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

Abstract

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.

Keywords

community-based participatory research partnering partnership processes power dynamics power sharing

In the last decades, community engaged research (CEnR) and community-based participatory research (CBPR), as the most established form of engagement, have become well-recognized research strategies to improve health equity (Dankwa-Mullan et al., 2010; Israel, Eng, Shulz, & Parker, 2013; Jagosh et al., 2012; Wallerstein, Duran, Oetzel, & Minkler, 2018). The W.K. Kellogg Foundation Community Health Scholars Program (2001) defined CBPR as a collaborative approach of equitable participation that begins with community strengths and concerns and seeks to translate knowledge into action for “social change to improve community health and eliminate health disparities.”

CBPR and other forms of participatory research arose partially in response to historic research abuse on marginalized communities, where inequitable research relationships generated deep-seated mistrust, with data often not returned to the community, nor community benefits considered. To counter this abuse, CBPR practitioners adopted principles of starting from community priorities and strengths, maintaining long-term commitments, and turning research results into action (Israel et al., 2013; Israel, Schulz, Parker, & Becker, 1998).

Early CBPR case studies often focused on equitable partnering practices and power-sharing. With the growth in the last decade of CBPR effectiveness studies and systematic reviews, engagement practices have begun to be linked to outcomes of sustainability, policy, or health equity improvements (Anderson et al., 2015; Drahota et al., 2016; O’Mara-Eves et al., 2015; Wallerstein et al., 2018). What remains largely unexplored, however, are the nuances of how partnerships specifically address their contexts of power, including structural inequities within U.S. society, the impact of traditional hierarchies of university research, and partnerships’ own articulation of desired processes and outcomes.

Within the U.S. context, power is operationalized through constructed racialized and gendered hierarchies, institutionalizing the subordination of people of color and other marginalized groups. Social processes and institutions have evolved to maintain associated structural inequities (i.e., poverty, environmental hazards, and health care access) that make injustices experienced by marginalized groups appear normal or routine. The power to sustain systems of privilege and advantage over oppressed people is often exercised covertly through “benign, abstract and inconsequential language” designed to evade or obscure critical dialogue about the sources of structural inequality (Muhammad, Garzón, Reyes, & The West Oakland Environmental Indicators Project, 2018, p. 51).

These covert forms of power mirror the role of communication articulated by Habermas and McCarthy (1985), when system world colonization can overpower the lifeworld of community interpretations of reality. More recent theorists have looked at power through the lens of knowledge democracy (de Sousa Santos, 2013; Hall & Tandon, 2017), asking the question, what actions are necessary to raise up community knowledge as equal. Epistemic (or cognitive) injustice has been seen when dominant groups, such as academics, marginalize, even unwittingly, community perspectives and meanings (Fricker, 2007).

How power is exercised structurally and relationally by partners in response to these multiple forms of oppressions, therefore, becomes fundamental to a CBPR partnership (Gaventa & Cornwall, 2015). From early recognition of the continuum of participation, that is, manipulation through citizen control (Arnstein, 1969), CBPR practitioners have sought to create partnerships based on “equal power relations.” Yet this phrase poses a serious challenge, with the potential for tokenistic or imaginary equality if systems of privilege are not carefully analyzed (Rose, 2018). Implicit bias, for example, masks institutional hierarchies within research, for example, when academics promote evidence-based interventions as the preferred funding strategy.

Yet power dynamics can also be emancipatory (Foucault, 1980), recognizing community histories of resistance, with partnerships able to leverage community strengths and use the research process to work toward greater equity in partnering dynamics and in society. Partnership processes can contribute to equity transformations by making historic oppressions visible and by adopting strategies of deliberative democratic engagement (Pratt, 2018). Indigenous scholars have pushed the demand for equity further, promoting knowledge creation in research oriented toward changing conditions through decolonizing, healing, and mobilizing (Tuhiwai Smith, 2012).

In 2006, the University of New Mexico (UNM) started a 3-year exploratory research project to identify core components of CBPR, including uncovering the role of power. After an extensive literature search, with input from academic and community experts, a CBPR conceptual model was created with four domains: (1) context, (2) partnering processes, which then impact (3) intervention and research design outputs, and contribute to (4) intermediate and long-term outcomes (Kastelic, Wallerstein, Duran, & Oetzel, 2018; Wallerstein et al., 2008). By 2009, UNM joined with the University of Washington and the Principal Investigator (PI), the National Congress of American Indians Policy Research Center, for a 4-year National Institutes of Health NARCH grant to conduct mixed-methods research to further the science of CBPR (Lucero et al., 2018). To describe the variability of CBPR/CEnR across the nation, internet surveys (with measures of partnership practices and outcomes) were conducted with 200 federally funded CBPR/CEnR projects (Pearson et al., 2015). Seven in-depth case studies were conducted of diverse communities, across ethnic/racial and other identity populations, health issue, and urban/rural geographies.

While the survey psychometrics (Oetzel et al., 2015) and results of the quantitative surveys are presented elsewhere (Duran et al., in press; Oetzel et al., 2018; Wallerstein et al., in press), this article analyzes the case studies to explore the question of how “power” operates within partnerships. We examine how power issues spread across the CBPR model, starting with how partnerships interact with their external contexts, building from their histories of emancipatory advocacy to challenge structural power inequities. We focus then on internal partnering processes of how power-sharing is shaped by these contexts and how communicative practices, collaborative structures, and negotiation between PIs and community leaders can challenge oppressions and create space to make community knowledge visible. We then suggest how these pathways of addressing power in a deliberative fashion contribute to short-term outputs of cultural-centeredness and greater community decisions in research, contributing to intermediate outcomes of shared power and community leadership toward changes in structural policies and epistemic justice. (See Figure 1 with its focus on power, adapted from the original CBPR model.)

Figure 1.

Power in CBPR conceptual model.

