Research has the potential not only to yield tremendous benefits, but also to inflict significant harms. Consider the example of genetic research on the relationship between schizophrenia and substance abuse. Such research may be undertaken with the legitimate goals of better understanding pathophysiology and comorbidity, seeking new modes of treatment, identifying causative environmental factors, and identifying high-risk individuals who might benefit from preventive interventions . However, such research also generates concerns such as possible insurance or employment discrimination if confidentiality is breached; concerns about negative psychological consequences of learning of a genetic risk; and questions regarding the appropriateness of sharing information pertinent to biological relatives [2–4,5••,6]. Complicating the resolution of these ethical issues, the field of psychiatric genetics is ‘haunted by memories of the eugenics movement of the early 1900s, which targeted psychiatric patients and others considered “genetically inferior” for forced sterilization and death [, p. 322].’ When abuse by researchers occurs in a community, mistrust may occur and people may be less willing to participate in research or even to seek help from the healthcare community, possibly exacerbating health disparities .
Although we may tend to think of individuals as those who are harmed or benefited by research endeavors, communities may feel that they too are directly affected for better or for worse when researchers study their members. In particular, they may be highly susceptible to stigmatization [8•]. For example, the term ‘scarlet genes’ has been coined to refer to the stigmatization of groups when popular media report on genetic predispositions to alcoholism or drug abuse within minority populations .
In this paper, we review what is community-engaged research (CEnR), how CEnR may improve our ability to address such ethical and social issues, and how CEnR may improve the quality of science. This article builds upon a National Institute of Mental Health-funded scientific meeting held in St Louis in June 2009 that reviewed the literature and recent studies at the intersection of research ethics and CEnR in mental health research. The authors served as panelists and include ethicists, mental health researchers, and community representatives, all of whom have played some role in CEnR in the areas of mental health or drug addiction research.
The panel strongly endorses the idea that CEnR is an essential and beneficial component of human research; however, CEnR is not easy. To that point, we have added ‘caveat’ sections to raise awareness of some of the more significant challenges that arise in CEnR. Table 1 uses the example of genetic research on comorbid schizophrenia and substance abuse to illustrate the application of concepts found throughout the paper.
What is community-engaged research?
CEnR is research that provides communities with a voice and role in the research process beyond providing access to research participants [10–12]. Clearly, this can be done to greater or lesser degrees. The forms of engagement may range from studying the views of community members regarding research protocols [13,14••] to incorporating community members as coinvestigators [11,14••,15,16•].
Table 2 provides a description of nine forms of engaging community members. Each of the approaches listed goes beyond international requirements that Institutional Review Boards (IRBs) or Institutional Ethics Committees (IECs) include at least one member who is a nonscientist and unaffiliated with the institution [20,47]. The various forms of CEnR provide ways of ensuring that a key stakeholder group is represented in the research enterprise as more than just a subject pool. In determining the degree to which communities are involved, key questions include the following:
- How many individuals from the community are provided with a voice (e.g., one representative, a small group of gatekeepers, or a random sample)?
- Do community members have authority to advise on the research protocol or to make key decisions regarding the research protocol?
- Are community members elevated to the level of coinvestigators? Do they share resources and play an investigative role in the conduct research? Do they participate in data interpretation and dissemination?
Community engagement in mental health research may involve interaction with individuals from any of the following groups: people with mental health disorders; people who are recovering; family members or caregivers; people at risk; clinicians, healthcare providers, service agencies, and insurers; government or industry funding representatives; and advocates. CEnR also involves members of communities who are affected by mental disorders, including employers, educators, prisoners, students, and minority members within any of these groups. CEnR may vary radically depending on whether, for example, mental health consumers are approached by researchers or, rather, initiate a research study themselves, with or without the collaboration of an academic center .
Different kinds and degrees of engagement may depend on how well certain values are embraced, how educated the researchers are regarding community engagement (techniques and benefits), time and financial resources, and also on the type of science (e.g., how much ‘scientific flexibility’ they have) and the funding source, which may mandate CEnR or make it more difficult. Figure 1 provides a hierarchy of forms of CEnR with the baseline representing forms that are minimally burdensome and should be integrated into most human participant research.
