A systematic review of community-based participatory research to enhance clinical trials in racial and ethnic minority groups.The value of fostering community engagement in health disparities research has long been apparent (Kindon, Pain, and Kesby 2007; Minkler and Wallerstein 2008). Engaging community members in interventional studies and projects is an attractive approach through which researchers may more effectively increase racial and ethnic minority participation in trials, theoretically improving measurement of health disparities and yielding more valuable research data (Minkler and Wallerstein 2008). Community-based participatory research (CBPR) is an approach to research that takes community involvement beyond the subject participant level. Studies employing CBPR engage community members not as subjects, but rather as partners, involving the community in every stage of research, ideally from identifying the study question at hand, to developing an intervention, recruiting participants, collecting data, interpreting research findings, delivering interventions, and disseminating results (Israel et al. 2005).
Community-based participatory research theory suggests that engaging community members as collaborators in health disparities research is powerful on multiple levels. Developing a research project from the bottom-up (starting with community members to identify salient issues important to a particular population) rather than the traditional top-down approach (where researchers identify an agenda that may not be reflective of a community's needs) would inherently appear to improve a population's participation and enthusiasm for an intervention. Since CBPR researchers approach community members as partners, not subjects, one would expect that the community's engagement and retention would be maximized, as the community would be invested in the intervention and outcomes. One could therefore argue that CBPR could be a powerful tool for researchers to improve measurement of health disparities and to analyze health care delivery to particular communities, as well as for policy makers interested in legislating effective and meaningful change for these communities.
Though appealing on many levels, CBPR is often a challenging investment for researchers. Often, the level of time commitment required is substantial, given the time needed for researchers to build and sustain community partnerships (Kindon, Pain, and Kesby 2007; Minkler and Wallerstein 2008). Furthermore, few studies have been identified that successfully combine the approach of community collaboration with rigorous research methods. In 2004, the Agency of Healthcare Research and Quality (AHRQ) published a review of the CBPR literature spanning the years 1975-2003, which revealed that while many studies employed the methods of CBPR, few combined this collaborative approach with rigorous methods of scientific inquiry such as randomized-controlled designs (Viswanathan et al. 2004). The report provided guidelines for researchers on how to increase the scientific rigor of studies employing CBPR. Since the AHRQ report was released, however, there has been no further examination of the quality, scientific rigor, and effectiveness of published CBPR studies. To address this knowledge gap, we performed a systematic review of published articles from 2003 to 2010 that employed CBPR methodology in clinical trials. Our study aims to establish the rigor and effectiveness of current CBPR clinical trials and thereby describe the current state of CBPR in the clinical trial literature. By examining the CBPR trials published during this time period and the effectiveness of interventions, we hope to assess whether this method of research holds promise as a meaningful method of investigation for health services research.
Recognizing that the body of CBPR literature is far more extensive than the studies indexed on Index Medicus (Wallerstein et al. 2008) and in keeping with the AHRQ systematic review method, we chose to review only those articles indexed in databases of peer-reviewed literature, which represent the journals with reliable peer-reviewed processes and are the most reliably accessible methods of study retrieval for researchers and policy makers. We therefore performed a systematic review of PubMed and CI-NAHL databases from 2003 to 2010 to find all English-language clinical trials in English-speaking North America that employed CBPR. We defined our limit starting in 2003 given the AHRQ review of the CBPR literature up until that year. This study was approved by the Humans Subjects Committee of Partners Health Care.
In efforts to specifically address the conclusions learned from the AHRQ report, we chose to include only clinical trials, or research studies in which an intervention was compared to usual care or another intervention, in our systematic review. We chose to focus our review on interventional studies so as to highlight how a CBPR approach might improve the validity of interventional studies with diverse populations, as clinical trials are currently a prominent focus of clinical research. It is of utmost importance to note, however, that a vital portion of the CBPR literature involves research that would not be categorized as interventional trials. Although there is much to learn from noninterventional studies, we hope that analysis of interventional trials in this article will better allow for comparison of how CBPR can improve on the existing clinical trial model.
