What Predicts Outcomes in CBPR?

CHAPTER 21 WHAT PREDICTS OUTCOMES IN CBPR? NINA WALLERSTEIN, JOHN OETZEL, BONNIE DURAN, GREG TAFOYA, LORENDA BELONE, & REBECCA RAE WITH THE INCREASING recognition over the last decade that communities need to be partners in order to reduce disparities and improve health status, community-based participatory research (CBPR) has moved to center stage in intervention research (Israel, Eng, Schulz, & Parker, 2005; Viswanathan et al., 2004; Minkler & Wallerstein, 2003; Wallerstein Note: Funding for this pilot CBPR study (U26IHS300009A Supplement, N. Wallerstein, PI; B. Duran, co-PI) came from the National Center on Minority Health and Health Disparities (NCMHD, 2006–2008) in partnership with the Native American Research Centers for Health (NARCH). To incorporate a community-based participatory research (CBPR) approach within this funded research, a national advisory committee was formed that included principal investigators from the NCMHD and NARCH partnerships, other CBPR national experts, community members involved in selected CBPR projects, and representatives of the Navajo Nation. c21.indd 371 7/31/08 7:31:12 PM 372 Community-Based Participatory Research for Health & Duran, 2006). Nonetheless, the actual study of the science of CBPR, that is, the effects of participation and partnerships on public health interventions and health outcomes, remains insufficient. The majority of CBPR intervention literature has employed case studies to describe partnerships, research designs, and interventions. Articles to date primarily report strategies for creating and maintaining research partnerships, methods of data collection and analysis that have been adapted and adopted by partners, and facilitators and challenges to building trust among stakeholders. Far fewer papers have documented outcomes that can be attributed to CBPR partnerships and interventions (Viswanathan et al., 2004; Cargo & Mercer, 2008; see also Chapters Fourteen and Eighteen). As CBPR has received greater attention from the National Institutes of Health (NIH) and other agencies, foundations, and training programs (discussed in Chapter One), however, academic and community investigators have become increasingly interested in documenting the outcomes and impacts of CBPR research. A number of recent studies, including some explored in this second edition, report policy and capacity changes that have resulted from CBPR (Minkler, Breckwich Vásquez, Tajik, & Petersen, 2008). Nevertheless, documenting the health outcomes of CBPR remains a challenge (Viswanathan et al., 2004; Cargo & Mercer, 2008). This chapter seeks to further advance the study of how CBPR processes influence or predict outcomes. To this end, we report results of a two-year pilot study to identify the core processes and pathways to CBPR outcomes. This study focused on two central questions: What is the added value of CBPR to the research itself and to producing outcomes? and, What are the potential pathways to intermediate system and capacity change outcomes, and to more distal health outcomes? In this final chapter, we provide a brief rationale for the study, and we discuss the results of our CBPR literature review, our Internet survey, and the consensus process of a national CBPR advisory committee1 formed to synthesize a unifying, conceptual logic model of CBPR processes leading to outcomes. We present the conceptual model and the list of characteristics for each dimension in the model as a framework for future research into the identified gaps in CBPR knowledge. We further offer examples of testable hypotheses regarding the pathways and relationships between different dimensions of CBPR. Although the focus of this chapter is intervention research, the conceptual logic model can also be used to inform research about partnership processes in CBPR epidemiologic or other assessment studies. STUDY BACKGROUND Gaps in the CBPR and related scientific literatures motivated this pilot study that addressed three major challenges: (1) translating evidence-based interventions to widespread implementation and sustainability in diverse settings with populations that face health disparities; (2) evaluating community-supported interventions—those founded on cultural normative beliefs and practices rather than on evidence-based practice per se— and (3) gaps in the scientific knowledge base of CBPR itself, that is, lack of knowledge about what constitutes effective participatory processes and practices, about the ways c21.indd 372 7/31/08 7:31:12 PM What Predicts Outcomes in CBPR? 373 these processes and practices may manifest differently in different contexts; and about what constitutes systems-level and capacity changes, such as new policies or culturally centered interventions that have an impact on health outcomes in CBPR. Each of these challenges is discussed in the following paragraphs. 1. Translation of research to multiple settings. The NIH roadmap has recently heightened the importance of translational research (which moves science into practical applications), with issues of context and external validity assuming greater importance (National Institutes of Health, Office of Portfolio Analysis and Strategic Initiatives, 2008). As noted in Chapter One, efficacy studies and randomized controlled trials, which focus on internal validity, do not provide the knowledge necessary for translating and disseminating interventions to real-world settings with high variability in culture, context, and levels of acceptance (Wallerstein, 2007; Glasgow et al., 2006; Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005; Miller & Shinn, 2005). In a comprehensive review of the implementation literature, Fixsen and colleagues (2005) articulate that although evidence-based interventions have core elements, that is, underlying principles or best practices, they need to be flexible in applying these elements to the “noise” (the organizational, cultural, and policy differences) of different settings (Hohmann & Shear, 2002). Green, Glasgow, and colleagues argue for greater practitioner [and community] engagement. They advocate for the use of practice-based evidence or frameworks, such as RE-AIM, to enhance external validity; increase the use of research findings; and enable greater implementation, adaptation, and dissemination to new settings, with higher potential for sustainability (Green & Glasgow, 2006; Glasgow & Emmons, 2007; Green & Ottoson, 2004; Bull, Gillette, Glasgow, & Estabrooks, 2003). A recent systematic review of diffusion of innovations supports a better understanding of the range of intervention adoption methods, from passive diffusion through active dissemination (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). 2. Empirically supported interventions (ESIs) in the dominant culture do not necessarily translate to minority cultures, especially when culturally supported interventions (CSIs), including their theories and contexts, are excluded from the research (terms adapted from Hall, 2001; Persaud & Mamdani, 2006). Culturally supported interventions, although rarely circulated in the academic literature or tested with Western scientific methods, fit within the values and social service systems of local communities, support cultural revitalization, and remain highly used and sustained over time (see Chapter Five; Duran & Walters, 2004; Smith, 1999). CBPR offers a valuable means of creating an integrated, or a hybrid, approach to knowledge and to codeveloped interventions by (a) translating and testing the core components of empirically supported interventions with communities while also (b) integrating culturally supported interventions to enhance translation and sustainability within the local context. 