Feature

Expanding Scholarship in Community-Based Research

By Ann Steinecke, PhD, and Amy Addams

Moving research beyond classic laboratory or medical settings into neighborhoods raises eyebrows in conventional medical circles. When faculty engage in community-based research, controversial questions arise:

• What constitutes scholarship versus service or education?
• Which outcomes and measures meet the rigorous standards of the review process?
• How can the work of individual faculty be teased out for fair assessment at promotion and tenure time?

Answers to these questions will encourage greater faculty participation and expand grant-makers' interest in funding scholarship for this new approach to research.

What is Community-Based Research?

This shared approach incorporates community participation into conducting research with four common features. Investigators:

• Address social, political, cultural, and economic systems to change health behaviors and outcomes;
• Engage community members in choosing research topics, developing projects, collecting data, and interpreting and disseminating results;
• Utilize both qualitative and quantitative research methods; and
• Place a high priority on converting findings into new practices and policies.¹

Advocates argue that a community-based approach to medical research has benefits for both the community and medical science.²

Community-based research is grounded in the power of interdisciplinary and interprofessional collaborations—both within and outside of the academy—that target health care disparities due to differences in quality of care based on race, ethnicity, or socioeconomic status. Through novel partnerships, community health researchers and community leaders, such as public health personnel, social workers, grassroots advocates, religious leaders, educators, and business people, are finding measurable improvements in the well being of community members.

Needs and Benefits to the Public

Despite an overall trend of better health for people in the United States, health care disparities remain an entrenched problem. Health and health care differences for racial and ethnic minority groups or those of low socioeconomic status result in shorter life spans and higher rates for many diseases (e.g., cancer, asthma, diabetes, cardiovascular disease, birth defects, and infant mortality). The 2006 National Healthcare Disparities Report issued by the Agency for Healthcare Research Quality (AHRQ) concludes that racial and ethnic minorities receive lower quality and worse access to care for sizeable proportions of these measures. As the United States continues to grow and diversify, disparities are affecting ever-larger segments of the nation. National Institutes of Health funding is an important source of financial support for community-based research with new program announcements becoming available June 2007.

Benefits to community and medicine from community-engaged scholarship include:

• The development and diversity of the health workforce;
• The delivery of quality health care;
• The relevance of research and its translation into practice and policy; and
• The health and economic vitality of communities.²

How Do Community-Based Researchers Approach Their Work?

Community-based researchers frame questions from social, economic, or political contexts to engage community members as partners. What does that mean in practice? Typically, the community participates in a needs assessment to identify specific health issues they would like to see addressed by building a stronger community infrastructure. Community ownership continues to grow as the project proceeds. Participants write or translate health education materials, build a cadre of patient recruiters within the community, and even invest in office space and computers for data collection and storage. As the project ends, the community shows its ownership by sharing in the evaluation of the project, dissemination of the results, and the determination of next steps. (For a model of how this appears in a research grant, see A New Investigator's Journal).

With this approach, community members put together their own capacity to improve their health and health care. Outcomes translate into long term gains. Health literacy, the ability to get and understand information that is important to health care, increases. Activities also can help repair trust and raise the profile of health professions in communities that have been previously underserved. For these reasons, community-based research is being increasingly recommended as a strategy to address health care disparities.

For other examples of institutional support, see Perspectives.

Challenges for Medical Faculty

Several community-based research tenets conflict with current expectations of medical practice and performance measures for academic-physician review, promotion, and tenure decisions. Jones and Wells explain that attributes of community-based research, "spending time in the community, power sharing, and action research methods" contradict the prevailing models of physicians' clinical training, practice, and advancement. This "often requires interactions under time pressure, the hierarchical structure of academic medicine, and the focus of medical research on controlled trials as the standard for evidence."³

Community-based research is an intense, complex, and time-consuming approach to scholarship. (For an example of a successful community-based research education program, see Spotlight. Because researchers learn about their research topics through the community's needs assessment, a researcher frequently can't anticipate the full scope of their project until they have already invested a significant amount of time and effort. Further, the research may require quantitative, qualitative, or mixed-method study, which means the researcher must be proficient with a variety of methods. Additionally, community-based researchers need to be adept at community outreach, interpersonal relationship-building, and interdisciplinary organizational skills as well as rigorous in their scientific conduct. Researchers need patience, flexibility, and stamina to conduct long-term projects that often unfold in unanticipated yet exciting ways. How can these many professional attributes be quantified and assessed?

