Being Part of Something

Abstract

Objectives. Calls for public health practices, including research, to better integrate social theories of power, agency, and social change suggest that increased reflexivity about both the process and outcomes of community engagement is warranted. Yet few community-based participatory research (CBPR) projects specifically report nonresearch outcomes of such projects. The authors analyzed “secondary outcomes” of Protecting the ’Hood Against Tobacco (PHAT), a CBPR project conducted in San Francisco, California. Methods. Interpretive analysis of quasi-ethnographic project documentation, including meeting minutes, field notes, retrospective observations, and interviews. Results. PHAT participation created “ripple effects,” encouraging healthier behaviors and public health promotion among community research partners, prompting academics to confront power asymmetries and recognize community knowledge, and widening social networks. Conclusions. CBPR benefits both communities and researchers beyond the findings of the research itself. More systematically capturing these effects, perhaps through wider use of ethnographic approaches, could help enhance understanding of CBPR’s true contributions.

Keywords

Black/African American community-based participatory research qualitative research tobacco prevention and control

Community-based participatory research (CBPR) can engage communities in research and help address health inequities (Green & Mercer, 2001; Hennessey Lavery et al., 2005; Malone, Yerger, McGruder, & Froelicher, 2006; Minkler, 2005; Viswanathan et al., 2004; N. Wallerstein & Duran, 2010). CBPR is a philosophy of action and approach to research in which different methods may be used (Viswanathan et al., 2004). Basic elements of CBPR include regarding the community as a unit of identity; focusing on strengths, rather than needs; conceiving research as collaborative; integrating knowledge and action to create change; promoting co-learning that addresses social inequalities; involving cyclical processes; addressing health from positive, ecological perspectives; and disseminating knowledge to all partners (Israel, Schulz, Parker, & Becker, 1998).

Although criteria for evaluating CBPR projects have been developed (Ahmed & Palermo, 2010), the process of conducting CBPR has subtle, potentially transformative effects which are often not captured in formal research reports. Calls for public health practices, including research practices, to better integrate understandings about power, agency, and social change suggest that increased reflexivity about both the process and outcomes of community engagement is warranted (Potvin, Gendron, Bilodeau, & Chabot, 2005). Reflexivity, in participatory approaches to research, means that the researchers (from both academia and the community) are engaged in a dialectical and recursive investigation: “a deliberate social process designed to help them learn more about (and theorize) their practices, their knowledge of their practices, the social structures that shape and constrain their practices, and the social media in which their practices are expressed” (Kemmis & McTaggart, 2000, p. 598). Researchers working in a reflexive tradition acknowledge that they are part of and affect the research (Hammersley & Atkinson, 1990).

This article draws on documentation and interviews with academic and community partners in a CBPR study to describe “secondary outcomes” of the project. Such outcomes are relevant to the health of communities, in addition to the formal scientific measurements most studies involve. We conclude by considering ways to appraise such observational “secondary outcomes” in future CBPR projects.

Background: The PHAT Project

Protecting the ’Hood Against Tobacco (PHAT) was a 4-year research project aimed at addressing tobacco use within a low-income neighborhood of San Francisco, the Bayview Hunters Point community (Froelicher, Doolan, Yerger, McGruder, & Malone, 2010; Malone et al., 2006; Yerger, Wertz, McGruder, Froelicher, & Malone, 2008). The effort focused on African Americans, because previous community surveys found they had significantly higher smoking rates compared with other groups (Grumbach, Mann, Pierce, & Wortis, 2001; San Francisco Department of Public Health, 2000). Based on previous work, which suggested that smokers were motivated to consider quitting when tobacco was presented as a social justice issue, including exposing them to evidence of tobacco industry targeting (Yerger, Daniel, & Malone, 2005; Yerger, Przewoznik, & Malone, 2007), we eventually designed and tested (using a randomized clinical trial design) a cessation program tailored for African Americans, findings from which are reported elsewhere (Froelicher et al., 2010).

Community members were involved in all project stages, including conception and design. Receiving ongoing training in basic research design and methods, tobacco industry targeting activity, and media advocacy, individuals identified through previous community focus groups became “community research partners” (CRPs), paid stipends for their work. Together, we conducted outreach to community groups and hosted a town hall meeting to assess community concerns about tobacco.

The initial research project conceived by CRPs, a systematic assessment of the prevalence of illegal sales of “loosie” single cigarettes in neighborhood stores, was refused approval by our university institutional review board (Malone et al., 2006). Subsequently, the lack of cessation programs in the neighborhood was prioritized as the community’s most important tobacco-related concern.