3. The challenge persists of identifying the specific CBPR practices and processes needed to improve community capacity building or other system changes and health outcomes; and of specifying the conditions under which participation is effective c21.indd 373 7/31/08 7:31:12 PM 374 Community-Based Participatory Research for Health in contributing to these outcomes. There are limitations (Buchanan, Miller, & Wallerstein, 2007) as well as potential for using randomized controlled trials (see Chapter Four) to study participation as an independent variable, and other innovative methodologies will be needed to assess variability of participation and potential outcomes from this variability across CBPR sites. With the reality of CBPR falling across a continuum of participatory characteristics (such as being more university driven or more community driven), the starting place remains the identification of effective CBPR partnership processes and practices (Wallerstein, Duran, Minkler, & Foley, 2005; see also Chapter Two). LITERATURE SEARCH The purpose of our literature review was to summarize the state of the knowledge about existing partnering characteristics as preparation for creating a new model with hypothesized pathways of the ways in which CBPR processes predict outcomes. (See Table 21.1; the model and the description of characteristics are discussed later in this chapter.) We examined two earlier reviews: the CBPR study by Green and colleagues (1995) and the systematic literature review commissioned by the Agency for Healthcare Research and Quality (AHRQ) (Viswanathan et al., 2004). From the earlier literature, we created an initial list of CBPR characteristics, paying particular attention to the comprehensive dimensions generated by Schulz, Israel, and Lantz (2003), who adapted a nationally used, validated, coalition instrument (Sofaer, 2000), including group dynamics variables (Johnson & Johnson, 1999). We used search terms that paralleled the AHRQ study terms and expanded our literature review to the year 2007 and to several new databases. Table 21.1 displays the databases, search terms, inclusion criteria, and number of articles reviewed. Articles were coded in an iterative process to generate a larger inclusive list of characteristics within six categories. For PubMed, SciSearch and SocioFile, and “colleague-recommended” articles, the largest number of mentions was in the dimension of group dynamics (236), followed by context/environmental characteristics (141), structural dynamics of the partnership (126), CBPR capacity and systems outcomes (95), and individual characteristics of the principal investigator or community investigators (46). Linkages to health had the fewest mentions (27). We also sought new literatures to deepen our understanding of participation from the perspective of the macro- and micro-forces of power and relationships. To identify these new literatures we examined (1) the Business Source Premier database, which covers organizational and international development, highlighting historical and power relations within CBPR; (2) the indigenous CBPR articles from the United States, Canada, New Zealand, and Australia that centered on historical contexts of colonization, trust or mistrust, and race relations; and (3) the mass communication literature (including that indexed in PsycInfo) that highlighted organizational and micro-team dynamics in workforce and community partnerships. The Business Source Premier database contributed literatures on the positive contributions to participatory research by consumer and advocate researchers (Drew, Nyerges, c21.indd 374 7/31/08 7:31:13 PM What Predicts Outcomes in CBPR? TABLE 21.1 Literature Review Databases and Inclusion Criteria Database & search terms Search limits PubMed (10 exact terms used by AHRQ) “Community-based Participatory Research,” “CBPR,” “participatory English; 2002 research,” “action research,” to 2007; Male; “Participatory Action Research,” Female; Humans “participatory evaluation,” “community driven research,” “action science,” “collaborative inquiry,” “empowerment evaluation” SciSearch; SocioFile Same search terms as PubMed English; published in the last 6 years Business Source Premier “Community-based Participatory Research,” “Participatory Action Research” 2003–2007; English; removal of PubMed duplicates Communication & Mass Media Complete; PsycINFO Under each category, Group, Organization, or Team: “effectiveness,” “process,” “structure,” “communication,” “participation,” “satisfaction,” “roles,” “leadership,” “outcomes,” “climate,” “voice” Colleague-recommended articles c21.indd 375 375 Inclusion criteria If yes to these questions, include the article: a. Dimensions between collaborators discussed? b. Participation characteristics mentioned? c. Dimensions of the participatory process measured? d. Are the CBPR processes linked to outcomes? Articles reviewed 45 85 21 English; Adulthood; Human; Original Journal Article a. Not therapy groups b. Not computermediated communication c. Not educational groups (research on teaching group dynamics) 87 N/A N/A 20 7/31/08 7:31:13 PM 376 Community-Based Participatory Research for Health & Leschine, 2004; Resnik, Zeldin, & Sharp, 2005; Russell, 2006) and on the importance of interdisciplinary collaborations and political analysis for CBPR policy success (Spielman et al., 2006). Of equal importance from the international development literature were the methodological and theoretical critiques of power issues in participatory processes. Among these issues are the challenge of governance and conflict of interest in interdisciplinary groups (Special section on urban planning & public health, 2006), the conflation of methods and politics by politically activist researchers (Danieli & Woodhams, 2005), and the obscuring of systematic oppression even in the arguments related to power dimensions in participation (Williams, 2004). These literatures supported CBPR processes of political education and analysis as necessary for both practice and research in public health. The CBPR literature from American Indian and Alaska Native communities has helped to set the standard for community voice, ownership, and control, in opposition to the historical acculturative force of medicine and public health research (Smith-Morris, 2007; Manson, Garroutte, Goins, & Henderson, 2004). With sovereign nation status, Native communities involved in CBPR and tribal participatory research have pioneered the joint interpretation and application of research results and cultural revitalization (Fisher & Ball, 2002, 2003, 2005; see also Appendix H) and have stressed indigenous theories such as historical trauma, lateral oppression, and other tribally specific determinants of disease and wellness (DeJong & Holder, 2006; English, Fairbanks, et al., 2004; English, Wallerstein, et al, 2006; Jumper Thurman, Allen, & Deters, 2004; Strickland, 2006; Denzin, Lincoln, & Smith, 2008). Many tribal health workers have challenged the use of evidence-based practices and research, seeing it as a veiled attempt to repackage acculturative public health instead of promoting a partnership based on power sharing and collaborative knowledge creation. Although CBPR researchers stress the importance of participation, very few have discussed how or why the group interaction plays out (two exceptions are Schulz et al., 2003; Israel, Lantz, McGranaghan, Kerr, & Guzman, 2005). In contrast, the Communication and Mass Media Complete and PsycInfo databases included research on the microprocesses, or the “black box,” of group dynamics (Pelled, Eisenhardt, & Xin, 1999; Wheelan, 1999). This research addresses the individual, cultural, and structural factors that influence and shape group communication; the patterns of group dynamics over time; and the correlations of these patterns with positive and negative group outcomes (for example, productivity, quality decision making, and so forth). These micro-processes demonstrate why certain patterns might occur in CBPR partnerships and how to craft and sustain the most effective partnership. In summary, our literature review gave depth and breadth to the previously identified barriers and promoters of CBPR practice and also provided new characteristics for the next stage of model development. For CBPR that has an emancipatory purpose of cocreating knowledge for democratizing society (see Chapter Two), these characteristics involved, most prominently, the role of context (historical, governance, and power differences) and its influence on group dynamics; cultural issues (that is, cultural humility, the ability to bridge across cultures in group settings, culturally centered interventions, and outcomes of cultural revitalization); and recognition of the importance of CBPR intermediate system and capacity change outcomes in producing health outcomes. c21.indd 376 7/31/08 7:31:13 PM What Predicts