Community Capacity as an “Inside Job”: Evolution of Perceived Ownership within a University-Aboriginal Community Partnership

How patient and community involvement in diabetes research influences health outcomes: A realist review

Background

Patient and public involvement in diabetes research is an international requirement, but little is known about the relationship between the process of involvement and health outcomes.

Objective

This realist review identifies who benefits from different types of involvement across different contexts and circumstances. Search strategies Medline, CINAHL and EMBASE were searched to identify interventions using targeted, embedded or collaborative involvement to reduce risk and promote self‐management of diabetes. People at risk/with diabetes, providers and community organizations with an interest in addressing diabetes were included. There were no limitations on date, language or study type.

Data extraction and synthesis

Data were extracted from 29 projects using elements from involvement frameworks. A conceptual analysis of involvement types was used to complete the synthesis.

Main results

Projects used targeted (4), embedded (8) and collaborative (17) involvement. Productive interaction facilitated over a sufficient period of time enabled people to set priorities for research. Partnerships that committed to collaboration increased awareness of diabetes risk and mobilized people to co‐design and co‐deliver diabetes interventions. Cultural adaptation increased relevance and acceptance of the intervention because they trusted local delivery approaches. Local implementation produced high levels of recruitment and retention, which project teams associated with achieving diabetes health outcomes.

Discussion and Conclusions

Achieving understanding of community context, developing trusting relationships across sectors and developing productive partnerships were prerequisites for designing research that was feasible and locally relevant. The proportion of diabetes studies incorporating these elements is surprisingly low. Barriers to resourcing partnerships need to be systematically addressed.

Community participation in health services development, implementation, and evaluation: A systematic review of empowerment, health, community, and process outcomes

Background

Community participation is widely believed to be beneficial to the development, implementation and evaluation of health services. However, many challenges to successful and sustainable community involvement remain. Importantly, there is little evidence on the effect of community participation in terms of outcomes at both the community and individual level. Our systematic review seeks to examine the evidence on outcomes of community participation in high and upper-middle income countries.

Methods and findings

This review was developed according to PRISMA guidelines. Eligible studies included those that involved the community, service users, consumers, households, patients, public and their representatives in the development, implementation, and evaluation of health services, policy or interventions. We searched the following databases from January 2000 to September 2016: Medline, Embase, Global Health, Scopus, and LILACs. We independently screened articles for inclusion, conducted data extraction, and assessed studies for risk of bias. No language restrictions were made. 27,232 records were identified, with 23,468 after removal of duplicates. Following titles and abstracts screening, 49 met the inclusion criteria for this review. A narrative synthesis of the findings was conducted. Outcomes were categorised as process outcomes, community outcomes, health outcomes, empowerment and stakeholder perspectives. Our review reports a breadth of evidence that community involvement has a positive impact on health, particularly when substantiated by strong organisational and community processes. This is in line with the notion that participatory approaches and positive outcomes including community empowerment and health improvements do not occur in a linear progression, but instead consists of complex processes influenced by an array of social and cultural factors.

Conclusion

This review adds to the evidence base supporting the effectiveness of community participation in yielding positive outcomes at the organizational, community and individual level.

Trial registration

Prospero record number:CRD42016048244.

Reclaiming food security in the Mohawk community of Kahnawà:ke through Haudenosaunee responsibilities

Indigenous Peoples are reclaiming their food security, nutrition, and well-being by revitalizing food systems, livelihoods, knowledge-systems, and governance. Our food security research is guided by sustainable self-determination that focuses on restoring Indigenous cultural responsibilities and relationships to land, each other, and the natural world (Corntassel, 2008). Our Kanien'kehá:ka (Mohawk) research team from Kahnawà:ke, in Quebec, Canada, examines food insecurity experiences in our community to explore ways of upholding our Haudenosaunee responsibilities and enhancing local food security. We collaboratively designed the study and interviewed Kahnawakehró:non (people from the Kahnawake community) with traditional knowledge, extensive community experience, and interests in food and culture. Interviews were audio-recorded, transcribed, and analysed by the team. Analysis characterized food insecurity experiences and conditions that challenge and enable food security with attention to traditional food systems, relationships to land, and gender-related responsibilities. Findings show that communal responsibilities generate resilient strategies that provide for all in times of crisis, and long-term food insecurity is managed through social programs, organized charities, and family support. Enhancing food security involves healing and protecting a limited land-base for food production, integrating food production with community priorities for education, training, health, economic development, and scientific innovation. Nurturing spiritual connections with tionhnhéhkwen (life sustaining foods), the natural world, and each other calls for accelerated teaching and practicing our original instructions. Challenges in developing food security leadership, balancing capitalism and subsistence economies, and strengthening social relationships are rooted in the historical colonial and current settler-colonial context that disrupts all aspects of Kanien'kehá:ka society.

