Interest in community-based participatory research (CBPR) continues to grow in public health across diverse populations and settings, and over the past two decades, the field has gained a great deal of experience in understanding what makes for successful CBPR. In spite of its increasing application, however, there is still much to be learned in terms of systematic evaluation in CBPR, how it is that CBPR partnerships adapt principles and practices to local context, and the nature of the specific adaptations they make. This dissertation looks at the state of the field in terms of recommended principles and practices of CBPR and then centers on the experience of the San Francisco Chinatown Restaurant Worker Health and Safety Project, a CBPR partnership focused on studying and addressing working conditions for Chinese immigrant restaurant workers.

First, an examination of the major CBPR review literature finds that the existing guidance on recommended CBPR principles and practices is large in volume and generally in agreement. But it also finds inconsistent use of terminology and typology with regard to CBPR characteristics and an overall lack of specificity associated with how the concepts should be applied in evaluation, particularly for partnership goal-setting and prioritization.

Second, using a recently developed CBPR process-to-outcomes model as a reporting framework, the dissertation details the salient contextual, group dynamics, intervention and research, and outcome factors emerging from the Chinatown partnership evaluation. Contexts of interest include the broader social and immigration environment of the community, historical trust and mistrust, and university and community capacity. In terms of group dynamics factors, partnership diversity and complexity, resource availability, and roles of individuals were important in shaping partnership dynamics, with formal partnership agreements playing less of a role. “Process outcomes” of dialogue, mutual learning, and communication; power dynamics; decision-making; leadership; trust; and perceptions of CBPR authenticity were in turn all affected and structured by the contexts. Research dynamics and capacity change outcomes were generally perceived positively, particularly with regard to the leadership development of restaurant worker partners.

Finally, the dissertation draws on evaluation data to focus on the CBPR principle of “equitable participation, ” particularly for Chinese immigrant worker partners on the project. The research finds that the social context and political or participatory “starting points” of the immigrant community, social justice values and drivers of the community-based organization partner, linguistic and cultural diversity within the partnership, and constrained resources led to specific adaptations in the structure and processes of the collaboration. Partner reflections on the outcomes of the adaptations are discussed.

Implications for this research suggest that further elucidation of the concepts and functions of CBPR principles and practices will advance the field's ability to effectively evaluate CBPR efforts and further understanding of CBPR “authenticity.” Future evaluation efforts may find use of a model of CBPR process to outcomes helpful in systematically designing and reporting on evaluations. Attention to contextual variables of particular communities and partnerships can contribute to understanding how adaptations unfold in CBPR efforts, what the adaptations actually entail, and to what extent they are consistent with CBPR principles and practices.

New Media include a wide range of programs, Internet access tools, and wireless computer-mediated communication devices, which facilitate reciprocal interaction with the media consumer. Integrating traditional media with dynamic communication tools and interactive user feedback, New Media allows for user participation and community formation. Public health leaders, as they actively seek innovative and cost effective health solutions to positively impact individual and community level health, are starting to look towards New Media as a viable option for communication and interaction with the populations they wish to serve.

Using data from the field of youth sexual health promotion and HIV/STI prevention, my dissertation aimed to unearth the potential application of New Media in public health by: conducting an overview of relevant literature, constructing a new social ecological model that incorporates New Media, and developing an evaluation plan for a New Media-based sexual health intervention.

The first project, the literature review, explored studies and statistics on New Media, and paid particular attention to the potential use of Social Media in youth retention, data collection, information dissemination, and participant privacy and confidentiality. The literature review illuminated what is known about the application of New Media in public health practice and identified that which has yet to be explored. The second project, developing a new social ecological model, examined the various models currently in use and their value in providing a framework to contextualize the individual and his or her environment. An archival case study and interview data were used as exemplars to construct a new social ecological model. This model takes the dynamic nature and utility of New Media into full consideration and unearths the emergence of a second social ecology, the "Virtual."

Research and evaluation of public health programs and interventions is key to verifying efficacy and defining applicability. Evaluating health interventions is intrinsically tied to program success and successful outcomes. The third project therefore outlined an evaluation plan for a New Media-based sexual health intervention, InSPOT (an Internet-based sexual partner notification tool for those recently diagnosed with an STI). The evaluation plan was not only developed to evaluate the intervention tool's potential for promoting youth sexual health, but to also act as an example of the level of evaluation necessary to address questions of efficacy. Implications of these projects suggest that: 1) New Media can provide viable and potentially cost effective means of health intervention; 2) there is a New Media-based social ecology which the current public health social ecological model needs to fully take into consideration; and 3) further research and evaluation of New Media-based programs and interventions is imperative if we are to verify its potential applicability in public health practice.

Background

Maternal and newborn mortality remain a pervasive problem in Sub-Saharan Africa and Asia; annually, as many as 300,000 maternal deaths occur worldwide from complications of pregnancy and childbirth. One million newborns do not survive their first day of life. Interventions to reduce facility-based maternal and newborn mortality often assume the presence of continuous light and electricity. In 2018, a detailed review of 128,000 health facilities in 78 low and middle income countries showed 59% lacked reliable electricity. This dissertation analyzes in-depth interviews of frontline health workers in 11 countries to examine the impact of unreliable electricity on emergency obstetric and neonatal services. It recounts the design and dissemination of a scalable solar electric intervention, called the Solar Suitcase, and examines its impact on maternal-newborn care.

Methods

The Solar Suitcase intervention was developed as a result of formative ethnographic research in 2008 by the author at a state hospital in Nigeria. The author described grim conditions in the hospital and her emerging conclusion that the lack of continuous electricity impaired the execution of life saving emergency obstetric and newborn care. She describes how she partnered with others provide solar power to one hospital, and later, how a compact rugged solar electric system tailored for maternal health care sparked an organization, We Care Solar that is dedicated to healthcare electrification in under-resourced health systems, as well as a movement to eradicate energy poverty in maternal healthcare.

The research studies within this dissertation utilize an existing database of in-depth interviews obtained by We Care Solar and partner organizations in 11 sub-Saharan African and Asian countries over the course of 10 years (2010 – 2019). A total of 1,213 semi-structured interviews were conducted with health workers in energy-deficient facilities before and 3–18 months after a solar electricity intervention. Interviews focused on current and/or past experiences conducting maternal-newborn health services in energy-deficient facilities. Topics included electricity reliability, alternative lighting sources, routine and emergency care, referral patterns, financial burdens, health worker morale, and patient-provider relations. Responses were documented in written or audio formats, translated when necessary, transcribed, and coded using Atlas.ti. Analyses followed the principles of Grounded Theory.

Results

Health workers in energy-deficient facilities reported their dependence on suboptimal light alternatives including kerosene lanterns, candles, torchlights, and cell phone lights, prohibiting efficient and effective care. They recounted difficulties in routine activities (reading medicine records, writing notes, locating equipment, maintaining hygiene), and performing standard Emergency Obstetric and Newborn Care signal functions (treatment of hemorrhage, eclampsia, obstructed labor, sepsis, and newborn resuscitation). The lack of visibility reportedly affected patient health-seeking behavior and referral patterns. Health workers described personal frustration, fear, and lack of confidence working without reliable electricity.

By contrast, health workers in facilities equipped with essential electricity and continuous medical lighting 3-18 months before their interviews reported a greater sense of confidence and efficiency, less fear of night time care, and a better ability to make decisions. With an improved working environment, health workers further described the provision of more timely procedures, enhanced management of obstetric emergencies and newborn care, improved sanitation and infection control, appropriate referrals, and improved mobile communication. Health workers perceived increased utilization of maternal services after the solar intervention, and cost savings for patients and health workers. 

Conclusion 

Maternal health providers in health centers lacking adequate and reliable electricity face significant challenges conducting routine and life-saving care. The conditions they describe indicate that health facility electricity, and in particular light, plays a critical role in the perceived quality of care, health worker experience, and patient health-seeking behavior. Health workers provided with access to reliable light and electricity via a compact, rugged solar electric system, report greater confidence and ability to conduct routine and emergency obstetric procedures.  Access to reliable lighting and basic electricity are a necessary, but not sufficient, component of quality maternal and newborn care. Energy access programs must be included in any comprehensive approach to improving quality of care and should complement other interventions designed to improve maternal and child health.

The Role of Women and Youth in Policy-Focused Community-Based Participatory Research: A Multi-Case Study Analysis

By

Analilia Patino Garcia

Doctor of Public Health

University of California, Berkeley

Professor Meredith Minkler, Chair

Communities that are marginalized by unequal distribution of resources and power are at an increased risk of suffering an undue burden of illness and premature death. Staggering health disparities persist throughout the United States, a collective result of a lack of affordable, accessible and culturally relevant health care services, missed opportunities for preventive services, and public health interventions grounded in approaches that focus too narrowly on individual behavior change. Such approaches cease to capture the complexities of local social, economic and political environments, which contribute to the myriad of inequalities that unjustly perpetuate disenfranchised communities. The active engagement of low-income individuals and communities of color who are disproportionately affected by health inequities can serve as a powerful tool to advocate for policies that can contribute to reversing health disparities. Increasingly, Community-Based Participatory Research (CBPR), as an orientation to research, has garnered attention and respect from academics and community-based organizations alike, as an approach that equitably engages community residents as part of the research process-- making it accessible and relevant--with a focus on action-oriented solutions to community identified problems of greatest importance.

This dissertation aims to illustrate the role of promotoras (lay health workers) and youth involvement in research and their subsequent contributions to policy change outcomes. Through a retrospective case study analysis of three CBPR partnerships in California, I describe their individual and collective contributions to the research process, and in leveraging research results to advocate for and bring about policy change. The first case is a partnership in Los Angeles' Skid Row with youth living in Single Occupancy Rooms (SROs), who were galvanized to action by violence in their community, discrimination they face at school, and their lack of access to the only park in their neighborhood. Their actions led to national media attention, which resulted in school district policy changes, and increased, albeit still limited, access to their local park. The second case involved youth in a Bakersfield community that worked collaboratively with adults from various city agencies and community organizations to achieve environmental changes that led to the creation of safe open spaces for families. The final case focused on a partnership in Old Town National City involving a group of women who were transformed into powerful advocates in the pursuit of environmental justice. Through culturally and linguistically appropriate trainings, the promotoras (lay health workers) who were also residents of National City, made significant contribution to the research process, that in turn contributed to subsequent policy wins.

The various participatory methods employed by each of the three partnerships explored facilitated participation and empowered participants to have an active voice through numerous community engagement activities. CBPR is well positioned to effectively mobilize residents, including, in the case for this dissertation, women and youth, and to build capacity within communities that will outlast any funded intervention.

Collectively, the three CBPR case studies offer exciting, innovative possibilities in the engagement of promotoras and youth as equitable partners in the research process. At the same time, the cases offer lessons learned and important implications for research, practice and policy. The voices of the women and youth involved in the partnerships are captured throughout the dissertation, a unique gift to this dissertation, on the insider perspectives they bring as they share their experiences, leadership development, and individual level outcomes as a result of their participation.