For a group to constitute a community, it must possess structure and leadership. In some cases, a clear community exists prior to a research study; in other cases, researchers must collaborate with group members to establish a community structure [49••]. The boundaries of communities are not always well defined and communities may range from fairly homogeneous to heterogeneous. Not all community members may wish to engage with researchers, and resources may limit the number of community members who can be engaged. The interests of the larger community may not always be congruent with the best interests or research goals of vulnerable groups within the community who will be recruited to participate in the research . Thus, one never fully engages a community.
Rather, community engagement is an ideal that may be more or less embodied by a study.
Why is community engagement important?
Researchers inevitably affect the communities they study and frequently leave a lasting impression: positive or negative. So-called ‘helicopter’ projects, in which researchers fly in and quickly fly out with data, may leave the impression that communities are simply used rather than valued. Research that does not address the knowledge or health priorities of communities may contribute to research fatigue and an unwillingness to participate in research [51,52].
Engaging communities in appropriate ways is a form of showing respect for community members as persons. It provides a voice to individuals who are often disenfranchised [16•]. The American Psychological Association has asserted that community engagement is a requirement of any ethical research with minority communities .
CEnR may also provide significant benefits to community members. Our researcher panelists believe that CEnR improves T3 or curbside translation of the results of health research. To the extent that decreasing health disparities is a health priority , we should increase CEnR efforts toward cultural competence, the recruitment of minorities, and the dissemination of health information among minority communities. CEnR may also provide significant peripheral benefits to community members. For example, mental health service users have reported that participatory research offered them opportunities to gain knowledge and to share their unique perspectives, increased their self-esteem, provided them with an opportunity for employment, and gave them a chance to give back to society and help others .
CEnR may also improve the quality of science insofar as it may assist researchers in recruitment and retention [49••,55,56]. The Framingham Heart study would not have been nearly as successful without intense engagement of the local community, including efforts to adapt the study in response to community concerns . CEnR may additionally contribute to the recruitment of participants who are genuinely representative of the larger community. Given that 6.7% of the population suffers from depression  and 3.8% from substance abuse disorders at any given time  (with a life-long prevalence of 16.2%  and 14.6% , respectively), a study that wishes to have a truly representative sample should refrain from excluding individuals with such diagnoses; in fact, extra efforts should be made to include them . CEnR methods have proven successful in recruiting marginalized populations into traditional clinical trials .
Moreover, community members may bring novel perspectives to questions of research design and recruitment; they may raise concerns or suggest useful strategies that may be unfamiliar to researchers . Indeed, in early HIV trials, not only was CEnR essential to obtaining the cooperation of the participant community, but some community members suggested improvements to the statistical analysis of the data . In other cases, the scientific expertise may be largely qualitative. For example, whereas researchers often focus on ‘objective’ outcomes of studies, mental health consumers may encourage a focus on subjective outcomes such as a sense of well being and empowerment or of sadness and hopelessness.
CEnR may also serve to foster trust in science and to improve institutional public relations. Although trust and trustworthiness are to be valued for their own sake, they are also prerequisites to any successful research enterprise .
Further, compliance with international policies requires at least some degree of CEnR. For example, 45 Code of Federal Regulations, part 46 (the US ‘common rule’) and European guidelines for good clinical practice require IRBs and IECs to have at least one member who is a nonscientist and unaffiliated with the institution . National Institutes of Health requires all Clinical and Translational Science Award programs to have a community engagement program. Finally, in certain kinds of research, such as research in emergency medicine when informed consent cannot be obtained (e.g., from unconscious patients), US regulations require investigators to consult with communities .
As Emanuel et al.  note, to be ethical, research must be scientifically valid . Invalid research benefits no one and wastes resources. CEnR must be conducted in ways that do not compromise the quality of science. Although CEnR can improve recruitment, retention, and the quality of participation, it can also compromise the quality of science if done poorly .
What are characteristics of successful community engagement?
The quality of a CEnR process depends in part upon the traits that the researchers and community members bring to the encounter. Some of the traits that panelists (engaged researchers and community members) considered ideal are as follows:
- Listen and learn
- Ask questions
- Educate and share their expertise (e.g., about science or community concerns and priorities)
- Be flexible and creative
- Demonstrate empathy, courtesy, and cultural sensitivity
- Be diverse in their backgrounds and thinking
While the panel first attempted to identify separately the ideal traits of researchers and community members, it became apparent that the ideal traits are shared, although the specific kinds of expertise that they provide will differ.