Method

Using a robust multiple case-study design (Stake, 2006; Yin, 2013), we used purposive sampling to draw seven “successful” and diverse partnerships from our internet-survey sample, with criteria of long-term relationships of more than one funding cycle and recognition within the literature (see Table 1). Site visits of 2 to 3 days included meeting observations, interviews, and focus groups with academic and community partners, leading to greater understanding of how historical and current community conditions interact with partnership processes and partner perceptions to address issues of power. For example, in focus groups, partners were asked to create a partnership timeline with key events (Sanchez-Youngman & Wallerstein, 2018). Rather than start with their funding, all partnerships brought in their histories, such as the U.S. army 100 years earlier destroying a tribal village, or the Missouri compromise, which maintained the balance of free and slave states, therefore strengthening federal segregation policy. These timelines illustrated the importance of understanding present-day inequities within historical contexts (Lucero et al., 2018). In total, we conducted 82 individual interviews (with an average of 12-15 interviews per partnership) and one focus group per partnership. Institutional review board (IRB) approval was granted by the University of New Mexico, HRRC: #10-186.

Table 1.

Partnerships and Projects.

Project	Region	Population	Partners
Healing of the Canoe (HOC): Substance abuse prevention, youth life skills	Pacific Northwest	Native youth	University of Washington and two tribes
Men on the Move (MOTM): Cardiovascular disease prevention, men’s employment	Bootheel, rural Missouri	African American men	St. Louis University; community members
Bronx Health REACH (BRX): Faith-based diabetes management and prevention, unequal access to care	Bronx, New York	African American and Latino congregations	Institute for Family Health, New York University, churches, and community organizations
Chinatown (CTN) Healthy Living: Lay health workers to increase colorectal cancer screening and nutrition education	San Francisco	Senior Residents of Chinatown (55-64)	University of California, San Francisco; San Francisco State University; NICOS Chinese Health Coalition (community partner), Chinatown Public Health Center
Tribal Nation: Barriers to Cancer Prevention	Northern Plains tribe	Native adults	Black Hills Center for American Indian Health and tribal review board
South Valley Partners for Environmental Justice (SV): Policies to reduce unequal exposure to toxins	South Valley, Albuquerque, New Mexico	Hispanic population	University of New Mexico, Bernalillo County, community partners
Assessment of health issues with Deaf communities	Rochester, New York	Populations of Deaf sign language users	Rochester Prevention Research Center, National Center for Deaf Health Research (NCDHR), University of Rochester, partners from Deaf communities

Note. Adapted from Kastelic et al. (2018)

Data Analysis

We used a comparative case study approach to synthesize similarities, differences, and patterns across two or more case studies on issues related to power. Interviews and focus groups were audio-recorded and transcribed for analysis using Atlas.ti. (For Deaf sign language users, recorded audio came from the interpreter’s translation of American Sign Language (ASL) into spoken English; one informant from another site asked not to be audio-recorded so observer notes were transcribed.) Through weekly meetings to create consistency, we developed the coding protocol deductively for each domain of the CBPR model (Kastelic et al., 2018; Wallerstein et al., 2008), and inductively from emerging themes from the data. Interviews were cross-coded with multiple codes, which enabled query formats across themes. All interviewees received their own interviews, and each partnership received a summary and theme reports with de-identified quotes analyzing their context, partnership processes, interventions and research, and outcomes.

Three levels of queries were conducted across six cases (the Northern Plains tribe included cancer prevention and ethics interviews; we only included those on ethics): (1) Power (as a single code query); (2) Power & CBPR; Power & PI Role; Power & Trust (cross-tabulating “power” separately with three other constructs); (3) Power & Context Family (“power” cross-tabulated with 14 codes within the context domain); and Power & Outcomes Family (14 codes). We then inductively identified new cross-cutting themes, which we organized into Figure 1—how power issues are expressed across the CBPR model.

Results

Contexts: Oppressive Power Exerted Within Communities and Through the Research Enterprise

Power or structural inequities were noted as core social determinants throughout all case studies. Examples from partnerships illustrate specific research and dialogue strategies about these inequities. Through Bronx Health REACH (Racial and Ethnic Approaches to Community Health), a coalition with churches and nonprofits, the Institute for Family Health developed a lay-oriented slideshow to unpack health disparities. Its action committee created a secret shopper survey to uncover the existence of what they termed medical apartheid, or differential access to care in the Bronx versus wealthier Manhattan zip codes (Golub et al., 2011). They also sought to identify differential access to healthy foods (Devia et al., 2017).

Men on the Move, a partnership between Saint Louis University and communities in the rural Missouri bootheel, with the highest rates of cardiovascular disease in African American men, developed dialogue strategies that evolved over time. Early dialogue centered on healthy food choices. As trust developed, dialogue shifted to the socioeconomic and cultural barriers that affected access to healthy food and employment (Baker, Barnidge, Schootman, Sawicki, & Motton-Kershaw, 2016; Baker et al., 2013). The academic team utilized a tree visual to cultivate shared consciousness of root determinants, such as the legacy of slavery, Jim Crow segregation, and poverty (Devia et al., 2017). This analysis, plus ongoing deliberative dialogue throughout the partnership, uncovered the White power structure which was perpetuating Black disenfranchisement within agriculture, in order to identify leverage points for partnership action.

A more covert form of oppressive power was exerted through academic language and knowledge, which can maintain hierarchies even within well-intentioned partnerships. In the colorectal cancer healthy living study, Chinatown community members successfully challenged the extensive use of academic theory for the lay health workers training (Jih et al., 2016). Similarly, the National Center for Deaf Health Research (NCDHR) established the primacy of ASL through many years of working with the IRB to transform spoken and written English surveys and consent forms into ASL videos (Barnett et al., 2011; Barnett et al., 2017; Graybill et al., 2010). The Center has supported Deaf community members to claim their language power, including challenging academic and English-language terminology. The community promotores of the South Valley Environmental Justice Project expressed a clear concern when they felt their oral knowledge was appropriated by academics (Avila, Sanchez-Youngman, Muhammad, & Domingo de Garcia, 2018). These examples illustrate conditions of inequitable power, both at the macro-structural level and the more micro-level of language and framing (Table 2).

Table 2.

Context.

