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Although intervention research is vital to eliminating health disparities, many groups with health disparities have had negative research experiences, leading to an understandable distrust of researchers and the research process. Community-based participatory research (CBPR) approaches seek to reverse this pattern by building trust between community members and researchers. We highlight strategies for building and maintaining trust from an American Indian CBPR project and focus on 2 levels of trust building and maintaining: (1) between university and community partners and (2) between the initial project team and the larger community. This article was cowritten by community and academic partners; by offering the voices of community partners, it provides a novel and distinctive contribution to the CBPR literature. HEALTH DISPARITIES AMONG AMERICAN INDIANS IN MONTANAThe American Indian population, Montana’s primary minority group, continues to grow in numbers and as a percentage of the total population of the state. The approximately 60 000 American Indians living on or off reservations in Montana comprise one of the largest percentages (6.2%) of American Indian state populations in the United States. The state’s 7 Indian reservations are homelands to 12 culturally unique and politically distinct tribes.Compared with Whites in Montana, American Indians experience significant health disparities across a number of areas.

From 1990 to 2003, the state’s American Indians had an all-cause death rate 58% higher than that for Whites. Montana’s American Indians die at a much younger median age than do Whites. From 1995 to 2004, the median age of death in Montana was 61.3 years for American Indian women and 77.4 for White women; for men, the age was 53.6 for American Indians and 70.7 for Whites. A recent article stated that health disparities between the American Indian and White populations in the United States have existed since the country was colonized—a 500-year history of disparities.

EFFECTS OF HISTORY ON RESEARCH INVOLVING AMERICAN INDIANSAlthough research is a fundamental component in the elimination of health disparities, many tribal nations have had adverse experiences with researchers and government workers; consequently, communities and community members have lost trust in both the process of research and the people who conduct it., Too often, research has been conducted “on” rather than “with” American Indian communities, resulting in their being stigmatized or stereotyped. Examples include research on hantavirus pulmonary syndrome (originally called Navajo flu), the Barrow Alcohol Study, and the collection of blood samples of tribal members being used for research purposes other than what was agreed on in consent forms.Crow tribal members say that researchers have collected information from them but did not inform them of the study results or use the information in a way to benefit the tribe. In common with other American Indian groups in the United States, the tribe has often experienced broken treaties and oppressive federal policies., The policies and practices of the US government plausibly appear genocidal to many American Indians. As recently as the 1960s and 1970s, government employees sterilized American Indian women without their full informed consent.

–True changes in health disparities will occur when American Indian communities are empowered partners in research regarding their health. Recently, some tribes have insisted that research benefit tribal communities and be conducted in a collaborative and respectful manner., There has been increasing recognition that more comprehensive and participatory approaches to research and interventions are needed to address the complex set of determinants associated with public health problems that affect populations generally, as well as those factors associated with racial and ethnic disparities in health more specifically. COMMUNITY-BASED PARTICIPATORY RESEARCHOne type of research that has the ability for true collaboration and partnership is community-based participatory research (CBPR). BACKGROUND OF RESEARCH PARTNERSHIPWe come from very different backgrounds. Three of us, A. Y., are enrolled members of the Crow tribe, wherein the Messengers for Health project is based; S. Is a non–American Indian faculty member at Montana State University.V.

Began her participation in Messengers for Health as an undergraduate student at Montana State University. Her involvement inspired her to apply to and attend graduate school at a prestigious university far from her home and family.

She perseveres because the value of her education will provide a beneficial resource for her tribe in combating health disparities. She continues to be involved in the project and is a doctoral candidate completing her dissertation exploring health issues that affect Crow people.A.K.H.G.M. Serves as the project coordinator for Messengers for Health but is otherwise not affiliated with the university. She lives and works in the community and is viewed as a community partner, not an academic partner.

