1. Community-based Participatory Research in International Settings
Kathie Culhane-Pera, MD MA Associate Medical Director West Side Community Health Services
AAFP Global Health Conference October 12, 2013

2. Activity Disclaimer ACTIVITY DISCLAIMER
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
I, Kathie Culhane-Pera, affirm that I have no relevant financial relationships to disclose.

3. Lecture Objectives
By the end of the presentation, the learner will be able to:
Describe benefits and challenges of CBPAR
Compare/ contrast qualitative and quantitative research
Describe strengths of mixed methods
List essential elements in international research

4. Presentation Overview
Community-based Participatory Action Research What? Why? How?
Mixed Methods Qualitative Quantitative
Essential Elements in International Research Language/s Background social/cultural knowledge Collaborators Ethics/ Consent

5. Introductions: International Research Experiences and Interests
Presenter
Participants International research experiences? Community members involved? Quantitative methods? Qualitative methods? Successful? Frustrations? Logistical challenges? Ethical challenges?
Choose a topic of interest to reflect upon during today’s session.

6. CBPAR - Definitions Community-based Participatory Action Research
Other acronyms: CBR, CBPR, PAR, CPR
Collaboration is a research partnership among equals with complementary knowledge/expertise. Partnership is the process of establishing and sustaining a mutually respectful relationship based on the sharing of responsibilities, costs and benefits, with outcomes that are satisfactory to all partners.

7. Barbara Israel - Definition
“CBPR is a partnership approach to research that equitably involves all participants in all aspects of the research process where each person shares his/her expertise in order to enhance knowledge and to develop interventions that will benefit the whole community.”

8. Barbara Israel- Key Principles
Recognizes community as a unit of identity
Begins with/ builds on strengths & resources in the community
Facilitates collaborative, equitable partnership in all phases of the research - an empowering and power-sharing process
Promotes co-learning and capacity building
Integrates and creates a balance between knowledge generation and action for mutual benefit of all partners
Emphasizes local relevance of public health problems… that attend to multiple determinants of health and disease.
Involves systems development through cyclical/ iterative process
Disseminates findings to all partners and involves all partners in the dissemination process as co-authors and presenters
Involves long-term process and commitment on the part of all partners.

9. Randy Stoecker - Definition
CBPAR is NOT a research project.
“It is a social change project of which the research is one piece.
As such, it has three goals: Learn relevant knowledge/ skills, Develop relationships of solidarity, Engage in action that wins victories and builds self-sufficiency.
Doing research is not, in itself, a goal.
Research is only a method to achieve these broader goals.”

10. Budd Hall - Seven Characteristics
The "problem" originates within the community or workplace
The research goal is to fundamentally improve the lives of those involved, through structural transformation.
The people in the community or workplace are involved in controlling the entire research process.
The focus of PAR is on oppressed groups whose issues include inaccessibility, colonization, marginalization, exploitation, racism, sexism, cultural disaffection, etc.
Participatory research plays a role in enabling by strengthening people’s awareness of their own capabilities.
The people themselves are researchers, as are those involved who have specialized research training.
The researchers with specialized training may be outsiders to the community, but are committed learners in a process that leads to militancy (fighting for change) rather than detachment.

11. The Spectrum of Research
Researcher Driven
Participatory
Communities & researchers decide about topics, questions, & methods
Power and decision making are shared equally
Communities/ researchers are experts and co-learners
Primary goals are improved health, empowerment & capacity building
Researchers select research topics, questions, & methods
Power and decision making are in researchers’ hands
Researchers are the experts
Primary goal is knowledge production for its own sake

12. Degrees of Community Engagement in Research
No community engagement
Community placed research
Collaboration with community, but researcher driven
CBPR or CBPAR
Secondary data analysis, or basic science
Recruitment from community organization
Community sponsor on researcher defined project
Community involved in all aspects of research

13. Application to your topic of interest
Consider how CBPAR could assist in addressing your topic of interest.
How can community be involved as an equal partner in this project? Who are relevant partners? What are appropriate questions? What types of data are needed? What dissemination and application could benefit community?

14. Mixed Methods Quantitative Qualitative
“Statistics are people without the tears.”
“Not everything that can be counted counts, and not everything that counts can be counted.”
“The methods should emanate from the goals and the questions asked.”
The methods should follow the goals

15. Quantitative Design Define the Formulate Make Design
research hypothesis operational research
question definitions instruments
Gather Analyze Draw
data data conclusions Publish
Generate more questions

16. Quantitative Methods/ Analyses
METHODS: 1. Measurements: biological, physical, psychological
2. Standardized instruments
3. Questionnaires/ surveys
4. Observation with standardized tool
ANALYSES:
Statistical analyses, inferential statistics

17. Qualitative Research Cycle
Explore area of concern
Collect
Data
Identify
area of
concern
Analyze
Data
Reformulate Refine
Verify Triangulate
Write
conclusions

18. 1. Participant Observation
Qualitative Methods
1. Participant Observation
2. Long in-depth interviews
3. Key informant interviews
4. Focus Groups
5. Case studies: 1 or series
6. Surveys with open-ended questions

19. Analysis Styles
Template style: Read text, use a predetermined codebook template to code data, and identify themes.
Editing style: Read text, identify codes, group into categories, create coding tree, and identify themes.
Immersion/ crystallization: Through intensive reading/ familiarity, become aware of themes.
Quasi-statistical: Use code book to create categories, and then use statistics to identify connections between categories.
Crabtree B & Miller W, Doing Qualitative Research, 2nd ed, 1999.

