A Case Study in Chamorro Community and Academic Engagement for a Community-Partnered Research Approach

Objective: We describe the development of a community and academic research partnership, share reflections on processes for collaborations, and identify key factors for establishing strong and effective relationships to foster high-quality research. Background: A community-based participatory research (CBPR) effort evaluating a community-based patient navigation program assisting Chamorro women to access breast cancer services in Southern California served as the foundation for the development of the community-academic partnership. Methods: Using a CBPR approach focusing on active involvement of community members, organizational representatives, and academic researchers in all aspects of research process, faculty from a research university and a local community-based organization were brought together to build a partnership. Community and academic partners engaged in a series of meetings where dialogue focused on developing and nurturing trust and shared values, respect for community knowledge, and establishing community-defined and prioritized needs and goals. Partners have also focused on defining and developing explicit structures and policies to implement an equal partnership. Results: Experiences and lessons learned are shared, reflecting the processes of relationship building, and planning and implementing preliminary research steps. Lessons Learned: Adequate time for relationship-building, open and honest communication, flexibility, and ongoing examination of assumptions are keys to developing successful CBPR partnerships. © 2010 Californian Journal of Health Promotion. All rights reserved.


Introduction
Pacific Islanders in the U.S. experience disparities in access to care leading to late stage breast cancer diagnosis and alarming disparities in 5-year cancer survival rates (Goggins, 2007).Community Based, Participatory Research (CBPR) approaches, characterized by full partnership among community stakeholders and academic researchers, are the subject of increasing interest in the fight to eliminate health disparities, and hold significant promise for the conduct of research concerning racial and ethnic minorities, including Pacific Islanders.
The purpose of this paper is to present reflections of community and academic research partners as they engage in the process of developing a new community-academic partnership, with the goal of conducting research evaluating a Chamorro community-led patient navigation program to reduce cancer disparities.We will review the health disparities facing Chamorros and other Pacific Islanders, the theoretical principles of CBPR and how we have sought to implement them in our partnership, and we identify key factors for establishing strong and effective relationships between academic and community researchers.

Background and Significance
Pacific Islander Health Pacific Islanders are the people of Polynesia (e.g., Native Hawaiians, Samoans), Micronesia (e.g., Chamorros, the indigenous people of Guam and the Northern Mariana Islands) and Melanesia (e.g., Fijians).Existing literature generally portrays the Asian and Pacific Islander population in aggregate as experiencing equal or better health than non-Hispanic whites.However, aggregating these data masks the high variability among subgroups (Tanjasiri, 1995).Chamorros are rarely specified as an ethnic subgroup in U.S. health statistics.Some reports specify Guamanian background; however, this categorization often groups Filipinos, Japanese and other diverse ethnicities living in Guam with Chamorros.
Existing data for Pacific Islanders in the U.S. indicate serious cancer disparities.Native Hawaiian women have the highest breast cancer incidence and mortality of all ethnic groups in Hawaii (Braun, 2004).Although breast cancer incidence has been declining over time for many ethnic groups in Los Angeles County, it has been increasing for Native Hawaiian and Samoan women (Cockburn, 2009).Moreover, Pacific Islander women experience significantly worse 5-year breast cancer survival rates than non-Hispanic whites, apparently associated with late stage at diagnosis (Goggins, 2007).These disparities are likely due, at least in part, to barriers to care spanning the care continuum, including screening, treatment and supportive services.For example, available data indicate that Chamorro women experience breast cancer screening rates that are far below national objectives (Special Services for Groups, 2001;Tanjasiri, 2001).Focus groups conducted as part of the Promoting Access to Health for Pacific Islander and Southeast Asian Women (PATH for Women) project in Southern California indicate that cancer knowledge, attitudes, beliefs about cancer causes, meanings of cancer, and deep distrust of the mainstream U.S. medical care system are significant barriers to care, as are structural barriers such as a lack of a regular source of care, health insurance, and transportation, as well as family care-giving responsibilities (Special Services for Groups, 2001).In particular, Chamorros in Southern California reported that lack of respect from health care providers poses a significant barrier to the use of breast health services (Special Services for Groups, 2001).

Who are Chamorro?
Chamorros are the indigenous people of the Mariana Islands, which include the American territory of Guam and the Commonwealth of the Northern Mariana Islands in Micronesia.According to the 2000 Census, approximately 65,000 people of Chamorro ancestry live on Guam and another 19,000 live in the Northern Marianas.Significant Chamorro populations reside in several U.S. states, with over 33,000 in California, approximately 18,000 of these in Southern California.

