Key issues for participatory research in the design and implementation of humanitarian assistance: a scoping review

Background

Participatory approaches that engage affected populations are increasingly applied in humanitarian health programs in concert with emerging accountability frameworks and the rapid growth of research in these settings. Participatory initiatives within this domain appear to be largely adopted at an operational level and are infrequently reported as a component of research efforts. Yet the evidence of the benefits of research involving community members is growing worldwide. This is the first review of participatory research (PR) in humanitarian settings.

Objectives

This study sought to understand the extent to which PR values and practices have been adopted in humanitarian health programs and to explore key issues in applying PR in this context.

Methods

This scoping review was based on the approach developed by Arksey and O’Malley. The search for relevant peer-reviewed articles included scientific databases, a humanitarian database, targeted journals and online resources published since 2009. Eleven articles were retrieved and reviewed to identify practices and key issues related to conducting PR in humanitarian settings.

Results

Four key themes were identified: building trust with local research stakeholders and participants; the importance of contextual understanding; implications of collaborating with affected populations in PR, and neutrality of researchers and Non-Governmental Organizations (NGOs). Study teams considered PR as a valued approach where there was mistrust or a need for contextualized understanding. The studies described how adaptations made during the study optimized collaboration with affected populations and how the presence of NGOs influenced the approach and results of PR.

Conclusions

One of the most important contributions of humanitarian health programs is to develop ‘medical practices that are better adapted to the living conditions and priorities of patients who are generally ignored’. Participatory approaches, such as PR, support the development of health-related practices that are more relevant and sustainable for affected populations.

How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field

Background

Research funders in Canada and abroad have made substantial investments in supporting collaborative research approaches to generating and translating knowledge as it is believed to increase knowledge use. Canadian health research funders have advocated for the use of integrated knowledge translation (IKT) in health research, however, there is limited research around how IKT compares to other collaborative research approaches. Our objective was to better understand how IKT compares with engaged scholarship, Mode 2 research, co-production and participatory research by identifying the differences and similarities among them in order to provide conceptual clarity and reduce researcher and knowledge user confusion about these common approaches.

Methods

We employed a qualitative descriptive method using interview data to better understand experts’ perspectives and experiences on collaborative research approaches. Participants’ responses were analysed through thematic analysis to elicit core themes. The analysis was centred around the concept of IKT, as it is the most recent approach; IKT was then compared and contrasted with engaged scholarship, Mode 2 research, co-production and participatory research. As this was an iterative process, data triangulation and member-checking were conducted with participants to ensure accuracy of the emergent themes and analysis process.

Results

Differences were noted in the orientation (i.e. original purpose), historical roots (i.e. disciplinary origin) and partnership/engagement (i.e. role of partners etc.). Similarities among the approaches included (1) true partnerships rather than simple engagement, (2) focus on essential components and processes rather than labels, (3) collaborative research orientations rather than research methods, (4) core values and principles, and (5) extensive time and financial investment. Core values and principles among the approaches included co-creation, reciprocity, trust, fostering relationships, respect, co-learning, active participation, and shared decision-making in the generation and application of knowledge. All approaches require extensive time and financial investment to develop and maintain true partnerships.

Conclusions

This qualitative study is the first to systematically synthesise experts’ perspectives and experiences in a comparison of collaborative research approaches. This work contributes to developing a shared understanding of collaborative research approaches to facilitate conceptual clarity in use, reporting, indexing and communication among researchers, trainees, knowledge users and stakeholders to advance IKT and implementation science.

Understanding how Indigenous culturally-based interventions can improve participants' health in Canada

There is increasing recognition that culturally-based diabetes prevention programs can facilitate the adoption and maintenance of healthy behaviours in the communities in which they are implemented. The Kahnawake School Diabetes Prevention Project (KSDPP) is a health promotion, community-based participatory research project aiming to reduce the incidence of Type 2 diabetes in the community of Kahnawake (Mohawk territory, Canada), with a large range of interventions integrating a Haudenosaunee perspective of health. Building on a qualitative, naturalistic and interpretative inquiry, this study aimed to assess the outcomes of a suite of culturally-based interventions on participants' life and experience of health. Data were collected through semi-structured qualitative interviews of 1 key informant and 17 adult, female Kahnawake community members who participated in KSDPP's suite of interventions from 2007 to 2010. Grounded theory was chosen as an analytical strategy. A theoretical framework that covered the experiences of all study participants was developed from the grounded theory analysis. KSDPP's suite of interventions provided opportunities for participants to experience five different change processes: (i) Learning traditional cooking and healthy eating; (ii) Learning physical activity; (iii) Learning mind focusing and breathing techniques; (iv) Learning cultural traditions and spirituality; (v) Socializing and interacting with other participants during activities. These processes improved participants' health in four aspects: mental, physical, spiritual and social. Results of this study show how culturally-based health promotion can bring about healthy changes addressing the mental, physical, spiritual and social dimensions of a holistic concept of health, relevant to the Indigenous perspective of well-being.

A systematic mixed studies review on Organizational Participatory Research: towards operational guidance

BACKGROUND

Organizational Participatory Research (OPR) seeks organizational learning and/or practice improvement. Previous systematic literature reviews described some OPR processes and outcomes, but the link between these processes and outcomes is unknown. We sought to identify and sequence the key processes of OPR taking place with and within healthcare organizations and the main outcomes to which they contribute, and to define ideal-types of OPR.

METHODS

This article reports a participatory systematic mixed studies review with qualitative synthesis A specialized health librarian searched MEDLINE, CINAHL, Embase Classic + Embase, PsycINFO, the Cochrane Library, Social Work Abstracts and Business Source Complete, together with grey literature data bases were searched from inception to November 29, 2012. This search was updated using forward citation tracking up to June 2014. Reporting quality was appraised and unclear articles were excluded. Included studies clearly reported OPR where the main research related decisions were co-constructed among the academic and healthcare organization partners. Included studies were distilled into summaries of their OPR processes and outcomes, which were subsequently analysed using deductive and inductive thematic analysis. All summaries were analysed; that is, data analysis continued beyond saturation.

