The increasing use of participatory research (PR) approaches to address pressing public health issues reflects PR's potential for bridging gaps between research and practice, addressing social and environmental justice and enabling people to gain control over determinants of their health. Our critical review of the PR literature culminates in the development of an integrative practice framework that features five essential domains and provides a structured process for developing and maintaining PR partnerships, designing and implementing PR efforts, and evaluating the intermediate and long-term outcomes of descriptive, etiological, and intervention PR studies. We review the empirical and nonempirical literature in the context of this practice framework to distill the key challenges and added value of PR. Advances to the practice of PR over the next decade will require establishing the effectiveness of PR in achieving health outcomes and linking PR practices, processes, and core elements to health outcomes.

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The Value and Challenges of Participatory Research: Strengthening Its Practice*‡

CONTEXT: Participatory research (PR) is the co-construction of research through partnerships between researchers and people affected by and/or responsible for action on the issues under study. Evaluating the benefits of PR is challenging for a number of reasons: the research topics, methods, and study designs are heterogeneous; the extent of collaborative involvement may vary over the duration of a project and from one project to the next; and partnership activities may generate a complex array of both short- and long-term outcomes. METHODS: Our review team consisted of a collaboration among researchers and decision makers in public health, research funding, ethics review, and community-engaged scholarship. We identified, selected, and appraised a large-variety sample of primary studies describing PR partnerships, and in each stage, two team members independently reviewed and coded the literature. We used key realist review concepts (middle-range theory, demi-regularity, and context-mechanism-outcome configurations [CMO]) to analyze and synthesize the data, using the PR partnership as the main unit of analysis. FINDINGS: From 7,167 abstracts and 591 full-text papers, we distilled for synthesis a final sample of twenty-three PR partnerships described in 276 publications. The link between process and outcome in these partnerships was best explained using the middle-range theory of partnership synergy, which demonstrates how PR can (1) ensure culturally and logistically appropriate research, (2) enhance recruitment capacity, (3) generate professional capacity and competence in stakeholder groups, (4) result in productive conflicts followed by useful negotiation, (5) increase the quality of outputs and outcomes over time, (6) increase the sustainability of project goals beyond funded time frames and during gaps in external funding, and (7) create system changes and new unanticipated projects and activities. Negative examples illustrated why these outcomes were not a guaranteed product of PR partnerships but were contingent on key aspects of context. CONCLUSIONS: We used a realist approach to embrace the heterogeneity and complexity of the PR literature. This theory-driven synthesis identified mechanisms by which PR may add value to the research process. Using the middle-range theory of partnership synergy, our review confirmed findings from previous PR reviews, documented and explained some negative outcomes, and generated new insights into the benefits of PR regarding conflicts and negotiation between stakeholders, program sustainability and advancement, unanticipated project activity, and the generation of systemic change.

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Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice

Madeleine U. Shalowitz, MD, MBA,* Anthony Isacco, PhD, Nora Barquin, PhD, MSW, Elizabeth Clark-Kauffman, MHS, Patti Delger, RD, Devon Nelson, BA, Anthony Quinn, BA, Kimberly A. Wagenaar, RN, MSC Healthy People 2000 and 2010, the federal public health strategic plans, proposed to eliminate health disparities in populations grouped by social factors that negatively affect the health of mothers, infants, and children.1 In particular, infants and children from low-income and racial and ethnic minority families have higher rates of obesity and preterm birth, infant mortality (including sudden infant death syndrome), and morbidity and mortality because of asthma, when compared with infants and children from white or middle-income families.2–7 Despite a substantial investment by the federal government nearly more than 20 years of research and demonstration, aggregate statistics on children’s health in these areas show negligible improvement, indeed some problems have worsened. In an effort to reconceptualize the approach to society’s most intractable health problems, communitybased participatory research (CBPR) has emerged as a promising new direction. The CBPR is innovative because it harnesses community wisdom in an equal partnership with academic methodological rigor throughout the research process.8 The Agency for Healthcare Research and Quality, in its comprehensive evidence report of CBPR, offered one well-stated definition of CBPR as “a collaborative research approach that is designed to ensure and establish structures for participation by communities affected by the issues being studied, representatives of organizations, and researchers in all aspects of the research process to improve health and well-being through taking action, including social change.”8 The purpose of this article is to review the CBPR literature and to provide a case example of the initial strategies that we used to engage community members in an academic-community partnership using CBPR as our guiding framework. HISTORY AND LITERATURE REVIEW Historical Roots of Community-Based Participatory Research The historical roots of community-based participatory research (CBPR) can be traced by Kurt Lewin, who was a social scientist in the 1940s and who developed CBPR to use research for social action and change.9 The CBPR was also heavily influenced by the writings of Paulo Freire and has been used in Latin American, Asia, Africa, Brazil, Tanzania, and India before gaining ground in the United States.10 Other common terms for the CBPR are community-based action research or community participatory action research. The CBPR diverged from the predominant research approaches by involving people affected by a problem in developing solutions through collaborative research, planned action, along with process and outcome evaluation.11 In essence, the CBPR is not a strict methodology but an orientation to research that guides decision making and allows for the use of qualitative and quantitative methods. The CBPR framework has become more widely used in the United States and considered an ethical approach to research within the historical context of research injustices against disadvantaged communities, which have contributed to community distrust of research and hesitation to partner with researchers.12 The Tuskegee syphilis experiment represents one shocking example13 (African-American men were followed up in a study of the natural history of syphilis beginning in the 1930s. Until 1972, they remained untreated and unaware that treatment was available—even though penicillin became available in the late 1940s and the study team knew about the effective treatment). In contrast, CBPR scholars agreed that an equal partnership between researchers and communities would facilitate trust, help ensure ethical conduct, and increase the likelihood for a successful project. The CBPR is consistent with scholarship from multiculturalist theory, anthropology, feminist theory, and other fields of the study, which have introduced relational process-oriented paradigms as alternatives or complements to traditional research approaches. Traditional research approaches have emphasized knowledge creation through the collection of observable, quantifiable data that test a priori hypotheses while maintaining a distant objective relationship with the research particiFrom the Department of Pediatrics, University of Chicago, Pritzker School of Medicine, Chicago, IL; *Northwestern University, Feinberg School of Medicine, Chicago, IL.

