Anguilla Community College (ACC) Approach to Research

Professor Delroy M. Louden, PhD FRSPH & Susan Hodge, Cert. Pub Ad, DipHE

Introduction

Community Based Participatory Research (CBPR) has in recent years emerged as a new paradigm in the conduct of scientific investigations. It bridges the gap between the traditional scientific approach and practice through community engagement and socialization by the involvement of a wide group of constituencies in the research process—in essence (CBPR) is about equity and access.

1. Approach to Scientific Investigation

Community Based Participatory Research (CBPR) is a collaborative approach to research that combines research methods on inquiry with community capacity building strategies to bridge the gap between knowledge produced through research and what is practiced in communities through health partners, academic partners and community partners.

Israel et. al (1998) has identified nine key principals of CBPR that support successful research partnerships:

• Recognizes community as a unit of identity;
• Builds on strengths and resources within the community;
• Facilitates collaborative, equitable involvement of all partners in all phases of the research;
• Integrates knowledge and intervention for mutual benefit of all partners;
• Promotes a co-learning and empowering process that attends to social inequalities;
• Involves a cyclical and iterative process;
• Addresses health from both positive and ecological perspectives;
• Disseminates findings and knowledge gained to all partners; and
• Involves long-term commitment by all partners.

Figure 1

Source: National Library of Medicine/AHRQ-Evidence Report 2005

CBPR expands the potential for transforming research findings into practice and application—commonly known as translational sciences to develop, implement and dissemination effective interventions across diverse communities through strategies designed to reduce power imbalances, facilitate mutual benefit among community and academic partners as well as promote reciprocal knowledge translation thereby incorporating community theories into research design.

Traditional Research Approaches

1. Traditional research designs such as:
   • Case studies; and
   • Focus groups;
   • Experimental design;
   • Survey research e.g random sampling, stratified random sampling; and
   • Randomized clinical trials (RCT).
2. Epidemiological Investigations
   • Prospective investigations;
   • Retrospective Investigations;
   • Cross-sectional;
   • Case control studies.
3. Broad categories
   • Qualitative; and
   • Quantitative

These approaches have not always served us well. Indeed there is ample evidence of disrespect for example - Tuskegee, as well as inappropriateness, in design and conduct for example - HIV/AIDS Investigations in South Africa. In countries where there are rudimentary or non-extinct research protection process to such as institutional review board (IRB) or patient's bill of rights, and where informed consent is not adequately enforced abuses are prone to occur.

CBPR is important because…

There is increased interest in research that aims to improve the health of disadvantaged (low income) populations. However, conventional research in these communities has a contentious history and offers limited opportunities to improve the health and well being of these communities.

CBPR is not so easy…

Participatory research in disadvantaged communities has a long and successful history in the social sciences and international and rural development. There is a growing recognition of the importance and promise of this type of research within health services and public health institutions and funding organizations. However, in spite of the increased interest expressed by communities, universities, and funders, CBPR is underutilized primarily as it is mistaken, perceived as lacking essential features of traditional scientific method namely - scientific rigour.

Characteristics and Consequences of Community-Based Research

Community-based research processes differ fundamentally from mainstream research in the following ways:

1. It is done in collaboration with community groups that are eager to know the research results and to use them in practical efforts to achieve constructive social change.
2. Community-based research is not only usable, it is generally used and, more than that, used to good effect.
3. Ample evidence now exists that Community-based research often produces unanticipated and far reaching ancillary results, including new social relationships and trust, as well as heightened social efficacy.
4. Conventional research and development—along with its many social benefits and periodic spectacular successes—also bears some responsibility for environmental pollution, occasional ethical breaches (such as dangerous medical or military experiments performed on uninformed human subjects), degraded work processes and industrial accidents.
5. Community-based research shows the potential not to produce such negative consequences; it often contributes directly to preventing, mitigating, or remedying them.
6. Community research projects frequently involve local groups reacting to urgent problems at the level such as environmental pollution, local poverty and youth violence. The majority of the community-based organizations often go to formulate further a macro social analysis that informs their programmatic activities, ensuring that their projects include a proactive component or a translocal outlook. Community-based research projects findings have practical implications often well beyond the local level.

Paradigm - Shift - Empowerment

1. Community-based research is intended to empower communities and to give everyday people influence over the direction of research and enable them to be a part of decision making processes on issues that affect them.
2. Community-based research is rooted in communities.
3. Communities often identify the issue or problem and participate in defining the research question, conducting the research and, finally, using the results toward an action-oriented outcome. Our definition of community-based research (which we sometimes shorten to simply "community research") is: research conducted by, with, and/or for communities.

2. Demand for Community-Based Research

There is significant demand for community-based research, however the need is not being met here in Anguilla and elsewhere. Every organization we consulted attests to the need for more community-based research as they understand it.