As a scientific project, PHAT developed and tested a smoking cessation intervention for African Americans (Froelicher et al., 2010; Robinson, Sutton, James, & Orleans, 2003). Recruitment was challenging; although we recruited aggressively, we were unable to enroll sufficient subjects to achieve statistical power (Froelicher et al., 2010).

Was the PHAT project, then, a failure? Despite our inability to determine statistically whether our intervention worked better than the standard approach, both academic and community partners felt that the project had accomplished much. Because our design included simultaneous collection of process data, we were able to analyze these data to better describe and understand secondary outcomes. This article describes these “reflexive results” and their relevance for future CBPR projects.

Method

This reflexive analysis draws on quasi-ethnographic project documentation collected during the project period and postproject interviews with the PHAT project research team. We use the term quasi-ethnographic to describe our informal observational and documentary records related to the process of conducting the project, distinguishing it from ethnographic research as method, which typically involves more long-term data gathering and more formalized data coding (Hammersley & Atkinson, 1990). Documentation included field notes taken during the project, meeting minutes, progress reports, retrospective reflections written by community participants, and other written project-generated materials.

We also conducted audiotaped, semistructured interviews with all academic and community researchers (n = 13) working on the project. These focused on eliciting narratives about their role and participation in the project, meaningful experiences, lessons learned, and how participation in the project affected them. See interview guide in the appendix.

Using an interpretive approach (Chan, Brykczynski, Malone, & Benner, 2010; Taylor, 1988), all interview transcripts and documentary materials were reviewed by the first author to identify patterns and themes in the data and to consider distinctions in how team members perceived the project’s contributions, lessons, and difficulties from within their respective roles. Examples of narratives exemplifying the identified themes were incorporated into summary texts that were reviewed by the other authors and sent to CRPs for consensual validation, review and comments, which were then incorporated into revisions.

Results

Being Part of Something

For community partners, one especially valued aspect was their sense of being part of helping others in their own community. At the time they volunteered for the project, several community partners were unemployed or underemployed, and most had little experience with public speaking. Some expressed concerns about previous researchers viewed as exploiting or “pimping” the community. The project’s capacity-building workshops, in which they learned and practiced skills such as preparing and delivering presentations, and teamed outreach sessions where they first assisted with and then initiated and delivered talks encouraging community participation in the project, built confidence in their own abilities to make a difference and in the academic partners’ commitment to working with them.

One community member observed,

It was a very rewarding and good experience. As far as the team of people working on the program, they were very enthusiastic—and the people that I was meeting along the way. . . . I was also passing out flyers, and met a lot of people. That was interesting, [that] being involved would help them out. . . . the fact that it was helping people. (CRP3)

Marginalized communities are too often regarded as places of pathology and need, contributing to a sense of helplessness among community members, which had been documented in a previous study within the same community (Grumbach et al., 2001). Seeing themselves as helpers whose participation had real consequences in peoples’ lives provided community partners incentive to continue this role. For example, one CRP working on outreach and recruitment for the smoking cessation program trial noted,

What I liked was I was trying to give out information that would help people with their addiction. . . . I saw a husband and wife at [the clinic where the program was offered]. . . . I didn’t even know they were smokers. I knew the wife because she worked at a local store. I saw her and her husband there together. . . . Maybe I put a flyer up that someone saw that drew them to [the clinic] . . . I hadn’t made that connection. I just knew I was putting information out. . . . I just happened to be at [the clinic] and I saw [them]. I said, “oh, this is good. This is good.” (CRP7)

Community partners engaged with the world of academic research in new ways. The community co–principal investigator (co-PI) observed,

I liked seeing the “inside” of the academic community. I never really thought about . . . all of the parts that must work together to get something out the door. This also proved very frustrating . . . all of the hoops that had to be jumped through to deal with the changes that come with any project.

An example of these challenges was the requirement to obtain institutional review board approval for protocol changes, which caused delays as the protocol was repeatedly adjusted.

Ongoing engagement with the community was humbling for academic partners. As many project meetings took place at a community library, academic partners experienced firsthand the constant concerns about violence and other neighborhood issues that shaped many study participants’ lives, promoting reflection on priorities. An academic co-investigator observed,

There are textbooks written on behavioral interventions, and yet when you deal with people who face so many social issues it really begs the question of how can you make a difference . . . A lot of the finest stuff in books isn’t working. And it isn’t working because there’s a bold underlying fabric that needs to be fixed. . . . And yet the expertise among the [academic] group was around smoking…so that makes me feel: was that [focusing on smoking cessation] the right choice? Did we ask the right questions when we came into the community?

