A scoping review on the key elements and effects of cardiovascular disease management programmes based on community-based participatory research

Background. This scoping review aims to analyse the literature on community based participatory research (CBPR) -based cardio vascular disease (CVD) management programmes, examining the key elements of their development and implementation and exploring their effectiveness. Methods. This study is based on the scoping review methodology, consisted of six stages: 1) identifying the research question; 2) identifying relevant studies —search strategy; 3) study selection; 4) charting the data; 5) collating, summarising, and reporting the results; and 6) consultation exercise. The electronic databases used for the literature search were PubMed, Cochrane, and CINAHL. The search period was from 4 March to 3 April 2020. We selected studies that: 1) were published after 2000; 2) targeted community residents over the age of 18; and 3) proposed a CBPR-based CVD management programme, described its development process, or evaluated its effects based on its application. The data were extracted independently by two researchers according to the standardised form. Results. Among the key elements of such programmes, there were many cases in which community organisations played the leading role in establishing partnerships and cases in which a decision-making committee was formed. Regarding the application of the CBPR principles, community partners participated only in executing the research and not in the process of analyzing and interpreting research results. In addition, In all six RCT studies, the experimental groups showed signicantly positive effects compared to the control groups. Conclusion. It is necessary to develop strategies to improve the criteria based on which CBPR principles cannot be implemented during the development and implementation of a CBPR-based CVD management programme. In addition, more attempts to verify the effectiveness of high-quality research methodology should be made when evaluating the effectiveness of programmes. 1 study measured the quality of life based on psychological characteristics. In addition, 4 studies evaluated research perceptions, benets, satisfaction, acceptability, and feasibility. In 6 of the selected studies with a randomised controlled group, the experimental group showed signicantly positive effects compared to the control group.

This study is based on the scoping review methodology developed by Arcsey and O'Malley [20] and modi ed by Levac et al. [21]. It consists of six stages: 1) identifying the research question; 2) identifying relevant studies-search strategy; 3) study selection; 4) charting the data; 5) collating, summarising, and reporting the results; and 6) consultation exercise. In the process of conducting this scoping review and reporting the results, we abided by the PRISMA extension for scoping reviews checklist [22].

Stage 1: Identifying the research questions
The research questions in this scoping review were formulated and divided into two categories: 1) the 'process' aspect of developing and implementing a CBPR-based CVD management programme, explored through a preliminary survey; and 2) the 'results' aspect of developing and implementing the programme.
The research questions are as follows: 1) What are the key elements to be considered in the process of developing and implementing a CBPR-based CVD management programme?
2) How is the CBPR-based CVD management programme structured, and what are the effects? Stage 2: Identifying relevant studies-the search strategy The electronic databases used for the literature search were PubMed, Cochrane, and CINAHL. The search period was from 4 March to 3 April 2020.
The search terms were selected by reviewing the main terms used in the abstract or main text of relevant studies. Based on the characteristics of search eld for each electronic database, a speci c search strategy was established. The search strategies used across all the electronic databases are as follows: 1) The 'population' search words include 'cardiovascular disease', 'vascul* disease', and 'vascular disease' and were combined using the Boolean operator OR; 2) The 'intervention' search words include 'community-based participatory research', 'participatory action research', 'CBPR', 'PAR', 'participat*', 'community engagement', 'community involvement', 'civic engagement', and 'engagement*' and were combined using the Boolean operator OR; 3) The population and intervention search results were combined using the Boolean operator AND; 4) For a comprehensive search, a Medical Subject Headings (MeSH) search was rst performed for all search words, which was followed by a search performed in the title/abstract eld; 5) The search results were saved after removing duplicate literature using a bibliographic management software (Endnote V.9.3.3.); 6) The search results were shared among the authors.