• Community-based research is seldom a component of grants applied for or awarded in Anguilla. Currently there are no Community Outreach Partnership Programmes that provide data collection or analysis of trends relating to issues such as environmental pollution, beach erosion, disaster risk reduction efforts etc
.
• CBPR encourages collaboration of "formally trained research" partners from any area of expertise, provided that the researcher provides expertise that is seen as
1. useful to the investigation by the community;
2. be fully committed to a partnership of equals; and
3. outcomes are beneficial and usable to the community development. Equitable partnerships require sharing power, resources, credit, results, and knowledge, as well as, a reciprocal appreciation of each partner's knowledge and skills at each stage of the project, including problem definition/issue selection, research design, conducting research, interpreting the results, and determining how the results should be used for action. CBPR differs from traditional research in many ways. For example instead of creating knowledge for the advancement of a field or for knowledge's sake, CBPR is an iterative process, incorporating research, reflection, and action in a cyclical process.

3. Financial Dimensions of Community-Based Research

Most Anguillan community centres/groups find their ability to conduct CBPR is chronically constrained by an inadequate funding base. Although some agencies are impacted more acutely than others, more than half the centres' personnel we talked to worry that lack of funding could force them to shut down.

Traditional research projects in academia, industry, and government often cost from $50,000 up to $1 million, and occasionally much more. In comparison, community-based research is cost-effective. A typical community research project in Anguilla can cost approximately US$15,000, and can be effective in addressing important social problems, by having data on the issues that affect individuals in the community, empowers and provides other tangible benefits to groups that are often among society's least advantaged, produces secondary social benefits (such as enhancing participating students' education-for-citizenship), and produces little or no unintended social or environmental harm.

4. Creating a Nationwide Community Research Network

Amongst the long term goals of Anguilla Community College is the establishment of a comprehensive community research system that can address questions on virtually any topic for any group or organization throughout Anguillan civil society located anywhere on the Island.

Later a regional Institute's Community Research Network (CRN) initiative can be sought to establish similar capabilities including organizing a national planning conference, creating a regional Internet discussion forum for community-based research, publishing a monograph, as well as designing a searchable Internet database of community research centres in the region.

1. One pressing area to be addressed is Translational research.
2. Community belief systems with respect to trust and confidentiality of information disclosed.
3. An understanding of the peer review process.

Of course the underlying rationale for wanting some type of regional/national collaboration is to conduct research that is in the social interest but that the conventional research system will not fund or is ill-prepared to conduct.

5. Characteristics of Good Community Research Centres and Programmes

Collaboration with grassroots and other non-expert groups is one of the defining characteristics of community-based research. The mutually respectful relationship that needs to exist between experts and other community member's takes time to build. For example, tensions constantly arise in trying to reconcile university timetables and pacing with the sense of urgency pervasive among community organizations. Community research centre staff creates environments supporting successful collaboration by developing sensitivity to the areas where tension arises and skills in nurturing and mediating partnerships.

Participatory Research - We see the Community College of Anguilla through its community research centre conducting more participatory research. "Participatory research" aspires to involve community members in all stages of the research process. From a societal or community research centre's point of view, there is a significant economic benefit in involving our students: they can be rewarded partially or entirely with academic credit rather than monetarily.

• Students also gain the satisfaction that comes with making a constructive contribution to social improvement, while honing their research skills in a practical setting. Society benefits further because the participating students receive a boost in their education-for-citizenship. Very often student interns have been profoundly affected and altered their outlooks or career paths as a result of their involvement in community-based research.
• Faculty-supervised student participation can also help colleges/universities maintain a more balanced social outlook during a period of deepening research ties to the community.

Linkages/Collaboration. There are differing strengths and drawbacks to community research centres that are based in colleges/universities versus those that are independent nonprofit organizations. For example, some groups may feel that a college/university affiliation enhances their stature in the eyes of potential funders, provided overhead support, or eased recruitment of student interns. Potential drawbacks, however, include the possible requirement to pay high overhead charges on research grants or becoming subject to inhibiting laws or regulations (e.g. Human Subjects Review Committee procedures that were never designed with participatory, community-based research in mind). (Anguilla does not have any guidelines or policy in place for the protection of Human Subjects.)

• The success of a community research centre depends largely on its being rooted socially and ideologically in the community it is serving as well as having an oversight structure that includes strong constituent community representation.

Many of the lead informants in Community Organization are people who when interviewed knowing that it will be recorded and documented are often reluctant to share their organizations' negative experiences. For example, when asked about tensions that may arise between community members and experts while conducting research often they outright deny or play down conflict experienced in working together and often reply with the lines: "We get on fine!" The question then becomes how do we as researchers interpret such remarks?

Role of opinion leaders - researchers must be mindful of the need to select opinion leaders from a wide cross section of the population are not those with loud voices thereby reducing bias in the selection of information gathered and reported.

Aside from limitations in our individual case studies, there are further limitations associated with issues of overall sampling and the criteria involved in selecting particular organization for a case study. Thus, although we often want to select project illustrating how community-based research has been used to support social change we are constrained as to the extent that we can generalize our findings.

