Horizontal Participatory Planning in Prostate Cancer Prevention: An Analysis of the Mississippi...

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Horizontal Participatory Planning inProstate Cancer Prevention: An Analysisof the Mississippi Prostate CancerProjectDavid Besong Tataw a & Olúgbémiga T. Ekúndayò ba School of Public and Environmental Affairs, Indiana University,Kokomo, Indiana, USAb Department of Epidemiology and Biostatistics, School of PublicService, Jackson State University, Jackson, Mississippi, USAPublished online: 02 Aug 2012.

To cite this article: David Besong Tataw & Olgbmiga T. Eknday (2012) Horizontal ParticipatoryPlanning in Prostate Cancer Prevention: An Analysis of the Mississippi Prostate Cancer Project, Journalof Human Behavior in the Social Environment, 22:6, 733-754, DOI: 10.1080/10911359.2012.692576

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Journal of Human Behavior in the Social Environment, 22:733–754, 2012

Copyright © Taylor & Francis Group, LLC

ISSN: 1091-1359 print/1540-3556 online

DOI: 10.1080/10911359.2012.692576

Horizontal Participatory Planning in ProstateCancer Prevention: An Analysis of the

Mississippi Prostate Cancer Project

DAVID BESONG TATAWSchool of Public and Environmental Affairs, Indiana University, Kokomo, Indiana, USA

OLÚGBÉMIGA T. EKÚNDAYÒDepartment of Epidemiology and Biostatistics, School of Public Service,

Jackson State University, Jackson, Mississippi, USA

We examined the Mississippi Prostrate Cancer Project (MPCP) using

a 12-point assessment tool organized within three conceptual el-

ements: stakeholder participation, cultural and structural rela-

tionships, and partnership synergy. A case study design involving

participant observation and content analysis is adopted, and in-

terpretive methods including frame and categorical analysis are

used in data analysis. Though MPCP did not meet all the criteria

specified in our conceptual framework, beneficiary participation

and empowerment was intense. The MCPCP a unique case of

community participation where lack of beneficiary project initi-

ation does not diminish quality of participation or empowerment.

Horizontal participatory approaches demonstrated in this project,

created space for the growth of community social capital neces-

sary for sustainable community development in disadvantaged

communities, by cultivating beneficiary project leadership in the

planning hierarchy.

KEYWORDS Action research, CBPR, community based research,

community development practice, community engagement, com-

munity health, community participation, disparities research, em-

powerment science, horizontal participation, horizontal participa-

tory planning, intervention research, partnership synergy, stake-

holder participation

Address correspondence to David Besong Tataw, School of Public and EnvironmentalAffairs, Indiana University, Kokomo, 2411 Schick Dr, Kokomo, IN 46902, USA. E-mail:[email protected]

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734 D. B. Tataw and O. T. Ekúndayò

INTRODUCTION

Despite the disproportionately heavy burden of prostate cancer among AfricanAmerican men (Centers for Disease Control and Prevention [CDC], 2007;American Cancer Society [ACS], 2008), they often fail to address their ownindividual health or make decisions to engage in preventive behavior or toaccess health care related to this condition (Cheatham, Barksdale, & Rodgers,2008; Fergus, Gray, & Fitch, 2002; Forrester-Anderson, 2005; Myers et al.,1996, 1999; ACS, 2006, 2008; Odedina et al., 2008; Lehto, Song, Stein, andColeman-Burns, 2010). Low levels of preventive behavior and utilization ofexisting prostate cancer prevention and early treatment services are relatedto the target population’s empowerment and acceptability of interventionsin research and practice environments (Parket et al., 2006; Sanchez, Bowen,Hart, & Spigner, 2007; Dunlop, Manheim, Song, & Chang, 2002; Du et al.,2006; Drake, Shelton, Gilligan, & Allen, 2010). The Mississippi Prostate Can-cer Project uses focus groups and survey research within a communityengagement and empowerment framework to enable the participation ofthe low-income African American urban community of Georgetown Jackson,Mississippi in assessing prostate cancer prevention needs and identifyinghealth promotion and policy preferences for the community. The focusgroup findings and survey research results of the project have been reportedin separate papers (Ekundayo & Tataw, 2011; Tataw & Ekundayo, 2011).This paper assesses the horizontal participatory character of the MississippiProstate Cancer Project.