Although not all forms of CEnR involve including community members as members of the research team (co-investigators), this would be considered the most robust and also most complex form of CEnR. A group of mental health consumer researchers have identified a list of requirements for appropriate involvement of consumers on the research team: payment for work; equal treatment; involvement in all stages of research; acknowledgement of power differentials; regular feedback on their work; safe work environment, including emotional support; and sufficient training .
Successful CEnR requires the ability to translate the community's values and research priorities to the audience of funding agencies and grant reviewers. This can be challenging when researchers and community members have different priorities and expectations [69••]. In these cases, mediation skills (listening, paraphrasing, seeking compromises, etc.) can be beneficial .
The success of CEnR in research should be measured in terms of all the potential benefits of CEnR identified above, including enhancing relationships with community members and facilitating high-quality research.
Successful CEnR takes time to develop. Initially, it may be difficult to recruit diverse community members to engage researchers; failure to do so may inappropriately empower one or a few individuals to set the agenda for a community. It may take time for researchers to adapt their frame of mind to appreciate the different values and the different kind of expertise that community members may bring to a project, just as it may take time for community members to understand the rules of science and research funding, which set limits to the accommodations that can be made within a research protocol. Further, when community members are integrated into the research team, they may, ironically, lose their ability to represent accurately the views of the community; community advisory boards may retain a significant role even in robust forms of CEnR.
What is required to foster community-engaged research?
Among the many resources needed to sustain CEnR, we believe two deserve particular attention: the need for training and funding. Successful CEnR requires training for community members to increase knowledge of the research process and of basic human participant protections, as well as training of researchers on strategies for respectful engagement of communities [69••,71,72••,73]. However, too few opportunities for such training exist, especially at the local level.
Although some forms of CEnR (such as exit interviews on participant satisfaction) are very affordable and low burden, other more robust forms of CEnR require budgetary support. Expenses may include the following: hiring diverse staff, translating documents, disseminating results to the community, and tracking hard-to-reach participants . The biggest funding challenge is typically faced at the conclusion of a particular project when bridge funding is required to sustain community-research partnerships .
Researchers frequently equate CEnR with community-based participatory research, which can be highly beneficial for researchers, science, and communities, but can also require significant training, resources, and commitment. Researchers would do well to recognize there are many forms of CEnR, including some that are relatively low burden, and that some forms of CEnR can enrich virtually any research program involving human participants.
The present study was made possible by grant 1R13MH079690 from National Institutes of Health (NIH)-National Institute of Mental Health and grant UL1 RR024992 from the NIH-National Center for Research Resources.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 259).
1 Westermeyer J. Comorbid schizophrenia and substance abuse
: a review of epidemiology and course. Am J Addict 2006; 15:345–355.
2 Hoop J. Ethical considerations in psychiatric genetics. Harv Rev Psychiatry 2008; 16:322–338.
3 Biesecker B, Peay H. Ethical issues in psychiatric genetics research: points to consider. Psychopharmacology 2003; 171:27–35.
4 Slattery L. Assessing the perceptions of African Americans toward genetics and genetics research. Thesis. University of Pittsburgh; 2007.
5•• Hoop J, Roberts L, Hammond K. Genetic testing of stored biological samples: views of 570 US workers. Genet Test Mol Biomarkers 2009; 13:331–337. A survey of 570 employees at a US defense laboratory and an academic medical center on their willingness to have tissue stored for genetic testing, their interest in receiving results of future testing, and their willingness to be contacted for future testing.
6 DuBois JM. Ethics in mental health
research: principles, guidance, and cases. New York: Oxford University Press; 2008.
7 Shavers V, Lynch C, Burmeister L. Knowledge of the Tuskegee study and its impact on the willingness to participate in medical research studies. J Natl Med Assoc 2000; 92:563–572.
8• Thornicroft G, Brohan E, Rose D, et al
. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 2009; 373:408–415. Conducted face-to-face interviews with people with schizophrenia from 27 different countries on their experiences of discrimination.