Chamorro Values
Pacific Islanders comprise diverse populations with distinct languages and cultures, but also many share common cultural values that govern their world view and relationships to one another.Examples include holism, family, and spirituality.Holism is the central element of the Pacific Islander world view: viewing all parts of the world as interconnected.Chamorros refer to this as kostumbren Chamorro (i.e., the Chamorro way of life including family, faith, and food).Pacific Islander cultures place a great emphasis and value on the family.Family includes relatives by blood, marriage and adoption.Kinship for many Pacific Islanders is viewed in the context of the entire community.Social networks are rooted in families (maternal and paternal lineage) which are an important part of one's identity (Farrell, 1991).Social networks also dictate group and community norms and are often associated with respect for elders and indigenous leaders.Spirituality is also a central element of the Pacific Islander world view and alludes to ancestral communication and connection as well as faith-based relationships (Farrell, 1991;Bureau of Primary Health Care, 1998).Recognition of the significance of these specific Pacific Islander cultural values, and of the potential for community-based navigation, formed the basis for Guam Communications Network's development of the Målle' (Godmother) program, a lay peer patient navigation program to assist Chamorro women with access to breast cancer services across the continuum of cancer care, from prevention and early detection, to treatment and end-of-life care.

Patient Navigation
Patient navigation was originally conceived as an intervention to address disparities in breast cancer care in Harlem in 1990, and has been gaining attention as a promising intervention to address barriers to care experienced by underserved minority patients (Freeman, 1995;2006).Although several studies have now described and evaluated clinic or hospital-based navigators, few published studies have described or examined the effectiveness of communitybased navigators, especially among Pacific Islanders (Wells, 2008).This model of navigation may be more likely to reach women who are not yet engaged with the healthcare system than a clinic-based model (Nguyen, 2006).Navigators in this model are more likely to be equipped with the social networks and understanding of cultural beliefs and values, and community resources, to enable them to provide the culturally appropriate services necessary to bridge gaps between communities and healthcare providers.This approach has the potential to foster trust and build a sense of community ownership and empowerment, in turn increasing utilization and adherence (Bird, 1996;Nguyen TT, 2006;Nguyen TN, 2006;Lisovicz 2006).

Community-based Participatory Research (CBPR)
Community participatory approaches to research are the subject of increasing interest in the fight to eliminate health disparities experienced by many racial and ethnic communities.Many racial and ethnic communities in the U.S. associate "research" with past experiences of exploitation, leaving communities distrustful and suspicious.(Tanjasiri 2002;Wells 2009).This is particularly true of Chamorros, who recall a recent history of occupation, radiation exposure, and the loss of indigenous lands for United States military installations.CBPR approaches hold particular significance for those who seek a more appropriate balance of leadership, power, and self-determination in the conduct of research concerning their communities.
CBPR is characterized by a full partnership among community members, representatives, and academic researchers (Israel, 2006).In CBPR, community and academic partners work according to key principles that seek to enhance the community's welfare, foster mutual respect and open communication, and recognize the importance of shared power among all community and academic research team members (Israel, 1998;Wallerstein, 2003).Table 1 notes some commonalities between principles and values of CBPR (adapted from Israel et al, 1998), and Chamorro cultural values.
CBPR has great potential to improve the validity and relevance of research efforts by increasing community motivation to participate in research efforts, increasing the likelihood of acceptability of the research approach, enhancing recruitment and retention, increasing the likelihood that measures will be reliable and valid, and increasing the potential to translate findings into interventions that will be appropriate and acceptable to the communities they are meant to serve.