Participation in decision making and in the implementation of healthservices decisions empowers health services consumers in at-risk popula-tions (Laverack, 2004, 2007; Woods et al., 2006). The consumer’s ability toparticipate in health services decision making is enhanced when communi-cation during consumer/expert encounters moves from an expert-dominatedmonologue to a dialogue where there is an exchange of information betweenexpert and consumer rather than a transfer of information from expert toconsumer (Leea & Garvin, 2003; Guerra, Jacobs, Holmes, & Shea 2007;Ross, Mead, Powe, & Howard, 2009). Dialogue nurtures consumers’ ac-ceptability of the expert’s services through active participation and trust-ing relationships (Oakley, 1991; Borden & Serido, 2009). Trust and par-ticipation in decision making has been shown to increase consumer self-efficacy and satisfaction with health services in at-risk low-income pop-ulations (Doescher et al., 2000; Tataw, Bazargan, & Patel, 2010; Gamble,1997; Powell, 1997; Weathers et al., 1999). Community health programs withcultural and/or structural horizontal relationships in which decision makingis consensual through a give-and-takeprocess rather than unidirectional fromexperts to low-income consumers have increased the consumer’s voice, self-efficacy, satisfaction, and greater participation in the health system (Tataw &Bazargan-Hejazi, 2010; Tataw, Bazargan-Hejazi, & James, 2010, 2011; Borden

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Horizontal Participatory Planning 735

& Serido 2009; Consedine et al., 2007). A horizontal culture means that thereis no attitude or feeling of superiority or inferiority among stakeholders.A horizontal structure implies that decision making is not top down as ina hierarchical framework. Decision makers are at the same level in thedecision-making process, with equal input and regard for all stakeholders(Tataw, 2010, 2011). Empowerment has been advanced as both a meansand an end in enhancing and promoting health (Wallerstein 1988, 1992;Braithwaite, Bianchi, & Taylor, 1994; Labonte, 1994; Perkins & Zimmerman,1995; Tataw, Bazargan, Johnson, Rahman, & Bean, 2007; Tataw, James, &Bazargan, 2009).

This paper assesses participatory planning in the Mississippi ProstrateCancer Project through the following specific aims:

1. To modify a horizontal participatory implementation qualitative assess-ment tool (Tataw, 2012).

2. To use the modified horizontal qualitative assessment tool in assessingparticipation in the Mississippi Prostrate Cancer Project.

3. To assess the implications of the findings for community health programplanning, intervention research, and community development practice.

The investigation and analysis are done within a participatory frame-work that encompasses three conceptual elements: stakeholder participationin the program, cultural and structural relationships, and partnership synergy.

PARTICIPATION IN COMMUNITY HEALTH

Citizen participation is not only an integral part of community development(Abbott, 1995) but it democratizes planning, and promotes social justice byallowing all citizens, especially disadvantaged groups, to influence policymaking at the city-level (Imparato & Ruster, 2003; Souza, 2003; Woods et al.,2006) and other community levels. Participation is also considered a crucialcomponent in the provision of basic needs, efficiency, and self-reliance (Cox& Sinclair, 1996; Cheatham, Barksdale, & Rodgers, 2008; Consedine et al.,2007; Taylor et al., 1999). Participatory governance leads to citizenship partic-ipation in community health and creates opportunities for citizens to be partof conceptualization, planning, implementation, and evaluation of commu-nity health programs (Ravenell, Johnson, & Whitaker, 2006; Aston, Meagher-Stewart, Edwards, & Young, 2009; World Health Organization [WHO], 2003).Participation leads to empowerment (Kretzman & McKnight, 1993) and stim-ulates critical consciousness and trusting relationships (Freire, 1970; Gamble,1997; Reynolds, 2008; Ross et al., 2007). Participatory governance can alsotrigger policy development and systems change (Rose, Gomez, & Valencia-Garcia, 2003) and ensures that local ownership and consensus are obtained,

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interagency coordination is established, and all stakeholders, not just propri-etary interests, are involved in policy development and planning (Penner,1994).