Understanding community-based participatory research through a social movement framework: a case study of the Kahnawake Schools Diabetes Prevention Project

BACKGROUND

A longstanding challenge of community-based participatory research (CBPR) has been to anchor evaluation and practice in a relevant theoretical framework of community change, which articulates specific and concrete evaluative benchmarks. Social movement theories provide a broad range of theoretical tools to understand and facilitate social change processes, such as those involved in CBPR. Social movement theories have the potential to provide a coherent representation of how mobilization and collective action is gradually developed and leads to systemic change in the context of CBPR. The current study builds on a social movement perspective to assess the processes and intermediate outcomes of a longstanding health promotion CBPR project with an Indigenous community, the Kahnawake Schools Diabetes Prevention Project (KDSPP).

METHODS

This research uses a case study design layered on a movement-building evaluation framework, which allows progress to be tracked over time. Data collection strategies included document (scientific and organizational) review (n = 51) and talking circles with four important community stakeholder groups (n = 24).

RESULTS

Findings provide an innovative and chronological perspective of the evolution of KSDPP as seen through a social movement lens, and identify intermediate outcomes associated with different dimensions of movement building achieved by the project over time (mobilization, leadership, vision and frames, alliance and partnerships, as well as advocacy and action strategies). It also points to areas of improvement for KSDPP in building its potential for action.

CONCLUSION

While this study's results are directly relevant and applicable to the local context of KSDPP, they also highlight useful lessons and conclusions for the planning and evaluation of other long-standing and sustainable CBPR initiatives. The conceptual framework provides meaningful benchmarks to track evidence of progress in the context of CBPR. Findings from the study offer new ways of thinking about the evaluation of CBPR projects and their progress by drawing on frameworks that guide other forms of collective action.

The shifting dynamics of social roles and project ownership over the lifecycle of a community-based participatory research project

BACKGROUND

. Community based participatory research (CBPR) is often initiated by academic researchers, yet relies on meaningful community engagement and ownership to have lasting impact. Little is understood about how ownership shifts from academic to community partners.

OBJECTIVES

. We examined a CBPR project over its life course and asked: what does the evolution of ownership look like from project initiation by an academic (non-community) champion (T1); to maturation-when the intervention is ready to be deployed (T2); to independence-the time when the original champion steps aside (T3); and finally, to its maintenance-when the community has had an opportunity to function independently of the original academic champion (T4)?

METHODS

. Using sociometric (whole network) social network analysis, knowledge leadership was measured using 'in-degree centrality'. Stakeholder network structure was measured using 'centralisation' and 'core-periphery analysis'. Friedman rank sum test was used to measure change in actor roles over time from T1 to T4.

RESULTS

. Project stakeholder roles were observed to shift significantly (P < 0.005) from initiation (T1) to project maintenance (T4). Community stakeholders emerged into positions of knowledge leadership, while the roles of academic partners diminished in importance. The overall stakeholder network demonstrated a structural shift towards a core of densely interacting community stakeholders.

CONCLUSION

. This was the first study to use Social network analysis to document a shift in ownership from academic to community partners, indicating community self-determination over the research process. Further analysis of qualitative data will determine which participatory actions or strategies were responsible for this observed change.

Engagement strategies that foster community self-determination in participatory research: Insider ownership through outsider championship

BACKGROUND

In order to maximize the benefits of community-based participatory research, effective ownership over the research process must be at least equally in the hands of the community. A previous social network analysis documented that the participatory research process shifted ownership from academic to community partners, but did not show what actions and strategies fostered this shift.

OBJECTIVES

This study follows the trajectory of a community-academic partnership and asks, from the perspective of the project stakeholders, which actions and strategies over the lifespan of the research led to the observed shift in ownership and decision-making from the original external academics to the community stakeholders?

METHODS

Qualitative description using inductive thematic analysis. One academic and five community stakeholders identified as central in a previous social network analysis, participated in retrospective, semi-structured interviews.