Stage 3: Study selection
The relevant studies identi ed using the search terms proposed in the literature search strategy were reviewed according to the study selection criteria. We selected studies that: 1) were published after 2000; 2) targeted community residents over the age of 18; and 3) proposed a CBPR-based CVD management programme, described its development process, or evaluated its effects based on its application. We did not impose any restrictions on the type of research design. Studies other than original research, such as protocols, reviews, and guidelines, studies on inpatients, and studies not written in English were excluded.
A study was selected if two researchers reached a consensus after independently screening the study title and abstract. When it was di cult to select a study based solely on the abstract, the full text was reviewed to make a nal decision. When the two researchers disagreed, the study selection was made only after su cient discussion.
A ow chart of the study selection process is shown in Fig. 1. Among the 731 studies identi ed during the preliminary search of electronic databases, 72 duplicate studies were removed. Upon reviewing the titles and abstracts of the remaining 659 studies, 525 studies were excluded from the analysis because they did not meet the selection criteria. We selected 27 studies after reviewing the full text of 134 studies; the remaining 107 studies did not meet the selection criteria. The following groups of studies were derived from the same research and hence, are considered as one study: 1) Balcazar, Rosenthal et al. [ [29]; and 4) Ralston, Lemacks et al. [30], Ralston, Young-Clark et al. [31], and Ralston, Wickrama et al. [32]. Finally, the number of studies included in the review was 21. After the data were extracted independently by two researchers according to the standardised form, the results of the extraction process were compared. A data extraction form was prepared before the start of data extraction and was adjusted as references were compiled on a pilot basis. Through regular research meetings for 2-3 hours twice a week, the results of data extraction were checked, and the degree of agreement was compared.
Stage 5: Collating, summarising, and reporting the results For the results regarding Research Question 1-the key factors to be considered in the process of developing and applying a CBPR-based CVD management programme-we summarised common characteristics observed in selected studies, such as partnership establishment (the subject of research initiation and the structure of partnership) and the process of development and application of a CVD management programme (the degree of CBPR principle application, application of planning model and theory, and eld activists). We referred to the CBPR quality assessment tool developed by Viswanathan et al. [33] and revised by Chen et al. [34] for the degree of CBPR principle applications, subsequently employing the questions recommended by the latter. The tool modi ed by Chen et al. [34] consists of two questions as the primary criteria of assessment-'Was the community partner identi ed?' and 'Was the community partner involved in the planning and/or execution of research?'-and three questions for the secondary criteria-'Was the community partner involved in selection of research topic or development(or review) of the programme?', 'Was the community partner involved in analysis and/or interpretation of research?', and 'Was the community partner involved in dissemination of research results?'. Each question is measured on a three-point scale (1 = 'poor'; 2 = 'fair'; and 3 = 'good'). question on whether the community partner was involved in selection of research topic or development (or review) of the programme, we considered participants from the community, who participated in the process of selecting a topic or changing an existing programme to suit their characteristics to be community partners. The results were summarised by evaluating each question, not on the aforementioned three-point scale, but on a simpli ed two-point scale (yes and no).
For Research Question 2-'How is the CBPR-based CVD management programme structured and what is its effects?'-we summarised the study design, characteristics of participants and intervention programmes, measurement scales, and results. The effects of the programme were listed in the order of study design [single group pre-post, non-randomised controlled trial (nRCT), randomised controlled trial (RCT), and qualitative study] and were described qualitatively.

Stage 6: Consultation exercise
In order to achieve the purpose of this scoping review, the authors received expert advice on the results derived through the nal step of the scoping review, namely reviewing. Three experts with experience in CBPR were asked to review the results. The experts suggested their opinions on whether the situation or experience in CBPR sites was properly re ected in the review result, and the researchers re ected the opinions of the experts during the process of data extraction and summarising of results.

