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Integrating research and action: a systematic review of community-based participatory research to address health disparities in environmental and occupational health in the USA

W K Cook

Correspondence to: Dr W K Cook, Alcohol Research Group, University of California, Berkeley, 6475 Christie Avenue, Suite 400, Emeryville, CA 94608, USA; [email protected]

Accepted 25 November 2007

ABSTRACT Introduction: Integrating research and action represents a goal and key principles of community-based participa- tory research (CBPR), but there has been little effort to synthesise the literature to evaluate whether such integration is occurring. Objectives: (1) To examine the extent to which CBPR integrates action to effect community-level change and (2) to ascertain factors that facilitate such integration. Methods: Original articles reporting on CBPR in environ- mental and occupational health in the USA were identified primarily through a MEDLINE search. Inceptions, pro- cesses, methods and outcomes of the projects were reviewed. Results: In 14 of the 20 studies reviewed, CBPR led to community-level action to improve the health and well- being of the community members. Observational studies that investigated problems posed by the affected community and that incorporated qualitative methods were more likely to lead to action. The collaboration among government scientists, university researchers and community partners emerged as a new model of CBPR partnerships that effectively integrates research and action. Conclusions: To help CBPR better integrate research and action, a shift towards community-initiated and action- oriented observational studies might be needed.

Community-based participatory research (CBPR) is essentially an egalitarian and action-oriented endeavour that strives to equitably involve com- munity members, organisational representatives and researchers in all aspects of the research process. The partners contribute unique strengths and share responsibilities to enhance the under- standing of a given phenomenon and the social and cultural dynamics of the community, and integrate the knowledge gained with action to improve the health and well-being of community members.1

Integrating action with research is an integral part of most known definitions of CBPR,1–4

representing one of the goals and key principles of CBPR, but there has been little effort to synthesise the literature to evaluate to what extent such integration is occurring. Most of the previous reviews have focused mainly on the process of CBPR to document institutional, methodological and other issues and challenges involved in build- ing and sustaining CBPR partnerships and the strategies to cope with them.5–7 To help CBPR deliver on its promises, it is imperative to take the

next step to evaluate the extent to which CBPR involves action to effect community-level changes and what factors facilitate such action. The present review represents such an effort.

One of the previous reviews, the most compre- hensive one to date,8 touches upon this issue to provide a brief account of CBPR projects in which research findings were translated into policy change, albeit with fundamental differences from the present review. First, even though they acknowledge the unique benefits of CBPR, the authors of this previous review take the perspective of the prevailing biomedical tradition of health research in evaluating the research quality of CBPR, mainly with respect to research design rigour (such as internal and external validity, intervention fidelity, outcome measures, statistical analysis, and blinding) and formulating recom- mendations on how to incorporate community involvement in a way that enhances such research quality in CBPR. Although an emphasis on design rigour is fundamentally legitimate, such criteria need to be reconsidered in evaluating CBPR in which scientific pursuit of knowledge is not an overarching goal but integrating action to address the problem investigated is considered an equally justifiable element of scientific endeavour. Second, the recommendations formulated in this compre- hensive review are more conceptual than empirical, and thus limited in providing meaningful, qualita- tive information that can help CBPR move forward. The present review offers such qualitative information.

The scope of the present review is limited to environmental and occupational health areas in the USA. More resources have been made available for CBPR projects in these two areas in recent years, with more public funding provided for CBPR in environmental health9 and with labour unions able to support CBPR to address health problems affecting their constituents.10 It is thus meaningful to take stock of the progress made in these areas. Also, given that occupational and environmental hazards and their remedies tend to be of a collective nature in their origins (that is to say, environmental and workplace hazards are likely to affect all those who live and work in the same physical environment), it is particularly appropri- ate to examine whether CBPR projects in these two areas have yielded community-level action to address such problems. On the basis of the recent developments in CBPR in these areas, the present

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review attempts to glean the facilitating factors for CBPR that successfully integrate research and action.

METHODS

Inclusion criteria To identify references for CBPR to address health disparities in environmental and occupational health, the MEDLINE database was searched using the key phrases ‘‘community-based partici- patory research’’, ‘‘participatory research’’, ‘‘participatory action research’’ (PAR) and ‘‘health disparities’’ in combination with ‘‘environmental health’’, ‘‘environmental justice’’, ‘‘worker health’’, ‘‘worker safety’’ and ‘‘occupational health’’. A manual search was conducted on all the references thus identified. Searches were not restricted to a specific time period.

Studies that met all of the following criteria were included: c original articles published in English

c CBPR/PAR studies conducted in the USA

c studies that investigated the effect of environmental or occupational risk factors on human health or those that implemented interventions to address them.

When more than one article was published from the same study, all the articles that documented the inception, process, findings and the use of findings were included.

Key aspects of CBPR to be reviewed First, I examine whether the research problem originated from the defined community. This is of critical importance in CBPR because a research problem originated from the community may be more likely to reflect genuine and central community concerns and the research project is more likely to be supported by members of the community. The three categories used to determine the degree to which the research problem was posed by the community are whether the project was initiated by (1) community members or groups, (2) academic researchers or (3) mutual agreement between community partners and research- ers. These categories—and most other categories used in the present review—are used mainly as ‘‘sensitising concepts’’,11

rather than strictly operationalised variables, to allow further generation of qualitative information.

