Introduction
The promotion of a healthy community is an ongoing concern which has assumed an international imperative for governments, policy makers, and practitioners. As we progress through the 21st century, health promotion and health improvement in community settings are first becoming priorities in global and national health policy agendas (Runciman et al., 2006). Indeed, wide-ranging national and international legislation and commendations have, for many years, called for unequivocal inclusion and application of health improvement and health promotion in community health nursing and all health professional practice (Whitehead, 2004). However, the need to ensure an enabling and progressive environment for equitable health promotion raises noteworthy challenges for nurses who work in community settings to a large extent due to society’s ever-shifting health demands, lack of health knowledge, and lack of information and statistics (Hitchcock et al., 2003; Nies & McEwen, 2001). Through a critical review of existing literature, this paper purposes to offer new insights on how community-based participatory research can be used by stakeholders in community health practice to address these challenges with the aim to improve practice.
There exist compelling evidence that healthcare systems throughout the world are in the active process of streamlining and reorganizing their health service delivery systems, reorienting and redirecting themselves to a primary healthcare model that employs multidisciplinary practice teams to offer a broad range of synchronized, integrated services within communities (Hills et al, 2007). Community-focussed health nursing practice is inarguably a high priority area in the ongoing restructuring since it directly deals with the improvement and promotion of health issues and practice across the whole population (Poulton, 2009). However, the mentioned challenges, namely changing health demands, lack of health knowledge on the part of community members, and lack of information and statistics on the part of the professionals, continue to dampen interdisciplinary efforts aimed at health promotion in community settings. This paper will therefore attempt to present arguments from the standpoint that collaboration between community health nurses and community members in a community-based participatory research model holds great potential for community-based health improvement and promotion, especially in underdeveloped and frontier areas.
Review of Related Literature
Understanding Community-Based Participatory Research
In layman’s language, Community-Based Participatory Research (CBPR) is defined as a collaborative process that aims to equitably and impartially involve all stakeholders in the research process for the explicit purpose of recognizing the unique strengths that each stakeholders brings (Delman, 2006). Stakeholders may include community members, health professionals, organizational representatives, and researchers. AASPIRE (2011) defines CBPR as “…an interdisciplinary research methodology in which scientific professionals and members of a specific community work together as equal partners in the development, implementation, and dissemination of research that is relevant to the community” (para. 1).
CBPR, according to Delman (2006), begins with a research concept of fundamental importance to the community with the objective of coalescing professional knowledge and action for social change to promote community health and eradicate health disparities across populations. According to Minkler et al (2006), “…community-based participatory research (CBPR) increasingly is being used in both developing and developed countries to study and address community-identified issues through a collaborative and empowering action-oriented process” (p. 293).
With its strong roots in the seminal studies of Paulo Freire and other researchers in South America, Asia and Africa, CBPR has an elongated and rich tradition in Brazil, Tanzania, and India, among other developing countries. In recent times, and grounded as well in the influential action research studies of Kurt Lewin, CBPR has received increased attention from a number of developed countries, particularly the US, the UK, and Australia, with internationally recognized health institutes such as the Institute of Medicine even describing it as a major focal point in which all schools of public and community health should offer training (Minkler et al., 2006; Israel et al., 2010).
Delman (2006) argues that the CBPR concept distinguishes the community to be a core unit of identity, and that a constructive sense of community is ingeniously cultivated by identification, collaboration, and emotional connection with other members of the community through the obligation to focus on and supplement existing strengths and assets in the community. Consequently, the CBPR approach has over the years demonstrated particular goodness of fit with critical health areas such as health improvement, health promotion and nursing (Minkler, 2006).
A central feature of CBPR, according to Delman (2006), is that the community must be allowed to drive the research process. In terms of health promotion research, this implies that the community must be facilitated and empowered to take a proactive stance in health issues affecting them to ensure that professionals do not misinterpret or render meaningless information and data composed due to their perceived lack of “lived experience” or simply because they do not identify with the concerned socio-cultural group (Delman, 2006; Israel et al., 2001). According to Israel et al (2001), “…partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved” (p. 182). Consequently, as suggested by Maiter et al (2008), Delman (2006), and Israel (2001), the CBPR approach works on the premise that abundant resources, strengths and skills exist within communities, and that these resources can be legitimately employed to address challenges and promote health and well-being
Community Health, Health promotion, and CBPR: Tracing the Big Divide
Community health is a term that has found wide usage and acceptance across the world, and its concept is to a large extent viewed as an interdisciplinary phenomenon. Baisch (2009) posits that “…for nursing, this concept is based on the premise that the community is the client when the focus is on the collective or common good of the population instead of on individual’s health’ in the context of that individual’s environment” (p. 2465). Largely viewed as a dynamic and evolving process, a number of researchers (Hitchcock et al., 2003; Jerden et al., 2006; Nies & McEwen, 2001; Baisch, 2009) have described it as a form of collaborative democracy where community members work together to shape and develop their community in a manner that will permit them to achieve the best possible health outcomes. The community health nurse is at the core of this accomplishment. This notwithstanding, the definition derived from the concept examination of community health, according to Baisch (2009), makes explicit the fundamental importance of including community-based participatory research in local health promotion processes.