Rewarding the Scholarship of Community-Based Research

New measures of scholarship are needed to support the professional development and advancement of faculty engaged in community-based research. In 1990, Boyer called on academia to rethink and expand the definition of scholarship and proposed four "separate, yet overlapping" categories: discovery, integration, application, and teaching.⁴ Glassick, Huber, and Maeroff later added the common standards for evaluating scholarship within these domains.⁵

Using these new categories and standards, a rich variety of creative work can be assessed and more equitably rewarded.

Medical school faculty are expanding the definition of scholarship—this approach has been referenced in the national consensus work on educational scholarship led by the AAMC Group on Educational Affairs. Although it has been difficult to transform review, promotion, and tenure systems, new guidance and tools are becoming available to help faculty document their community-based work. The Commission on Community-Engaged Scholarship in the Health Professions Initiative has prepared a toolkit for faculty.

Additionally, the Community-Engaged Scholarship for Health Collaborative has developed several resources that can inform faculty and administrators in developing criteria for reviewing community-based scholarship in the promotion process.

Calleson and colleagues⁶ suggest evaluation standards for community-based research that includes specific process, products, and impact/outcome measures.

Evaluation Standards for Community-Based Research

By using, refining, and sharing these tools, faculty and review committees can help one another build and reward the portfolios of faculty engaged in community-based research.

Institutional Benefits

Expanding the vocabulary and benchmarks used to evaluate community-based research will be insufficient, however, without organizational leadership that recognizes the value of aligning the health of an academic medical center with the health of its surrounding communities. Institutional advantages include the ability to:

• Demonstrate tangible community health gains,
• Expand networks within the institution, across disciplines, and with external entities; and
• Create opportunities to strengthen the education pipeline that brings diversity to the health professions workforce.

Further, there are examples of institutional collaboration on community-based research projects. For example, Shaw University, which has a historical commitment to underserved communities, and the research-intensive University of North Carolina at Chapel Hill have strategically combined resources and new initiatives for their mutual benefit. Since the inception of the Carolina-Shaw Partnership in 2000, staff and faculty of the two universities have worked through differences in administration, culture, and research bureaucracies. Their collective ability works well within the community to address health care disparities in communities in North Carolina and to provide better cross-training opportunities for faculty development and collaborative interdisciplinary pilot studies.⁷ Concurrently, the increasing availability of grants to support community-based research allowed these universities to strengthen their research capacity.

Summary

The many complex and centuries-old issues that have resulted in health care disparities in our country call for innovative research. Community-based research holds promise as just such an innovation. Its power for change emerges from a new lens of cooperation between academia and communities. The continued success of community-based research depends, in large part, on the willingness of medical schools and grant makers to expand their recognition of scholarship to coincide with community-based research practices.

References

1. Viswanathan M, Ammerman A, Eng E, et al. Community-Based Participatory Research: Assessing the Evidence. Rockville, MD: Agency for Healthcare Research and Quality, 2004. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.44133 Accessed 3/14/2007.

2. Commission on Community-Engaged Scholarship in the Health Professions. Linking Scholarship and Communities. Seattle, WA: Community-Campus Partnerships for Health, 2005.

3. Jones L, Wells K. Strategies for academic and clinician engagement in community-participatory partnered research. JAMA. 2007;297:407-410.
   
   
4. Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching, 1990.
   
   

5. Glassick CE, Huber MR, Maeroff GI. Scholarship Assessed: Evaluation of the Professoriate. San Francisco, CA: Jossey-Bass Publishers, 1997.

6. Calleson DC, Jordan C, Seifer SD. Community-engaged scholarship: is faculty work in communities a true academic enterprise? Acad Med. 2005;80:317-321.

7. Carey TS, Howard DL, Goldman M, Roberson JT, Godley PA, Ammerman A. Developing effective interuniversity partnerships and community-based research to address health disparities. Acad Med. 2005;80:1039-1045.