Second, I examine whether the collaboration was relatively equitable. Researchers possess inherent power when forming partnerships with community members,12 and they convention- ally take the lead role in designing and implementing research. An equitable partnership in the CBPR process was operationa- lised as community partners’ active participation in decision- making in central research areas, that is to say, over setting research agendas/priorities, developing and implementing the research project and how to use the findings, beyond the customary roles of providing consultation and volunteering or working as supportive research staff.

Third, I evaluate research designs and methods used in the CBPR projects in search of clues for those more compatible with action-oriented CBPR. The categories used to classify research designs are (1) randomised control trial, (2) retrospective or prospective cohort study and (3) cross-sectional study. I also examine whether a given project used quantitative methods, qualitative methods, or both.

Fourth, I examine whether a given CBPR project led to community-level action, which was operationalised as collective efforts to effect community-level changes that go beyond efforts to modify individual-level behaviours of community members. With little prior research to guide the conceptualisation of

community-level action, further operationalisation was not attempted.

On the basis of the evidence provided by this review, suggestions are formulated concerning appropriate methodolo- gical approaches and funding policies that might facilitate CBPR better integrating research and action to improve the health and well-being of community members.

RESULTS Thirty-three articles reporting on 20 studies—17 in environ- mental health and three occupational—met the inclusion criteria. They were conducted in collaboration with low-income communities, mostly African American and/or Latino commu- nities, with the exception of two Native American communities and a Vietnamese community. A summary of the studies included is presented in table 1.

The inception of the studies Ten of the 20 studies reviewed were initiated by the affected communities: seven of them by community-based organisations (CBOs) or groups (studies 1, 2, 6, 9, 12, 13, 20); one by a labour union (study 11); one by community residents (study 14); and one as an outgrowth of preliminary research initiated by a community member and a nurse (study 5). The rest of the studies were initiated by university researchers (studies 4, 8, 17, 19), by US Environmental Protection Agency (EPA) scientists (study 7), by both a CBO and university researchers with mutual understanding that CBPR was needed (study 3), and grew out of an existing CBPR partnership (study 10). Authors of three studies (studies 15, 16, 18) did not explicitly state who initiated the projects.

It appears that community partners who initiated the research partnerships recognised the strategic importance of collaboration with academic researchers. Communities tend to lack the expertise needed to conduct health research, and academic researchers can lend support to them by compiling credible evidence to validate community concerns. For example, a CBO routinely collected information on the community’s exposure to environmental hazards, but was unable to collect, synthesise and present the data in a way that would effectively influence public opinion and policy, so they sought to collaborate with researchers (study 3). In other cases, commu- nity partners chose to work with researchers because of the credibility lent by the latter’s affiliation with academic and other respectable institutions (studies 7, 9). In one study, this validation of community concerns helped spur the community’s readiness to act, further promoting changes (study 11).

Academic researchers reported that community collaboration had been valuable in making the studies possible and valid and in generating credible data. Community partners helped academic researchers to recruit and retain study participants (studies 2, 4, 8, 10, 11, 12), to increase compliance and improve accuracy of reported information (study 14) and to render the research more culturally sensitive and acceptable to the participants and relevant to the local context (studies 4, 8, 10).

Community collaboration The most common role that community partners played was to provide consultation, as staff of a CBO, as individual commu- nity members or as members of a community advisory board or a steering committee. In just one study (study 17), consultation was the only role that community members played in the research process otherwise dominated by academic researchers.

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Table 1 Summary of studies included in the review

Study no/ authors Location

Project goals/ objectives

Research design/ methods

Partnership composed of

Project initiated by

Community collaboration

Action taken by community/outcomes

1 Farquhar and Wing

13

Rural eastern NC

Investigate health effects of a flood and the needs of survivors

Cross-sectional/ quantitative and qualitative

A coalition of local CBOs and university researchers

A community coalition on the basis of input from flood survivors

Consultation; generated survey questions; conducted interviews; determined how to apply findings to create changes

Rallies, media and legislature advocacy/ extended provision of temporary housing for survivors

2 Wing 14

Rural Halifax County, NC

Quantify potential impacts of industrial hog-feeding operations on health and quality of life

Cross-sectional/ quantitative and qualitative

Community groups and university researchers

A grassroots environmental group

Determined the research problem, participated in developing the survey, selecting the research site, collecting data and determining how to present the results

Plans to build hog-feeding operations cancelled

3 McCauley et al;

15 McCauley et

al16

Willamette Valley, OR

Assess pesticide exposure and its health effects

Cross-sectional/ quantitative and qualitative

CBOs and university researchers

A CBO and university researchers

Consultation on instrument design, data collection, data interpretation and presentation of results; youth worked as research assistants

Not reported

4 Swartz et al17 Baltimore, MD Test the effectiveness of a pollutant and allergen control strategy on childhood asthma

Randomised controlled trial/quantitative

Community members, social worker, public health practitioner and university researchers

University researchers

Consultation: served on CAB to jointly develop principles of research protocol and to facilitate communication and recruitment

Not reported (university researchers assisted community beyond the conduct of the study)