COMMUNITY BASED PARTICIPATORY RESEARCH IN ACTION

Examples

Coordinating the Environmental Health Research Aims and Methods of Scientists and Affected Communities

A roundtable to examine the scientific method of coordinating environmental health research and other methods to observe health effects in various communities. Some topics that will be addressed by the presenters are as follows: Healthy public housing initiatives; social and environmental determinants of hypertension in Anguillians; eliminating health disparities through community-based research, training, and outreach; lessons learned from a community outreach study in the populations; determining health risks from toxic waste sites.

Learning Objectives: At the conclusion of the session, the participant (learner) in this session will be able to: articulate the process of implementing a multi-stakeholder community based participatory research infrastructure and project in a unique setting; identify at least 3 ways community members can be directly involved in the design and implementation of an environmental health study; discuss the need to have a dynamic organizational structure capable of responding to inevitable challenges that are present in complex community-based projects; articulate procedures for assessing exposure to chemicals within cultural context; identify the failures and successes of community based research on the environmental determinants of hypertension, and health disparities in the populations; discuss issues related to conducting health effects and intervention/education research in the Anguillian population; describe the evidence linking lead exposure and stress with disparities in hypertension in Anguillians.

Moderator(s): Kacee Deener, MPH

Key Historical Results CBPR has contributed to in these cases: improved health outcomes

Examples from the US

Cancer/Early Detection (NCI)

• Led to significant increase in screening for colorectal cancer among men and women.
• Telephone care management significantly increases PAP, mammography early detection rates

HIV/AIDS and Behaviour - NIH

Group-based stress Management and relaxation training for HIV and women significantly -

• Deceased HIV Viral load
• Decreased depression in moderately depressed women
• Enhanced emotional well-being and quality of life
• Improvements in nutrition, alcohol and safe sex.

Hypertension Control

• Home-based pressure monitoring with and without telephone.
• Nurse case management significantly increases blood pressure control rates.

Asthma (EPA, HRSA)

• Home based education and assessments.

Anguilla Community College Research - Linking Research and Practice

• Collaborative Investigation and learning;
• Best practice
• Difference knowledge through collaboration
• Building enduring partnerships among clinicians, researchers, policy makers and communities
• Multi-disciplinary
• Ensure adequate representation of neglected sub-groups, providers and patients

Our CBPR approach allows us to include relevant stakeholders in:

• Design
• Conduct
• Analysis
• Implementation and
• Sustainability

This encourages

• Practice-based research
• Education and training
• Professional development

Example of CBPR to be launched by Anguilla Community College

Shape-up Anguilla - Obesity Prevention

EAT SMART, PLAY HARD is a campaign to increase daily physical ability and healthy eating through programming, physical infrastructure improvements and policy work.

This campaign will target schools, government departments, private sector workplaces, civil organizations and community groups.

The study will employ and implement strategies designed to create energy balance for elementary school children. These strategies will be employed in a before, during and after school environments and focused on improving dietary choices and on increasing the number of physical activity options available to children throughout the day.

Translation/ Prevention/ Outcomes envisaged

• Leads to successful outcomes for
  • Clinicians
  • Patients
  • Communities

Through

1. Training
2. Practice-based research
3. Academic partners
4. Community partners
5. Funders

Significant Improvements in

• Clinical preventive services
• Disease management
• Health Behaviour Change
• Quality of Life

Some unresolved issues in CBPR

CBPR - focusing on Community strengths and issues and engages the community in the research process.

1. External Validity - Engaging community stakeholders to adapt to complex systems and organization new context - new knowledge. Findings from highly complex interventions designs to real world community interventions in diverse contexts which often has high variability in resources, organizational capacity and research acceptance.
2. Language - Incompatibility between academia, discourse and real life situations and "Ivory Tower" where the language used has varied meanings research discourse now speak of "research participants" rather than "research subjects".
3. Power Dimensions - Shifts power through bi-directional learning, shared resources, collective decision-making, community voice representative at the table—reduction in marginalization of group and acceptance by the community of evidence based practices.

The ultimate goal of CBPR is the integration of science and practice.

Limitations

On the other hand we must be mindful of the inherent limitations that CBPR faces due often to resource constraints, but also methodological overreliance on the case study method. Often case studies are based almost entirely on information provided by the organizations being investigated. Thus in most (but not all) cases we were not able to take into account the perspectives of outside evaluators; of community constituents with whom these organizations had collaborated; or of any additional organizations involved in multi-institutional, community-based research partnerships.

Conclusion

CBPR PROVIDES A MUCH NEEDED MECHANISM where the needs of countless communities across the Island and the region can be addressed. By expanding the social infrastructure for conducting community-based research, thereby making empowerment-through-mutual-learning universally accessible, we can better direct the island's capabilities toward its social and environmental needs. We can help alleviate suffering, revitalize democracy and community life, and bequeath future generations a world better than we found it.

Endnote

Many community researchers challenge the conventional distinction between "laypeople" and "experts," which tends to denigrate lay knowledge and expertise. Thus, some adopt alternative distinctions, such as "no credentialed experts" versus "credentialed experts."

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© Professor Delroy M. Louden & Susan Hodge

HTML last revised 29th April, 2012.

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