Bonnie Duran

Using community-based participatory research to address health disparities.

Community-based participatory research (CBPR) has emerged in the past decades as an alternative research paradigm, which integrates education and social action to improve health and reduce health disparities. More than a set of research methods, CBPR is an orientation to research that focuses on relationships between academic and community partners, with principles of colearning, mutual benefit, and long-term commitment and incorporates community theories, participation, and practices into the research efforts. As CBPR matures, tensions have become recognized that challenge the mutuality of the research relationship, including issues of power, privilege, participation, community consent, racial and/or ethnic discrimination, and the role of research in social change. This article focuses on these challenges as a dynamic and ever-changing context of the researcher-community relationship, provides examples of these paradoxes from work in tribal communities, discusses the evidence that CBPR reduces disparities, and recommends transforming the culture of academia to strengthen collaborative research relationships.

Community-Based Participatory Research Contributions to Intervention Research: The Intersection of Science and Practice to Improve Health Equity

Community-based participatory research (CBPR) has emerged in the last decades as a transformative research paradigm that bridges the gap between science and practice through community engagement and social action to increase health equity. CBPR expands the potential for the translational sciences to develop, implement, and disseminate effective interventions across diverse communities through strategies to redress power imbalances; facilitate mutual benefit among community and academic partners; and promote reciprocal knowledge translation, incorporating community theories into the research. We identify the barriers and challenges within the intervention and implementation sciences, discuss how CBPR can address these challenges, provide an illustrative research example, and discuss next steps to advance the translational science of CBPR.

Healing the American Indian Soul Wound

It was almost two decades ago that the authors became aware of the concept of a “soul wound,” although knowledge of what is characterized as the “soul wound” had been an integral part of indigenous knowledge ever since Columbus landed in this hemisphere and Cortez arrived in Vera Cruz, Mexico. Native people who were asked about problems in the contemporary Native community explained that present problems had their etiology in the traumatic events known as the “soul wound” Knowledge of the soul wound has been present in Indian country for many generations. Current synonymous terms include historical trauma (Brave Heart, in press a), historical legacy, American Indian holocaust, and intergenerational posttraumatic stress disorder (Brave Heart & De Brun, in press). In addition, there has been academic literature documenting the American Indian holocaust, thus bringing some validation to the feelings of a community that has not had the world acknowledge the systematic genocide perpetrated on it (Brave Heart-Jordan & DeBruyn, 1995; Brown, 1971; Legters, 1988; Stannard, 1992; Thornton, 1987).

Socioeconomic disparities in intimate partner violence against Native American women: a cross-sectional study

BackgroundIntimate partner violence (IPV) against women is a global public health problem, yet data on IPV against Native American women are extremely limited. We conducted a cross-sectional study of Native American women to determine prevalence of lifetime and past-year IPV and partner injury; examine IPV in relation to pregnancy; and assess demographic and socioeconomic correlates of past-year IPV.MethodsParticipants were recruited from a tribally-operated clinic serving low-income pregnant and childbearing women in southwest Oklahoma. A self-administered survey was completed by 312 Native American women (96% response rate) attending the clinic from June through August 1997. Lifetime and past-year IPV were measured using modified 18-item Conflict Tactics Scales. A socioeconomic index was created based on partners education, public assistance receipt, and poverty level.ResultsMore than half (58.7%) of participants reported lifetime physical and/or sexual IPV; 39.1% experienced severe physical IPV; 12.2% reported partner-forced sexual activity; and 40.1% reported lifetime partner-perpetrated injuries. A total of 273 women had a spouse or boyfriend during the previous 12 months (although all participants were Native American, 59.0% of partners were non-Native). Among these women, past-year prevalence was 30.1% for physical and/or sexual IPV; 15.8% for severe physical IPV; 3.3% for forced partner-perpetrated sexual activity; and 16.4% for intimate partner injury. Reported IPV prevalence during pregnancy was 9.3%. Pregnancy was not associated with past-year IPV (odds ratio = 0.9). Past-year IPV prevalence was 42.8% among women scoring low on the socioeconomic index, compared with 10.1% among the reference group. After adjusting for age, relationship status, and household size, low socioeconomic index remained strongly associated with past-year IPV (odds ratio = 5.0; 95% confidence interval: 2.4, 10.7).ConclusionsNative American women in our sample experienced exceptionally high rates of lifetime and past-year IPV. Additionally, within this low-income sample, there was strong evidence of socioeconomic variability in IPV. Further research should determine prevalence of IPV against Native American women from diverse tribes and regions, and examine pathways through which socioeconomic disadvantage may increase their IPV risk.

Process and outcome constructs for evaluating community-based participatory research projects: a matrix of existing measures

Community-based participatory research (CBPR) has been widely used in public health research in the last decade as an approach to develop culturally centered interventions and collaborative research processes in which communities are directly involved in the construction and implementation of these interventions and in other application of findings. Little is known, however, about CBPR pathways of change and how these academic-community collaborations may contribute to successful outcomes. A new health CBPR conceptual model (Wallerstein N, Oetzel JG, Duran B et al. CBPR: What predicts outcomes? In: Minkler M, Wallerstein N (eds). Communication Based Participatory Research, 2nd edn. San Francisco, CA: John Wiley & Co., 2008) suggests that relationships between four components: context, group dynamics, the extent of community-centeredness in intervention and/or research design and the impact of these participatory processes on CBPR system change and health outcomes. This article seeks to identify instruments and measures in a comprehensive literature review that relates to these distinct components of the CBPR model and to present them in an organized and indexed format for researcher use. Specifically, 258 articles were identified in a review of CBPR (and related) literature from 2002 to 2008. Based on this review and from recommendations of a national advisory board, 46 CBPR instruments were identified and each was reviewed and coded using the CBPR logic model. The 46 instruments yielded 224 individual measures of characteristics in the CBPR model. While this study does not investigate the quality of the instruments, it does provide information about reliability and validity for specific measures. Group dynamics proved to have the largest number of identified measures, while context and CBPR system and health outcomes had the least. Consistent with other summaries of instruments, such as Granner and Sharpes inventory (Granner ML, Sharpe PA. Evaluating community coalition characteristics and functioning: a summary of measurement tools. Health Educ Res 2004; 19: 514-32), validity and reliability information were often lacking, and one or both were only available for 65 of the 224 measures. This summary of measures provides a place to start for new and continuing partnerships seeking to evaluate their progress.