9 Rothenberg K, Wang A. The scarlet gene: behavioral genetics, criminal law, and racial and ethnic stigma. Law Contemp Probl 2006; 69:343–365.
10 Reeve P, Cornell S, D'Costa B, et al
. From our perspective: consumer researchers speak about their experience in a community mental health
research project. Psychiatr Rehabil J 2002; 25:403–408.
11 Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health 1998; 19:173–202.
12 Centers for Disease Control and Prevention, et al
. Building community partnership in research: Recommendations and strategies. Washington, DC: Centers for Disease Control and Prevention; 1998.
13 Fisher C. Ethics in drug abuse and related HIV risk research. Appl Dev Sci 2004; 8:91–103.
14•• Sweeney A, Morgan L. The levels and stages of service user/survivor involvement in research. In: Wallcraft J, Schrank B, Amering M, editors. Handbook of service user involvement in mental health
research. West Sussex: Wiley-Blackwell; 2009. pp. 25–35.
Useful description of the various ways that people with mental health
service needs can be engaged in CEnR.
15 Ahmed SM, Beck B, Maurana CA, Newton G. Overcoming barriers to effective community-based participatory research in US medical schools. Educ Health (Abingdon) 2004; 17:141–151.
16• Campbell J. ‘We are the evidence’ an examination of service user research involvement as voice. In: Wallcraft J, Schrank B, Amering M, editors. Handbook of service user involvement in mental health
research. West Sussex: Wiley-Blackwell; 2009. pp. 113–137.
An account of the ethical and social justification for CEnR in mental health
17 Jones I, Scourfield J, McCandless F, Craddock N. Attitudes towards future testing for bipolar disorder susceptibility genes: a preliminary investigation. J Affect Disord 2002; 71:189–193.
18 Milner K, Han T, Petty E. Support for the availability of prenatal testing for neurological and psychiatric conditions in the psychiatric community. Genet Test 1999; 3:279–286.
19 Trippitelli C, Jamison K, Folstein M, et al
. Pilot study on patients' and spouses' attitudes toward potential genetic testing for bipolar disorder. Am J Psychiatry 1998; 155:899–904.
20 European Medicines Agency. ICH Topic E 6 (R1) Guideline for Good Clinical Practice. London; 2006.
21 Baylis F. IRBs: protecting the well being of subject-participants with mental health
disorders that may affect decisionmaking capacity. Account Res 1999; 7:183–199.
22 Angermeyer MC, Holzinger A. Is there currently a boom of stigma research in psychiatry? An analysis of scientific journals. Psychiatr Prax 2005; 32:399–407.
23 Carey MP, Morrison-Beedy D, Carey KB, et al
. Psychiatric outpatients report their experiences as participants in a randomized clinical trial. J Nerv Ment Dis 2001; 189:299–306.
24 Chu AT, DePrince AP, Weinzierl KM. Children's perception of research participation: examining trauma exposure and distress. J Empir Res Hum Res Ethics 2008; 3:49–58.
25 Cohen CI. Consumer preferences for psychiatric research. Psychiatr Serv 2000; 51:936–937.
26 DuBois JM, Callahan O'Leary C, Cottler LB. The attitudes of females in drug court toward additional safeguards in HIV prevention research. Prev Sci 2009; 10:345–352.
27 Fogas BS, Oesterheld JR, Shader RI. A retrospective study of children's perceptions of participation as clinical research subjects in a minimal risk study. J Dev Behav Pediatr 2001; 22:211–216.
28 Hummer M, Holzmeister R, Kemmler G, et al
. Attitudes of patients with schizophrenia toward placebo-controlled clinical trials. J Clin Psychiatry 2003; 64:277–281.
29• Kaminsky A, Roberts LW, Brody JL. Influences upon willingness to participate in schizophrenia research: an analysis of narrative data from 63 people with schizophrenia. Ethics Behav 2003; 13:279–302. The study presents qualitative research data from interviews with patients with schizophrenia on the factors that influence their decisions whether to participate in research studies. Different response patterns were found for those with versus those without prior research experience.
30 Kassam-Adams N, Newman E. Child and parent reactions to participation in clinical research. Gen Hosp Psychiatry 2005; 27:29–35.
