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1 of 10
The Future of Community-
Engaged & Practice-Based
Research: Challenges and
Opportunities
“The Future of Community-Engaged Research”
May 2, 2011
Johns Hopkins University
Lawrence W. Green
University of California at San Francisco
The Challenges & Opportunities
The two biggest challenges:
To close the gap between what policy makers,
program planners, practitioners and communities
need & what they are getting from our research
The obesity epidemic
The two biggest opportunities
Extend CBPR principles to work with policy
makers, program planners & practitioners in use
of natural experiments
Combine CBPR with multi-site RCT methods that
expand the external validity of the results
Where
am I?
You’re 30
metres
above the
ground in a
balloon
You must
be a
researcher
Yes.
How
did you
know?
Because what
you told me is
absolutely
correct but
completely
useless
You must
be a policy
maker
Yes,
how did
you
know? Because you
don’t know where
you are, you
don’t know where
you’re going, and
now you’re
blaming me
The problem
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Narrow focus: Lack of attention to larger
systems context
Lacking details of implementation process
Lack of relevance to real world
Many studies focus on one intervention, but
obesity may require a combination of
interventions; in fact, some things appear not
to work when tested alone, but are essential
ingredients in a more comprehensive program
Problems Identified by IOM Report*
(www.nap.edu)
*Institute of Medicine. Bridging the Evidence Gap in Obesity Prevention: A Framework
to Inform Decision Making. Washington, DC: The National Academies Press, 2010.
IOM Conclusions about
Status of Evidence The current evidence lacks the power to set a clear
direction for obesity prevention across a range of
target populations
This lack of evidence for effectiveness seen as a lack
of effectiveness
It is difficult to fund, conduct & publish research on
community, environmental, and policy-based obesity
prevention initiatives
Assessing or reporting on the generalizability of
research results to other populations or settings has
not been given priority
Types of Community-Engaged
Evidence for Health Research
Participatory research evidence
Community-Based Participatory Research (CBPR)
Practice-based or action research
Surveillance evidence
Population diagnostic evidence
Program evaluation evidence
Multi-component
Continuous quality improvement
How context effects (moderates) outcomes
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Three Paradoxes
The internal validity--external validity paradox
The more rigorously controlled a study testing the
efficacy of an intervention, the less reality-based it
becomes, so it cannot be taken to scale or generalized
The specificity – generalizability paradox
The more relevant and particular to the local context,
the less generalizable to other contexts
The homophily -- social distancing paradox
The effectiveness of indigenous community health
workers draws on their commonalities with the
community, but they are sometimes seen as losing that
Granted, a living legend. But what has he done for his people?
Six Questions About CBPR
1 What is it? Define participatory research, CBPR.
2 What is the added value for health behavior research?
3 What predicts outcomes in CBPR? What are successful
methods to establish CBPR, measure CBPR-related outcomes
4 What sustains effective partnerships?
5 The Intersection of CBPR and translational research: What is
the cutting edge in community engagement in translating
health behavior research to practice?
Innovations in health behavior research targeting improvements
in minority health and health disparities using CBPR
Measurement issues in CBPR
Challenges, opportunities for health behavior research & CBPR
4 of 10
“It’s simple, Dr. Green. Just chip away anything
that doesn’t look like health education.”
I”It’s easy, Green, just chip away at anything that
doesn’t look like CBPR”
Definition and Standards of
Participatory Research for Health*
Systematic investigation…
Actively involving people in a co-learning
process…
For the purpose of action conducive to
health
--not just involving people more intensively as subjects of research or evaluation
*Green, George, Daniel, et al., Participatory Research…Ottawa: Royal
Society of Canada, 1997. www.lgreen.net/guidelines.html
“To begin with, I would like to express my sincere thanks and deep
appreciation for the opportunity to meet with you. While there are
still profound differences between us, the very fact of my presence
here tonight is a major breakthrough.”
Professor to Community
5 of 10
Gary Larson
“I want you to quit smoking and lose 35 pounds. Then I
want you to come back and tell me how the hell you did it.”
Caption
adapted
from
Bizarro,
Universal
Press, 1997.
1. What constitutes CBPR?
2. What is the added value?
3. What predicts
successful outcomes?
4. What sustains
it? 5. What translates it
into policy or changes
in practice?
