The Road Not Taken (often enough)

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The Road Not Taken (often enough)

• William Baldyga, DrPH, MA
• Associate Director, Institute for Health Research
  and Policy
• Adjunct Assistant Professor,
• Health Policy and Administration, SPH

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Institute for Health Research and Policy

• Campus wide, transdisciplinary, led by Dr. Susan
  Curry
• Facilitates a wide range of research through
  infrastructure supports including the MRC
• Currently, faculty from 11 colleges and 43
  departments collaborate on about 19 m in
  research yearly

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Objectives

• Overview of social and behavioral health
  research
• Look at alternatives to traditional models
• Talk about benefits, costs and effectiveness of
  CBPR

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Traditional Scholarship

• Scholarship is defined as the creation,
  discovery, advancement, or transformation of
  knowledge
• The fruits of such efforts are evidenced only
  when that knowledge is assessed for quality by
  peer review and made public
• (Boyer, Carnegie Fdtn., 1990)

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Community Engaged Scholarship

• "Community-engaged scholarship is scholarship
  that involves the faculty member in a mutually
  beneficial partnership with the community"
  (Community Campus Partnerships for Health)
• Incorporates co-education and capacity building
  links knowledge with action (Wallerstein and
  Duran, 2006)

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Traditional Research Paradigm

• Responsive to funding priorities
• Investigator initiated
• Theory driven
• Hypothesis testing
• Tightly controlled methods (RCT, case control or
  quasi experimental design)
• Dissemination to a professional audience

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Resultant

• Has created a massive and rich body of knowledge
• Builds effectively on previous studies and
  incrementally develops theory to explain
  relationships
• Results in evidence for action

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Resultant

• Interventions that are
• costly, highly intensive, difficult and require
  high levels of staff expertise
• are not designed considering user needs or to be
  self sustaining
• are highly specific to a population or setting
• not packaged or easily customized
• have strong internal and weak external validity
• Glasgow, RE, Emmons, KM. 2007.

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Focus on Disparities

• Population based approach to improving health
  status
• Ecological approach to addressing health
• Interdisciplinary/team based strategy
• Use of evidence
• Translational research

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Reducing Disparities

• In 2006, the U.S. invested 116 billion in health
  research (Research America)
• NIH budget - 29 b (2006)
• Pharma research - 52 b (2005)
• U.S. - leads world in health expenditures-
  6.1k/person
• Norway - 4k mean about 3k for post industrial
  economies

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Measures of Success

• Measures of quality for which members of selected
  groups experienced better, same, or poorer
  quality of care
• Blacks, AIs and Alaska Natives received poorer
  quality care than Whites for about 40) of core
  report measures
• - Hispanics received poorer quality of care than
  non-Hispanic Whites for over half of core report
  measures
• Poor people received lower quality of care than
  high income people for 85 core report measures
• 2005 National Health Care Disparities Report, AHRQ

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Measures of Success

• Nationally, disparities are worsening for
  Hispanics and the poor and improving only
  slightly for AAs and Asians (AHRQ, 2005)
• If current improvements continue, disparities
  in all cause mortality will disappear in 127 yrs
  (est.)
• Locally, the picture is worse

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Measures of Success

• Between 1980-and 1998 BlackWhite disparities
  increased in Chicago on 19 of 22 measures
• (Silva A, Whitman S, Margellos H, Ansell D,
  2001).
• Narrowing of the BlackWhite rate ratios between
  1990 and 1998 for only 4 of 14 indicators
• (A, Whitman S, Margellos H, Ansell D., 2001)

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What Went Wrong?

• Where did the field get the idea that evidence
  of an intervention's efficacy from carefully
  controlled trials could be generalized as THE
  best practice for widely varied populations and
  settings?
• Greene, LW. 2001

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What Went Wrong?

• The gap between research and practice is so wide
  that the IOM calls it a chasm
• Use the best available evidence rather than
  waiting for the best possible evidence
• Lack of information about contextual, cultural
  and historical evidence

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What Went Wrong?