Results
General characteristics of selected studies First, the selected 21 studies were divided into the following main areas of research: purpose, method, country in which the study was conducted, participants, and health problems of participants ( Table 1). As for the purpose of study, there were four studies (19.0%) on the development process of a CBPR-based CVD management programme, three studies (14.3%) on the development, investigation, and evaluation of a CBPR-based CVD management programme, and 14 studies (66.7%) that evaluated a CBPR-based CVD management programme. As for the research method, quantitative studies accounted for the largest proportion, with nine studies (42.9%), followed by six qualitative studies (28.6%) and six mixed-methods studies (28.6%). As for the race of the participants in the study, studies on African Americans accounted for the largest proportion (8; 38.1%), followed by four studies on Hispanics (19.0%), two studies on Africans (9.5%), and one study on Asians (4.8%). In addition, six studies (28.6%) did not mention the race of participants. There were 15 studies (71.4%) on adult males and females, one study (4.8%) on adults and children, and two studies (9.5%) on only adult females. The remaining three studies (14.3%) did not mention the age of the participants. In terms of the participant selection criteria, there was one study (4.8%) on healthy subjects without any underlying disease and eight studies (38.1%) on subjects with underlying diseases. The underlying disease was further classi ed into high blood pressure, overweight or obesity, diabetes, and other CVD risk factors. Puoane [35], the research began once the local community health worker (CHW) received complaints from local residents and consulted local health experts. In a study by Delisle et al. [36], re ghters took the initiative to establish a cooperative relationship with the local community to manage CVDs caused by exposure to occupational risk factors and stress. Lynch et al. [37] initiated their study on African American participants, as the pastor of an African American church requested help from local colleges for improving health care of the church members, which subsequently led to the establishment of a cooperative relationship. In Ralston et al. [30][31][32], cooperative relationships with local colleges for health promotion programmes were established, being led by a church in North Florida.

Partnership establishment status
The status of partnership establishment in the selected studies is shown in Table 2. In all studies, the details of partnership establishment are described in the beginning stage of the CBPR. With 13 studies, the most common form of partnership that led the studies was between community members, through community-based organisations (CBO) or faith-based organisations (FBO), and researchers from universities. In studies in which CBOs or FBOs did not participate, CHW, public institutions, and medical institutions played the leading role. There were nine studies in which the resident representatives participated as a member of the partnership. However, there were very few studies (two), in which only resident representatives participated without the participation of local community organisations. In the nine studies, after establishing community partnerships, a steering committee or advisory board was formed to carry out the project, which made decisions through regular meetings. In some studies, a working-level meeting was held by forming a subcommittee during the programme development process.

Development and implementation of intervention programmes
Application of CBPR principles CBPR quality evaluation criteria (whether community partners participated in the process of planning and conducting research, selection and modi cation of research topics, and analysis/interpretation and dissemination of research results) were used to analyse how consistently the CBPR principles were applied during the process of development and implementation of intervention programmes (Table 3). While it has been observed that community partners participated in the process of conducting research in all studies, they participated in the process of research planning only in 16 studies. Among 16 studies in which community partners participated in the research topic selection or modi cation process, community partners and researchers participated in the research topic selection process in 11 studies; in the remaining ve studies, community partners participated in modifying the previously developed programme to suit the needs of local residents. There was no study in which community partners participated in the analysis and interpretation of the research results. In 10 studies, community partners participated in the process of disseminating the research results. Among them, community partners participated as co-authors of research papers in eight studies, in addition to disseminating research results to local residents through yers or newspapers in the only three studies. Seven studies applied a health-related theory, two of which applied two or more theories in combination: four studies applied self-determination theory; three studies, socio-ecological theory; and two studies, transtheoretical models. The theory of planned behaviour, social cognitive theory, health belief model, and theories on self-e cacy, social support, motivation, and social norms were applied in the studies.