6. Challenges and opportunities
for health behavior research
6 of 10
The Spheres of Practice-Based,
Community-Based, Academic &
Participatory Research
Practice-
Based
Research
Community-
Based
Research
Participatory
Research
Highly
Controlled
Academic
Research
CBPR
Number of Publications on CBPR
Based on Scopus Search*
0
50
100
150
200
250
300
350
400
450
1987
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Publications on CBPR
Publications
*Based on unpublished Scopus review by Doug Brugge, Tufts U., 2011.
Top 9 journals publishing CBPR papers
Progress in Community Health Partnerships: Research, Education & Action (87)
American Journal of Public Health (49)
Journal of Health Care for the Poor and Underserved(33)
Health Promotion Practice (30)
Environmental Health Perspectives (29)
Ethnicity and Disease (26)
Health Education and Behavior (25)
American Journal of Preventive Medicine (21)
Journal of Urban Health (21)
*Based on unpublished Scopus review by Doug Brugge, 2011
7 of 10
Second Tier of CBPR Journals*
Social Science and Medicine (16)
Journal of Empirical Research on Human Research Ethics (14)
AIDS Education and Prevention (14)
Family and Community Health (14)
American Journal of Community Psychology (13)
American Journal of Bioethics (13)
Cancer (13)
Journal of General Internal Medicine (13)
*Based on unpublished Scopus review by Doug Brugge, 2011
Authors publishing most CBPR articles*
Minkler, M. (23)
Israel, B.A. (21)
Parker, E.A. (15)
Jones, L. (13)
Hergenrather, K.C. (11)
Rhodes, S.D. (10)
Schulz, A.J. (10)
Flicker, S. (9)
Macaulay, A.C. (8)
Wallerstein, N. (8)
Rhodes, S.D. (7)
Eng, E. (7)
Travers, R. (7)
Wells, K.B. (6)
Senturia, K. (6)
Montano, J. (6)
Farquhar, S.A. (6)
Sullivan, M. (6)
Shiu-Thornton, S. (6)
Vasquez, V.B. (6)
Horowitz, C.R. (6)
Christopher, S. (6)
*Scopus
Institutions with Most CBPR
Publications Univ Michigan School of Public Health
(47) & Univ Michigan, Ann Arbor (29)
UCLA (35) & UCLA Sch Public Health
(20) & David Geffin School of Medicine
at UCLA (19)
UC Berkeley (33)
University of Toronto (31)
RAND Corporation (23)
The University of British Columbia (23)
Univ of North Carolina at Chapel Hill
(22)
Univ of Illinois at Chicago (22)
Univ California, San Francisco (20)
Johns Hopkins Bloomberg School of
Public Health (18) & JHU (15)
Mount Sinai School of Medicine (18)
University of Washington Seattle (18)
CDC (18)
Columbia Univ (18) & Med Center (12)
University of New Mexico (18)
Wake Forest Univ School of Medicine
(16)
University of Pennsylvania (15)
Harvard School of Public Health (15)
University of Manitoba (14)
University of Florida (14)
University of South Carolina (14)
George Washington University (13)
VA Medical Center (13)
National Inst Environmental Health Sci
(13)
Charles R. Drew Univ of Med and
Science (12)
University of Arizona (12)
Meharry Medical College (12)
University of Maryland (11)
8 of 10
Subject Areas with Most CBPR Pubs*
Medicine & Public Health
(1,056)
Social Sciences (407)
Nursing (187)
Environmental Science (141)
Psychology (118)
Agricultural and Biological
Sciences (54)
Health Professions (53)
Biochemistry, Genetics and
Molecular Biology (49)
Business, Management and
Accounting (33)
Economics, Econometrics and
Finance (22)
Earth and Planetary Sciences
(19)
Engineering (19)
Pharmacology, Toxicology and
Pharmaceutics (13)
Immunology and Microbiology
(12)
Neuroscience (12)
Computer Science (9)
Arts and Humanities (6)
Dentistry (5)
*Scopus
Subject Areas with Most CBPR Pubs
Medicine & Public Health (1,056)
Social Sciences (407)
Nursing (187)
Environmental Science (141)
Psychology (118)
Agricultural and Biological Sciences
(54)
Health Professions (53)
Biochemistry, Genetics and
Molecular Biology (49)
Business, Management and
Accounting (33)
Economics, Econometrics and
Finance (22)
Earth and Planetary Sciences (19)
Engineering (19)
Pharmacology, Toxicology and Pharmaceutics (13)
Immunology and Microbiology (12)
Neuroscience (12)
Computer Science (9)
Arts and Humanities (6)
Dentistry (5)
Energy (4)
Chemical Engineering (3)
Chemistry (2)
Multidisciplinary, Mathematics, Materials Science, Decision Sciences, Vetenary (1)
Undefined (26)
*Scopus
The Lenses of Scientists, Health
Professionals and Lay People
Objective
Indicators
of Health
Subjective
Indicators
of Health
Professional,
ScientificLayperson
9 of 10
Closing the Gaps Between Population & Scientists or Practitioners’ Perception of Needs, and Funders’ Assessments
A
*Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.