These reflections, and the relationships formed as the academic partners also became “part of something” within the community, reshaped how these academics viewed research itself and evoked respect and humility.

Motivation to Change Health Behaviors

This notion of being part of something important was a catalyst for community partners to change their own health practices. Several partners who had been smokers at the beginning of the study decided to quit after working to design the project during its first year. One later said,

It’s been a couple of years now since I quit smoking, and I don’t even think about smoking. But when I first quit, when I did think about a cigarette, I would think—I wouldn’t just be letting myself down if I picked up a cigarette and started smoking it. I would be letting a lot of other folks down; my family and people that I work with. Not just myself . . . My life is different now since I’m working on [the PHAT project]. I’m willing to give it more of myself, and use it to empower myself and others and my children . . . and help others see what I’m seeing . . . smoking’s not only affecting you, it affects everybody around you. (CRP1)

Another observed,

I was able to quit smoking . . . and today I still remain smokefree . . . if I’ve gotten anything out of the project, that was one thing I could say I’m most proud of the project as well as myself . . . The project in itself made me have the ability to help others. [re: staying smokefree] I didn’t want to let the project down as well as let myself down. (CRP5)

It is notable that these CRPs were not enrollees in the PHAT cessation study; they were involved with design and recruitment. As a group, they sought out a county-funded cessation program elsewhere in the city on their own after working with the project for about a year. Their emphasis on how sustaining cessation was linked with their involvement in the project suggests that individual-level cessation may be enhanced by social engagement in community norm change around tobacco.

One CRP who had quit positioned this change in a larger context that included extending his social networks:

Looking at my life today, it’s not all the way I would like for it to be, but I’m moving along pretty well in this new lifestyle that I’m in, without my cigarettes. . . . My brains are a little clearer . . . my thoughts, and that’s important. I feel healthier. I have more confidence in myself. [INT: and that’s a result of working on the PHAT project?] Yes. [INT: How does the PHAT project contribute to your thoughts being clearer?] Because of the different walks of people in life. There were different groups of people that came into the PHAT project. (CRP2)

This discussion seems to suggest that the very nature of the research partnership—working with “different walks of people” from academia and community—opened up new possibilities for this participant, shaping his sense of agency and power as a change agent.

The community co-PI said,

More than anything [I valued] the impact that the project has had on some of our CRPs, of seeing them grow and take off. Knowing that they will always be a force for positive change in their communities. It is amazing to see that transformation and how it has carried over into other areas of their lives and general health.

The project director pointed out in an interview that even among other community members not enrolled in the smoking cessation study, some were affected by its presence. Discussing a man who filled out an initial baseline questionnaire but then never followed up, she said,

I remember this one individual . . . At some point he just stopped calling and he was not returning calls and then the next thing you know, you haven’t had any contact with them for awhile. And a good year later, I had a chance to meet this individual in person because I had never met him, I’d only spoken to him on the phone . . . And he came up to me, and he knew who I was, and he was excited and wanted me to know that he had quit smoking. And that meant a lot . . . I got so excited and happy . . . he went out of his way to come to the center . . . and he was there waiting [to speak to me]. So that was inspiring for me.

That this man made an effort to “report back” on his progress despite not participating in the program is an example of the “ripple effects” of CBPR in a community, many of which might never be known from outcome measurements.

Extending Health Awareness

A community facilitator, reflecting on the project, noted that as a result of participation, she now placed more emphasis on tobacco in her other work: “I think I really look at tobacco a lot more, bringing it in. I’m doing health education classes, and I really bring that in as a priority.” She also had begun to think creatively about other approaches: “I’m kind of interested in tobacco legislation. . . . I really want to write a grant around stop smoking, men only. I’m going to start in the barbershop.”

CRPs also reported that the program attuned them to neighborhood cues to smoke such as advertising. One noted, “I’m more observant to what the tobacco industry is doing, their labeling, their advertisements. When I walk into a store to buy some milk or some cereal, I’m paying attention to the way the signs light up” (CRP3). This awareness, in turn, led to independent advocacy efforts:

And I do approach some people that I know that own businesses . . . I can’t tell a person what to do and not do. All I can tell them is what they’re doing, and they may not be aware of it, as far as placing a [tobacco advertising] sign so low for a child to read outside of a liquor store, when it should be more at a level for an adult. . . . I’ve had many people move their advertisements with no problem at all, and no argument. (CRP3)

Engagement with the project, for this community partner, extended to individual activism that had no direct relationship with the cessation program being tested. Yet it is evidence that the research partner’s understanding about tobacco’s effects now extended to awareness of the role of larger social organizations like retailers and advertisers in promoting and sustaining tobacco use.

