摘要：Objectives. We used community-partnered participatory research (CPPR) to measure collective efficacy and its role as a precursor of community engagement to improve depression care in the African American community of South Los Angeles. Methods. We collected survey data from participants at arts events sponsored by a CPPR workgroup. Both exploratory (photography exhibit; n = 747) and confirmatory (spoken word presentations; n = 104) structural equation models were developed to examine how knowledge and attitudes toward depression influenced community engagement. Results. In all models, collective efficacy to improve depression care independently predicted community engagement in terms of addressing depression (B = 0.64–0.97; P < .001). Social stigma was not significantly associated with collective efficacy or community engagement. In confirmatory analyses, exposure to spoken word presentations and previous exposure to CPPR initiatives increased perceived collective efficacy to improve depression care (B = 0.19–0.24; P < .05). Conclusions. Enhancing collective efficacy to improve depression care may be a key component of increasing community engagement to address depression. CPPR events may also increase collective efficacy. Both collective efficacy and community engagement are relevant constructs in the South Los Angeles African American community. Although depressive disorders are treatable, many people with such disorders, especially members of underserved minority groups, do not receive treatment. 1 – 7 Access to high-quality depression care can be improved through evidence-based programs, 8 , 9 but such programs are not widely disseminated in underserved communities. 10 Collective action through cooperative efforts among service agencies and community members may be necessary to increase their implementation. 11 – 16 However, little is known about how to engage underserved groups in efforts to improve depression care. Perceived racism in health care, the stigma of mental illness, and lack of knowledge about depression may result in individuals in the African American community deciding not to seek help for depression. 17 , 18 However, as noted by one of the members of the minority community that was the focus of study, “Depression is a silent killer. We need to get the word out to the community that we can do something about it.” In addition, distrust in services and research engendered by travesties such as Tuskegee and experiments on slaves in the antebellum period is a barrier to participation in research among African Americans. 18 – 22 According to another study participant, “People in our community … have been involved with research before—the problem is universities never come back … and tell us what they did in our community.” Community-based participatory research is recommended as one means of engaging members of minority groups in addressing health issues. 12 , 15 , 23 , 24 In public health, community-based research focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved. 23 Both sides can gain from such an approach, as noted by another participating community member: To participate with academics, the community can develop expertise in research—like [institutional review boards], data collection, and methods… . The academics get to learn about how to work in [the] community … being transparent, gaining trust, and planning with community instead of on community. Community-partnered participatory research (CPPR), a variant of community-based participatory research, emphasizes equal power sharing among community and academic participants while engaging stakeholders and community members in planning, action, and research that have a mutual benefit. 24 – 26 For example, as noted by one of the participants in our study: “Allowing the community to participate in the hypothesis, data collection, analysis, and interpretation gave the community partnership over every aspect of the project.” Our study represented one component of a CPPR initiative called Witness for Wellness ( http://www.witness4wellness.org ), initiated in 2003 to reduce the burden of depression in underserved communities of color in South Los Angeles. 26 – 29 In Witness for Wellness, a multi-agency council was developed under the leadership of Healthy African American Families (HAAF), the University of California at Los Angeles, the RAND Corporation, and Charles Drew University. 26 The council developed a written agreement to reinforce CPPR principles and initiated 3 working groups including Talking Wellness, the group we studied. 17 , 25 , 27 , 28 The Talking Wellness group focused on improving the capacity of the community to discuss depression and reduce stigma; community members suggested the approach of presenting community-generated arts events. 27 The Talking Wellness group had 74 participants during January 2004 through November 2007, the period of work leading to this article: 10 academic members (7 White, 2 Asian American, 1 African American) and 64 members of the South Los Angeles African American community. We evaluated 2 events for this study: spoken word and comedy presentations and a photography exhibit. (Spoken word is a form of artistic performance in which poetry or stories are recited aloud.) Our study involved several goals. The first was to explore whether concepts of collective efficacy and community engagement concerning depression care were important in the African American community of South Los Angeles and determine how they were related through causal modeling. Collective efficacy is a group's shared belief in its conjoint capabilities to improve a problem in the community (in this case, depression care). Community engagement refers to the perception that individual problems (in this case, depression and mental wellness) are problems of the community as a whole. The second goal was to determine whether and how exposure to Talking Wellness arts events and other CPPR initiatives influenced community engagement. The third goal was to determine the feasibility of applying a CPPR paradigm of equal power sharing for community and academic partners through all phases of a rigorous research process, as evidenced through maintaining group membership across phases and completing products such as research protocols, data collection instruments, grant submissions, and research papers. We expected that low levels of knowledge and high levels of stigma about depression would predict lower levels of community engagement or perceived collective efficacy around depression than would high levels of knowledge and low levels of stigma. In addition, we expected that exposure to Talking Wellness events and CPPR initiatives would increase community engagement. We are not aware of other studies identifying pathways to community engagement as a means of addressing depression in minority communities. 15 , 24 The attitudinal constructs we used in this study were derived from the Health Belief Model (i.e., in terms of perceived importance of a problem and stigma as a barrier), 23 , 29 the theory of reasoned action and planned behavior (i.e., in terms of perceived norms and attitudes concerning a behavior), 30 Bandura's social cognitive theory of collective efficacy as measured through individual perceptions, 31 – 38 and the concept of community engagement from the CPPR model. 25 Previous studies have shown that measures of collective efficacy are associated with health outcomes. 39 – 42