The year 2009 marked the inception of the Medical Subject Heading (MESH) "Community-based participatory research" in literature search databases. With the guidance of experienced research librarians, we identified relevant clinical trials using a combination of the formal MeSH "community-based participatory research," the MeSH "cooperative behavior" which was utilized prior to the introduction of CBPR as a MeSH heading from 1997 to 2008, the MeSH "community-institutional relations," and informal search terms, including "participatory research," "community-based participatory action," and "clinical trials." Our search identified 369 abstracts for review. One of the authors (D. D.) thereafter assessed the appropriateness of the studies for review. Articles were excluded initially if they were conducted outside of the United States or Canada or were not clinical trials. After this initial review, 161 articles remained for data abstraction. This process was similar to that employed in the AHRQ systematic review (Viswanathan et al. 2004). Figure 1 illustrates the detailed search strategy employed for this review.
Four reviewers independently conducted a systematic review of the CBPR studies using the PRISMA approach as a guideline for data abstraction and assessment (Moher et al. 2009). After consensus was obtained on the abstraction tool, all four reviewers used a small sample of studies (three articles) and tested reviewer agreement (kappa = 0.87). From each article, eligibility was first identified based on the following criteria: (1) employment of CBPR methodology; (2) whether the article was a clinical trial; (3) whether the study reported clinical results. These criteria led to the final inclusion of only 19 of the 161 articles for further extraction. From these 19 articles, the following data were extracted: (1) clinical trial design (controlled versus noncontrolled, randomized versus nonrandomized, and level of randomization); (2) rigor of the CBPR method (including whether descriptions of community partner involvement were cited in recruitment of subjects, development of interventions, delivery of interventions, and interpretation of research findings); (3) racial and ethnic composition of participants, as well as subject recruitment and retention; and (4) intervention effects.
[FIGURE 1 OMITTED]
We present data from all included studies regarding methodology of CBPR, recruitment and retention of research participants, and presentation of clinical results. Although the studies were too heterogeneous to perform a meta-analysis, aggregate frequencies, means, and proportions of data are identified as appropriate.
Our systematic review covered 19 peer-reviewed articles of which 13 were randomized-control trials (Table 1). Of the 19 studies, 18 reported the numbers of individual participants. Of these, 17 studies (representing 18,818 participants) reported the racial and ethnic composition of participants. Six studies had samples that were >50 percent Latino, six studies recruited participant pools that were >50 percent non-Hispanic black, one study reported a subject population that was 100 percent Asian, and the remainder had a majority of non-Hispanic white study participants (Table 1). The majority of the trials (68 percent) were randomized-control trials, and of these studies, 23 percent were randomized at the level of the individual, with the remaining 77 percent employing cluster randomization. Of the six nonrandomized trials, 50 percent had a control group, with the remaining trials comparing measures preintervention and postintervention in a given cohort.
Rigor of CBPR Approach
Table 2 presents the level of involvement of community partners in each interventional trial, among the studies reporting the degree to which community members participated. The majority of studies reported community involvement in identifying study questions (63 percent), recruitment of subjects (84 percent), development of the intervention (74 percent), delivery of the intervention (84 percent), data collection (68 percent), or the formation of a community advisory committee (63 percent). However, very few of the studies cited involvement of the community in the interpretation of either quantitative or qualitative research findings (21 and 37 percent, respectively) or in efforts to disseminate trial findings (47 percent) (Table 2).
Presentation of Results
For each of the 19 reviewed articles, we describe the presentation of their clinical results in Table 3. The majority of reviewed trials (14/19) examined behavioral outcomes (such as daily salt intake or level of physical activity), either alone (5/19), in combination with clinical outcomes (such as body mass index or blood pressure) (7/19), or in combination with process measures (such as recruitment of participants) (2/19). The majority of the trials (17/19) included a control group, and of these, 10 studies (59 percent) described baseline differences between control and intervention participants. Of the 17 articles examining either a concurrent or historical control group, 13 reported a significant difference in outcomes among the intervention group when compared with controls; however, four of these studies did not adjust for baseline differences between groups in the analyses (Table 3). Overall, the majority of studies we reviewed (89 percent) demonstrated a statistically positive effect of their interventions.
