Power Dynamics in Community-Based Participatory Research: A Multiple-Case Study Analysis of Partnering Contexts, Histories, and Practices.

Community-based participatory research has a long-term commitment to principles of equity and justice with decades of research showcasing the added value of power-sharing and participatory involvement of community members for achieving health, community capacity, policy, and social justice outcomes. Missing, however, has been a clear articulation of how power operates within partnership practices and the impact of these practices on outcomes. The National Institutes of Health-funded Research for Improved Health study (2009-2013), having surveyed 200 partnerships, then conducted seven in-depth case studies to better understand which partnership practices can best build from community histories of organizing to address inequities. The diverse case studies represented multiple ethnic-racial and other marginalized populations, health issues, and urban and rural areas and regions. Cross-cutting analyses of the qualitative results focus on how oppressive and emancipatory forms of power operate within partnerships in response to oppressive conditions or emancipatory histories of advocacy within communities. The analysis of power was conducted within each of the four domains of the community-based participatory research conceptual model, starting from how contexts shape partnering processes to impact short-term intervention and research outputs, and contribute to outcomes. Similarities and differences in how partnerships leveraged and addressed their unique contexts and histories are presented, with both structural and relational practices that intentionally addressed power relations. These results demonstrate how community members draw from their resilience and strengths to combat histories of injustice and oppression, using partnership principles and practices toward multilevel outcomes that honor community knowledge and leadership, and seek shared power, policy, and community transformation changes, thereby advancing health equity.

Pediatric Blood Lead Levels Within New York City Public Versus Private Housing, 2003-2017.

Objectives. To compare blood lead levels (BLLs) among children residing in public and private housing in New York City and examine the implications for lead identification and remediation policies. Methods. We examined electronic medical records for BLLs among 4693 children receiving care at a multisite Federally Qualified Health Center during 2003 to 2017. We plotted home addresses against city housing data to assess BLL differences between children living in public housing and private housing. Results. Only 0.25% of children residing in public housing had BLLs exceeding the upper reference limit of 5 micrograms per deciliter, as compared with 2.76% of children residing in private housing. After adjustment for age, gender, and race/ethnicity, public housing was associated with 92% lower odds of having a BLL of 5 micrograms per deciliter or above (odds ratio [OR] = 0.08; 95% confidence interval [CI] = 0.02, 0.33; P = .001). Decreases in BLLs were observed in both public and private housing over time. Conclusions. Children living in public housing in New York City were significantly less likely to have elevated BLLs than were children living in private housing. Decreases in BLLs over time were likely a result of lead reduction legislation.

Advancing system and policy changes for social and racial justice: comparing a Rural and Urban Community-Based Participatory Research Partnership in the U.S.

BACKGROUND: The paper examines the role of community-based participatory research (CBPR) within the context of social justice literature and practice. METHODS: Two CBPR case studies addressing health inequities related to Type 2 Diabetes and Cardiovascular disease were selected from a national cross-site study assessing effective academic-community research partnerships. One CBPR partnership works with African Americans in rural Pemiscot County, Missouri and the other CBPR partnership works with African American and Latinos in urban South Bronx, New York City. Data collection included semi-structured key informant interviews and focus groups. Analysis focused on partnerships' context/history and their use of multiple justice-oriented strategies to achieve systemic and policy changes in order to address social determinants of health in their communities. RESULTS: Community context and history shaped each partnership's strategies to address social determinants. Four social justice approaches (identity/recognition, procedural, distributive, and structural justice) used by both partnerships were identified. These social justice approaches were employed to address underlying causes of inequitable distribution of resources and power structures, while remaining within a scientific research framework. CONCLUSION: CBPR can bridge the role of science with civic engagement and political participation, empowering community members to become political agents who integrate evidence into their social justice organizing strategies.

Health, community, and spirituality: evaluation of a multicultural faith-based diabetes prevention program.

PURPOSE: The purpose of this study was to evaluate Fine, Fit, and Fabulous (FFF), a faith-based diabetes prevention program for black and Latino congregants at churches in low-income New York City neighborhoods. FFF includes nutrition education and fitness activities while incorporating Bible-based teachings that encourage healthy lifestyles. METHODS: FFF is a 12-week, bilingual program developed by the Bronx Health REACH coalition, a Centers for Disease Control and Prevention-funded Center of Excellence for the Elimination of Disparities. This program has been implemented in 15 Bronx and Harlem churches, engaging a primarily black and Latino overweight and obese urban population. Pre-post surveys, nutrition tests, and weight logs were collected to assess knowledge, attitudes, and behaviors regarding healthy eating and physical activity. RESULTS: Participants (n = 183) reported statistically significant improvements in knowledge and healthy behaviors from baseline. Increased numbers of participants reported exercising in the past 30 days, eating fruit daily, being able to judge portion sizes, and reading food labels. Statistically significant numbers reported that they ate less fast food and were less likely to overeat at follow-up. The average weight loss across churches was 4.38 lbs or 2% of participants' initial body weight. Significant differences were observed when stratifying by race/ethnicity. CONCLUSION: Evaluation results show FFF's success at engaging overweight adults in behavior changes related to healthy eating and exercise. FFF demonstrates the potential of faith-based health interventions to address obesity and diabetes risk in high-need communities of color.