STUDY SETTING AND POPULATIONCHARACTERISTICS

Disparities in Prostate Cancer Burdens in Mississippi andthe United States

Cancer is the second-leading cause of death in both the United States (US)and Mississippi (Kung, Hoyert, Xu, & Murphy, 2008; Mississippi Departmentof Health, 2006). The ACS estimates that 13,400 new cases of cancer werediagnosed in Mississippi by the end of 2005, including 2,010 new casesof prostate cancer (ACS, 2008). By the end of 2004, data from the CDCrevealed that Mississippi ranked second in U.S. cancer death rate (CDC,2007). In 2003, the incidence rate for cancer in Mississippi was lower thanthe average incidence rate for the nation; however, the death rate from cancerin Mississippi as enumerated above was higher than that of the United States(Mississippi State Department of Health, 2005).

Prostate cancer was the most common type of cancer found in Mis-sissippi men with incidents at 161 per 100,000 in 2005 closely followed bylung and bronchial cancer with incidents at 111.9 per 100,000 (MississippiDepartment of Health, 2005). Although the ACS reported that the incidenceof prostate cancer is on the decline in Mississippi, prostate cancer still rankssecond as the leading cause of death among men. African American menhave the highest incidence, prevalence, and mortality due to prostate cancerrelative to other racial and ethnic groups in Mississippi.

According to the CDC, between 1970 and 1994, the death rate due toprostate cancer among Black males in the state was twice the rate for Whitemales. Mortality rates for White males are 21.2 per 100,000 versus 41.91per 100,000 for African American males (CDC, 2007). According to NationalInstitutes of Health estimates, in 2008 dollars, the median cost effectivenessratio for prostate cancer was $34,500 (Greenberg, Earle, Fang, Eldar-Lissai,and Neumann, 2010). Also, the overall cost of cancer care in the UnitedStates in 2007 was estimated to be $219 billion, with direct care costs being$89.0 billion, of which $18.2 billion was attributed to productivity loss and thebalance due to indirect mortality costs (i.e., productivity lost due to prematuredeath; Meropole et al., 2009).

In 2005, U.S. cancer statistics revealed that the incidence of prostatecancer in Mississippi among African American men almost doubled that ofWhite men (i.e., 221.2 per 100,000 versus 139.2 per 100,000; ACS, 2008).This number clearly shows a disparity in the incidence of prostate cancer in

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the state with African American men bearing the heaviest burden, and theirnumbers drive the state distribution compared to national levels. Table 2below adapted from the Mississippi Statistical Automated Health Systemsshows that from 2005 to 2009, the prostate cancer death rate among AfricanAmerican men was about one-and-a-half times higher than the death rate ofWhite men (31.9 per 100,000 versus 19.0 per 100,000 for Whites).

The Mississippi State Department of Health Vital Statistics (2005) re-ported that other than trachea, bronchus, and lung cancer, prostate canceris the second-leading cause of cancer deaths among Mississippi men, anda heavy burden of the disease is still borne by Black men in the state(Mississippi Department of Health, 2006). Unless innovative programs areput in place to combat this trend, it will continue to be a major health issue inthe state, costing lives and resources. Increased awareness of risk factors forthis disparity, effective planning and implementation of prevention programs,and policy development/adjustment are major requirements to address thedisparate incidence and prevalence of disease among minority populations(Guerra, Jacobs, Holmes, & Shea, 2007; Ford, Vernon, Havstad, Thomas,& Davis, 2006; Taylor et al., 2001; Bennet et al., 1998; Parker et al., 2006;Sanchez et al., 2007).

The Community

The target community of Georgetown is at the center of a mostly minor-ity population that usually comes with high levels of poverty and otherdemographic, socioeconomic risks for negative health outcomes, includingprostate cancer (Sanchez et al., 2007; Dunlop et al., 2002; Du et al., 2006;Myers et al., 1999).

Table 1 presents the demographic statistics for Mississippi, city of Jackson,and the Georgetown community. Georgetown community is part of HindsCounty district 2, with a population of 28,939 (U.S. Census Bureau, 2010).The African American population of Georgetown is 86.4%, with Black malesbeing 11,574 (45.13%), whereas Black males 45 years old and older numbered3,372 or 29.14%. The city of Jackson (of which Georgetown forms about 40%of City Council Ward 3), has a population of 175,283 (U.S. Census Bureau,2010). African Americans make up 76.77% or 134,567 of City Council Ward 3.

