Public Health Research and Action: Reflections on Challenges and Possibilities of Community-Based Participatory Research

S. Lazarus1,2,3, B. Duran4, L. Caldwell5,6,7 and S. Bulbulia1 1Safety and Peace Promotion Research Unit (SAPPRU) 2Institute for Social and Health Sciences, University of South Africa 3Faculty of Education, University of the Western Cape 4Indigenous Wellness Research Institute (IWRI), University of Washington, Seattle 5University of Nebraska, Lincoln, Rhodes College 6University of Memphis 7Annie E. Casey Foundation 1,2,3South Africa 4,5,6,7USA


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The chapter commences with an overview of CBPR as a particular approach, and locates this approach within broader meta-theoretical paradigmatic frameworks. Drawing on both literature and personal experiences of the authors, the next section focuses on the utility, possibilities and potential outcomes of CBPR. Key challenges often faced in this kind of activity are then identified. The authors then draw on their own experiences to provide some suggestions for how some of these challenges can be addressed.

CBPR as an approach to research and action in public health
Community-engaged research is labeled in different ways, including the following terms: Community-Based Participatory Research (CBPR) (Israel, 2005;Minkler & Wallerstein, 2008), Participatory Action Research (PAR) (Cornwall & Jewkes, 1995), Action Research (Reason & Bradbury, 2001, and Research Practice Networks (Green & Hickner, 2006;Westfall, Mold & Fagnan, 2007), amongst others. Community engagement, a term currently commonly used in university circles in South Africa, is also often used in this context, although it goes beyond only research activities, including various levels of community participation.
The following definitions of CBPR are useful. Israel et al. (2005) state that CBPR refers to a partnership approach to research that equitably involves community members, organisation representatives, and researchers in all aspects of the research process. According to the Kellogg Foundation's Community Scholars Programme, CBPR is a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve the community.
In contrast to an instrumental research approach, CBPR constitutes a worldview reflected through an applied approach or process which includes the following specific characteristics: • The Community as the unit of identity, solutions and practice (Israel, Schulz, Parker & Becker, 2001;Schulz et al., 2002) • Community engagement at all levels of the research, from problem identification and theory development to sustainability • A multi-level focus of change, including individual, community and social determinants (Hawe, Shiell & Riley, 2009) • Epistemological diversity in theory and methods; including indigenous decolonizing approaches, empowerment, feminist, queer, systems theory and other critical approaches  • Research that includes clearly outlined mutual benefits and co-learning between partners (Israel et al., 2001, Schulz et al., 2002 • A long term process and commitment to sustainability (Israel, 2005;Minkler & Wallerstein, 2008) This approach is in line with general community engagement approaches which include the following key characteristics (Attree & French, 2007;Herbertson, Ballesteros, Goodland & Munilla, 2009;Popay, 2006;Rifkin, Lewando-Hundt & Draper, 2000): The community engagement approach aligns with CBPR in its focus on the relationship between the 'university and community', with CBPR emphasizing the need for shared control, thus emphasizing the power relations in the process.
Historically, the CBPR approach has been informed by action research, led by Kurt Lewin in the 1940s. Lewin's action research approach included cycles of action, reflection, problemsolving and decision-making for new actions, with organisational change being a major focus (Lewin, 1938(Lewin, , 1951(Lewin, , 1997Lewin & University of Michigan Research Center for Group Dynamics, 1975). In the 1970s, participatory research became popular, as a result of radical critiques of research traditions by social scientists from Asia, Africa, and Latin America in particular. Orlando Fals-Borda, most notably, combined scientific research, adult education and political action that aimed to: (a) raise levels of consciousness (b) empower class and group interests to organize, and (c) evaluated by concrete benefits to communities, not abstractions (Fals-Borda & Rahman, 1991). This included critiques of structural underdevelopment and the need to redistribute inequitable structures, challenges to academic distance from communities, and the development of new academic discourses of feminism, post-colonialism, post structuralism .