“Actual
needs”
Resources,
feasibilities,
policy
People’s
perceived needs,
priorities A
Reconciling Perceived Needs,
“Actual Needs,” & Resources
Participatory researchAction
Advocacy for
regulation &
organizational
development
Health educationPeople’s
perceived needs,
priorities
“Actual
needs”
Resources,
feasibilities,
policy
PolicyResearch &Surveillance
Source: Green LW & Kreuter MW. Health Program Planning, 4th edition, 2004.
New (neglected) Evidence Forms
Participatory research evidence
Community-Based Participatory Research
Practice-based or action research
Surveillance evidence
Population diagnostic evidence
Program evaluation evidence
Multi-component evaluations
Continuous quality improvement
How context effects (moderates) outcomes
10 of 10
Uses of Evidence & Theory in Population-Based,
Diagnostic, Planning & Evaluation Models*
1. Assess Needs & Capacities of Population
2. Assess Causes (X) & Resources
3. Design & ImplementProgram
4. Evaluate Program
Reconsider X
Program Evidence& Effectiveness Studies,and use of Theory
Evidence fromEtiologic Research
Evidencefrom communityor population
Evidence from Efficacy Studies,and Use of Theory to Fill Gaps
*Green & Kreuter, Health Program Planning. 4th ed. NY: McGraw-Hill, 2005, Fig. 5-1.
Reasons for Surveillance as a
Challenge and an Opportunity
For CBPR
Communities need/want more particular, local data
CBPR projects usually can’t afford to do population
surveys, much less time-series surveys
For health behavior research
Provides the most powerful alternative to RCTs for
population-level change & community interventions
Provides the most credible source of evidence for
external validity and dissemination of practice-based
evidence
Change in Per Capita Cigarette ConsumptionCalifornia & Massachusetts vs Other 48 States, 1984-1996
-25
-20
-15
-10
-5
0
5
Perc
en
t R
ed
uc
tio
n
Other 48 States California Massachusetts
1984-1988 1990-1992 1992-1996
11 of 10
http://www.cdc.gov/tobacco
New (neglected) Evidence Forms
Participatory research evidence
Community-Based Participatory Research
Practice-based or action research
Surveillance evidence
Population diagnostic evidence
Program evaluation evidence
Multi-component evaluations
Continuous quality improvement
How context effects (moderates) outcomes
Quality of
life
Phase 1
Social
Assessment
Health
Educational
strategies
Policy
regulation
organization
HealthProgram
Phase 4a
Intervention
Alignment
Output Longer-term
health outcome
Short-term
social impact
Short-term
impactProcessInput Long-term
social impact
Phase 5
Implementation
Phase 6
Process evaluation
Phase 7
Impact and outcome evaluation
Predisposing
Reinforcing
Enabling
Phase 3
Educational &
Ecological
Assessment
Behavior
Environment
Precede Evidence Tasks: Specifying needs
as measurable baselines, objectives & targets
for evaluation.
Phase 4b
Administrative
& Policy
Assessment
Proceed Evaluation Tasks: Monitoring & Continuous Quality Improvement
Phase 2
Epidemiological, Behavioral
and Environmental
Assessment
Genetics
PRECEDE-PROCEED as both
Logic Model and Procedural Model
12 of 10
New (neglected) Evidence Forms
Participatory research evidence
Community-Based Participatory Research
Practice-based or action research
Surveillance evidence
Population diagnostic evidence
Program evaluation evidence
Multi-component evaluations
Continuous quality improvement
How context effects (moderates) outcomes
Intervention
or Program
Mediator
Mediator
Outcome Variable(s)
Moderators
Mediating and Moderating Variables
Moderators
Green & Kreuter, Health Program Planning: An Educational and Ecological
Approach. 4th ed. New York: McGraw-Hill, 2005. Green & Glasgow, E&HP, 2006.
