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Partnering to Improve Health: the Partnering to Improve Health: the Science of Community EngagementScience of Community Engagement

Researchers and Communities: Summary of Best Methods and Models of Selecting

Meaningful Outcomes

Sergio Aguilar-Gaxiola, MD, PhDSergio Aguilar-Gaxiola, MD, PhDProfessor of Internal MedicineProfessor of Internal Medicine

Director, Center for Reducing Health DisparitiesDirector, Center for Reducing Health DisparitiesDirector, Community Engagement Component, CTSCDirector, Community Engagement Component, CTSC

UC Davis School of MedicineUC Davis School of Medicine

Arlington, VAArlington, VAMay 14, 2010May 14, 2010

““Strength is in our culture, Strength is in our culture, but let us show you our but let us show you our success, not use your success, not use your measurements of measurements of success…”success…”

““We are developing our We are developing our own workforce, but not own workforce, but not getting recognition getting recognition because you use your because you use your measurements to measurements to measure us…”measure us…”

““We can’t only treat We can’t only treat children, we have to children, we have to treat the whole family”treat the whole family”

NA Community LeaderNA Community Leader

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““There is a way you talk to people in our There is a way you talk to people in our communities…You have to know communities…You have to know

how to talk to black people.”how to talk to black people.”

Dr. Vanessa Siddle Walker, 2010Dr. Vanessa Siddle Walker, 2010

Source: Kindly Provided by Forrest Toms, 2010.

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Words of WisdomWords of Wisdom

“The most basic of all human needs is the need to understand and be understood. The best way to understand people

is to listen to them.”

Ralph Nichols

The Road(s) Ahead: Outcomes that Matter

Who benefits?

Matter to Whom?

Who Defines the Outcomes?

How do we KnowWhen we Get There? Wrong Turn!

A Change in Strategy is NeededA Change in Strategy is Needed

While it is important to conduct research involving diverse communities, their role should not be their role should not be limited to just being subjects of researchlimited to just being subjects of research.

Partnerships should be developedPartnerships should be developed with diverse communities so they can participate fully in the they can participate fully in the formulation, design, implementation, and formulation, design, implementation, and evaluation of promising and best practices evaluation of promising and best practices modelsmodels.

Source: Blasé & Fixsen, 2004, National Implementation Research Network, Louie de la Parte Florida Mental Health Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.

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““Go in search of people. Begin with Go in search of people. Begin with what they know. Build on what they know. Build on

what they have”what they have”

Chinese proverbChinese proverb

We must Restore Balance to the Community-Academic Partnership

Source: Ahmed ,SM , NIH Council of Public Representatives, April 2010 .

Rationale

• Contextual Rationale

• Community Rationale

• Academic Rationale

• Policy Rationale

Source: Ahmed ,SM , NIH Council of Public Representatives, April 2010 .

Contextual Rationale

• Interest in the contextual factors (e.g. social, economical, cultural, environmental, etc.)

• Enhance the relevance and use of the research data by all partners

Source: Ahmed ,SM , NIH Council of Public Representatives, April 2010 .

Community Rationale

• Community demand

• Incorporation of local knowledge which overcome “community distrust” of academic research

• Provides resources (e.g. funds, training, job opportunities for communities)

• Active participation of the target population

Source: Ahmed ,SM , NIH Council of Public Representatives, April 2010 .

Academic Rationale

• The challenge of “Translational Research”

• Failure of “Traditional” research approaches:

– 98% of Americans receive their health care outside of academic medical centers

• Enhance the relevance and use of the research data by all partners

Source: Ahmed ,SM , NIH Council of Public Representatives, April 2010 .

Policy Rationale• IOM 2002 report, Who Will Keep Public Healthy:

Educating Public Health Professionals for the 21st Century.

• Public health workers need additional training to meet new challenges posed by globalization, medical advances and an aging and increasingly diverse population.

• Demand for elimination health disparities Potent alternative to “outside expert” driven research

Source: Modified from Ahmed ,SM , NIH Council of Public Representatives, April 2010 .

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Agencies

University

CBO’s

CommunityStructuralDynamics

IndividualDynamics

RelationalDynamics

Group DynamicsGroup DynamicsEquitable PartnershipsEquitable Partnerships InterventionIntervention

Fits Local /Cultural Beliefs,Norms & Practices

Fits Local /Cultural Beliefs,Norms & Practices

Reflects Reciprocal LearningReflects Reciprocal Learning

OutcomesOutcomes

Policies/PracticesSustained InterventionsChanges in Power RelationsCultural Renewal

DisparitiesSocial Justice

ContextsContexts

•Social-economic, cultural, geographic, political-historical, environmental factors

•Policies/Trends: National/local governance & political climate

•Historic degree of collaboration and trust between university & community

•Community: capacity, readiness & experience

•University: capacity, readiness & reputation

•Perceived severity of health issues

Structural Dynamics:• Diversity• Complexity• Formal Agreements• Real power/resource sharing• Alignment with CBPR principles• Length of time in partnership