Much of the above is aligned with the principles of empowerment (Fetterman & Wandersman, 2005) where capacity building, community ownership and democratic participation, within a, social justice framework, are emphasized. This incorporates a key indigenous principle which states: "Don't plan about us, without us!" (NACCO, 2001).
It is important to note that the principle of participation is central to this approach and that not all collaboration meets standards of CBPR. One way to view community engagement is on a continuum from minimal participation to full participation of the community concerned. These different positions on the continuum can be seen as either consultation, involvement, or engagement (Hashagen, 2002).
• Consultation suggests simply providing information to the community and requesting feedback, and carries no undertaking that there is to be a shift in what is done or how it is done.
• Involvement carries a stronger message, implying that the academic institution decides on the structures and decision-making processes, and that the community needs to be encouraged to become involved in them. The community has no part in deciding on the suitability of those structures or processes.
• Engagement suggests a different sort of relationship which avoids making assumptions about communities, asks for a dialogue, and implies that the development of the relationship itself will need to be a focus of attention.
Community research in general draws on a variety of research methodologies, which can be viewed on a continuum of control over phenomena <------> collaboration Heller et al. (1984). Specific research methods used include: participant observation, ethnographic approach, network analysis, studies of community populations, and social indicators (measures of social and community well-being), action research, simulation, field experiments, quasiexperimental approaches, and time-series designs.
Some examples of different methods used in public health include: participatory community case studies, including random community trials (RCT) (Pokorny et al., 2004); epidemiological research including both science and community participation (Torres-Harding et al., 2004); participatory project-based research, where both scientific standards and maximum impact are considered important (Stoeker, 2005); participatory rural appraisal (including historical mapping and inventory asset mapping (Stoeker, 2005); participatory or empowerment evaluation linked to public health interventions, where "participatory evaluation is a health-promoting intervention in itself" (Springett and Wallerstein, 2008, p. 205); and community-driven asset identification, referred to as "barefoot epidemiology" by Minkler and Hancock (2008), which uses a variety of traditional and innovative methods. Community asset mapping is used as a tool for identifying community resources, promoting community pride and eliciting community-embedded knowledge (Minkler & Hancock, 2008).
Health promotion research, which usually includes some form of programme development, implementation and evaluation (Reddy et al., 2003), targets populations, communities or settings, and is oriented towards community change; draws on the strengths of the community; takes the sociocultural context into account; and is usually community-based, emphasizing "empowering people through mediating structures, networks, and community institutions" (Revenson & Schiaffino, 2000, p. 473).
CBPR could use any of the above methods, but the process is guided by the values and principles outlined above, with community participation and ownership being central. This approach to research is generally located within a participatory paradigm (Guba & Lincoln, 2005), but draws from a number of research paradigms such as post-positivist, constructivist and transformative perspectives (Mertens, 2005), including both hermeneutic and critical traditions (Springett & Wallerstein, 2008). The participatory paradigm reflects holistic, systemic, and relational worldviews Guba & Lincoln, 2005), where knowledge is generated as partners (Springett & Wallerstein, 2008). The participatory paradigm outlined in Guba and Lincoln's (2005, p. 195-199) updated version of 'basic beliefs of alternative inquiry paradigms' focuses on the generation of a participative reality, cocreated by mind and cosmos; a critical subjectivity, favouring experiential, propositional and practical knowing, and co-created findings; political participation in collaborative action inquiry, within a language grounded in shared experiential contexts; pursued in communities of practice; focusing on transforming the world in the service of human flourishing; including self-reflective action; drawing on voices through narrative, movement, song, dance and other presentational forms; and pursued by co-researchers who learn through active engagement in the process, using democratic qualities and skills.