RESULTS

Actions deemed to have fostered the observed shift in ownership included: existence of a strong champion; stimulating 'outside' ideas; emergence of core people; alignment of project goals with stakeholders' professional roles; involving the right people; personal qualities of the champion; trust-building; and active use of participatory engagement strategies.

CONCLUSION

Although communities must take ownership over the research process to assure sustained action and change, a strong, trusted and accepted outside champion who actively enacts participatory engagement strategies can facilitate the participatory process and provide community stakeholders the time and support they need to achieve meaningful and sustained leadership roles. These findings have implications for how partnership research is designed and implemented, both in community and in clinical organisational settings.

Champions for social change: Photovoice ethics in practice and 'false hopes' for policy and social change

Photovoice methodology is growing in popularity in the health, education and social sciences as a research tool based on the core values of community-based participatory research. Most photovoice projects state a claim to the third goal of photovoice: to reach policy-makers or effect policy change. This paper examines the concerns of raising false hopes or unrealistic expectations amongst the participants of photovoice projects as they are positioned to be the champions for social change in their communities. The impetus for social change seems to lie in the hands of those most affected by the issue. This drive behind collective social action forms, what could be termed, a micro-social movement or comparative interest group. Looking to the potential use of social movement theory and resource mobilisation concepts, this paper poses a series of unanswered questions about the ethics of photovoice projects. The ethical concern centres on the focus of policy change as a key initiative; yet, most projects remain vague about the implementation and outcomes of this focus.

Community-Academic Partnerships: A Systematic Review of the State of the Literature and Recommendations for Future Research

POLICY POINTS

Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research, to provide firsthand knowledge and insight. Based on our systematic review of major literature databases, we recommend using a single term, community-academic partnership (CAP), and a conceptual definition to unite multiple research disciplines and strengthen the field. Interpersonal and operational factors that facilitate or hinder the collaborative process have been consistently identified, including "trust among partners" and "respect among partners" (facilitating interpersonal factors) and "excessive time commitment" (hindering operational factor). Once CAP processes and characteristics are better understood, the effectiveness of collaborative partner involvement can be tested.

CONTEXT

Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research. Community stakeholders can provide firsthand knowledge and insight, thereby increasing research relevance and feasibility. Despite the greater emphasis and use of community-academic partnerships (CAP) across multiple disciplines, definitions of partnerships and methodologies vary greatly, and no systematic reviews consolidating this literature have been published. The purpose of this article, then, is to facilitate the continued growth of this field by examining the characteristics of CAPs and the current state of the science, identifying the facilitating and hindering influences on the collaborative process, and developing a common term and conceptual definition for use across disciplines.

METHODS

Our systematic search of 6 major literature databases generated 1,332 unique articles, 50 of which met our criteria for inclusion and provided data on 54 unique CAPs. We then analyzed studies to describe CAP characteristics and to identify the terms and methods used, as well as the common influences on the CAP process and distal outcomes.

FINDINGS

CAP research spans disciplines, involves a variety of community stakeholders, and focuses on a large range of study topics. CAP research articles, however, rarely report characteristics such as membership numbers or duration. Most studies involved case studies using qualitative methods to collect data on the collaborative process. Although various terms were used to describe collaborative partnerships, few studies provided conceptual definitions. Twenty-three facilitating and hindering factors influencing the CAP collaboration process emerged from the literature. Outcomes from the CAPs most often included developing or refining tangible products.

CONCLUSIONS

Based on our systematic review, we recommend using a single term, community-academic partnership, as well as a conceptual definition to unite multiple research disciplines. In addition, CAP characteristics and methods should be reported more systematically to advance the field (eg, to develop CAP evaluation tools). We have identified the most common influences that facilitate and hinder CAPs, which in turn should guide their development and sustainment.

Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations

BACKGROUND

Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models.

OBJECTIVES

To assess effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

SEARCH METHODS

We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index, Dissertation Abstracts, System for Information on Grey Literature in Europe (SIGLE) (from January 1990 through September 30, 2013), and Global Health Library (from January 1990 through March 31, 2014).

SELECTION CRITERIA

Cluster-randomized controlled trials, randomized controlled trials, quasi-experimental designs, controlled before-after studies, interrupted time series studies, and prospective controlled cohort studies. Only studies of community coalitions with at least one racial or ethnic minority group representing the target population and at least two community public or private organizations are included. Major outcomes of interest are direct measures of health status, as well as lifestyle factors when evidence indicates that these have an effect on the direct measures performed.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each study.