Challenges to “Best Practices”
from Controlled Trials* Challenge of translating “best practices” from science to
practitioner behavior, and to public health
…of generalizing from research in one place, with one
population, to other places, people and circumstances
…of imposing experimental controls to generate “best
practices” for community and population efforts
Recommend “best practices” with “best processes” of
locally-specific, diagnostic-planning procedures & CBPR to
adapt efficacy-tested interventions to moderating variables…
*Green LW. From research to ‘best practices’… Am J H Behav, 25: 2001.
http://www.ajhb.org/
13 of 10
The Multi-Site Translational
Community Trial (mTCT) Proposal* Blends the internal validity advantages of
Cluster randomized trial or multi-site RCT
Fidelity to the function (but not the form) of an efficacy-
tested intervention
With the external validity advantages of
Diversity of settings, cultures, circumstances
Adaptation of the form (not the function) of the efficacy-
tested intervention
With some sacrifice of CBPR degrees of freedom*Katz DL et al. From controlled trial to community adoption…Am J Public Health, in
press, 2011.
The mTCT for Practice-Based,
Community-Based, Academic to
Participatory Research
Practice-
Based
Research
Community-
Based
Research
Participatory
Research
Highly
Controlled
Academic
Research
CBPR
Aligning Evidence* with (and deriving it from)
Practice: Matching, Mapping, Pooling & Patching
Matching ecological levels of a system or community
with RCT evidence of efficacy for interventions at
those levels
Mapping theory to the causal chain to fill gaps in the
evidence for effectiveness of interventions
Pooling experience to blend interventions to fill gaps
in evidence for the effectiveness of programs in
similar situations
Patching pooled interventions with indigenous
wisdom and professional judgment about plausible
causes & interventions to fill gaps in the program for
the specific population
*Green & Kreuter, Health Program Planning: An Educational and EcologicalApproach. 4th ed. NY: McGraw-Hill, 2005, Chapter 5. Green & Glasgow, 2006.
14 of 10
“A university’s values are most clearly described
by its promotion and tenure policy and by the
criteria used to evaluate faculty members”
--Conrad Weiser et. al.
Scholarship Unbound for the 21st Century, 2000
The Ultimate Litmus Test
for University Values
Scholarship in the Health
Professions*
“Federal funders of research and academic institutions
should recognize and reward faculty scholarship related to
public health practice research”
“Academic institutions should develop criteria for
recognizing and rewarding faculty scholarship related to
service activities that strengthen public health practice”
“Schools of public health should provide increased
academic recognition and reward for policy-related
activities.”
*Institute of Medicine, The Future of the Public’s Health in the 21st Century.
(Washington, DC: National Academies Press, 2002).
The Case for Participatory and
Practice-Based Research
“Participatory approach at the front-end of the
research pipeline is the best assurance of
relevance and utilization of the research at the
other end of the pipeline.” Commission on Community-Engaged Scholarship in the Health Professions.
Linking Scholarship and Communities: Report of the Commission on
Community-Engaged Scholarship in the Health Professions. Seattle:
Community-Campus Partnerships for Health, 2005.
“If we want more evidence-based practice…
…we need more practice-based evidence” AJPH, 2006
15 of 10
6 Challenges & Opportunities
Reform the research funding priorities
Reform publication criteria
Reform the criteria for inclusion & weighting of
studies into systematic reviews & research syntheses;
Reform the derivation and qualification of practice
guidelines from the systematic reviews;
Reform the academic promotion & tenure criteria
& weights given to community- & practice-based
research;
Reform the research training of students & fellows in
methods of practice-based and participatory research
A Vision
A future in which we would not need to ask
how to get more evidence-based practice…
Rather, how to engage students,
practitioners, patients and communities in a
participatory process of practice-based
research and program evaluation?
How to adapt the “best practices”
guidelines through best processes of
collecting data to diagnose the behavioral
needs of their patients & communities…
The Vision (expanded)
How to match evidence-based interventions
to those needs, filling gaps in the evidence
with the use of theory , mutual consultation,
and prospective testing of complementary
interventions
The cumulative, building-block tradition of
evidence-based medicine from RCTs would
be complemented by parallel strengthening
and support of a tradition of participatory
research & evaluation conducted in practice
settings.