31 Kerkorian D, Traube DE, McKay MM. Understanding the African American Research Experience (KAARE): implications for HIV prevention. Soc Work Ment Health 2007; 5:295–312.
32 Kitchin R. The researched opinions on research: disabled people and disability research. Disabil Soc 2000; 15:25–47.
33 Marshall R, Spitzer R, Vaughan S, et al
. Assessing the subjective experience of being a participant in psychiatric research. Am J Psychiatry 2001; 158:319–321.
34 Murphy MR, Escamilla MI, Blackwell PH, et al
. Assessment of caregivers' willingness to participate in an intervention research study. Res Nurs Health 2007; 30:347–355.
35 Roberts LW, Warner TD, Brody JL. Perspectives of patients with schizophrenia and psychiatrists regarding ethically important aspects of research participation. Am J Psychiatry 2000; 157:67–74.
36 Rosen C, Grossman LS, Sharma RP, et al
. Subjective evaluations of research participation by persons with mental illness. J Nerv Ment Dis 2007; 195:430–435.
37 Schafer I, Gschwend C, Karow A, Naber D. Attitudes of patients with schizophrenia to psychiatric research. Int J Psychiatry Clin Pract 2008; 12:165–170.
38 Slomka J, Ratliff EA, McCurdy SA, et al
. Decisions to participate in research: views of underserved minority drug users with or at risk for HIV. AIDS Care 2008; 20:1224–1232.
39• Ulivi G, Reilly J, Atkinson JM. Protection or empowerment: mental health
service users' views on access and consent for nontherapeutic research. J Ment Health 2009; 18:161–168. The study reports on results from focus groups with mental health
service users on their preferences regarding recruitment and consent in nontherapeutic research.
40 Wagner KD, Martinez M, Joiner T. Youths' and their parents' attitudes and experiences about participation in psychopharmacology treatment research. J Child Adolesc Psychopharmacol 2006; 16:298–307.
41 Fisher CB, Wallace SA. Through the community looking glass: reevaluating the ethical and policy implications of research on adolescent risk and sociopathology. Ethics Behav 2000; 10:99–118.
42 Fisher CB, Oransky M, Mahadevan M, et al
. Marginalized populations and drug addiction research: realism, mistrust, and misconception. IRB 2008; 30:1–9.
43• Oransky M, Fisher CB, Mahadevan M, Singer M. Barriers and opportunities for recruitment for nonintervention studies on HIV risk: perspectives of street drug users. Subst Use Misuse 2009; 44:1642–1659. The study reports findings from a focus group study with urban drug users on their fears and attitudes toward recruitment for nonintervention HIV studies. Issues explored include stigma, trust, and recruitment payments.
44 Fisher CB. Adolescent and parent perspectives on ethical issues in youth drug use and suicide survey research. Ethics Behav 2003; 13:303–332.
45 Minogue V, Boness J, Brown A, Girdlestone J. The impact of service user involvement in research. Int J Health Care Qual Assur 2005; 18:103–112.
46 Levkoff SE, Levy BR, Weitzman PF. The matching model of recruitment. J Ment Health Aging 2000; 6:29–38.
47 Department of Health and Human Services. Protection of human subjects (45CFR46); 2005.
48 Ochocka J, Janzen R, Nelson G. Sharing power and knowledge: professional and mental health
consumer/survivor researchers working together in a participatory action research project. Psychiatr Rehabil J 2002; 25:379–387.
49•• Ross LF, Loup A, Nelson RM, et al
. The challenges of collaboration for academic and community partners in a research partnership: points to consider. J Empir Res Hum Res Ethics 2010; 5:19–32. The study explores key points to consider for academic and community partners as they engage in various stages of community-based participatory research.
50 Fisher CB, Hoagwood K, Boyce C, et al
. Research ethics
for mental health
science involving ethnic minority children and youths. Am Psychol 2002; 57:1024–1040.
51 Brown P, Morello-Frosch R, Brody JG, et al.
IRB challenges in multipartner community-based participatory research. Environ Health 2010; 9:39.
52 Quandt S, McDonald J, Bell R, Arcury T. Aging research in multiethnic rural communities: gaining entree through community involvement. J Cross Cult Gerontol 1999; 14:113–130.
53 American Psychological Association. Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. Am Psychol 2003; 58:377–402.