Prior to the development of the project, she was involved in a state health department project aimed at increasing awareness and prevention of cancer among tribal members. Her passion for working with cancer projects resulted from her own experience of having had a child who lost a battle with cancer at a very early age.S. Has spent most of her professional career as an educator on the Crow Reservation and director of programs for American Indian students in the sciences at Montana State University.

She has maintained her involvement with reservation education and lives on the Northern Cheyenne Reservation, adjacent to the Crow Reservation. Serves as a tribal adviser for the principal investigator of the Messengers for Health project.S. Datafit 9 serial crack.

Began working with Crow Reservation projects early in her career at Montana State University through a collaboration with a state health department project, at which time she and A. Began working together.A. And other community members informed S.

Of the need for cancer education and outreach on the Crow Reservation, and S. Shared with A. G.M her interest in writing a collaborative grant for a cancer project with the Crow Nation. Messengers for Health evolved as a result of more than 5 years of meetings between community and university partners.Partners for the project included the coordinator; the principal investigator and staff from Montana State University, Bozeman (including students who are members of the Crow Nation and other American Indian tribes); members of the advisory board; and tribal members in leadership roles in the community. The advisory board, which guides the direction of grant activities, includes tribal members who helped with planning the grant, cancer survivors, tribal elders and leaders, and tribal members and one nontribal member who work with or are interested in women’s health. An additional 35 tribal members involved as outreach workers play a vital role in the project. Partners represent the different districts of the reservation and vary in age, political affiliation, educational background, and involvement in traditional practices.

Most speak the Crow language.Project partners found that trust building occurred on 2 levels: first, between an academic partner and several community partners, and second, between initial partners and the greater community and academic settings. Our recommendations for building trust are based on 11 years of working together. A relationship of trust had to be established during the early stages of the project’s development; as in other projects, building and maintaining trust required ongoing attention. Trust building and trust maintaining is a never-ending process. Acknowledge Personal and Institutional HistoriesAs Wallerstein and Duran have noted, researchers are influenced by their backgrounds and values when they come into a community to do research; they also carry with them other histories (e.g., history of their institution in that community) that they may or may not know anything about.

To work effectively and build trust, researchers need to acknowledge these backgrounds and histories. Hermeneutic scholars state that individuals can never be fully aware of these histories because they permeate everything that they do. – Although researchers cannot uncover all of their assumptions and stereotypes or ever fully understand how their personal history affects their work, it is essential to continually work toward more self-understanding.The academic partner (S. C.) took the advice of medical and allied health educators and used tools that built self-reflective awareness and skills, attended anti-bias training, and realized that we will never fully understand the impact of our personal histories. – She has a mentor who continues to assist her in this process. This mentor taught her that it is important to think about how our history affects our work on the level of theory and research. Her recommended readings included Overcoming Our Racism: The Journey to Liberation and A Framework for Understanding Poverty.

The book Teaching About Culture, Ethnicity, and Diversity is a compilation of useful structured activities and exercises for building self-awareness. Understand the Historical Context of the ResearchResearchers need to gain an understanding of the broader histories that they engage in with their work, including the history of research between the specific community and institution, the broader history of research and interactions between the community and the US government, and, for the researchers, the history of the community with which they are working.For an understanding of the broader history, S. First audited a university course, “Indians in Montana.” Second, she read history books that presented history from the perspective of American Indians, including Bury My Heart at Wounded Knee: An Indian History of the American West. Third, she read critiques of Western research, such as Custer Died for Your Sins, Peace, Power, Righteousness: An Indigenous Manifesto, and Decolonizing Methodologies: Research and Indigenous Peoples. Fourth, initial partners had open discussions about past research in the community and the history of the tribe and its relations with the US government, and S. Visited with people in the Crow and university community who could provide insights into these histories.