Though the specific population characteristics of Georgetown are notavailable, the community nevertheless reflects the trends in Jackson cityitself. For Jackson, the median household income (2007–2009) was $32,306(African Americans, $28,007; White: $51,337) compared to that of Mississippi($37,034) and Hinds County ($38,250). With regard to educational attainmentfor people 25 years and older, 76.18% of African Americans had high schooland higher education, compared to 92.02% of Whites in Jackson. This ishigher than the state rates at 69.12% for African Americans and 83.03% forWhites.

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TABLE 2 Demographic Characteristics for Mississippi, Hinds County, and City of Jackson

Mississippi Hinds county Jackson

Total population 2,937,976 248,018 175,283Black 1,093,403 163,401 134,567Total male 1,423,071 116,966 81,513Black male 513,830 76,387 63,635Black male 45C 138,747 19,174 15,886Median household income (total) $37,034 $38,250 $32,306Median household income (black) $24,289 $29,620 $28,007Median household income (white) $46,630 $54,140 $51,337Per capita income (total) $19,743 $20,822 $19,605Per capita income (Black) $12,488 $15,015 $15,151Per capita income (White) $24,536 $33,274 $39,119Education* (Black) 69.12% 77.08% 76.18%Education (White) 83.03% 91.94% 92.02%

*Population age 25 years and older.Source. U.S. Census Bureau 2007–2009 3-year data set.

Table 3 provides prostate cancer mortality rates for Jackson and Hindscounty from 2007 to 2009, and Table 4 presents screening rates from 2004to 2010. Prostate cancer mortality rates for African Americans drive the highrates in the state compared to national figures. Prostate cancer mortality ismuch higher among African Americans than Whites across all age groupsaffected, with rates for 2007 through 2009 in Jackson ranging between227.5/100,000 among 65- to 74-year-old African Americans and 1,015/100,000among African American men 85 and older compared to 48.4/100,000 to347.1/100,000 among White men of the same age categories and the rateratios ranging between 2.93 and 4.70 Black to White. However, even withthese glaring rate differences, African American men tend to engage inprostate cancer screening at much lower levels than White men, with ratedifference widening from 2006 through 2010.

TABLE 3 Prostrate Cancer Mortality Rates by Age and Race in Metropolitan Jackson area ofHinds County, Mississippi

45–54 55–64 65–74 75–84 85C Total

Race n Rate* n Rate n Rate n Rate n Rate n Rate

White 0 0.0 2** 7.2 8 48.4 13 122.4 13 347.1 36 18.8Black 1 2.1 7 23.5 28 227.5 29 522.7 19 1,015.5 84 21.9Total 1 1.2 9 15.3 36 122.9 42 256.6 32 562.5 120 20.5

Notes. Rates expressed as per 100,000 population. Rates in cells based on fewer than 20 events areunstable. Prostate cancer rate based on male-specific population.Source. MSTAHRS: Mississippi Statistically Automated Health Resource System, Deaths Table ID: 59931http://mstahrs.msdh.ms.gov/forms/morttable.html Retrieved 07-17-2011.

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TABLE 4 Prostate Cancer Screening (PSA): Men Aged 40C Who Have Had a PSA Test Withinthe Past 2 Years. Mississippi 2004–2010

Race

White Black All

Year % CI n % CI n % CI n

2004 54.2 (50.4–58.0) 453 51.3 (44.4–58.2) 152 53.0 (49.7–56.3) 6362006 55.7 (52.3–59.1) 623 53.6 (47.1–60.1) 172 54.7 (51.7–57.7) 8262008 57.2 (54.1–60.4) 938 49.8 (44.3–55.4) 272 54.5 (51.8–57.2) 1,2612010 57.3 (54.0–60.7) 937 46.9 (41.1–52.7) 290 53.6 (50.7–56.5) 1,274

% D weighted percentage; CI D confidence interval; n D cell size (numerator).Source. Adapted from the U.S. CDC Office of Surveillance, Epidemiology and Laboratory Services, BRFSSPrevalence and Trends Data.

CASE SUMMARY

The Mississippi Prostate Cancer Project used focus groups and survey re-search to engage and empower the African American urban communityof Georgetown in Jackson, Mississippi in leading prostate cancer healthpromotion and policy advocacy. The goals of the project were to identify theknowledge of prostate cancer risk factors and symptoms; resource utiliza-tion; health education strategies; and policy preferences of the community.The project was initiated by faculty at the school of public service andfunded by the Mississippi Comprehensive Cancer Control Program of theState Department of Health. Though the project was administered by aprincipal investigator, a project director and a student intern, it was underthe direction of a Technical Advisory Committee and Community AdvisoryBoard (CAB).

