.S.”

Although U.S. immigration and health care policies appear to be highly correlated, scholarship has yet to gauge the public's views toward providing undocumented immigrants with health coverage at the state level. We analyze support for including undocumented immigrants in health care reform in New Mexico. Utilizing an original public opinion survey of New Mexico adults, we find that individuals are more supportive of the state providing health care to the children of undocumented immigrant than to their parents. Multivariate logistic regression analyses suggest that factors such as liberal ideology and perceptions of commonalities with Latinos increase support levels. Despite a lack of support among a majority of respondents, the influence of perceived commonalities with immigrants suggests that reform advocates and political elites who mobilize along ethnic or human solidarity may be successful in creating conditions for the inclusion of undocumented immigrants in the public provision of health care at the state level.

The Impact of Health Care and Immigration Reform on Latino Support for President Obama and Congress

At the start of their term, the Obama administration pledged to reform two failing policy systems in the United States: immigration and health care. The Latino populations’ attitudes toward these two critical policy areas are particularly relevant due to the large foreign born population in the Latino community and the large number of Latinos who lack health insurance. Yet studies have not examined what factors shape Latino approval ratings and whether support for health and immigration reform affect Latino approval ratings of the current administration. We use the 2009 Latino Decisions survey and find that the foundations of Latino approval ratings are political in nature, with support for health and immigration policy reform driving support of the current administration. Given the vital role the Latino electorate played during the 2008 election, the success of these two policy reform efforts may have major implications for the 2012 elections.