Gurus and Griots: Revisiting the research informed consent process in rural African contexts

BACKGROUND

Researchers conducting community-based participatory action research (CBPAR) in highly collectivistic and socioeconomically disadvantaged community settings in sub-Saharan Africa are confronted with the distinctive challenge of balancing universal ethical standards with local standards, where traditional customs or beliefs may conflict with regulatory requirements and ethical guidelines underlying the informed consent (IC) process. The unique ethnic, socioeconomic, and cultural diversities in these settings have important implications for the IC process, such as individual decisional autonomy, beneficence, confidentiality, and signing the IC document.

MAIN TEXT

Drawing on insights and field observations from conducting CBPARs across several rural, highly communal, low literate, and low-income communities in Ghana, we discuss some theoretical, ethico-cultural, and methodological challenges associated with applying the universal, Western individualistic cultural value-laden IC process in sub-Saharan Africa. By citing field situations, we discuss how local cultural customs and the socioeconomic adversities prevalent in these settings can influence (and disrupt) the information disclosure process, individual decisional authority for consent, and voluntariness. We review the theoretical assumptions of the Declaration of Helsinki's statement on IC and discuss its limitations as an ultimate guide for the conduct of social science research in the highly communal African context. We argue that the IC process in these settings should include strategies directed at preventing deception and coercion, in addition to ensuring respect for individual autonomy. We urge Universities, research institutions, and institutional review boards in Africa to design and promote the use of context-appropriate ethical IC guidelines that take into consideration both the local customs and traditional practices of the people as well as the scientific principles underpinning the universal IC standards.

CONCLUSION

We recommend that, rather than adopt a universal one-size-fits-all IC approach, researchers working in the rural, highly collectivistic, low literate, socioeconomically disadvantaged settings of sub-Saharan Africa should deeply consider the roles and influence of cultural values and traditional practices on the IC and the research process. We encourage researchers to collaborate with target communities and stakeholders in the design and implementation of context-appropriate IC to prevent ethics dumping and safeguard the integrity of the research process.

The Effects of Two Community-Based Participatory Action Research Programs on Violence Outside of and in School Among Adolescents and Young Adults in a Latino Community

PURPOSE

Violence is the leading cause of death among adolescents and young adults in the Americas. Community-Based Participatory Action Research engaged youth and parents to develop and implement two interventions. A Violence Prevention Program (VPP) focused on risk factors for violence, and a Positive Youth Development Program (PYDP) focused on protective factors. Program effects on violence outside of and in school were assessed at 6 and 12 months.

METHODS

Both interventions included an 8-week internet-based program and an in-person youth summit. Participants were prospectively randomized twice, first to the VPP and a no-VPP control group and again to the PYDP and a no-PYDP control group. Participants self-reported violence outside of and in school through self-administered baseline surveys with repeat assessments at 6 and 12 months. Analysis of covariance models examined VPP and PYDP effects on violence.

RESULTS

The analysis sample was 86% Latino, 56% female, 36% aged 10-13 years, 45% aged 14-18, and 19% aged 19-23 years. Analysis of covariance models of violence outside of school demonstrated small program interaction effects at 6 months (partial eta² = .030; p = .007) and small VPP effects at 12 months (partial eta² = .023; p = .025). Models of violence in school demonstrated small PYDP effects at 6 months (partial eta² = .023; p = .018).

CONCLUSIONS

Community-Based Participatory Action Research engaging adolescents, young adults, and parents to address locally relevant health issues can have multiple benefits. In this study, a VPP had positive effects on violence outside of school at 12 months, and a PYDP had positive effects on violence in school at 6 months.

Muxeres en Acción: The Power of Community Cultural Wealth in Latinas Organizing for Health Equity

Community psychology, despite its commitment to social justice, is prone to engage in deficit-based perspectives that do not appropriately capture the strengths of Latinx communities. Given these limitations, we use a Community Cultural Wealth (CCW) (Yosso, 2005) framework to describe how muxeres, Latina women who identify as promotoras, madres, and mamás, leveraged their political power and culturally informed leadership to improve the health and well-being of their communities. We highlight instances from our fieldwork, witnessing the agency of muxeres en acción for health equity. We offer three case studies to describe how we approached our collaborations with three groups of muxeres situated in different geographic locations in the state of California. The first case study discusses how immigrant muxeres who identify as promotoras (e.g., health workers) in the Central Valley developed their research skills through a promotora model that allowed them to build the capacity to advocate for the well-being of their communities. The second example offers reflections from a Community-Based Participatory Action Research (CBPAR) project with a group of Mexican immigrant madres in a gentrified community in San José. Lastly, the third case study describes how a group of mamás in the East Side of Los Angeles addressed issues of educational inequities. Together, these case studies illustrate muxeres' advocacy for their health and well-being. Because women in general, and muxeres in particular, are considered gatekeepers of culture and tradition within their families, it is crucial that community psychologists ground their work in ethically and culturally appropriate frameworks that highlight the power of muxeres.

Involving Urban Single Low-Income African American Mothers in Genomic Research: Giving Voice to How Place Matters in Health Disparities and Prevention Strategies

This article describes the process of using principles from community-based participatory action research to involve low-income, single, African American mothers on the south side of Chicago in genomic research, including as citizen scientists. The South Chicago Black Mothers' Resiliency Project used a mixed methods design to investigate how the stress of living in neighborhoods with high levels of violence affects mothers' mental and physical health. This article seeks to serve as a model for physicians and scholars interested in successfully involving low-income African American mothers in genomic research, and other health-related activities in ways that are culturally sensitive and transformative. The lives of Black mothers who struggle under interlocking systems of oppression that are often hidden from view of most Americans are at the center of this article. Therefore, we provide extensive information about the procedures used to collect the various types of data, the rationale for our procedures, the setting, the responses of mothers in our sample and methodological challenges. This study also has implications for the current COVID-19 pandemic and the need to train a corps of citizen scientists in health and wellness to avoid future extreme loss of life such as the 106,195 lives lost in the United States as of June 1, 2020.