Methods
The authors are currently engaging in an ongoing process of implementing a CBPR approach focusing on active involvement of community members, community-based organizational representatives, and academic researchers in all aspects of the research process.This exemplifies the iterative process necessary to develop trust and respect to foster strong, effective, participatory partnerships.This manuscript grew out of a process of reflection Through an iterative process, the program director interacted with the researcher and community agency to establish interest and readiness to partner in a community-based evaluation effort.Information including the researcher's curriculum vitae and a brief personal statement were provided for the partners to learn more about the researcher's interests.Face to face meetings were also arranged so that all parties had the opportunity to get to know one another.As a result of these interactions, including monthly face to face meetings lasting two to three hours each, conference calls, and email exchanges, a partnership began to develop over the Fall of 2008, and in 2009 we began the process of actively considering a research collaboration.As a result of continued monthly meetings as well as email and telephone communications over the first quarter of 2009, a set of community-defined and prioritized needs and goals was established, while nurturing trust and a sense of shared values and common goals.This reflects the CBPR principles of recognizing the community as a unit of identity and building on the strengths and resources within the community to facilitate an effort for mutual benefit to all partners.
In the Pacific Islands, people engage in informal conversations commonly known as "talk story" (Taosaka, 2002).Talk story is focused on conversations to help newly introduced parties to learn more about one another, share information, establish common ground, and build trust.Among those with an existing relationship, talk story serves to re-establish and reinforce relationships and trust.While curriculum vitas and personal biographies are important, it is through this iterative process in which individuals are able to dialogue that foundations for trust and partnership are established.Following this tradition, initial meetings involved face-to-face gatherings of GCN staff and the researcher, talking story, and sharing meals.GCNs Executive Director as well as staff members interviewed the researcher about her background, motivations, interests, and commitment to CBPR and to Pacific Islanders and the Chamorro community.Key principles were established, namely, the importance of viewing the community as a partner in, rather than the subject of research, the establishment of a full and equal partnership in all phases of the work, with commitments to shared power in terms of decision-making, data ownership, and ensuring results benefit the community through the dissemination of findings to all partners and the community.
Other concerns included the establishment of a long-term relationship, and leveraging project activities to involve the mentorship of young community members.These principles, recognized as fundamentals of CBPR, are also highly consistent with the Chamorro cultural concept of Inafa' maolek, which encompasses understanding how others feel, and acting on those feelings with care and concern; the promotion of interconnectedness, compassion, and caring; developing and nurturing trust, sharing, mutual respect, and co-learning; and mutuality, reciprocity, and cooperative spirit over individualism (Table 1).
Together, through various discussions, alternative directions for collaborative research were considered.The pros and cons of various research ideas with respect to community priorities, the resources of each partner, feasibility of implementation, and potential for future sustainability through grants for follow-on work were discussed in a series of subsequent meetings.Input and advice were also obtained from the PATH for Women director and the senior academic partner, who have been longstanding, trusted partners of the community for many years.After discussions and deliberations over approximately six face-toface meetings and numerous follow-up email and telephone communications including proposals, counter-proposals, and discussions of pros and cons, we decided to pursue a process evaluation of GCN's or Målle' program.While this process was time consuming, it was important in the relationship building process and in identifying the priorities and needs of the community.This process also helped to facilitate co-learning about one another, as individuals, agencies and the roles of both within the community.This interdependence facilitates the CBPR principle of co-learning and empowerment to address social inequalities, as well as learning to recognize each other's strengths.
Early meetings also focused on an ongoing process of defining and articulating principles and values of the partnership, and developing structures and explicit policies to ensure that the principles and values of an equal partnership would be implemented in day-to-day practice.Together we developed a memorandum of understanding which outlined our partnership principles and values, based on the principles of CBPR as articulated by Israel (1998) and Wells (2009), roles and responsibilities, and outlined several policies, procedures, and to begin to establish and to guide our actual operating norms, modeled after work by Wells and Jones (2009), Palermo et al, (2006), andGreene-Moton et al. (2006).Significant issues included transparency with respect to each partner's needs and goals, data ownership, budget and other resource issues, designated point persons, preferred modes of communication, decision-making processes, and approaches for conflict resolution should the need arise.
Over the following several months, we set to work laying out the details of our research protocol and developing our application for review by academic and community institutional review boards (IRBs) for the protection of research subjects.To honor the equitable and collaborative aspect of CBPR and to empower community, we agreed to develop applications for both IRBs.The Special Services for Groups community IRB application process is a rigorous one, which compels partners to simultaneously examine details of their plans for their research activities, participation of and impact on the community, and the fundamentals of the project and research partnership.The University of California Los Angeles IRB additionally required human subjects protection training of the community staff who would be involved with recruitment of participants, focus group moderation, and data analysis, and also required the community agency to obtain a Department of Health and Human Services Office for Human Research Protections Federalwide Assurance.The process from reaching preliminary agreement on research project concept, directions and strategies to obtaining approvals from both IRBs took nearly one year.

Discussion
Overcoming Challenges Next, we share observations and reflections regarding certain challenges that can often arise in community partnered research projects.The following is not meant to be an exhaustive discussion, but reflects issues that we have experienced in our partnership.The following issues were identified through a review of notes from project meetings and discussions on challenges we have faced, lessons learned, and recommendations we believe may be useful to others planning to engage in CBPR.These are summarized in Table 2.