5 Maslia et al18 Ocean County, NJ

Assess environmental exposures and its effect on childhood cancers; conduct community/ professional education

Cross-sectional and case–control; quantitative

A community group, county and state health departments, federal Agency for Toxic Substances and Disease Registry and university researchers

Outgrowth of preliminary research, initiated by a community member and a nurse

Jointly developed research/action plan; consulted on further research activities; facilitated communication with community

Increased community/ professional education; developed and implemented an environmental health curriculum for students

6 Quigley et al19 Native American communities in NV, UT and CA

Build community capacity for managing the health risks of nuclear contamination

Cross-sectional/ quantitative and qualitative

Community groups, EH research institute and university researchers

An organisation representing Native American Reservation Communities

Consultation; shared decision- making on grant applications, publications and presentations and staff recruitment; jointly developed a research plan and protocol and educational programme; collected data

Educational programme developed and implemented for community and healthcare providers

7 Corburn20 Brooklyn, NY Investigate health risks of subsistence fishing

Cross-sectional/ quantitative and qualitative

US EPA scientists and a community group composed of CBOs

US EPA scientists Consultation; jointly developed a research plan and protocol; tailored and administered survey; made observations

Developed and conducted community education; identified alternative food sources

Continued

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Table 1 Continued

Study no/ authors Location

Project goals/ objectives

Research design/ methods

Partnership composed of

Project initiated by

Community collaboration

Action taken by community/outcomes

8 Quandt et al;21

Quandt et al; 22

Quandt et al;23

Arcury et al24

Rural east– central NC

Formative research; design, implement and evaluate health education interventions

Formative research (quantitative and qualitative); intervention (randomised controlled trial)

A CBO and university researchers

University researchers

Consultation; assisted in or collaborated on research design, data collection and design and implementation of intervention

Not reported

9 Loh et al25 Boston, MA Institute an air- monitoring system; establish a data management centre; promote use of data by the community to reduce exposures to air pollutants

Cross-sectional/ quantitative and qualitative

A CBO, state Department of Environmental Protection, county conservation district and university researchers

Youth and a CBO working with them

Defined research questions; collaborated on grant writing; collected data; developed and implemented interventions

Advocacy for measures to reduce air pollutants

10 Egren et al; 26

Parker et al; 27

Lewis et al;28

Keeler et al 29

Detroit, MI Investigate environmental exposures; design and implement an intervention study to reduce asthma triggers

Randomised controlled trial/quantitative

Community members, CBOs, city health department, a healthcare system and university researchers

Grew out of an existing CBPR partnership

Collaborated on research design, design of survey instruments, and participant and staff recruitment; collected data and implemented intervention

Not reported

11 Lee et al;10

Krause et al30 San Francisco, CA, and Las Vegas, NV

Investigate health and workload issues of hotel room cleaners

Cross-sectional/ quantitative and qualitative

Labour union, university researchers and university occupational health programme

A labour union Provided funding; defined research priorities and methods; collaborated on instrument development; recruited participants and collected data

Collective action that led to reduced workload and increased labour representation on problem-solving committee

12 Lipscomb et al31

Rural north- eastern NC

Investigate health effects of employment in poultry-processing plants

Cohort and cross- sectional/quantitative and qualitative

Community members as paid staff and university researchers

A CBO Consultation; recruit participants; collect data; provide other research/ administrative support

Not reported (research still under way)

13 Perera et al; 32

Vasquez et al;33

Kinney et al 34

New York City, NY/African American and Dominican

Assess the effects of exposures to air pollutants on infant/child health; test health education interventions

Prospective cohort/ quantitative

A CBO, youth, university researchers and US EPA

A CBO Identified problem; consulted on study design; facilitated communication and collaboration with community; conducted air-quality assessment

Public awareness campaign/advocacy for environmental justice policy and regulations/

14 Jordan et al35 Minneapolis, MN

Investigate the effects of lead exposure on child development

Prospective cohort Community residents, university researchers, local businesses and city/state health departments

Community residents

Consultation; set research agenda; made decisions on proposals and future research direction; collaborated on research design and data collection

Preventive action to change city policy and to create lead-safe transitional housing; advocacy for families affected by lead

15 Krieger et al;36

Krieger et al;37

Krieger et al; 38

Krieger et al39

Seattle and King County, WA

Investigate indoor asthma triggers and implement intervention to reduce exposure to indoor asthma triggers

Randomised controlled trial/quantitative

CBOs, advocacy groups, health department, housing authority and university researchers

Not stated Provided input on research design and process; as research staff, conducted home environment assessment; implemented intervention

Organised a policy advocacy group; identified policy advocacy issues; secured funding to evaluate substandard housing units

Continued

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In the rest of the studies, consultation was provided in conjunction with other research-related activities.

It appears that community partners in some CBPR projects were in more equitable partnerships than others: they defined research questions, set research agendas or determined research priorities (studies 2, 9, 11, 13, 14), jointly made decisions on the design of research or intervention (studies 2, 5, 6, 7) or how to use the findings to create change (study 1), and approved grant applications or publications/presentations (study 6). In one study (study 11), community partners appear to have been more dominant than the academic researchers, with one of them—a labour union—providing the bulk of the research funding and setting research priorities.