• Research does not address specific needs or
  resource limitations
• No consistent reporting of outcomes such as QOL
  change
• Little ability to compare programs or understand
  their resource requirements
• Investment Utilization

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Enhancing Research Relevance

• Heterogeneous and representative sampling
• Multiple and diverse settings
• Measures that support translation (level of
  effort, cost effectiveness, QOL)
• Comparisons to alternative programs vs. no
  treatment groups

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Disincentives to CBPR

• Less direct control
• Longer time lines for research
• Intensive involvement of researchers
• Giving up power and sharing decision making
• Sharing budget and rewards

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Value Added of CBPR for Researchers

• Refined, new research questions
• Community readiness to participate
• Fewer barriers to participation
• More appropriate research strategies
• Higher response rates, recruitment
• and retention

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Value Added of CBPR for Researchers

• Enhanced external validity
• Stronger alliance between community and academic
  partners
• Improved reach of results to diverse audiences
• Better utilization of information
• Enhanced capability for sustained research

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Evidence of CBPR Effectiveness

• What is the value added of participation?
• Participation enhances recruitment, uptake,
  utility and sustainability
• Health outcomes remain elusive
• Methodological and measurement challenges

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Evidence of the Effectiveness of CBPR

• Insufficient evidence and too much variation to
  establish effectiveness of CBPR (AHRQ, 2004).
  Similar to EBPH findings ( The Commuity Guide,
  CDC)
• CBPR did improve community capacity
• Newer studies incorporating evaluation of CBPR
  outcomes in the pipeline

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Research Questions

• What CBPR practices are most important to success
  ?
• What measurement strategies can be used across
  CBPR projects ?
• How does variation in CBPR approaches effect
  process and outcome ?
• What does cost-effectiveness analysis tell us
  about impact ?

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Conclusions

• Despite significant investments, health
  improvements have eluded poor and minority
  communities
• CBPR approaches offer an alternative to
  traditional models
• CBPR approaches bring opportunity and new
  challenges
• Are you ready?

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The Beginning
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Resources

•  The NIH Office of Behavioral and Social Sciences
  Research is sponsoring a one-day technical
  assistance workshop on community-based
  participatory research (CBPR) to highlight the
  advancements of CBPR and facilitate the CBPR
  Funding Opportunity Announcements released on
  January 16
• PA-08-074 http//grants.nih.gov/grants/guide/pa-f
  iles/PA-08-074.html
• PAR-08-075 http//grants.nih.gov/grants/guide/pa-
  files/PAR-08-075.html
• PAR-08-076 http//grants.nih.gov/grants/guide/pa-
  files/PAR-08-076.html

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Resources

• The workshop will be held on the NIH campus but
  there also ways to participate online
• Webcast http//videocast.nih.gov Podcast
  http//videocast.nih.gov/podcasting
• For more information, visit http//grants.nih.gov
  /grants/training/esaig/cbpr_sig.htm
• Stay on top of the latest CBPR news and funding
  announcements Subscribe to the CBPR listserv at
  https//mailman1.u.washington.edu/mailman/listinfo
  /cbpr

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Resources

• COMMUNITY-ENGAGED SCHOLARSHIP
• FACULTY DEVELOPMENT CHARRETTE
• Call for Applications (due March 17, 2008)
• is available at
• http//depts.washington.edu/ccph/faculty-engaged.
  html 
• For more information, email Faculty for the
  Engaged Campus Deputy Director Piper McGinley at
  fipse2_at_u.washington.edu
• Stay connected with the initiative and related
  work through the Community-Engaged Scholarship
  electronic discussion group at
  https//mailman1.u.washington.edu/mailman/listinfo
  /comm-engagedscholarship

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Acknowledgements

• This presentation was supported by Cooperative
  Agreement Number 1-U48-DP-000048 from the Centers
  for Disease Control and Prevention. The findings
  and conclusions in this presentation are those of
  the authors and do not necessarily represent the
  official position of the Centers for Disease
  Control and Prevention.
• http//uic-ihrp.org/iprc