In our comprehensive systematic review of all North American CBPR clinical trials published since 2003, we found 19 articles reporting clinical trial results. To our knowledge, this study is the first detailed examination of the progress CBPR has made in publishing interventional research and provides a benchmark for the effectiveness of utilizing CBPR in clinical trials. Despite the paucity of published clinical trials utilizing CBPR, particularly in the examination of health care oriented interventions, the results of our review suggest that the state of the published CBPR clinical trial literature has actually grown significantly since the findings of the 2004 AHRQ report (Viswanathan et al. 2004). Viswanathan et al. identified 30 interventional studies in a 28-year period, whereas our findings reveal 19 clinical trials published recently in just 7 years, a fourth of the time period investigated for the AHRQ report. We also found that these peer-reviewed articles describe some measures of community participation in research in fair detail, but that other parts of CBPR methodology, most notably involvement in interpretation of research findings and dissemination efforts, are poorly described. Lastly we found that although CBPR trials examined a wide range of behavioral, process-related, and clinical outcomes, such trials had very high success rates in recruiting and retaining minority participants and achieving significant intervention effects.
Prior examination of the state of CBPR has suggested that published interventional studies are relatively few, and when published, frequently do not report final analytic results. In their examination of 60 CBPR articles published from 1975 to 2003, the AHRQ group found that 30 of the studies did not report an intervention (Viswanathan et al. 2004). Of the remaining 30 studies, only 12 (20 percent) evaluated an intervention and the remaining 18 had not completed or fully evaluated an intervention. Further, they found that CBPR was frequently published in special issues related to CBPR. For example, of the 12 CBPR articles that evaluated an intervention, three (25 percent) were published in the same special issue (Viswanathan et al. 2004). Similarly, we found 19 published interventional studies utilizing CBPR from 2003 to 2010. There may, however, be positive trends both in the number of journals publishing CBPR research and in the number of CBPR interventions being published. The 19 studies in our review were published in 13 different journals. Of the 19 trials identified, the majority (68 percent) were randomized trials utilizing control groups and therefore may be considered to have a strong evidence base in their findings. We also found that 14 (74 percent) of the articles in our review were published since 2007, representing a stark contrast to the low number (5) of CBPR interventional studies published in the 3-year period from 2003 to 2006. Furthermore, in 2007, a peer-reviewed journal specifically dedicated to CBPR, the journal Progress in Community Health Partnerships, was released. This journal may become a forum for more CBPR interventional research to be published in peer-reviewed literature moving forward.
The degree to which community participation in research is the key factor separating CBPR from other research paradigms is thought to be a critical component of improving both the measurement and the elimination of health disparities. We found that the community involvement described in recently published CBPR trials is variable (Horowitz, Robinson, and Seifer 2009). In our review, community partners were most frequently described as being involved in participant recruitment and in the development and delivery of the intervention. However, community partners were only described as participating in the interpretation of quantitative research findings 21 percent of the time and in dissemination efforts in 47 percent of the studies. Our findings are supported by prior evaluations that demonstrate community involvement in intervention development in over 90 percent of CBPR trials, though CBPR articles rarely, if ever, mention involvement of community partners in interpretation of research findings, the manuscript preparation process, or other dissemination efforts (Viswanathan et al. 2004). One possible explanation for this variability may be that researchers have yet to identify the best strategies for community inclusion in analysis. This may be in part due to differences in research knowledge and in part due to differences in interest. In addition, both community and academic research partners may feel far less comfortable with the process and time required to teach community partners analytic and manuscript writing skills. It is reasonable to assume that community partners may prefer to limit involvement to their particular strengths, such as community recruitment and intervention delivery. Our findings underscore the need to further emphasize the importance of knowledge sharing activities in CBPR partnerships in an effort to increase research literacy among community partners.