Use of eld activists
In 12 of the selected studies, community activists were recruited to run the programmes. Among them, ve studies presented the details of activist education programmes. In a programme for Hispanics, activists (called 'promotores') were mainly recruited [23][24][25]38]. Promotores were selected from among those with participation history in community projects and were asked to obtain health-related quali cations within 30 days of employment. They were trained for a total of 45 hours over two weeks on CVD risk factor reduction methods, capacity reinforcing strategies, community resource identi cation, advocacy, and data collection methods. Community partners participated in the development of education programmes for promotores. In a study by Kim et al. [39], a Lay Health Advisor (LHA) was recruited to provide a total of 13 education sessions, which took place twice a week (3 hours per  However, the remaining seven studies only described the role of activists without the details of activist education programmes. Activists were recruited from among residents who spoke the same language as the residents. Their main roles were participant recruitment [26, 31,40], resident education [40], operational assistance for programmes [26,31,41,42], and a point of contact between participants and researchers during the programme [43]. Some studies that described how they utilised activists, reported paying salaries to some or all activists so that they can ful l their roles [24,25,38,40].

The effects of CBPR-based CVD management programmes
Of the 21 selected studies, 17 studies evaluated the effectiveness of the CBPR-based CVD management programme after implementation (Table 4). The studies were categorised by the study design as follows: 5 studies with one group pre-/post test design, 4 RCTs, and 1 non-randomised control group design among quantitative studies, 5 mixed-methods studies, and 2 qualitative studies. As for the age of participants, 10 studies were on adults over the age of 18 years, and 5 studies were on middle-aged people over the age of 30 to 40 years. The duration of the intervention varied from 4 weeks to 36 weeks, with 24 weeks (6 months) being the most common (5 studies), followed by 8 weeks (3 studies). Regarding programme details, 10 studies explored two or more topics: 15 programmes were on nutrition (or diet) and physical activity, 7 on knowledge related to CVD, 3 on smoking-free habits, 3 on stress management, 2 on weight loss, and 1 on mobile health screening. As for how the programme was run, 9 studies were conducted with counselling (personal contacts, home visits, and calls), 3 studies with multimedia-based education (social networking and text messages), 7 studies with lectures (video and audio tape), 3 studies with cooking demonstrations (models), 8 physical activity programmes (walking, dance, exercise classes, treadmill, and pedometer), 6 small group discussions and seminars, 3 posters, and 1 civic engagement (HEART club).
To measure the effectiveness of each CBPR-based CVD management programme Clinical, behavioural, cognitive, and psychological variables were used; 7 studies measured clinical characteristics (BP, total cholesterol, HDL-cholesterol, LDL-cholesterol, weight, and heart rate); 9 studies measured behavioural characteristics (diet, physical activity, smoke-free, pill pickup rate, treatment compliance, screening rates, follow-up appointments, and participation rates); 5 studies measured changes in CVD-related knowledge as cognitive characteristics; and 1 study measured the quality of life based on psychological characteristics. In addition, 4 studies evaluated research perceptions, bene ts, satisfaction, acceptability, and feasibility. In 6 of the selected studies with a randomised controlled group, the experimental group showed signi cantly positive effects compared to the control group.
Qualitative studies cited statements from interviews with participants in the CBPR-based CVD management programme to report their positive evaluation of the programmes [44,45], improved awareness of CVD, and positive changes in health behaviour [38,39,46]. Some studies have shown that eld activists have the capacity to play an intermediary role between residents and health care professionals [44] and play a key role in ensuring that CBOs recruit and retain participants. In addition, the importance of fostering trust and rapport between programme facilitators and participants as well as the need for family participation were suggested [38,46]. On the other hand, the lack of sustainability of participation was suggested as a limitation [31].