Available literature (Jerden et al., 2006; Nies & McEwen, 2001) demonstrates that the field of community health was promoted through community empowerment and participatory action models, namely community-based leadership and collaborative ownership of specific programs (Baisch, 2009), training and utilization of local community health workers (Whitehead, 2004), joint planning for sequenced approaches aimed at addressing a multiplicity of challenges in a culturally sensitive and acceptable way, and interdisciplinary community practice (Whitehead, 2006). Thus, in a community-based participatory approach, members could own and direct a myriad of activities that constituted their own understanding and health for their community in equally collaborative processes that were facilitated by professionals (Baisch, 2009).
Baisch (2009) points out that the above conceptualization of community health based on participatory action didn’t hold for long in many critical areas of community health due to varied reasons that have also been well espoused by other scholars. Indeed, Baisch (2009) postulates that “…confusion over the concept of community health is compounded, in part, because an increasing number of health professionals practice community health without a clearly defined and universally accepted meaning of the concept” (p. 2465). Additionally, the author argues that community health delinked from its basic paradigm of community-based participatory approach in part due to the interdisciplinary nature of community health practice, education and research witnessed in contemporary times.
Society’s shifting health demands is yet another attribute derived from the reviewed literature as to why fundamental issues of community health and health promotion seemed to move away from the CBPR Model. In one of their most influential books named ‘Community Health Nursing: Caring in Action,’ Hitchcock et al (2003) argues that “society’s changing demands require that community health nurse function in a variety of roles and practice settings” (p. 3). The interplay of shifting roles for the community nurse, according to Nies & McEwen (2003), continues to broaden the distance between community health and CBPR yet the former was originally grounded on the constructs and concepts of the latter. Indeed, Baisch (2009) suggests that community health and CBPR shares similar and complementary backgrounds.
Contextual and conceptual issues have also served to enhance the divide between community heath and its original methodological approach – community-based participatory action (Nies & McEwen, 2003). Baisch (2009) postulates that when nursing professionals of diverse fields and community members collaborate on a multiplicity of community health initiatives and research aimed at health promotion, “…the language they use to describe their work may differ, the meaning they give to the same terms may vary and approaches they use for research may be derived from different disciplinary models” (p. 2468). Such a scenario, according to Nies & McEwen (2001), has posed both theoretical and practical problems for effective utilization of CBPR to promote community health. Additionally, Israel et al (2010) reports that while great advancement has been achieved on the research on health promotion, health improvement, and disease prevention within the community setting, we have failed in the conversion and operationalization of this research into practice due to, among other things, abandonment of the CBPR approach, employment of different ‘tools’ to address health promotion and improvement, and lack of consultations on the design and conduct of community-wide research projects.
Towards Finding a Common Ground
In his seminal works on community work, Baisch (2009) argues that “…in a participatory action approach, community members own and direct the activities that constitute their own definition of health for their community in processes that can be facilitated by professionals” (p. 2468). This, to a large extent, comprises the rallying call for both community health and the CBPR methodology in health promotion across communities.
In addition, both community health and the CBPR methodology call for community empowerment in health promotion and improvement. Irvine (2007) suggests that education and empowerment in community and other aspects of the nursing practice should be concerned with empowering community members to gain greater control over their lives, health, and wellbeing. This theme, according to a research paper done by Israel et al (2001), has been echoed repeatedly in many of the community-based health promotion projects utilizing the participatory action research. In their influential research papers on community-focussed public health nursing and community-based participatory action research, Polton (2009) and Maiter et al (2008) puts across the fact that empowered communities have the expertise, know-how, and confidence to take control of community health promotion, planning, and implementation. Consequently, the fact that the community health nurse will benefit immensely by adhering to participatory action principles in health promotion cannot be further from the truth. Israel et al (2010) is categorical that the community health nursing practice must reintegrate CBPR back into the fold if practitioners are expected to win the war on health promotion and ameliorate health disparities.