It should be noted that community partners tended to play a more integral role in studies initiated by community members or organisations: eight (studies 1, 2, 5, 6, 9, 11, 13, 14) of the nine (studies 1, 2, 5, 6, 7, 9, 11, 13, 14) studies in which community partners shared power with academic researchers in defining the research problem and developing the project on a more or less equal footing were initiated by the community.

Research designs and methods Four (studies 4, 8, 10, 15) of the 20 studies reviewed involved randomised controlled trials (RCTs); the rest were observational studies. One of the observational studies was a combination of cross-sectional/case–control design; another a combination of cross-sectional/cohort design; two were prospective cohort studies; and the rest were cross-sectional studies. In most of the cross-sectional studies, both quantitative (ie administering structured questionnaires and conducting exposure assessment) and qualitative methods (observation, in-depth interviews, focus group sessions, etc.) were used.

All of the 10 studies initiated by the community were observational studies: six (studies 1, 2, 6, 9, 11, 20) of them were cross-sectional, using both quantitative and qualitative meth- ods; three involved prospective cohort studies (studies 1, 12, 14); and one (study 5) combined cross-sectional exposure assessment and a case–control design. None of the studies originated from the community involved a RCT.

Research quality of the observational studies included in this review may not rate high with respect to research design rigour. Most of these studies relied on purposive or snow-ball sampling,

Table 1 Continued

Study no/ authors Location

Project goals/ objectives

Research design/ methods

Partnership composed of

Project initiated by

Community collaboration

Action taken by community/outcomes

16 Litt et al40 Boston, MA Quantify lead levels in residential soil, reduce exposure to lead through low-cost landscaping interventions, and develop educational materials

Pilot study A CBO, university researchers, EPA laboratory, community health centre and local landscape contractors

Not stated Shared local knowledge for site selection and the design of intervention; as staff, conducted outreach, education and landscaping; donated materials and tools

Soil lead abatement as part of intervention; disseminate the model and information about the technology to other CBOs and government agencies

17 Hynes et al 41

Boston, MA Investigate indoor environmental health issues, develop an action plan and design/ implement an educational programme

Cross-sectional/ quantitative

A community group, community health centre and university researchers

University researchers

Consultation to guide survey construction and to provide feedback on survey

Educational programmes developed; replacement of the central heating system at a public housing scheme; a collaboration formed to improve community environmental health

18 Brugge et al 42

Boston, MA Investigate the connections between the environment and health in Chinatown

Cross-sectional/ quantitative

CBO, community health centre and university researchers

Not stated Provided cultural knowledge and local concern about environmental conditions; jointly developed instrument; administered survey

Not stated

19 Schurman and Israel;

43

Schurman44

South–central MI

Conduct needs assessment and develop/implement an intervention to reduce long-term stress-related illness

Cross-sectional/ quantitative and qualitative

Labour union, university researchers, workers, supervisors and management

Initially by a company medical director but by the researchers for this particular project

Participated in diagnosing problems, developing/ implementing a pilot intervention, evaluating outcomes and making recommendations

A corporate-wide programme reflecting recommendations implemented

20 Corburn20 Brooklyn, NY Conduct community health surveys focusing primarily on asthma

Cross-sectional/ quantitative and qualitative

A CBO and a non- profit research organisation

A CBO in response to local students’ suggestion

Consultation; jointly developed and administered survey; led focus group discussions

Developed and implemented community and professional education; organised residents to enrol in a free insurance programme

CAB, Community Advisory Board; CBO, community-based organisation; CBPR, community-based participatory research; EH, environmental health; EPA, Environmental Protection Agency.

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finding willing study participants through community partners in communities that were willing or sought to work with professional researchers. Cross-sectional studies may have fared worse because of the limitations inherent in the design—that is, the inability to establish temporality between the exposure(s) and the outcome(s). Prospective cohort and case–control studies were designed to address this issue but were not free from the limitations that plague exposure assessment in environmental and occupational health—that is, the difficulty of assessing simultaneous and cumulative exposures to multiple hazards/ risk factors and their unknown combined effects.45

In the four studies that involved RCTs, arrangements were made to enhance design validity by randomly assigning study participants to intervention and comparison groups. However, community partners in all four RCTs found the design too complex or simply unacceptable, with the main contention being over the withholding of beneficial interventions from the control group. In response to such community reactions, investigators of three RCTs instituted staggered designs in which what initially was to be the control group became a ‘‘treat later’’ (studies 4, 10) or a ‘‘lower-intensity’’ (study 15) group. Still, field staff members recruited from the community had ‘‘concerns about asking low-intensity groups to wait one year before receiving the benefits of the high-intensity inter- vention’’ (study 15). These findings indicate that the design rigour involved in the RCT may be fundamentally at odds with the healthy commonsense of community partners that bene- ficial treatments should not be withheld from those who could benefit from them just to satisfy rigorous research require- ments. To the extent that such a design appears unreasonable to community members, it may undermine the trust that the academic researchers worked hard to forge with community members: in one study, the use of a RCT gave the impression to some community partners that ‘‘research mattered more’’ to the academic partners than their well-being (study 10).