Many authors have suggested that the role community partners and liaisons play in recruitment may significantly improve the effectiveness and retention of minority participation in research. For example, in a recent systematic review, Yancey et al. examined the relative effectiveness of strategies for recruiting racial and ethnic minorities and concluded that among factors most associated with success, active involvement of existing community stakeholders was critical (Yancey, Ortega, and Kumanyika 2006). In another study, researchers found that among veterans, most minorities recruited for focus groups were recruited with the help of community-based liaisons (Dhanani et al. 2002). Our finding that the majority of participants in 13 (68 percent) of the published CBPR interventional trials were racial and ethnic minorities supports the assertion that CBPR may be particularly effective in the recruitment of minorities in clinical research. For those articles that reported retention (16/19 trials), retention was notably favorable (average retention rate 65 percent), indicating that CBPR may be effective not only for recruitment of participants but also for retention. Furthermore, the success rate of the interventions reported in our review was extremely high (89 percent); while this finding is likely influenced by a significant bias toward publication of positive results and must be interpreted with caution (Emerson et al. 2010), our review suggests that CBPR may also be effective in improving behavioral- and health-related outcomes among largely minority populations. Lastly, most (15/19) of the clinical trials identified in our review were designed for addressing clinical or behavioral outcomes among minority communities. The goal of these studies was to identify methods through which clinicians and researchers can improve the health behaviors and outcomes of disadvantaged communities, thereby addressing the disparities in health outcomes that currently exist. Given the effectiveness of CBPR in improving outcomes from behaviorally targeted interventions, our findings suggest that CBPR is underutilized in interventions aimed at health care improvement (e.g., improving blood pressure or cancer screening rates) and that future research investigating health services interventions may benefit from the CBPR paradigm.
This review is subject to several limitations. Chiefly, our examination of the state of CBPR was limited only to examining clinical trials. We chose to limit our assessment to clinical trials because prior research has documented that CBPR publications are historically lacking in this methodology. We aimed to go beyond heralding the potential of CBPR by more concretely examining the scientific rigor and effectiveness of the research. Second, we chose to limit our analysis to an examination of only those CBPR clinical trials published in peer-reviewed literature and indexed in Index Medicus. We acknowledge that this renders our analysis subject to publication bias in the literature; a recent article in Archives of Internal Medicine highlights that positive-outcome studies are more likely to be published in peer-reviewed journals than equally methodologically sound null studies (Emerson et al. 2010). However, in keeping with the PRISMA approach for reporting systematic reviews (Moher et al. 2009), we chose to limit our initial search strategy to only those studies published in peer-reviewed literature and indexed in Index Medicus, which we acknowledge as the most reliable and most easily accessible database utilized by researchers and policy makers. We nevertheless advocate that continued research focused on the critical analysis of all study designs employed with the CBPR methodology in both the published and nonpublished literature is needed to fully explore the unique contributions of the CBPR model to interventional research, as recently reinforced by two of the field's leading researchers (Wallerstein and Duran 2010). Since one limitation of systematic reviews is that they are cross-sectional in nature, it is possible that our search did not yield eligible articles published from 2003 to 2010 that had not been indexed at the time of our search. In addition, there remain the possibilities that a significant publication lag in CBPR exists when compared with other research paradigms, and that much of the CBPR interventional research conducted in recent years has not yet been submitted or completed the peer-review process. Our finding of a significantly increasing trend in the rate of CBPR clinical trials published over the past few years may suggest such a lag exists and is supported by a prior review that demonstrated that 67 percent of published CBPR interventional trials were either in progress or the intervention had not fully been evaluated (Viswanathan et al. 2004). Furthermore, our review was limited to studies published in English and conducted in North America; we anticipate that the state of CBPR conducted outside of the North America and its effectiveness in recruiting minority subjects may differ. Lastly, the studies included in our analyses employed a wide variety of intervention strategies and examined a myriad of clinical and behavioral outcomes, precluding our ability to conduct a more detailed meta-analysis examining the effectiveness of CBPR interventions. As a result, we remain unable to compare outcomes of CBPR studies to other interventional research strategies.
Limitations aside, our study highlights that CBPR excels in two areas: (1) recruitment and retention of racial and ethnic minority participants, a population that has traditionally been difficult to engage in clinical trials, and (2) effectiveness of interventions geared toward these communities. We therefore theorize that CBPR can be an incredibly rich and effective approach to the research of health care delivery, resource allocation, and health care utilization. A recently published study of the use of patient navigators for promotion of colorectal cancer screening among patients at community health centers, for example, revealed a statistically significant increase in colon cancer screening rate with the use of patient navigators, compared with the population of patients who received routine colon cancer screening recommendations alone without the aid of a patient navigator (Lasser et al. 2009, 2011). Lessons learned from such a study can be used by policy makers to help fund patient navigators in community health care center settings, increase cancer screening rates, and thereby improve long-term outcomes in this population. Our results suggest that CBPR is a promising tool that may contribute to interventional studies and analyses and therefore could play a role in facilitating research's impact on health care policy and resource allocation.