MAIN RESULTS

Fifty-eight community coalition-driven intervention studies were included. No study was considered to be at low risk of bias. Behavioral change outcomes and health status change outcomes were analyzed separately. Outcomes are grouped by intervention type. Pooled effects across intervention types are not presented because the diverse community coalition-led intervention studies did not examine the same constructs or relationships, and they used dissimilar methodological designs. Broad-scale community system level change strategies led to little or no difference in measures of health behavior or health status (very low-certainty evidence). Broad health and social care system level strategies leds to small beneficial changes in measures of health behavior or health status in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions led to beneficial changes in health behavior measures of moderate magnitude in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions may lead to beneficial changes in health status measures in large samples of community residents; however, results were not consistent across studies (low-certainty evidence). Group-based health education led by professional staff resulted in moderate improvement in measures of health behavior (very low-certainty evidence) or health status (low-certainty evidence). Adverse outcomes of community coalition-led interventions were not reported.

AUTHORS' CONCLUSIONS

Coalition-led interventions are characterized by connection of multi-sectoral networks of health and human service providers with ethnic and racial minority communities. These interventions benefit a diverse range of individual health outcomes and behaviors, as well as health and social care delivery systems. Evidence in this review shows that interventions led by community coalitions may connect health and human service providers with ethnic and racial minority communities in ways that benefit individual health outcomes and behaviors, as well as care delivery systems. However, because information on characteristics of the coalitions themselves is insufficient, evidence does not provide an explanation for the underlying mechanisms of beneficial effects. Thus, a definitive answer as to whether a coalition-led intervention adds extra value to the types of community engagement intervention strategies described in this review remains unattainable.

Using community advisory boards to reduce environmental barriers to health in American Indian communities, Wisconsin, 2007-2012

Background

American Indian communities have a high prevalence of chronic diseases including diabetes, obesity, cardiovascular disease, and cancer. Innovative community-based approaches are needed to identify, prioritize, and create sustainable interventions to reduce environmental barriers to healthy lifestyles and ultimately improve health.

Community Context

Healthy Children, Strong Families was a family-based and community-based intervention to increase healthy lifestyles on Wisconsin American Indian reservations. This intervention arose from a long-standing partnership between University of Wisconsin researchers and 3 of these American Indian communities.

Methods

In each community, community advisory boards (CABs) were established by the residents and university partners. CAB meetings were open and held at various times and locations to increase member participation. CABs featured continual, snowball recruitment; internal and external expert consultation; and coordination with standing tribal committees. Meetings initially focused on understanding community supports for and barriers to healthy lifestyles but quickly turned toward community action for change.

Outcome

CAB interventions decreased environmental barriers to health at each site and improved options for healthy lifestyle choices. Over 5 years, 71 CAB meetings occurred with a total of 1,070 participants. Successful CAB interventions included planting community gardens and an apple orchard, conducting gardening and canning workshops, instituting food-related policies and dog control regulations, building an environmentally friendly playground, and providing access to recreational facilities. The CABs are now self-sustaining.

Interpretation

CABs can be highly effective action teams capable of improving community environments. Our experience shows that academic researchers can partner with community residents to generate programs and policies that will expand access to local food, increase people’s choices for engaging in physical activity, and encourage local policy changes that improve overall community health.

Sandy lake health and diabetes project: a community-based intervention targeting type 2 diabetes and its risk factors in a first nations community

The Sandy Lake Health and Diabetes Project (SLHDP) was initiated in 1991 as a partnership between Sandy Lake First Nation and researchers interested in addressing the high rates of type 2 diabetes mellitus (T2DM) in the community. Following the expressed wishes of the community, the SLHDP has encompassed a variety of community-wide interventions and activities including: community surveys to document T2DM prevalence and risk factors, the Northern Store program aimed at increasing the availability and knowledge of healthy food options, a home visit program for the prevention and management of T2DM, a local diabetes radio show, a school diabetes curriculum for grades 3 and 4, a community-wide walking trail to encourage increased physical activity, youth diabetes summer camps, and a variety of community events focusing on nutrition and physical activity. Over the 22 year existence of the SLHDP, the community has taken ownership of the program and activities have evolved in alignment with community needs and priorities. This paper discusses the history, implementation, evaluation, and outcomes of the SLHDP and describes its sustainability. The SLHDP is a model of culturally appropriate participatory research that is iterative, with reciprocal capacity building for both key community stakeholders and academic partners.