Arizona Prevention Research Center The Use of Community ... · Arizona Prevention Research Center...

Arizona Prevention Research Center

The Use of

Community Based Participatory Research

in a Policy Intervention

Susan Kunz, MPH

Mariposa Community

Health Center

&

Community Action Board

Co-Chair

Arizona Prevention

Research Center

Kerstin M. Reinschmidt,

PhD, MPH

Arizona Prevention

Research Center

at the

Mel and Enid Zuckerman

College of Public Health


Community-based Research Committee Members:

Mariajose Almacen, Oscar Franco, Vaira Harik,

Lucy Murrieta, Rosie Piper, Floribella Redondo, Laurie

Robinson, Ila Tittlebaugh,

Arizona Prevention Research Center (AzPRC):

Scott Carvajal, Maia Ingram, Mary Contreras,

Christopher L. Davidson, Jill G. de Zapien, M. Lourdes

Fernandez, Perry Gast, Kerstin M. Reinschmidt,

Samantha Sabo, Ken Schachter, Tanyha Zepeda

AzPRC CAB Co-Chair: Susan Kunz

Former AzPRC Director: Lisa K. Staten


Purpose of Presentation

• Look at CBPR in context of AzPRC’s current

policy intervention and Wallerstein’s (W&D

2010) logic model for CPBRCited in Wallerstein and Duran , Am J Public Health. 2010;100:S40–S46.

– Policy and CBPR

– AzPRC CBPR policy project

– W’s logic model applied to AzPRC project

– Conclusions

– CBPR as transformative research paradigm

– Remaining challenges and future directions


Policy and CBPR• Policy change is essential to addressing health disparities

• CBPR is essential to addressing health disparities

• W&D (2010) see CBPR as a means of addressing the

challenges of intervention sciences / translational research

– Challenges: being unidirectional and having unequal power relations

– CBPR: bi-directional and equalizing power relationships

• CBPR has emerged “as transformative research paradigm that

bridges the gap between science and practice through

community engagement and social action to increase health

equity.” (W&D 2010:S40)

• “CBPR has an important role in expanding the reach of

translational intervention and implementation sciences to

influence practice and policies for eliminating health disparities.” (W&D 2010:44)


• Our belief / hypothesis: We think that

using community based participatory

research rather than a traditional research

design will be more likely to result in a

policy intervention (that is promotores

doing community advocacy) that results in

changes in community health


AzPRC Community Partners


CBPR Infrastructure

Community Action Board

Research Committee

Cochise

CHD

Mariposa

CHC Regional

Center for

Border

Health

Sunset

CHC

Campesinos

Sin

Fronteras

Chiricahua

CHC


Primary Aim of

AzPRC’s policy focused project

• To determine the effectiveness of

integrating community advocacy into CHW

outreach and education activities in

increasing community-driven policy change

related to chronic disease prevention within

organizations, systems, and the broader

social and physical environment in

communities along the Arizona-Mexico

Border.


Phase II: CHW Advocacy and Policy Intervention Efforts

CHW Advocacy: An Adaptation of Kingdon’s Three Streams Theory


RESEARCH DESIGN


The CBPR Logic Model

and the AzPRC

• Use logic model to analyze our CBPR

process involving CHWs in engaging

communities to address health disparities

through policies and environmental

changes


Logic Model for CBPR

Cited in Wallerstein and Duran , Am J Public Health. 2010;100:S40–S46.


Project Context• Increased community capacity leads to

policy change/research

• Local organizations are the best partners

to outreach and understand the

community

• Promotores de Salud (CHWs) are trusted

advocates and liaisons for policy work.

• Anti-immigrant policy in Arizona affects life

and work along the border


Project Context

• “Increased core services allow for a focus on larger scale policy research.”

• “The only way to understand community needs is to actively conduct outreach and talk to people, and the structure of this project allows the community organizations to do that within the context of their current work.”

• “The complexity of the environments with respect to policy work, the border, and documentation status is overwhelming. CHWs, as trusted members of the community, can walk between the boundaries of those issues. It is a tough path to walk but they can mitigate the fear factor that stops people from being involved.”

• “Our CHWs are comfortable with that and feel they are trusted by the community. People would not talk to anyone else.”