Utility, possibilities and potential outcomes of CBPR
Why should we use a CBPR approach? Some of the reasons are briefly outlined below.
• There is a increasing interest in health disparities which are appropriately addressed by this approach. www.intechopen.com

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• There is an increasing community and funder demand for community-driven research.
• There have been disappointing results in intervention research Complex health and social problems are ill-suited to "outside expert" research.
• It supports implementation and research dissemination.
• It supports the principle of democracy, and addresses issues of power and domination.
• It builds capacity and reduces dependency on "professional outsiders".
• It ensures cultural and local competence.
• It enhances fit and productivity of programmes.
• It produces more valid research.
• Ethical considerations are well addressed. Minkler and Baden (2008) argue that CBPR often results in more effective research. It is externally valid in terms of utility, and internally valid because people are likely to be more honest and willing to participate, resulting in more accurate data. The development of local knowledge is facilitated, and CBPR methods contribute to better translation of research and practice by facilitating community-academic communication and flows of knowledge.
The potential outcomes of this approach are clear. As Wallerstein's ( , 2010 Interactive CBPR Conceptual Model (refer Figure 1 below)

Key challenges of community-based participatory research
The following set of challenges linked to conducting research within a CBPR approach has been identified in the literature.
There are various tensions inherent in this approach to research. These tensions include (a) science <---> community participation, (b) science/research <---> practical goals/action, and (c) control over phenomena <---> collaboration continuum. These tensions are described in more detail below.
Issues of control are central to challenges experienced in CBPR. In particular, nonrandomized designs, which are often favoured in this kind of research, raise a number of challenges in CBPR (Farquhar andWing, 2008: Heller et al., 2004;Springett & Wallerstein, 2008;Stoeker, 2005). This means that (a) you cannot randomly assign people, resulting in selection bias, (b) the research often cannot be replicated as communities are different, (c) disparities in programmes means you cannot generalize findings, (d) external, intervening events create bias, (e) uncontrollability is exacerbated if there is too much discretion and community choice across sites, and (f) you cannot clearly attribute effects to interventions because of these 'interferences'. One of the 'interferences' is the actual participation and partnership which is acknowledged as having an effect on the interventions and outcomes of the research (Springett & Wallerstein, 2008).
It is clear that validity requirements are an ongoing challenge, given the 'messiness' of community-engaged research. Although this remains an area of contestation in mainstream research circles, particularly within medical arena, many researchers have found ways to address the concerns usually raised (e.g. Mertens, 2005;Torres-Harding et al., 2004). These strategies are described below.
In addition to the various methodological challenges identified above, community research has political inherency (Mertens, 2005) and is messy, requiring longer time-frames and high levels of flexibility. Historical abuse of research, and political agendas and dynamics in the community, can also hamper the research (Farquhar & Wing, 2008 • Pre-existing goals of the research can constrain issue selection.
• It often involves a great deal of time and resources which need to be built into research protocols and funding grants.
• Funders hold back on funding unpredictable processes and outcomes.
• Researchers often lack all the skills required, and the community does not always think 'critically'.

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The larger the reach of a project, the more difficult it is to ensure a democratic process.
• It is difficult to control the 'coming and going' of people in the project.

