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Am J Public Health. 2003 August; 93(8): 1210–1213.
PMCID: PMC1447939

Community-Based Participatory Research: Implications for Public Health Funding

Abstract

Community-based participatory research (CBPR) increasingly is being recognized by health scholars and funders as a potent approach to collaboratively studying and acting to address health disparities.

Emphasizing action as a critical part of the research process, CBPR is particularly consistent with the goals of “resultsoriented philanthropy” and of government funders who have become discouraged by the often modest to disappointing results of more traditional research and intervention efforts in many lowincome communities of color.

Supporters of CBPR face challenging issues in the areas of partnership capacity and readiness, time requirements, funding flexibility, and evaluation. The authors suggest strategies for addressing such issues and make a case for increasing support of CBPR as an important tool for action-oriented and community-driven public health research.

IN ITS RECENT, WIDELY CITED report on educating public health professionals for the 21st century, the Institute of Medicine included community-based participatory research (CBPR) as one of 8 new areas in which schools of public health should be supplementing their traditional curricula.1 In so doing, this organization joined a growing number of health scholars and government and private philanthropic organizations2–5 in arguing that many of today’s complex health problems may profitably be studied and addressed through approaches that emphasize collaboration with communities in exploring and acting on locally identified concerns.

As Green and Mercer have noted, CBPR participants give “more than informed consent”3(1926): they share their knowledge and experience in helping to identify key problems to be studied, formulate research questions in culturally sensitive ways, and use study results to help support relevant program and policy development or social change.3 For present purposes, CBPR is defined as “a collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities.”6

We begin with a brief discussion of the fit between CBPR and the mission of a growing number of foundations and government funders in the health field. We then explore the challenges and opportunities that CBPR may present for health scholars and funders interested in promoting collaborative approaches to scholarship in which action is a critical part of the research process itself.

GOVERNMENT AND PRIVATE INTEREST IN SUPPORTING CBPR

In the United States, both large and small philanthropic organizations, including the W. K. Kellogg Foundation, the Ford Foundation, the Annie E. Casey Foundation, the California Endowment, and the Aspen Institute, have begun providing substantial support for actionoriented participatory research approaches in health and related fields. Through its Community Health Scholars Program, the Kellogg Foundation also has supported training, at the postdoctoral level, of a new cadre of researchers with experience in CBPR and a commitment to the use of this approach in their future academic careers.6

In addition, some foundations have played a leadership role in advocating and funding a form of CBPR—participatory evaluation or “empowerment evaluation”—as a means of increasing community capacity while actively engaging those affected by a particular program intervention in ongoing efforts to assess and improve its outcomes and effectiveness.7,8 Participatory evaluation figures prominently in The California Endowment The Public Health Institute’s $137 million Partnership for the Public’s Health program, as well as in The Rockefeller Foundation/The California Endowment’s Work and Health Initiative.

Curiously, however, while foundations often pride themselves on their commitment to “results-oriented philanthropy”9 and are increasingly viewing CBPR as an action-oriented approach that fits within this framework, it has been government funding, rather than foundation funding, that has played the biggest role in spurring CBPR in the United States. As Lawrence W. Green, director of extramural prevention research at the Centers for Disease Control and Prevention (CDC), has pointed out with respect to his organization, “a long tradition of ‘bootstrap epidemiology’ and strong ties to state and local health departments have provided a sympathetic environment for the promotion of participatory concepts” that extend to the fields of research and evaluation.2(p414)

Recently, for example, the CDC funded 25 “community-based prevention research” grants totaling $13 million; these 3-year grants are intended to fund multidisciplinary, multilevel, participatory research with the goal of enhancing the capacity of communities and population groups to address health promotion and prevention of disease, disability, and injury. As Green has noted, the 560 letters of intent received in response to this grant initiative “greatly exceeded the response” to most calls for proposals at either the CDC or the National Institutes of Health, suggesting “a growing interest and perhaps a pent up demand for opportunities to pursue this kind of research in public health, and for the U.S. federal government to support it.” 2(p415)

The CDC’s support of 3 urban research centers, for which CBPR is a central modus operandi, and the commitment by the National Institute of Environmental Health Sciences (NIEHS) of substantial funds for “community-driven” and action-oriented participatory research have set an important precedent for federal funding in this area. Similarly, the Agency for Healthcare Research and Quality’s recent commissioning of a comprehensive and systematic study of the evidence base for CBPR and the National Institute of Health’s creation of a new network of “breast cancer and the environment” research centers, emphasizing partnerships between scientists, advocates, community members, and health care providers (http://www.grants.nih.gov/grants/guide/rfa/files/RFA-ES-03-001.htlm), represent new indications of federal support for and belief in the importance of this collaborative and action-oriented approach.