A Framework for Culturally Relevant Online Learning: Lessons from Alaska's Tribal Health Workers

Culturally relevant health promotion is an opportunity to reduce health inequities in diseases with modifiable risks, such as cancer. Alaska Native people bear a disproportionate cancer burden, and Alaska's rural tribal health workers consequently requested cancer education accessible online. In response, the Alaska Native Tribal Health Consortium cancer education team sought to create a framework for culturally relevant online learning to inform the creation of distance-delivered cancer education. Guided by the principles of community-based participatory action research and grounded in empowerment theory, the project team conducted a focus group with 10 Alaska Native education experts, 12 culturally diverse key informant interviews, a key stakeholder survey of 62 Alaska Native tribal health workers and their instructors/supervisors, and a literature review on distance-delivered education with Alaska Native or American Indian people. Qualitative findings were analyzed in Atlas.ti, with common themes presented in this article as a framework for culturally relevant online education. This proposed framework includes four principles: collaborative development, interactive content delivery, contextualizing learning, and creating connection. As an Alaskan tribal health worker shared "we're all in this together. All about conversations, relationships. Always learn from you/with you, together what we know and understand from the center of our experience, our ways of knowing, being, caring." The proposed framework has been applied to support cancer education and promote cancer control with Alaska Native people and has motivated health behavior change to reduce cancer risk. This framework may be adaptable to other populations to guide effective and culturally relevant online interventions.

Community-based participatory action research on rheumatic heart disease in an Australian Aboriginal homeland: Evaluation of the 'On track watch' project

Strategies to date have been ineffective in reducing high rates of rheumatic heart disease (RHD) in Australian Aboriginal people; a disease caused by streptococcal infections. A remote Aboriginal community initiated a collaboration to work towards elimination of RHD. Based in 'both-way learning' (reciprocal knowledge co-creation), the aim of this study was to co-design, implement and evaluate community-based participatory action research (CBPAR) to achieve this vision. Activities related to understanding and addressing RHD social determinants were delivered through an accredited course adapted to meet learner and project needs. Theory-driven evaluation linking CBPAR to empowerment was applied. Data collection comprised focus groups, interviews, observation, and co-development and use of measurement tools such as surveys. Data analysis utilised process indicators from national guidelines for Aboriginal health research, and outcome indicators derived from the Wallerstein framework. Findings include the importance of valuing traditional knowledges and ways of learning such as locally-meaningful metaphors to explore unfamiliar concepts; empowerment through critical thinking and community ownership of knowledge about RHD and research; providing practical guidance in implementing empowering and decolonising principles / theories. Lessons learned are applicable to next stages of the RHD elimination strategy which must include scale-up of community leadership in research agenda-setting and implementation.

Culturally-Relevant Online Cancer Education Modules Empower Alaska's Community Health Aides/Practitioners to Disseminate Cancer Information and Reduce Cancer Risk

To address a desire for timely, medically accurate cancer education in rural Alaska, ten culturally relevant online learning modules were developed with, and for, Alaska's Community Health Aides/Practitioners (CHA/Ps). The project was guided by the framework of Community-Based Participatory Action Research, honored Indigenous Ways of Knowing, and was informed by Empowerment Theory. A total of 428 end-of-module evaluation surveys were completed by 89 unique Alaska CHA/Ps between January and December 2016. CHA/Ps shared that as a result of completing the modules, they were empowered to share cancer information with their patients, families, friends, and communities, as well as engage in cancer risk reduction behaviors such as eating healthier, getting cancer screenings, exercising more, and quitting tobacco. CHA/Ps also reported the modules were informative and respectful of their diverse cultures. These results from end-of-module evaluation surveys suggest that the collaboratively developed, culturally relevant, online cancer education modules have empowered CHA/Ps to reduce cancer risk and disseminate cancer information. "brought me to tears couple of times, and I think it will help in destroying the silence that surrounds cancer".

Description of YESHealth: A consumer-directed intervention in a randomized trial of methods to improve quality of care for persons with disability

BACKGROUND

Persons leading their own evaluations of care quality offers the promise of generating maximally meaningful information to ensure person-centered care.

OBJECTIVES

To describe an intervention where persons with disability engage other persons with disability, develop their own metrics to assess their care, and provide these care evaluations directly to primary care practitioners, with the goal of improving care. The context was a research study involving One Care, a Massachusetts demonstration program with capitated reimbursement for individuals ages 18-64 dually eligible for Medicare and Medicaid.

METHODS

Individuals with serious mental illness or significant physical disability designed and implemented "YESHealth: Your Experience, Speak up for better health care." To solicit and communicate with YESHealth members, they mailed postcards announcing YESHealth to potential participants, created a website, sponsored a Facebook group, and staffed telephones in English and Spanish. YESHealth also involved reaching out to numerous disability advocacy organizations, developing and conducting short quarterly surveys about quality concerns they identified, and reporting survey results to YESHealth members and their primary care practitioners.

RESULTS

Over 12 months, YESHealth staff visited 60 community organizations to recruit participants. Recruiting participants was challenging and ultimately required offering monetary compensation. Participants preferred telephone to online communication. Efforts to engage targeted primary care practitioners had very limited success.

CONCLUSIONS

Despite these challenges, YESHealth represents a unique model for consumers' voices to try to affect change in care delivery. A randomized trial has evaluated whether the YESHealth intervention affected care quality for One Care members with disability.