This is a mixed-method project involving a single focus group of 20participants and a survey of 79 participants drawn from the Georgetown com-munity of Jackson, Mississippi. The project utilized a community-engagedparticipatory action approach consisting of a CAB and a Technical Advi-sory/implementation Committee (TAC). The CAB consisted of representationfrom community stakeholders including prostate cancer sufferers/survivors;prostate cancer support groups; faith-based, community–based, and ethnicorganizations (FBOs, CBOs, EOGs); academia; care givers/providers; policyrepresentatives from state and local governments; target community mem-bers; representatives from the private sector, including the local chambers ofcommerce; business owners;, and other community coalitions and networks.The TAC consisted of prostate cancer research and education experts inacademia and the community.

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Focus Groups February 6, 2008

Focus group discussions covered six questions developed by a TAC andvalidated by a CAB. The TAC and CAB were also responsible for recruitmentand facilitating the focus group. Data were collected during one focus groupsession that took place from 6.00 p.m. to 8.00 p.m. on February 6, 2008involving 20 members drawn from the Georgetown community of Jackson,Mississippi. The TAC developed the questions, and the CAB administeredboth the questions and the consent forms and facilitated the discussions. Thequestions developed by the TAC were reviewed and validated by the CAB.The informed consent form administered by the CAB members was readand explained to all attendees, then signed by all participants. Participants’focus group questions were asked by a CAB member, and responses anddiscussions were recorded by the program director and student interns via

� flip charts,� audio recorder (Olympus N 4123 – Olympus Imaging Corp),� focus group participants notes, and� project director’s notes.

Participants were chosen using a modified snowball sampling method-ology that was supported by a CAB. A CAB was also selected using asnowball sampling method. Focus group participants were then recruited byCAB members during community association meetings, community events,at barbershops, at service stations, via telephone calls, and in house-to-housevisits.

Before the focus group meetings, community representatives weretrained in outreach and in-reach (Ekúndayò & Buckner-Brown, 2010) educa-tion for the CAB. The TAC and CAB were formed and engaged to implementthe project. Meetings of the TAB and CAB were held, and training wasprovided to members on their roles in both research and advocacy. A focusgroup agenda and fliers were distributed to CAB members, who distributedthe fliers and meeting information through announcements at churches,community centers, community events, barber shops, television, radio andtelephone calls. No specific incentives were provided for participation;however, dinner was provided due to the time of activity (6.00 p.m.–8.00p.m.)

Survey Research March 6 to 27, 2008

Survey data were collected using a cross-sectional survey design relying onprimary quantitative and qualitative data collected using a 21-point surveyinstrument of structured and unstructured questions. Survey research took

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place from March 6 to March 27 in 2008. Participants were chosen using amodified snowball sampling methodology that was supported by the CAB.A CAB that made up the first and core survey participants was selected usinga snowball sampling method. Community participants were then recruitedby CAB members who invited additional participants during communityassociation meetings, community events, at barbershops, at service stations,via telephone calls, and in house-to-house visits.

CONCEPTUAL FRAMEWORK

The analysis of the Mississippi Prostrate Cancer Project is done within aparticipatory framework that encompasses three conceptual elements: stake-holder participation in the program, cultural and structural relationships, andpartnership synergy (Tataw, 2012).

Implementation in development work has been described using a con-tinuum ranging from simple participation to complete participatory imple-mentation. Participatory implementation efforts are those ‘‘involving usersand communities in all stages of the development process’’ (Narayan, 1993,p. iii). Oakley (1991, p. 8) describes participation as ‘‘voluntary or otherforms of contribution by rural people to predetermined programs or projects’’Many activities constitute participation by beneficiaries including completingquestionnaires, taking part in a focus group, or responding to key informantinterviews, but a true participatory project is one that is initiated and ownedby the project beneficiaries and contributes to the empowerment of the ben-eficiaries (Cummings, 1997). Participation in planning is enabled by culturaland structural relationships and strengthened by partnership synergy.