Discussion
We reviewed the studies published over the last 10 years on CBPR-based CVD management programmes for adults and aimed to examine the key factors and effects of such programmes and provide fundamental evidence for seeking effective interventions in the future.
In the process of designing a study to develop a CVD management program based on CBPR, we judged that it was necessary to grasp how and how much CVD management programs based on CBPR were developed and applied in the community. In order to nd answers to these research questions, a scope review was more suitable than a systematic literature review. A scoping review differs from other types of literature review in the sense that it provides information on practice, policy making, and research by mapping the literature on a speci c subject or research area to identify the types of evidence, data sources, key concepts, and gaps in the studies [47], and provide maps or snapshots of existing literature without quantitative synthesis or quality assessment [48]. We conducted the scoping review according to the procedure proposed by Arksey and O'Malley [20].
In the process of applying CBPR, the following results were derived. First, CBPR partnership is initiated by local residents, local health experts, or researchers. In the studies selected for this review, there were only four studies in which local residents voluntarily proposed research topics. The fact that community partners have become the subject of research initiation means that they are aware of community health problems and are active in the process of nding alternative solutions. Whether local residents are the subject of a CBPR initiation is considered an important factor, because there is a higher possibility that it can be implemented as an actual health promotion project [13]. Therefore, in-depth exploration of the context of the community and previous experiences is required for the region where the community partner has been the subject of research initiation.
In community-based health research, it is recommended or required to establish and operate a community advisory board or steering committee to re ect and communicate the opinions of community members throughout the research process [49]. In previous studies, the role of the participant organisation was limited to a consultation role in which it relayed the opinions and responses of the community. On the other hand, in CBPRs, these act as a representative organisation that provides key information such as the characteristics, strengths, weaknesses, and needs of the local community and play the role of an equal partner in practice during the decision-making process on a problem at hand [50]. For community participation to be considered as community capacity, a global and solid foundation for participation must be formed. It should depart from the typical participation that merely lls up the positions of participants as a formality and instead, be practical such that it involves cooperative discussions on planning and assessment of community health promotion projects through active participation with a sense of ownership [51]. However, while most of the selected studies have described the details of partnership establishment, there were only a few studies in which community representatives played a leading role. Therefore, it is necessary to provide opportunities for them to participate in research to exert in uence on the community.
The key of CBPR is that members of the local community continuously and actively participate as equal partners with health experts and researchers during the entire process, from research planning to evaluation and re ection of results. Such a process enhances autonomous and sustainable community capacity for health promotion [12]. In this study, for the quality assessment of CBPRs in the selected studies, we partially modi ed the tool, which was originally developed by Viswanathan et al. [33] and modi ed by Chen et al. [34], and lays out the core principles of community participation research. In all the studies selected in this study, community partners partially participated during the process of conducting research. However, there were relatively few studies in which they participated in the process of planning and selecting or modifying the research topic. In the case of studies in which they did not participate during the process of planning, but during conducting, the quality of CBPR can be evaluated as low, as community partners mostly participated passively by recruiting participants or assisting in the programme. In particular, none of the studies involved community partners in the analysis or interpretation of the research results. It is necessary to develop strategies, including the development of evaluation tools, to allow community partners to be effectively involved in the process of evaluating research results. A total of 10 studies were conducted in which community partners participated in the dissemination of research results. In three of them, community partners participated in disseminating the research results to local residents through lea ets or newspapers. In the existing conventional health care research system, the low rate of practical implementation has been criticised [52]. However, since CBPR places an emphasis on 'practice' as its core element and has an advantage of offering a possibility of participatory linkages that facilitates dissemination of academic research results to the eld, the Prevention Research Center (PRC) of Centers for Disease Control and Prevention (CDC) requires its programme to perform more than one CBPR per core research area [53,54]. Nevertheless, according to the results of our study, there were very few studies in which community residents participated in the wide dissemination of research results to the community, which is considered one of the merits of CBPR. While an ideal study would satisfy all ve criteria of CBPR quality evaluation, none of the selected studies did so. Since inputs from community residents on health projects can make an important contribution to the health promotion and welfare improvement of the local community and act as an important factor in disease prevention [55], it is necessary to understand the practical reasons why it is di cult for community members to participate in the entire research process from an equal position and apply the true CBPR principles.
Cook [13] proposed to use two complementary methods, a qualitative research method using participatory observation and a quantitative research method using data analysis for effective CBPR research. Among selected studies, quantitative studies were the most at 10. Next, there were six mixed method studies, and ve qualitative studies. CBPR is a process-centred research in which qualitative research methods have been proven to be particularly useful, as it emphasises the process of conversation and discussion between community members, researchers, and representatives of public-private organisations, in order to share an understanding of the signi cance and background of current health problems in the community [12]. In addition, despite having the same research topic, its need and signi cance can be perceived differently depending on the context and characteristics of each community; a combination of quantitative and qualitative research methods should be used to address this issues. Therefore, the use of mixed-methods research approaches can well re ect the characteristics of CBPR that exhibit a cyclical structure in the process of identifying and solving various problems in communities [13].
An RCT is the gold standard in terms of generating scienti c evidence in clinical research; it is conducted with the most rigorous and thorough research methods to explain the relationship between the intervention and an outcome and can provide the highest level of evidence [56]. However, most of the studies selected in our review were nRCTs or pre-post studies; only six studies were RCTs. In the future, to clarify the effectiveness of interventions on CBPR-based CVD management programmes and apply the best evidence to practice, more research should use an RCT design. On the other hand, since the evaluation design with experimental and control groups can contradict the basic premise of CBPR that emphasises the context and participation of the community, a lagged intervention used in Schulz et al. [42] may be considered to solve this issue.
As examined in our review, CBPR-based CVD management programmes showed positive effects on clinical, behavioural, cognitive, relational, and psychological aspects. In particular, Ralston et al. [30][31][32] showed that there is a longer effect in the experimental group than in the control group through repeated measurements after an intervention with an RCT design. However, while CPBR emphasises strengthening community capacity by allowing community residents to participate in decisions that affect their own health and exert in uence on the quality of life of the entire community by establishing cooperative partnerships, securing su cient resources, and promoting active participation and leadership of community members [57], none of the selected studies in our review measured the effects on community capacity. Speci cally, measuring the effectiveness should not end with a one-time measurement immediately after the intervention; instead, it should evaluate the sustainability of an intervention and re ect the CBPR evaluation criteria suggested by Plumb et al.
[58], including cooperation of community, group dynamics, and evaluation of community participation.
This scoping review for the key elements and effects of CBPR-based CVD management programmes over the last 10 years examined the recent trends in such programmes. Our results examined the sustainability and applicability of the CBPR-based CVD management programme by allowing community partnerships to understand the health needs of community residents, develop and implement programmes that are acceptable to community residents, and con rm for their effectiveness, instead of using the unilaterally provided standardised programmes.
This review has the following limitations: rst, as our review included only studies published in English, most of the selected studies were conducted in North America, which did not re ect the cultural diversity of non-English speaking countries; and, second, with a focus on the development, implementation, and evaluation of CVD management programmes, problems such as obstacles and challenges arising in some processes of CBPR could not be emphasised.