20. Comparing Quantitative and Qualitative Paradigms
Quantitative Qualitative
Objective Subjective
One reality Multiple realities
Impersonal Personal
Testing Discovery
Generalizable Situation specific
Global Local

21. Research Intent QUANTITATIVE QUALITATIVE Overall Goal Discovery
“We found the earth”
Interpretation
“This is what the earth means to us”
Describe Explain Predict
Describe Explain
Discover universal truths
Generalizations
Discover local truths
Theory testing
Theory generating Theory testing
Test causal hypotheses
Discover experiences Discover meaning
Evaluate interventions

22. Research Questions QUANTITATIVE QUALITATIVE Identification Description
What is this? Who is that?
Description
How many? How much? How often? What size?
What is the nature of the phenomena? What variations exist? What does this mean?
Explanations Associations
Does X relate to Y, Z? Why did it happen?
What is happening? What patterns exist? How similar/ different? How did it happen?
Explanations Predictions
Does X cause Y?
Evaluation
What difference did program make?

23. Comparing Qualitative & Quantitative Research
 QUANTITATIVE
 QUALITATIVE
Dominant
Disciplines
Epidemiology
Basic Science
Anthropology
Theory
Positivistic
Relativistic
Model of
Reasoning
Linear
Reductionistic
Deductive
Iterative (recursive)
Holistic
Inductive
Unit of
Study
Measurable
phenomena
Experienced
reality
Language
Mathematical NUMBERS
Naturalistic WORDS/ STORIES

24. Comparing Qualitative & Quantitative Research
 QUANTITATIVE
 QUALITATIVE
Types of Data
Collection
Measurements
Questionnaires
Participant Observation
Long Interviews
Focus Groups
Sample Size
Generally Large
Generally Small
Sampling Strategy
Based on statistical power analyses & randomization
Search for information rich cases & continue until “saturation” Purposeful Snowballing
Data Analysis
Statistical
Interpretive (to quasi-statistical)
Generalizability
High
Often low

25. Comparing Qualitative & Quantitative Research
Validity (goodness)
Non-contextually based
Contextually based on completeness, plausibility, illustrativeness Multiple methods/ triangulation of data
Reliability
(trustworthiness)
Statistically determined
Researcher dependent
Role of Researcher
Objective bystander – outside of the process
Research instrument –
part of the process
Reflexivity
Non-existent
Instrumental/ essential
Strengths
Easier to analyze and generalize to larger number of persons
In-depth understandings, unexpected insights

26. Why Mix Methods?
Added value and understanding from different “ways of knowing”
Iterative approach where results from each method support use of the next method
Examples:
Explore then count
Count then explain
Explore, then count, then explain
Production of multiple “truths” or “realities”
Triangulation of methods for comparison of results
Involvement and buy-in from community

27. Application to your topic of interest
Consider how mixed methods could assist in addressing this issue.
How could you conduct qualitative methods initially?
How could you build upon qualitative results to design and conduct quantitative methods?

28. Essential Elements of International Research
Background community knowledge: Language Social structures Cultural beliefs, values and practices Political systems Economic conditions
Background research knowledge: International literature search
Partnerships with community members, researcher institutions, and local organizations
Research team Local researchers Bilingual-bicultural community workers

29. Essential Elements continued: Ethics/ Consent
Permission: country, institution, IRBs
Websites for further information: NIH-Fogarty Center WHO: COIMS: International Ethical Guidelines for Biomedical Research Involving Human Subjects WHO: Ethical Issues in Patient Safety DHHS
Cross-cultural ethics in research
NAPCRG Policy: Community Participatory Research
Green et al: Guidelines for Participatory Research in Health Promotion

30. Application to your topic of interest
What background information/ knowledge/ understanding do you need before doing research?
Who are your partners?
What government regulations do you need to follow?
What IRB regulations do you need to follow?

31. Recommendations Create partnerships with community members
Choose social projects that will improve health of the community
Conduct research to serve the community’s needs, not just the researchers’ needs
Carefully chose appropriate quantitative and qualitative methods that fit the research questions
Combine quantitative and qualitative methods to strengthen results
Obtain permission consistent with country’s laws

32. References- CBPAR
Hall BL. Participatory research, popular knowledge, and power: A personal reflection. Convergence. 14(3): 6-19.
Israel BA, Eng E, Schulz A, and Parker E, ed. Methods in Community-Based Participatory Research for Health. First ed. San Francisco, CA: John Wiley & Sons; 2005:52-72.
Minkler M and Wallerstein N, eds. 2nd ed. Community-Based Participatory Research for Health: From Process to Outcomes. San Francisco: Jossey-Bass, 2008:47-66.
Macaulay AC, Commanda LE, Freeman WL, et al. Participatory research maximizes community and lay involvement. North American Primary Care Research Group. BMJ. 1999;319:
Macaulay AC CL, Freeman WL, Gibson N, McCabe ML, Robbins CM, Twohig PL,. Responsible Research with Communities: Participatory Research in Primary Care.
Stoecker R. Research Methods for Community Change: A project-based approach. Thousand Oaks, CA: Sage
Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Publ Health. 2010;100 Supplement 1:S40-46.

33. References
Qualitative research: Crabtree B & Miller W, eds. Doing Qualitative Research. 2nd ed. Thousand Oaks CA: Sage Publications; Mack N, Woodsong C, MacQueen KM, et al. Qualitative Research Methods: Data Collectors Field Guide. Family Health International, 2005.
WHO Standards for Ethics Review -2011: WHO Patient Safety in Research -2013:
Justice: Pratt B and Loff B. A Framework to Link International Clinical Research to the Promotion of Justice in Global Health. Bioethics doi: /bioe.12009