Case study partnerships	Societal oppressive conditions or policies affecting communities	Academic language and research knowledge	Strategies for addressing oppression
Men on the Move: Bootheel, Missouri	There’s agribusiness down here that has power over and above anything else; and the extent to which they can keep some of these structures hidden enables the power structures to maintain their power. And I think, as a result, a lot of times people who haven’t left the community have absolutely no idea that you could do things differently. . . . There are policies down here that are clearly against federal policy. Whether or not it is brought to light as such, they actually try not to bring it to light. (Community partner)		There’s some work that we did that was helpful in terms making sure we were on the same page. . . . We have this tree picture that shows two different trees. One tree has heavy disease burden in the branches, and then minimal community supports in the trunk, and then root determinants such as high levels of poverty, high unemployment, racism. The other tree has lower disease burden, strong community networks and supports, and root determinants such as good educational opportunities and jobs. So we use things like that to start talking about kind of what’s going on. We also read some things together that addressed race and racism. (Academic partner)
Bronx Health REACH	Well, here’s what I do know about. I know that people are not getting proper care in these hospitals. I know that there’s two systems of care. I know that there’s a better system for people who don’t look like you, . . . You keep telling us to eat [healthy], but we don’t have any place to shop. The bodega on my corner doesn’t have low-fat milk or 1% fat milk. They don’t have vegetables. They don’t have fruit. (Community partner)		I took all the disparities literature on diabetes and heart disease, and I translated the abstracts into a three or four sentence summary of what in common language the study showed. . . . And it was just mind-boggling to sort of hear what people thought about the health care system and thought about the way they were treated . . . people feeling completely like ashamed and horrified at the treatment that they and their families had got in health care. It was like their experiences were like universally bad. (Academic partner)
	To me, the disparity is that here we are in 2012 and still there’s a colored door and a white door. You know that you can’t go into that white door. And if you do, they’re going to throw some water on you or hose you down or beat you up or hit you over the head or put you in jail. (Community partner)
Chinatown Healthy Living: Lay Health Workers		I know that we had a problem with the Stages of Change, because of [our academic’s] training . . . she’s very knowledgeable . . . it was very helpful in that sense to bring in the Stages of Change in the telephone call piece. . . . But the original training material on the Stages of Change was like four or five, eight pages of training material. It was very detailed [for] lay health workers. (Community partner)	[PI] has given us [community members] a lot of leadership power. But sometimes I think, at what point should we take a more active role? There’s a lot of leeway in our partnership to grow, and also learning that I can speak for my community, because we’re seen as experts of our community. . . . It helps when the academy trusts us so that we can take risks voicing our opinions, or stand up for the community. . . . When we were working Stage of Change, the theory was too heavy for me, and trying to make it more laymans. I had to advocate for the community, especially when training lay health workers. (Community partner)
Rochester Deaf Community		I remember another thing that happened early on. We had a retreat for the NCDHR. And the researchers have a passion for big English words. They’re researchers. They speak their own language, and I got to say that I didn’t get it. Even though we had skilled interpreters, I just didn’t get it. So I had to pull one of the researchers aside and ask them through the interpreter, “What did this mean?” And the researcher got very flustered. This researcher was inexperienced with the ability to translate research to lay language, to a community level. That was an issue there. There’s been a struggle with translating research language to lay language, not just English to ASL, but from research to community speak. (Deaf community partner)	So I guess like internally with our IRB, we have sort of a long history with them with our first project, the deaf health survey, this ASL survey. They’d never been asked to approve any studies in ASL. We had literally a couple of years of education and meetings with the IRB about research with deaf people. Like all the data collection tools were going to be in ASL, but we were giving them the English. We got to a place where the IRB folks sort of trusted us that we had our best translators working from the English into ASL, and they should trust the English as [the] best we could do to give them.
South Valley Environmental Justice		I guess we did share responsibilities, but we didn’t share power. We felt that we were doing most of the work. . . . We did community profiles, and went and talked to people and knew what the issues were. Then other partners got that information from us and did the research, such as going into the census tract. Then they used our data, created their own documents. In other words, they documented our data; we just had it verbally, and we had it in an unofficial way. And then they made it official. (Community promotora partner)	I saw the project is first of all, it’s certainly not a deficit model of knowledge from a community perspective, but rather a capacity model. There’s already tremendous knowledge from what I call organic venues within the community. So when we’re going to tap into those venues it’s which one are we going to tap? How are we going to tap it? How do we acknowledge the depth and width of expertise? So it always comes from a model that acknowledges the foundation of knowledge that comes from a community. (Community partner)

Note. REACH = Racial and Ethnic Approaches to Community Health; PI = principal investigator; NCHDR = National Center for Deaf Health Research; ASL = American Sign Language; IRB = institutional review board.

Context: Emancipatory Power Based on Leveraging Community Strengths

Partnerships were able to build on histories of community leadership and activism as key to their effectiveness. The Bronx Health REACH coalition, for example, which began in 1999, built on the leadership of pastors who had been part of the Civil Rights movement and who fought the 1980s insurance-driven epidemic of arsons in the Bronx. As respected organizers, the pastors served as knowledge brokers for research involvement with the PI and staff from the Institute for Family Health in Manhattan (Kaplan et al., 2009). Community leadership and power was recognized by both academic and community partners.

Some of the [BHR] leaders were part of a very big movement in the Bronx in the ‘80s to rebuild the Bronx after it had been really gutted by arson and greed. These are people out of the community who wrested the Bronx from those forces, [and] cleaned up the community. Those are the people who are the leaders and the foundations of our work. (Academic partner)

Our group has been able to pull people together around an issue that’s really important to them, and to have them understand that they never understood it before how and why it is important and why you should have a voice in it. . . . So I think that you can’t change things unless you have people power. People power equals change. (Community partner)

Other partnerships built on the structural strength of nonprofit organizations, which understood community priorities. NICOS, as the Chinatown community partner, had a well-recognized history of providing community services, and was a broker with academic partners, University of California San Francisco and San Francisco State University. NICOS was also well situated to engage with an emerging Asian American political presence in the city.