Outcomes of CBPR Did CBPR lead to action? In 14 (studies 1, 2, 5, 6, 7, 9, 11, 13, 14, 15, 16, 17, 19, 20) of the 20 studies reviewed, CBPR led to action to improve the health and well-being of the community members; for example, to force the cancellation of plans to build industrial hog plants (study 2); to clean a river bank and to identify alternative sources of food to fish caught in contaminated river (study 7); to successfully negotiate a new union contract that reduced workload for hotel room cleaners (study 11); and to force the local housing authority to replace the central heating system at a public housing scheme to improve air quality (study 17). In some studies, the intervention itself—for example, one that involved soil lead abatement for homes (study 16) and another to reduce indoor asthma triggers (study 15)—represented a significant action to improve community health.

Nine (studies 1, 2, 5, 6, 9, 11, 13, 14, 20) of the 14 studies that led to community-level action were initiated by the members or CBOs of the affected community. This may be because community partners who initiated CBPR continued to search for solutions to the problems investigated during the course of the research. In a way, the CBPR that they initiated may in itself constitute a community-level action to address the problems that negatively affected their communities.

It is noteworthy that CBPR projects initiated or prompted by government agencies also led to action to improve the conditions within communities. The US EPA seems to have led the way: in at least three studies reviewed, the partnership

of community groups, EPA scientists and university researchers investigated environmental health risks, and developed/imple- mented interventions to address them or engaged in action otherwise. In study 4, the federal Agency for Toxic Substances and Disease Registry played a similarly pivotal role. In five other studies reviewed, state or city departments of health, environ- mental protection and housing were integral partners, providing funding and technical assistance in designing and implementing interventions. Only two of the CBPR projects that led to action were initiated by university researchers (studies 17, 19), one of which was initially proposed by the company medical director who became aware of similar health problems plaguing the workforce (study 19). Thus, CBPR projects that led to action are much more likely to have been initiated by the affected community or by government scientists/agencies than by academic researchers.

With the exception of one study that involved a RCT (study 15), all of the studies that led to action were observational studies, most of which had cross-sectional designs employing both qualitative and quantitative methods. While quantitative methods were useful in collecting and synthesising data to estimate epidemiological measures, qualitative methods were invaluable in developing research tools, for example survey instruments (studies 1, 9, 10, 11) and culturally appropriate and contextually relevant interventions (studies 3, 8), and incorpor- ating community knowledge and observations to uncover new sources of health risks previously unknown to researchers (studies 6, 7).Thus, qualitative methods played a more central role in many of the CBPR projects reviewed than in conven- tional biomedical health research to produce more informative findings.

Did CBPR help to build the community’s capacity? Enhanced capacity of the community has been reported in several studies in terms of the acquisition of research skills (studies 3, 6, 8, 9, 12, 14) or an improved ability to secure funding (studies 3, 6, 8, 15). However, for CBPR to truly energise and empower communities, a critical consciousness on the part of community members and their increased desire and ability to mobilise their community to effect change are essential. In this respect, building leadership skills is critical.

Two studies stand out in the ways in which community members built and demonstrated their leadership skills. In one study, youth interns became more knowledgeable about air pollution and air monitoring and cultivated and exercised key leadership skills while engaging in public speaking, strategising and educating community members to successfully rally the community behind them (study 9). In another study, some hotel room cleaners—the core members of the research team— emerged as peer leaders to serve on a hotel’s joint labour management problem-solving committees even after the com- pletion of CBPR (study 11). Both of these studies were initiated by the communities and further aided by the related social movements—the former by the environmental justice move- ment in which the youth leaders were initially trained and the latter by the labour movement that supported the CBPR project.

DISCUSSION To summarise the findings, community partners in studies initiated by the community are more likely to participate in the CBPR process in a more integral and equitable manner, build leadership skills and use the findings to take community-level

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action to address the problems investigated. The integration of research and action in CBPR is more likely to occur in observational studies incorporating qualitative methods.

The limitations of the present review should be noted. First, in relying on published articles to synthesise information, I was unable to use unpublished articles or independently verify the information provided by the authors in published articles. Although inherent in most systematic reviews, this limitation may have biased the findings, to the extent that pertinent information was omitted or misrepresented in the published articles. Second, in evaluating the integration of research and action in CBPR, the present review was not able to take into account the circumstances under which the practitioners of CBPR deemed no immediate action to be the best option, mainly owing to little documentation of such circumstances in the literature reviewed.

The findings of the current review offer clues on key facilitating factors for successful CBPR. First, who initiated the study is of critical importance in shaping the process and outcome of CBPR. The needs of the researcher are often guided by theoretical research questions, whereas the needs of the community are practical and action oriented.46 Therefore, it is not surprising that, when the impetus of CBPR came from the affected community, the research problem was more likely to reflect genuine community concerns and the research to be carried out with potential, relatively near-term solutions in mind and to lead to meaningful action.

Second, CBPR can be more successful when supported by social movements. The findings of this review offer examples of CBPR in which community partners who had built their organisational strength in related social movements—that is, the environmental justice and labour movements—came to play an integral role in CBPR to generate tangible benefits for the community. To conduct successful CBPR, therefore, the community itself should be mature enough to offer a vision and the ability to jointly investigate community health issues and to plan a course of action to address them.