Read history books on the Crow Tribe, such as From the Heart of Crow Country: The Crow Indians’ Own Stories and Parading Through History: The Making of the Crow Nation in American, 1805–1935, and was continually educated about Crow history and culture by community members. Community partners suggest that researchers openly ask how best to gain an understanding of broader histories.Developing meaningful research within an American Indian community will probably benefit if university partners take time to learn about the history of the specific tribe with which they wish to work. American Indian tribes are sovereign nations within the United States, and although there are similarities among tribes, there are also many differences, just as there are differences between cultures in France and Greece.

Just as these sovereign nations have different languages, governmental structures, child-rearing practices, educational structures, and other values and beliefs, so do different tribal groups. Assuming that all American Indians are alike is a common misconception. Be Present in the Community and Listen to Community MembersTribal communities are often aware when strangers come to the reservation, and word spreads quickly regarding who the strangers are and why they are there. Academic partners are often unaware of the extent to which this occurs. Being present and listening is the process; building relationships is the essential outcome.S. Spends at least every first Wednesday and Thursday of the month on the reservation and more time as required by project work. Community members notice, and communicate to others, whether the academic partner attends social and cultural events.

Being present in the community builds trust because her presence shows that she has a broader interest in the community and is not only there for her own gain. She attends social and cultural events such as the annual Masquerade Halloween Party, the annual Crow Fair celebration, birthday and graduation parties, basketball games, and sweat lodge ceremonies. Acknowledge Expertise of All PartnersUniversity partners need to come into the initial relationship conscious of the fact that both community and university partners are experts. When university partners trust the expertise of community partners, community partners are freer to fully participate and the research is enhanced. Acknowledging community expertise may entail some unlearning on the part of university partners of what they were taught during their academic careers.Our project is a lay health adviser intervention, a method that naturally lends itself to showing that academic partners have trust in community members because the researcher has to trust community members to carry out the intervention. The vehicle for change in the Messengers for Health project is the American Indian people themselves.

The researchers did not choose the lay health advisers; other community members nominated them or they volunteered themselves.The Crow people report that they felt S. Approached them as equal partners and experts. After community members expressed an interest in working on issues of women’s cancer prevention and made a connection with the academic partner, S.

Found appropriate grant opportunities for the partners to work on together. Did not come in as the expert, but instead provided information from granting agencies, explained her intentions in a clear, concise manner, and then asked how best to proceed. Together, the community and academic partners developed the proposal. Be Upfront About Expectations and IntentionsCommunity partners want university partners who are sincere and honest about their intentions, and unless community members have worked as university faculty members, they may be unaware of the university’s expectations. THE SECOND LEVEL OF TRUSTRecommendations for the second level of building and maintaining trust are intended to assist initial partners in expanding to the greater community and academic settings.

These recommendations arose from our experiences, and other projects using a CBPR approach may come up with other recommendations. Building this second level of trust may include adding new people who will work closely with the project (e.g., a new project staff person from the university or community setting) or who will be affiliated with it more distally (e.g., a new tribal chair in the community or new department chair at the university). Existing partners should discuss how to approach these recommendations on the basis of the degree of involvement of new individuals. Recommendations include the following: (1) do not assume people know that the project uses a CBPR approach, (2) revisit the first-level recommendations with potential new partners, and (3) match words with actions. Create Ongoing Awareness of Project HistoryBecause of the often time-intensive nature of developing a project with a CBPR approach, initial project personnel can be lulled into thinking that other individuals in the community and university settings know the project’s history and the work of project partners. It is the duty of initial partners to continually educate others on the project’s history, methods, and partners. In our case, we realized that education had to continue for the length of the project (11 years thus far).Soon after Messengers for Health received funding, and several years into community–university meetings, a small group of community members who had not been involved in the project attempted to contact our funding agency and take over the project.

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Initially we were surprised, but after realizing that the community members were unaware of how the project started or how it was being run, and being aware of past research in American Indian communities, their actions made sense. Project staff met with the group, explained the history of the project, and asked for their support and participation. The group became avid supporters of our work and has been involved with it ever since. As a result, we realized the importance of always telling the project’s history when new people become involved or interested in the work.

