EDITORIAL

CommunityBased Participatory Research as Worldview or Instrumental Strategy: Is It Lost in Translation(al) Research?

Community involvement in community-wide interventions is important for a variety of scientic, ethical, and pragmatic reasons.1,2 However, the specic meaning of community involvement depends on the details of how it is enacted. Katz et al.3 outline an ambitious effort to blend the science of randomized controlled trials (RCTs) with the processes of community-based participatory research (CBPR) in translational research. RCTs provide the science, while CBPR provides the processes of tailoring and implementation. Katz et al. offer a detailed example of how research might occur through the use of community portals and community health advisors as local advocates for the delivery of interventions. Their examples are rich and raise fundamental issues regarding the importance of CBPR and the role of local participation in translational research more generally. 3. structural, policy, community capacity, empowerment, and individual change goals; 4. a critical realist or constuctivist philosophy of science1; and 5. a concern that communities are able to sustain what they nd useful resulting from the intervention.6 The use of CBPR as an instrumental strategy differs fundamentally from every aspect of this worldview. As described by Katz et al., CBPR is selectively invoked to accomplish predetermined aims or goals not collaboratively developed or locally dened. Local inuence appears in translating ndings to local context. This is an important area on which to focus, and local participation in this process is important to theorize and enact. However, it relegates local knowledge and inuence to carrying out the science devised by others. While there is exibility in how it is done, local involvement occurs within a framework of expertdesignated xed components. In the context of these givens, CBPR as instrumental strategy brackets rather than embraces the larger CBPR worldview in terms of when and how local inuence is expressed. The RCT and CBPR paradigms are not blended, but sequenced under the assumption that, early on, science is enhanced by ruling context out (the RCT, not the CBPR assumption) but scientic ndings need to be subsequently recontextualized through local participation. In this role, CBPR is in the service of the RCT, its assumptions, and its givens. Included in these givens are the outcomes of importance. In the exemplar Diabetes Prevention Program (DPP) intervention described in the Katz et al. article, the goals are exclusively individual-level or lifestyle outcomes. But the goals of CBPR also address communitylevel concerns such as increasing capacity-building of individuals and social settings.6 In Katz et al., the heuristically useful concept of portals is expressly viewed as means to the end of diabetes prevention (dened in terms of individual outcomes), rather than also being explicitly included as objects of community capacity building and empowerment for future local problem solving. In fundamental ways, then, CBPR as an instrumental strategy ranges far from its worldview.

THE FORM VERSUS FUNCTION DISTINCTION

In arguing for CBPR as an instrumental strategy for translational efforts, Katz et al. employ the form versus function distinction of Hawe et al.7 The notion is that instead of standardizing the specic forms or components of an intervention, the functions they are designed to serve should be standardized across settings, allowing the forms to vary. For example, if the function of an intervention is to educate patients about depression, rather than standardize and distribute a patient information kit, sites would be free to devise their own ways of distributing the relevant information tailored to local literacy, language, culture, and learning styles.7(p1562) As they put it,

CBPR AS WORLDVIEW OR INSTRUMENTAL STRATEGY

Over time, CBPR has developed as a coherent worldview, and the concept includes several characteristics outlined both in the Katz et al. article and in the writing of leaders in the CBPR eld1---5: 1. the community as the unit of identity, solution, and practice1---5; 2. community involvement in decision-making throughout the intervention process, from problem denition to planning for sustainability;

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intervention integrity is dened as the evidence of t with the theory or principles of the hypothesized change process.7(p1563) There is obvious merit to freeing the RCT from a literal denition of standardization-as-repetition of the same activities across diverse communities. However, the Hawe et al. worldview from which the form and function distinction ows is one that regards community interventions as complex rather than simple.7 Whereas simple interventions are conceptualized as the sum of their discrete parts or core components, complex interventions rest on systems theory perspectives that address interactive functions rather than core components and ripple effects of interventions including, but going beyond, individuals. Here, reducing a complex system to its component parts amounts to irretrievable loss of what makes it a system.7(p1561) Applying this perspective to translational research raises important questions about the concept of core components. First, they are neither easy to identify nor isolate as independent contributors to outcomes.7 The DPP, for example, was not designed to test the relative contributions of dietary changes, increased physical activity, and weight loss to the reduction of risk in diabetes.8(p398) Rather, it was planned to assess the combined effects of the intervention components addressing these different outcomes. How these components combined, or how they may combine in different contexts or with different populations, is unknown. More fundamentally, the Hawe et al. perspective begins with theorizing principles of change, mechanisms, or mediators of intended outcomes, and translating those principles into forms that may

vary across contexts. In the translational example in Katz et al., the core (xed) components are conceptualized as forms rather than functions. The participatory task is to gure out how the function they presumably serve can be translated. But starting with the form rather than the function reverses the process suggested by Hawe et al. and seemingly assumes that forms or core components serve the same function across communities but need to be tailored to local context. A focus on function at the outset of the translation process would complicate greatly the notion of core components and the science behind it. For the translation of the 16-session curriculum of the DPP, for example, a discussion of function in diverse communities may result in varying the length or content of a prescribed curriculum, or it may imply developing something other than a curriculum to fulll the same function in different communities. In CBPR terms, the greater the emphasis on form, the less formative the local inuence on translation, and the greater the emphasis on function, the stronger the local inuence is, but the issue of delity as traditionally dened becomes more imperative. Katz et al.s concern about local inuence diluting the generalizabilty of interventions reoccurs in the translation process if Hawe et al. are to be taken seriously.

