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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
Arizona Prevention Research Center
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
Arizona Prevention Research Center
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
Arizona Prevention Research Center
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)
Arizona Prevention Research Center
• 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
Arizona Prevention Research Center
AzPRC Community Partners
Arizona Prevention Research Center
Arizona Prevention Research Center
CBPR Infrastructure
Community Action Board
Research Committee
Cochise
CHD
Mariposa
CHC Regional
Center for
Border
Health
Sunset
CHC
Campesinos
Sin
Fronteras
Chiricahua
CHC
Arizona Prevention Research Center
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.
Arizona Prevention Research Center
Phase II: CHW Advocacy and Policy Intervention Efforts
CHW Advocacy: An Adaptation of Kingdon’s Three Streams Theory
Arizona Prevention Research Center
RESEARCH DESIGN
Arizona Prevention Research Center
Arizona Prevention Research Center
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
Arizona Prevention Research Center
Logic Model for CBPR
Cited in Wallerstein and Duran , Am J Public Health. 2010;100:S40–S46.
Arizona Prevention Research Center
Arizona Prevention Research Center
Arizona Prevention Research Center
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
Arizona Prevention Research Center
Arizona Prevention Research Center
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.”
Arizona Prevention Research Center
Arizona Prevention Research Center
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
Arizona Prevention Research Center
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.“
Arizona Prevention Research Center
Arizona Prevention Research Center
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.
Arizona Prevention Research Center
Intervention / Research
• 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
Arizona Prevention Research Center
Arizona Prevention Research Center
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
Arizona Prevention Research Center
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
Arizona Prevention Research Center
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
Arizona Prevention Research Center
Intervention / Research
– 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
Arizona Prevention Research Center
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?
Arizona Prevention Research Center
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
Arizona Prevention Research Center
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.
Arizona Prevention Research Center
THANK YOU!
¡MUCHAS GRACIAS!
• Susan Kunz, [email protected]
• Kerstin M. Reinschmidt, PhD, [email protected]