From the core assumptions outlined above, those most relevant to the relationships maintained by professional and community participants in CBPR are as follows:

Building on strengths and resources. Whereas conventional approaches in health care begin with a deficit-based “needs assessment” so as to inform what reparative professional knowledge or resources to bring into a community from the outside, CBPR partnerships emphasize the identification and advancement of local wisdom, strengths, and energies to solve problems. This then sets the foundation for the equal valuing of professional and lay contributions to the work (Mendenhall & Doherty, 2005a; Reason & Bradbury, 2001, 2006, 2008).

Democratic and equitable partnership. In contrast to conventional top-down, provider-led care, research and public health initiatives, CBPR projects are advanced with a flattened professional hierarchy that honors the unique wisdom and expertise of everyone involved. While health care professionals and academic researchers bring with them a knowledge- and skill-set regarding a chronic illness or investigatory design, for example, patients bring with them a knowledge base regarding what it is like to live with a chronic illness. Patients’ family members bring with them wisdom about how to be supportive without being a nag, best strategies for affording indicated foods and medicines, and/or self-care so as to not burn out in the role of an involved caregiver and loved one. Community leaders bring with them knowledge and understanding about the local “pulse” and impact(s) that an illness or health-related issue is having on their people (however defined). By recognizing and honoring all project members’ respective contributions to a larger whole, patients, community stakeholders, health care providers, and academic researchers are able to collaborate through every stage of knowledge and intervention development—from early steps in trust-building and defining what is most important to focus on to later steps of project evaluation and establishing long-term sustainability (Christopher, Watts, McCormick, & Young, 2008; Horowitz, Robinson, & Seifer, 2009; Israel, 2005; Wallerstein & Duran, 2010).

Co-learning and capacity building. By focusing on each other’s unique strengths and wisdom and working collaboratively together, professionals and lay community members learn from each other. For example, as patients and families learn about important disease-management sequences and information from providers (e.g., the components of a good diet, indicated amounts of exercise), they are also learning from other patients and families about where to find the most affordable foods or participate in physical activities safely. As providers learn from patients about local value-systems regarding food and health, they are able to advance more sensitive and culturally tailored care, suggestions, and dialogue (Bradbury & Reason, 2003; Doherty et al., 2010; Mendenhall et al., 2010; Minkler & Wallerstein, 2008).

Humility and flexibility. As with any healthy relationship, project members in CBPR maintain a consistent humility regarding the extent of their knowledge, and along with this, a receptivity to others’ knowledge. They are responsive to new information that suggests change is necessary across individual (e.g., a patient learning that s/he must alter a dietary or health-related routine) and project/community (e.g., modifying an intervention component in response to evaluation data that show it is or is not working). This can be especially difficult for professional members of the team, as much of their training in medical or graduate school socialized them to function as infallible experts (Hayes, 1996; Mendenhall, 2002; Mendenhall & Doherty, 2003; Minkler, 2000; Minkler & Wallerstein, 2008).

Long-term engagement and commitment to the work. CBPR projects can be very slow and messy to advance, especially during early phases of development, as providers/researchers and patients/families/community members learn to work together in a very different way than they may be accustomed to and/or until a new initiative is firmly grounded in a professional or community organization. Our experience across several projects suggests that one to two years is a reasonable amount of time to expect between first meetings and the launching of action steps and new interventions. It is important that participants understand this from the outset, and that they are invested in the long haul (Doherty et al., 2010; Jones & Wells, 2007; Wallerstein & Duran, 2006; Wallerstein & Duran, 2010).