This recommendation, as all others given here, will vary by the characteristics of the community. The Crow Reservation consists of 2.25 million acres, just under 12 000 tribal members, and communities separated by distances of over 85 miles, which makes relaying information a constant challenge.When new partners are aware of the initial partnership and when they trust the initial partners, there is greater likelihood that they will want to become part of the partnership. In our project, expanding the trust relationship in the community was facilitated by well-respected community partners who validated the credibility of the academic partner (S. One way to increase the likelihood of trust building is to choose the initial partnership wisely. Researchers and community members do not need to determine all the different players and what their views are before starting a research project. It does help, however, to know that there is often more than one view on how policies are developed, how they may be changed in the future, and how research is to be conducted. It may be a mistake to assume that having one contact or a few good contacts will bring about consensus on how to conduct a project.

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In reservation communities, it is worth determining the different views of federal and tribal policy-makers. Knowing what views are most important to key decisionmakers can save researchers a lot of time and resources.The initial partnerships in Messengers for Health proved critical in gaining the trust of extended community partners because A. (an initial community partner) is a member of the tribe, is fluent in her language, and is a well-respected individual in the community. At an interview training session one year into funding, community women stated that they were interested in the project because this particular person was involved. Her dedication to the project is seen as sincere rather than just a passing interest in cancer education or a job opportunity in a community with few employment options. Revisit First-Level RecommendationsAs illustrated in the last point, it is not guaranteed that trust established in the first level will transfer to different people and agencies, nor that everyone will want to be involved with the project once the details of a CBPR approach are apparent.For example, when the initial academic partner discussed requirements for working with the project with potential academic partners, one potential academic partner decided that CBPR was not the type of work for which he was suited. We believe it is better to know this information upfront rather than finding it out after time and energy have been expended.

CBPR is not for every researcher or every project. RESULTS OF TRUST BUILDINGCrow community members listened to what the project partners said and then sat back and watched.

They saw over time that our actions matched our words, and slowly we saw evidence that the project was trusted in the broader community.A recent indication of this trust occurred at the 2005 Crow Fair, at which the Messengers for Health project was invited to enter a float in the parade; the float obtained first-place recognition. Crow Fair is considered to be the most important social event of the year for the Crow people and has been a part of the culture for over 100 years. Project staff were told that the award was less for the float itself and more a gesture of respect and appreciation by the community for the work the project had done.In another show of trust, male community members have approached community and university partners and asked them to develop a project to work on men’s health issues on the reservation. Being approached by community men is especially significant because there has never been a men’s health project on the reservation and there are cultural restrictions about men and women talking about personal issues.The final example of trust is that the number of community partners has greatly increased as more community members want to be involved in Messengers for Health.

The conference room is packed at our monthly meetings, and cancer survivors are now coming forth to share their personal stories and bring encouragement, hope, and strength to others. BARRIERS TO TRUST BUILDINGBuilding and maintaining trust is an ongoing process.

The trust relationship discussed here took considerable time and effort to establish, and implementing this process in any community will have unique challenges.One barrier to building trust was that we did not have funding for the initial stages of project development. Funding would have provided partners with time and resources to build relationships and trust. Not having such resources may be common in CBPR research; there is a need to build relationships between community and academic partners, and most grants do not fund this essential work. Dedication by all initial partners is required in the early stages of project development.Another obstacle was the distance—200 miles—between the university and the reservation community. Coupled with Montana winters and a mountain pass between the 2 locations, this distance has meant that the academic partners have had to make considerable effort to be seen in the community and be a part of community events. By doing so, however, they have enhanced the community’s perception of their commitment to the project and the community.There are also issues that have to be grappled with in any project in which people come together from different backgrounds to work together.