Cultural and structural relationships in program implementation couldbe horizontal or vertical. Structural relationships refer to the manner in whichstakeholders within or between settings are organized. Are they organizedinto hierarchical systems or are they interacting at the same level? Culturalrelationships refer to the extent to which there is dialogue or monologueamong stakeholders. It also refers to the opportunities for all stake-holdersto be heard and equally regarded without a sense of superiority or inferiority.A horizontal culture means that there is no attitude or feeling of superiorityor inferiority among stakeholders in the decision-making process or duringinteractions in other program activities. Decision makers are at the samelevel in the decision-making process with equal input and regard for allstakeholders. A horizontal structure implies that stakeholder participationis not organized in a hierarchical framework. A horizontal program struc-ture allows for stakeholder representation at all decision- making levelsand in all program structures. Structural and cultural relationships are im-portant enablers and reinforcers of stakeholder participation. A horizontalculture provides space for the beneficiary to participate in the planning

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process and to either shape or take leadership in the process. When theprocess is not welcoming to the stakeholders in low-income communities,it is harder for community members to open up, freely provide informa-tion, and actively participate in and/or take leadership of some or all el-ements of the process (Odedina et al., 2004; Wallner, Sarma, & Lieber,2008).

Partnership synergy has been identified as a primary characteristic of asuccessful collaborative process (Lasker, Weiss, & Miller, 2001) and involveseffectively merging perspective, knowledge, and skills to maximize synergyand realize the full potential of collaboration (Weiss, Anderson, & Lasker,2002). The most successful alliances are in companies with a departmentspecifically assigned to overseeing alliances (Wagner, Lee, & Glasser, 2009).A dedicated alliance function within the participating organization acts as afocal point for learning and for leveraging feedback from prior and ongoingalliances and capturing the attention of senior management. It systemati-cally establishes processes to articulate, document, codify and share allianceknow-how (Dyer, Kale, & Singh, 2001).

Horizontal cultural and structural relationships are related to synergy andparticipation. Without the space created by horizontal cultural and structuralrelationships, beneficiary and other stakeholder participation will be verylimited or nonexistent. Conceptually, the willingness to commit resourcesand a dedicated alliance function to the partnership by stakeholder organi-zations or groups is determined by the existence of the space to participate.Also, the existence or intensity of synergy depends on the existence and sizeof the space created by horizontal cultural and structural relationships. If thespace provided by horizontal relationships is small, the intensity of synergywill be low and vice versa.

METHODS

Design

This is a single case study involving participant observation and contentanalysis of program reports. One of the authors participated in the devel-opment and implementation of the plan as a principal investigator. Theprogram assessments and analysis in this paper are based on both theauthors’ personal observations and a review of published reports. This studywas approved by the institutional review boards of both Indiana University,Kokomo in Indiana and Jackson State University in Jackson, Mississippi.

Measurements

The Mississippi Cancer Prevention Project is assessed using a 12-item instru-

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ment within the 3-element framework including stakeholder participationin the program, cultural and structural relationships, and partnership syn-ergy (Tataw, 2012). The tool used is a modified adaptation of a qualitativeassessment instrument that has been used in multiple case analysis of com-munity health programs (Tataw, 2012). The assessment is organized aroundthe program cycle including program initiation; needs assessment; problemidentification; project and program design/formulation; feasibility analysis;project and program implementation; implementation success; beneficiarysatisfaction; and empowerment. For every stage of the program cycle, theplanning process is assessed to determine the degree to which stakeholders(experts and beneficiaries) participated in the program. In addition, culturaland structural relationships between experts and beneficiaries are assessedto determine the degree to which they are horizontal or hierarchical. Fur-thermore, program partnership synergy is assessed. The assessment itemsare described below:

1. Program initiation participation refers to the degree to which beneficia-ries and other stakeholders are involved in the conceptualization andinitiation of the project. Did the experts or external parties initiate theproject or was it initiated by beneficiaries?

2. Problem identification participation refers to the degree to which ben-eficiaries and other stakeholders participate in the identification of theproblems facing the community and the root causes of identified prob-lems facing the community.

3. Needs assessment participation refers to the degree to which beneficia-ries and other stakeholders are involved in completing the resource-needgap analysis that will be used to develop future programs addressingbeneficiary or community needs.

4. Feasibility analysis participation refers to the degree to which bene-ficiaries and other stakeholders are involved in deciding whether theproject/program should be conducted or implemented.

5. Project and program implementation refers to the degree to which stake-holders and participants are involved in helping the project plan cometo life.