An essential element throughout CBPR relates to the clarity of its “R,” (e.g., advancing a clear effort in the arenas that project members and others on the outside would call “research”). Because participants (providers, administrators, researchers, patients, families, etc.) are often dealing with novel problems within the unique contexts of local communities, they must be methodologically flexible and eclectic in order to best match data collection efforts with what is going on in the CBPR process (McNicoll, 1999; Mendenhall & Doherty, 2005b). In order to be sensitive to the perspectives and needs of multiple participants, careful use of methods and measures that have high face validity and practical (and immediate) utility are indicated. For this reason, CBPR researchers often gravitate toward qualitative methods of data collection and analysis during early phases of the work. Exploring, for example, participants’ subjective experiences can engage communities in identifying concerns that run deep within them, monitor inter-member and inter-group processes as problems are identified, solutions are democratically and collaboratively developed, and/or as action is taken, and assessing satisfaction with the results of new interventions. While objective (read: quantitative) measures of “success” can be created to assess a program’s impact on a particular dependent variable (e.g., metabolic control in a local ethnic community), most CBPR studies do not do this until after a project is comparatively underway.

To this end, a myriad of qualitative data in CBPR have been described in the literature, including in-depth interviews (Lindsey & McGuinness, 1998; Mendenhall & Doherty, 2003; Mendenhall, Harper, Stephenson, & Haas, 2011; Razum, Gorgen, & Diesfeld, 1997); naturalistic case studies (Casswell, 2000); reflective journaling and meeting minutes (Hampshire, Blair, Crown, Avery, & Williams, 1999; Nichols, 1995); thematic and content analysis of group process notes and publicly available documents (Nichols, 1995; Razum et al., 1997); focus groups (Small, 1995); participant observation (Lindsey & McGuinness, 1998; Maxwell, 1993); social network mapping (Bradbury & Reason, 2003); and oral histories and open-ended stories (Small, 1995). Access to many of these types of data is generally easy for investigators in CBPR, because the very nature of the work requires that they be active participators in the research that is being evaluated (Mendenhall & Doherty, 2005b).

Whereas qualitative analyses are especially useful in helping researchers to understand participants’ contexts, cultures, beliefs, attitudes, community practices, and subjective experiences related to CBPR processes, quantitative measures are most usually and most usefully employed to evaluate an intervention’s efficacy (Mendenhall & Doherty, 2005b; Reese, Ahern, Nair, O’Faire, & Warren, 1999). These efforts are also important on “political” grounds, insofar as formally testing for objective change in tangible measures (whatever measures these may be) helps to advance regard by the broader scientific community that the work that is being conducted is rigorous and credible (Minkler & Wallerstein, 2008; National Institutes of Health, 2009).

Consistent with the basic tenets of CBPR, however, it is important to involve participants in selecting what to quantitatively evaluate, test, or measure. For example, in a CBPR initiative designed to reduce smoking on a school campus, participants (researchers and community members) discussed how students’ smoking prevalence was—and was not—an important measure of “success.” Indeed, student participants saw the number of available after-school activities (which were advanced by the project to target the very stress and boredom that students commonly attributed to smoking) was a more important quantitative measure of success. Put simply, students saw this initial step as a stage-setter for the improved subjective sense of self-efficacy and social support that will eventually help students to quit smoking (Mendenhall, Whipple, Harper, & Haas, 2008b; Mendenhall et al., 2011). In another project, providers involved in a diabetes CBPR initiative for adolescents saw metabolic control as the most important dependent variable of success, whereas adolescent patients’ wanted to track school-policies regarding whether students with diabetes were allowed to go on fieldtrips with their peers (Mendenhall & Doherty, 2007b). In these and other CBPR projects, what is tested quantitatively is up to the whole group to decide. It is important to note, too, that quantitative analyses of CBPR projects tend to remain “local”—e.g., for, by, and within the community in which a project is positioned (Mendenhall & Doherty, 2005b). Efforts to test widespread generalizability (e.g., a randomized control trial) are less indicated than efforts to test local effectiveness (e.g., a single-group repeated-measures trial) because CBPR projects are designed purposefully to tap and reflect the unique resources and challenges of their local contexts.