Other CRPs reported that they now were more assertive about asking people not to smoke around them. “I think I know more about the effects of what happens when people smoke, so I always have something to say. [laughs] I do . . . I speak out. If I see people smoking, I’ll say something” (CRP4). This willingness to speak up contributes to educating the community that smoking is no longer accepted as the norm.

Another reported changing home smoking policies:

I have children, and it helped me encourage them not to be smokers . . . My Mom smokes. My husband smokes. It helped me to push them to the outside versus being enclosed [with] smoking because of the secondhand smoke. . . . What I do better now is encourage people as I see them smoking, not to smoke. (CRP6)

They also reported that they continued to voluntarily counsel smokers about their options even after the program ended. Another CRP said,

Sometimes I ask them, “Hey, do you have health insurance? You can get the nicotine patch. You can get Nicoderm gum. There are other ways to relieve your stress.” I’m more bold in approaching people now. Somehow we just have to try to reach more people. (CRP7)

Bridging Communities and Addressing Power Dynamics

Among CBPR’s potential strengths is the way it calls on researchers to respect the knowledge of community members (Bastida, Tseng, McKeever, & Jack, 2010). A spirit of openness to learning together is required for bridging the worlds of academia and marginalized communities, and the clear power asymmetries call for adjustments that are not always comfortable, especially for academics. The PHAT project’s funder required two co-PIs: one from academia and one from the community. The co-PIs were to share overall project responsibility. The academic co-PI, a White woman accustomed to being “in charge” of “her” projects, initially tended to make decisions without consulting the community co-PI. The African American community co-PI (an experienced tobacco control advocate and community health educator) and the Project Director (an African American researcher residing in a similar community who had a long-standing and collegial working relationship with the academic co-PI) both challenged this practice, provoking the academic co-PI to consider how the power asymmetries were shaping team relationships. Subsequently, the two co-PIs worked out a better division of labor, consulting regularly with one another.

Of this process, from which a more equitable, explicitly shared power arrangement emerged, the academic co-PI noted,

There are going to be things you’re not even conscious of and much as you try, you’re going forth with your taken for granted expectations . . . we’re trying to feel our way. Keeping those lines of communication open is what we’ve learned is the most important.

The community co-PI agreed, “Once we got some of the (human personality) bumps worked out, [I valued] the genuine respect for different viewpoints, experiences, and opinions. Real debate, discussions about finding the best solution or strategy for whatever issues came up.”

As the project proceeded, the obstacles encountered helped build group problem-solving skills and further enhanced community members’ power in the relationship as they became more willing to express their perspective, on both community issues and research issues. The project director commented, “It’s gone from people having particular roles and responsibilities to all of us having—like it’s a co-op.”

At one point, a CRP was not fulfilling project obligations. The academic co-PI felt uncomfortable confronting this and worried about appearing insensitive. The community co-PI helped her work through these feelings and in the end the individual was asked to leave the project:

That was a difficult time in terms of working through how best to handle that situation… I learned a lot from my community co-PI in setting boundaries and limits and saying, you know, this really isn’t okay. And we need to do what is best for the project.

For academic participants, another “Aha” came in reflecting on specific procedural issues such as the use of nicotine replacement therapy (NRT) during the program. The academic co-PI noted,

We had all this discussion about NRT and how we were going to distribute it, and a lot of discussion of not wanting to give it to people unless we were sure they were serious because of our limited budget. But I saw later, reading the interviews [with trial participants] that we really were doing a sort of controlling that was not very beneficial to our participants, in terms of letting them have control of their cessation experience . . . realizing the embedded ways in which we were still assuming controlling roles even on a project that really was so committed to a more egalitarian approach.

Limitations

Documentation and interviews collected for the PHAT project, although systematic, were open-ended to capture broadly the project’s process. We may have missed important outcomes because we did not ask specific questions about them. Our findings are not statistically generalizable and we cannot make clear causal claims. Some of the outcomes might have occurred without the PHAT project. Researchers may have been subject to social desirability bias when interviewed. However, all reflexive research is subject to similar limitations.

