556926
research-article2014
SJP0010.1177/1403494814556926Health Promotion ResearchCC. Eriksson et al.
Scandinavian Journal of Public Health, 2014; 42(Suppl 15): 88–95
Original Article
Academic practice–policy partnerships for health promotion research: Experiences from three research programs
Charli C-G Eriksson, Ingela Fredriksson, Karin FRÖDING, Susanna Geidne & Camilla Pettersson School of Health and Medical Sciences, Orebro University, Orebro, Sweden
Abstract Background: The development of knowledge for health promotion requires an effective mechanism for collaboration between academics, practitioners, and policymakers. The challenge is better to understand the dynamic and ever-changing context of the researcher–practitioner–policymaker–community relationship. Aims: The aims were to explore the factors that foster Academic Practice Policy (APP) partnerships, and to systematically and transparently to review three cases. Methods: Three partnerships were included: Power and Commitment–Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden; Healthy City–Social Inclusion, Urban Governance, and Sustainable Welfare Development; and Empowering Families with Teenagers–Ideals and Reality in Karlskoga and Degerfors. The analysis includes searching for evidence for three hypotheses concerning contextual factors in multi-stakeholder collaboration, and the cumulative effects of partnership synergy. Results: APP partnerships emerge during different phases of research and development. Contextual factors are important; researchers need to be trusted by practitioners and politicians. During planning, it is important to involve the relevant partners. During the implementation phase, time is important. During data collection and capacity building, it is important to have shared objectives for and dialogues about research. Finally, dissemination needs to be integrated into any partnership. The links between process and outcomes in participatory research (PR) can be described by the theory of partnership synergy, which includes consideration of how PR can ensure culturally and logistically appropriate research, enhance recruitment capacity, and generate professional capacity and competence in stakeholder groups. Moreover, there are PR synergies over time. Conclusions: The fundamentals of a genuine partnership are communication, collaboration, shared visions, and willingness of all stakeholders to learn from one another. Key Words: Health promotion, research strategy, practice-based research, participatory research, review
Introduction It is well established that community participation is an essential component of health promotion and health intervention [1]. But, just how to achieve community participation in activities that aim to impact on health outcomes is less well established [2]. Moreover, health promotion research needs to be participatory. It needs to be practice-based, and built on a philosophy of partnership and the principles of self-determination, equity, and social justice. Development of knowledge for health promotion requires a well-developed mechanism for collaboration between academics, practitioners, and policymakers. Can an academic–practice–policy partnership
(APPP) be a mechanism for improving health promotion research? More than 17 years have passed since Nutbeam [3] noted the gap between the needs for knowledge and the priorities of research. There is an increasing demand for evidence-based methods and practice [4– 7]. The call for more practice-based evidence is a challenge to policymakers, practitioners, researchers, and funding agencies [8]. However, the gap between evidence and practice has still not been bridged, although some important progress has been made [8–19]. There have been different approaches to closing the practice-research gap. One has been to develop
Correspondence: Charli C-G Eriksson, Orebro University, School of Health and Medical Sciences, Orebro, SE-70182, Sweden. E-mail: charli. [email protected] (Accepted 02 October 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814556926
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Partnership for Health Promotion Research 89 topic-based research units, such as addiction research centers [20–23]. However, although a common element in the missions of these centers is to monitor substance use in the population, and its causes and courses, prevention research is not high on their agenda. A second approach lies in practice-based research. However, although practice-based research networks can be of value, a study of 46 networks, presented in 2006, found that barely half showed any kind of participation on the part of their members (patients), and none employed a fully participatory method [24]. A third approach to closing the worldwide gap between research and practice is to use applied academic centers, where a university, on the one hand, and treatment, public health and social welfare services, on the other, jointly make a long-term investment [25]. In The Netherlands, a central aim of such centers is to provide all the parties involved with meaningful knowledge of both practical and scientific value. Activities include developing a knowledge-exchange infrastructure within the organization, a long-term research program, and specific research projects. A fourth approach is that of participatory research (PR), which involves empowerment evaluation, collaborative evaluation, and stakeholder evaluation, and can be distinguished from approaches in which the researcher has an independent role. PR can be defined in terms of systematic inquiry, where there is collaboration between the people affected by the matter in question with regard to education, and taking action or effecting change [26]. In the arena of health promotion, one important purpose of community-based PR is to reduce health disparities [27,28]. PR focuses on the relationships between academic and community partners, according to the principles of co-learning, mutual benefit, and long-term commitment, and introduces community theories, participation and practices into research efforts [28]. What can PR offer to both researchers and endusers? It has become more accepted, due, among other things, to the claims that it increases awareness of the relevance of research to the people involved in the health promotion process and facilitates the translation of knowledge into practice [29]. And there are some critical reviews [30,31]. A recent assessment of the outcomes of PR adopted a realist review methodology to generate a robust understanding of complex and heterogeneous PR practice [32,33], and concluded that PR is a favorable approach to research, which supports health by improving research quality, empowerment, capacity building, sustainability, program extension, and unanticipated new activities. One aim of this paper was to explore factors that foster academic practice policy partnership (APPP).