We believe that every interaction between academic and community partners is an exercise in cultural competence and cultural humility. The differences between partners run across many levels, including gender, race, education level, urban versus rural setting, and economics. Thus, there have been and will be misunderstandings because of differences in cultural background. As relationships build, however, there are chances for both parties to learn to forgive each other’s mistakes as long as there is an understanding that both parties are sincere in their commitment to the project and the relationship.Another barrier is that researchers come into the community from the academic setting. In academia, researchers are expected to be the experts in their field.

That they must view community members as experts on community needs and values may be a new concept. To build trust, we found that the priorities of the community needed to be acknowledged and appreciated just as academic priorities are considered. Reversing the negative perceptions American Indian communities have of research and researchers will take time. CONCLUSIONWhat we learned as project partners about trust may be applicable to community members and researchers interested in or already working in partnership research.

The stepwise approach to building trust, which occurred naturally in Messengers for Health, may not be the best strategy for all community–academic partnerships. In an article on developing trust to conduct clinical research with elders from different ethnic groups and communities, Moreno-John et al. Found that many different strategies—some similar to ours and others different—were effective among the communities they studied. We realize that most of our readers will not be American Indian community members and hope that community partners will have access to this information or that a discussion between community and academic partners will result. A follow-up article with a focus on recommendations for community partners is in development.One of the major benefits of the trust-building process was that an increased level of safety developed over time.

As a result of our history of working together, community and academic partners are now more willing and able to go beyond earlier limits of what was comfortable for us. Partners involved in Messengers for Health realize that we cannot always be culturally appropriate, but we can accept one another’s misunderstandings.As an example of what can happen when there is a trusting relationship, the project recently contracted with someone to do work that none of the partners and no one on the reservation could accomplish. The person was hired via contacts through S. Unfortunately, the person who was hired was unconsciously disrespectful to community partners.

Community members understood that S. Was not to blame for the mishap. The existing trusting relationship helped all partners get through the incident much more easily.We are not asserting that trust is the only or best means for addressing all health disparities.

However, building trust was particularly important in Messengers for Health. Several studies have concluded that trust is important in developing mutually beneficial relationships between academic and community partners. – Long-term partnerships and implementation of CBPR is expected to lead to increased trust. In particular, researchers working with American Indian communities have cited trust as important in establishing research partnerships.

– Often, communities feel that researchers are not concerned with community needs and that the partnership provides more rewards for the researcher.,Communities may be initially distrustful of university partners if researchers often come into the community with new projects, or community members may be distrustful because of past abuses of research. The inability to build strong academic and community partnerships often stems from power imbalances., It is necessary to have mutual respect and a partnership that is mutually beneficial to foster trusting relationships. An open dialogue and an appreciation for each other are both ways of ensuring a successful partnership. It is also critical to make certain that there is equal input and ownership among community and academic partners in the research project.Equal partnerships are built on mutual respect, which can stem from cultural sensitivity. Cultural sensitivity, which implies respect for each other’s specific cultural beliefs and practices, is essential for culturally appropriate interventions. If the project does not work within the context of culture and community, there is less likelihood that an appropriate intervention will be designed.

Culturally sensitive interventions are necessary to address health disparities. If interventions are not designed in partnership with the community, they will not be as successful as those that do include the community members in the process. While academic partners provide resources such as funding and theoretical approaches such as CBPR, the communities provide the context. Collaboration between community partners and researchers is one component that helps ensure that the intervention addresses community concerns.,Successful models for working with tribes and indigenous entities require that the academic partners integrate a participatory process so that both partners are learning from each other.

Mutual learning is essential to acknowledging and reconciling past abuses inflicted upon tribal communities by researchers. Another vital component is to integrate opportunities for the non–American Indian researcher to appreciate the concept of tribal sovereignty as well as the concerns of the community, thus allowing for the researcher to be an authentic advocate for American Indian communities.As each successful CBPR project develops and builds credibility for the research community, meaningful research to address health disparities will grow. Ideally, more and more tribal members will become involved in research and use it as a tool for community health improvements.