And it helps now that there’s greater political power with Asian Americans. So there’s some representation now on the board of supervisors, whereas before there were maybe one or no persons of Chinese descent represented on the board, or even of Asian American descent; and now there are four out of eleven seats. And the mayor is actually Asian American now. (Academic partner)

Partnering Processes: Relationships and Collaborative Structures

Core relational practices for challenging power inequities were identified as those that fostered deliberative processes of reflection and bidirectional communication that fostered respect and mutual trust based on their actions with each other. According to Lucero et al. (2018), trust is a dynamic process that can grow to a high level of “reflective” trust through ability to talk truthfully and respectfully, for example, to be supported to take risks in difficult conversations. This transformation over time was seen in part as a result of deliberate conversations through praxis that simultaneously sought to co-create emancipatory knowledge and encourage self-determination of community members as they advocated for themselves or their community.

In addition to fostering trust-enhancing relationships, partnerships implemented structures to ensure community power in decision making. Tribal communities have the unique ability to assert governance and can embed research regulation into their governmental tribal councils and new regulatory bodies, such as research review boards. The two tribal partnerships offered a model that may provide lessons for other communities, with research being seen as a tool for sovereignty (NCAI Policy Research Center and MSU Center for Native Health Partnerships, 2012). For one of the Northwest tribes, Suquamish, the Healing of the Canoe project was first approved by tribal council and then research oversight was allocated to a preexisting cultural committee that became the community advisory board (Thomas, Donovan, Sigo, Austin, Marlatt, & The Suquamish Tribe, 2009). For the other Northern Plains partnership, the research review board asserted its tribal authority over the entire research enterprise, assuming a position of community stewardship and tribally led decisions.

Several of the case studies that did not have tribal legal-political authority also developed committee structures that promoted community ownership and decision making. Within the NCDHR, community power was invested into the Deaf Health Community Committee. In the Chinatown partnership, participants spoke about the importance of language fluencies within their core translation committee, ensuring culture-centered development of research instruments and interventions. In all communities, valuing the CBPR approach was considered an important equalizer, with committees providing protective structures and norms for community knowledge and priorities to be paramount (Table 3).

Table 3.

Partnering Processes.

Case study partnerships	Deliberative relationship processes and communicative reflection	Power-equalizing structures
Men on the Move	Trust? I would definitely say there’s a good level of trust in terms of the nature that both sides of the partnership are benefiting. If you look at it like from an institutional or racial dynamic, there still might be a lot of tension or questioning there. . . . And we talk about “realness” now, that we’re having real conversations, we’re having difficult conversations, and we’ve gone through different process-oriented conversations and retreats within the core team. (Academic partner)
Bronx Health REACH	Respect for each other is key. You know how somebody can have a title and they walk around like, “I’m the head person in charge. You better listen to me.” We don’t get that; at the [Family Urban] Institute, it never came that way. (Community partner)
National Center for Deaf Health Research (NCDHR)	I think another thing occurs to me. We deaf people like direct communication. We would rather not need an interpreter. We would rather not have an interpreter in the room, but not all of our researchers are fluent in sign language; so we have to depend on sign language interpreters, and that’s why we require highly skilled sign language interpreters who can facilitate our communication well. As deaf people, we have also learned that we have a responsibility to ask questions, to ask for clarification if we’re not sure about things. Oftentimes I think we’re used to being passive. Many of us grew up in an oppressed situation where we weren’t expected to be heard from; and I think that we’re in a process of learning to be assertive and learning to get more clarification, and I think that we’re getting better at this. (Deaf community partner)	Committee Structures: Community partnership came because we were able to establish this entity. . . . The health committee didn’t exist beforehand. . . . The DHCC [Deaf Health Community Committee] was in place before the second five year cycle. . . . The DHCC is a committee that works in partnership with NCDHR, because NCDHR requires our input for their research project. (Deaf community partner)Community Leadership: We’ve already had a lot of feedback that nothing like this [Deaf Weight Wise] has ever been offered before in sign language. Deaf leaders leading the [Deaf Weight Wise] group is pretty new. (Academic hearing partner)
Chinatown Healthy Living	So it does take a little bit of risk taking sometimes for me to move along that continuum; and I think it helps when academia, the core research team, trusts us so that we can take a little bit more risks of saying things or voicing our opinions, or stand up for the community. It takes a lot of compromise and discussion, and trying to have open communication to make that happen. Yeah. So I felt I’m learning that. It’s important for the leader to be understanding of that, and make sure that even those who do not have the same kind of degree or expertise, that their voice is also heard. (Community partner)
Chinatown Healthy Living		Having a translation team, we’re fortunate to have Mandarin and Cantonese speakers. I think when we were reviewing the material, we respect each other. All the materials we developed, it’s scrutinized by a group of Chinese people. Like we spend so much time on translation and reviewing whether the pictures are culturally appropriate, the wordings . . . it’s unbelievable how much time we spend on that. . . . We’re debating words for 20 minutes. . . . It’s not just translating the language, but we’re also translating the culture. (Community partner)
Healing of the Canoe	And I think we have followed the steps that are seen as really the crucial elements in the conduct of CBPR; and I think one of the things that has been important is that it’s not just that we’re doing them rote because that’s what we need to do. It’s not because that’s what the experts tell us to do, although, obviously the guidance of those who have come before us is crucial to our adopting them. But it is because I think we, as a group, firmly believe that’s what we should do, and that’s the way in which we should do it. (HOC academic partner)	Governmental Structures: Our tribe is self-governed . . . we have strong leadership. We have people committed to finding projects available to help our families. [Tribal Council] resolution is what says you have permission to do this (research). We’ve made it a very specific focus of doing everything openly and transparently in requesting council review and approval. (Tribal partner)The [Community advisory board], are the gatekeepers. . . . We need their authority. We need them to approve, and they have a significant amount of oversight. . . . They have the power to stop what we’re doing. (Academic partner)

South Valley	I saw the project is first of all, it’s certainly not a deficit model of knowledge from a community perspective, but rather a capacity model. There’s already tremendous knowledge from what I call organic venues within the community. So when we’re going to tap into those venues it’s which one are we going to tap? How are we going to tap it? How do we acknowledge the depth and width of expertise? So it always comes from a model that acknowledges the foundation of knowledge that comes from a community. (Community partner)

Note. REACH = Racial and Ethnic Approaches to Community Health; CBPR = community-based participatory research; HOC = Healing of the Canoe.

