Transcript Partnering to Improve Health: the Science of Community Engagement Researchers and Communities: Summary of Best Methods and Models of Selecting Meaningful Outcomes Sergio Aguilar-Gaxiola, MD,

Partnering to Improve Health: the
Science of Community Engagement
Researchers and Communities: Summary
of Best Methods and Models of Selecting
Meaningful Outcomes
Sergio Aguilar-Gaxiola, MD, PhD
Professor of Internal Medicine
Director, Center for Reducing Health Disparities
Director, Community Engagement Component, CTSC
UC Davis School of Medicine
Arlington, VA
May 14, 2010
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“Strength is in our culture,
but let us show you our
success, not use your
measurements of
success…”
“We are developing our
own workforce, but not
getting recognition
because you use your
measurements to
measure us…”
“We can’t only treat
children, we have to
treat the whole family”
NA Community Leader
“There is a way you talk to people in our
communities…You have to know
how to talk to black people.”
Dr. Vanessa Siddle Walker, 2010
Source: Kindly Provided by Forrest Toms, 2010.
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Words 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
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Wrong Turn!
How do we Know
When we Get There?
Who benefits?
Matter to Whom?
Who Defines
the Outcomes?
The Road(s) Ahead: Outcomes that Matter
A Change in Strategy is Needed
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While it is important to conduct research involving
diverse communities, their role should not be
limited to just being subjects of research.
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Partnerships should be developed with diverse
communities so they can participate fully in the
formulation, design, implementation, and
evaluation of promising and best practices
models.
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.
“Go in search of people. Begin with
what they know. Build on
what they have”
Chinese proverb
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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 .
Figure One: CBPR Conceptual Logic Model
Contexts
Socio-Economic, Cultural,
Geography & Environment
National & Local
Policies/Trends/Governance
Historic Collaboration:
Trust & Mistrust
Community Capacity
& Readiness
(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, JosseyBass, 2008.)
Group Dynamics
Equitable Partnerships
Community
Structural
Dynamics
Individual
Dynamics
Agencies
Relational
Dynamics
Outcomes
Intervention
Fits Local /Cultural Beliefs,
Norms & Practices
Reflects Reciprocal Learning
CBO’s
Appropriate
Research Design
University
University Capacity
& Readiness
System & Capacity Changes
Policies/Practices
Sustained Interventions
Changes in Power Relations
Cultural Renewal
Improved Health
Disparities
Social Justice
Health Issue Importance
Contexts
Group Dynamics
Structural Dynamics:
• Diversity
•Social-economic, cultural, geographic,
political-historical, environmental factors • Complexity
• Formal Agreements
•Policies/Trends: National/local
• Real power/resource sharing
governance & political climate
•Historic degree of collaboration and trust • Alignment with CBPR principles
• Length of time in partnership
between university & community
•Community: capacity, readiness &
Individual Dynamics:
experience
• Core values
•University: capacity, readiness &
• Motivations for participating
reputation
• Personal relationships
•Perceived severity of health issues
• Cultural identities/humility
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
• Bridge people on research team
• Individual beliefs, spirituality & meaning
• Community reputation of PI
Intervention
•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
Outcomes
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
14conditions
• Reduced health disparities
Projected Outcomes for Effective Community-Academic
Partnering
Community
Participation
Community
Health Improvement
Goals
Community &
Academic Science
Partnership
Community &
Academic Leadership
Development
Evidence
Partnered
evaluation
Community Health
Improvement Intervention
Dissemination
Community Health
Improvement
Capacity Development
Individual
Outcomes
Community
Outcomes
Community
Outcomes
New Community
Programs
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.
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?
Oipc|t
How do characteristics of
target population affect
outcomes?
The conditional
probability
of an outcome,
for this type of
intervention with
this population in
this context, given
what is known at
the present time.
How are outcomes
affected by history,
resources, and
contexts?
Source: Rapkin, 2010
A Logic Model For Evaluating Community Engagement:
Community Health Connections, UW ICTR-CAP
Source: Hogle, J.A, Spearman, C.J., Cross Dunham, N., Cohn, T. University of Wisconsin Institute for Clinical and Translational
Research, 2010.
CTSAs Community Engagement:
Where are we at?
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.
Source: Michener, L., 2010
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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.
Summary of Methods, Models,
and Outcomes
Lee Green, MD, MPH
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A Framework Toward Positive
Health Outcomes for ALL
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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.