摘要：Meaningful improvements in health require modifying the social determinants of health. As policies are often underlying causes of the living conditions that shape health, policy change becomes a health goal. This focus on policy has led to increasing interest in expanding the focus of community-based participatory research (CBPR) to change not only communities but also policies. To best realize this potential, the relationship between evidence and power in policy change must be more fully explored. Effective action to promote policies that improve population health requires a deeper understanding of the roles of scientific evidence and political power in bringing about policy change; the appropriate scales for policy change, from community to global; and the participatory processes that best acknowledge the interplay between power and evidence. In recent years, public health researchers and advocates have recognized that meaningful improvements in health and health equity require modifying the social determinants of health, the fundamental drivers of a population’s health and disease. 1–3 Public health researchers seek to identify such modifiable determinants of health and use this evidence to make the case for change. Because policies, being defined as the actions of public or private organizations that allocate resources and set courses of action, are often underlying causes of health enhancing or damaging conditions, policy change becomes a public health goal. 4–6 This renewed focus on policy change has also led to changes in the discourse on community-based participatory research (CBPR). CBPR, influenced by a variety of earlier research traditions, 7–9 emerged in the 1980s and 1990s to engage those most affected by a problem. The goals of CBPR are to ensure that a community’s health needs are assessed and interventions to address these needs are implemented in partnership with community residents and leaders. 10,11 In the last decade, CBPR practitioners have expanded their focus to work to change policies as well as community environments and behaviors, strategically diversifying their methods and approaches. 12–14 In so doing, they have helped to lay the foundation for a range of participatory policy successes. 15,16 In this commentary, we argue that to best realize CPBR’s potential for significantly improving population health, the relationship between evidence and power in policy change must be more fully explored. Policy changes that improve population health and reduce health inequality do not typically come about solely as a result of strong scientific evidence, the mobilization of a few communities, or the convictions of a few politicians. Instead, these changes result from multiple actions in many domains. Effective action to promote health-enhancing policies requires a deep understanding of the respective roles of scientific evidence and political power in bringing about policy change. By calling attention to this need, we hope to encourage community-, policy-, and academically based CBPR participants and the researchers and policymakers from other research traditions with whom they interact to focus more attention on the complex relationships between power and evidence. Public health researchers and advocates describe a variety of approaches to balancing the relationship between evidence and power. 17–19 In this discussion, we define evidence as data on the nature and magnitude of a problem and the efficacy of various methods to reduce that problem. Although many disciplines have proposed definitions of power, 20 we consider power simply as the ability to influence allocation of resources, engage players, and shape policy. Because policy decisions are made at the local, state and national levels in both the public and private sectors, we are interested in the dynamic interplay between evidence and power within and across these domains. Among the approaches that have examined the relationship between evidence and power in the literature in recent years are participatory action research, 21 media advocacy, 22 legal advocacy, 23 knowledge synthesis, 24 policy analysis and advocacy, 25,26 and community-based participatory research. 10–12 These approaches are usefully defined and critiqued elsewhere. 19,27,28 In this commentary, we highlight ways that power dynamics and structures are woven throughout participatory policy efforts to improve health. Our critique of CBPR and similar approaches takes the concept’s primary elements—community, participation, and research—as points of departure. We ask: What are the benefits and limits of the scale of community as a focus of policy change and when are other scales more appropriate venues for policy work? Who are the appropriate participants in policy change initiatives? What are appropriate roles for various players in the policy change process? What are the procedures that allow meaningful participation by necessary constituencies? What is the role of research (or scientific evidence) in policy change? In what circumstances does evidence drive policy change and when are other levers of change needed? By exploring the role of political power in bringing about policy change, we seek to develop a more useful understanding of how power shapes the evidence researchers uncover, the communities in which policy change takes place, and the participation of various constituencies in the processes of CBPR. To answer these questions, we propose and discuss four hypotheses on the characteristics of effective partnerships for policy change, drawn from our own policy work 29–31 and our interpretation of the recent literature on CBPR. 10–15 In the box on the next page, we illustrate these hypotheses with selected vignettes from policy change case studies. Examples of Participatory Policy Change Work Supporting Hypotheses Hypothesis Example 1. Effective partnerships for policy change work on multiple levels and scales. Case 1: Tribal Efforts Against Lead (TEAL) in the Tar Creek region of Ottawa County, OK, sought to address high blood lead levels and related problems among Native American children in the area. One of TEAL’s policy goals was to implement mandatory blood lead screening and reporting, which they knew would require both persuasive advocacy and strong community buy-in. They worked at the tribal, county, state, and federal levels to achieve this and other goals. Clan Mothers and Fathers who were part of the coalition visited each tribal government in the area, “to urge passage of resolutions supporting mandatory screening. They then used these resolutions to persuade the Indian Health Service (IHS) to fully implement IHS screening and reporting” 16 (p33). TEAL partners also shared data with and served as members of the Governor’s Task Force on Tar Creek, and worked with the Ottawa County Health Department and IHS to implement the mandatory screening policy. 16 2. Effective partnerships for policy change recognize that political power plays a key role in policy change. Case 2: The Southern California Environmental Justice Collaborative worked for years to change a rule that allowed toxic air emissions along the southern California coast at levels that were 100 times the level recommended by the Clean Air Act. They tracked this closely and when an opportunity to renegotiate the rule arose, they mobilized their partners, community members, and policymakers in part by helping to outline “the powerful institutional forces driving the outcomes of prior decision-making.” 16 (p27) As a result, the Collaborative was successful in lowering the allowable cancer risk from pollution in that area from 100 cases per million to 25 cases per million. 16 3. Effective partnerships for policy change recognize that power influences what is considered acceptable evidence, what evidence is available, and what role evidence will play in driving policy. Case 3: The Concerned Citizens of Tillery in North Carolina sought to ameliorate the public health effects of large-scale hog production in their region, and partnered with researchers to collect spatial and resident data on the location and nature of these health impacts. However, when the partnership released the data publicly, the state’s Pork Council challenged the findings, insisting on being granted access to confidential data, a demand that cost the partnership time and funds to negotiate. By releasing their findings to local and national media, the partnership was able to use another source of power, media coverage, to keep their evidence in the policy debates. 16 4. Effective partnerships for policy change develop processes that reflect the differing roles of power and evidence. Case 4: The Literacy for Environmental Justice Partnership (LEJ) in San Francisco, CA, demonstrates how processes that recognize the need for capacity building and colearning can move coalitions toward successful policy change. LEJ’s work ultimately led to the adoption of a voluntary municipal policy encouraging stores selling alcohol, tobacco, and processed foods to decrease the availability of these goods and increase access to healthy foods, and a state-level bill to establish a similar corner store conversion program. To achieve these goals, LEJ youths were trained by health department staff to collect data from their neighbors and in stores, and to use Geographic Information Systems mapping software to analyze store locations against neighborhood demographics. The youth partners also learned how to assess economic feasibility from a local business school student, and they collaborated with their neighborhood’s city-level elected official to learn about similar policies in other cities. 16 Open in a separate window