Partnership Processes: Role of Academic PI for Shifting Power

The role of the academic PI and team was critical for acknowledging the importance of addressing racial and structural–economic inequities and supporting greater equality among partners. Despite its values, participatory research still resides within inequitable research hierarchies. Funding, technical expertise, and institutional resources are overwhelmingly controlled by academic researchers. Most research is conducted by majority-White institutions led by White and other PIs with normative privilege (e.g., male, hearing).

It is often assumed that academics from majority backgrounds understand their privilege and status as resources of power to be distributed. Yet their privilege, even with multiple insider/outsider identities, may create a crisis of conscience or personal dilemma. As one White CBPR researcher reflected, “How do you work against privilege while simultaneously benefiting from it?”

As a power-equalizing strategy, we found that many PIs in our cases believed it was insufficient to merely recognize their privilege and deliberatively sought to deconstruct academic power, including within their universities. Bronx community members spoke about the White PI, who explained complex political–economic inequities within health care, at the same time validating community members’ experiences. The White PI of Men on the Move was able to confront inequitable access to resources between rural White and Black communities. In Chinatown, the Vietnamese PI adopted community partner goals of lay health worker job and research-capacity development, though these were not specific grant aims. The Native PI demanded her University accept tribal authority on IRB issues (see Table 4).

Table 4.

Academic Role in Combatting Hierarchies Toward Shared Power Outcomes.

Case study partnerships	Combating hierarchies
Bronx Health REACH: Confronting inequities through dialogue and bidirectional listening	The Institute [for Family Health] came, first of all . . . and I tell you the truth . . . when you began to hear some of the stuff that Neil Calman [the PI] talks about as a white doctor in a people of color community, you have to listen to him. . . . He’s always proved fine with me.You just mentioned about Neil being white. . . . I’ve often thought that . . . this group is able to be more honest about race than most of the groups that I sit in. . . . And the reason is that because he has a real passion for this work. . . . Although he knows all about what he’s doing, he’s open to hearing what this community is talking about. He don’t force his power. (Community partner)
Men on the Move: Using outsider White privilege to challenge inequitable community conditions	We’ve found that having the academic presence there, which for better or worse [is] primarily a White presence [white PI], helps people. . . . When we’re trying to do things in our white community, they don’t hear us sometimes. We have to get our university partners on the phone, in person to do it. . . . When we run out of seeds on planting day in the community and our white counterparts go to the local seed store and hear all of the racist conversation around the black community, and it’s like, “They’re buying seeds for the black community. How is it that you can converse with them about . . . ?” “Do you not have any respect?” And so that’s a vendor that we don’t trade with any more. (Community partner)
Chinatown: Adopting community goals	Certainly the workforce development issues . . . we didn’t play that up too much in the grant, but in the back of our mind, and certainly from NICOS agency point of view, my understanding is that’s a huge priority. We didn’t write it up, but it was always the unspoken aim. (Academic partner)
Men on the Move: Expressing frustration of barriers to CBPR (community-based participatory research)	CBPR, it’s understanding how to share power when . . . you know we’re government funded. . . . And there are specific standards and regulations that we have to meet. . . . Goes back to capacity. Some of us have education and training in order to meet what the government wants us to do; and others of us don’t have that experience yet. . . . That gets in the way of really sharing power, even if it’s coming up with a logic model and disseminating information. And who does that? And how much time do we have to actually get something out? Sometimes we have time constraints that I find frustrating . . . if we really want to share power. And do we allow enough time for that? So I think that’s part of the barriers of doing CBPR. (Academic partner)
Healing of the Canoe: Reducing university authority	You have to have a lot of grit . . . because I think for me part of being a good CBPR partner to the tribes is being willing to stand up to my institution [the university] when it’s the right thing to do; and not just my institution, but funders, which I have done. . . . You have to be willing to be transparent, not hold knowledge to yourself. (Academic partner)And I think that a lot of that comes from the willingness for the university partners to really learn . . . well, I guess it goes both ways. There’s really a willingness for each of us to recognize others’ expertise, and really learn from each other, and really rely on each other . . . that [University] recognizes and is always willing to learn how to make things better, whether it’s how to make the consent forms less daunting to tribal members or how to make the program more accessible, that the university partners are always willing to make it easier for the community to have access to this program. . . . We said that to make sure that you have people in the community who are educated about research, and definitely have a clear idea of what the community wants to get out of the research project. (Tribal partner)

Note. REACH = Racial and Ethnic Approaches to Community Health; PI = principal investigator; CBPR = community-based participatory research.

Intervention and Research Processes and Outputs Contributing to Outcomes

The academic teams were also held to a high degree of accountability by their community partners who pushed them to integrate community and cultural perspectives for shared power and other equity outcomes. Rochester, Chinatown, and Healing of the Canoe made key decisions to create culture-centered interventions based on community language and knowledge (Barnett, Cuculick, DeWind, Matthews, & Sutter, 2018; Donovan et al., 2015; Wang et al., 2014). This evidence of community leadership within research enhanced the capacity of partnerships to make co-creation of knowledge paramount. Bronx Health REACH took on medical apartheid and succeeded in transforming NYC schools to adopt low-fat milk (Devia et al., 2017; Golub et al., 2011); Men on the Move worked to strengthen men’s employment as core to cardiovascular disease risk (Baker et al., 2013; Harris et al., 2014); Chinatown developed capacity of lay health workers setting the stage for greater workforce training (Nguyen et al., 2017).

Discussion

Across the seven partnerships, we identified strategies for how power could be effectively addressed, not as a facile phrase of “sharing power,” but as a complex phenomenon, that needed to be continually challenged on multiple external and internal levels.

Exposing Oppressive External Contexts

Partnerships adopted a conscious awareness of historical, structural, racial, and economic inequities, and shared a commitment to align their missions to challenge inequities through naming how oppression continues within institutions, systems, and everyday social practices. These dialogues were critical groundwork to avoid reproducing inequalities within their own partnerships.

Building From Community Strengths

Partnerships recognized and drew from community histories of organizing and leadership strengths (i.e., the pastors in the Bronx or agencies in Chinatown), and also the strengths of community knowledge and language (i.e., ASL, South Valley knowledge, Tribal cultures and language).

Paying Attention to Oppressive Academic Language and Research Hierarchies

Intentional dialogues and paying attention to language hierarchies reduced barriers to communication and facilitated bidirectional transfer of knowledge. Community members in all case studies pushed back on overuse of academic language in research methods, interventions, and daily interactions.

Working Toward More Equal Partnership Processes: Deliberative Communication

Intentionally seeking equity in partnering meant creating communicative spaces for dialogue on societal inequities and partnership processes. The literatures on deliberative democracy (Ercan, Hendriks, & Dryzek, 2019; Lupia & Norton, 2017) and empowerment (Freire, 1970; Wallerstein & Auerbach, 2004) bolster this call for iterative cycles of action/reflection for healthy collective decision making. Knowledge democracy was both a process of their interactions and an outcome, as community leadership was built from and strengthened in partnership processes. Time was important, in the time it took to engage in these critical dialogues and build trust, and in long-term commitments to each other through multiple projects and funding.

Working Toward More Equal Partnership Processes: Structural Practices

Decision-making committees were essential structures that enabled community power, such as in Chinatown, the Bronx, and the Deaf community, with governmental bodies within tribes being able to demand greater authority over the lifespan of research.

Role of PI

PI actions were critical in taking a stand against their own power and the power of the academic partner. Sandoval (1991) describes the subjectivity necessary to negotiate between multiple positionalities within social contexts as differential consciousness. These PIs understood the power they held by virtue of their race, their academic positions, their relationships to funders, and their control over funding streams. Most important, they were responsive to community expectations as they learned and saw through the eyes of their community partners and were intentional about taking an oppositional stand against their own privilege and toward sharing power with the community. The PI in Healing of the Canoe, for example, ensured the university upheld the primacy of community benefit; in the Bronx, the PI exposed unequal power in medical care; and in rural Missouri, academic leaders used their privilege to upend White power structure control of resources.

Supporting Shared Power and Community-Defined Outcomes

In seeking shared power, academic teams were deliberate in creating outputs and outcomes that privileged the community, that is, in their commitment to culture-centered interventions and community leadership. In other quotes not possible to include here, academic partners supported community decision making, that is, through community boards and collaborative publication and dissemination guidelines. Shared power and policy targets were constructed through community leader actions.

Implications for Policy, Research, and Practice

In analyzing cross-cutting themes emerging from seven case studies, our understanding of the role of power in CBPR partnerships has been enhanced. Though the purpose of this article was not to focus on which strategies contributed to outcomes, the strategies to seek equity in power relations supported the principles of explicitly addressing socioeconomic and racial injustices, engaging community partners in equal decision making (also supported by Oetzel et al., 2018, and Pratt, 2018), and building on community organizing for multiple levels of change (Wolff et al., 2017). Short-term outputs included integration of culture-centered interventions and community decision-making, contributing to increased community leadership, shared power, and policy changes. Through deliberative processes, partnerships can have a significant role in making historic and current oppressions visible and developing collective strategies toward structural and epistemic justice.

The term community as a unit of identity, an essential feature of CBPR, may be a simplistic construct suggesting homogeneity among community members and a linear relationship between power and emancipatory processes. “Communities” and “partnerships” require a nuanced understanding of their complex social systems consisting of intersections of race/ethnicity, gender, education, culture, histories, languages, capacities, and socioeconomic status. These entities contain similarly complex systems for communicating priorities for change that may not be apparent nor easily predictable throughout the partnering process (Campbell, 2014).

This article has indicated that structural and deliberative knowledge democracy processes within relationships are necessary to seek transformation of power inequities. Future research and practice needs to continue to examine these pathways to deepen our collective knowledge of how to challenge inequities that are both external to partnerships and internal within our own power dynamics, in order to seek an equity consonant with our shared values.

Footnotes

Acknowledgements

We thank the members of the Research for Improved Health research team and the members of the community–academic Think Tank for their collaboration on the project. We also thank all the academic and community partners who participated in the case studies and in interpretation and translation of the learnings from case study data to their own communities: Healing of the Canoe (HOC)/Suquamish Tribe, Men on the Move (MOTM), Bronx Health REACH (BRX), Chinatown Healthy Living (CTN), South Valley Partners for Environmental Justice (SV), and the National Center for Deaf Health Research (NCDHR).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was supported by the Research for Improved Health Study (NARCH V; Grants U261HS300293 and U261IHS0036-04-00) and funded by the National Institute of General Medical Sciences, National Institute of Drug Abuse, National Center for Research Resources, Office of Behavioral Social Sciences Research, National Cancer Institute, National Institute of Minority Health and Health Disparities, and Health Resources Services Administration.

ORCID iDs

Nina Wallerstein

Julie Lucero

Supplement Note

This article is part of the Health Education & Behavior supplement issue, “Collaborating for Equity & Justice.” The supplement issue was supported by an educational grant from the Robert Wood Johnson Foundation. The entire supplement issue is available open access at .

References

Anderson

L. M.

Adeney

K. L.

Shinn

Safranek

Buckner-Brown

Krause

L. K.

(2015). Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations. Cochrane Database of Systematic Reviews, (6), CD009905. doi:10.1002/14651858.CD009905.pub2

Arnstein

(1969). Ladder of citizen participation. Journal of the American Institute of Planners, 35, 216-224.

Avila

Sanchez-Youngman

Muhammad

Domingo de Garcia

(2018). South Valley Partners for Environmental Justice: A story of alignment and misalignment. In Wallerstein

Duran

Oetzel

Minkler

(Eds.), Community-based participatory research for health: Advancing social and health equity (3rd ed., pp. 123-140). San Francisco, CA: Jossey-Bass.

Baker

E. A.

Barnidge

Langston

Schootman

Motton

Rose

(2013). Leadership and job readiness: Addressing social determinants of health among rural African American men. International Journal of Men’s Health, 12, 245-259. doi.org/10.3149/jmh.1203.245

Baker

E. A.

Barnidge

E. K.

Schootman

Sawicki

Motton-Kershaw

F. L.

(2016). Adaptation of a modified DASH diet to a rural African American community setting. American Journal of Preventive Medicine, 51, 967-974. doi:10.1016/j.amepre.2016.07.014

Barnett

Cuculick

DeWind

Matthews

Sutter

(2018). National Center for Deaf Health Research: CBPR with deaf communities. In Wallerstein

Duran

Oetzel

Minkler

(Eds.), Community-based participatory research for health: Advancing social and health equity (3rd ed., pp. 157-174). San Francisco, CA: Jossey-Bass.