Ultimately, participants in CBPR tend to combine both qualitative and quantitative methods. Using multiple methods over the course of a project enables researchers to triangulate different sources of data, and this increases confidence in conclusions that are drawn (Hagey, 1997; Lindsey & McGuinness, 1998; McKibbin & Castle, 1996; Nichols, 1995). Throughout this and the cyclical processes of CBPR, all data that are collected and analyzed are presented back to the initiative’s participants (Hambridge, 2000; Mendenhall & Doherty, 2005b; Meyer, 2000; Nichols, 1995). This facilitates an active and purposeful dialogue between providers, researchers, and community participants about the meanings and usefulness of data, which then informs the generation of ensuing action steps en route to collaboratively identified and mutually shared goals.

Disseminating research findings is another important aspect of community-based participatory research. This allows for important findings to be distributed to academic researchers, providers, administrators, and the patients/families/communities that are involved in the work. Results communicate success of the project, changes brought about by its labors, and the ongoing efforts that researchers/families/community members are doing to sustain the initiative. CBPR teams, then, collaborate fully in writing and disseminating study findings to professional/scientific communities, community-specific organizations, and the general public. To share knowledge with the scientific community, they target refereed journals and local, national, and international conferences and forums. To share knowledge with community-­specific organizations, the local community itself, and the general public, team members connect with community service-providing sites and resources, e.g., targeting local and state-wide public print and electronic media and community events/celebrations (Berge et al., 2009; Minkler & Wallerstein, 2008).

More and more health care providers and researchers are engaging in CBPR projects and, with this, rigorous expert-driven investigatory methods aimed at widespread generalizability are losing ground to comparatively small but locally relevant and meaningful efforts that are co-created by patient and provider communities working collaboratively together. What was once broadly viewed by academic and research institutions as flimsy or unscientific is now establishing a niche in the world(s) of valued health care research and service-provision (Mendenhall & Doherty, 2005b; Minkler & Wallerstein, 2008). This evolution is advancing in synchrony with our increased emphases on patient/family-centered medical homes, wherein ­comprehensive approaches for children, youth, and adults are attended to within settings that facilitate partnerships between individuals/families and respective (and collaborating) members of multidisciplinary care teams (Minkler & Wallerstein; Peek, 2011; Wallerstein & Duran, 2010). Through CBPR methods, the patient/family community partnerships with providers are held up as an essential foundation to create care that is of high quality, culturally competent, strength based, and effective (Chavez, Duran, Baker, Avila & Wallerstein, 2003; Doherty et al., 2010; Tobin, 2000; Ward & Trigler, 2001). Over the last decade, projects driven by this approach have gained credibility through their ­ability to inform understanding of patients’ experiences, improve or generate services, facilitate community outreach and engagement, enhance education, and augment cultural awareness (Chavez et al., 2003; Tobin, 2000; Ward & Trigler, 2001). Projects have advanced improvements in asthma (Brugge, Rivera-Carrasco, Zotter, & Leung, 2010), diabetes (Mendenhall & Doherty, 2003, 2007a), dental and mouth-care practices (Watson, Horowitz, Garcia, & Canto, 2001), smoking cessation (Mendenhall et al., 2011), patient and practitioner satisfaction (e.g., through improved communication and problem-solving skills) (Hampshire et al., 1999; Lewis, Sallee, Trumbo, & Janousek, 2010; Lindsey & McGuinness, 1998; Meyer, 2000; Schulz et al., 2003), and a number of other significant health care foci (Doherty et al., 2012; Mendenhall & Doherty, 2005b).