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The relationship between researcher and researched, the balance between expert and lay involvement, and insider/outsider dynamics are all challenges.
A further area of concern for many in public health and other circles is that of ongoing colonisation through research and knowledge production. Foucault's theory of "governmentality" (Foucault, 1980) describes the powerful conditions that influence individuals and populations to actively self-regulate their own behavior in alignment with scientific and evidence based prescription of health. This insight unveils the hidden mechanism of power in standard approaches to community engagement. Through the privileging of evidence-based interventions, health becomes an "ethical imperative", requiring individuals to regulate their behavior and reshape their selves in keeping with new biomedical and public health knowledge. Those who acquire these science sanctioned behaviours earn the status of sanitary citizens (Briggs & Mantini-Briggs 2003), individuals deemed to possess modern medical understandings of the body, health, and illness, practice hygiene, and depend on doctors and nurses when they are sick (Briggs, 2001;Ong, 1987). People who are assumed to be incapable of accepting this modern medicalised relationship to the body, hygiene, illness, and healing-or who reject this subjectivity-become unsanitary subjects (Briggs, 2005). These terms incorporate what have been referred to as biomedical citizens (Ong 1995, Shah 2001) and, at the same time, draw attention to the broader moral, social, political, and cultural meanings that shape how social responsibility is defined in terms of health. These discursive mechanisms are a return to the historical uses of medicine and public health in colonisation.
The literature consulted revealed that researchers working within this paradigm have found a variety of strategies to address the challenges highlighted above Farquhar & Wing, 2008;Flicker et al., 2008;Mertens, 2005;Minkler & Baden, 2008;Springett & Wallerstein, 2008;). This includes: • Ensuring that the community's needs and agenda's are addressed  Springett and Wallerstein (2008) stress the need to balance the requirements of participation, the use of rigorous tools and techniques, and the practical demands of the real world, while retaining the values of social action. They argue that this requires good participatory leadership skills to hold the project.
As mentioned earlier, a number of researchers have found ways to address the concerns usually raised around validity (e.g. Mertens, 2005;Torres-Harding et al., 2004). This includes emphasizing that there are different kinds of validity (e.g. methodological validity, interpersonal validity, consequential validity, and multicultural validity) which need to be taken into account. Bradbury and Reason (2008) argue for the alternative use of the term quality which is linked to relational praxis, reflexive or practical outcome, plurality of knowing, conceptual and theoretical integrity, extending ways of knowing, methodological appropriateness, and engaging in significant work.
With regard to addressing the participation challenges in each of the research steps, Minkler and Baden (2008) make the following suggestions: • Research question selection: The question needs to meet the needs from both sides • Instrument and research design: Community input is necessary and one often needs to forego an emphasis on 'control' • Ethical review and informed consent: This needs to fit the local culture • Data collection: Methods need to be developed with the community and adjusted where needed • Data analysis and interpretation: Involvement of community in analysis is not always possible or appropriate, but it is optimal and can be very successful • Dissemination and use of findings: Various methods, including public approaches, need to be pursued for dissemination, and the focus on 'action' can create tensions between academics and community because researchers generally do not get involved in the 'action'. Flicker et al. (2008) provide a very useful framework for ethical considerations in CBPR research, providing guidelines for CBPR ethics boards, based on an analysis across 30 schools of public health in the USA. They argue that, in addition to normal ethics guidelines (e.g. autonomy, nonmaleficence, beneficence, justice), the principles of CBPR must also be m a d e v i s i b l e . T h i s i n c l u d e s e n s u r i n g t h a t there is a clear Terms of Reference or Memorandum of Understanding between the research partners. They also argue that the process of the research needs to be documented.

Reflections on CBPR challenges in practice
The following challenges have been found to be particularly relevant to the authors based on their varied experiences in marginalised and historically oppressed communities. Many of these challenges can be located within researcher-community relationship dynamics, particularly in relation to participation and community consent, knowledge and power, resources and privilege, general community dynamics, and specific research considerations.

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Knowledge and power
Challenges relating to knowledge and power include the following key issues: • Researchers and communities usually have different interests in knowledge production, with the latter usually being more interested in solving particular practical problems.
• Academic researchers are usually viewed as being the experts who have 'scientific knowledge', and this creates imbalances in power relations. This perceived academic expertise may silence others' voices.
• These imbalances are supported by government and other powerful structures which favour academic language and a particular form of scientific knowledge that reflects an Anglo-Euro-American worldview.
• There is generally a lack of acknowledgement and honouring of all kinds of knowledge systems.

Resources and power
Challenges relating to resources, which are linked to access to power in society, include the following: • There is clearly inequitable access to all resources relating to research, with local communities having minimal, if any, access to the required financial and skillresources.
• Academic researchers usually have access to the resources for the research, and therefore the balance of power.
• The role and interests of funders play a key role, often overtly or covertly guiding the community research agenda.