We found that the state of CBPR interventional research is rapidly evolving with a significant increase in both the number of journals publishing CBPR and the number of interventional studies published. However, there remains a relative lack of published peer-reviewed CBPR interventional studies and a significant gap in publication between CBPR and other interventional research methods. Our findings demonstrate that CBPR is particularly effective in increasing participation of racial and ethnic minority subjects in research and may be a powerful tool to improve both the measurement of health disparities and in testing the generalizability of effective interventions among populations traditionally under-represented in clinical trials. For these reasons, CBPR is a promising research approach that may be useful in analyses of health care delivery for disadvantaged patients.
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Appendix SA1 : Author Matrix.
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Address correspondence to Denise De Las Nueces, M.D., Commonwealth Fund/Harvard University Fellowship in Minority Health Policy, 164 Longwood Avenue, 2nd Floor, Boston, MA 02115; e-mail: firstname.lastname@example.org. Karen Hacker, M.D., M.P.H., is with the Community-Based Participatory Research Program, Harvard Medical School, Boston, MA, and the Institute for Community Health, Cambridge Health Alliance, Cambridge, MA. Ann DiGirolamo, Ph. D., M.P.H., is with the Health Equity Unit, Program, Partnerships, Learning and Advocacy, CARE USA, Atlanta, GA. LeRoi S. Hicks, M.D., M.P.H., is with the Division of Hospital Medicine, University of Massachusetts Memorial Health Care, Worcester, MA, and the Department of Quantitative Sciences, University of Massachusetts Medical School, Worcester, MA.
Table 1: Characteristics of Articles Included in Analysis (N = 19) Primary Type of Author, Year Clinical Type of Area of Article Trial Randomization of Focus Balcazar Randomized Individual Participant et al. (2009) control participant behavior Balcazar Randomized Individual Participant et al. (2010) control participant behavior Blumenthal Randomized Cluster Clinical et a1. (2010) control randomization by site of recruitment (church, community center, or clinic) Estabrooks Nonrandomized NA Participant et al. (2008) behavior Feinberg Randomized Cluster Other et al. (2007) control randomization by community Froelicher Randomized Cluster Participant et al. (2010) control randomization behavior by groups Horowitz Randomized Individual Other et al. (2009) control, participant delayed intervention Kim Nonrandomized, NA Participant et al. (2008) concurrent control behavior Leeman Nonrandomized NA Participant Castillo behavior et al. (2010) Levine Randomized Cluster Health care et al. (2003) control randomization delivery by census blocks Linnan Nonrandomized NA Other et al. (2005) Mikami, Randomized Cluster Other Boucher, control randomization and by classroom Humphreys (2005) Nguyen Nonrandomized, NA Health care et al. (2006) cross-sectional, delivery with control community Parikh Randomized Cluster Participant et al. (2010) control with randomization behavior delayed by recruitment intervention site Redmond Randomized Cluster Participant et al. (2009) control randomization behavior by community Reed and Randomized Cluster Participant Kidd (2004) control randomization behavior by school Riggs, Randomized Cluster Other Nakawatase, control randomization and Pentz by community (2008) Siegel Randomized Cluster Participant et al. (2010) control randomization behavior by school Two Feathers Nonrandomized NA Participant et al. (2005) behavior Number of Primary Participants Number of Number of Percent Author, Year Eligible Participants Participants Retained of Article for Study Enrolled