6. Project/program design participation refers to the degree to which ben-eficiaries and other stakeholders are involved in the development of theplan or project.

7. Implementation success refers to the degree to which the project planis successfully implemented and the degree to which beneficiaries andother stakeholders are involved in bringing about that success.

8. Beneficiary satisfaction and empowerment refer to the degree to whichbeneficiaries are empowered by and/or satisfied with the project orprogram.

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9. Cultural relationships among stakeholders refers to the degree to whichthere is no attitude or feeling of superiority or inferiority among stakeholders.

10. Structural relationships among stakeholders refers to the degree to whichorganizational structures and reporting relationships are horizontal andthat decision making is not top down as in a hierarchical framework.

11. Partnership synergy refers to the degree to which partners are effectivelymerging perspective, knowledge, and skills to maximize synergy andrealize the full potential of collaboration. This also includes leadershipcommitment of participating organizations by providing a dedicated al-liance function within the participating organization acting as a focalpoint for learning and for leveraging feedback from prior and ongoingalliances and capturing the attention of senior management.

12. An overall participation-participatory continuum refers to the qualita-tively assessed position of the project or program on the participatorycontinuum. This ranges from simple participation to a complete partici-patory position. This should involve very low to very high ratings on theassessment items 1 to 11 above and it depends on the programs/projectsposition on the participation-participatory continuum.

Data Analysis

A total of 12 assessment points are identified and utilized in the review.The results of the 12-point assessment are then arranged in a table and sub-jected to interpretive methods of data analysis including frame and categoryanalysis.

RESULTS

The results of the 12-point assessment of the Mississippi Prostate CancerProject are summarized in Table 5. The assessment reveals that stakeholdersincluding beneficiaries fully participated in the following activities: needsassessment; problem identification; project and program design/formulation;project and program implementation; and securing implementation success.Beneficiary success could not be fully assessed as recommended interventionprograms have not yet been developed and implemented. However, bene-ficiary empowerment is evidenced by their extensive involvement in the as-sessment points described above. In addition, cultural and structural relation-ships between experts and beneficiaries were determined to be horizontalwith mutual respect for all stakeholders. Furthermore, program partnershipsynergy is assessed to be very high with the university, and communityinvestment in the project is considered to be very profound. There was nobeneficiary participation in program initiation and feasibility analysis.

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TABLE 5 Results of a Twelve-Point Qualitative Assessment of the Mississippi CancerPrevention Project

Assessment criteria The Mississippi Prostate Cancer Project

1. Program initiation External expert initiation. No participation from communityand beneficiaries.

2. Needs assessment Extensive involvement of community members indetermining community needs for both health promotionand policy through focus groups and survey research.

3. Problemidentification

Experts determined with refining done by beneficiaries viafocus groups and survey research. Technical AdvisoryCommittee (TAC) and Community Advisory Board (CAB)were involved in both identifying , refining and reframingsurvey and focus group questions.

4. Project and programdesign/formulation

TAC and CAB were involved in both identifying, refining,and reframing survey and focus group questions.

5. Feasibility analysis Expert participation only.6. Project and program

ImplementationExpert participation with full involvement of the community

through the TAC and the CAB. TAB and CAB membersalso facilitated participant recruitment and actual datacollection.

7. Implementationsuccess

The community was critical in assuring implementationsuccess both in facilitating the focus groups and surveyquestionnaire delivery but also in reframing many focusgroup questions that allowed for beneficiaries tounderstand issues and contribute fully.

8. Beneficiarysatisfaction andempowerment

As this is a planning process and programs have not yetbeen designed and implemented, satisfaction could notbe determined. However, the participation level of thecommunity in selecting the survey and focus grouppatterns and in identifying health promotion and policypreferences demonstrates a high level of empowerment.

9. Cultural relationshipsamong stakeholders

Relationships were culturally horizontal as the stakeholdersrespected each other including survey participants andevery partner in the project participated freely in theproject decision making process.

10. Structuralrelationships amongstakeholders

Horizontal among all stakeholders including beneficiariesdemonstrated by membership in the TAC and CAB thatdrew participants from all stakeholders. The Advisorybodies oversaw the entire planning process.

11. Partnership synergy Very high synergy as the School of Health Sciences atJackson State University and the Georgetown communityprovided significant resources to both the TAC and CAB,which allowed for mutual learning and community anduniversity updates on the project progress and dynamics.