Discussion

CBPR has transformative potential for all parties. Few CBPR studies (Christopher, Watts, McCormick, & Young, 2008), however, have explicitly reported on their non–research-specific outcomes, although the importance of participation itself is recognized (N. B. Wallerstein & Duran, 2006). Our experience suggests that authentic engagement in CBPR has benefits for all parties that can endure beyond the project funding period (Table 1). Such projects can have “ripple effects” within communities and academia that are challenging to document and measure but should be considered.

Table 1

Outcomes of the Protecting the ’Hood Against Tobacco (PHAT) Project

Community Partners	Academic Partners
Increased knowledge, skills, confidence	Increased knowledge, skills, confidence
Improved health behaviors, willingness to speak out in social situations	Increased sensitization to community context and effects on health behaviors
Increased interest in advocacy for health policies/practices	Increased engagement in educating funders and institutions about community-based participatory research (CBPR)
Wider social networks	Wider social networks
Increased awareness of constraints of formal research process	Increased consciousness of power asymmetries and increased power sharing

On the community side, CRPs’ lives were changed by learning transferable work skills and gaining confidence in their ability to make a difference in others’ lives. They increased health promoting behaviors, stopped smoking, gained confidence, and went back to school or obtained better jobs. These community members remain as a foundation for social norm change that would be unlikely to happen with a traditional academic research process.

Academic members of the project are now personally invested in the CBPR process and better understand its strengths and challenges. They have sought to help academic institutions and funders move beyond well-intentioned but not fully realized efforts to encourage inclusivity and community collaboration by instituting the necessary policy, funding, and attitudinal changes that foster this unique research approach. Several years after the project ended, the academic and community co-PIs continue a collegial relationship.

For those seeking to advance social justice through research, it is tempting to romanticize CBPR. However, enormous obstacles still make this type of research extraordinarily difficult to do well. Among these is funding. This project was funded by an innovative state research program mechanism, but the funding was entirely inadequate. For busy academics, traveling to other locations for meetings is also a barrier, but it is essential for building partnerships. Deeply embedded perspectives about race, class, control, and boundaries may be uncovered, creating additional challenges. Cultural humility is required (Tervalon & Murray-García, 1998).

The difficulties of the clinical trial itself, described elsewhere (Froelicher et al., 2010), are common to many such studies: difficulty recruiting and retaining contact with sufficient participants, protocol modifications, and other similar issues. It was not our purpose in this analysis to explore how such pitfalls could be avoided in similar future research. However, some of our findings may help researchers anticipate, for example, the frustrations “action-oriented” community members may feel with the constraints of the academic research enterprise; the discomforts that authentic power sharing with community members may create for academics; and most of all, the need to consider in advance and try to capture “secondary outcomes” of CBPR.

Based on our reflexive findings, several elements appeared to enhance positive secondary outcomes such as increased community engagement, health awareness, and motivation to change health behaviors. These included the project’s regular meetings in the community and emphasis on nonhierarchical communication in those meetings, encouraging community members to recognize and use their own special expertise, which in turn increased their confidence. We also provided regular opportunities for group celebration, such as annual project dinners and birthday cards, provided awards for community partners, and participated together in recruitment activities at outside events such as health fairs. These types of activities, which could be subsumed as team building, helped the group develop an identity that went beyond the technical aspects of the research work.

However, the design of the cessation program itself may have also contributed. We sought to emphasize the tobacco industry’s targeting of the black community and the community’s ability to fight back in development of the intervention. Community partners who were involved in developing this work, including reviewing internal tobacco company documents and websites and selecting materials to use in the intervention, increased their understanding of tobacco as an issue that extended beyond individual behavior choices, and began to act on that understanding. This suggests that other CBPR programs may benefit from including an “upstream” emphasis even in intervention studies measuring individual-level outcomes.

Despite its challenges, CBPR offers much for both communities and researchers beyond the findings of the research itself. Developing better ways to systematically capture some of these effects, perhaps through more extensive use of reflexive approaches and ethnographic methods, can enhance understanding of CBPR’s more subtle contributions to healthy communities, even in cases where the “research” does not achieve scientifically generalizable results.

Footnotes

Appendix

Authors’ Note:

We thank Olivia Boudreaux-Harris, Ernestine Daniel, Marian Fields, Marion Fisher, Vera Harrell, Anthony Holmes, Edna James, Walter Johnson, LaShawnda Thomas, Marcia Wertz, Pamela Jones, and Catherine Waters for their contributions to the project.

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