Communication of Each Partner's Needs and Goals
Academic researchers and community advocates often share many of the same overarching long-term goals such as a desire to ameliorate health disparities in the community.However, some intermediate goals do not always overlap.Doyle (2006;2008) has articulated a number of community and researcher goals that can at times be sources of tension in the process of conducting CBPR.In the world of research, in Doyle's view, individuals are often driven to meet the institutional expectations of "productivity," which in this setting is measured in terms of publication volume and ongoing extramural funding within a limited time frame prior to decisions about faculty retention and promotion.Community service, even when required, is frequently viewed as making a negligible contribution towards decisions about faculty retention.Moreover, in research universities, evidence of "independent" work is often emphasized over more collaborative team efforts.In the world of community leaders and advocates are driven by the need to build and sustain trusting relationships over time, in order to work towards long-term goals of real and lasting change in the community.Community leaders must be concerned not only with the short-term needs of a particular project, but long-term consequences of what they ask of their staff, clients, partner organizations, and other constituents in the community, and what relevant results or benefits accrue to the community to which they are accountable.Developing a shared understanding of each partners' needs, pressures, and perspectives through both ongoing dialogue and action is essential to developing a trusting, sustainable relationship.

Structure of Funding Mechanism
The particular context in which the authors' partnership was born presented certain opportunities and challenges.In this case, the academic partner was funded by an award mechanism with an aim focused on career development.The benefit of this arrangement from the standpoint of a new CBPR project was that a large proportion of her total time was protected to work on this project, as compared with common arrangements in which the researcher's time is split across numerous research projects and a large teaching and/or clinical workload.The disadvantage was that, as is common with career development award mechanisms, funds for actual project operations were limited.In addition, funds were controlled by the academic partner's research institution.Lack of independent funding controlled by community partners is not ideal for true partnership in the conduct of CBPR.Although sub-optimal, our arrangement proved workable due to the synergies between this project and GCN's funded PATH for Women scope of work.The PATH for Women project ensured resource support to GCN to operate and maintain the Målle' project, such that an evaluation component could be developed through this career development project.Often, community and academic partners alike continue their efforts well beyond the funding cycle of a grant; commitments do not drop because funding has ceased.It must, therefore, be noted that financial resources are needed to initiate, support, and maintain CBPR efforts.While in this case other resources supported the community organization, it is important to consider what value there is for communitybased agencies to engage in CBPR efforts when initially there are no resources to support the time and effort involved in relationship development.In addition, the typical funding arrangement in which academic institutions hold and distribute grant funds perpetuates power imbalances.Faced with this situation in our case, we did our best for transparency and partnership in terms of laying out the budget within the parameters for what funds could be allocated for what purposes, and have sought to work in partnership to determine, for example, what funds could be used to include community members as focus group moderators and interpreters, and for stipends to honor the time of community advisors.

The Need for Time
Time is arguably as scarce a resource as funding.In the community, active community advocates, directors and staff of community-based organizations are typically pressured to deliver more and more services with less and less funding, working long hours, many of which are often uncompensated, to meet the needs of their clients while keeping their organization afloat.Monthly face-to-face meetings during office hours when staff could be paid.Commitment to iterative process with input, questions, and revisions from multiple stakeholders.Willingness to question assumptions, reexamine prior decisions.
Equally shared data ownership.
IRB concerns regarding secure data storage by community agency; agency director access to data which included staff interviews.IRB requirement of Federal-Wide Assurance (FWA) introduced confusion, delays.
Mutually agreed-upon data security plans to include de-identification of data, data storage by third-party community partner agency.
All partners learned process for and obtained FWA Community capacity-building, e.g., training and opportunities for involvement of community members in research activities throughout project.
Relatively limited funds to include community members as paid project staff.
Competing priorities, distrust, uncertainty regarding value among community members.
Reductions in planned participant numbers and reimbursement to ensure funding for community-based focus group moderator, transcription.Plan to involve student intern to work on project though paid Pipeline program.Community partner outreach, "talk story," to facilitate introductions, establish linkages between community and researchers.
Shared power in terms of funds.
Grant controlled by academic institution.Subcontract administratively burdensome for partners given small size of budget.
Delays in payment from academic institution.
Misunderstanding among partners regarding non-receipt of payment.
Transparency regarding budget, with agreements documented in MOU.
Transparency regarding academic institutional processes and rules for fund disbursements.
Learned most efficient and appropriate payment mechanisms for needs of project.Multiple methods of communication; involving all partners in communications.
Academic researchers, particularly junior faculty who face a "publish or perish" tenure clock, are constantly pressured to demonstrate productivity in terms of publishing results as quickly as possible, lest they find themselves with insufficient publications for promotion and consequently without a job.It is ironic that often those most interested in conducting CBPR are the younger generation of junior faculty who are most vulnerable to "publish or perish" time pressures.The time needed to establish new relationships with unknown individuals from different and often unfamiliar disciplines is often viewed as a luxury, yet it is an essential The time needed for this process often exceeds either partner's expectations, and is time that is taken away from competing priorities such as service delivery, fund-raising, teaching, and conference and other travel demands.