From this foundation, efforts in CBPR are now underway to further advance the research agenda for collaborative care by extending our attention beyond disease-­specific arenas and narrowly defined clinical outcomes (like many CBPR and related research studies regarding collaborative care practices have done to-date) (AHRQ, 2011; Doherty et al., 2012; Fauth & Tremblay, 2011). Understanding(s) about the effects of specific strategies and care processes, levels of integration per se, and financial models of clinical outcomes are sorely needed, alongside regard for broader clinic and health system(s) level functioning (Miller, Kessler, Peek, & Kallenberg, 2010). In order to do this, we must first establish a common language and lexicon of terms and definitions to consistently guide researchers, systems (re)designers, experts in quality improvement and performance measurement, policymakers, and patients/citizens (Peek, 2010). This aligns well with CBPR’s emphasis on involving all stakeholders collectively and throughout the aforementioned iterative process(es) of research and intervention development and improvement (Mendenhall & Doherty, 2005b; Minkler & Wallerstein, 2008). Indeed, to do less would be to fall back on conventional provider-led, expert-driven methods of defining care parameters, and to leave behind the voices of the very people that our efforts are oriented to helping.

Following recommendations put forth by the Agency for Healthcare Research and Quality (AHRQ) and Miller, Kessler, Peek, and Kennenberg (AHRQ, 2011; Miller et al., 2010), we must then begin asking descriptive questions to create systematically articulated pictures of how collaborative practices are carried out, followed by evaluative questions that assess outcomes across clinical, operational, and financial foci. CBPR is, again, well equipped to answer these calls. By engaging all stakeholders in care processes, comprehensive descriptions of clinical practices can be gleaned (e.g., providers can describe who they see in their practices and in what care settings; administrators can describe processes by which patients are identified and how care is coordinated and paid for; patients and family members can describe their experiences in working with clinic providers and staff throughout care sequences). To evaluate outcomes connected to a practice’s care, engaged stakeholders’ voices will similarly inform what is discovered (e.g., providers and patients can describe clinical outcomes related to health; providers and administrators can describe health system processes related to clinic flow and interdisciplinary collaboration; administrators and patients can describe the financial costs related to care initiation and maintenance). Efforts to engage in collaborative efforts such as these (e.g., that involve all stakeholders versus researchers (only) or administrative personnel (only)) are now emerging, as leaders in the field are working to advance CBPR methods into larger health systems. See Fauth and Tremblay’s example, using “practice-based participatory research” (Fauth & Tremblay, 2011), in Box 1, above.

In addition to its increasing visibility in health-related foci, community-based participatory research has extended into the overlapping arenas of business, public policy, food-distribution practices, education, housing, and family time (Bogart & Uyeda, 2009; Bradbury-Huang, 2010; Jacobs, 2010; Kwok & Ku, 2011; Weaver-­Hightower, 2010). It is thereby challenging to single out single organizations in this movement, because to do so in one area is to neglect pioneering groups in other areas. Having prefaced the following with this caveat, examples of leading organizations in CBPR partnerships around health include the following.

Figure 6.2 presents a summary of key leadership and action strategies that we have learned for the initiation and conduct of CBPR (Doherty & Mendenhall, 2006; Doherty et al., 2010; Mendenhall et al., 2010). In the early phases of a project’s evolution, we have found that it is best to request little or no financial support from key professionals and/or administrative leaders because this helps to facilitate their buy-in while at the same time allowing the project to evolve sans external pressures in terms of time or outcomes/deliverables. This enables professionals and community members to extend considerable attention to “going deep” in identifying health-related issues that are of great concern to all involved. Before inviting a large group of community leaders to begin generating solutions and/or interventions, it is important for a small group of community members with personal experience (but not with institutional priorities or constraints) to establish consensus in its focus and desire to proceed. As the project’s membership is then thoughtfully expanded and its momentum increases, community and citizen dimensions of the issue are perused, which then informs the development and implementation of action initiatives. Throughout this journey, key processes and guiding principles of CBPR are advanced and maintained. Democratic planning and decision-making are carried out through each step of the work. Professionals and community members continue to learn from each other, and project results continue to inform intervention designs and revisions (if/as indicated). Attention is consistently paid to identifying and developing new leaders, who then carry forward the project’s efforts over time and en route to its larger mission(s) of effecting widespread and beneficent change.