RESULTS

Eighty-three studies were included from the 8873 records retrieved. Eight key OPR processes were identified. Four follow the phases of research: 1) form a work group and hold meetings, 2) collectively determine research objectives, 3) collectively analyse data, and 4) collectively interpret results and decide how to use them. Four are present throughout OPR: 1) communication, 2) relationships; 3) commitment; 4) collective reflection. These processes contribute to extra benefits at the individual and organizational levels. Four ideal-types of OPR were defined. Basic OPR consists of OPR processes leading to achieving the study objectives. This ideal-type and may be combined with any of the following three ideal-types: OPR resulting in random additional benefits for the individuals or organization involved, OPR spreading to other sectors of the organization and beyond, or OPR leading to subsequent initiatives. These results are illustrated with a novel conceptual model.

CONCLUSION

The model provides operational guidance to help OPR stakeholders collaboratively address organizational issues and achieve desired outcomes and more.

REVIEW REGISTRATION

As per PROSPERO inclusion criteria, this review is not registered.

Understanding the Sleep Habits of Children Within an Indigenous Community

This study was developed within the participatory research framework of a diabetes prevention project to understand the meaning of sleep and sleep habits of Indigenous preschool and elementary school children. Sleep deprivation is a known risk factor for obesity and Type 2 diabetes. A philosophical hermeneutic approach utilized interviews and focus groups with cultural knowledge holders, Elders, parents, teachers, and school administrators. The findings reflect how Indigenous community members understood sleep through the themes of traditional ways, changing times and concerns, increasing technology, generation gaps, parental responsibility, eating habits, physical activity, and children’s behaviours in school. After dissemination to the community, the findings were combined with traditional teachings and national recommendations to develop culture- and age-appropriate sleep-promoting educational materials for schools and the broader community.

Patient and public engagement in research and health system decision making: A systematic review of evaluation tools

BACKGROUND

Patient and public engagement is growing, but evaluative efforts remain limited. Reviews looking at evaluation tools for patient engagement in individual decision making do exist, but no similar articles in research and health systems have been published.

OBJECTIVE

Systematically review and appraise evaluation tools for patient and public engagement in research and health system decision making.

METHODS

We searched literature published between January 1980 and February 2016. Electronic databases (Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL and PsycINFO) were consulted, as well as grey literature obtained through Google, subject-matter experts, social media and engagement organization websites. Two independent reviewers appraised the evaluation tools based on 4 assessment criteria: scientific rigour, patient and public perspective, comprehensiveness and usability.

RESULTS

In total, 10 663 unique references were identified, 27 were included. Most of these tools were developed in the last decade and were designed to support improvement of engagement activities. Only 11% of tools were explicitly based on a literature review, and just 7% were tested for reliability. Patients and members of the public were involved in designing 56% of the tools, mainly in the piloting stage, and 18.5% of tools were designed to report evaluation results to patients and the public.

CONCLUSION

A growing number of evaluation tools are available to support patient and public engagement in research and health system decision making. However, the scientific rigour with which such evaluation tools are developed could be improved, as well as the level of patient and public engagement in their design and reporting.

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.

Localizing Global Medicine: Challenges and Opportunities in Cervical Screening in an Indigenous Community in Ecuador

This participatory research study examines the tensions and opportunities in accessing allopathic medicine, or biomedicine, in the context of a cervical cancer screening program in a rural indigenous community of Northern Ecuador. Focusing on the influence of social networks, the article extends research on "re-appropriation" of biomedicine. It does so by recognizing two competing tensions expressed through social interactions: suspicion of allopathic medicine and the desire to maximize one's health. Semistructured individual interviews and focus groups were conducted with 28 women who had previously participated in a government-sponsored cervical screening program. From inductive thematic analysis, the article traces these women's active agency in navigating coherent paths of health. Despite drawing on social networks to overcome formidable challenges, the participants faced enduring system obstacles-the organizational effects of the networks of allopathic medicine. Such obstacles need to be understood to reconcile competing knowledge systems and improve health care access in underresourced communities.

Evaluating an Indigenous health curriculum for diabetes prevention: engaging the community through talking circles and knowledge translation of results

BACKGROUND

Kahnawà:ke is a Kanien'kehá:ka (Mohawk) community in Quebec, Canada. In 1997, the community-controlled Kateri Memorial Hospital Centre in partnership with the Kahnawake Education Center, and the Kahnawake Schools Diabetes Prevention Project (KSDPP) developed an elementary school diabetes prevention health education program, aimed to increase knowledge of Type 2 diabetes, healthy eating and active lifestyles. Long-term goals for KSDPP community and school interventions are to decrease obesity and diabetes.

OBJECTIVES

To evaluate the Kateri Memorial Hospital Centre Health Education Program for Diabetes Prevention (HEP) and use key principles of knowledge translation to promote understanding of results to upgrade HEP content and improve delivery.

METHODS

A KSDPP community-based participatory research team used mixed methods for evaluation, combining a cross-sectional survey for 23 teachers with interviews of two elementary school principals and three culturally appropriate Indigenous talking circles with HEP authors, teachers and parents. Questionnaire results were presented as descriptive statistics. The thematic textual analysis identified emerging themes from talking circles and interviews.

RESULTS

Facilitators of HEP delivery were an acknowledgement of its importance; appreciation of prepared lesson plans for teachers; and KSDPP's strong community presence. Barriers included reduced administrative support and instructional time due to competing academic demands; the need for increased Kanien'kehá:ka cultural content; and outdated resource materials. Recommendations included increasing teacher training, Kanien'kehá:ka cultural content and administrative support.

CONCLUSION

Community researchers undertook detailed knowledge translation activities of facilitators, barriers and recommendations with hospital and education centre administrators and Kahnawà:ke community to maximize uptake of findings before external dissemination of results.

Organizational participatory research: a systematic mixed studies review exposing its extra benefits and the key factors associated with them

BACKGROUND

In health, organizational participatory research (OPR) refers to health organization members participating in research decisions, with university researchers, throughout a study. This non-academic partner contribution to the research may take the form of consultation or co-construction. A drawback of OPR is that it requires more time from all those involved, compared to non-participatory research approaches; thus, understanding the added value of OPR, if any, is important. Thus, we sought to assess whether the OPR approach leads to benefits beyond what could be achieved through traditional research.

METHODS

We identified, selected, and appraised OPR health literature, and at each stage, two team members independently reviewed and coded the literature. We used quantitative content analysis to transform textual data into reliable numerical codes and conducted a logistic regression to test the hypothesis that a co-construction type OPR study yields extra benefits with a greater likelihood than consultation-type OPR studies.