Retained Balcazar 98 98 98 100 et al. (2009) Balcazar 568 328 284 87 et al. (2010) Blumenthal 645 369 259 70 et a1. (2010) Estabrooks 4,609 1,190 1,045 88 et al. (2008) Feinberg 157 53 29 55 et al. (2007) Froelicher 191 60 22 37 et al. (2010) Horowitz 249 99 Not NA et al. (2009) reported Kim Not 73 61 84 et al. (2008) reported Leeman 333 299 245 82 Castillo et al. (2010) Levine 817 789 471 60 et al. (2003) Linnan Not 162 83 51 et al. (2005) reported Mikami, Not 24 classrooms Not NA Boucher, reported (individuals reported and not reported) Humphreys (2005) Nguyen Not 1,566, 2009 NA NA et al. (2006) reported (at each cross sectional survey) Parikh 103 99 72 73 et al. (2010) Redmond 13,257 11,931 9,438 79 et al. (2009) Reed and Not 1,138 373 33 Kidd (2004) reported Riggs, 431 431 154 36 Nakawatase, and Pentz (2008) Siegel Not 413 125 30 et al. (2010) reported Two Feathers 300 1.51 111 74 et al. (2005) Ethnic Composition of Primary Participants Author, Year (%) of Article Balcazar Latino (100) et al. (2009) Balcazar Latino (100) et al. (2010) Blumenthal Non-Hispanic et a1. (2010) black (100) Estabrooks Non-Hispanic et al. (2008) white (95) Latino (1) Native American (1) Not cited (3) Feinberg Not cited et al. (2007) Froelicher Non-Hispanic et al. (2010) black (100) Horowitz Latino (89) et al. (2009) Non-Hispanic black (9) Asian (1) Native American (1) Kim Non-Hispanic et al. (2008) black (100) Leeman Latino (100) Castillo et al. (2010) Levine Non-Hispanic et al. (2003) black (100) Linnan Non-Hispanic et al. (2005) black (68.5) Non-Hispanic white (31.5) Mikami, Not reported Boucher, and Humphreys (2005) Nguyen Asian (100) et al. (2006) Parikh Latino (89) et al. (2010) Non-Hispanic black (9) Not reported (2) Redmond Non-Hispanic et al. (2009) white (83) Non-Hispanic black (3) Latino (5) Not reported (9) Reed and Non-Hispanic Kidd (2004) white (98) Not reported (2) Riggs, Not reported Nakawatase, (100) and Pentz (2008) Siegel Latino (48.4 et al. (2010) control, 60.8 intervention) Non-Hispanic white (27 control, 19.8 intervention) Non-Hispanic black (9.7 control, 4.1 intervention) Not reported (17.8 control, 15.5 intervention) Two Feathers Non-Hispanic et al. (2005) black (64) Latino (36) Table 2: Description of Community Partners' Involvement in Clinical Trials (N = 19) Identifying Primary Study Recruitment Development of Author Questions of Subjects Intervention Balcazar Yes Yes Yes '(2009) Balcazar Yes Yes Yes '(2010) Blumenthal No Yes Yes Estabrooks Yes Yes Yes Feinberg Yes Yes No Froelicher No Yes Yes Horowitz Yes Yes Yes Kim Yes Yes Yes Leeman-Castillo No Yes No Levine Yes Yes No Linnan Yes Yes Yes Mikami No No No Nguyen Yes Yes Yes Parikh Yes Yes Yes Redmond No Yes Yes Reed Yes No Yes Riggs No Yes No Siegel No No Yes Two Feathers Yes Yes Yes Quantitative Primary Delivery of Data Interpretation Author Intervention Collection of Findings Balcazar Yes Yes No '(2009) Balcazar Yes Yes No '(2010) Blumenthal Yes Yes No Estabrooks Yes Yes No Feinberg No No Yes Froelicher No No No Horowitz Yes Yes No Kim Yes Yes No Leeman-Castillo Yes No No Levine No Yes Yes Linnan Yes Yes Yes Mikami Yes Yes No Nguyen Yes Yes Yes Parikh Yes Yes No Redmond Yes No No Reed Yes Yes No Riggs Yes Yes No Siegel Yes No No Two Feathers Yes No No Qualitative Presence of Primary Interpretation Dissemination Advisory Author of Findings Efforts Committee Balcazar Yes Yes No '(2009) Balcazar Yes No No '(2010) Blumenthal No Yes Yes Estabrooks No No Yes Feinberg Yes Yes No Froelicher No Yes No Horowitz No No Yes Kim Yes No Yes Leeman-Castillo No No No Levine Yes Yes Yes Linnan Yes Yes Yes Mikami No No No Nguyen No Yes Yes Parikh Yes Yes Yes Redmond No No Yes Reed No No Yes Riggs No No No Siegel No No Yes Two Feathers No Yes Yes Table 3: Presentation of Results in CBPR Clinical Trials (N = 19) Significant