Barnett

Klein

J. D.

Pollard

R. Q.

Jr. Samar

Schlehofer

Starr

. . . Pearson

T. A.

(2011). Community participatory research with deaf sign language users to identify health inequities. American Journal of Public Health, 101, 2235-2238. doi.org/10.2105/AJPH.2011.300247

Barnett

S. L.

Matthews

K. A.

Sutter

E. J.

DeWindt

L. A.

Pransky

J. A.

O’Hearn

A. M.

. . . Pearson

T. A.

(2017). Collaboration with deaf communities to conduct accessible health surveillance. American Journal of Preventive Medicine, 52, S250-S254.

Campbell

(2014). Community mobilisation in the 21st century: Updating our theory of social change? Journal of Health Psychology, 19(1), 46-59.

10.

Dankwa-Mullan

Rhee

K. B.

Williams

Sanchez

F. S.

Stinson

Jr. Ruffin

(2010). The science of eliminating health disparities: Summary and analysis of the NIH Summit recommendations. American Journal of Public Health, 100(Suppl. 1), S12-S18. doi:10.2105/AJPH.2010.191619

11.

de Sousa Santos

(2013). Epistemologies of the south: Justice against epistemicide. Boulder, CO: Paradigm Publishers.

12.

Devia

Golub

Ruddock

Baker

E. A.

Barnidge

Sanchez-Youngman

. . . Wallerstein

(2017). Advancing system and policy changes for social and racial justice: Comparing a rural and urban community-based participatory research partnership in the U.S. International Journal for Equity in Health, 16(1), 17. doi:10.1186/s12939-016-0509-3.

13.

Donovan

D. M.

Rey Thomas

Sigo

R. L. W.

Price

Lonczak

Lawrence

. . . Bagley

(2015). Healing of the canoe: Preliminary results of a culturally grounded intervention to prevent substance abuse and promote tribal identity for native youth in two Pacific Northwest tribe. American Indian and Alaska Native Mental Health Research, 22(1), 42-76.

14.

Drahota

Meza

Brikho

Naaf

Estabillo

Gomez

. . . Aarons

(2016). Community-academic partnerships: A systematic review of the state of the literature and recommendations for future research. Milbank Quarterly, 94, 163-214. doi:10.1111/1468-0009.12184

15.

Duran

Oetzel

Pearson

Magarati

Zhou

Roubideaux

. . . Wallerstein

(in press). Promising practices and outcomes: Learnings from a CBPR cross-site national study. Progress in Community Health Partnerships.

16.

Ercan

S. A.

Hendriks

C. M.

Dryzek

J. S.

(2019). Public deliberation in an era of communicative plenty. Policy & Politics, 47(1), 19-36. doi:10.1332/030557318X15200933925405

17.

Foucault

(1980). Power/knowledge: Selected interviews and other writings, 1972–1977 ( Gordon

, Ed.; Gordon

Marshall

Mepham

Soper

, Trans.). New York, NY: Pantheon Books.

18.

Freire

(1970). Pedagogy of the oppressed. New York, NY: Herder & Herder.

19.

Fricker

(2007). Epistemic injustice: Power and the ethics of knowing. New York, NY: Oxford University Press. doi:10.1093/acprof:oso/9780198237907.001.0001

20.

Gaventa

Cornwall

(2015). Power and knowledge. In Bradbury

(Ed.), The Sage handbook of action research: Participative inquiry and practice (3rd ed., pp. 465-471). Thousand Oaks, CA: Sage.

21.

Golub

Calman

Ruddock

Devia

Linnell

Mathur

. . . Backer

B. A.

(2011). A community mobilizes to end medical apartheid. Progress in Community Health Partnerships-Research Education and Action, 5, 317-325.

22.

Graybill

Aggas

Dean

R. K.

Demers

Finigan

E. G.

Pollard

R. Q. J.

(2010). A community-participatory approach to adapting survey items for deaf individuals and American Sign Language. Field Methods, 22, 429-448. doi:10.1177/1525822X10379201

23.

Habermas

McCarthy

(1985). The theory of communicative action, Volume 2: Lifeworld and system: A critique of functionalist reason. Boston, MA: Beacon Press.

24.

Hall

B. L.

Tandon

(2017). Decolonization of knowledge, epistemicide, participatory research and higher education. Research for All, 1(1), 6-19. doi:10.18546/RFA.01.1.02

25.

Harris

J. K.

Baker

E. A.

Radvanyi

Barnidge

Motton

Rose

(2014). Employment networks in a high-unemployment rural area. Connections (02261766), 34(1/2), 6-13.

26.

Israel

B. A.

Eng

Schulz

A. J.

Parker

E. A.

(2013). Methods for community-based participatory research for health. Somerset, NJ: Wiley.

27.

Israel

Schulz

A. J.

Parker

E. A.

Becker

A. B.

(1998). Review of community-based research: Assessing partnership approaches to improve public health. Annual Review of Public Health, 19, 173-202.

28.

Jagosh

Macaulay

A. C.

Pluye

Salsberg

Bush

P. L.

Henderson

. . . Herbert

C. P.

(2012). Uncovering the benefits of participatory research: Implications of a realist review for health research and practice. Milbank Quarterly, 90, 311-346.

29.

Jih

Woo

Tsoh

J. Y.

Stewart

Gildengorin

. . . Nguyen

T. T.

(2016). Educational interventions to promote healthy nutrition and physical activity among older Chinese Americans: A cluster-randomized trial. American Journal of Public Health, 106, 1092-1098. doi:10.2105/AJPH.2016.303111

30.

Kaplan

S. A.

Ruddock

Golub

Davis

Foley

Devia

. . . Carter

(2009). Stirring up the mud: Using a community-based participatory approach to address health disparities through a faith-based initiative. Journal of Health Care for the Poor and Underserved, 20, 1111-1123.

31.