RESULTS

From 8873 abstracts and 992 full text papers, we distilled a sample of 107 OPR studies. We found no difference between the type of organization members' participation and the likelihood of exhibiting an extra benefit. However, the likelihood of an OPR study exhibiting at least one extra benefit is quadrupled when the impetus for the study comes from the organization, rather than the university researcher(s), or the organization and the university researcher(s) together (OR = 4.11, CI = 1.12-14.01). We also defined five types of extra benefits.

CONCLUSIONS

This review describes the types of extra benefits OPR can yield and suggests these benefits may occur if the organization initiates the OPR. Further, this review exposes a need for OPR authors to more clearly describe the type of non-academic partner participation in key research decisions throughout the study. Detailed descriptions will benefit others conducting OPR and allow for a re-examination of the relationship between participation and extra benefits in future reviews.

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.

Can we Build on Social Movement Theories to Develop and Improve Community-Based Participatory Research? A Framework Synthesis Review

A long-standing challenge in community-based participatory research (CBPR) has been to anchor practice and evaluation in a relevant and comprehensive theoretical framework of community change. This study describes the development of a multidimensional conceptual framework that builds on social movement theories to identify key components of CBPR processes. Framework synthesis was used as a general literature search and analysis strategy. An initial conceptual framework was developed from the theoretical literature on social movement. A literature search performed to identify illustrative CBPR projects yielded 635 potentially relevant documents, from which eight projects (corresponding to 58 publications) were retained after record and full-text screening. Framework synthesis was used to code and organize data from these projects, ultimately providing a refined framework. The final conceptual framework maps key concepts of CBPR mobilization processes, such as the pivotal role of the partnership; resources and opportunities as necessary components feeding the partnership's development; the importance of framing processes; and a tight alignment between the cause (partnership's goal), the collective action strategy, and the system changes targeted. The revised framework provides a context-specific model to generate a new, innovative understanding of CBPR mobilization processes, drawing on existing theoretical foundations.

Engaging with communities, engaging with patients: amendment to the NAPCRG 1998 Policy Statement on Responsible Research With Communities

BACKGROUND

In 1998, the North American Primary Care Research Group (NAPCRG) adopted a groundbreaking Policy Statement endorsing responsible participatory research (PR) with communities. Since that time, PR gained prominence in primary care research.

OBJECTIVES

To reconsider the original 1998 Policy Statement in light of increased uptake of PR, and suggest future directions and applications for PR in primary care. This work contributed to an updated Policy Statement endorsed by NAPCRG in 2015.

METHODS

32 university and 30 community NAPCRG-affiliated research partners, convened a workshop to document lessons learned about implementing processes and principles of PR. This document emerged from that session and reflection and discussion regarding the original Policy Statement, the emerging PR literature, and our own experiences.

RESULTS

The foundational principles articulated in the 1998 Policy Statement remain relevant to the current PR environment. Lessons learned since its publication include that the maturation of partnerships is facilitated by participatory processes that support increased community responsibility for research projects, and benefits generated through PR extend beyond research outcomes. Future directions that will move forward the field of PR in primary care include: (i) improve assessment of PR processes to better delineate the links between how PR teams work together and diverse PR outcomes, (ii) increase the number of models incorporating PR into translational research from project inception to dissemination, and (iii) increase application of PR approaches that support patient engagement in clinical settings to patient-provider relationship and practice change research.

CONCLUSION

PR has markedly altered the manner in which primary care research is undertaken in partnership with communities and its principles and philosophies continue to offer means to assure that research results and processes improve the health of all communities.

Active transportation to support diabetes prevention: Expanding school health promotion programming in an Indigenous community

BACKGROUND

School-based physical activity (PA) interventions, including school active transportation (AT), provide opportunities to increase daily PA levels, improves fitness, and reduces risk of diseases, such as type 2 diabetes. Based on a community-identified need, the Kahnawake Schools Diabetes Prevention Project, within an Indigenous community, undertook school travel planning to contribute to PA programming for two elementary schools.

METHODS

Using community-based participatory research, the Active & Safe Routes to School's School Travel Planning (STP) process was undertaken in two schools with an STP-Committee comprised of community stakeholders and researchers. STP activities were adapted for local context including: school profile form, family survey, in-class travel survey, pedestrian-traffic observations, walkability checklist, and student mapping.

RESULTS

STP data were jointly collected, analyzed and interpreted by researchers and community. Traffic-pedestrian observations, walkability and parent surveys identified key pedestrian-traffic locations, helped develop safe/direct routes, and traffic calming strategies. In-class travel and mapping surveys identified a need and student desire to increase school AT. The STP-Committee translated findings into STP-action plans for two schools, which were implemented in 2014-2015 school year.

CONCLUSIONS

Combining CBPR with STP merges community and researcher expertise. This project offered evidence-informed practice for active living promotions. Experience and findings could benefit Indigenous and non-Indigenous communities.

Incarcerated women develop a nutrition and fitness program: participatory research

PURPOSE

Women in prison throughout the world experience higher rates of mental and physical illness compared with the general population and compared with men in prison. The paper finds no published studies that report on men or women in prison engaging in participatory health research to address their concerns about nutrition and fitness. The purpose of this paper is to describe a pilot nutrition and fitness program, which resulted from a unique prison participatory health research project.

DESIGN/METHODOLOGY/APPROACH

Women in prison designed, led, and evaluated a six-week pilot fitness program in a minimum/medium security women's prison. Pre- and post-program assessments included a self-administered questionnaire and body measures. Open-ended questionnaire responses illuminated the quantitative findings.

FINDINGS

Sixteen women in prison completed the program evaluation. Weight, body mass index, waist-to-hip ratio, and chest measurements decreased, and energy, sleep, and stress levels improved by the end of the program.

RESEARCH LIMITATIONS/IMPLICATIONS

As a component of a participatory research project, incarcerated women designed and led a nutrition and fitness program, which resulted in improved body measures and self-reported health benefits. ORIGINALITY VALUE: Incarceration provides opportunities to engage women in designing their own health programs with consequent potential long-term "healing" benefits.

The Chilcapamba-McGill Partnership: Exploring Access to Maternal and Newborn Care in Indigenous Communities of Ecuador

BACKGROUND

Based on a participatory research (PR) partnership between Family Medicine at McGill University, Canada and the Andean community of Chilcapamba, Ecuador, a medical student study focused on maternal and newborn health.