Third, CBPR projects that integrated research with action are more likely to be observational studies, most of which incorporated qualitative methods. With the exception of one study (study 15) that led to advocacy, the RCTs reviewed did not lead to community-level action geared towards delivering tangible benefits for the community; none of the RCTs were initiated by the community. The findings involving the contention over RCTs—that, by design, they deny the benefits of interventions to control group members, albeit temporarily in some RCTs—suggest an inherent tension between the rigour required of RCTs and the core principles of CBPR to integrate research and action for the mutual benefit of all partners.

Critics have questioned whether the preoccupation with RCTs is appropriate in addressing research questions posed in community interventions with long and complex causal path- ways,47 especially for those that require flexibility to incorporate the perceptions and characteristics of the community.48 RCTs involving community participation have been used mainly in phase 2 translational research that promotes the adoption of an intervention whose efficacy has been established in clinical research.49 50 A case can be made that in action-oriented CBPR a higher priority should be given to making a beneficial intervention available to the community than to testing its effectiveness in the most rigorous manner. Observational designs closely integrated with surveillance51 might be more appropriate in evaluating the effectiveness of the intervention in CBPR.

Qualitative methods are conducive to eliciting in-depth information from the participants without imposing more structured research protocols on them. Also, while quantitative, individual-level data collection is likely to decontextualise the ways in which risk-taking behaviours and environment are generated and sustained, well-designed and carefully conducted qualitative studies can enhance one’s understanding of the problem within the context it is generated.52 These qualities render qualitative methods particularly useful for CBPR in that they are likely to help generate actionable knowledge—better informed by community members living under local condi- tions—and integrate it into contextually relevant strategies to effect community-level changes.

Fourth, the collaboration among government scientists, university researchers and community partners emerged as a new model of CBPR that effectively integrates research and action. Armed with scientific expertise and access to resources and governmental decision-making, and yet unencumbered by the requirements made by funding agencies of research fund recipients, government scientists may be in a unique position to freely investigate and promote action to better serve disadvan- taged communities. Such is the flexibility that should be allowed to CBPR researchers to enable them to conduct truly participatory research that integrates research and action.

CONCLUSIONS The focus on action in the present review is not intended to downplay CBPR projects that do not lead to action. Even when not generating immediate benefits, CBPR has been an impor- tant vehicle in public health research by incorporating commu- nity involvement to better identify the community needs and to conduct a more valid and relevant study, while engaging the community in a more or less equitable manner. Such progress should be duly recognised.

Rather, I argue that action-oriented CBPR seeking solutions to the community’s problems though community-level change—one that is perhaps more consistent with the proclaimed goals and ethical principles of CBPR—should be recognised and promoted. Some federal research funding agencies that have been at the forefront of promoting CBPR, most notably the National Institute of Environmental Health Sciences (NIEHS), recognise that, to be successful, research and prevention/intervention strategies must address the concerns of the community residents and that the scientific knowledge that community residents acquire may be used to inform policy and regulatory decisions.53 However, reflecting the currently pre- vailing paradigm of biomedical research, their funding criteria favour biomedical, hypothesis-driven research questions.54

Advocates of CBPR have already argued that funding and academic institutions need to extend their criteria for research excellence and be flexible enough to incorporate the input of community partners.6 I go further: I recommend that ‘‘action’’ should be a legitimate component of the criteria. It might be helpful for funding agencies to create programmes to support action-oriented CBPR or institute special emphasis panels to evaluate the merits of proposed CBPR projects in their ability to integrate research and action.

When communities engage in CBPR, their primary concern is to generate usable or actionable knowledge.19 55 To help communities generate actionable knowledge and use it to promote the health and well-being of community members, the extent to which research findings are used to effect change should be an integral part of the criteria to evaluate the quality of outcome-oriented CBPR. A new set of funding criteria and

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priorities or, indeed, a paradigmatic shift in determining what constitutes good public health research is called for to promote community-initiated and action-oriented CBPR.

Competing interests: None declared.

REFERENCES 1. Israel BA, Schultz AJ, Parker EA, et al. Critical issues in developing and following

community based participatory research principles. In: Minkler M, Wallerstein N, eds. Community-based participatory research for health. San Francisco, CA: Jossey-Bass, 2003: 53–76.

2. Minkler M, Wallerstein N. Introduction to community based participatory research. In: Minkler M, Wallerstein N, eds. Community-based participatory research for health. San Francisco, CA: Jossey-Bass, 2003: 3–26.

3. Green LW, Mercer SL. Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? Am J Public Health 2001;91:1926–9.

4. George MA, Daniel M, Green LW. Appraising and funding participatory research in health promotion. Int Q Community Health Educ 1998;18:181–97.

5. Israel BA, Schultz AJ, Parker EA, et al. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health 1998;19:173–202.

6. Israel BA, Parker EA, Rowe Z, et al. Community-based participatory research: lessons learned from the Centers for Children’s Environmental Health and Disease Prevention Research. Environ Health Perspect 2005;113:1463–71.

7. Israel BA, Krieger J, Vlahov D, et al. Challenges and facilitating factors in sustaining community-based participatory research partnerships: lessons learned from the Detroit, New York City and Seattle Urban Research Centers. J Urban Health 2006;83:1022–40.