Outcomes in CBPR? 377 ASSESSING DIMENSIONS OF PARTICIPATION AND PARTNERSHIP Internet Survey As noted previously and as graphically illustrated later in Figure 21.1, we identified characteristics under each of four dimensions of CBPR that are critical to consider if communities and researchers are to achieve a greater understanding of the pathways by which CBPR may lead to outcomes. These characteristics range from historical trust or mistrust to evidence of shared power, and they operate on individual, partnership, and contextual levels (see Figure 21.1). Employing the list of characteristics, our evolving model, and iterative discussions and input from our national advisory committee, we developed an Internet survey instrument to begin to test the saliency of the identified characteristics. The goals of the survey were to elicit community member and researcher opinions about the importance of different contexts and participatory characteristics and practices for CBPR projects and to pilot-test questions on the relationship of these participatory processes to outcomes. We sent the survey by e-mail link to the twenty-five CBPR projects funded by the National Center on Minority Health and Health Disparities (NCMHD), to the thirteen Native American Research Centers for Health (NARCH) projects, to our advisory committee members, and to additional CBPR projects. The following lists provide an overview of some of the questions included in this survey. All questions had Likert scale response categories. Internet Survey Questions About Contexts How important is ■ ■ ■ ■ ■ ■ ■ the issue of historical trust or mistrust between a community and the university’s overall research efforts to the eventual success of the CBPR project? the level of community strengths or history of organizing? the level of the university’s support and capacity to engage the community as partners? community concern about or perceived severity of the health problem as a stimulus to working together? cultural difference between the university and the community? openness and respect from the principal investigator or lead researcher? the actual distribution of resources? Internet Survey Questions About Participation Issues Within Group Dynamics: How important is ■ diversity of the partnership to achieving overall CBPR and health outcomes? ■ complexity of the partnership (number and kind of partners and issues)? ■ formality (for example, memorandums of agreement [MOAs], written principles, or by-laws)? ■ ability to bridge across cultural differences? c21.indd 377 7/31/08 7:31:14 PM 378 ■ ■ ■ ■ Community-Based Participatory Research for Health ability to accept, manage, and maintain trust through conflicts? ability to negotiate and make decisions in a participatory manner? ability to communicate and complete tasks? ability in a partnership to have a sense of closeness or supportive relationships? Although this was explicitly not a survey created to evaluate any individual partnership, we did ask about respondents’ own experiences with their overall participation in CBPR projects. Questions were framed, for example, on how much “cross-cultural bridging by the university members” or “power-sharing” they thought had really been achieved in the partnerships they had worked with. A final section of the survey adapted the RAND/UCLA appropriateness method2 to two contexts (Shekelle, 2004; Shekelle & Schriger, 1996): (1) high and low trust between universities and communities and (2) high and low community capacity to organize. Questions in this section asked respondents to think about how each context might affect, first, their group dynamics and, second, their ability to have an impact on the internal outcome of a strengthened partnership or on external outcomes of improved CBPR capacities, policies, practices, and health status. The purpose of adapting this appropriateness method was to demonstrate whether there was a consensus about best practices in CBPR and whether each participatory practice was considered worthwhile or a waste of time. There has been an assumption in the field, for example, that certain group dynamic practices should be implemented, but before this survey, there has been no empirical evidence supporting this assumption. Findings from the online survey of ninety-six respondents were generated (from sixteen NCMHD and seven NARCH projects) and used as discussion points for a meeting of our national advisory committee. In brief, the importance of CBPR group dynamics in creating effective CBPR processes leading to outcomes was ranked high, with little difference among racially and ethnically diverse respondents. Highest among these were the ability within the partnership to ■ ■ ■ ■ ■ accept, manage, and maintain trust through conflicts; communicate and complete tasks; negotiate and make decisions in a participatory manner; bridge across cultural differences; manage, recognize, and share power and resources. The contexts ranked highest for the success of the CBPR project were the importance or level of ■ ■ ■ ■ ■ c21.indd 378 trust/mistrust between a community and the specific university research team; university support and capacity to engage the community as partners; openness and respect from the principal investigator; community concern or perceived severity about the health problem; historic trust/mistrust between a community and the university’s overall research effort. 7/31/08 7:31:14 PM What Predicts Outcomes in CBPR? 379 National Advisory Committee Consensus Process As described earlier, a national advisory committee of CBPR experts has acted as participatory partners to provide consultation and direction throughout our research, offering feedback on the iterations of the list of characteristics and the evolving model, on the survey items, and on the committee members’ own experiences in taking the pilot survey. In a face-to-face consensus meeting, committee members interpreted survey results, sharpened the model, and discussed implications for further research. There was much discussion of the adapted RAND appropriateness method section because of findings which suggested differences in community member and university staff responses to low trust and low community capacity conditions, versus similarities in responses in high trust or high capacity conditions. Although there were concerns about the validity of the findings from this adapted RAND appropriateness method section (because of the compressed and abstract language used), important discussion emerged on the salience of context for influencing outcomes based on potential pathways in the model. The discussion provoked us to grapple with the challenge of creating methodologies and instruments for assessing contextual differences, whether they are differences in socio-economic inequities, cultural or population context, level of university or community capacity to work in partnership, or the dynamic and nuanced issues of trust and mistrust between the community and the university or university team. In particular, this led us to the inadequacy of current measurement tools to assess contextual and partnership power inequities and to our next steps to develop methodologies and instruments that take into consideration the complex contexts of power and the comparability of these complicated contextual constructs cross-culturally. Open-ended questions at the end of the survey revealed data that triangulated with the quantitative results. These data identified key barriers to success, such as time conflicts, lack of trust between partners, nonsustainable funding, power differences, and lack of communication. Key facilitators identified in the survey were successful communication, having a respected community member in the partnership, having a PI truly open to the CBPR process, and having long-standing partnerships characterized by commitment, trust, mutual understanding, and power sharing. The consensus meeting helped generate a final model (discussed later). Additionally, the following CBPR research questions for future research were developed: 1. What is the variability of CBPR projects within different contexts and partnerships, and are there minimal standards for classifying projects as being truly inside or outside the universe of CBPR? 2. How do we better understand dynamic power relations between academic and community partners? 