Differences Significant between Baseline Control and Differences Type (s) of Baseline Primary Study Adjusted for Outcomes Measures Author Group Noted? in Results under Study Reported Balcazar Yes Yes Clinical Yes (2009) behavioral Balcazar Yes Yes Clinical Yes (2010) behavioral Blumenthal Yes No Clinical Yes knowledge, behavioral Estabrooks No NA Behavioral Yes Feinberg No NA Process Yes Froelicher Yes No Behavioral Yes Horowitz NA NA Process Yes (recruitment) Kim Yes Yes Clinical Yes behavioral Leeman- NA NA Behavioral Yes Castillo Levine No NA Clinical Yes Linnan NA NA Process No (communication regarding health messages) Mikami No NA Report of peer Yes relations Nguyen No NA Behavioral Yes process (capacity building infrastructure) Parikh Yes No Clinical Yes behavioral Redmond No No Behavioral No attitudes Reed Yes No Behavioral No attitudes Riggs Yes No Behavioral Yes process (community organization empowerment) Siegel Yes Yes Clinical Yes behavioral Two Yes Yes Clinical Yes Feathers behavioral other Outcome Primary Measures Primary Outcomes Author Reported of Study Balcazar Yes No difference in waist (2009) circumference or BM I; significant differences among perceived benefits and salt, cholesterol, and fat intake Balcazar Yes Significant improvement (2010) in diastolic BP, weight control practices, salt, cholesterol, and fat intake Blumenthal Yes Significant increase in colorectal cancer knowledge, increase in colorectal cancer screening rates within 6 months of intervention Estabrooks Yes Inactive or insufficiently active participants at baseline experienced significant increases in both moderate and vigorous physical activity Feinberg Yes Coalition functioning in a youth recruitment intervention Froelicher Yes No statistically significant differences in smoking between control group and interventional group Horowitz Yes Recruitment of minority populations Kim Yes Anthropometrics (BMI, waist: hip ratio) and health behaviors Leeman- Yes Nutritional intake by Castillo guidelines, physical activity by guidelines, smoking cessation Levine Yes Mean systolic and diastolic blood pressure Linnan Yes Discussion/ communication of health behaviors Mikami Yes Ratings of peer relationships Nguyen Yes Pap test outcomes Parikh Yes Weight loss Redmond Yes Youth, parent and family relationship (general child management, parent-child effective quality, parent-child activities) Reed No Farm safety attitudes Riggs Yes Quality of strategic plans; committee functioning; prevention plan activities Siegel Yes BMI, waist: hip ratio, minutes of physical activity, fruit and vegetable intake Two Yes Change in Hg Feathers A1C, weight, BMI, BP Study Successful in Achieving Primary Primary Author Outcome Balcazar Yes (2009) Balcazar Yes (2010) Blumenthal Yes Estabrooks Yes Feinberg Yes Froelicher No Horowitz Yes Kim Yes; reduced weight, reduced hip and weight girth, and increased physical activity compared with control Leeman- Yes; improved fruit Castillo and vegetable intake, increased levels of physical activity Levine No; both groups exhibited increased BP control, no difference between more versus less intensive care Linnan Yes; high levels of self-reported discussions of health behaviors, and high recall of discussions after 12 months Mikami Yes; intervention group had improved peer relationships over time Nguyen Yes Parikh Yes; significant weight loss noted in intervention group Redmond Yes; general child management, parent child activities, and skill outcomes improved in intervention group Reed Yes; positive changes in farm safety attitudes and discussions related to injury prevention, and improved safety behavior Riggs Yes; increased quality of strategic plans; higher committee functioning; increased prevention plan activities Siegel Yes; reduction in BMI Two Yes Feathers