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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

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“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

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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

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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

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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)

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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

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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


Community-Based Participatory Research





Multi-component evaluations



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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

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http://www.cdc.gov/tobacco











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

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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/

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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.

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“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

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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.

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