Primary care and health reform.

Skyrocketing health care costs are burdening our people and our economy, yet health care indicators show how little we are achieving with the money we spend. Federal and state governments, along with public-health experts and policymakers, are proposing a host of new initiatives to find solutions. The Patient Protection and Affordable Care Act is designed to address both the quality and accessibility of health care, while reducing its cost. This article provides an overview of models supported by the Affordable Care Act that address one or more goals of the "Triple Aim": better health care for individuals, better health outcomes in the community, and lower health care costs. The models described below rely on the core principles of primary care: comprehensive, coordinated and continuous primary care; preventive care; and the sophisticated implementation of health information technology designed to promote communication between health care providers, enhance coordination of care, minimize duplication of services, and permit reporting on quality. These models will support better health care and reduced costs for people who access health care services but will not address health outcomes in the community at large. Health care professionals, working in concert with community-based organizations and advocates, must also address conditions that influence health in the broadest sense to truly improve the health of our communities and reduce health care costs.

A community mobilizes to end medical apartheid.

PROBLEM: People of color suffer worse health outcomes than their White counterparts due, in part, to limited access to high-quality specialty care. PURPOSE: This article describes the events that led to the Bronx Health REACH coalition's decision to file a civil rights complaint with the New York State Office of the Attorney General alleging that three academic medical centers in New York City discriminated on the basis of payer status and race in violation of Title VI of the Civil Rights Act of 1964, the Hill-Burton Act, New York State regulations, and New York City Human Rights Law. KEY POINTS: Although the problem has not yet been resolved, the related community mobilization efforts have raised public awareness about the impact of disparate care, strengthened the coalition's commitment to achieve health equality, and garnered support among many city and state legislators. CONCLUSION: Community groups and professionals with relevant expertise can tackle complex systemic problems, but they must be prepared for a long and difficult fight.

Got low-fat milk? How a community-based coalition changed school milk policy in New York City.

In 2006, New York City, the largest school district in the country, eliminated whole milk and reduced the availability of sweetened milk in 1,579 schools. Despite pressure from the American Dairy Council, skepticism from school food administrators and elected officials, and the difficulties inherent in changing a system that serves 120,000,000 containers of milk per year, a community-led coalition prevailed. This article describes how parents, educational leaders, advocates, and health professionals collaborated to educate school children and their families to choose low-fat milk, and created change at a system, policy, and environmental level to promote health in the community.

Stirring up the mud: using a community-based participatory approach to address health disparities through a faith-based initiative.

This case study provides a mid-course assessment of the Bronx Health REACH faith-based initiative four years into its implementation. The study uses qualitative methods to identify lessons learned and to reflect on the benefits and challenges of using a community-based participatory approach for the development and evaluation of a faith-based program designed to address health disparities. Key findings concern the role of pastoral leadership, the importance of providing a religious context for health promotion and health equality messages, the challenges of creating a bilingual/bi-cultural program, and the need to provide management support to the lay program coordinators. The study also identifies lessons learned about community-based evaluation and the importance of addressing community concern about the balance between evaluation and program. Finally, the study identifies the challenges that lie ahead, including issues of program institutionalization and sustainability.

The role of faith-based institutions in addressing health disparities: a case study of an initiative in the southwest Bronx.

Although many public health initiatives have been implemented through collaborations with faith-based institutions, little is known about best practices for developing such programs. Using a community-based participatory approach, this case study examines the implementation of an initiative in the Bronx, New York, that is designed to educate community members about health promotion and disease management and to mobilize church members to seek equal access to health care services. The study used qualitative methods, including the collaborative development of a logic model for the initiative, focus groups, interviews, analysis of program reports, and participant observation. The paper examines three key aspects of the initiative's implementation: (1) the engagement of the church leadership; (2) the use of church structures as venues for education and intervention; and (3) changes in church policies. Key findings include the importance of pre-existing relationships within the community and the prominent agenda-setting role played by key pastors, and the strength of the Coalition's dual focus on health behaviors and health disparities. Given the churches' demonstrated ability to pull people together, to motivate and to inspire, there is great potential for faith-based interventions, and models developed through such interventions, to address health disparities.

Fostering organizational change through a community-based initiative.

Program funders and managers are increasingly interested in fostering changes in the policies, practices, and procedures of organizations participating in community-based initiatives. But little is known about what factors contribute to the institutionalization of change. In this study, the authors assess whether the organizational members of the Bronx Health REACH Coalition have begun to change their functioning and role with regard to their clients and their staff and in the broader community, apart from their implementation of the funded programs for which they are responsible. The study identifies factors that seemed to contribute to or hinder such institutional change and suggests several strategies for coalitions and funders that are seeking to promote and sustain organizational change.

Racial and ethnic disparities in health: a view from the South Bronx.

This study seeks to understand the perspective of Black and Hispanic/Latino residents of the South Bronx, New York, on the causes of persistent racial and ethnic disparities in health outcomes. In particular, it focuses on how people who live in this community perceive and interact with the health care system. Findings from 9 focus groups with 110 participants revealed a deep and pervasive distrust of the health care system and a sense of being disrespected, exacerbated by difficulties that patients experience in communicating with their providers. The paper suggests how health care institutions might respond to these perceptions.