Individual Dynamics:• Core values • Motivations for participating• Personal relationships• Cultural identities/humility• Bridge people on research team• Individual beliefs, spirituality & meaning• Community reputation of PI

Relational Dynamics:• Safety• Dialogue, listening & mutual

learning• Leadership & stewardship• Influence & power dynamics• Flexibility• Self & collective reflection• Participatory decision-making

& negotiation• Integration of local beliefs to

group process• Task roles and communication

CBPR System & Capacity Changes:• Changes in policies /practices -In universities and communities• Culturally-based & sustainable interventions• Changes in power relations• Empowerment: -Community voices heard -Capacities of advisory councils -Critical thinking• Cultural revitalization & renewal

Health Outcomes:• Transformed social /econ conditions• Reduced health disparities

Group DynamicsGroup Dynamics

•Intervention adapted or created within local culture

•Intervention informed by local settings and organizations

•Shared learning between academic and community knowledge

•Research and evaluation design reflects partnership input

•Bidirectional translation, implementation & dissemination

System & Capacity ChangesSystem & Capacity Changes

Improved Health Improved Health

ContextsContexts InterventionIntervention OutcomesOutcomes

Socio-Economic, Cultural,Geography & Environment

National & LocalPolicies/Trends/Governance

Historic Collaboration:Trust & Mistrust

Community Capacity & Readiness

University Capacity& Readiness

Health Issue Importance

Appropriate Research Design

Appropriate Research Design

Figure One: CBPR Conceptual Logic Model (adapted from: Wallerstein , Oetzel, Duran, Tafoya, Belone, Rae, “What Predicts Outcomes in CBPR,” in CBPR: From Process to Outcomes, Minkler and Wallerstein (eds). San Francisco, Jossey-Bass, 2008.)

Community Outcomes

CommunityHealth Improvement

Goals

CommunityParticipation

Community & Academic Leadership

Development

Community & Academic Science

Partnership

Community HealthImprovement Intervention

Evidence

Dissemination

IndividualOutcomes

Community Health Improvement

Capacity Development

New Community Programs

Partneredevaluation

Adapted from Wells KB, Staunton A, Norris KC, et al. Building an academic-community partnered network for clinical services research: the Community Health Improvement Collaborative (CHIC). Ethn Dis. 2006;16(1 Suppl 1):S3-17.

Projected Outcomes for Effective Community-Academic Partnering

CommunityOutcomes

Communities and Universities have Different Desired Outcomes

Community• Specific mission with

matching priorities• Service/Civic

• Ethic/social justice

University• Specific mission with

matching priorities• Scientific

Identify and focus on areas of overlap across community & university missions and priorities.

Health Policy, Local Public Health Agency, Community Clinics

Chung B, et al. Story of stone soup: a recipe to improve health disparities. Ethn Dis. 2010; 20[Suppl 2]:s2-9–s2-14.

The Multi-way Decision Matrix

What outcomes distinct are associated with different intervention approaches?

How do characteristics of target population affect outcomes?

How are outcomes affected by history, resources, and contexts?

Oipc|t

The conditionalprobability of an outcome, for this type ofintervention with this population inthis context, givenwhat is known atthe present time.

Source: Rapkin, 2010

Community Health Connections, UW ICTR-CAP

A Logic Model For Evaluating Community Engagement:

Source: Hogle, J.A, Spearman, C.J., Cross Dunham, N., Cohn, T. University of Wisconsin Institute for Clinical and Translational Research, 2010.

2020

CTSAs Community Engagement: CTSAs Community Engagement: Where are we at?Where are we at?

Source: Michener, L., 2010

There is a progression to community engagement that could be characterized in three phases:

1. Discovering each other - gifts, strengths, needs, and preferences - how to work together, how not to, and to what aims. This generally takes time, can be done well or poorly, and has been the focus of much of the CE KFCs efforts.

2. Beginning to collaborate on projects of common interest - including identifying opportunities, working out power/funding issues, sharing information and credit.

3. Forging respectful mature partnerships which easily engage in projects together and are shaped by each other so that neither/none is complete alone.

Yaggy S, Michener L, Yaggy D, Champagne M, Silberberg M, Lyn M, Johnson F, Yarnall KS. Just for Us: An Academic Medical Center-Community Partnership to Maintain the Health of a Frail Low-Income Senior Population. The Gerontologist 2006;46(2): 271-276.

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Summary of Methods, Models, Summary of Methods, Models, and Outcomesand Outcomes

Lee Green, MD, MPHLee Green, MD, MPH

A Framework Toward Positive A Framework Toward Positive Health Outcomes for ALLHealth Outcomes for ALL

Public spending should be consistent with the best science (includes community-defined evidence);

Identify the issues and build on the strengths; Bring diverse partners to the table; Engage in shared, strategic planning involving primary care, schools

and communities; Identify interventions that are culturally and linguistically effective and

implementation strategies; Develop metrics and outcomes that matter to individuals, populations

and policy makers Evaluate the effort and use the data to continuously improve the

strategies; Invest in prevention and early intervention in addition to health

services.