The Need for Ongoing Clear Communication, and Examination of Assumptions
The process of developing the community IRB application challenged us to reexamine several aspects of our research plans initially thought to be resolved.First, in considering the questions posed by the application about inclusion and exclusion criteria, representativeness, and rationale, GCN raised concerns about initial plans to include only monolingual Englishspeaking women.This decision had been made initially on the basis of financial limitations.However, as the team reconsidered the demographic and cultural realities of the women most likely to utilize navigation services and to participate in the study, it became apparent that making no provisions for use of Chamorro language and needs for interpretation would severely limit the acceptability and the generalizability of the study, as well as the applicability of the pilot study results to future research plans.
Second, in drafting the narrative of our project description, we discovered a misconception regarding the Målle' program.Although it was understood that a unique aspect of PATH for Women community patient navigators is that they work across the entire continuum of cancer care, the academic researcher had been working under the impression that the majority of GCN Målle' work dealt primarily with navigating women through breast cancer screening services.
In fact, this is not the case: the GCN Målle' devote a large proportion of their time and efforts to navigating individuals who have received cancer diagnoses and are undergoing treatment (as well as their family members and caregivers).This experience served as a striking reminder that, despite numerous in-depth conversations, misunderstandings may go undetected until such time as assumptions are made explicit.This may result from a number of factors, including assumptions or incorrect understanding regarding shared meaning of language, particularly jargon or terms with inherently imprecise meaning (e.g., "patient navigator," "access to services"), and use of generalities without articulation of precise details.
Again, sufficient time must be protected for a cyclical, incremental process of initial development, evaluation, critique, and revision of plans and protocols, questioning assumptions, and checking in with one another on an ongoing basis as realities on the ground evolve.Previous research has found that community partners feel community-academic partnerships work best when all issues are potentially open for negotiation (Wolff, 2001).This approach can contribute to a time consuming and difficult process for any collaborative effort, but such an approach may be essential to communityacademic partnerships, potentially operating under a cloud of issues of past imbalances of power, control, decision-making and accountability.

Conclusions
In summary, to date, we have taken steps to establish a new community-academic research partnership, guided by principles including coequal community control of the research processes such as problem-definition and protocol planning (Table 3).We have successfully developed a working set of research priorities and plans, have begun to develop data collection instruments, and have developed protocols for human subjects protection.We are developing a memorandum of understanding aimed at translating CBPR principles into a realworld equal community and academic research partnership.Next steps will involve further development and refinement of data collection instruments in partnership with GCN and Chamorro advisors, and data collection with mixed methods involving interviews, focus groups, and direct observation, to begin to evaluate the impact of a culturally tailored community-based health navigation model for breast cancer in the Southern California Chamorro community.Analysis and interpretation of data, and synthesis and dissemination of findings for community and academic audiences will also occur with the full participation of all team members.The results of this work will be used for ongoing program quality improvement, as well as to leverage future funding to enhance program sustainability.
Adequate time for relationship-building, open and honest communication, flexibility, humility, and willingness to release assumptions are keys to developing successful CBPR partnerships.This effort is an example of the various factors that must be identified and discussed to build strong and effective research relationships.Although, on the surface, it seems quite appropriate to bring together groups with similar interests to work together, there must be an iterative "getting to know you" process in which trust and respect are developed and partners can negotiate roles and responsibilities.In these processes the strengths and assets of each group/community are brought to light and highlighted to strengthen the partnership.

Table 1
CBPR Principles and Chamorro Values: A Comparison

Table 2
Overcoming Challenges

Table 3
Patient Navigation Project Partnership Activities