Group Dynamics and Equitable

Partnership

• Interconnectedness - High level of existing

relationships between individuals and

organizations for readiness

• Regional peer network - Sharing between

promotores enhances communication and

collaboration on a local and regional level

Power – Community partners will determine the

intervention , which is exciting but challenging

for the academic partners


Group Dynamics and Equitable Partnership

• “Interconnectedness of people and organizations meant that we already had a lot of sharing and trust across partners and were in many ways ready to go with this project.”

• “Communication is very important and the peer network which allowed sharing between promotores really enhances that communication. It allows collaboration on different levels, not just organizationally, but on the level of the CHWs regionally.”

• “Who has the power?”

• “Probably the communities have more power in this project because they are deciding on what the intervention will be.”

• “That is scary but exciting for the academic partners. However, as the grantee the academic partner also has to follow a timeline and move things along.“


Intervention / Research

• Reciprocal learning in terms of sharing

capacity, writing papers, actively engaging staff.

.

• Regional policy intervention is locally informed.

• Research design allows for the political capital

necessary for broad policy change.



• Reciprocal learning in terms of sharing

capacity, writing papers, engaging staff

• Policy change requires a lot of people to be

behind it and the project CHWs facilitate that

• We are creating one policy intervention that

is individually tailored across many

communities

• This project requires political capital and

CBPR lends itself to building that capital


Outcomes• Power Relations – Community Action Board

highly vested in design and intervention (local

control not always easy for researchers)

• Empowerment – Promotores moving

discussion into action.

• Cultural renewal – Regional strength to

confront negative anti-immigrant environment

• Change – Embrace the unexpected


Outcomes

• “Things are going that direction [the direction we want them to], but we need more time to know how things will change.”

• “In terms of empowerment we are seeing the promotores take discussions a little further than they did before.”

• “It is an evolution through time, rather than mapped out at the beginning.”

• Challenge for researchers: allow the unfolding of the CBPR process to determine outcomes through community action, rather than defined at outset


Conclusion:

Why CBPR with policy focus?Context

• Chronic Disease, in

particular, diabetes

infrastructure has

improved dramatically

• Context has shifted over

time with increased

emphasis on immigration

• Trust between CHWs and

community

Group Dynamics

• Long-standing coalitions to

address community health

• CHW model has facilitated

increasingly participatory

nature of the research

• Trust between UA staff and

community members

• Peer communication

among CHWs



– Ongoing activity that

followed a natural

trajectory from

documenting prevalence,

to interventions, and

addressing policy

– Active engagement of

community partners in all

aspects of research

– Researchers learning to

share leadership roles

Outcomes

• Short-term

– Empowered CHWs

– Researchers committed to

CBPR

– Achieving pre-planned

outcomes = setting up

local policy interventions

• Long-term

– Open to outcomes

emerging from local

projects


CBPR as transformative research paradigm

• AzPRC addresses translational research challenges through

CBPR

– bidirectional approach

• Investing two years of CAB meetings to design current policy project

• Working with research and training committees

• However, AzPRC staff takes lead in research protocol

– redistribution of power between academics and community by

• Almost reversing power relations

• However, most of the writing done by AzPRC staff and funding

granted to AzPRC

• Yes, a transformative paradigm, but maintaining commitment to

CBPR is a conscious negotiation process for the long-term

• Need to watch out for: What is the “outcome” of the intervention?

– Better science or better community outcome?


Remaining Challenges/Future Directions

• The BIG challenge of a CBPR policy-focused

intervention is related to measuring societal issues,

policy changes and health outcomes, because they are – not all pre-determined at onset of the research

– long term, outside of the research time frame

– difficult to connect directly

– not only concrete, isolated measures such as BMI

– not necessarily generalizeable due to the complexity of communities

• Include multiple qualitative and quantitative measures, and broaden

research design to capture social determinants of health

• Involve community partners in data collection and processing

• Explore systems thinking as framework to understand policy-

focused interventions

• Design follow-up studies related to long-term outcomes


Acknowledgements

• The Arizona Prevention Research Center is a member ofthe Prevention Research Centers Program, supported bythe Centers for Disease Control and Prevention (CDC)cooperative agreement number 1U48DP001925-01. Thecontents of this presentation are solely the responsibility ofthe authors and do not necessarily represent the officialviews of the Centers for Disease Control and Prevention.


THANK YOU!

¡MUCHAS GRACIAS!

• Susan Kunz, [email protected]

• Kerstin M. Reinschmidt, PhD, [email protected]

mailto:[email protected]

mailto:[email protected]

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