In summary, a dramatic increase in federal and private foundation support for CBPR has been observed over the past decade, with annual support estimated at $45 million10 even before the infusion of substantial new CDC and National Institute of Health support for such work in 2002 alone. However, notwithstanding this important trend, such funding still represents a tiny fraction of the billions of dollars in support available for more traditional research efforts. Furthermore, studies conducted in both the United States and Canada have documented that researchers continue to have substantially greater difficulty in obtaining funding for CBPR than in obtaining funding for other research.4,10–12

CHALLENGES FOR FUNDERS IN SUPPORTING CBPR

There are a number of challenging issues for health funders who are considering embarking on a commitment to CBPR or expanding their commitment.

Centrality of Partnerships and the Role of Funders

By involving and building on the strengths of multiple stakeholders in the research process, CBPR offers the opportunity to achieve what Roz Lasker and her colleagues at the New York Academy of Medicine term “partnership synergy,” the idea that through collaboration, multiple organizations can tackle difficult issues more effectively than could any one alone.13 However, funders may face difficulty in defining their own role in relation to such partnerships. While some have argued that funders themselves should be considered partners in CBPR efforts, Green suggests that once they have judged the merits of a proposed CBPR project, funders should move aside, allowing autonomy for the community and research partners and limiting themselves to providing accountability for the project (L. W. Green, oral communication, September 2002).

A helpful middle ground in this debate may be found in the role that some funders are playing in both offering autonomy to funded CBPR projects and engaging partnership members in conferences and other technical assistance activities in which funders are, in fact, key players. The role of the NIEHS in relation to its community-driven environmental justice grants provides a useful case in point. The identified partners in these grants typically are community-based organizations, academic researchers, and local health departments, and the NIEHS encourages partner representatives from all of the environmental justice projects it supports to come together annually to promote co-learning and provide direct technical assistance. The role of the NIEHS as an “outsider” in these meetings keeps it from impinging on the autonomy and selfdetermination of its grantees and may offer a helpful template for funders who wish to both support CBPR financially and play a more active role in encouraging such work.

Community Building: Special Challenges and Roles for Funders

In the low-income communities of color where much of CBPR takes place, funders may need to invest in front-end processes, including supporting intermediary organizations that can facilitate the community building that is often an important precursor to, and first step in, CBPR. As does CBPR, community building promotes participation in decisionmaking processes, emphasizes collaboration, builds on community strengths, stresses data collection, and aims to build capacity within low-income communities of color.14 However, because it involves broad cross sections of the community—from residents and corporate leaders to law enforcement officials and clergy—in addressing such interrelated issues as health, housing, and unemployment, effective community building frequently requires considerable training of residents and representatives of community-based organizations to support their meaningful and equitable participation.

The critical role of intermediary organizations in such processes, and the added value for funders who invest in these agencies and are concerned about long-term sustainability, is illustrated in the work of 3 foundation-supported intermediary organizations based in Oakland, Calif: the Urban Strategies Council, the University Oakland Metropolitan Forum, and the Community Health Academy. These organizations trained 20 community members to conduct, and help analyze data from, a massive door-to-door survey campaign undertaken as part of the city’s Enhanced Enterprise Community Project. Participants also underwent training that helped them in working with representatives of governmental agencies, health departments, and academic institutions to develop new approaches to the problems identified through the survey. Seven years later, many of the residents originally trained remain involved in research and action in their communities, including partnering with the local health department to study and address environment-related illnesses such as asthma.

Finally, and in keeping with their commitment to encouraging sustainability and leaving communities better positioned to address their problems, funders may play a critical role in helping build the fiduciary capacity of community-based organizations, enabling them to serve as lead agencies on future grants and contracts.