Changing Patterns in Health Behaviors and Risk Factors Related to Cardiovascular Disease Among American Indians and Alaska Natives

OBJECTIVES We assessed changes in cardiovascular disease-related health outcomes and risk factors among American Indians and Alaska Natives by age and gender. METHODS We used cross-sectional data from the 1995 to 1996 and the 2005 to 2006 Behavioral Risk Factor Surveillance System. The respondents were 2548 American Indian and Alaska Native women and men aged 18 years or older in 1995-1996 and 11 104 women and men in 2005-2006. We analyzed the prevalence of type 2 diabetes, obesity, hypertension, cigarette smoking, sedentary behavior, and low vegetable or fruit intake. RESULTS From 1995-1996 to 2005-2006, the adjusted prevalence of diabetes among American Indians and Alaska Natives increased by 26.9%, from 6.7% to 8.5%, and obesity increased by 25.3%, from 24.9% to 31.2%. Hypertension increased by 5%, from 28.1% to 29.5%. Multiple logistic models showed no meaningful changes in smoking, sedentary behavior, or intake of fruits or vegetables. In 2005-2006, 79% of the population had 1 or more of the 6 risk factors, and 46% had 2 or more. CONCLUSIONS Diabetes, obesity, and hypertension and their associated risk factors should be studied further among urban, rural, and reservation American Indian and Alaska Native populations, and effective primary and secondary prevention efforts are critical.

Prevalence and Correlates of Mental Disorders Among Native American Women in Primary Care

OBJECTIVES We examined the lifetime and the past-year prevalence and correlates of common mental disorders among American Indian and Alaska Native women who presented for primary care. METHODS We screened 489 consecutively presenting female primary care patients aged 18 through 45 years with the General Health Questionnaire, 12-item version. A subsample (n = 234) completed the Composite International Diagnostic Interview. We examined associations between psychiatric disorders and sociodemographic variables, boarding school attendance, and psychopathology in the family of origin. RESULTS The study participants had high rates of alcohol use disorders, anxiety disorders, and anxiety/depression comorbidity compared with other samples of non-American Indian/Alaska Native women in primary care settings. CONCLUSIONS There is a need for culturally appropriate mental health treatments and preventive services.

Evaluating Community-Based Participatory Research to Improve Community-Partnered Science and Community Health

Background: Since 2007, the National Congress of American Indians (NCAI) Policy Research Center (PRC) has partnered with the Universities of New Mexico and Washington to study the science of community-based participatory research (CBPR). Our goal is to identify facilitators and barriers to effective community-academic partnerships in American Indian and other communities, which face health disparities.Objectives: We have described herein the scientific design of our National Institutes of Health (NIH)-funded study (2009-2013) and lessons learned by having a strong community partner leading the research efforts.Methods: The research team is implementing a mixed-methods study involving a survey of principal investigators (PIs) and partners across the nation and in-depth case studies of CBPR projects.Results: We present preliminary findings on methods and measures for community-engaged research and eight lessons learned thus far regarding partnership evaluation, advisory councils, historical trust, research capacity development of community partner, advocacy, honoring each other, messaging, and funding.Conclusions: Study methodologies and lessons learned can help community-academic research partnerships translate research in communities.

Reflections on Researcher Identity and Power: The Impact of Positionality on Community Based Participatory Research (CBPR) Processes and Outcomes

The practice of community based participatory research (CBPR) has evolved over the past 20 years with the recognition that health equity is best achieved when academic researchers form collaborative partnerships with communities. This article theorizes the possibility that core principles of CBPR cannot be realistically applied unless unequal power relations are identified and addressed. It provides theoretical and empirical perspectives for understanding power, privilege, researcher identity and academic research team composition, and their effects on partnering processes and health disparity outcomes. The team’s processes of conducting seven case studies of diverse partnerships in a national cross-site CBPR study are analyzed; the multi-disciplinary research team’s self-reflections on identity and positionality are analyzed, privileging its combined racial, ethnic, and gendered life experiences, and integrating feminist and post-colonial theory into these reflections. Findings from the inquiry are shared, and incorporating academic researcher team identity is recommended as a core component of equalizing power distribution within CBPR.

Obstacles for rural American Indians seeking alcohol, drug, or mental health treatment

The purpose of this study was to identify factors associated with 4 clusters of obstacles (self-reliance, privacy issues, quality of care, and communication and trust) to mental health and substance abuse treatment in 3 treatment sectors for residents of 3 reservations in the United States. Participants (N=3,084) disclosed whether they had sought treatment for emotional, drug, or alcohol problems in the past year and, if so, whether they had faced obstacles in obtaining care from Indian Health Services, tribal services, and other public or private systems. Correlates of these obstacles included negative social support, instrumental social support, utility of counselors, utility of family doctors, treatment sector, treatment type, diagnosis of an anxiety disorder, and tribe.