3. How do we better define best or promising practices within varying contexts of CBPR? 4. How can we best research the theoretical pathways between processes and outcome dimensions of the CBPR model? c21.indd 379 7/31/08 7:31:14 PM 380 Community-Based Participatory Research for Health FINAL MODEL AND RELATIONSHIPS BETWEEN DIMENSIONS The final model is presented in Figure 21.1, with examples of the characteristics or variables in each dimension (for a detailed outline of characteristics, see our project Web site: http://mycbpr.org). This model identifies four dimensions of CBPR characteristics and suggests relationships between each category. First, contextual factors shape the nature of the research and the partnership and can determine whether and how a partnership is initiated. Next, group dynamics, consisting of three subdimensions (structural and individual dynamics that influence relational dynamics), interact with contextual factors to produce the intervention and its research design. Finally, intermediate system and capacity changes, and ultimately, health outcomes result directly from the intervention research. Although CBPR partnership processes and practices are presented linearly in this model, they are in reality dynamic and changing, with embedded paradoxes and tensions that are driven by both external and internal context changes (for example, loss of funding, new leadership, differences in partners’ interpretations of events, and so forth). In the remainder of this chapter, we discuss the potential relationships among and within the four general dimensions represented in the model, constructs within each dimension, as well as testable hypotheses for research on CBPR processes leading to outcomes. We hope partnerships will use this model and possibly identify additional constructs meaningful for their situation. For more in-depth descriptions of currently identified constructs within the dimensions, see http://mycbpr.org. Contexts Five specific constructs are part of the context that frames any CBPR partnership. First, socio-economic, environmental, and cultural factors provide the backdrop to all of our work, with inequitable structural conditions being a primary risk factor for health disparities, and with cultural dimensions influencing both risk and protective factors. Second, national and local policies and trends relevant to CBPR shape its frequency and prestige. Despite increased funding for CBPR in recent years (see Appendix B), skepticism remains among many scientists, and there are far fewer avenues for funding CBPR than there are for traditional research approaches, such as clinical trials (Schulz et al., 2003; Buchanan et al., 2007; see also Chapter Fourteen). Governance and leadership are also policy contexts in that questions may be raised, for example, regarding whether CBPR projects in Indian country, grounded in sovereign nation status and formal tribal leadership approval (see Appendix H), would have impacts different from the impacts of other CBPR projects operating under multiple leadership models in more diffuse community settings. Third, the historical contexts of collaboration influence how CBPR partnerships face and address issues of trust or mistrust over time. The multiple contextual challenges to building trust include (1) the congruence or lack of congruence over core values and mission, with communities traditionally focused on services and action and universities focused on new knowledge and scholarship; (2) historical, institutionalized racism in research, health care, and U.S. government–community relations, such that communities of color have less faith in health research than white Americans (Yonas et al., 2006; Aday, 2001; du Pré, 2000; Williams, 2001); and (3) the specific histories (both positive and negative) of university relationships with particular communities. c21.indd 380 7/31/08 7:31:15 PM FIGURE 21.1 Conceptual Logic Model of Community-Based Participatory Research: Processes to Outcomes What Predicts Outcomes in CBPR? c21.indd 381 381 7/31/08 7:31:15 PM 382 Community-Based Participatory Research for Health The fourth contextual characteristic is the community’s capacity for research, or more broadly, its capacity to create change. These capacities encompass the community’s history of successful organizing, its ability to mobilize local cultural strengths and practices, its articulation of a shared identity and vision, and its organizational readiness to embrace changes. The capabilities for handling the time and commitment needed for a CBPR research process may be greater when the community has experience with organizing efforts, whether they were political, social, cultural, economic, or health related. Fifth, much like the community’s capacity, the university’s capacity for CBPR is critical to the success of the partnership. University practices that promote CBPR— for example, supportive tenure and promotion guidelines or existing CBPR research centers—have been shown to foster greater university capacity (see Appendix E). Formal university agreements to share resources, knowledgeable institutional review boards, and university legal counsel who are supportive of CBPR approaches are essential to avoid undue bureaucracy and time delays. Finally, diversity of the research team matters. Even though historically CBPR researchers have been primarily white, ethnic or minority and bicultural academics are increasingly embracing CBPR research practice. Diverse research teams, built with research assistants and students who identify with the communities with which they are working, are critical for cultural understanding. The sixth contextual factor that shapes the CBPR process is the perceived severity and seriousness of the health issues. Communities and researchers need to tap into health issues that are salient enough to mobilize involvement yet are not perceived as overwhelming. Community organizing and capacity-building strategies, including adequate incentives such as sharing grant funds with communities, also are important in enabling marginalized communities to participate in studying and addressing issues high on their list of concerns. Funding streams often dictate the health conditions to be studied, however, and therefore may limit the opportunity for true negotiation of the health issue of most concern. Group Dynamics The second overarching dimension is that of group dynamics, or how the practice of CBPR takes place with our core values of creating equitable partnerships. Group dynamics has three subdimensions: the individual, structural, and relational dynamics of the partnership. At the individual level, CBPR team members may have differing levels of motivation and belief about their own self-efficacy to do CBPR, and these levels may also change over time. The principal investigator is a critical team member, and his or her ability to work across cultures with flexibility and grace is critical for the project’s success. This spanning ability is equally important for the community coinvestigator or key leaders. Cultural humility and critical self reflection, especially from high-status or otherwise privileged members of the respective teams (including a reflection on white privilege by white researchers) may be critical to high emotional and social capacity, trust, empathy, and a successful partnership (Yonas et al., 2006; Tervalon & Murray-Garcia, 1998; Goleman, 1995, 2006; see also Appendix I). Structural dynamics refers to the nature of the team, its composition, extent of diversity, and level of complexity of membership or issues addressed and to the rules and resources used to guide the CBPR partnership. Diversity in values influences the way that c21.indd 382 7/31/08 7:31:16 PM What Predicts Outcomes in CBPR? 383 individuals communicate in teams (Oetzel, 1998), and partnerships may face challenges because of cultural distance in values, ethnic or racial group identities, or even differences in profession and sector among partners (Oetzel, 2005). Higher complexity, such as that found with a health coalition that addresses many issues with multiple organizations as members, may also pose challenges not seen in a more limited partnership that addresses one set of issues, such as immunizations