Kastelic

Wallerstein

Duran

Oetzel

(2018). Socio-ecological framework for CBPR: Development and testing of a model. In Wallerstein

Duran

Oetzel

Minkler

(Eds.), Community-based participatory research for health: Advancing social and health equity (3rd ed., pp. 77-94). San Francisco, CA: Jossey-Bass.

32.

Lucero

Wallerstein

Duran

Alegria

Greene-Moton

Israel

. . . White Hat

E. R.

(2018). Development of a mixed methods investigation of process and outcomes of community-based participatory research. Journal of Mixed Methods Research, 12, 55-74.

33.

Lupia

Norton

(2017). Inequality is always in the room: Language & power in deliberative democracy. Daedalus, 146(3), 64-76.

34.

Muhammad

Garzón

Reyes

, & The West Oakland Environmental Indicators Project. (2018). Understanding contemporary racism, power, and privilege and their impacts on CBPR. In Wallerstein

Duran

Oetzel

Minkler

(Eds.), Community-based participatory research for health: Advancing social and health equity (3rd ed., pp. 47-59). San Francisco, CA: Jossey-Bass.

35.

NCAI Policy Research Center and MSU Center for Native Health Partnerships. (2012). “Walk Softly and Listen Carefully”: Building research relationships with tribal communities. Retrieved from http://www.ncai.org/attachments/PolicyPaper_SpMCHTcjxRRjMEjDnPmesENPzjHTwhOlOWxlWOIWdSrykJuQggG_NCAI-WalkSoftly.pdf

36.

Nguyen

T. T.

Tsoh

J. Y.

Woo

G. M.

Burke

Pasick

R. J.

. . . Stewart

S. L.

(2017). Colorectal cancer screening and Chinese Americans: Efficacy of lay health worker outreach and print materials. American Journal of Preventive Medicine, 52(3), E67-E76.

37.

Oetzel

Wallerstein

Duran

Sanchez-Youngman

Nguyen

Woo

. . . Alegria

(2018). Testing the CBPR conceptual model: Pathways to outcomes within community-academic partnerships. Biomedical Research International, 2018, 7281405. doi:10.1155/2018/7281405

38.

Oetzel

J. G.

Zhou

Duran

Pearson

Magarati

Lucero

. . . Villegas

(2015). Establishing the psychometric properties of constructs in a community-based participatory research conceptual model. American Journal of Health Promotion, 29, e188-e202. doi:10.4278/ajhp.130731-QUAN-398

39.

O’Mara-Eves

Brunton

Oliver

Kavanagh

Jamal

Thomas

(2015). The effectiveness of community engagement in public health interventions for disadvantaged groups: A meta-analysis. BMC Public Health, 15, 129.

40.

Pearson

C. R.

Duran

Oetzel

Margarati

Villegas

Lucero

Wallerstein

(2015). Research for improved health: Variability and impact of structural characteristics in federally-funded community engaged research. Progress in Community Health Partnerships, 9(1), 17-29.

41.

Pratt

(2018). Constructing citizen engagement in health research priority-setting to attend to dynamics of power and difference. Developing World Bioethics. Advance online publication. doi:10.1111/dewb.12197

42.

Rose

(2018). Participatory research: Real or imagined. Social Psychiatry and Psychiatric Epidemiology, 53, 765-771. doi:10.1007/s00127-018-1549-3

43.

Sanchez-Youngman

Wallerstein

(2018). Appendix 7: Partnership river of life: Creating an historical timeline. In Wallerstein

Duran

Oetzel

Minkler

(Eds.), Community-based participatory research for health: Advancing social and health equity (3rd ed., pp. 375-378). San Francisco, CA: Jossey-Bass.

44.

Sandoval

(1991). U.S. Third World feminism: The theory and method of oppositional consciousness in the postmodern world. Genders, 10, 1-24. doi.10.5555/gen.1991.10.1

45.

Stake

R. E.

(2006). Multiple case study analysis. New York, NY: Guilford Press.

46.

Thomas

L. R.

Donovan

D. M.

Sigo

Austin

Marlatt

G. A.

, & The Suquamish Tribe. (2009). The community pulling together: A tribal community-university partnership project to reduce substance abuse and promote good health in a reservation tribal community. Journal of Ethnicity in Substance Abuse, 8, 283-300.

47.

Tuhiwai Smith

(2012). Decolonizing methodologies: Research and indigenous peoples (2nd ed.). New York, NY: Zed Books.

48.

Wallerstein

Auerbach

(2004). Problem-posing at work: Popular educators guide. Edmonton, Alberta, Canada: Grass Roots Press.

49.

Wallerstein

Duran

Oetzel

J. G.

Minkler

(2018). Community-based participatory research for health: Advancing social and health equity (3rd ed.). San Francisco, CA: Jossey-Bass.

50.

Wallerstein

Oetzel

Duran

Magarati

Pearson

Belone

. . . Dutta.

. (in press). Culture-centeredness in community based participatory research: Its impact on psycho-social health interventions. Health Education Research.

51.

Wallerstein

Oetzel

Duran

Tafoya

Belone

Rae

(2008). What predicts outcomes in CBPR? In Minkler

Wallerstein

(Eds.), Community based participatory research for health: Process to outcomes (2nd ed., pp. 371-392). San Francisco, CA: Jossey-Bass.

52.

Wang

Burke

Tsoh

J. Y.

G. M.

Wong

Chow

. . . Nguyen

T. T.

(2014). Exploring a culturally relevant model of cancer prevention involving traditional Chinese medicine providers in a Chinese American community. European Journal of Integrative Medicine, 6(1), 21-28.

53.

W.K. Kellogg Foundation Community Health Scholars Program. (2001). Stories of impact [Brochure]. Ann Arbor, MI: University of Michigan, School of Public Health, Community Health Scholars Program, National Program Office.

54.

Wolff

Minkler

Wolfe

S. M.

Berkowitz

Bowen

Butterfoss

F. D.

. . . Lee

K. S.

(2017, January 9). Collaborating for equity and justice: Moving beyond collective impact. Nonprofit Quarterly. Retrieved from https://nonprofitquarterly.org/collaborating-equity-justice-moving-beyond-collective-impact/

55.

Yin

(2013). Case study research: Design and methods (5th ed.). Thousand Oaks, CA: Sage.