OBJECTIVES

To evaluate the access to maternal and newborn care and the occurrence of intrafamilial violence in women with children 5 years of age or less in three indigenous communities of Ecuador.

METHODS

A semistructured survey explored the perinatal and intrapartum care as well as intrafamilial violence.

RESULTS

All women (N = 30) received prenatal care, 29 received postnatal care from a physician and 77% gave birth at the hospital. Eighty percent of women experienced intrafamilial violence; 73% reported psychological and 53% physical violence.

CONCLUSIONS

There is good access to maternal and newborn health care, although the reported level of violence is high. Results were shared with the community and will be used in a local community health worker (CHW) training program. Our project highlights the importance of PR to investigate sensitive health challenges.

A realist evaluation of community-based participatory research: partnership synergy, trust building and related ripple effects

BACKGROUND

Community-Based Participatory Research (CBPR) is an approach in which researchers and community stakeholders form equitable partnerships to tackle issues related to community health improvement and knowledge production. Our 2012 realist review of CBPR outcomes reported long-term effects that were touched upon but not fully explained in the retained literature. To further explore such effects, interviews were conducted with academic and community partners of partnerships retained in the review. Realist methodology was used to increase the understanding of what supports partnership synergy in successful long-term CBPR partnerships, and to further document how equitable partnerships can result in numerous benefits including the sustainability of relationships, research and solutions.

METHODS

Building on our previous realist review of CBPR, we contacted the authors of longitudinal studies of academic-community partnerships retained in the review. Twenty-four participants (community members and researchers) from 11 partnerships were interviewed. Realist logic of analysis was used, involving middle-range theory, context-mechanism-outcome configuration (CMOcs) and the concept of the 'ripple effect'.

RESULTS

The analysis supports the central importance of developing and strengthening partnership synergy through trust. The ripple effect concept in conjunction with CMOcs showed that a sense of trust amongst CBPR members was a prominent mechanism leading to partnership sustainability. This in turn resulted in population-level outcomes including: (a) sustaining collaborative efforts toward health improvement; (b) generating spin-off projects; and (c) achieving systemic transformations.

CONCLUSION

These results add to other studies on improving the science of CBPR in partnerships with a high level of power-sharing and co-governance. Our results suggest sustaining CBPR and achieving unanticipated benefits likely depend on trust-related mechanisms and a continuing commitment to power-sharing. These findings have implications for building successful CBPR partnerships to address challenging public health problems and the complex assessment of outcomes.

Dental students' perceptions of and attitudes about poverty: a Canadian participatory case study

This qualitative case study was conducted in a Canadian dental school using a participatory approach and was based on Paulo Freire's theoretical concept of conscientização, a form of critical consciousness that involves awareness of social reality and fosters action towards social justice. The aim of the study was to understand dental students' perceptions of and attitudes about poverty and dental care provided to people living in poverty. It also examined how these perceptions shape students' plans for their professional careers, as well as their opinions on educational strategies to prepare them to work with poor patients. The sources of data generation were semistructured interviews, participant observations, and document analysis. A deductive-inductive thematic strategy was used to analyze the data. Out of a class of thirty-five senior dental students, the authors interviewed a convenience sample of twelve: five male and seven female. The findings suggest that the students had incipient conscientização about poverty-related themes. They perceived poverty as a distant issue and as the responsibility of the government or of the poor individuals themselves. The students did not have plans to work with patients living in poverty in the future and struggled to envision ways to address these patients' needs other than volunteer work. This research supports the need for academic dental institutions to adopt strategies to increase students' critical consciousness about oral health inequities. Reducing oral health inequities is a matter of social justice, and dental care providers are key actors in this endeavor.

Using a participatory approach to the development of a school-based physical activity policy in an Indigenous community

BACKGROUND

This study is part of a larger community-based participatory research (CBPR) project to develop, implement, and evaluate the physical activity component of a school-based wellness policy. The policy intervention is being carried out by community stakeholders and academic researchers within the Kahnawake Schools Diabetes Prevention Project, a well-established health promotion organization in the Indigenous community of Kahnawake, Quebec.

METHODS

We explored how a group of stakeholders develop a school physical activity policy in a participatory manner, and examined factors serving as facilitators and barriers to the development process. This case study was guided by an interpretive description approach and draws upon data from documentary analysis and participant observation.

RESULTS

A CBPR approach allowed academic researchers and community stakeholders to codevelop a physical activity policy that is both evidence-based and contextually appropriate. The development process was influenced by a variety of barriers and facilitators including working within existing structures, securing appropriate stakeholders, and school contextual factors.

CONCLUSIONS

This research offers a process framework that others developing school-based wellness policies may use with appropriate modifications based on local environments.

From policy to practice: implementing frontline community health services for substance dependence--study protocol

Background

Substance abuse is a worldwide public health concern. Extensive scientific research has shown that screening and brief interventions for substance use disorders administered in primary care provide substantial benefit at relatively low cost. Frontline health clinicians are well placed to detect and treat patients with substance use disorders. Despite effectiveness shown in research, there are many factors that impact the implementation of these practices in real-world clinical practice. Recently, the Ministry of Health and Social Services in Quebec, Canada, issued two policy documents aimed at introducing screening and early intervention for substance abuse into frontline healthcare clinics in Quebec. The current research protocol was developed in order to study the process of implementation of evidence-based addiction treatment practices at three primary care clinics in Montreal (Phase 1). In addition, the research protocol was designed to examine the efficacy of overall policy implementation, including barriers and facilitators to addictions program development throughout Quebec (Phase 2).

Methods/Design

Phase 1 will provide an in-depth case study of knowledge translation and implementation. The study protocol will utilize an integrated knowledge translation strategy to build collaborative mechanisms for knowledge exchange between researchers, addiction specialists, and frontline practitioners (guided by the principles of participatory-action research), and directly examine the process of knowledge uptake and barriers to transfer using both qualitative and quantitative methodologies. Evaluation will involve multiple measures, time points and domains; program uptake and effectiveness will be determined by changes in healthcare service delivery, sustainability and outcomes. In Phase 2, qualitative methods will be utilized to examine the contextual facilitators and barriers that frontline organizations face in implementing services for substance dependence. Phase 2 will provide the first study exploring the wide-scale implementation of frontline services for substance dependence in the province of Quebec and yield needed information about how to effectively implement mandated policies into clinical practice and impact public health.