EXTERNAL VALIDITY AS SCIENCE AND RESOURCE BURDEN

The rationale behind translational research rests in part on the generalizability of scientic ndings. A contextualist perspective congruent with CBPR is likely to ask for whom and under what

conditions ndings were generated, and how do the ndings apply to the local community. The DPP screened over 158 000 individuals to achieve a nal sample of 3234,9 with most exclusion criteria . . . chosen to reduce the risk of adverse effects of the intervention.9(p624) The implications of such selectivity needs to be claried for local participating organizations not only as a translation issue but as an ethical issue of not overstating what we know about for whom the intervention has shown efcacy. However, translational research, in addition to issues of local acceptability and commitment, also involves an assessment of resources necessary to translate and sustain the intervention. The high impact arm of the DPP included an elaborate recruitment process, culturally tailored dietary and exercise components, a 16-session core curriculum delivered by trained case managers, an exercise regimen of 150 minutes per week,9 and additional staff to monitor adherence and retention.10 These are all part of what it took to get the intervention effect. The lack of take of the DPP program cited in Katz et al. may be inuenced less by lack of community involvement than by the scope of needed resources. Scientic humility about the generalizability of externally derived and candid assessments with local portals on the resources necessary to conduct and sustain such an effort would seem to be a prime topic for important local input in translational research. The CBPR worldview includes thinking systemically and contextually. It addresses sustainability through such goals as capacity building and empowerment. The form versus function distinction of Hawe et al. likewise conceptualizes

interventions as complex and the intervention process as systemic. The Katz et al. article operates on a quite different paradigm that focuses on intervention as simple with xed components, and views the intervention as the technology rather than an event in a system with multiple outcomes and interactive rather than additive aspects.10 In these areas the CBPR worldview differs fundamentally with the worldview as portrayed in Katz et al. and in the DPP example and is subservient to it. As Katz et al. point out, the adaptive requirements for investigators to secure external funding often set constraints on the degree to which local participation can meaningfully contribute to the co-creation of locally relevant interventions. We need more conversations about moving translational research beyond the image of community interventions as product development and product dissemination. The Katz et al. article serves this very important function. j

Edison J. Trickett, PhD

About the Author

Edison J. Trickett is with the Department of Psychology, University of Illinois, Chicago. Correspondence should be sent to Edison J. Trickett, Department of Psychology (MC 285), 1007 W. Harrison St., Chicago, IL 60607. Reprints can be ordered at http:// www.ajph.org by clicking the Reprints/ Eprints link. This editorial was accepted January 11, 2011. doi:10.2105/AJPH.2011.300124

Acknowledgments
The author wishes to thank Kenneth McLeroy for comments on versions of this editorial.

References
1. Minkler M, Wallerstein N, eds Community-Based Participatory Research in Health. 2nd ed. San Francisco, CA: JosseyBass; 2008.

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2. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173---202. 3. Katz DL, Murimi M, Gonzalez A, Njike V, Green LW. From controlled trial to community adoption: the Multisite Translational Community Trial. Am J Public Health. 2011;101(8):e17---e27. 4. Mohatt GV, Hazel KL, Allen J, et al. Unheard Alaska: culturally anchored participatory action research on sobriety with Alaska Natives. Am J Community Psychol. 2004;33:263---273. 5. Eng E, Hatch J, Callan A. Institutionalizing social support through the church and into the community. Health Educ Behav. 1985;12(1):81---92. 6. Schensul JJ. Sustainability in HIV prevention research. In: Trickett EJ, Pequegnat W, eds Community Interventions and AIDS. New York, NY: Oxford University Press; 2005:176---195. 7. Hawe P, Shiell A, Riley T. Complex interventions: how far out of control should a randomised controlled trial be? BMJ. 2004;328:1561---1563. 8. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393---403. 9. The Diabetes Prevention Program Research Group. The Diabetes Prevention Program: baseline characteristics of the randomized cohort. Diabetes Care. 2000;23:1619---1629. 10. The Diabetes Prevention Program Research Group. The Diabetes Prevention Program: design and method for a clinical trial in the prevention of type 2 diabetes. Diabetes Care. 1999;22(4): 623---634.

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