12. Overall participation-participatorycontinuum

Beneficiaries substantially participated in the project, but theproject was not completely participatory becausebeneficiaries did not initiate the project.

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DISCUSSION

The overall results show that though the Mississippi Prostate Cancer Projectinvolved participation of beneficiaries, it was not a complete participatorycommunity health program based on the conditions established for partic-ipatory planning and implementation in the conceptual framework above.Based on the three conceptual elements of the framework used to analyzethis case, the Mississippi Prostate Cancer Project fully satisfied the criteriaestablished for structural and cultural relationships and partnership synergyin this analysis. Though beneficiaries did not participate in program initiationand feasibility analysis, the intensity of participation in all other programcycle activities was very high. In fact, the community took leadership of theproject after feasibility analysis and the decision to proceed was made bythe experts. This is certainly a unique situation in which the experts retreatto the role of facilitators once the community becomes engaged.

CONCLUSION AND IMPLICATIONS FOR PROGRAMIMPLEMENTATION AND COMMUNITY DEVELOPMENT

This paper has described the participatory character of the Mississippi CancerPrevention Project implemented in February and March, 2008. The project isa horizontal participatory planning project, and it exhibits significant partici-pation, horizontal cultural and structural relationship, and strong partnershipsynergy.

The intensity of beneficiary participation and empowerment in a projectinitiated by experts challenges the suggestion that when communities do notinitiate programs, their participatory quality and intensity of empowermentare diminished (Narayan, 1993; Oakley, 1991; Cumming, 1997; Laverack,2004, 2007). This makes the Mississippi Prostrate Cancer Project a uniquecase of participation. The dynamic participation of the community in thecancer prevention project once it was invited to engage and provide lead-ership in operationalizing the project bears testimony to the possibility forexperts to be catalyst in the creation of social capital in community health.

The project demonstrated strong structural and cultural relationships,beneficiary empowerment, and high partnership synergy. Cultural relation-ships, partnership synergy, and beneficiary empowerment are forms of socialcapital as identified in social capital theory (Hustede, 2009). The process ofsocial capital formation has been described as a community developmentprocess (Philips & Pittman, 2009). As the cultural relationships and part-nership synergy referred to above are generated by a community healthproject and benefit an entire community, they are community social capitalas defined by Mattessich (2009).

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As an example of a horizontal participatory implementation approach toprogram development, this project represents emergent community healthprograms (Tataw et al., 2007, 2009, 2010; Tataw & Bazargan-Hejazi, 2010;Tataw & Rosa-Lugo, 2011) which advance an empowerment slant to programdevelopment practice and challenge the conceptual approaches representedin classical policy/program implementation models mainly by lifting theprofile of the service beneficiary in the project cycle. Top-down and bottom-up implementation models that are also known as the classical models havedominated the framing of our conceptual understanding of program andpolicy implementation in recent history. Top-down models advocate forthe supremacy of formulation settings and decisions made at formulationsettings (Van Meter and Van Horn, 1975; Sabatier, 1986), whereas bottom-up models generally advocate for the dominance of the implementationsettings and actors (Berman, 1978, Hjern & Porter, 1981; Hjern, 1982; Hjern& Hull, 1982; Hull & Hjern, 1987; Lipsky, 1978). Both models present avertical construction of the implementation process in an intergovernmentalhierarchical framework. Though the Mississippi Prostrate Cancer PreventionProject is similar to top down-models in terms of project initiation andfeasibility analysis, it is also significantly different from top-down modelsbecause it presents a horizontal construction of the program/policy processand creates space for at-risk low-income populations such as the residents ofGeorgetown in Jackson, Mississippi to participate in community developmentby emphasizing horizontal cultural relationships between frontline expertsand beneficiaries. This leads to the growth of community social capitalnecessary for sustainable community development.

Future analysis of this emergent horizontal participatory program imple-mentation approach for at-risk populations should go beyond interpretivecase analyses and should include quantitative data collection and analysis.The qualitative assessment items used in this study could be transformed intocategorical or quantitative scales that would allow for quantitative statisticalanalysis. Additional research could seek to determine the prevalence of hor-izontal participatory implementation among a larger sample of communityhealth programs and ascertain the minimum level of participation necessaryfor beneficiary satisfaction and empowerment to occur.

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