Discussion

Findings from this research program will contribute to the understanding of factors associated with implementation of frontline services for substance dependence and help to inform future policy and organizational support for the implementation of evidence-based practices.

Critical reflections on realist review: insights from customizing the methodology to the needs of participatory research assessment

Realist review has increased in popularity as a methodology for complex intervention assessment. Our experience suggests that the process of designing a realist review requires its customization to areas under investigation. To elaborate on this idea, we first describe the logic underpinning realist review and then present critical reflections on our application experience, organized in seven areas. These are the following: (1) the challenge of identifying middle range theory; (2) addressing heterogeneity and lack of conceptual clarity; (3) the challenge of appraising the quality of complex evidence; (4) the relevance of capturing unintended outcomes; (5) understanding the process of context, mechanism, and outcome (CMO) configuring; (6) incorporating middle-range theory in the CMO configuration process; and (7) using middle range theory to advance the conceptualization of outcomes - both visible and seemingly 'hidden'. One conclusion from our experience is that the degree of heterogeneity of the evidence base will determine whether theory can drive the development of review protocols from the outset, or will follow only after an intense period of data immersion. We hope that presenting a critical reflection on customizing realist review will convey how the methodology can be tailored to the often complex and idiosyncratic features of health research, leading to innovative evidence syntheses.

Transforming primary healthcare by including the stakeholders involved in delivering care to people living in poverty: EQUIhealThY study protocol

BACKGROUND

Ensuring access to timely and appropriate primary healthcare for people living in poverty is an issue facing all countries, even those with universal healthcare systems. The transformation of healthcare practices and organization could be improved by involving key stakeholders from the community and the healthcare system in the development of research interventions. The aim of this project is to stimulate changes in healthcare organizations and practices by encouraging collaboration between care teams and people living in poverty. Our objectives are twofold: 1) to identify actions required to promote the adoption of professional practices oriented toward social competence in primary care teams; and 2) to examine factors that would encourage the inclusion of people living in poverty in the process of developing social competence in healthcare organizations.

METHODS/DESIGN

This study will use a participatory action research design applied in healthcare organizations. Participatory research is an increasingly recognized approach that is helpful for involving the people for whom the research results are intended. Our research team consists of 19 non-academic researchers, 11 academic researchers and six partners. A steering committee composed of academic researchers and stakeholders will have a decision-making role at each step, including knowledge dissemination and recommendations for new interventions. In this project we will adopt a multiphase approach and will use a variety of methods, including photovoice, group discussions and interviews.

DISCUSSION

The proposed study will be one of only a few using participatory research in primary care to foster changes aimed at enhancing quality and access to care for people living in poverty. To our knowledge this will be the first study to use photovoice in healthcare organizations to promote new interventions. Our project includes partners who are targeted for practice changes and improvements in delivering primary care to persons living in poverty. By involving knowledge users, including service recipients, our study is more likely to produce a transformation of professional practices and encourage healthcare organizations to take into account the needs of persons living in poverty.

Uncovering the benefits of participatory research: implications of a realist review for health research and practice

Context

Participatory research (PR) is the co-construction of research through partnerships between researchers and people affected by and/or responsible for action on the issues under study. Evaluating the benefits of PR is challenging for a number of reasons: the research topics, methods, and study designs are heterogeneous; the extent of collaborative involvement may vary over the duration of a project and from one project to the next; and partnership activities may generate a complex array of both short- and long-term outcomes.

Methods

Our review team consisted of a collaboration among researchers and decision makers in public health, research funding, ethics review, and community-engaged scholarship. We identified, selected, and appraised a large-variety sample of primary studies describing PR partnerships, and in each stage, two team members independently reviewed and coded the literature. We used key realist review concepts (middle-range theory, demi-regularity, and context-mechanism-outcome configurations [CMO]) to analyze and synthesize the data, using the PR partnership as the main unit of analysis.

Findings

From 7,167 abstracts and 591 full-text papers, we distilled for synthesis a final sample of twenty-three PR partnerships described in 276 publications. The link between process and outcome in these partnerships was best explained using the middle-range theory of partnership synergy, which demonstrates how PR can (1) ensure culturally and logistically appropriate research, (2) enhance recruitment capacity, (3) generate professional capacity and competence in stakeholder groups, (4) result in productive conflicts followed by useful negotiation, (5) increase the quality of outputs and outcomes over time, (6) increase the sustainability of project goals beyond funded time frames and during gaps in external funding, and (7) create system changes and new unanticipated projects and activities. Negative examples illustrated why these outcomes were not a guaranteed product of PR partnerships but were contingent on key aspects of context.

Conclusions

We used a realist approach to embrace the heterogeneity and complexity of the PR literature. This theory-driven synthesis identified mechanisms by which PR may add value to the research process. Using the middle-range theory of partnership synergy, our review confirmed findings from previous PR reviews, documented and explained some negative outcomes, and generated new insights into the benefits of PR regarding conflicts and negotiation between stakeholders, program sustainability and advancement, unanticipated project activity, and the generation of systemic change.

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

Purpose.

To assess the evolution of perceived ownership of a university-Aboriginal community partnership across three project stages.

Design.

Survey administration to project partners during project formalization (1996—T1), mobilization (1999—T2), and maintenance (2004—T3).

Setting.

Aboriginal community of Kahnawake, outside Montreal, Quebec, Canada.

Participants.

Partners involved in influencing decision making in the Kahnawake Schools Diabetes Prevention Project (KSDPP).

Measure and Analysis.

A measure of perceived primary ownership subjected to linear trend analysis.

Results.

KSDPP staff were perceived as primary owner at T1 and shared ownership with Community Advisory Board (CAB) members at T2 and T3. Trend tests indicated greater perceived ownership between T1 and T3 for CAB (χ21 = 12.3, p < .0001) and declining KSDPP staff (χ21 = 10.5, p < .001) ownership over time. Academic partners were never perceived as primary owners.

Conclusion.

This project was community driven from the beginning. It was not dependent on an external academic change agent to activate the community and develop the community's capacity to plan and implement a solution. It still took several years for the grassroots CAB to take responsibility from KSDPP staff, thus indicating the need for sustained funding to build grassroots community capacity.

