Community-Based Participatory Research: toward eliminating rural health disparities

Online Journal of Rural Nursing & Health Care, Spring, 2009 by Barbara Ann Graves

The National Healthcare Disparities Report (NHDR) (2008) tracks and documents access to healthcare as well as quality of healthcare. This report provides information to policymakers, clinicians, administrators, and community leaders for the improvement of healthcare services. From this report it is apparent that disparities in healthcare still exist and that many opportunities for improvement remain across racial, ethnic, socioeconomic, and geographical groups.

The Health Resources and Service Administration (HRSA) (2009) designates medically underserved areas (MUAs) and medically underserved populations (MUPs) as areas or populations having too few primary health care providers, high infant mortality, high poverty, and/or high elderly populations. One underserved and priority population is residents of rural areas. According to the NHDR (2005), "compared with their urban counterpart, rural residents are more likely to be elderly, poor, in fair to poor health, to have chronic conditions, and to die from heart disease". Residents of rural areas experience more health disparities than residents of urban areas.

Access to quality healthcare is an ongoing problem for rural populations. Financial, sociocultural, and structural features of the rural environment create barriers to healthcare. These factors affect health-seeking behaviors, healthcare access, and ultimately health outcomes in rural areas (Bushy, 2000; Ricketts, 1999; Eberhardt, et al., 2001). Rural areas are often identified as medically underserved areas (MUAs) and medically underserved populations (MUPs).

A disproportionate burden of health disparities for rural populations requires attention. Because the burden of poor health is great in terms of cost and disability, further research into specific healthcare disparities for specific rural communities is needed. It is important to learn as much as possible about the ecology of health and disease within the context of individual communities. How can this best be accomplished?

Communities have identities developed from their unique strengths and resources. Health is relevant to this identity. Communities need to be empowered to generate knowledge and interventions to solve their own health problems. Israel et al. (2001) conducted a review of literature regarding community-based research. From this seminal review comes a comprehensive definition of Community-Based Participatory Research (CBPR) as a:

   .... collaborative approach to research that equitably involves,
   for example, community members, organizational representatives, and
   researchers in all aspects of the research process. The partners
   contribute unique strengths and shared responsibilities to enhance
   understanding of a given phenomenon and the social and cultural
   dynamics of the community, and integrate the knowledge gained with
   action to improve the health and well-being of community members
   (p. 177).

The Agency of Healthcare Research and Quality (AHRQ), in ongoing initiatives to address health care disparities, promotes the use of CBPR. AHRQ defines CBPR as a collaborative process of research involving researchers and community representatives (AHRQ, 2001). Key principles as identified by AHRQ (2001) are that CBPR:

* Recognizes the community as a unit of identity.

* Builds on the strengths and resources within the community.

* Facilitates collaborative, equitable partnerships in all phases of the research and involves an empowering process.

* Promotes co-learning and capacity building among all partners.

* Integrates knowledge generation and intervention for the mutual benefit of all partners.

* Emphasizes the local relevance of public health problems and the multiple determinates of health and disease including biomedical, social, economic, and physical environmental factors.

* Process is cyclical and iterative, and research goals are not always known at the beginning of work with the community.

* Can disseminate findings and knowledge gained to all partners and involve them in the dissemination process (AHRQ, 2001).

As one may see, the benefits of CBPR are multidimensional. CBPR:

* Enhances the relevance and use of data.

* Increases the quality and validity of research.

* Improves intervention design and implementation by facilitating participant recruitment and retention.

* Benefits the community through knowledge gained and actions taken.

* Provides resources for communities.

* Joins partners with diverse expertise to address complex health problems.

* Increases trust and bridges cultural gaps between partners.

* Has potential to translate research findings to guide further interventions and policy changes (AHRQ, 2001).

According to HRSA (2009), CBPR can be an effective approach in targeting health disparities in specified communities and specific populations. Research, jointly conducted by communities and researchers, can assess health problems and design targeted interventions in underserved communities, thereby leading to improved healthcare access and health outcomes. CBPR may be one of the nation's best options for eliminating rural health disparities