with providers as partners. Partnerships differ in their structural agreements, with tribal partners, for example, requiring formal tribal resolutions or memorandums of agreement whereas other partners may have more informal rules. Other factors, such as the closeness of alignment among partners’ principles and expectations and the length of time the partnership has existed, may also influence the need for formal agreements. Relational dynamics are the core interactive or communicative processes used to negotiate work, relationships, and identities during the partnership. Although group dynamics can be both problematic and positive (Hirokawa, 1988; Hirokawa & Keyton, 1995), effective CBPR dynamics might well include reflection on core values to enhance mutual respect and congruence, dialogue, and mutual learning; recognizing power dynamics; self- and collective reflection (especially about the group’s process); participatory decision making; integrating local beliefs into the group’s process; and the research team’s involvement with the community, for example, holding meetings in community locations and participating in community social and cultural events. Intervention The third dimension of the model, the intervention, is both a result of the contextual factors and group dynamics and the major independent variable leading to outcomes. While this category focuses on interventions, it includes research designs that also are influenced by contextual factors and group dynamics. Often initiated by university partners who use the evidence-based literature, both CBPR interventions and the research designs used for implementation need to be shaped by the interaction with community partners in order to reflect local culture, community-supported practices, contexts, and program environments. Attention to implementation and translation issues in diverse contexts becomes especially important for sustainability as a system change outcome. The extent of organizational readiness to adopt new interventions, for example, can enhance the likelihood of sustainability of the intervention even after the grant funding ends. As seen in the AHRQ study, CBPR studies enhanced the implementation of the research (producing, for example, greater participation rates and decreased loss to follow-up) and also enhanced outcomes of capacity, without decreasing research rigor, as feared (Viswanathan et al., 2004). For CBPR projects not engaged in intervention research—namely, for epidemiologic or other descriptive studies—implementation and translation research knowledge is equally important for constructing appropriate research designs and collaborating with community members and leaders in research issues of recruitment, data collection, and participatory data analysis, among others. Outcomes The final category in the model focuses on outcomes: intermediate system and capacity change outcomes, and health outcomes. System and capacity outcomes focus on structural c21.indd 383 7/31/08 7:31:16 PM 384 Community-Based Participatory Research for Health and relationship changes that promote greater equity in power dynamics. These include new institutional practices and policies in the university and community, new policies, new capacities such as community research infrastructures, and cultural revitalization (Wallerstein, Duran, Aguilar, Belone, Loretto, Padilla, et al., 2003; Appendix D). They also include enhanced empowerment for individuals, organizations, and communities and opportunities for sustained changes in conditions that enable health. Sustainability of interventions is key for communities and is more likely with the integration of local culture and attention to organizational readiness to adopt interventions. Although community capacity is mentioned frequently in published articles, equally important are researcher capacity in CBPR and supportive institutional practices within universities, factors that are seldom mentioned (Viswanathan et al., 2004). Health outcomes and the reduction of health disparities toward social justice are the ultimate goals of research interventions designed through a CBPR partnership, though as shown through our literature review, evidence is still limited as to the impact of CBPR processes on health outcomes and disparities. Because of the wide variation in studies, Viswanathan et al. (2004) found insufficient evidence for CBPR effectiveness. Only twelve out of sixty studies had health outcome data: four randomized clinical trials had moderate effects, and the others had mixed or no effects. A recent comprehensive review article on participatory research cited seven other studies with health impacts, and there is a promise of more in the publishing pipeline due to the current infusion of CBPR intervention research dollars (Cargo & Mercer, 2008). Other recent case studies on CBPR efforts aimed in part at health-promoting public policy have demonstrated some success in terms of health outcomes, though in each case the CBPR effort was one among a number of associated factors (see Chapters Eighteen, Nineteen, and Twenty; Minkler et al., 2008; Minkler, Brechwich Vásquez, Chang, Blackwell, et al., 2008). Relationships Among the Categories Although the model presented here can serve as a framework for individual partnerships to evaluate selected characteristics and their own practices, its overall purpose is to strengthen the CBPR research agenda on pathways and on relationships that may link CBPR processes and practices to CBPR system and capacity changes and health outcomes. Presented here are potentially testable propositions derived from the model. Although not exhaustive, these propositions serve to illustrate potential starting points for further research. Context and Group Dynamics The first propositions consider the relationships between context and group dynamics. The six contextual constructs frame the nature of the interactions between CBPR team members. Although there are multiple bivariate relationships, we made an assumption that relational dynamics have a consistent relationship with the context factors (that is, all relational dynamics will be positive or negative). In fact, it is possible to have differing relational dynamics characteristics (for example, a group may be good with leadership but not necessarily good with dialogue), but the c21.indd 384 7/31/08 7:31:16 PM What Predicts Outcomes in CBPR? 385 characteristics likely follow one another. The following propositions are offered as concrete testable hypotheses. Proposition One. Communities that have histories of being exploited and used by universities without attention to community engagement will have more relational dynamic difficulties within the partnership, even over the long term, than will communities that have histories of trust with researchers. Proposition Two. Formal governance structures in communities promote greater equality in group decision making with university partners early on in the partnership. CBPR projects have the opportunity to benefit from a structural and environmental scan of these contextual issues, both in terms of assessing their potential influence on the partnership, and also because contexts can be influenced by the success (or failure) of CBPR processes. Within Group Dynamics Given the primacy of group dynamics within CBPR, it is important to investigate the relationships among structural, individual, and relational dynamics. In fact, prior CBPR researchers have strongly emphasized investigating and evaluating group dynamics as a primary goal for CBPR projects (for example, Schulz et al., 2003). Proposition Three. The more culturally diverse the CBPR partnership, the more difficulty it will have with relational dynamics. Proposition Four. The more individuals demonstrate cultural humility or collectivistic identities, or both, the stronger relational dynamics will be. These propositions are based in the literature on group dynamics from management, intercultural, and group communication; cross-cultural psychology; and social psychology. Although cultural diversity can provide important benefits in terms of insights and innovation, it also raises challenges (McLeod, Lobel, & Cox, 1996; Oetzel, 2005). A consistent finding about organizational processes is that the more cultural diversity there is, the more likely it is that high levels of tension, lack of respect for group members, and inequality in turn-taking will exist (Oetzel, Burtis, Chew Sanchez, & Perez, 2001; Watson, Kumar, & Michaelsen, 1993). Recognizing the potential for these tensions in culturally diverse groups, especially when there are power differences, therefore becomes an important starting place for generating best and promising practices to create positive relational and structural dynamics. The cultural and individual identities that members bring to the partnership influence their communication styles and the overall climate of the interactions (Bond & Ng, 2004; Earley, 1993; Oetzel et al., 2001). Prior research demonstrates that individuals who bring a sense of collectivistic (as opposed to individualistic) identity and values and a willingness to reflect on their own culture and understand how it influences their behavior are more likely to engage in positive relational dynamics such as collaborative conflict resolution, shared decision making, and collective reflection (Oetzel, 1998; Oetzel et al., 2001; Yonas et al., 2006). Context, Group Dynamics, and Outcomes Some of the more complex relationships in the model focus on the mediating and moderating role of group dynamics in the CBPR process. c21.indd 385 7/31/08 7:31:16 PM 386 Community-Based Participatory Research for Health Specifically, group dynamics are the medium through which contexts (for example, health problems and historical factors) are addressed and changed and result in concrete outcomes. Group dynamics can simply mediate or enable the work to be done but also can moderate or change the contexts to produce positive (or negative) outcomes. The potential negative outcome is important to consider, because poorly done CBPR (or research done under the guise of CBPR) can do more harm than good. One exemplar proposition is offered. Proposition Five. In CBPR partnerships that begin in a context of historical mistrust or low community capacity, increased use of formal structures for the partnership (for example, memorandums of agreement detailing the roles of partners), relate positively to relational dynamics and CBPR outcomes. The fifth proposition recognizes the need to explore the relationship between structural and personal relationships. Contextual historical mistrust, based on egregious university or government action, is sufficiently prevalent in communities of color facing health disparities that strategies need to be supported to enable research partnerships to be successful. As indicated in the Internet survey, in low-trust conditions, community members may question the value of structural agreements, though for CBPR within tribes, official tribal approvals are mandated. The empirical questions remain, however: Do structural agreements facilitate the growth of trust through setting mutual expectations and guidelines for action, and how do these structural arrangements interact with the importance of personal relationships? Group Dynamics, Intervention Research, and Outcomes The final complex relationship examines the last three characteristics of the CBPR model and places some emphasis on the mediating and moderating role of intervention and research methods in the CBPR process. The following propositions suggest some of the research possibilities related to these three factors. Proposition Six. The better group dynamics are, the greater the probability of CBPR system and capacity changes and improved health outcomes. Proposition Seven. The more a CBPR partnership can integrate local beliefs in the research, the more positive the CBPR system and capacity change outcomes will be. Proposition Eight. The better the CBPR system and capacity change outcomes, the better the health outcomes for the community. These propositions are based on the experience of the research team (coauthors of this chapter) and the advisory board as well as prior research on CBPR interventions, especially in the literature on indigenous CBPR and CBPR with other communities of color. Enhanced use of culturally supported beliefs and practices (Hall, 2001) within relational dynamics that honor shared decision making and community power can create culturally acceptable interventions to address health problems and increase capacities in the community. The additional question is, What else is necessary to create system change within universities? Viswanathan et al.’s (2004) survey of sixty CBPR studies found that forty-seven studies reported strong community involvement, resulting in new c21.indd 386 7/31/08 7:31:17 PM What Predicts Outcomes in CBPR? 387 community capacities, such as grant funding and job creation as well as better intervention quality. The last proposition is more speculative: it states that health outcomes are a direct result of CBPR system and capacity change outcomes, such as collaboratively produced and more sustainable interventions, transformed policies, and other practices, rather than a result of positive group dynamics per se. The specifics of the health impact, of course, depend on the specifics of the intervention or policy target. The health-enhancing factors of partnership participation may also have an impact on individuals. Yet to have an impact on community health, participation needs to be sustained through systemslevel support and infrastructures in order to reach beyond the impact of a single CBPR project. MEASUREMENT ISSUES Measurement issues have, intentionally, not been considered in this chapter, although we are currently compiling a comprehensive list of measurement tools for dimensions and characteristics in the model. The majority of existing instruments focus on the group dynamics core of the model. However, study of the contexts underlying these dynamics, the relationship among structural conditions, institutional history, and personal participation, the individual characteristics of partners, and the unfolding power dynamics are not addressed by currently available tools. We suggest that measurement be directed toward these issues and toward each end of the model, for example, the contextual factors and system and capacity change outcomes. In particular, measurement efforts should focus on the ability of interventions to reach culturally and deeply into the communities served. Research would benefit from the development of vignette-based instruments that would make the contextual factors more concrete and potentially culturally-centered (King & Wand, 2007; Noe et al., 2007). The compiled list of existing tools and initial vignettebased questions that address contextual variables and others currently without measurement tools are both available on our Web site (http://mycbpr.org). We hope to use these instruments to create the next stage of cross-site research on CBPR projects, assessing variability in core participation dimensions and their relationships to outcomes in order to test the model. SUMMARY AND IMPLICATIONS FOR FUTURE RESEARCH The story of a baby hippo and a 130-year-old male tortoise living in an animal facility in Mombassa, Kenya, offers an allegory for the challenges and potentials of CBPR. Swept into the Indian Ocean during the 2004 tsunami, the baby hippo (an animal that typically stays with its mother for four years) latched onto the tortoise after its rescue. Since this time, they have become inseparable, sleeping, swimming, and eating together (“We can all learn from the animals,” 2006). Like the hippo in this unexpected partnership, the lumbering and sometimes clumsy university can bond with communities—and the ancient and newer histories communities bring to the table—to find common ground. In this study we have sought to find the common-ground characteristics of effective research partnerships that allow them to produce system and capacity change outcomes c21.indd 387 7/31/08 7:31:17 PM 388 Community-Based Participatory Research for Health and improve well-being and health status within communities. We have garnered knowledge from our review of “outside” literature, from discussions with and experiences of working with our advisory board, and from the findings of an Internet-based survey in order to develop a new unifying, conceptual model that embodies the next stages for CBPR research. Our review uncovered challenges to this burgeoning