A synopsis of literature done by Israel et al (2001) demonstrates that “partners [in a CBPR framework] contribute their expertise and share responsibilities and ownership to increase understanding of a given phenomenon, and incorporate the knowledge gained with action to enhance the heath and wellbeing of community members” (p.184). Community health nursing practice also revolves around similar principles (Runciman et al., 2006), thus the need to integrate the two to achieve optimal outcomes in community-wide health promotion (Irvine, 2007). Further analysis done by Israel et al (2001) reveals that not only does the CBPR approach recognizes the community as a basic unit of identity, but it integrates knowledge and social action for mutual benefit of all stakeholders. In their resourceful research on establishing the contribution of nursing in the community, Kennedy and colleagues (2008) lays bare the fact that such reciprocal transfer of knowledge and integration of knowledge, skills and capacity is of outmost benefit and value to community health nursing practice in health promotion and improvement processes. The transfer of knowledge is also proportionately beneficial to community members by virtue of health knowledge impartment, co-learning and capacity building (Stanhope & Lancaster, 2003).
A critical analysis of Whitehead et al (2008) study on ‘health promotion and health education practice’ demonstrates that health promotion takes a more community-based approach as opposed to an individualistic approach. Health promotion, according to the authors, may include coming up with community-based programs aimed at environmental protection, healthy living, pollution management, healthy sexual lifestyles, and community exercise programs. A synopsis of Maiter et al (2008) work on community-based participatory action research reveals that the community must be involved in decision-making processes aimed at developing and implementing such health promotion programs, thus the need to integrate CBPR with community health nursing practice.
Justification of Using CBPR in Community Health Nursing Practice
Before expounding on the justifications, it is imperative to recall that most early community health nursing practice solidly relied on the CBPR approach to change communities according to the health needs established collaboratively by members. Community health professionals were tasked with the responsibility of assisting community members to solve their own health needs for the greater good of all stakeholders (Birks et al., 2010; Whitehead, 2008). However, changing community health needs, proliferation of multidisciplinary fields in the practice, and lack of a clearly defined and universally accepted meaning of community health continue to threaten the gains already made in holistically integrating CBPR with community heath nursing practice. This is especially so in the broad area of health promotion (Whitehead, 2004).
There exist a myriad of justifications for reintegrating CBPR with community health nursing practice for effective delivery of health services at the community level. CBPR not only augments the relevance and utilization of critical research data by all stakeholders involved, but it links stakeholders with diverse levels of skills, know-how, and expertise in addressing fundamental challenges affecting the community (Israel et al., 2001). Consequently, it can be argued that CBPR is an evidence-based approach that could be employed by community health nurses to objectively undertake a review of community health needs for possible action. It is objective by the virtue of the fact that it is the community members themselves who own and direct all activities that comprise their own description of health (Baisch, 2009; Whitefield et al., 2006). On the periphery of this argument, it can still be argued that such an approach is beneficial to community health nursing practice as well as to other stakeholders, including donors, because it curtails wastage and duplication of resources.
Education and empowerment are critical ingredients in any efforts aimed at health promotion in community settings, and CBPR guarantees both (Irvine, 2007). Under the CBPR flagship, community members get to learn from each other by incorporating the local knowledge of individuals involved (Israel et al., 2001), not mentioning that through empowerment, community members get to learn to solve the health challenges afflicting them. This is a strong point for community health nursing practice that, as a matter of principle, gravitates towards improving the practice. Indeed, Israel (2001) is of the opinion that the CBPR approach integrates knowledge and social action for mutual benefit of all stakeholders. As such, this approach can be used to intrinsically add value to efforts by community health nurses aimed at health promotion within the community.
Community health nurses need to continually undertake objective research to keep abreast with the ever shifting health needs and other health demands affecting communities (Kennedy et al., 2008). According to AASPIRE (2011), the CBPR approach not only assist the community to get its demands and needs met through research that is objectively pertinent to the community’s needs, but it undoubtedly assists nursing professionals to conduct more valid, quality research with respect to the demands espoused by the community. In addition, “…the methodology gets high quality and more useful results by taking into account the full context of individuals rather than seeing people in isolation from their environment, culture, or identity” (AASPIRE, 2011 para. 4). These arguments provide adequate evidence that CBPR can only serve to improve community health nursing practice since it entails a long-term process and re-energized commitment to community sustainability.
Conclusion
A number of studies (Poulton, 2009; Birks et al, 2010; Jerden et al, 2006) have reported the challenges community health nurses go through in their attempt to promote health within community settings and galvanize the gains achieved. Issues of community’s ever-shifting health demands, lack of health knowledge on the part of community members, and lack of information and statistics on the part of community health practitioners continue to pose serious challenges not only to the practice, but also to the health and well-being of community members. However, the critical analyses of literature on the CBPR approach have demonstrated that the methodology can be effectively used to bring community-wide, mutual health benefits, especially in areas of health promotion, education and empowerment, inclusivity in decision-making processes, funding for community health promotion projects, responsibility sharing, and knowledge and skills sharing.