8. Viswanathan M, Ammerman A, Eng E, et al. Community-based participatory research. 2004. http://www.ahrq.gov/downloads/pub/evidence/pdf/cbpr/cbpr.pdf (accessed 31 March 2007).

9. O’Fallon LR, Dearry A. Commitment of the National Institute of Environmental Health Sciences to community-based participatory research for rural health. Environ Health Perspect 2001;109:469–73.

10. Lee PT, Krause N, Goetchius C. Participatory action research with hotel room cleaners: from collaborative study to the bargaining table. In: Minkler M, Wallerstein N, eds. Community-based participatory research for health. San Francisco, CA: Jossey-Bass, 2003: 390–404.

11. Patton MQ. How to use qualitative methods in evaluation. Newburry Park, CA: Sage, 1987.

12. Suarez-Balcazar Y, Harper GW. Community-based approaches to empowerment and participatory evaluation. J Prev Interv Community 2003;26:1–4.

13. Farquhar SA, Wing S. Methodological and ethical considerations in community- driven environmental justice research: two case studies from rural North Carolina. In: Minkler M, Wallerstein N, eds. Community-based participatory research for health. San Francisco, CA: Jossey-Bass, 2003: 221–41.

14. Wing S. Social responsibility and research ethics in community-driven studies of industrialized hog production. Environ Health Perspect 2002;110:437–44.

15. McCauley LA, Beltran M, Phillips J, et al. The Oregon migrant farmworker community: an evolving model for participatory research. Environ Health Perspect 2001;109:449–55.

16. McCauley LA, Lasarev MR, Higgins G, et al. Work characteristics and pesticide exposures among migrant agricultural families: a community-based research approach. Environ Health Perspect 2001;109:533–8.

17. Swartz LJ, Callahan KA, Butz AM, et al. Methods and issues in conducting a community-based environmental randomized trial. Environ Res 2004;95:156–65.

18. Maslia ML, Reyes JJ, Gillig RE, et al. Public health partnerships addressing childhood cancer investigations: case study of Toms River, Dover Township, New Jersey, USA. Int J Hyg Environ Health 2005;208:45–54.

19. Quigley D, Handy D, Goble R, et al. Participatory research strategies in nuclear risk management for native communities. J Health Commun 2000;5:305–31.

20. Corburn J. Combining community-based research and local knowledge to confront asthma and subsistence-fishing hazards in Greenpoint/Williamsburg, Brooklyn, New York. Environ Health Perspect 2002;110:241–8.

21. Quandt SA, Arcury TA, Pell AI. Something for everyone? A community and academic partnership to address farmworker pesticide exposure in North Carolina. Environ Health Perspect 2001;109:435–41.

22. Quandt SA, Arcury TA, Austin CK, et al. Preventing occupational exposure to pesticides: using participatory research with Latino farmworkers to develop an intervention. J Immigr Health 2001;3:85–96.

23. Quandt SA, Doran AM, Rao P, et al. Reporting pesticide assessment results to farmworker families: development, implementation, and evaluation of a risk communication strategy. Environ Health Perspect 2004;112:636–42.

24. Arcury TA, Austin CK, Quandta SA, et al. Enhancing community participation in intervention research: farmworkers and agricultural chemicals in North Carolina. Health Educ Behav 1999;26:563–78.

25. Loh P, Sugerman-Brozan, Wiggins S, et al. From asthma to AirBeat: community- driven monitoring of fine particles and black carbon in Roxbury, Massachusetts. Environ Health Perspect 2002;110:297–301.

26. Egren KK, Parker EA, Israel BA, et al. Community involvement in the conduct of a health education intervention and research project: Community Action Against Asthma. Health Promot Pract 2005;6:263–9.

27. Parker EA, Israel BA, Williams M, et al. Community action against asthma: examining the partnership process of a community-based participatory research project. J Gen Intern Med 2003;18:558–67.

28. Lewis TC, Robins TG, Joseph CL, et al. Identification of gaps in the diagnosis and treatment of childhood asthma using a community-based participatory research approach. J Urban Health 2004;81:472–88.

29. Keeler GJ, Dvonch T, Yip FY, et al. Assessment of personal and community-level exposures to particulate matter among children with asthma in Detroit, Michigan, as part of Community Action Against Asthma. Environ Health Perspect 2002;110:173–81.

30. Krause N, Scherzer T, Rugulies R. Physical workload, work intensification, and prevalence of pain in low wage workers: results from a participatory research project with hotel room cleaners in Las Vegas. Am J Ind Med 2005;48:326–37.

31. Lipscomb HJ, Argue R, McDonald MA, et al. Exploration of work and health disparities among black women employed in poultry processing in the rural south. Environ Health Perspect 2005;113:1833–40.

32. Perera FP, Illman SM, Kinney P, et al. The challenge of preventing environmentally related disease in young children: community-based research in New York city. Environ Health Perspect 2002;110:197–204.

33. Vasquez VB, Minkler M, Shepard P. Promoting environmental health policy through community based participatory research: a case study from Harlem, New York. J Urban Health 2006;83:101–10.

34. Kinney PL, Aggarwal M, Northridge ME, et al. Airborne concentrations of PM2.5 and diesel exhaust particles on Harlem sidewalks: a community-based pilot study. In: Brugge D, Hynes HP, eds. Community research in environmental health: studies in science, advocacy and ethics. Burlington, VT: Ashgate, 2005:187–201.