research movement and suggested that constructive analysis of social and environmental contexts, political governance, historical institutional dynamics, and evolving power dynamics between partners and also self-reflection among members of research teams and partners should be included in the list of minimal core characteristics of CBPR, aimed at reducing health disparities. The next steps are clearly indicated. Future research needs to assess variability in CBPR contexts and processes and to identify which processes and practices are most salient in which contexts, to test the various pathways of the model from processes to outcomes, and to develop a better understanding of best and promising practices for successful CBPR efforts. As community-based participatory research achieves greater acceptance within the research community, it becomes essential for the field to engage in the science of discovery and to learn how CBPR pathways work to promote new capacities, system changes, and health outcomes, both to generate stability for the field and to enhance our collective ability to have an impact on health status and health equity. QUESTIONS FOR DISCUSSION 1. From the core dimensions of the CBPR model presented here (the contexts, group dynamic processes, and interventions), pick one or two and provide examples from your experience or reading of the literature about the ways in which each of the dimensions you picked might influence the ability of CBPR research projects to successfully affect outcomes. What are the core tensions within each dimension as described here or in your experience? 2. Why are power dimensions so central to CBPR processes, and how do you think they have an impact on CBPR system and capacity change outcomes and health outcomes? 3. Of the testable hypotheses discussed here, which two or three would you prioritize as the most important, and why? If you were to construct your own, what hypotheses or propositions would you propose as priorities for CBPR research? NOTES 1. The national advisory committee members were Margarita Alegria, Beverly BecentiPigman, Eugenia Eng, Barbara Israel, Jeffrey Henderson, Michele Kelley, Loretta Jones, Paul Koegel, Marjorie Mau, Meredith Minkler, Lynn Palmanteer-Holder, Amy Schulz, Edison Trickett, Jesus Valles, Kenneth Wells, Earnestine Willis, and Kalvin White. New participating members include: Magdalena Avila, Elizabeth c21.indd 388 7/31/08 7:31:17 PM What Predicts Outcomes in CBPR? 389 Baker, Shelley Frazier, Ella Greene-Morton, Lyndon Haviland, Sarah Hicks, Laurie Lachance, Tassy Parker, Cynthia Pearson, Victoria Sanchez, and Lauro Silva. 2. The RAND/UCLA appropriateness method has typically been used to develop a consensus of expert opinion on the appropriateness of clinical procedures or other inputs that do not yet have proven effectiveness (in our case CBPR participatory processes and practices) for different patient conditions (in our case different contexts) in order to produce different outcomes (in our case capacity and system changes and public health outcomes). REFERENCES Aday, L. A. (2001). At risk in America: The health and health care needs of vulnerable populations in the United States (2nd ed.). San Francisco: Jossey-Bass. Bond, M. H., & Ng, I. W.-C. (2004). The depth of a group’s personality resources: Impacts on group process and group performance. Asian Journal of Social Psychology, 7, 285–300. Buchanan, D. R., Miller, F. G., & Wallerstein, N. (2007). Ethical issues in community-based participatory research: Balancing rigorous research with community participation in community intervention studies. Progress in Community Health Partnerships: Research, Education, and Action 1(2), 153–160. Bull, S. S., Gillette, C., Glasgow, R. E., & Estabrooks, P. (2003). Work site health promotion research: To what extent can we generalize the results and what is needed to translate research to practice? Health Education & Behavior, 30(5), 537–549. Cargo, M., & Mercer, S. L. (2008). The value and challenges of participatory research: Strengthening its practice. Annual Review of Public Health, 29, 325–350. Special section on urban planning and public health 2006. Journal of the American Planning Association, 72(1), 119–120. Danieli, A., & Woodhams, C. (2005). Emancipatory research methodology and disability: A critique. International Journal of Social Research Methodology, 8(4), 281–296. DeJong, J. A., & Holder, S. R. (2006). Indian boarding schools and the therapeutic residential model project. American Indian and Alaska Native Mental Health Research, 13(2), 1–16. Denzin, N. K., Lincoln, Y. S., & Smith, L. T. (2008). Handbook of critical and indigenous methodologies. Thousand Oaks: Sage. Drew, C. H., Nyerges, T. L., & Leschine, T. M. (2004). Promoting transparency of long-term environmental decisions: The Hanford decision mapping system pilot project. Risk Analysis, 24(6), 1641–1664. du Pré, A. (2000). Communicating about health: Current issues and perspectives. Mountain View, CA: Mayfield. Duran, B., & Walters, K. L. (2004). HIV/AIDS prevention in “Indian country”: Current practice, indigenist etiology models, and postcolonial approaches to change. AIDS Education and Prevention, 16(3), 187–201. Earley, P. C. (1993). East meets West meets Mideast: Further explorations of collectivistic and individualistic work groups. Academy of Management Journal, 36, 319–348. English, K. C., Fairbanks, J., Finster, C. E., Rafelito, A., Luna, J., & Kennedy, M. (2006). A socioecological approach to improving mammography rates in a tribal community. Health Education & Behavior, 35(3), 396–409. English, K. C., Wallerstein, N., Chino, M., Finster, C. E., Rafelito, A., Adeky, S., et al. (2004). Intermediate outcomes of a tribal community public health infrastructure assessment. Ethnicity & Disease, 14(3, Suppl. 1), S61–S69. Fisher, P. A., & Ball, T. J. (2002). The Indian Family Wellness project: An application of the tribal participatory research model. Prevention Science, 3(3), 235–240. Fisher, P. A., & Ball, T. J. (2003). Tribal participatory research: Mechanisms of a collaborative model. American Journal of Community Psychology, 32(3–4), 207–216. Fisher, P. A., & Ball, T. J. (2005). Balancing empiricism and local cultural knowledge in the design of prevention research. Journal of Urban Health, 82(2, Suppl. 3), iii, 44–55. c21.indd 389 7/31/08 7:31:17 PM 390 Community-Based Participatory Research for Health Fixsen, D. L., Naoom, S. F., Blasé, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature (FMHI Pub. No. 231). Tampa: University of South-Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network. Glasgow, R. E., & Emmons, K. M. (2007). How can we increase translation of research into practice? Types of evidence needed. Annual Review of Public Health. 28, 413–433. Glasgow, R. E., Green, L. W., Klesges, L. M., Abrams, D. B., Fisher, E. B., Goldstein, M. G., et al. (2006). External validity: We need to do more. Annals of Behavioral Medicine, 31, 105–108. Goleman, D. (1995). Emotional intelligence. NY: Bantam Books. Goleman, D. (2006). Social intelligence: The new science of human relations. NY: Bantam Books. Green, L. W., George, M. A., Daniel, M., Frankish, C. J., Herbert, C. J., Bowie, W. R., et al. (1995). Study of participatory research in health promotion: Review and recommendations for the development of participatory research in health promotion in Canada. Vancouver, BC: Royal Society of Canada. Green, L. W., & Glasgow, R. E. (2006). Evaluating the relevance, generalization, and applicability of research: Issues in external validation and translation methodology. Evaluation & the Health Professions, 29(1), 126–153. Green, L. W., & Ottoson, J. M. (2004). From efficacy to effectiveness to community and back: Evidence-based practice vs. practice-based evidence. In L. Green et al. (Eds.), From clinical trials to community: The science of translating diabetes and obesity research. Bethesda, MD: National Institutes of Health. Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004), Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Quarterly, 82(4), 581–629. Hall, G. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69(3), 502–510. Hirokawa, R. Y. (1988). Group communication and decision-making performance: A continued test of the functional perspective. Human Communication Research, 14, 487–515. Hirokawa, R. Y., & Keyton, J. (1995). Perceived facilitators and inhibitors of effectiveness in organizational work teams. Management Communication Quarterly, 8, 424–446. Hohmann, A., & Shear, M. (2002). Community-based intervention research: Coping with the noise of real life in study design. American Journal of Psychiatry, 159, 201–207. Israel, B. A., Eng, E., Schulz, A. J., & Parker, E. A. (Eds.). (2005). Methods in community-based participatory research for health. San Francisco: Jossey-Bass. Israel, B. A., Lantz, P. M., McGranaghan, R. J., Kerr, D. L., & Guzman, J. R. (2005). Documentation and evaluation of CBPR partnerships: In-depth interviews and close-ended questions. In B. A. Israel, E. Eng, A. J. Schulz, & E. A. Parker (Eds.), Methods in community-based participatory research for health (pp. pp. 255–278). San Francisco: Jossey-Bass. Johnson, D. W., & Johnson, F. P. (1999). Joining together: Group theory and group skills (7th ed.). Englewood Cliffs, NJ: Prentice Hall. Jumper Thurman, P., Allen, J., & Deters, P. B. (2004). The Circles of Care evaluation: Doing participatory evaluation with American Indian and Alaska Native communities. American Indian and Alaska Native Mental Health Research, 11(2), 139–154. King, G., & Wand, J. (2007). Comparing incomparable survey responses: Evaluating and selecting anchoring vignettes. Political Analysis, 15, 46–66. Manson, S. M., Garroutte, E., Goins, R. T., & Henderson, P. N. (2004). Access, relevance, and control in the research process: Lessons from Indian country. Journal of Aging and Health, 16(5, Suppl.), 58S–77S. McLeod, P. L., Lobel, S. A., & Cox, T. H. (1996). Ethnic diversity and creativity in small groups. Small Group Research, 27, 248–264. Miller, R. L., & Shinn, M. (2005). Learning from communities: Overcoming difficulties in dissemination of prevention and promotion efforts. American Journal of Community Psychology, 35(3–4), 169–183. Minkler, M., Breckwich Vásquez, V., Chang, C., Blackwell, A. G., Thompson, M., & Rubin, V. (in press). Promoting healthy public policy through community-based participatory research. Oakland, CA: PolicyLink. Minkler, M., Breckwich Vásquez, V., Tajik, M., & Petersen, D. (2008). Promoting environmental justice through community-based participatory research: The role of community and partnership capacity. Health Education & Behavior, 35(1), 119–137. c21.indd 390 7/31/08 7:31:18 PM What Predicts Outcomes in CBPR? 391 Minkler, M., & Wallerstein, N. (Eds.). (2003). Community-based participatory research for health. San Francisco: Jossey Bass. National Institutes of Health, Office of Portfolio Analysis and Strategic Initiatives. (2008). NIH Roadmap for Medical Research. Retrieved May 12, 2008, from nihroadmap.nih.gov. Noe, T., Manson, S., Croy, C., McGough, H., Henderson, J., & Buchwald, D. (2007). The influence of communitybased participatory research principles on the likelihood of participation in health research in American Indian communities. Ethnicity & Disease, 17(Suppl. 1), S6–S14. Oetzel, J. G. (1998). Explaining individual communication processes in homogeneous and heterogeneous groups through individualism-collectivism and self-construal. Human Communication Research, 25, 202–224. Oetzel, J. G. (2005). Intercultural work group communication theory. In W. B. Gudykunst (Ed.), Theorizing about intercultural communication (pp. 351–371). Thousand Oaks, CA: Sage. Oetzel, J. G., Burtis, T. E., Chew Sanchez, M. I., & Perez, F. G. (2001). Investigating the role of communication in culturally diverse work groups: A review and synthesis. In W. B. Gudykunst (Ed.), Communication Yearbook 25 (pp. 237–269). Mahwah, NJ: Erlbaum. Pelled, L. H., Eisenhardt, K. M., & Xin, K. R. (1999). Exploring the black box: An analysis of work group diversity, conflict, and performance. Administrative Science Quarterly, 44, 1–28. Persaud, N., & Mamdani, M. (2006). External validity: The neglected dimension in evidence ranking. Journal of Evaluation in Clinical Practice, 12(4), 450–453. Resnik, D. B., Zeldin, D. C., & Sharp, R. R. (2005). Research on environmental health interventions: Ethical problems and solutions. Accountability in Research: Policies & Quality Assurance, 12(2), 69–102. Russell, C. A. (2006). Consumer researchers for public health: Insights from three government-funded programs. Advances in Consumer Research, 33(1), 59–62. Schulz, A. J., Israel, B. A., & Lantz, P. M. (2003). Instrument for evaluating dimensions of group dynamics within community-based participatory research partnerships. Evaluation and Program Planning, 26, 249–262. Shekelle, P. (2004). The appropriateness method [Editorial]. Medical Decision Making, 24(2), 228–231. Shekelle, P., & Schriger, D. L. (1996). Evaluating the use of the appropriateness method in the Agency for Health Care Policy and Research clinical practice guidelines development process. Health Services Research, 31(4), 453–468. Smith, L. T. (1999). Decolonizing methodologies: Research and indigenous peoples. New York: Zed Books. Smith-Morris, C. (2007). Autonomous individuals or self-determined communities? The changing ethics of research among Native Americans. Human Organization, 66(3), 327–337. Sofaer, S. (2000). Working together, moving ahead: A manual to support effective community health coalitions. City University of New York, Baruch College, School of Public Affairs. Spielman, S. E., Golembeski, C. A., Northridge, M. E., Vaughan, R. D., Swaner, R., Jean-Louis, B., et al. (2006). Interdisciplinary planning for healthier communities. Journal of the American Planning Association, 72(1), 100–108. Strickland, C. J. (2006). Challenges in community-based participatory research implementation: Experiences in cancer prevention with Pacific Northwest American Indian tribes. Cancer Control, 13(3), 230–236. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. Viswanathan, M., Ammerman, A., Eng, E., Gartlehner, G., Lohr, K. N., Griffith, D., et al. (2004). Community-based participatory research: Assessing the evidence (Evidence Report/Technology Assessment No. 99; prepared by RTI, University of North Carolina). Rockville, MD: Agency for Healthcare Research and Quality. Wallerstein, N. (2007). Making traces: Evidence for practice and evaluation. In J. Green & R. Labonté (Eds.), Critical perspectives in public health (pp. 80–92). New York: Routledge. Wallerstein, N., & Duran, B. (2006). Using community-based participatory research to address health disparities. Health Promotion Practice, 7(3), 312–323. Wallerstein, N., Duran, B., Aguilar, J., Belone, J. L., Loretto, F., Padilla, R., Shendo, K., Toya, A., & Yepa-Waquie, H. (2003). Jemez Pueblo: Built and social-cultural environments and health within a rural American Indian community in the Southwest. American Journal of Public Health, 93(9), 1517–1518. c21.indd 391 7/31/08 7:31:18 PM 392 Community-Based Participatory Research for Health Wallerstein, N., Duran, B., Minkler, M., & Foley, K. (2005). Developing and maintaining partnerships with communities. In B. A. Israel, E. Eng, A. J. Schulz, & E. A. Parker (Eds.), Methods in community-based participatory research for health (pp. 31–51). San Francisco: Jossey-Bass. Watson, W. E., Kumar, K., & Michaelsen, L. K. (1993). Cultural diversity’s impact on interaction process and performance: Comparing homogeneous and diverse task groups. Academy of Management Journal, 36, 590–602. “We can all learn from the animals.” (2006). Retrieved May 12, 2008, from www.criticalconcern.com/hiipo-and-turtle.htm. Wheelan, S. (1999). Creating effective teams: A guide for members and leaders. Thousand Oaks, CA: Sage. Williams, D. R. (2001). Race and health: Trends and policy implications. In. J. A. Auerbach & B. K. Krimgold (Eds.), Income, socioeconomic status, and health: Exploring the relationships (pp. 67–85). Washington, DC: National Policy Association. Williams, G. (2004). Evaluating participatory development: Tyranny, power and (re)politicisation. Third World Quarterly, 25(3), 557–578. Yonas, M. A., Jones, N., Eng, E., Vines, A. I., Aronson, R., Griffith, D. M., et al. (2006). The art and science of integrating undoing racism with CBPR: Challenges of pursuing NIH funding to investigate cancer care and racial equity. Journal of Urban Health, 83(6), 1004–1012. c21.indd 392 7/31/08 7:31:18 PM