Challenges to the provision of diabetes care in first nations communities: results from a national survey of healthcare providers in Canada

Background

Aboriginal peoples globally, and First Nations peoples in Canada particularly, suffer from high rates of type 2 diabetes and related complications compared with the general population. Research into the unique barriers faced by healthcare providers working in on-reserve First Nations communities is essential for developing effective quality improvement strategies.

Methods

In Phase I of this two-phased study, semi-structured interviews and focus groups were held with 24 healthcare providers in the Sioux Lookout Zone in north-western Ontario. A follow-up survey was conducted in Phase II as part of a larger project, the Canadian First Nations Diabetes Clinical Management and Epidemiologic (CIRCLE) study. The survey was completed with 244 healthcare providers in 19 First Nations communities in 7 Canadian provinces, representing three isolation levels (isolated, semi-isolated, non-isolated). Interviews, focus groups and survey questions all related to barriers to providing optimal diabetes care in First Nations communities.

Results

the key factors emerging from interviews and focus group discussions were at the patient, provider, and systemic level. Survey results indicated that, across three isolation levels, healthcare providers' perceived patient factors as having the largest impact on diabetes care. However, physicians and nurses were more likely to rank patient factors as having a large impact on care than community health representatives (CHRs) and physicians were significantly less likely to rank patient-provider communication as having a large impact than CHRs.

Conclusions

Addressing patient factors was considered the highest impact strategy for improving diabetes care. While this may reflect "patient blaming," it also suggests that self-management strategies may be well-suited for this context. Program planning should focus on training programs for CHRs, who provide a unique link between patients and clinical services. Research incorporating patient perspectives is needed to complete this picture and inform quality improvement initiatives.

Assessing the benefits of participatory research: a rationale for a realist review

Participatory research (PR) experts believe that increased community and stakeholder participation in research augments program pertinence, quality, outcome, sustainability, uptake, and transferability. There is, however, a dearth of assessments and measurement tools to demonstrate the contribution of participation in health research and interventions. One systematic review of PR, conducted for the Agency for Health Research and Quality (AHRQ), provided no conclusive evidence concerning the benefits of community participation to enhance research and health outcomes. To overcome methodological gaps and barriers of the AHRQ review, we propose to conduct a systematic realist review, which can be understood as a theory-driven qualitative review capable of capturing the often complex, diffuse and obtuse evidence concerning participation. Reviewing how PR mechanisms and contextual factors mediate and moderate outcomes, the review will generate and test hypotheses (middle-range theories) conceptualizing the benefits of participation and will portray the manner and circumstances in which participation influences outcomes.

Assessing the outcomes of participatory research: protocol for identifying, selecting, appraising and synthesizing the literature for realist review

Background

Participatory Research (PR) entails the co-governance of research by academic researchers and end-users. End-users are those who are affected by issues under study (e.g., community groups or populations affected by illness), or those positioned to act on the knowledge generated by research (e.g., clinicians, community leaders, health managers, patients, and policy makers). Systematic reviews assessing the generalizable benefits of PR must address: the diversity of research topics, methods, and intervention designs that involve a PR approach; varying degrees of end-user involvement in research co-governance, both within and between projects; and the complexity of outcomes arising from long-term partnerships.

Methods

We addressed the above mentioned challenges by adapting realist review methodology to PR assessment, specifically by developing inductively-driven identification, selection, appraisal, and synthesis procedures. This approach allowed us to address the non-uniformity and complexity of the PR literature. Each stage of the review involved two independent reviewers and followed a reproducible, systematic coding and retention procedure. Retained studies were completed participatory health interventions, demonstrated high levels of participation by non-academic stakeholders (i.e., excluding studies in which end-users were not involved in co-governing throughout the stages of research) and contained detailed descriptions of the participatory process and context. Retained sets are being mapped and analyzed using realist review methods.

Results

The librarian-guided search string yielded 7,167 citations. A total of 594 citations were retained after the identification process. Eighty-three papers remained after selection. Principle Investigators (PIs) were contacted to solicit all companion papers. Twenty-three sets of papers (23 PR studies), comprising 276 publications, passed appraisal and are being synthesized using realist review methods.

Discussion

The systematic and stage-based procedure addressed challenges to PR assessment and generated our robust understanding of complex and heterogeneous PR practices. To date, realist reviews have focussed on evaluations of relatively uniform interventions. In contrast our PR search yielded a wide diversity of partnerships and research topics. We therefore developed tools to achieve conceptual clarity on the PR field, as a beneficial precursor to our theoretically-driven synthesis using realist methods. Findings from the ongoing review will be provided in forthcoming publications.

A participatory approach to understanding and measuring patient satisfaction in a primary care teaching setting

BACKGROUND

Patient satisfaction is a complex, multidimensional concept that is difficult to measure. However, there is agreement that understanding the expectations of a patient community or "what is important to them" is an essential consideration. We chose a participatory approach to address patient satisfaction in the context of a primary care teaching clinic.

OBJECTIVES

The objectives of this project were to use a participatory research team of patients staff and researchers to (1) adapt an existing patient satisfaction questionnaire (PSQ) to the specific cultural and organizational elements ofa primary care teaching clinic, (2) administer the revised questionnaire and use the findings as a tool for organizational improvement, with the ultimate goal of increasing patient satisfaction, and (3) ensure that all decision making involved patients and staff to empower them in the process of organizational change.

METHODS

We used an iterative, mixed methods approach to conduct this project. An interdisciplinary committee composed of members of the patient community, clinical and administrative staff, and researchers worked together as the primary decision making body.

RESULTS

We modified a preexisting questionnaire to address the unique care delivery model of the clinic, issues of cultural sensitivity, and the need for simplified language and response format. Patient dissatisfaction was found to center on continuity and access to care.

CONCLUSIONS

The participatory approach was critical to our success in understanding and measuring patient satisfaction from the patients' perspective. The involvement of the interdisciplinary committee and the high level of joint decision making in this project represents a unique contribution to assessing primary care patient satisfaction.

Lessons learned in using community-based participatory research to build a national diabetes collaborative in Canada

BACKGROUND

Using community-based participatory research (CBPR) principles, the Canadian First Nations Diabetes Clinical Management Epidemiologic (CIRCLE) study documents the current clinical management of type 2 diabetes (T2DM) and complications in 19 partnering First Nations (FN) communities.