Participation and power
Who is involved in the research, and how, is a key consideration when conducting CBPR. Some of the key challenges relating to participation are listed below.
• On a practical level, the question of who initiates the project is an important one as it often reflects and perpetuates imbalanced power relations in the research partnership.
• A related question is 'whose research agenda' is on the table. A challenge for communitybased researchers is accepting that everything that has statistical significance may not be relevant to community outcomes. Community based researchers are often confronted with meaningful findings from mixed method studies that could advance the communities objectives but not their respective fields. Similarly researchers are challenged with the tensions between community capacity (e.g. empowerment) and professional outcomes (i.e. publication).

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The question of who is involved in the research process is also an important question. This includes challenges relating to identifying the 'right' people, and then including them fully in the process.
• Once one has all the relevant people 'around the table', a central challenge relates to facilitating optimal participation. This includes mediating ongoing power dynamics and tensions. It is important to note that the levels of participation and control are never static, and expectations of levels of participation vary by levels of ownership. Furthermore, power and control shifts with function and content.

Community dynamics
Challenges relating to community dynamics are always present. This includes the following issues: • Conducting research in and with the community always involves formal and informal political dynamics which can interfere with the research process.
• This includes challenges relating to cultural diversity which is a reality in any modern community.
• It is necessary to understand the current power dynamics, including a historical and contemporary analysis of positions and other forms of power.

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The challenge of understanding one's own position of power in these dynamics is crucial. This relates to the challenge of reflexivity -self-reflection on one's position within power relations.

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The community's possible history of oppression (a reality in all the contexts of practice of the authors of this paper) needs to be understood and healed and utilised for the purposes of both personal and political empowerment. The collective memory of oppression is often transmitted inter-generationally through folklore, fables, or direct instruction and serves as the foundation for cultural mistrust that influences health behaviour. Researchers rarely take the time to hear the stories of marginalisation, exploitation, and often terror that serve as determinants to a community's health behaviours. Balancing historical realities with contemporary outcomes often challenges researchers who exist in a "pseudo objective" scientific bubble. Communities approach researchers with an ascribed set of characteristics based on previous exposure to exploitation.
• There are many challenges relating to community empowerment. This includes both fostering personal and collective agency, and managing an understandable but often destructive reaction of entitlement.
• Sustainability relating to community development is also a key challenge. Many of the above mentioned challenges relate to this issue.