35. Jordan C, Lee P, Shapiro E. Measuring developmental outcomes of lead exposure in an urban neighborhood: the challenges of community-based research. J Expo Anal Environ Epidemiol 2000;10:732–42.

36. Krieger JW, Song L, Takaro TK, et al. Asthma and the home environment of low- income urban children: preliminary findings from the Seattle-King County Healthy Homes project. J Urban Health 2000;771:50–67.

37. Krieger J, Allen C, Cheadle A, et al. Using community-based participatory research to address social determinants of health: lessons learned from Seattle Partners for Healthy Communities. Health Educ Behav 2002;29:361–82.

38. Krieger J, Takaro TK, Allen C, et al. The Seattle-King County Healthy Homes Project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. In: Brugge D, Hynes HP, eds. Community research in environmental health: studies in science, advocacy and ethics. Burlington, VT: Ashgate, 2005:49–78.

39. Krieger J, Takaro TK, Song L, et al. The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health 2005;95:652–9.

40. Litt JS, Hynes HP, Carroll P, et al. A program to improve urban neighborhood health through lead-safe yard interventions. In: Brugge D, Hynes HP, eds. Community research in environmental health: studies in science, advocacy and ethics. Burlington, VT: Ashgate, 2005:101–22.

41. Hynes HP, Brugge D, Watts J, et al. Public health and the physical environment in Boston public housing: a community-based survey and action agenda. In: Brugge D, Hynes HP, eds. Community research in environmental health: studies in science, advocacy and ethics. Burlington, VT: Ashgate, 2005:13–32.

42. Brugge D, Leong A, Averbach A, et al. An environmental health survey of residents of Boston Chinatown. In: Brugge D, Hynes HP, eds. Community research in environmental health: studies in science, advocacy and ethics. Burlington, VT: Ashgate, 2005:145–68.

What this study adds

Posing research questions not addressed in previous reviews of CBPR, this review produces findings that will help facilitate the integration of research and action in future CBPR. It also offers a new model of CBPR partnerships that are conducive to action- oriented CBPR.

Policy implications

Funding agencies need to revise the currently prevailing criteria for research excellence in evaluating proposed CBPR projects. It might be helpful for funding agencies to create programmes to support action-oriented CBPR or to institute special emphasis panels to evaluate the merits of proposed CBPR projects in their ability to integrate research and action.

Review

J Epidemiol Community Health 2008;62:668–676. doi:10.1136/jech.2007.067645 675

43. Schurman SJ, Israel BA. Redesigning work systems to reduce stress: a participatory action research approach to creating change. In: Murphy LR, Hurrell JJ, Sauter SL, eds. Job stress: interventions. Washington, DC: American Psychological Association, 1995:235–63.

44. Schurman SJ. Making the ‘‘new American workplace’’ safe and healthy: a joint labor–management–researcher approach. Am J Ind Med 1996;29:373–7.

45. De Rosa CT, El Masri HA, Pohl H, et al. Implications of chemical mixtures in public health practice. J Toxicol Environ Health 2004;7:337–50.

46. Suarez-Balcazar Y, Harper GW, Rhonda L. An interactive and contextual model of community–university collaborations for research and action. Health Educ Behav 2005;32:84–101.

47. Victora CG, Habicht J, Bryce J. Evidence-based public health: moving beyond randomized trials. Am J Public Health 2004;94:400–5.

48. Sorensen G, Emmons K, Hunt MK, et al. Implications of the results of community intervention trials. Annu Rev Public Health 1998;19:379–416.

49. Green L. From efficacy to effectiveness to community and back: evidence-based practice vs. practice-based evidence. In: National Institutes of Health, ed. From clinical trials to community: the science of translating diabetes and obesity research. Bethesda,

MD: NIH, 2004. http://www.niddk.nih.gov/fund/other/Diabetes-Translation/ conf-publication.pdf (accessed 2 March 2007).

50. Hiss RG. Translation research—two phases of a continuum. In: National Institutes of Health, ed. From clinical trials to community: the science of translating diabetes and obesity research. Bethesda, MD: NIH, 2004. http:// www.niddk.nih.gov/fund/other/Diabetes-Translation/conf-publication.pdf (accessed 2 March 2007).

51. Kaufman JS, Kaufman S, Poole C. Causal inference from randomized trials in social epidemiology. Soc Sci Med 2003;7:2397–409.

52. McKinlay JB. The promotion of health through planned sociopolitical change: challenges for research and policy. Soc Sci Med 1993;36:109–17

53. O’Fallon LR, Dearry A. Community-based participatory research as a tool to advance environmental health sciences. Environ Health Perspect 2002;110:155–9.

54. National Institute of Environmental Health Sciences. Environmental justice & community-based participatory research: program description. http://www.niehs.nih. gov/research/supported/programs/justice/ (accessed 21 September 2007).

55. Collin RW, Collin RM. The role of communities in environmental decisions: communities speaking for themselves. J Environ Law Litig 1998;37:72–83.

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Review

676 J Epidemiol Community Health 2008;62:668–676. doi:10.1136/jech.2007.067645