OBJECTIVES

To outline the lessons learned in developing and fostering community health partnerships, and demonstrate the feasibility of using CBPR in multisite research at a national level.

METHODS

Investigators developed investigator-FN community partnerships from seven Canadian provinces, and research assistants were hired from each community to facilitate data collection. Research assistants randomly selected patients from each community's diabetes registry, and audited the charts of consenting patients from 2006 to 2009 for diabetes indicators in accordance with national diabetes guidelines.

LESSONS LEARNED

Lessons learned in using CBPR on a national scale are outlined by highlighting challenges and facilitating factors associated with (1) building collaborative relationships, (2) culture and ethics, (3) collaboration and partnership, and (4) innovative avenues of data management and dissemination. Lessons learned include the need for a flexible research agenda, clear and mutually agreed upon roles, partnership from all community levels including Elders, regional coordinators managing several sites, and wide-scale dissemination methods.

CONCLUSION

The CIRCLE national CBPR multisite collaborative is unprecedented in Canada, and provides a feasible model for other studies. Using CBPR on a national scale exacerbates challenges commonly faced with single-site or multisite research, but the benefits provided in developing partnerships based on mutual trust and goals makes it of great importance.

Community-based participatory research: lessons from sharing results with the community: Kahnawake Schools Diabetes Prevention Project

BACKGROUND

Kahnawake Schools Diabetes Prevention Project (KSDPP) is an ongoing, community-based participatory research project with an Aboriginal community in Canada, promoting healthy lifestyles to prevent type 2 diabetes.

OBJECTIVES

To document lessons learned from sharing results with the community, and analyzing feedback from attendees.

METHODS

In 2004, a researcher-community team delivered 16 sessions of a contextualized presentation of data collected from 1994 to 2002. The team documented the resulting questions and discussions, attendees completed anonymous questionnaires including open-ended questions, and presenters summarized their impressions.

RESULTS

One hundred eighty-one people attended the presentations and question/discussion periods were summarized. One hundred sixty-two (82%) of attendees (87% female), completed the questionnaires; 99% understood the presentations and 142 (88%) stated they intended to improve their lifestyles. Qualitative analysis of discussions and open-ended comments categorized attendees' comments about KSDPP, the 1994 through 2002 results, the community, and lifestyle habits. Lessons learned included the time needed to develop and make the presentations, the importance of using community knowledge to guide the experience, ways of attracting an audience, difficulty of reaching men, use of feedback from those attending the presentations, and the need to plan prospectively for analyzing attendee feedback.

CONCLUSIONS

Community feedback was used to improve interventions and finalize interpretation of the results.

Primary health care: applying the principles within a community-based participatory health research project that began in a Canadian women’s prison

Objectives: the purpose of this research was to determine the feasibility of engaging incarcerated women in community-based participatory research and to identify, by and with the women, the health concerns to be addressed. Design: the integration of primary health care, community-based participatory research, a settings approach to health promotion and transformative action research guided the overall design of this study. Participants: Incarcerated women, correctional centre staff and academic researchers participated collaboratively. Setting. The study was conducted in the main short sentence (two years or less) minimum/medium security women’s correctional centre in a Canadian province. Results: In-depth interviews were conducted with 16 incarcerated women; in-depth group interviews were facilitated with 16 correctional centre staff. Twenty-one themes, which emerged from participatory, inductive and content analysis of the data, were presented at a face-to-face meeting attended by 120 incarcerated women, 10 correctional centre staff and 5 academic researchers. Underlying values and principles for the project were identified prior to a discussion of the results. During the course of this meeting, the themes were converged into five major categories: addictions and mental health; HIV, hepatitis and infections; health care in prison; life skills and re-entry into society (including homelessness and housing); and children, family and relationships. Numerous suggestions for health interventions and participatory projects were generated, each relating to one of the five major categories. Conclusions: this study was unique in that, to our knowledge, no other studies have utilized community-based participatory research methods in which incarcerated women played a role in designing the research questions and tools, collecting the data, analyzing the data, interpreting the data and authoring the publications and presentations. This study demonstrated that it is feasible for incarcerated women to engage in developing and utilizing community-based participatory research methods and that these methods can be grounded in a settings approach to whole prison health promotion. (Global Health Promotion, 2009; 16 (4): pp. 43—53)

Incidence and prevalence of type 2 diabetes in the First Nation community of Kahnawá:ke, Quebec, Canada, 1986-2003

BACKGROUND

Type 2 diabetes is an increasing global health concern, most notably for Aboriginal peoples living in Canada among whom prevalence rates are 3 to 5 times those of the general population. The objective of this study is to determine the incidence and prevalence of type 2 diabetes among adults living in a First Nation community from 1986 to 2003.

METHODS

Kahnawá:ke is a Kanien'kehá:ka (Mohawk) community in Quebec, Canada. Numerators for incident and prevalent cases were derived from the community hospital Diabetes Registry. Denominators were derived from population distributions provided to Kahnawá:ke by Indian and Northern Affairs Canada. Rates were standardized to 2000/01 Canadian population.

RESULTS

From 1986-88 to 2001-03, incidence rates per 1000 for those 18 years and over decreased from 8.8 to 7.0 in males, and 8.8 to 5.2 in females. Prevalence rates increased from 6.0% to 8.4% in males and 6.4% to 7.1% in females. The prevalence rate among Kahnawá:ke men aged 45-64 years was 14%, twice the corresponding rate among Canadian men. Male to female ratios for both incidence and prevalence rates were above 1.0.

DISCUSSION

Kahnawá:ke incidence rates are much lower than those of First Nation peoples of Manitoba. Kahnawá:ke prevalence rates are midway between national Aboriginal and general Canadian populations. Kahnawá:ke incidence rates and gender ratios are closer to those of the Canadian population. The results highlight the variations of type 2 diabetes between individual communities, and may reflect Kahnawá:ke's socio-economic status, ongoing diabetes education, clinical care and diabetes primary prevention efforts.