The review of literature supports the findings of other studies (Israel et al. 2001; Israel et al, 2010) indicating that CBPR should be holistically integrated with community health nursing to improve the practice and enhance service delivery. As a matter of fact, CBPR methodology should be incorporated as a core unit during the training of community health nurses to give the trainees a feel of how the methodology can be used to improve practice.
List of References
Academic Autistic Spectrum Partnership in Research and Education (2011). Community Based Participatory Research. Web.
Baisch, M.J (2009). Community Health: An Evolutionary Concept Analysis. Journal of Advanced Nursing, Vol. 65, No. 11, pp 2464-2476
Birks, M., Mills, J., Francis, K., Coyle, M., Davis, J., & Jones, J (2010). Models of Health Service Delivery in Remote or Isolated Areas of Queensland: A Multiple Case Study. Australian Journal of Advanced Nursing, Vol. 28, No. 1, pp 25-34
Delman, J (2006). The Community-Based Participatory Action Framework. Web.
Hills, M., Mullet, J., & Carroll, S (2007). Community-Based Participatory Action Research: Transforming Multidisciplinary Practice in Primary Healthcare. Pan American Journal of Public Health, Vol. 21, No. 2/3, pp 125-135. Web.
Hitchcock, J.E., Schubert, P.E., & Thomas, S.A (2003). Community Health Nursing: Caring in Action. New York, NY: Delmar Learning
Irvine, F (2007). Examining the Correspondence of Theoretical and Real Interpretation of Health Promotion. Journal of Clinical Nursing, Vol. 16, No. 3, pp 593-602
Israel, B.A., Coombe, C.M., Cheezum, R.R., Schulz, A.J., McGranaghan, R.J., Lichtenstein, R…Burris, A (2010). Community-Based Participatory Research: A Capacity-Building Approach for Policy Advocacy Aimed at Eliminating Health Disparities. American Journal of Public Health, Vol. 100, No. 11, pp 2094-2102
Israel, B.A., Schulz, A.J., Parker, E.A., & Becker, A.B (2001). Community-Based Participatory Research: Policy Recommendations for Promoting a Partnership Approach in Health Research. Education for Health, Vol. 14, No. 2, pp 182-197
Jerden, L., Hillervik, C., Hansson, A.C., Flacking, R., & Weinehall, L (2006). Experiences of Swedish Community Health Nurses Working with Health Promotion and a Patient-Held Health Record. Scandinavian Journal of Caring Sciences, Vol. 20, No. 4, pp 448-454
Kennedy, C., Christie, J., Harbison, J., Maxton, F., Rutherford, I., & Moss, D (2008). Establishing the Contribution of Nursing in the Community to the Health of the People of Scotland: Integrative Literature Review. Journal of Advanced Nursing, Vol. 64, No. 5, pp 416-439
Maiter, S., Simich, L., Jacobson, N., & Wise, J (2008). Reciprocity: An Ethic for Community-Based Participatory Action Research. Action Research, Vol. 6, No. 3, pp 35-325
Minkler, M., Vasquez, V.B., Warner, J.R., Steussey, H., & Facente, S (2006). Sowing the Seeds for Sustainable Change: A Community-Based Participatory Research Partnership for Health Promotion in Indiana, USA and its Aftermath. Health Promotion International, Vol. 21, No. 4, pp 293-300
Nies, M.A., & McEwen, M (2001). Community Health Nursing: Promoting the Health of Populations, 3rd Ed. Pennsylvania: Saunders
Poulton, B (2009). Barriers and Facilitators to the Achievement of Community-Focused Public Health Nursing Practice: A UK Perspective. Journal of Nursing Management, Vol. 17, No. 1, pp 74-83
Runciman, P., Watson, H., Mcintosh, J., & Tolson, D (2006). Community Nurses’ Health Promotion Work with Older People. Journal of Advanced Nursing, Vol. 55, No. 1, pp 46-57
Stanhope, M., & Lancaster, J (2003). Community and Public Health Nursing. New York, NY: Mosby
Whitehead, D (2004). Health Promotion and Health Education: Advancing the Concepts. Journal of Advanced Nursing, Vol. 47, No. 3, pp 311-320
Whitehead, D (2006). The Health-Promoting School: What Role for Nursing. Journal of Clinical Nursing, Vol. 15, No. 3, pp 264-271
Whitehead, D., Yonghuan, W., Jianhong, W., Jing, Z., Zhen, S., & Chen, X (2008). Health Promotion and Health Education on Practice: Nurses Perceptions. Journal of Advanced Nursing, Vol. 61, No. 2, pp 181-187