54 Committee on Understanding and Eliminating Racial and Ethnic Disparities in Healthcare. Unequal treatment: confronting racial and ethnic disparities in healthcare. Washington DC: Institute of Medicine of the National Academies; 2003.
55 Barnes M, Davis A, Tew J. Valuing experience: Users' experiences of compulsion under the 1983 Mental Health
Act. Mental Health
Review Journal 2000; 5:11–14.
56 Happell B, Roper C. Consumer participation in mental health
research: articulating a model to guide practice. R Aust N Z Coll Psychiatrists 2007; 15:237–241.
57 Levy D, Brink S. A change of heart: how the people of Framingham, Massachusetts, helped unravel the mysteries of cardiovascular disease. New York: Knopf; 2005.
58 Kessler R, Chiu W, Demler O, Walters E. Prevalence, severity, and comorbidity of 12-month DSM-IV Disorders in the National Comorbidity Survey replication. Arch Gen Psychiatry 2005; 62:617–709.
59 Kessler RC. The epidemiology of major depressive disorder: results from the national comorbidity survey replication (NCS-R). JAMA 2003; 289:3095–3105.
60 Kessler RC, Angermeyer M, Anthony JC, et al
. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's World Mental Health
Survey Initiative. World Psychiatry 2007; 6:168–176.
61 Striley C, Callahan C, Cottler L. Enrolling, retaining and benefitting out-of-treatment drug users in intervention research. J Empir Res Hum Res Ethics 2008; 3:19–25.
62 Cottler L, Compton W, Ben-Abdallah A, et al
. Achieving a 96.6 percentage follow-up rate in a longitudinal study of drug abusers. Drug Alcohol Depend 1996; 41:209–217.
63 Melton GB, Levine RJ, Koocher GP, et al
. Community consultation in socially sensible research: lessons from clinical trials on treatment for AIDS. Am Psychol 1988; 43:573–581.
64 Guidance for institutional review boards, clinical investigators, and sponsors: exception from informed consent requirements for emergency research. In: US Department of Health and Human Services FaDA, editor; 2000. http://fda.gov/ora/compliance_ref/bimo/emrfinal.pdf
65 Emanuel E, Wendler D, Grady C. What makes clinical research ethical? JAMA 2000; 283:2701–2711.
66 National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont report: ethical principles and guidelines for the protection of human subjects of research. Washington, DC: US Government Printing Office; 1979.
67 Fisher CBX. Participant consultation: ethical insights into parental permission and confidentiality procedures for policy relevant research with youth. In: Lerner RM, Jacobs F, Wertlieb D, editors. Handbook of applied developmental science. Thousand Oaks, CA: Sage; 2002. pp. 371–396.
68 Morrell-Bellai T, Boydell K. The experience of mental health
consumers as researchers. Can J Commun Health 1994; 13:97–110.
69•• Delman J, Lincoln A. Service users as paid research workers: principles for active involvement and good practice guidance. In: Wallcraft J, Schrank B, Amering M, editors. Handbook of service user involvement in mental health
research. West Sussex: Wiley-Blackwell; 2009. pp. 139–151.
Practical guidance from mental health
service users on effective involvement of service users as paid members of the research team.
70 Dubler N, Liebman C. Bioethics mediation: a guide to shaping shared solutions. New York: United Hospital Fund of New York; 2004.
71 Horsfall J, Cleary M, Walter G, Malins G. Challenging conventional practice: placing consumers at the centre of the research enterprise. Issues Ment Health Nurs 2007; 28:1201–1213.
72•• Ross LF, Loup A, Nelson RM, et al
. Nine key functions for a human subjects protection program for community-engaged research: points to consider. J Empir Res Hum Res Ethics 2010; 5:33–48. Overview of the ethical considerations that arise most prominently in CEnR.
73 Goodman MS, Dias JJ, Stafford JD. Increasing research literacy in minority communities: CARES fellows training program. J Empir Res Hum Res Ethics 2010; 5:33.
74 Israel B, Krieger J, Vlahov D, et al
. Challenges and facilitating factors in sustaining community-based participatory research partnerships: lessons learned from the Detroit, New York City and Seattle urban research centers. J Urban Health 2006; 83:1022–1040.