Research methodology challenges
Challenges relating to the actual research methodology employed in a CBPR project are real, and need to be addressed.
• Challenges relating to control have been well articulated in the literature briefly discussed above. The tensions of control have to be managed in an ongoing way.
• Acknowledgement of the messiness of this approach to research is also important. This includes being aware of the need to be flexible in the process of the research.
• Challenges relating to research translation include ensuring that the action envisaged actually happens, and is sustained in some way within the community concerned. exploration because their wellbeing is often not intrinsically dependent on the answer to a research question. Time to think deeply and employ systematic methods to answering questions is a privilege that researches take for granted. The challenge is for researchers to respect the cultural and pragmatic function of time when participating in research with communities.
The suggestions of ways of addressing these challenges identified in the literature (refer the previous section) are relevant in the varied contexts of practice of the authors of this paper. In addition to the points raised by others, the following important considerations and recommendations are offered, based on reflections of our own practices in historically oppressed communities that are still marginalised in one way or another. It should be noted that most of these recommendations relate directly to the challenges of power highlighted in the previous section. Given the historical (and contemporary) realities of these communities, this is not surprising.
• Given the power dynamics relating to knowledge generation, researchers should engage community stakeholders in a dialogue that genuinely honours the different forms of knowledge 'around the table'.
• This includes decolonising knowledge systems, and honouring and providing opportunities to engage with different knowledge systems and research approaches. In meeting these challenges it is important to honour both academic and community-bedded or indigenous knowledges in order to realign the power dynamics.
• With regard to the privileging of academic knowledge, it is important to create spaces for postcolonial and hybrid knowledge production, and including culturally supported interventions, indigenous theories, and decolonising methodologies.
• With regard to incompatible discourses between academia and community, we need to broaden the discourse to include 'life world' cultural and social meanings.
• We need to shift power between universities and communities through bidirectional learning, shared resources, collective decision making and outcomes beneficial to the community, including the co-discovery and promotion of community scholarship.
• A researcher's ability to acknowledge privilege and share power in community settings is a powerful tool in CBPR. Effective engagement with communities requires the shedding of the formal academic training which over emphasizes individual contributions in favour of a more ecological perspective of community health. Shifting paradigms to more collective strength-based approaches is probably one of the most important methods of addressing the challenges to CBPR.
• Our collective experience has highlighted the important of reflexivity. This self-reflective process is discussed in more detail in a forthcoming publication (Duran, Lazarus, Caldwell & Bulbulia). For the purpose of this paper, it is important to emphasise that we need to start with ourselves, examining our own interests and position in the research process and community dynamics. This includes constantly reflecting on 'whose research agenda' is being promoted and pursued, ensuring that community interests are always at the forefront.
• Acknowledgement of cultural diversity is central to working with the inevitable differences in any community. Dealing with these differences includes advocating for inclusive, accountable and transparent processes, and promoting ongoing facilitated dialogue which, at times, may require various conflict management strategies.
• Facilitating empowerment requires employing strategies to foster both personal and collective agency, within the context of collective accountability.
• Engagement requires addressing various gaps. This includes general gaps in accessing resources, including information and knowledge. It is therefore important to redress current inequalities relating to accessing information and knowledge, as well as access to inclusive processes in knowledge construction.
• Sustainability relating to community development is a challenge which has to be addressed. It is important to build this capacity during project development. All CBPR project should be guided by general community development principles which have been developed over time, in our own and other similar contexts.
• To ensure that research translation d o e s o c c u r , t h a t i s , t h a t t h e a c t i o n p r o p o s e d i s followed through, it is important that appropriate forms of research dissemination are developed. This includes ensuring that knowledge dissemination and production is mutually owned and respected. Proper 'follow through' also means that resources must be allocated to 'action' phases of the research intervention. This means that researchers have to consider their commitment to the community(ies) concerned beyond normal academic requirements! A central challenge in CBPR is to conduct rigorous research that is both culturally responsive and scientifically sound. Putting these two aspects together requires creative and innovative strategies, and fundamentally, a deep respect for diverse ways of seeing and doing, and embracing different knowledge systems. Research needs to be demystified and decolonized and made accessible, appropriate and relevant to the community context.

In conclusion
No matter how ignorant a person is, there is one thing he / she knows better than anybody else, and that is where the shoes pinch his / her own feet, and because it is the individual that knows his / her own troubles even if he / she is not literate or sophisticated in other respects, every individual must be consulted in such a way, actively, not passively, that he himself / herself, becomes a part of the process of authority, of the process of social control, that his / her needs and wants have a chance to be registered in a way that they count in determining social policy (John Dewey) Central to the arguments in this discussion on CBPR as a research and action strategy within public health is the need for respect. Engaging with this value and principle, within ourselves and with our research partners, provides a firm basis for the development of related values and principles which should guide our research practice. Reflection on ourselves and our practice, emphasised in this chapter, must include an honest engagement with our position in the various dynamics of power within the research relationship. We are all challenged to recognise that our individual and collective development and liberation is a joint journey which requires us to walk and talk together in mutual respect and wonder.
If you have come to help me, you are wasting your time, but if you have come because your liberation is bound to mine, then let us work together (Lila Watson: Aboriginal woman leader)