Time Requirements and Flexible Funding

Adequate and flexible funds are needed to support both the longer front-end time needed to build community–researcher relationships and the additional time often involved as the community participation process unfolds. This may mean supporting a longer planning process or extending the length of time for the project to become operational. In addition, increased success has been demonstrated in programs that have had access to flexible, discretionary dollars or “braided funding streams,” allowing these programs the authority to fund efforts that are based on emerging community needs and are not tied to rigid preprogram budgets.15

As Green has noted with respect to federal funding, the fact that most research dollars “are tied up in congressionally restricted vertical silos of categorical disease earmarks or line items in agency budgets” presents a particular difficulty for CBPR. Such a limitation “makes the principle of local autonomy in selecting local needs to define research priorities seem somewhat hollow. . . .” 2(p416) The most recent CDC funding for CBPR through the earlier-mentioned community-based prevention research grants program avoided this dilemma by enabling far greater flexibility in the choice of topics to be investigated, and similar flexibility may profitably be encouraged in other government and foundation calls for proposals.

Finally, the potential for success of CBPR efforts may be enhanced if sufficient funds are allocated to pay stipends for community members’ time and to absorb costs associated with their participation, such as child care, transportation, and meal expenses. Some analysts have suggested that community members be compensated for their time at the level of graduate student researchers as a further demonstration of respect for their contributions.

Appraising and Evaluating CBPR Process and Impact

The complex environments in which CBPR takes place, and the fact that these projects often seek change at multiple levels, sometimes render traditional evaluation approaches ill suited to this work.16 Similarly, as a result of the high level of community involvement entailed in CBPR, often the parameters and end points of such efforts cannot be defined with the degree of clarity that is possible when outside researchers are developing study protocols on their own. However, as noted earlier, partnerships with communities may be far more likely to uncover, study, and take action to address the health issues of greatest concern to local communities, thereby increasing the chances for success.

Both health scholars and funders may benefit from using the detailed set of guidelines and criteria developed by Green and his colleagues for assessing the goodness of fit between CBPR research proposals and the principles of participatory research.11,17 The guidelines, which also are available on-line (http://www.ihpr.ubc.ca/guidelines.html), include a range of scaled question items for funders to consider, among them:

  • Did the impetus for the research come from the community?
  • Is attention given to barriers to participation, with consideration of those who have been underrepresented in the past?
  • Can the research facilitate collaboration between community participants and resources external to the community?
  • Do community participants benefit from the research outcomes?
  • Is there attention to or an explicit agreement between researchers and community participants with respect to ownership and dissemination of the research findings?

These guidelines formed the basis of discussions and decisionmaking regarding the feasibility of beginning a CBPR research agenda in Alberta, Canada, and a modified version is being used in the University of California’s funding programs in tobacco control and breast cancer prevention research. The guidelines also were posted on the CDC Web site in conjunction with the earlier-mentioned 2002 call for CBPR proposals and were used by some members of the external review panel to help guide funding decisions.

As suggested earlier, evaluation of CBPR efforts should include greater attention to such intermediate outcomes as the effects of community participation itself. Are new community structures or problemsolving mechanisms in place as a result of the project? Have new leaders emerged? Is there evidence of a deeper sense of community ownership or civic participation? Questions such as these may help capture critical mediating variables between the implementation of CBPR efforts and the achievement of distal health and social change outcomes.16,18,19

CONCLUSIONS

CBPR holds considerable relevance as we attempt to study and take action to address the complex health problems of the 21st century. A number of foundations and government agencies have played leadership roles in promoting and funding CBPR, but reluctance to fund in this area remains common. CBPR presents a number of challenges for health funders. The longer time frame required for partnering with communities and the related need for sustained financial commitment may be problematic for those seeking clear funding goals and short-term outcomes.4,20 Evaluating the effects of CBPR also may prove challenging, although new approaches, including tools for examining shorter term system-level effects,11,16 appear to hold promise.

Funders can lay important groundwork for CBPR by supporting the community building and organizational capacity development that is a critical precursor to and first step in such partnership approaches. Using carefully developed and tested guidelines for appraising participatory research in health,11,17 funders can further enhance their ability to evaluate proposed CBPR efforts so that funding is targeted toward those projects with the best potential to eliminate health disparities and build healthier communities.

Acknowledgments

We gratefully acknowledge Victor Rubin, Lawrence W. Green, Thomas A. Bruce, and Toby Citrin for their very helpful comments and insights.

Notes

Contributors

M. Minkler was primarily responsible for the writing of the article. A. G. Blackwell, M. Thompson, and H. B. Tamir each contributed substantially to the writing and editing of drafts of the article and the final version.

References

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