Another aim was to systematically and transparently review three projects in line with recent critical realist reviews of participatory research [29,32–34] in order to better understand the dynamic and ever-changing context of the researcher-practitioner-policymakercommunity relationship. Methods We have chosen three projects within our own health promotion research programs as cases of APPP. The three research programs involved were practice based, and were conducted with careful attention paid to research ethics and to the use of research methods appropriate for the different questions addressed. For more information about the cases see Table I. The analysis includes searching for evidence for the three hypotheses proposed in a previous review [33]: (a) contextual factors, existing before a partnership is formed, partially determine the extent to which PR can enhance research outcomes; (b) synergy generated through multi-stakeholder collaboration, bringing diversity of perspectives and skills, advances research capacity beyond what could be achieved by a single stakeholder group working toward the same goals; and (c) partnership synergy has cumulative effects (i.e., builds momentum, strength, mutual trust, and understanding) over time, so that a PR outcome at one stage of research will influence subsequent stages. Data from the three case studies include results from reflective dialogues, evaluation meetings, and interviews with politicians, public health professionals and representatives of national agencies. In the three cases different types of triangulation have been used (data, methodological, investigator and theory). In this study the cases have been reviewed with regard to evidence on factor fostering APPP. By triangulation the core elements have been explored. Moreover, quotations will be provided from different cases. A key challenge in evaluating PR is that the PR approach may apply to an array of interventions, encompassing a multitude of research paradigms, methodologies, and methods [33]. For this study a realist review was chosen [34]. Adopting a realist approach provides a rationale and tools for synthesizing complex, difficult-to-interpret evidence [34]. A realist review is a theory-driven and abductive (informed–intuitive) approach to understanding context, mechanism, and outcome (CMO) configurations. Using this approach, the review focuses on exploring the impact of participatory processes or cogovernance on research processes and outcomes.
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90 C. Eriksson et al. Table 1. Characteristics of included cases of health promotion research. Case 1: Power and commitment– alcohol and drug prevention by non-governmental organizations in Sweden
Case 2: Healthy city–social inclusion, urban governance and sustainable welfare development
Case 3: Empowering families with teenagers–ideals and reality in Karlskoga and Degerfors
Aim
To promote integrated research and development in NGOs with regard to alcohol and drug prevention
To gain knowledge for family support to all parents, and to promote a municipal strategy for promoting competent families
Approach
The research program started in 2003, and is based on collaboration with NGOs (approx. 40 each year) [35].
Agencies involved
As part of the national strategy for alcohol, narcotics, doping and tobacco (ANDT), the National Board of Health and Welfare (NBHW), followed by the National Institute of Public Health (NIPH) and, from 2014, by the Public Health Agency of Sweden (PHAS)
Planning and design
The responsibilities of the national agency concerned, and the NGOs and the research team at Örebro University, were outlined at the start of the collaboration
Emergence of the partnership
Consultations, two conferences, project leader meetings each year. Implementation of annual work programs, annual progress reports on NGO projects and research
Research Outcome
In-depth studies, including two doctoral dissertations [36,37], and published papers [see, e.g., 38–41]
To work for the development of people’s health and welfare in four poor neighborhoods, with health, housing, economy, and education as the key arenas [42] A Partnership for Sustainable Welfare Development (PSWD) based on four municipalities, including municipal public housing companies and Örebro University (2003–2009) Sweden’s NIPH, the Swedish Association of Local Authorities and Regions, and the Swedish Association of Municipal Housing Companies. Research program was supported by the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning The partnership agreement and a research program were developed at the same time A planning grant was awarded by the NIPH, and the partnership agreement included the making of a small payment by each of the partners A steering group (politicians, public health officers, researchers), a coordinating committee (public health officers, researchers), and working groups) and annual conferences One doctoral dissertation [42] and research papers [see, for example, 43–46]
The emergence of APPP in the three cases was first analyzed chronologically. Then, configurations of context-mechanism-outcome (CMO) were used as heuristics to generate causal explanations, which means exploring the relationship between program context, mechanism, and outcomes of interest. Results It was possible to identify a number of CMO configurations in the three cases, which pertained to either a whole program or to just certain aspects of it, either embedded or in a series. In this paper, a selection of the most important processes for fostering the APPP in the three cases is presented.
The public health administration in Karlskoga and our research group developed a program called Empowering Families with Teenagers As part of its national strategy for parental support, the National Institute of Public Health (NIPH) published a call for proposals for research and development activities to be run by a municipality in collaboration with an academic institution The program was conducted jointly with regard to developmental activities and research questions
Collaboration between academics, practitioners and politicians in the municipalities took place in a steering group and a joint working group that met monthly Nine research studies and two meta-analytic studies, a family guide and a book in Swedish [47], and presentations at national and international conferences
Hypothesis 1: Contextual factors as partial determinants of PR outcomes Contextual factors, prevailing before a partnership was formed, were important for the emergence of PR, but there were differences between the three cases. In Case 1, the researcher was given the opportunity to develop a plan for the research and the development of an integrated research and competence-strengthening strategy to reinforce alcohol and drug prevention. There was limited previous experience of collaborating with NGOs. In Case 2, contextual factors played a more prominent role. One politician, one public health and one researcher had previously been the nexus for a
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Partnership for Health Promotion Research 91 national network for public health action in larger municipalities in Sweden, supported by the National Institute of Public Health (NIPH). Based on the evaluation report, a call for collaboration was sent to a number of Swedish municipalities, which resulted in the Partnership for Sustainable Welfare Development (PSWD). A key characteristic of this partnership was the involvement of politicians, public health officers and researchers, and also staff from the municipal housing company. The research program was developed jointly by researchers within the public health sciences and from the Center for Urban and Regional Studies at Örebro University. These researchers had not met before, but they found that they had many interests and perspectives in common. In Case 3, the joint public health administration in Karlskoga and Degerfors was responsible for public health strategy and initiative taking. The political board was responsible for the application to the NIPH that was developed by public health professionals and researchers. The NIPH decided on how the money should be divided between the partners. The academy, practice and policy had not been working together before, The experiences in the cases supported the hypothesis that contextual factors are important preconditions for PR. Researchers need to be trusted by practitioners and politicians, as indicated by the records of previous research records and the relevance and quality of research achievements. Hypothesis 2: Synergy generated through multistakeholder collaboration Four different patterns of CMO have previously been observed to support this hypothesis in the previous review [33]. The cases chosen in this article give further support for the value of multi-stakeholder collaboration through the four different patterns, which emerged from the data collected in the three cases. Culturally appropriate and logistically sound research. One important result of research collaboration was found to be the development of culturally appropriate and logistically sound research. Several different CMOs contributed to this development. Shaping the scope and direction of research. In all three cases the development of the research approach was of critical importance. In Case 1, the NGOs had responsibility for planning, implementing, and reporting on the organizations’ projects. The research team had responsibility for in-depth studies of selected projects, and also for support activities.
A program officer at a national agency stated in Case 1: It is important that research and evaluation are independent of the national agency and the NGOs. Also, there is added value to the knowledge that the researchers bring to the process. This is acknowledged by the NGOs, since all of them want their own project to be selected as an in-depth study.
A politician in Case 2 put it like this: Generally, it is the municipality, at least in Sweden, that focuses on the daily work. There is less focus on evaluation, even less on research, and almost no focus at all on the combination of research and action, going from theory to practice. That’s why our approach is important (Politician, Case 2).
Developing program and research protocols. The indepth studies in Case 1 involved joint planning by the NGO in question and the research team, which resulted in a written agreement between the research team and the organization. The agreement outlined details of the implementation of the research collaboration. In Case 2 a politician said: We spent a lot of time on discussions to formulate common goals and conclude written agreements.
In all cases, the health promotion activities were valuebased. In Case 3 a public health strategist stated: The program rests on the UN Convention of the Child and Sweden’s National Public Health Strategy, which both highlight participation and involvement. Accordingly, there is a strong emphasis on participatory processes.
Implementing program and research protocols. In Case 1 the NGOs involved in the in-depth studies had responsibility for the implementation of their intervention program, while the research team had the responsibility to perform the research activities. The design of the study, and also the research questions, were discussed with the NGOs. Moreover, the NGOs facilitated the data collections, since they had been tailored to the intervention. Mixed methods designs were used as part of the research protocol in all cases. For instance, in Case 3, qualitative studies were performed to investigate “what is a good family.” They included participatory research with teenagers, interviews with teenagers and parents, essay writing by teenagers, and open questions in a survey administered to parents. The
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92 C. Eriksson et al. results were presented locally at dialogue seminars, which constituted both a validity check and a form of dissemination to participants, including municipal professionals, politicians and parents. In Case 1 a project leader stated: Three important elements are good contacts, respect for different roles, and talking about timetables.
Interpreting and disseminating research findings. As part of the participatory process in Case 1, final results were presented and discussed with the NGOs. The end results were published at conferences, in scientific articles and research reports, and on the research team’s website. An important avenue for dissemination was the biannual conference, Reflection on Prevention, which is a national conference, organized by our research team that focuses on alcohol and drug prevention. In Case 1 a project leader said: It has been important that the research group has shown sensitivity, been understanding and believed in the program, and also shown respect for the Little Sisters [the target group] and the Big Sisters [the volunteers]. Regular feedback has also been important.
PR generates capacity to recruit. In all cases, a second pattern was that the PR generated capacity to recruit participants. Development of relationships was an important outcome of the extended planning period in Case 2. Such development was reinforced by regular meetings in the different groups. The annual meetings and planning for the second agreement involved all the partners. Politicians from both the majority and opposition parties participated. Also, partners presented the PSWD at national and international conferences, which strengthened the collaboration. The research team participated in most of the partnership groups. Moreover, the PhD students were responsible for practice-based studies, involving practitioners and managers at strategic and operational levels. People working and living in the neighborhoods participated in the innovative research, i.e., the collegial inquiry and the participatory research. The research questions were also discussed in the coordinating committee. In Case 2 a public health officer stated: We aimed to build bridges between strategic and operational levels, between politicians and practitioners, which can transform and share the knowledge possessed by each group.
In Case 3 the public health strategist said:
It is important to involve the politicians. The joint political board for public health in Karlskoga and Degerfors has been highly instrumental).
PR develops capacity and competence of stakeholders. A third pattern was that PR develops capacity and competence. The participatory process was important for the practitioners and politicians as well as the researchers. In Case 2 a researcher state: The good thing about the partnership is that we can inspire one another, at the same time as we learn from one another
In the same case a politician said: It was also important that politicians from the four municipalities met each other alone to discuss political issues.
In Case 3, different stakeholders and family members participated in a dialogue forum during the planning phase, and engaged in further dialogue in seminars after implementation of the various studies. PR generates disagreements between the co-governing stakeholders during decision-making processes. In contrast with the findings of the previous review, the fourth pattern of disagreements was not much in evidence in the three cases. One concern, however, was raised about partnership quality by a politician in Case 2: Meeting places are not good enough. The sectorial organization is a barrier for pursuing multi-sectorial issues, such as public-health promotion and neighborhood renewal. The chief executive or top managers should also be involved.
Moreover, in the participatory research project in one of the neighborhoods in Case 2, among the lessons learned were the needs openly to discuss individual situations, personal commitments, and mutual expectations, and also to unmask power and authority among the people involved in the participatory process. For more details see the separate paper [45]. Hypothesis 3: Cumulative partnership synergy over time PR contributed to an increase in the quality of outputs and outcomes over time through repeated successful partnering. In Case 1, partnership synergy was facilitated by the collaboration. This involved a number of program components that fostered trustful partnership
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Partnership for Health Promotion Research 93 between the researchers, practitioners, and policymakers: meetings with project leaders, project dialogues, competence strengthening, support for documentation, in-depth studies, and biannual national conferences. A detailed analysis has been published [35]. In Case 2, the partnership synergy resulted in a second partnership agreement, thus extending the program for three additional years beyond a national election. A public health officer said: It is important to hold regular meetings in the partners’ own environments, engage in a long-term process with a clear political program for more than one election period.
Moreover, the PR generated new unanticipated projects and activity. For instance, in Case 1, NGOs made alliances and developed new joint activities. They were competitive and received funding from the national agency. Discussion We found by using the critical realist approach and the theory proposed in a recent review of PR [32,33] that PR can generate positive results through beneficial contextual factors, multi-stakeholder collaboration, and cumulative partnership synergy. Successful partnership of APP requires contexts that foster a trustful partnership with respectful recognition of each partner’s competence and interests. Moreover, multi-stage collaboration could ensure culturally and logistically appropriate research, enhance recruitment capacity, and generate professional capacity and competence in stakeholder groups. Cumulative partnership synergy could increase the quality of outputs and outcomes over time, increase the sustainability of project goals beyond funded time frames, and create new unanticipated projects and activities. However, as show in our three cases, there are also factors that may reduce the added value of PR. For example in participatory research it may still be a challenge to recruit interviewee [45] and the sustainability of collaboration may be influence by changes in political elections [46]. Participatory research rests on certain pillars [48]. Genuine partnerships require a willingness on the part of all stakeholders to learn from one another. In addition to conducting research, there is a commitment to training community members in research methods. The knowledge and other products gained from research activities should benefit all partners. Politicians were closely involved in two of the Cases 2 and 3, and their involvement was regarded as a success factor by the practitioners and researchers
as well as politicians themselves. The involvement of NGOs was also high. In a previous study of five partnerships, ten different community/partnership capacities were analyzed [49]. The importance of strong leadership, participation, skills and resources to support the work, of an ability to form and maintain social and organizational networks and coalitions, and of shared values were among the capacity dimensions that resonated well with the partnerships examined here. All three cases were strong in this regard. Is there a gap between theory and reality in participatory research? In our three cases, the involvement of partners in shaping the scope and direction of research was found to be important. This may be an important step, as it is the degree of relevance and fit of the evidence to the practice that determines applicability [50]. There were similarities regarding the use of mixed methods research. Why do we need mixed methods? Qualitative and quantitative methods used in tandem provide a better understanding of research problems than does either method alone, i.e. used in the same study [51]. All methods have limitations, but the potential for triangulation may improve the quality of research. Focusing on processes, effects and context, as in these three cases, requires a mixed methods approach. A lesson learned during the emergence of the APPs partnership was that, right from the outset, there was a strong belief among the partners that a partnership for knowledge development was needed. Health promotion research needs to overcome the gap between practice and research. Involving relevant partners, such as politicians, practitioners, academics, and community members, and also joint planning, are important steps in initiating a trustful partnership. Commitment to the PSWD was for over 6 years, and partnership survived a changing political majority in two of the four municipalities. The Empowering Families program lasted for three years, but many of the alcohol-and-drug-prevention projects were of only a short duration. Sustainable structures and a trustful partnership of APP require long-term commitment from the partners. It was important in the three cases to have shared objectives for programs and dialogues about research. The partners facilitated data collection, and also the use of the results for further development. In contrast to our experiences, it has been reported that many grassroots community members, or organizations controlled by them, are rarely involved at the crucial decision stages of research, and instead limit their participation to the collecting of data [52]. In addition, most of the research is designed to produce
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94 C. Eriksson et al. papers, presentations or websites, rather than directly to support activities. Our three cases illustrate that it is possible to combine health promotion research and action. Dissemination was an integral part of activities in all three cases, and is an important component of a trustful APPP. Conclusion Development of a trustful academic–practice–policy partnership for research takes time. The fundamental elements are communication, collaboration, and shared visions, which all our three cases illustrate. Moreover, genuine partnership requires willingness on the part of all stakeholders to learn from one another. The knowledge and other products gained from research activities should benefit all partners. Bridging the research–practice–policy gaps requires shared knowledge about effective methods and tools, time and skilled personnel, leadership and administrative support, a shared language for concepts and tools, and a mandate for, commitment to and belief in the added value of implementing the actions involved. Acknowledgements Special thanks to Jonny Andersson, Ida Broman, Sofia Green, Ann-Britt Hagel, Eva Järliden, Madelene Larsson, Cecilia Ljung, Åke Setréus, Agneta Tinnfält and Lotta Zetterqvist, and to the participants in the workshops in Vestfold for discussions in relation to this analysis of APP partnerships. Conflict of interest The authors declare that there is no conflict of interest. Funding The research programs in the three cases were supported by grants to the first author from the National Board of Health and Welfare, the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, the National Institute of Public Health, and Swedish Public Health Agency. References [1] Draper AK, Hewitt G and Rifkin S. Chasing the dragon: developing indicators for the assessment of community participation in health programmes. Soc Sci Med 2010;71:1102– 9. [2] Stephens C. Community as practice: social representations of community and their implications for health promotion. J Community Appl Soc Psychol 2007;17:103–14. [3] Nutbeam D. Achieving best practice in health promotion: Improving the fit between research and practice. Health Educ Res 1996;11:317–26. [4] Baum F. The New Public Health. Victoria, Australia: Oxford University Press, 2002.
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[39] Geidne S and Eriksson C. Working together with or against the stores? Two different alcohol preventive strategies for working with purchase attempts. Health Educ 2009;109:259–78. [40] Pettersson C, Özdemir M and Eriksson C. Effects of a Parental Program for Preventing Underage Drinking – The NGO Program Strong and Clear. BMC Public Health 2011;11:251. [41] Geidne S, Quennerstedt M and Eriksson C. The implementation process of alcohol policies in eight different football clubs in Sweden. Health Educ 2013;113:196–215. [42] Fröding K. Public Health, Neighbourhood Development and Participation – Research and Practice in four Swedish Partnership Cities. PhD Thesis, Örebro University, Örebro Studies in Care Sciences 32, 2011. [43] Fröding K, Elander I and Eriksson C. Neighbourhood development and public health initiatives: who participates? Health Promot Int 2012; 27:102–16. [44] Geidne J, Fröding K, Montin S, et al. Implementation structure and participation at neighbourhood level- a multiple case study of neighbourhood development in Sweden. Syst Pract Action Res 2012; 25(4), 305–322. DOI 10.1007/ s11213–012–9227-y. [45] Fröding K, Elander I and Eriksson C. A community-based participatory research process in a poor Swedish neighbourhood. Syst Pract Action Res, 2014; May, on-line first. DOI 10.1007/s11213–014–9319-y. [46] Fröding K, Geidne J, Elander I, et al. Towards sustainable structures for neighbourhood development? Healthy city research in four Swedish municipalities 2003–2009. J Health Org Management 2013;27:225–45. [47] Eriksson C, Fröding K, Hulldin J, et al. Kompetenta familjer med ungdomar – Ideal och realitet i familjestödet i Karlskoga och Degerfors. [Empowering families with Teenagers: Ideals and realities of family support in Karlskoga and Degerfors]. Örebro: Örebro University, Studier i folkhälsovetenskap, 1, 2014. [48] Minkler M and Wallerstein N. Community-based Participatory Research for Health. San Francisco: Jossey-Bass, 2003. [49] Minkler M, Breckwich Vásquez V, Mansoureh Tajik M, et al. Promoting environmental justice through community-based participatory research: The role of community and partnership capacity. Health Educ Behav 2008;35:119–37. [50] Green LW. Closing the chasm between research and practice: evidence of and for change. Health Prom J Austr 2014;25:25–9. [51] Padgett DK. Qualitative and Mixed Methods in Public Health. London: Sage, 2012. [52] Stoecker R. Are we talking the walk of community-based research? Action Res 2009; 7(4): 385–404.
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research-article2014
SJP0010.1177/1403494814556926Health Promotion ResearchCC. Eriksson et al.
Scandinavian Journal of Public Health, 2014; 42(Suppl 15): 88–95
Original Article
Academic practice–policy partnerships for health promotion research: Experiences from three research programs
Charli C-G Eriksson, Ingela Fredriksson, Karin FRÖDING, Susanna Geidne & Camilla Pettersson School of Health and Medical Sciences, Orebro University, Orebro, Sweden
Abstract Background: The development of knowledge for health promotion requires an effective mechanism for collaboration between academics, practitioners, and policymakers. The challenge is better to understand the dynamic and ever-changing context of the researcher–practitioner–policymaker–community relationship. Aims: The aims were to explore the factors that foster Academic Practice Policy (APP) partnerships, and to systematically and transparently to review three cases. Methods: Three partnerships were included: Power and Commitment–Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden; Healthy City–Social Inclusion, Urban Governance, and Sustainable Welfare Development; and Empowering Families with Teenagers–Ideals and Reality in Karlskoga and Degerfors. The analysis includes searching for evidence for three hypotheses concerning contextual factors in multi-stakeholder collaboration, and the cumulative effects of partnership synergy. Results: APP partnerships emerge during different phases of research and development. Contextual factors are important; researchers need to be trusted by practitioners and politicians. During planning, it is important to involve the relevant partners. During the implementation phase, time is important. During data collection and capacity building, it is important to have shared objectives for and dialogues about research. Finally, dissemination needs to be integrated into any partnership. The links between process and outcomes in participatory research (PR) can be described by the theory of partnership synergy, which includes consideration of how PR can ensure culturally and logistically appropriate research, enhance recruitment capacity, and generate professional capacity and competence in stakeholder groups. Moreover, there are PR synergies over time. Conclusions: The fundamentals of a genuine partnership are communication, collaboration, shared visions, and willingness of all stakeholders to learn from one another. Key Words: Health promotion, research strategy, practice-based research, participatory research, review
Introduction It is well established that community participation is an essential component of health promotion and health intervention [1]. But, just how to achieve community participation in activities that aim to impact on health outcomes is less well established [2]. Moreover, health promotion research needs to be participatory. It needs to be practice-based, and built on a philosophy of partnership and the principles of self-determination, equity, and social justice. Development of knowledge for health promotion requires a well-developed mechanism for collaboration between academics, practitioners, and policymakers. Can an academic–practice–policy partnership
(APPP) be a mechanism for improving health promotion research? More than 17 years have passed since Nutbeam [3] noted the gap between the needs for knowledge and the priorities of research. There is an increasing demand for evidence-based methods and practice [4– 7]. The call for more practice-based evidence is a challenge to policymakers, practitioners, researchers, and funding agencies [8]. However, the gap between evidence and practice has still not been bridged, although some important progress has been made [8–19]. There have been different approaches to closing the practice-research gap. One has been to develop
Correspondence: Charli C-G Eriksson, Orebro University, School of Health and Medical Sciences, Orebro, SE-70182, Sweden. E-mail: charli. [email protected] (Accepted 02 October 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814556926
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Partnership for Health Promotion Research 89 topic-based research units, such as addiction research centers [20–23]. However, although a common element in the missions of these centers is to monitor substance use in the population, and its causes and courses, prevention research is not high on their agenda. A second approach lies in practice-based research. However, although practice-based research networks can be of value, a study of 46 networks, presented in 2006, found that barely half showed any kind of participation on the part of their members (patients), and none employed a fully participatory method [24]. A third approach to closing the worldwide gap between research and practice is to use applied academic centers, where a university, on the one hand, and treatment, public health and social welfare services, on the other, jointly make a long-term investment [25]. In The Netherlands, a central aim of such centers is to provide all the parties involved with meaningful knowledge of both practical and scientific value. Activities include developing a knowledge-exchange infrastructure within the organization, a long-term research program, and specific research projects. A fourth approach is that of participatory research (PR), which involves empowerment evaluation, collaborative evaluation, and stakeholder evaluation, and can be distinguished from approaches in which the researcher has an independent role. PR can be defined in terms of systematic inquiry, where there is collaboration between the people affected by the matter in question with regard to education, and taking action or effecting change [26]. In the arena of health promotion, one important purpose of community-based PR is to reduce health disparities [27,28]. PR focuses on the relationships between academic and community partners, according to the principles of co-learning, mutual benefit, and long-term commitment, and introduces community theories, participation and practices into research efforts [28]. What can PR offer to both researchers and endusers? It has become more accepted, due, among other things, to the claims that it increases awareness of the relevance of research to the people involved in the health promotion process and facilitates the translation of knowledge into practice [29]. And there are some critical reviews [30,31]. A recent assessment of the outcomes of PR adopted a realist review methodology to generate a robust understanding of complex and heterogeneous PR practice [32,33], and concluded that PR is a favorable approach to research, which supports health by improving research quality, empowerment, capacity building, sustainability, program extension, and unanticipated new activities. One aim of this paper was to explore factors that foster academic practice policy partnership (APPP).
Another aim was to systematically and transparently review three projects in line with recent critical realist reviews of participatory research [29,32–34] in order to better understand the dynamic and ever-changing context of the researcher-practitioner-policymakercommunity relationship. Methods We have chosen three projects within our own health promotion research programs as cases of APPP. The three research programs involved were practice based, and were conducted with careful attention paid to research ethics and to the use of research methods appropriate for the different questions addressed. For more information about the cases see Table I. The analysis includes searching for evidence for the three hypotheses proposed in a previous review [33]: (a) contextual factors, existing before a partnership is formed, partially determine the extent to which PR can enhance research outcomes; (b) synergy generated through multi-stakeholder collaboration, bringing diversity of perspectives and skills, advances research capacity beyond what could be achieved by a single stakeholder group working toward the same goals; and (c) partnership synergy has cumulative effects (i.e., builds momentum, strength, mutual trust, and understanding) over time, so that a PR outcome at one stage of research will influence subsequent stages. Data from the three case studies include results from reflective dialogues, evaluation meetings, and interviews with politicians, public health professionals and representatives of national agencies. In the three cases different types of triangulation have been used (data, methodological, investigator and theory). In this study the cases have been reviewed with regard to evidence on factor fostering APPP. By triangulation the core elements have been explored. Moreover, quotations will be provided from different cases. A key challenge in evaluating PR is that the PR approach may apply to an array of interventions, encompassing a multitude of research paradigms, methodologies, and methods [33]. For this study a realist review was chosen [34]. Adopting a realist approach provides a rationale and tools for synthesizing complex, difficult-to-interpret evidence [34]. A realist review is a theory-driven and abductive (informed–intuitive) approach to understanding context, mechanism, and outcome (CMO) configurations. Using this approach, the review focuses on exploring the impact of participatory processes or cogovernance on research processes and outcomes.
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90 C. Eriksson et al. Table 1. Characteristics of included cases of health promotion research. Case 1: Power and commitment– alcohol and drug prevention by non-governmental organizations in Sweden
Case 2: Healthy city–social inclusion, urban governance and sustainable welfare development
Case 3: Empowering families with teenagers–ideals and reality in Karlskoga and Degerfors
Aim
To promote integrated research and development in NGOs with regard to alcohol and drug prevention
To gain knowledge for family support to all parents, and to promote a municipal strategy for promoting competent families
Approach
The research program started in 2003, and is based on collaboration with NGOs (approx. 40 each year) [35].
Agencies involved
As part of the national strategy for alcohol, narcotics, doping and tobacco (ANDT), the National Board of Health and Welfare (NBHW), followed by the National Institute of Public Health (NIPH) and, from 2014, by the Public Health Agency of Sweden (PHAS)
Planning and design
The responsibilities of the national agency concerned, and the NGOs and the research team at Örebro University, were outlined at the start of the collaboration
Emergence of the partnership
Consultations, two conferences, project leader meetings each year. Implementation of annual work programs, annual progress reports on NGO projects and research
Research Outcome
In-depth studies, including two doctoral dissertations [36,37], and published papers [see, e.g., 38–41]
To work for the development of people’s health and welfare in four poor neighborhoods, with health, housing, economy, and education as the key arenas [42] A Partnership for Sustainable Welfare Development (PSWD) based on four municipalities, including municipal public housing companies and Örebro University (2003–2009) Sweden’s NIPH, the Swedish Association of Local Authorities and Regions, and the Swedish Association of Municipal Housing Companies. Research program was supported by the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning The partnership agreement and a research program were developed at the same time A planning grant was awarded by the NIPH, and the partnership agreement included the making of a small payment by each of the partners A steering group (politicians, public health officers, researchers), a coordinating committee (public health officers, researchers), and working groups) and annual conferences One doctoral dissertation [42] and research papers [see, for example, 43–46]
The emergence of APPP in the three cases was first analyzed chronologically. Then, configurations of context-mechanism-outcome (CMO) were used as heuristics to generate causal explanations, which means exploring the relationship between program context, mechanism, and outcomes of interest. Results It was possible to identify a number of CMO configurations in the three cases, which pertained to either a whole program or to just certain aspects of it, either embedded or in a series. In this paper, a selection of the most important processes for fostering the APPP in the three cases is presented.
The public health administration in Karlskoga and our research group developed a program called Empowering Families with Teenagers As part of its national strategy for parental support, the National Institute of Public Health (NIPH) published a call for proposals for research and development activities to be run by a municipality in collaboration with an academic institution The program was conducted jointly with regard to developmental activities and research questions
Collaboration between academics, practitioners and politicians in the municipalities took place in a steering group and a joint working group that met monthly Nine research studies and two meta-analytic studies, a family guide and a book in Swedish [47], and presentations at national and international conferences
Hypothesis 1: Contextual factors as partial determinants of PR outcomes Contextual factors, prevailing before a partnership was formed, were important for the emergence of PR, but there were differences between the three cases. In Case 1, the researcher was given the opportunity to develop a plan for the research and the development of an integrated research and competence-strengthening strategy to reinforce alcohol and drug prevention. There was limited previous experience of collaborating with NGOs. In Case 2, contextual factors played a more prominent role. One politician, one public health and one researcher had previously been the nexus for a
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Partnership for Health Promotion Research 91 national network for public health action in larger municipalities in Sweden, supported by the National Institute of Public Health (NIPH). Based on the evaluation report, a call for collaboration was sent to a number of Swedish municipalities, which resulted in the Partnership for Sustainable Welfare Development (PSWD). A key characteristic of this partnership was the involvement of politicians, public health officers and researchers, and also staff from the municipal housing company. The research program was developed jointly by researchers within the public health sciences and from the Center for Urban and Regional Studies at Örebro University. These researchers had not met before, but they found that they had many interests and perspectives in common. In Case 3, the joint public health administration in Karlskoga and Degerfors was responsible for public health strategy and initiative taking. The political board was responsible for the application to the NIPH that was developed by public health professionals and researchers. The NIPH decided on how the money should be divided between the partners. The academy, practice and policy had not been working together before, The experiences in the cases supported the hypothesis that contextual factors are important preconditions for PR. Researchers need to be trusted by practitioners and politicians, as indicated by the records of previous research records and the relevance and quality of research achievements. Hypothesis 2: Synergy generated through multistakeholder collaboration Four different patterns of CMO have previously been observed to support this hypothesis in the previous review [33]. The cases chosen in this article give further support for the value of multi-stakeholder collaboration through the four different patterns, which emerged from the data collected in the three cases. Culturally appropriate and logistically sound research. One important result of research collaboration was found to be the development of culturally appropriate and logistically sound research. Several different CMOs contributed to this development. Shaping the scope and direction of research. In all three cases the development of the research approach was of critical importance. In Case 1, the NGOs had responsibility for planning, implementing, and reporting on the organizations’ projects. The research team had responsibility for in-depth studies of selected projects, and also for support activities.
A program officer at a national agency stated in Case 1: It is important that research and evaluation are independent of the national agency and the NGOs. Also, there is added value to the knowledge that the researchers bring to the process. This is acknowledged by the NGOs, since all of them want their own project to be selected as an in-depth study.
A politician in Case 2 put it like this: Generally, it is the municipality, at least in Sweden, that focuses on the daily work. There is less focus on evaluation, even less on research, and almost no focus at all on the combination of research and action, going from theory to practice. That’s why our approach is important (Politician, Case 2).
Developing program and research protocols. The indepth studies in Case 1 involved joint planning by the NGO in question and the research team, which resulted in a written agreement between the research team and the organization. The agreement outlined details of the implementation of the research collaboration. In Case 2 a politician said: We spent a lot of time on discussions to formulate common goals and conclude written agreements.
In all cases, the health promotion activities were valuebased. In Case 3 a public health strategist stated: The program rests on the UN Convention of the Child and Sweden’s National Public Health Strategy, which both highlight participation and involvement. Accordingly, there is a strong emphasis on participatory processes.
Implementing program and research protocols. In Case 1 the NGOs involved in the in-depth studies had responsibility for the implementation of their intervention program, while the research team had the responsibility to perform the research activities. The design of the study, and also the research questions, were discussed with the NGOs. Moreover, the NGOs facilitated the data collections, since they had been tailored to the intervention. Mixed methods designs were used as part of the research protocol in all cases. For instance, in Case 3, qualitative studies were performed to investigate “what is a good family.” They included participatory research with teenagers, interviews with teenagers and parents, essay writing by teenagers, and open questions in a survey administered to parents. The
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92 C. Eriksson et al. results were presented locally at dialogue seminars, which constituted both a validity check and a form of dissemination to participants, including municipal professionals, politicians and parents. In Case 1 a project leader stated: Three important elements are good contacts, respect for different roles, and talking about timetables.
Interpreting and disseminating research findings. As part of the participatory process in Case 1, final results were presented and discussed with the NGOs. The end results were published at conferences, in scientific articles and research reports, and on the research team’s website. An important avenue for dissemination was the biannual conference, Reflection on Prevention, which is a national conference, organized by our research team that focuses on alcohol and drug prevention. In Case 1 a project leader said: It has been important that the research group has shown sensitivity, been understanding and believed in the program, and also shown respect for the Little Sisters [the target group] and the Big Sisters [the volunteers]. Regular feedback has also been important.
PR generates capacity to recruit. In all cases, a second pattern was that the PR generated capacity to recruit participants. Development of relationships was an important outcome of the extended planning period in Case 2. Such development was reinforced by regular meetings in the different groups. The annual meetings and planning for the second agreement involved all the partners. Politicians from both the majority and opposition parties participated. Also, partners presented the PSWD at national and international conferences, which strengthened the collaboration. The research team participated in most of the partnership groups. Moreover, the PhD students were responsible for practice-based studies, involving practitioners and managers at strategic and operational levels. People working and living in the neighborhoods participated in the innovative research, i.e., the collegial inquiry and the participatory research. The research questions were also discussed in the coordinating committee. In Case 2 a public health officer stated: We aimed to build bridges between strategic and operational levels, between politicians and practitioners, which can transform and share the knowledge possessed by each group.
In Case 3 the public health strategist said:
It is important to involve the politicians. The joint political board for public health in Karlskoga and Degerfors has been highly instrumental).
PR develops capacity and competence of stakeholders. A third pattern was that PR develops capacity and competence. The participatory process was important for the practitioners and politicians as well as the researchers. In Case 2 a researcher state: The good thing about the partnership is that we can inspire one another, at the same time as we learn from one another
In the same case a politician said: It was also important that politicians from the four municipalities met each other alone to discuss political issues.
In Case 3, different stakeholders and family members participated in a dialogue forum during the planning phase, and engaged in further dialogue in seminars after implementation of the various studies. PR generates disagreements between the co-governing stakeholders during decision-making processes. In contrast with the findings of the previous review, the fourth pattern of disagreements was not much in evidence in the three cases. One concern, however, was raised about partnership quality by a politician in Case 2: Meeting places are not good enough. The sectorial organization is a barrier for pursuing multi-sectorial issues, such as public-health promotion and neighborhood renewal. The chief executive or top managers should also be involved.
Moreover, in the participatory research project in one of the neighborhoods in Case 2, among the lessons learned were the needs openly to discuss individual situations, personal commitments, and mutual expectations, and also to unmask power and authority among the people involved in the participatory process. For more details see the separate paper [45]. Hypothesis 3: Cumulative partnership synergy over time PR contributed to an increase in the quality of outputs and outcomes over time through repeated successful partnering. In Case 1, partnership synergy was facilitated by the collaboration. This involved a number of program components that fostered trustful partnership
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Partnership for Health Promotion Research 93 between the researchers, practitioners, and policymakers: meetings with project leaders, project dialogues, competence strengthening, support for documentation, in-depth studies, and biannual national conferences. A detailed analysis has been published [35]. In Case 2, the partnership synergy resulted in a second partnership agreement, thus extending the program for three additional years beyond a national election. A public health officer said: It is important to hold regular meetings in the partners’ own environments, engage in a long-term process with a clear political program for more than one election period.
Moreover, the PR generated new unanticipated projects and activity. For instance, in Case 1, NGOs made alliances and developed new joint activities. They were competitive and received funding from the national agency. Discussion We found by using the critical realist approach and the theory proposed in a recent review of PR [32,33] that PR can generate positive results through beneficial contextual factors, multi-stakeholder collaboration, and cumulative partnership synergy. Successful partnership of APP requires contexts that foster a trustful partnership with respectful recognition of each partner’s competence and interests. Moreover, multi-stage collaboration could ensure culturally and logistically appropriate research, enhance recruitment capacity, and generate professional capacity and competence in stakeholder groups. Cumulative partnership synergy could increase the quality of outputs and outcomes over time, increase the sustainability of project goals beyond funded time frames, and create new unanticipated projects and activities. However, as show in our three cases, there are also factors that may reduce the added value of PR. For example in participatory research it may still be a challenge to recruit interviewee [45] and the sustainability of collaboration may be influence by changes in political elections [46]. Participatory research rests on certain pillars [48]. Genuine partnerships require a willingness on the part of all stakeholders to learn from one another. In addition to conducting research, there is a commitment to training community members in research methods. The knowledge and other products gained from research activities should benefit all partners. Politicians were closely involved in two of the Cases 2 and 3, and their involvement was regarded as a success factor by the practitioners and researchers
as well as politicians themselves. The involvement of NGOs was also high. In a previous study of five partnerships, ten different community/partnership capacities were analyzed [49]. The importance of strong leadership, participation, skills and resources to support the work, of an ability to form and maintain social and organizational networks and coalitions, and of shared values were among the capacity dimensions that resonated well with the partnerships examined here. All three cases were strong in this regard. Is there a gap between theory and reality in participatory research? In our three cases, the involvement of partners in shaping the scope and direction of research was found to be important. This may be an important step, as it is the degree of relevance and fit of the evidence to the practice that determines applicability [50]. There were similarities regarding the use of mixed methods research. Why do we need mixed methods? Qualitative and quantitative methods used in tandem provide a better understanding of research problems than does either method alone, i.e. used in the same study [51]. All methods have limitations, but the potential for triangulation may improve the quality of research. Focusing on processes, effects and context, as in these three cases, requires a mixed methods approach. A lesson learned during the emergence of the APPs partnership was that, right from the outset, there was a strong belief among the partners that a partnership for knowledge development was needed. Health promotion research needs to overcome the gap between practice and research. Involving relevant partners, such as politicians, practitioners, academics, and community members, and also joint planning, are important steps in initiating a trustful partnership. Commitment to the PSWD was for over 6 years, and partnership survived a changing political majority in two of the four municipalities. The Empowering Families program lasted for three years, but many of the alcohol-and-drug-prevention projects were of only a short duration. Sustainable structures and a trustful partnership of APP require long-term commitment from the partners. It was important in the three cases to have shared objectives for programs and dialogues about research. The partners facilitated data collection, and also the use of the results for further development. In contrast to our experiences, it has been reported that many grassroots community members, or organizations controlled by them, are rarely involved at the crucial decision stages of research, and instead limit their participation to the collecting of data [52]. In addition, most of the research is designed to produce
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94 C. Eriksson et al. papers, presentations or websites, rather than directly to support activities. Our three cases illustrate that it is possible to combine health promotion research and action. Dissemination was an integral part of activities in all three cases, and is an important component of a trustful APPP. Conclusion Development of a trustful academic–practice–policy partnership for research takes time. The fundamental elements are communication, collaboration, and shared visions, which all our three cases illustrate. Moreover, genuine partnership requires willingness on the part of all stakeholders to learn from one another. The knowledge and other products gained from research activities should benefit all partners. Bridging the research–practice–policy gaps requires shared knowledge about effective methods and tools, time and skilled personnel, leadership and administrative support, a shared language for concepts and tools, and a mandate for, commitment to and belief in the added value of implementing the actions involved. Acknowledgements Special thanks to Jonny Andersson, Ida Broman, Sofia Green, Ann-Britt Hagel, Eva Järliden, Madelene Larsson, Cecilia Ljung, Åke Setréus, Agneta Tinnfält and Lotta Zetterqvist, and to the participants in the workshops in Vestfold for discussions in relation to this analysis of APP partnerships. Conflict of interest The authors declare that there is no conflict of interest. Funding The research programs in the three cases were supported by grants to the first author from the National Board of Health and Welfare, the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, the National Institute of Public Health, and Swedish Public Health Agency. References [1] Draper AK, Hewitt G and Rifkin S. Chasing the dragon: developing indicators for the assessment of community participation in health programmes. Soc Sci Med 2010;71:1102– 9. [2] Stephens C. Community as practice: social representations of community and their implications for health promotion. J Community Appl Soc Psychol 2007;17:103–14. [3] Nutbeam D. Achieving best practice in health promotion: Improving the fit between research and practice. Health Educ Res 1996;11:317–26. [4] Baum F. The New Public Health. Victoria, Australia: Oxford University Press, 2002.
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