Community-based participatory research: a review of the literature with strategies for community engagement.

Background
Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models.

Objectives
To assess effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

Search methods
We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index, Dissertation Abstracts, System for Information on Grey Literature in Europe (SIGLE) (from January 1990 through September 30, 2013), and Global Health Library (from January 1990 through March 31, 2014).

Selection criteria
Cluster-randomized controlled trials, randomized controlled trials, quasi-experimental designs, controlled before-after studies, interrupted time series studies, and prospective controlled cohort studies. Only studies of community coalitions with at least one racial or ethnic minority group representing the target population and at least two community public or private organizations are included. Major outcomes of interest are direct measures of health status, as well as lifestyle factors when evidence indicates that these have an effect on the direct measures performed.

Data collection and analysis
Two review authors independently extracted data and assessed risk of bias for each study.

Main results
Fifty-eight community coalition-driven intervention studies were included. No study was considered to be at low risk of bias. Behavioral change outcomes and health status change outcomes were analyzed separately. Outcomes are grouped by intervention type. Pooled effects across intervention types are not presented because the diverse community coalition-led intervention studies did not examine the same constructs or relationships, and they used dissimilar methodological designs. Broad-scale community system level change strategies led to little or no difference in measures of health behavior or health status (very low-certainty evidence). Broad health and social care system level strategies leds to small beneficial changes in measures of health behavior or health status in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions led to beneficial changes in health behavior measures of moderate magnitude in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions may lead to beneficial changes in health status measures in large samples of community residents; however, results were not consistent across studies (low-certainty evidence). Group-based health education led by professional staff resulted in moderate improvement in measures of health behavior (very low-certainty evidence) or health status (low-certainty evidence). Adverse outcomes of community coalition-led interventions were not reported.

Authors' conclusions
Coalition-led interventions are characterized by connection of multi-sectoral networks of health and human service providers with ethnic and racial minority communities. These interventions benefit a diverse range of individual health outcomes and behaviors, as well as health and social care delivery systems. Evidence in this review shows that interventions led by community coalitions may connect health and human service providers with ethnic and racial minority communities in ways that benefit individual health outcomes and behaviors, as well as care delivery systems. However, because information on characteristics of the coalitions themselves is insufficient, evidence does not provide an explanation for the underlying mechanisms of beneficial effects. Thus, a definitive answer as to whether a coalition-led intervention adds extra value to the types of community engagement intervention strategies described in this review remains unattainable.

Community coalition‐driven interventions to reduce health disparities among racial and ethnic minority populations

tive choice. Note also that there were no serious medical complications from ECP and the failure rate was the same as would be expected from the literature. The authors concluded that ECP given prophylactically was safe, could be used correctly, and did not result in significant changes in use of a regular method of contraception. Further, those given prophylactic ECP to take home did not misuse it in lieu of a standard contraceptive regimen and were more likely to use ECP than the subjects who had to call their clinician for a prescription.

Abstinence and safer sex HIV risk-reduction interventions for African-American adolescents.

Adolescence is a time for exploration and risk-taking; in today’s urban environment, with the twin threats of substance abuse and HIV/AIDS, the stakes are particularly high. This paper describes a community-based participatory research project to design, implement, and evaluate a faith-based substance abuse and HIV/AIDS prevention program for African-American adolescents. A coalition of university-based investigators and African-American church member stakeholders collaborated on all aspects of Project BRIDGE, the 3-year intervention to reduce substance abuse and HIV/AIDS in African-American adolescents. Our results support the use of community-based participatory research to create desirable change in this setting. Adolescents who participated in Project BRIDGE reported significantly less marijuana and other drug use and more fear of AIDS than a comparison group. Project BRIDGE has been designated an official ministry of the church and the program has been extended to others in the larger metropolitan community. The church now has a welltrained volunteer staff. University faculty developed skills in negotiating with community-based settings. The coalition remains strong with plans for continued collaborative activities.

Community-based participatory research to prevent substance abuse and HIV/AIDS in African-American adolescents.

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment.

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Community-based participatory research to prevent substance abuse and HIV/AIDS in African-American adolescents.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment.