- Email: [email protected]
Linking service-learning with community-based participatory research: An interprofessional course for health professional students
Available online at www.sciencedirect.com
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
www.nursingoutlook.org
Linking service-learning with community-based participatory research: An interprofessional course for health professional students Marianne T. Marcus, EdD, RN, FAANa,*, Wendell C. Taylor, PhD, MPHb, Mark D. Hormann, MDc, Thomas Walker, BAd, Deidra Carroll, BSa a
b
The University of Texas Health Science Center at Houston, School of Nursing, Houston, TX The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX c The University of Texas Health Science Center at Houston, School of Medicine, Houston, TX d St. Mary’s United Methodist Church, Houston, TX
article info
abstract
Article history: Received 25 June 2010 Revised 28 September 2010 Accepted 7 October 2010
Service-learning is a valued strategy for educating health professionals. Linking service-learning with community-based participatory research (CBPR) engages students with community stakeholders and faculty in a collaborative process to bring about social change and improved health. The purpose of this paper is to describe a strategy for involving interprofessional students in ongoing faculty CBPR in an underserved community. The process includes the design and implementation of a course that combines weekly seminars with field experiences in the targeted community, emphasizing community assessment, and working with community members to find solutions to health problems. Nursing, public health, and medical students were recruited to the initial course, and offered the opportunity to meet objectives of required components of their disciplinary curriculum. Community members became actively involved in educating students while working to solve identified health problems. Important principles of CBPRdtrust, collaboration, excellence in science, and ethicsd are emphasized throughout the initiative. This course is now a regular offering for interprofessional students, providing valuable learning experiences for students, faculty, and the community. Ongoing faculty CBPR continues a trusting community-academic relationship and gives the community a voice in the solution for health problems.
Keywords: Service-learning Interprofessional Community-based participatory research Health professional education
Cite this article: Marcus, M. T., Taylor, W. C., Hormann, M. D., Walker, T., & Carroll, D. (2011, FEBRUARY). Linking service-learning with community-based participatory research: An interprofessional course for health professional students. Nursing Outlook, 59(1), 47-54. doi:10.1016/j.outlook.2010.10.001.
Service-learning has become a major pedagogical movement across academic environments, from primary and secondary school levels,1 to higher
education2 and education for the health professions.3-7 Service-learning combines structured reciprocal experiences in response to community-identified needs
* Corresponding author: Marianne T. Marcus, Director, Center of Substance Abuse Education, Prevention, and Research, University of Texas Health Science Center at Houston, School of Nursing. 6901 Bertner Blvd., SON 649, Houston, TX 77030. E-mail address: [email protected] (M.T. Marcus). 0029-6554/$ e see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.outlook.2010.10.001
48
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
with academic education.8 Witchger-Hansen et al4 assert that there is a synergy between the need for students to practice in real-world settings and the moral obligation of academia to reduce social injustices. Grounded in constructionist theory and experiential education, service-learning links theory with practice and cognitive learning with affective learning.2,8 Although experiential learning is not new to health professional education, there is increased interest in expanding service-learning and community involvement for health professional students,9,10 particularly as a means to address health disparities within communities.11 Research continues to indicate that there is an inverse relationship between socioeconomic status and physical health.12-14 Health professional students should have opportunities to learn in neighborhoods where health disparities exist, where even brief experiences of such have been shown to positively influence students’ attitudes and beliefs about the impact of poverty on health.15 One potential strategy to accomplish this goal is to link service-learning with community-based participatory research (CBPR), an approach that is finding favor in health professional education.5,16-18 Community health problems are complex and their solutions must be evidence-based, so research should be an integral part of service-learning.8,19 CBPR is a collaborative approach that involves community stakeholders and researchers in an equitable process to bring about social change and improved health conditions.20,21 CBPR builds on a trusting relationship in which community members and organizations are equal partners with researchers in all phases of the research process.18 Because social issues are complex, the perspectives of multiple and varied disciplines enhance the CBPR process, making it an ideal service-learning endeavor for interprofessional faculty and students of the health disciplines.22 The purpose of this paper is to describe a process for involving students in ongoing faculty CBPR initiatives in an underserved community. A key element of the process was the design and implementation of an interprofessional course that engages faculty, students, and the community in a collaborative process to foster student education while addressing community health problems. The method adheres to the CBPR principles outlined by Savage et al23: trust based on communication; collaboration involving shared responsibility; excellence in science through training, fidelity monitoring, and strict adherence to protocol; and ethics or strict guidelines and agreement on handling of confidential information. The initial goals of the strategy were to: (1) offer a community-based interprofessional service-learning course for health professional students at the University of Texas Health Science Center at Houston (UTHSC-H); (2) integrate the course into ongoing faculty CBPR initiatives; and (3) sustain a collaborative relationship with members of a community to facilitate ongoing research to improve the health of the community.
Building Trust UTHSC-H faculty representing nursing, public health, and medicine established a research partnership with an African-American community in 1999 to conduct a CBPR study aimed at prevention of HIV/AIDS and substance abuse in adolescents in a faith-based setting. Faculty interests and expertise included substance use disorders, physical activity, and community pediatrics. The study, funded by the Substance Abuse Mental Health Services Administration, Center for Substance Abuse Prevention, involved the implementation and evaluation of a youth program that has remained a part of the outreach ministry of a large urban church.24-26 Academic team members continued to collaborate when the youth pastor of the urban church was appointed head pastor at St. Mary’s United Methodist Church, located in an underserved African-American neighborhood near UTHSC-H. Collaboration in the new church involved meetings with stakeholders to elicit their perceived health needs. An initial concern was the health of seniors of the church, so health promotion classes, conducted by students of the School of Nursing, were instituted with the overall goal of improving the health of seniors. The relationship in the new setting was strengthened through frequent meetings between the interprofessional academic team and community stakeholders. Community members expressed an interest in addressing a broader range of health needs. Because the church is strategically located between middle and elementary schools, church members have become increasingly concerned about the health of the school children. Thirty percent of the families live below the poverty line in a community where health problems such as obesity and substance use could be targeted for health promotion activities. Community members identified healthy eating, increased physical activity, and avoidance of risky behaviors related to substance use as critical concerns in this low-income community. In response to these concerns, the community-academic partnership expanded to include additional health professional faculty with expertise in nutrition, interprofessional students at UTHSC-H, and staff from the elementary and middle schools. Disciplines and research interests of the core academic team include nursing and substance use disorders, public health and physical activity, and medicine and community pediatrics. The collaboration is entitled Project SMART (St Mary’s Academic Research Team) to reflect the reciprocal exchange of knowledge between community stakeholders and research scientists, and to acknowledge the church as primary site for the initiative.
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
Collaboration Course A cornerstone of Project SMART is a collaborative, interprofessional service-learning course that provides a vehicle for involving health professional students, their faculty, and the community in CBPR. With grant support from the Association for Prevention Teaching and Research, faculty designed and implemented the course in 2007. Faculty of the core academic team met with the curriculum committees of their schools and posted information about the availability of the course. Students from the UTHSC School of Nursing could meet course requirements for the undergraduate community health clinical. UTHSC-H School of Public Health has a number of appropriate courses including one that explores social and behavioral aspects of physical activity. The School of Public Health also requires a three hour practicum for all Master of Public Health students that may be met through this course. The Liaison Committee on Medical Education (LCME), the body that accredits medical schools, adopted a new standard on service-learning in February of 2007. The new Standard IS-14-A, states that “medical schools should make available sufficient opportunities for medical students to participate in service-learning activities, and should encourage and support student participation.”27 UTHSC-H School of Medicine has a fourth-year elective that could be achieved through participation in Project SMART, and there is a place for this initiative in the third-year pediatrics rotation.
49
The initial student group was recruited from the Schools of Nursing, Public Health, and Medicine and offered an opportunity to participate in faculty CBPR while receiving academic credit consistent with the curriculum of their discipline as recommended by Seifer.28 Table 1 indicates the overlapping course objectives between the undergraduate nursing community clinical and the graduate public health practicum. The singlesemester course is a structured experience in which students perform comprehensive assessments of the health needs of the community, prioritize those needs, suggest solutions, and discuss the feasibility of implementing various approaches with community members. The course includes time spent in weekly seminars, field experiences, research, and documentation. Students are asked to keep reflective journals to frame discussions about the experience and its meaning and value to their future professional practice. Although the course is taught collaboratively by the interprofessional team and community members, students are supervised by the faculty member of their discipline and school. The first group of students consisted of six undergraduate nursing students, two public health graduate students, and one undergraduate medical student. Baccalaureate nursing students met objectives for the clinical component of their community health course. Public health graduate students received independent study credit and the medical student was a volunteer who desired to gain pediatric experience in an underserved community because he intended to practice in such a community.
Table 1 e Course Objectives for Health Professional Students Community Health Objectives (BSN)
Public Health Practicum Objectives (MPH)
Apply the nursing process in the provision of health care to individuals, groups, and populations. Analyze risk factors including historical, economical, environmental, cultural, and political that influence the health of individuals, groups, and populations.
Identify causes of social and behavioral factors that affect health of individuals and populations. Describe the role of social and community factors in both the onset and solution of public health problems. Specify multiple targets and levels of intervention for social and behavioral science or policies.
Apply epidemiological principles and methods to recognize the needs of individuals, groups, and populations. Interpret assessment data to identify health problems of individuals, groups, and populations to develop a community nursing diagnosis. Apply planning principles to the development and evaluation of interventions to promote health and reduce health risks for individuals, groups, and populations.
Identify individual, organizational, and community concerns, assets, resources, and deficits for social and behavioral science interventions. Identify critical stakeholders for the planning implementation, and evaluation of public health programs, policies, and interventions. Describe steps and procedures for the planning, implementation, and evaluation of public health programs, policies, and interventions.
50
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
In the weekly seminar, students discussed general topics and topics specific to the community of interest. Seminars took place at the School of Nursing and were conducted collaboratively by the three core faculty members and the pastor. An AmeriCorps volunteer from the elementary school also attended seminars to provide information about services available in the school. Seminar topics included: (1) An overview of service-learning; (2) the nature of interprofessional practice; (3) introduction to the targeted community; (4) history, rationale, and purpose of environmental audits; (5) types of audits; (6) steps in performing audits; (7) feedback on experiences in the community; and (8) community-based participatory research approaches. As the semester progressed, seminar time was used to discuss identified health problems and assist the students in prioritizing the problems.
Excellence in Science Environmental Audits In addition to the seminar, the students engaged in field experiences that occurred on a flexible schedule to accommodate the varying clinical schedules inherent in health professional education. Faculty emphasized environmental audits as a way to structure the field experience, add scientific rigor, and help students develop a skill useful to all professions. Environmental audits are performed using an instrument designed to inventory and assess various environmental features of a community that promote or inhibit healthy lifestyle behaviors.29,30 A spatiophysical audit checklist was used to assess environmental features.31,32 Figure 1 provides an example of the audit checklist. Audits provide a way for students to gather important data on barriers and facilitators to healthy eating and physical activity as part of their comprehensive assessment of the community. The environmental audits also allowed the group to take advantage of the scientific expertise of one of the faculty team members. Before beginning field work, students in the initial group conducted practice environmental audits to establish consistency and fidelity in procedures and ratings, and gain familiarity with evidence-based tools.31,32 Students then performed environmental audits in the targeted community, documenting facilitators to physical activity in the community by locating parks, running tracks, and playgrounds. Absence of these facilities and hazardous conditions such as cracked sidewalks were recorded as barriers to physical activity. The students audited grocery stores and restaurants to determine the availability and affordability of healthy foods.33 They met with members of the church and elementary school staff and observed classes and lunch times at the school. They also gathered state and local public health data that revealed mortality and morbidity figures for the area. Ultimately, with faculty guidance and extensive stakeholder input, the students compiled a comprehensive written document that identified and prioritized
the major health prevention needs of the community, with a particular focus on the children. Armed with information that the school population could benefit from healthier lifestyle behaviors, the students suggested an after-school program and presented their findings at a community meeting at the end of the semester.
Ethics As noted by Bastida et al,34 the increased use of CBPR warrants increased attention to ethical practices, particularly in communities where health disparities present additional challenges to health promotion activities. All partners must be involved and respected in the CBPR process. Toward that end, our students rehearsed what they planned to present to community stakeholders before the community meeting. The rehearsal session took the form of sensitivity training, how best to address difficult issues in such a setting, how to respect individuals living under difficult circumstances, and how to emphasize the strengths of the community while engaging community members in finding acceptable solutions to health concerns. Subsequent groups of students have conducted community assessments to update information and participate in an after-school intervention that is being pilot-tested as a part of faculty CBPR. Current students are required to take the University’s Human Subjects Education Course to participate in data collection and interventions and to further ensure that they adhere to ethical principles in the conduct of the research.
Outcomes Initial Course Attainment of student, faculty, and community objectives for the original course offering was measured in several ways. Faculty were able to attract and retain students in the course. Although the initial group of students was only 9 in number, the smaller number allowed the faculty research team to address challenges such as scheduling conflicts before offering the course to a larger group. Students acquired skills in performing rigorous environmental audits and, as a group, produced a comprehensive assessment that represents the work of individuals and the interprofessional group, and clearly reflects input from stakeholders. Analysis of student reflections on the experience indicated that the course expanded their horizons, providing opportunities to work outside of the hospital while learning teamwork and respect for other disciplines and for community members. They noted that everyone should have this experience and that students of political science, theology, and city planning should be involved because of the complex nature of community health issues, an outcome that the core faculty hope to achieve in the future. It was noted by faculty and some students alike that it was possible to spend one’s entire academic career in
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
51
Figure 1 e Audit tool checklist version.
classrooms, acute care settings, and laboratories without ever observing how patients live in their communities. According to one student:
“This course opened my eyes and taught me there’s much to learn from seeing people in their communities.”
52
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
An unanticipated and serendipitous outcome of the first course offering was that students not only represented interprofessional diversity, but cultural diversity. Students were Kenyan, Nigerian, Chinese, African American, Hispanic, and European American. They learned to view community issues from the perspective of individuals from other countries and to question the local way of resolving complex social and health issues. This perspective was an important lesson for faculty and students alike. As a pre-eminent academic health science center, UTHSC-H continues to attract faculty and students from many cultures, so this aspect of the course is expected to continue. The students also gained a greater understanding and appreciation for each other’s professions. As an example, a public health student did not know that there are several educational avenues available for individuals entering nursing. She was encouraged by the nursing students to consider nursing in addition to public health. One of the nursing students had applied to medical school and received his acceptance during the semester. The acceptance to medical school provided an opportunity for discussion of the roles and responsibilities of the various professions among the students as well as the community members who celebrated this important milestone with the student. One of the most significant outcomes of the initial course for the community was the response of the community members to information presented by the students as the students presented their final report. As was noted by the pastor, the presentation “galvanized” the church members to action on issues they could tackle immediately, such as the quality of school lunches. Church members learned from the health professional students that the state has guidelines for lunch menus and, as concerned citizens, they could monitor what is being served and make suggestions when appropriate. Church members were very engaged in the process and pleased to have data they could use to discuss community health needs with city officials and work to find solutions to the problems. In this way, the capacity of the community to address their health needs expanded through participation in the students’ learning experience. An approach for an after-school program was discussed at the community meeting. The proposed program, Olympic Stars, recommended that schoolchildren, their parents, and church members be involved in training and competing in various athletic games. Community members only asked, “When do we start?”
Ongoing Course The course continues, providing a way for maintaining the collaboration between community stakeholders and the academic research team and a way of furthering the trusting relationship and respectful engagement that was in place when the pastor moved to St Mary’s. The faculty team continues to focus on school children in their research, pilot testing an evidence-based after-
school health promotion curriculum that involves senior members of the church as mentors. Interprofessional students participate in the CBPR by updating community assessments, assisting with mentor training, and taking part in the intervention. The usual class size for subsequent student groups is 12. Additional interprofessional faculty members have now been welcomed into the community with their research ideas and will be conducting studies with adults. Research is valued as an important way to find evidence-based answers to health questions that concern the community. Community members take an interest in study findings and appreciate opportunities to contribute information. Outcomes for the initial goals of the process of linking servicelearning with community-based participatory research have been met. A structured interprofessional servicelearning course is in place. The course is integrated into ongoing faculty CBPR initiatives. Finally, there is a sustained and expanded relationship with the community, Project SMART, which continually monitors the health of the community and works with the community to overcome health problems.
Conclusion Project SMART provides valuable learning experiences for students, faculty, and the community. In addition to those noted before, students and faculty gain new appreciation for the valuable contributions community members make to the research process, providing data that only community members could know. In this case, community stakeholders include the pastor, the AmeriCorps volunteer to the school, the school principal, and members of the senior ministry of the church. All of these individuals take an active interest in the project, giving important information, making suggestions for solving community problems, and cautioning the group about safety issues. The intensity of community involvement in the partnership was strong before student involvement but increased as a result of the course. This development was an unanticipated outcome of the project and possibly a reflection of the community’s desire to educate others to their needs. Community involvement in all phases of the research, such as those experienced in Project SMART, helps to overcome the negative connotation often associated with medical care and research in underserved communities and ensures that community assets are valued.35,36 Community members also express pleasure at having health professional students in the community as role models for youth and take pride in the fact that they are contributing to this educational process, placing great value on having integral roles as teachers in service-learning activities.28 The course contributes to the continuing efforts of our faculty team to maintain a partnership with an underserved community to engage in research efforts
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
that involve the community in addressing their health needs. There are a number of additional opportunities within the curricula of our schools for students to participate in CBPR and service-learning. Graduate nursing students in pediatrics and gerontology can choose the Project SMART collaboration for clinical rotations. Dietetic and other interns from the School of Public Health can meet their objectives through servicelearning in this setting. As noted, medical schools are now required to provide opportunities for their students to participate in service-learning activities. Project SMART offers an excellent possibility for servicelearning to occur as an elective or in a specified rotation. Service-learning is an important part of education for the health professions but too often, students return to the classroom to view their experiences from the perspectives of the instructor and the designated course material.1 CBPR values the life experience of members of the community and seeks to empower them to solve their problems.39 CBPR provides a framework for students and faculty to work together in a way that respects community knowledge and results in evidence-based approaches to the solution of health problems. This approach is particularly important in underserved communities where research may have a negative connotation, a sense of being exploited rather than valued.35,37 Each of the UTHSC-H schools espouses interprofessional competence, service-learning, and evidencebased practice. By combining these values in an ongoing structured learning experience integrated with faculty community research, students are exposed to the true “scholarship of engagement,”38 which focuses on the application of faculty expertise to the public welfare and common good. The scholarship of engagement not only links theory with practice but forges relationships between academic institutions and communities, relationships that enhance the effectiveness of both entities to bring about social change that contributes to the elimination of health disparities.37,40,41
2.
3.
4.
5.
6. 7.
8. 9.
10.
11.
12. 13. 14.
Acknowledgment 15.
We acknowledge grant support from the Association for Prevention Teaching and Research for the development of the course and an Innovative Teaching Award from the University of Texas Academy of Science Educators, which contributes to continuing CBPR in the community. We also thank the students and community members who participate in the course and contribute to its success.
references 1. DeBlasis AL. From revolution to evolution: making the transition from community service learning to
16.
17.
18.
53
community based research. International Journal of Teaching & Learning in Higher Education 2006;18:36-42. Butin DW. Disciplining service learning: institutionalization and the case for community studies. International Journal of Teaching & Learning in Higher Education 2006;18:57-64. Commission on Community-Engaged Scholarship in the Health Professions. Linking scholarship and communities: Report of the Commission on Community-Engaged Scholarship in the health professions. Seattle: Community-Campus Partnerships for Health; 2005. Witchger-Hansen AM, Munoz J, Crist PA, et al. Service learning: meaningful, community-centered professional skill development for occupational therapy students. Occup Ther Health Care 2007;21: 25-49. Reising DL, Shea RA, Allen PN, et al. Using servicelearning to develop health promotion and research skills in nursing students. Int J Nurs Educ Scholarsh 2008;5. Article 29. Hood JG. Service learning in dental education: meeting needs and challenges. J Dent Educ 2009;73:454-63. Seifer SD, Calleson DC. Health professional faculty perspectives on community-based research: implications for policy and practice. J Interprof Care 2004;18:416-27. Furco A. Advancing service-learning at research universities. New Directions for Higher Education 2001;114:67-78. Brown RL, Marcus MT. Bearing witness: the political agenda of community-based service learning. Subst Abus 2005;26:3-4. Boutin-Foster C, Phillips E, Palermo A. The role of community-academic partnerships: implications for medical education, research, and patient care. Progr Community Health Partnersh 2008;2:55-60. Cene CW, Peek ME, Jacobs E, et al. Community-based teaching about health disparities: combining education, scholarship, and community service. J Gen Intern Med 2009;25:S130-5. Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. Milbank Q 1993;71:279-322. Krause N. Neighborhood deterioration and self-rated health in later life. Psychol Aging 1996;11:342-52. Feldman PJ, Steptoe A. How neighborhoods and physical functioning are related: the roles of neighborhood socioeconomic status, perceivedneighborhood strain, and individual health risk factors. Annals of Behavioral Medicine 2004;27:91-9. Proctor P, Lake D, Jewell L, et al. Influencing student beliefs about poverty and health through interprofessional community-based educational experiences. J Res Interprof Pract Educ 2010;1:145-58. Northridge ME, Shoemaker K, Jean-Louis B, et al. Using community-basedparticipatory research to ask and answer questions regarding the environment and health. Essays on the Future of Environmental Health Research: A Tribute to Dr. Kenneth Olden. Environmental Health Perspectives 2005;113(Suppl 1): 34-41. Mcintosh S, Block RC, Kapsak G, et al. Training medical students in community health: a novel required fourth-year clerkship at the University of Rochester. Acad Med 2008;38:357-64. Dalal M, Skeete R, Yeo HL, et al. A physicians team’s experiences in community-based participatory
54
19.
20.
21.
22. 23. 24.
25. 26. 27.
28. 29. 30.
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
research: insights into effective group collaborations. Am J Prev Med 2009;37:S288-91. Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health 2010;100:S40-6. Ahmed SM, Beck B, Maurana CA, et al. Overcoming barriers to effective community-based participatory research in US medical schools. Educ Health 2004;17: 141-51. Horowitz C, Robinson M, Seifer S. Community-based participatory research from the margin to the mainstream: are researchers prepared? Circulation AHA; 2009:2633-42. Nyden P. Academic incentives for faculty participation in community-based participatory research. J Gen Intern Med 2003;18:576-85. Savage CL, Xu Y, Lee R, et al. A case study in the use of community-based participatory research in public health nursing. Public Health Nursing 2006;23:472-8. Marcus MT, Walker T, Swint JM, et al. Communitybased participatory research to prevent substance abuse and HIV/AIDS in African American adolescents. J Interprof Care 2004;18:347-59. Taylor WC, Liehr P, Laws DY, et al. Linguistic inquiry and word count: an unobtrusive strategy to evaluate youth camps. Journal of Youth Ministry 2005;4:39-51. Busen NH, Marcus MT, vonSternberg KL. What African American middle school youth report about risk-taking behavior. J Pediatr Health Care 2006;20:393-400. Liaison Committee on Medical Education. Accreditation Standards. Available at: http://www. lcme.org/standard.htm. Accessed April 27, 2007. Seifer SD. Service-learning: community-campus partnerships for health professions education. Acad Med 1998;73:271-7. Brownson RC, Hoehner CM, Day K, et al. Measuring the built environment for physical activity. Am J Prev Med 2009;36:S99-123. Moudon AV, Lee C. Walking and bicycling: an evaluation of environmental audit instruments. The Science of Health Promotion 2003;18:21-37.
31. Brownson RC, Hoehner CM, Brennan LK, et al. Reliability of two instruments for auditing the environment for physical activity. J Phys Act Health 2004;1:191-208. 32. Hoehner CM, Ivy A, Brennan-Ramirez L, et al. How reliably do community members audit the neighborhood environment for its support of physical activity? Implications for participatory research. J Public Health Manage Pract 2006;12:270-7. 33. Baker EA, Schootman M, Barnridge E, et al. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Preventing Chronic Diseases 2006;3:1-11. 34. Bastida EM, Tseng T, McKeever C, et al. Ethics and community-based participatory research: Perspectives from the field. Health Promot Pract 2010;11:16-20. 35. Wells K, Jones L. Research in community-partnered, participatory research. JAMA 2009;302:320-1. 36. Brandon DT, Issac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc 2005;97:951-6. 37. Armstrong TD, Crun LD, Rieger RH, et al. Attitudes of African Americans toward participation in medical research. J Appl Soc Psychol 1999;29:552-74. 38. Boyer EL. The scholarship of engagement. The Journal of Public Service and Outreach 1996;1:11-20. 39. Dankwa-Mullan I, Rhee KB, Stoff DM, et al. Moving toward paradigm shift research in health disparities through translational, transformational, and transdisciplinary approaches. Translational, Transformational, and Transdisciplinary Research 2010;100:S19-24. 40. Minkler M. Linking science and policy through community-based participatory research to study and address health disparities. Am J Public Health 2010; 100:S81-7. 41. Blue AV, Mitcham M, Smith T, et al. Changing the future of health professions: embedding interprofessional education within an academic health center. Academic Medicine 2010;85: 1290-5.
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
www.nursingoutlook.org
Linking service-learning with community-based participatory research: An interprofessional course for health professional students Marianne T. Marcus, EdD, RN, FAANa,*, Wendell C. Taylor, PhD, MPHb, Mark D. Hormann, MDc, Thomas Walker, BAd, Deidra Carroll, BSa a
b
The University of Texas Health Science Center at Houston, School of Nursing, Houston, TX The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX c The University of Texas Health Science Center at Houston, School of Medicine, Houston, TX d St. Mary’s United Methodist Church, Houston, TX
article info
abstract
Article history: Received 25 June 2010 Revised 28 September 2010 Accepted 7 October 2010
Service-learning is a valued strategy for educating health professionals. Linking service-learning with community-based participatory research (CBPR) engages students with community stakeholders and faculty in a collaborative process to bring about social change and improved health. The purpose of this paper is to describe a strategy for involving interprofessional students in ongoing faculty CBPR in an underserved community. The process includes the design and implementation of a course that combines weekly seminars with field experiences in the targeted community, emphasizing community assessment, and working with community members to find solutions to health problems. Nursing, public health, and medical students were recruited to the initial course, and offered the opportunity to meet objectives of required components of their disciplinary curriculum. Community members became actively involved in educating students while working to solve identified health problems. Important principles of CBPRdtrust, collaboration, excellence in science, and ethicsd are emphasized throughout the initiative. This course is now a regular offering for interprofessional students, providing valuable learning experiences for students, faculty, and the community. Ongoing faculty CBPR continues a trusting community-academic relationship and gives the community a voice in the solution for health problems.
Keywords: Service-learning Interprofessional Community-based participatory research Health professional education
Cite this article: Marcus, M. T., Taylor, W. C., Hormann, M. D., Walker, T., & Carroll, D. (2011, FEBRUARY). Linking service-learning with community-based participatory research: An interprofessional course for health professional students. Nursing Outlook, 59(1), 47-54. doi:10.1016/j.outlook.2010.10.001.
Service-learning has become a major pedagogical movement across academic environments, from primary and secondary school levels,1 to higher
education2 and education for the health professions.3-7 Service-learning combines structured reciprocal experiences in response to community-identified needs
* Corresponding author: Marianne T. Marcus, Director, Center of Substance Abuse Education, Prevention, and Research, University of Texas Health Science Center at Houston, School of Nursing. 6901 Bertner Blvd., SON 649, Houston, TX 77030. E-mail address: [email protected] (M.T. Marcus). 0029-6554/$ e see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.outlook.2010.10.001
48
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
with academic education.8 Witchger-Hansen et al4 assert that there is a synergy between the need for students to practice in real-world settings and the moral obligation of academia to reduce social injustices. Grounded in constructionist theory and experiential education, service-learning links theory with practice and cognitive learning with affective learning.2,8 Although experiential learning is not new to health professional education, there is increased interest in expanding service-learning and community involvement for health professional students,9,10 particularly as a means to address health disparities within communities.11 Research continues to indicate that there is an inverse relationship between socioeconomic status and physical health.12-14 Health professional students should have opportunities to learn in neighborhoods where health disparities exist, where even brief experiences of such have been shown to positively influence students’ attitudes and beliefs about the impact of poverty on health.15 One potential strategy to accomplish this goal is to link service-learning with community-based participatory research (CBPR), an approach that is finding favor in health professional education.5,16-18 Community health problems are complex and their solutions must be evidence-based, so research should be an integral part of service-learning.8,19 CBPR is a collaborative approach that involves community stakeholders and researchers in an equitable process to bring about social change and improved health conditions.20,21 CBPR builds on a trusting relationship in which community members and organizations are equal partners with researchers in all phases of the research process.18 Because social issues are complex, the perspectives of multiple and varied disciplines enhance the CBPR process, making it an ideal service-learning endeavor for interprofessional faculty and students of the health disciplines.22 The purpose of this paper is to describe a process for involving students in ongoing faculty CBPR initiatives in an underserved community. A key element of the process was the design and implementation of an interprofessional course that engages faculty, students, and the community in a collaborative process to foster student education while addressing community health problems. The method adheres to the CBPR principles outlined by Savage et al23: trust based on communication; collaboration involving shared responsibility; excellence in science through training, fidelity monitoring, and strict adherence to protocol; and ethics or strict guidelines and agreement on handling of confidential information. The initial goals of the strategy were to: (1) offer a community-based interprofessional service-learning course for health professional students at the University of Texas Health Science Center at Houston (UTHSC-H); (2) integrate the course into ongoing faculty CBPR initiatives; and (3) sustain a collaborative relationship with members of a community to facilitate ongoing research to improve the health of the community.
Building Trust UTHSC-H faculty representing nursing, public health, and medicine established a research partnership with an African-American community in 1999 to conduct a CBPR study aimed at prevention of HIV/AIDS and substance abuse in adolescents in a faith-based setting. Faculty interests and expertise included substance use disorders, physical activity, and community pediatrics. The study, funded by the Substance Abuse Mental Health Services Administration, Center for Substance Abuse Prevention, involved the implementation and evaluation of a youth program that has remained a part of the outreach ministry of a large urban church.24-26 Academic team members continued to collaborate when the youth pastor of the urban church was appointed head pastor at St. Mary’s United Methodist Church, located in an underserved African-American neighborhood near UTHSC-H. Collaboration in the new church involved meetings with stakeholders to elicit their perceived health needs. An initial concern was the health of seniors of the church, so health promotion classes, conducted by students of the School of Nursing, were instituted with the overall goal of improving the health of seniors. The relationship in the new setting was strengthened through frequent meetings between the interprofessional academic team and community stakeholders. Community members expressed an interest in addressing a broader range of health needs. Because the church is strategically located between middle and elementary schools, church members have become increasingly concerned about the health of the school children. Thirty percent of the families live below the poverty line in a community where health problems such as obesity and substance use could be targeted for health promotion activities. Community members identified healthy eating, increased physical activity, and avoidance of risky behaviors related to substance use as critical concerns in this low-income community. In response to these concerns, the community-academic partnership expanded to include additional health professional faculty with expertise in nutrition, interprofessional students at UTHSC-H, and staff from the elementary and middle schools. Disciplines and research interests of the core academic team include nursing and substance use disorders, public health and physical activity, and medicine and community pediatrics. The collaboration is entitled Project SMART (St Mary’s Academic Research Team) to reflect the reciprocal exchange of knowledge between community stakeholders and research scientists, and to acknowledge the church as primary site for the initiative.
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
Collaboration Course A cornerstone of Project SMART is a collaborative, interprofessional service-learning course that provides a vehicle for involving health professional students, their faculty, and the community in CBPR. With grant support from the Association for Prevention Teaching and Research, faculty designed and implemented the course in 2007. Faculty of the core academic team met with the curriculum committees of their schools and posted information about the availability of the course. Students from the UTHSC School of Nursing could meet course requirements for the undergraduate community health clinical. UTHSC-H School of Public Health has a number of appropriate courses including one that explores social and behavioral aspects of physical activity. The School of Public Health also requires a three hour practicum for all Master of Public Health students that may be met through this course. The Liaison Committee on Medical Education (LCME), the body that accredits medical schools, adopted a new standard on service-learning in February of 2007. The new Standard IS-14-A, states that “medical schools should make available sufficient opportunities for medical students to participate in service-learning activities, and should encourage and support student participation.”27 UTHSC-H School of Medicine has a fourth-year elective that could be achieved through participation in Project SMART, and there is a place for this initiative in the third-year pediatrics rotation.
49
The initial student group was recruited from the Schools of Nursing, Public Health, and Medicine and offered an opportunity to participate in faculty CBPR while receiving academic credit consistent with the curriculum of their discipline as recommended by Seifer.28 Table 1 indicates the overlapping course objectives between the undergraduate nursing community clinical and the graduate public health practicum. The singlesemester course is a structured experience in which students perform comprehensive assessments of the health needs of the community, prioritize those needs, suggest solutions, and discuss the feasibility of implementing various approaches with community members. The course includes time spent in weekly seminars, field experiences, research, and documentation. Students are asked to keep reflective journals to frame discussions about the experience and its meaning and value to their future professional practice. Although the course is taught collaboratively by the interprofessional team and community members, students are supervised by the faculty member of their discipline and school. The first group of students consisted of six undergraduate nursing students, two public health graduate students, and one undergraduate medical student. Baccalaureate nursing students met objectives for the clinical component of their community health course. Public health graduate students received independent study credit and the medical student was a volunteer who desired to gain pediatric experience in an underserved community because he intended to practice in such a community.
Table 1 e Course Objectives for Health Professional Students Community Health Objectives (BSN)
Public Health Practicum Objectives (MPH)
Apply the nursing process in the provision of health care to individuals, groups, and populations. Analyze risk factors including historical, economical, environmental, cultural, and political that influence the health of individuals, groups, and populations.
Identify causes of social and behavioral factors that affect health of individuals and populations. Describe the role of social and community factors in both the onset and solution of public health problems. Specify multiple targets and levels of intervention for social and behavioral science or policies.
Apply epidemiological principles and methods to recognize the needs of individuals, groups, and populations. Interpret assessment data to identify health problems of individuals, groups, and populations to develop a community nursing diagnosis. Apply planning principles to the development and evaluation of interventions to promote health and reduce health risks for individuals, groups, and populations.
Identify individual, organizational, and community concerns, assets, resources, and deficits for social and behavioral science interventions. Identify critical stakeholders for the planning implementation, and evaluation of public health programs, policies, and interventions. Describe steps and procedures for the planning, implementation, and evaluation of public health programs, policies, and interventions.
50
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
In the weekly seminar, students discussed general topics and topics specific to the community of interest. Seminars took place at the School of Nursing and were conducted collaboratively by the three core faculty members and the pastor. An AmeriCorps volunteer from the elementary school also attended seminars to provide information about services available in the school. Seminar topics included: (1) An overview of service-learning; (2) the nature of interprofessional practice; (3) introduction to the targeted community; (4) history, rationale, and purpose of environmental audits; (5) types of audits; (6) steps in performing audits; (7) feedback on experiences in the community; and (8) community-based participatory research approaches. As the semester progressed, seminar time was used to discuss identified health problems and assist the students in prioritizing the problems.
Excellence in Science Environmental Audits In addition to the seminar, the students engaged in field experiences that occurred on a flexible schedule to accommodate the varying clinical schedules inherent in health professional education. Faculty emphasized environmental audits as a way to structure the field experience, add scientific rigor, and help students develop a skill useful to all professions. Environmental audits are performed using an instrument designed to inventory and assess various environmental features of a community that promote or inhibit healthy lifestyle behaviors.29,30 A spatiophysical audit checklist was used to assess environmental features.31,32 Figure 1 provides an example of the audit checklist. Audits provide a way for students to gather important data on barriers and facilitators to healthy eating and physical activity as part of their comprehensive assessment of the community. The environmental audits also allowed the group to take advantage of the scientific expertise of one of the faculty team members. Before beginning field work, students in the initial group conducted practice environmental audits to establish consistency and fidelity in procedures and ratings, and gain familiarity with evidence-based tools.31,32 Students then performed environmental audits in the targeted community, documenting facilitators to physical activity in the community by locating parks, running tracks, and playgrounds. Absence of these facilities and hazardous conditions such as cracked sidewalks were recorded as barriers to physical activity. The students audited grocery stores and restaurants to determine the availability and affordability of healthy foods.33 They met with members of the church and elementary school staff and observed classes and lunch times at the school. They also gathered state and local public health data that revealed mortality and morbidity figures for the area. Ultimately, with faculty guidance and extensive stakeholder input, the students compiled a comprehensive written document that identified and prioritized
the major health prevention needs of the community, with a particular focus on the children. Armed with information that the school population could benefit from healthier lifestyle behaviors, the students suggested an after-school program and presented their findings at a community meeting at the end of the semester.
Ethics As noted by Bastida et al,34 the increased use of CBPR warrants increased attention to ethical practices, particularly in communities where health disparities present additional challenges to health promotion activities. All partners must be involved and respected in the CBPR process. Toward that end, our students rehearsed what they planned to present to community stakeholders before the community meeting. The rehearsal session took the form of sensitivity training, how best to address difficult issues in such a setting, how to respect individuals living under difficult circumstances, and how to emphasize the strengths of the community while engaging community members in finding acceptable solutions to health concerns. Subsequent groups of students have conducted community assessments to update information and participate in an after-school intervention that is being pilot-tested as a part of faculty CBPR. Current students are required to take the University’s Human Subjects Education Course to participate in data collection and interventions and to further ensure that they adhere to ethical principles in the conduct of the research.
Outcomes Initial Course Attainment of student, faculty, and community objectives for the original course offering was measured in several ways. Faculty were able to attract and retain students in the course. Although the initial group of students was only 9 in number, the smaller number allowed the faculty research team to address challenges such as scheduling conflicts before offering the course to a larger group. Students acquired skills in performing rigorous environmental audits and, as a group, produced a comprehensive assessment that represents the work of individuals and the interprofessional group, and clearly reflects input from stakeholders. Analysis of student reflections on the experience indicated that the course expanded their horizons, providing opportunities to work outside of the hospital while learning teamwork and respect for other disciplines and for community members. They noted that everyone should have this experience and that students of political science, theology, and city planning should be involved because of the complex nature of community health issues, an outcome that the core faculty hope to achieve in the future. It was noted by faculty and some students alike that it was possible to spend one’s entire academic career in
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
51
Figure 1 e Audit tool checklist version.
classrooms, acute care settings, and laboratories without ever observing how patients live in their communities. According to one student:
“This course opened my eyes and taught me there’s much to learn from seeing people in their communities.”
52
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
An unanticipated and serendipitous outcome of the first course offering was that students not only represented interprofessional diversity, but cultural diversity. Students were Kenyan, Nigerian, Chinese, African American, Hispanic, and European American. They learned to view community issues from the perspective of individuals from other countries and to question the local way of resolving complex social and health issues. This perspective was an important lesson for faculty and students alike. As a pre-eminent academic health science center, UTHSC-H continues to attract faculty and students from many cultures, so this aspect of the course is expected to continue. The students also gained a greater understanding and appreciation for each other’s professions. As an example, a public health student did not know that there are several educational avenues available for individuals entering nursing. She was encouraged by the nursing students to consider nursing in addition to public health. One of the nursing students had applied to medical school and received his acceptance during the semester. The acceptance to medical school provided an opportunity for discussion of the roles and responsibilities of the various professions among the students as well as the community members who celebrated this important milestone with the student. One of the most significant outcomes of the initial course for the community was the response of the community members to information presented by the students as the students presented their final report. As was noted by the pastor, the presentation “galvanized” the church members to action on issues they could tackle immediately, such as the quality of school lunches. Church members learned from the health professional students that the state has guidelines for lunch menus and, as concerned citizens, they could monitor what is being served and make suggestions when appropriate. Church members were very engaged in the process and pleased to have data they could use to discuss community health needs with city officials and work to find solutions to the problems. In this way, the capacity of the community to address their health needs expanded through participation in the students’ learning experience. An approach for an after-school program was discussed at the community meeting. The proposed program, Olympic Stars, recommended that schoolchildren, their parents, and church members be involved in training and competing in various athletic games. Community members only asked, “When do we start?”
Ongoing Course The course continues, providing a way for maintaining the collaboration between community stakeholders and the academic research team and a way of furthering the trusting relationship and respectful engagement that was in place when the pastor moved to St Mary’s. The faculty team continues to focus on school children in their research, pilot testing an evidence-based after-
school health promotion curriculum that involves senior members of the church as mentors. Interprofessional students participate in the CBPR by updating community assessments, assisting with mentor training, and taking part in the intervention. The usual class size for subsequent student groups is 12. Additional interprofessional faculty members have now been welcomed into the community with their research ideas and will be conducting studies with adults. Research is valued as an important way to find evidence-based answers to health questions that concern the community. Community members take an interest in study findings and appreciate opportunities to contribute information. Outcomes for the initial goals of the process of linking servicelearning with community-based participatory research have been met. A structured interprofessional servicelearning course is in place. The course is integrated into ongoing faculty CBPR initiatives. Finally, there is a sustained and expanded relationship with the community, Project SMART, which continually monitors the health of the community and works with the community to overcome health problems.
Conclusion Project SMART provides valuable learning experiences for students, faculty, and the community. In addition to those noted before, students and faculty gain new appreciation for the valuable contributions community members make to the research process, providing data that only community members could know. In this case, community stakeholders include the pastor, the AmeriCorps volunteer to the school, the school principal, and members of the senior ministry of the church. All of these individuals take an active interest in the project, giving important information, making suggestions for solving community problems, and cautioning the group about safety issues. The intensity of community involvement in the partnership was strong before student involvement but increased as a result of the course. This development was an unanticipated outcome of the project and possibly a reflection of the community’s desire to educate others to their needs. Community involvement in all phases of the research, such as those experienced in Project SMART, helps to overcome the negative connotation often associated with medical care and research in underserved communities and ensures that community assets are valued.35,36 Community members also express pleasure at having health professional students in the community as role models for youth and take pride in the fact that they are contributing to this educational process, placing great value on having integral roles as teachers in service-learning activities.28 The course contributes to the continuing efforts of our faculty team to maintain a partnership with an underserved community to engage in research efforts
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
that involve the community in addressing their health needs. There are a number of additional opportunities within the curricula of our schools for students to participate in CBPR and service-learning. Graduate nursing students in pediatrics and gerontology can choose the Project SMART collaboration for clinical rotations. Dietetic and other interns from the School of Public Health can meet their objectives through servicelearning in this setting. As noted, medical schools are now required to provide opportunities for their students to participate in service-learning activities. Project SMART offers an excellent possibility for servicelearning to occur as an elective or in a specified rotation. Service-learning is an important part of education for the health professions but too often, students return to the classroom to view their experiences from the perspectives of the instructor and the designated course material.1 CBPR values the life experience of members of the community and seeks to empower them to solve their problems.39 CBPR provides a framework for students and faculty to work together in a way that respects community knowledge and results in evidence-based approaches to the solution of health problems. This approach is particularly important in underserved communities where research may have a negative connotation, a sense of being exploited rather than valued.35,37 Each of the UTHSC-H schools espouses interprofessional competence, service-learning, and evidencebased practice. By combining these values in an ongoing structured learning experience integrated with faculty community research, students are exposed to the true “scholarship of engagement,”38 which focuses on the application of faculty expertise to the public welfare and common good. The scholarship of engagement not only links theory with practice but forges relationships between academic institutions and communities, relationships that enhance the effectiveness of both entities to bring about social change that contributes to the elimination of health disparities.37,40,41
2.
3.
4.
5.
6. 7.
8. 9.
10.
11.
12. 13. 14.
Acknowledgment 15.
We acknowledge grant support from the Association for Prevention Teaching and Research for the development of the course and an Innovative Teaching Award from the University of Texas Academy of Science Educators, which contributes to continuing CBPR in the community. We also thank the students and community members who participate in the course and contribute to its success.
references 1. DeBlasis AL. From revolution to evolution: making the transition from community service learning to
16.
17.
18.
53
community based research. International Journal of Teaching & Learning in Higher Education 2006;18:36-42. Butin DW. Disciplining service learning: institutionalization and the case for community studies. International Journal of Teaching & Learning in Higher Education 2006;18:57-64. Commission on Community-Engaged Scholarship in the Health Professions. Linking scholarship and communities: Report of the Commission on Community-Engaged Scholarship in the health professions. Seattle: Community-Campus Partnerships for Health; 2005. Witchger-Hansen AM, Munoz J, Crist PA, et al. Service learning: meaningful, community-centered professional skill development for occupational therapy students. Occup Ther Health Care 2007;21: 25-49. Reising DL, Shea RA, Allen PN, et al. Using servicelearning to develop health promotion and research skills in nursing students. Int J Nurs Educ Scholarsh 2008;5. Article 29. Hood JG. Service learning in dental education: meeting needs and challenges. J Dent Educ 2009;73:454-63. Seifer SD, Calleson DC. Health professional faculty perspectives on community-based research: implications for policy and practice. J Interprof Care 2004;18:416-27. Furco A. Advancing service-learning at research universities. New Directions for Higher Education 2001;114:67-78. Brown RL, Marcus MT. Bearing witness: the political agenda of community-based service learning. Subst Abus 2005;26:3-4. Boutin-Foster C, Phillips E, Palermo A. The role of community-academic partnerships: implications for medical education, research, and patient care. Progr Community Health Partnersh 2008;2:55-60. Cene CW, Peek ME, Jacobs E, et al. Community-based teaching about health disparities: combining education, scholarship, and community service. J Gen Intern Med 2009;25:S130-5. Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. Milbank Q 1993;71:279-322. Krause N. Neighborhood deterioration and self-rated health in later life. Psychol Aging 1996;11:342-52. Feldman PJ, Steptoe A. How neighborhoods and physical functioning are related: the roles of neighborhood socioeconomic status, perceivedneighborhood strain, and individual health risk factors. Annals of Behavioral Medicine 2004;27:91-9. Proctor P, Lake D, Jewell L, et al. Influencing student beliefs about poverty and health through interprofessional community-based educational experiences. J Res Interprof Pract Educ 2010;1:145-58. Northridge ME, Shoemaker K, Jean-Louis B, et al. Using community-basedparticipatory research to ask and answer questions regarding the environment and health. Essays on the Future of Environmental Health Research: A Tribute to Dr. Kenneth Olden. Environmental Health Perspectives 2005;113(Suppl 1): 34-41. Mcintosh S, Block RC, Kapsak G, et al. Training medical students in community health: a novel required fourth-year clerkship at the University of Rochester. Acad Med 2008;38:357-64. Dalal M, Skeete R, Yeo HL, et al. A physicians team’s experiences in community-based participatory
54
19.
20.
21.
22. 23. 24.
25. 26. 27.
28. 29. 30.
N u r s O u t l o o k 5 9 ( 2 0 1 1 ) 4 7 e5 4
research: insights into effective group collaborations. Am J Prev Med 2009;37:S288-91. Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health 2010;100:S40-6. Ahmed SM, Beck B, Maurana CA, et al. Overcoming barriers to effective community-based participatory research in US medical schools. Educ Health 2004;17: 141-51. Horowitz C, Robinson M, Seifer S. Community-based participatory research from the margin to the mainstream: are researchers prepared? Circulation AHA; 2009:2633-42. Nyden P. Academic incentives for faculty participation in community-based participatory research. J Gen Intern Med 2003;18:576-85. Savage CL, Xu Y, Lee R, et al. A case study in the use of community-based participatory research in public health nursing. Public Health Nursing 2006;23:472-8. Marcus MT, Walker T, Swint JM, et al. Communitybased participatory research to prevent substance abuse and HIV/AIDS in African American adolescents. J Interprof Care 2004;18:347-59. Taylor WC, Liehr P, Laws DY, et al. Linguistic inquiry and word count: an unobtrusive strategy to evaluate youth camps. Journal of Youth Ministry 2005;4:39-51. Busen NH, Marcus MT, vonSternberg KL. What African American middle school youth report about risk-taking behavior. J Pediatr Health Care 2006;20:393-400. Liaison Committee on Medical Education. Accreditation Standards. Available at: http://www. lcme.org/standard.htm. Accessed April 27, 2007. Seifer SD. Service-learning: community-campus partnerships for health professions education. Acad Med 1998;73:271-7. Brownson RC, Hoehner CM, Day K, et al. Measuring the built environment for physical activity. Am J Prev Med 2009;36:S99-123. Moudon AV, Lee C. Walking and bicycling: an evaluation of environmental audit instruments. The Science of Health Promotion 2003;18:21-37.
31. Brownson RC, Hoehner CM, Brennan LK, et al. Reliability of two instruments for auditing the environment for physical activity. J Phys Act Health 2004;1:191-208. 32. Hoehner CM, Ivy A, Brennan-Ramirez L, et al. How reliably do community members audit the neighborhood environment for its support of physical activity? Implications for participatory research. J Public Health Manage Pract 2006;12:270-7. 33. Baker EA, Schootman M, Barnridge E, et al. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Preventing Chronic Diseases 2006;3:1-11. 34. Bastida EM, Tseng T, McKeever C, et al. Ethics and community-based participatory research: Perspectives from the field. Health Promot Pract 2010;11:16-20. 35. Wells K, Jones L. Research in community-partnered, participatory research. JAMA 2009;302:320-1. 36. Brandon DT, Issac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc 2005;97:951-6. 37. Armstrong TD, Crun LD, Rieger RH, et al. Attitudes of African Americans toward participation in medical research. J Appl Soc Psychol 1999;29:552-74. 38. Boyer EL. The scholarship of engagement. The Journal of Public Service and Outreach 1996;1:11-20. 39. Dankwa-Mullan I, Rhee KB, Stoff DM, et al. Moving toward paradigm shift research in health disparities through translational, transformational, and transdisciplinary approaches. Translational, Transformational, and Transdisciplinary Research 2010;100:S19-24. 40. Minkler M. Linking science and policy through community-based participatory research to study and address health disparities. Am J Public Health 2010; 100:S81-7. 41. Blue AV, Mitcham M, Smith T, et al. Changing the future of health professions: embedding interprofessional education within an academic health center. Academic Medicine 2010;85: 1290-5.