Conclusions
We examined the key elements and effects of CBPR-based CVD management programmes using the scoping review method. Among the key elements of such programmes, there were many cases in which community organisations (CBOs, FBOs) played the leading role in establishing partnerships and cases in which a decision-making committee was formed. Regarding the application of the CBPR principles, community partners rarely participated during the process of analysis and interpretation of research results and dissemination of research results to residents. Of the 17 studies in which the program effect were evaluated, all of the six RCT studies showed signi cantly positive effects in the experimental groups compared to the control groups.
It is necessary to develop strategies to improve the criteria based on which CBPR principles cannot be implemented during the development and application of a CBPR-based CVD management programme. In addition, more attempts to verify the effectiveness of high-quality research methodology should be made when evaluating the effectiveness of programmes.

Declarations
Authors' contributions BP provided the main idea including research design of this study. BP and JY conceptualised the research questions, developed and agreed the search strategy, data extraction and synthesis, and conducted the search, screening, data extraction and analysis. All authors contributed to the manuscript, critically reviewed and approved the nal manuscript.

Funding
This study was nancially supported by National Research Foundation of Korea (No: 2020R1A2C1008591). The funding agency had no in uence on the design, data collection, analysis, interpretation of data, or results of this study, nor on the writing of this manuscript.

Availability of data and materials
The datasets to be generated and analyzed in this study will not be publicly available and will be available by contacting the corresponding author on reasonable request.