Can the democratic ideal of participatory research be achieved? An inside look at an academic-indigenous community partnership

Democratic or equal participation in decision making is an ideal that community and academic stakeholders engaged in participatory research strive to achieve. This ideal, however, may compete with indigenous peoples' right to self-determination. Study objectives were to assess the perceived influence of multiple community (indigenous) and academic stakeholders engaged in the Kahnawake Schools Diabetes Prevention Project (KSDPP) across six domains of project decision making and to test the hypothesis that KSDPP would be directed by community stakeholders. Self-report surveys were completed by 51 stakeholders comprising the KSDPP Community Advisory Board (CAB), KSDPP staff, academic researchers and supervisory board members. KSDPP staff were perceived to share similar levels of influence with (i) CAB on maintaining partnership ethics and CAB activities and (ii) academic researchers on research and dissemination activities. KSDPP staff were perceived to carry significantly more influence than other stakeholders on decisions related to annual activities, program operations and intervention activities. CAB and staff were the perceived owners of KSDPP. The strong community leadership aligns KSDPP with a model of community-directed research and suggests that equitable participation-distinct from democratic or equal participation-is reflected by indigenous community partners exerting greater influence than academic partners in decision making.

Promoting participatory research by family physicians

In the past, researchers have inadvertently caused stigmatization of various populations, first by not involving community members and then through publishing negative findings. In contrast, participatory research, which is based on a partnership between researchers and those affected by the issue being studied, promotes the voice of those being researched. This essay highlights key principles, processes, complexities, and challenges of participatory research and outlines when participatory research is not appropriate. It also reflects on the training and skills of family physicians that make them especially suited to participatory research. Family physicians have established clinical partnerships with their patients and sometimes entire communities, are trained in patient-centered care-a good basis for community centered research-and are accustomed to working with uncertainty. In addition, they are frequently pragmatic, interested in questions arising from their patients and communities, and likely to respond well to community requests. The main challenges to participatory research are lack of funding, expertise, and time, which may improve as more funding agencies and universities support this approach to research.

Protecting participants in family medicine research: a consensus statement on improving research integrity and participants' safety in educational research, community-based participatory research, and practice network research

Recent events that include the deaths of research subjects and the falsification of data have drawn greater scrutiny on assuring research data integrity and protecting participants. Several organizations have created guidelines to help guide researchers working in the area of clinical trials and ensure that their research is safe and valid. However, family medicine researchers often engage in research that differs from a typical clinical trial. Investigators working in the areas of educational research, community-based participatory research, and practice-based network research would benefit from similar recommendations to guide their own research. With funding from the US Office of Research Integrity and the Association of American Medical Colleges, we convened a panel to review issues of data integrity and participant protection in educational research, community-based participatory research, and research conducted by practice-based networks. The panel generated 11 recommendations for researchers working in these areas. Three key recommendations include the need for (1) all educational research to undergo review and approval by an institutional review board (IRB), (2) community-based participatory research to be approved not just by an IRB but also by appropriate community representatives, and (3) practice-based researchers to undertake only valid and meaningful studies that can be reviewed by a central IRB, rather than separate IRBs for each participating practice.

Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien'keha:ka (Mohawk) children 6 to 11 years old: 8-year results from the Kahnawake Schools Diabetes Prevention Project

OBJECTIVES

Report the 8-year impact on body size, physical activity, and diet of a community-based diabetes prevention program for elementary-school children in a Kanien'keha:ka (Mohawk) community in Canada.

METHODS

Follow-up (1994-1996) of subjects in the intervention and comparison community and repeat cross-sectional measurements in the intervention community alone from 1994 to 2002. Measures included triceps and subscapular skinfold thicknesses, body mass index (BMI), weekly number of 15-minute episodes of physical activity, run/walk test times, television watching, and consumption of sugared foods, fatty foods, and fruits and vegetables.

RESULTS

The longitudinal data of 1994-1996 showed some early positive effects of the program on skinfold thickness but not on BMI, physical activity, fitness, or diet. Repeat cross-sectional measures from 1994 to 2002 showed increases in skinfold thickness and BMI. Physical activity, fitness, and television watching showed favorable trends from 1994 to 1999 that were not sustained in 2002. Key high-fat and high-sugar foods consumption decreased, as did consumption of fruits and vegetables.

CONCLUSIONS

Although early results showed some successes in reducing risk factors for type 2 diabetes, these benefits were not maintained over 8 years.

Legitimizing diabetes as a community health issue: a case analysis of an Aboriginal community in Canada

The Kahnawake Schools Diabetes Prevention Project (KSDPP) is an ongoing participatory research and intervention project aimed at the primary prevention of type 2 diabetes. Formally initiated in 1994 with strong community support, KSDPP provides a fertile opportunity to learn about how a community came to identify the need for preventive action on a health problem such as diabetes. The purpose of our study was to describe the various conditions in the community of Kahnawake, which gave rise to its mobilization for the prevention of type 2 diabetes. Qualitative data consisted of 12 individual interviews and one focus group with key community members and health professionals living and/or working in the community of Kahnawake, along with historically relevant documents. The data collection and analysis procedures of the grounded theory method were applied. Results describe a preceding phase to formal KSDPP implementation, triggered by returning research results on the community prevalence of type 2 diabetes. This phase of 'legitimizing diabetes as a community health issue' is characterized by a shift in the perceived preventability of diabetes among community members; from a problem that was to be lived with to a problem that was to be prevented. The shift in perceptions was facilitated by the context in the community, described by structural developments, cognitive and relational elements. In addition to reaffirming the critical importance of utilizing lay knowledge during the planning of a health promotion intervention, our study has uncovered some of the key conditions through which individuals in the community came to participate in the identification and planning of a diabetes prevention project.

Health sciences research and Aboriginal communities: pathway or pitfall?

OBJECTIVE

To provide health researchers and clinicians with background information and examples regarding Aboriginal health research challenges, in an effort to promote effective collaborative research with Aboriginal communities.

METHODS

An interdisciplinary team of experienced Aboriginal-health researchers conducted a thematic analysis of their planning meetings regarding a community-based Aboriginal health research training project and of the text generated by the meetings and supplemented the analysis with a literature review.

RESULTS

Four research challenges are identified and addressed: (1) contrasting frameworks of Western science and indigenous knowledge systems; (2) the impact of historic colonialist processes upon the interface between health science research and Aboriginal communities; (3) culturally relevant frameworks and processes for knowledge generation and knowledge transfer; and (4) Aboriginal leadership, governance, and participation.

CONCLUSION

Culturally appropriate and community-controlled collaborative research can result in improved health outcomes in Aboriginal communities and contribute new insights and perspectives to the fields of public health and medicine in general.