Our findings provide compelling evidence that multistakeholder co-governance can be beneficial to research contexts, processes, and outcomes in both intended and unintended ways and can occasionally contribute to negative outcomes. To access such evidence, we expanded the scope of assessment beyond a narrowed synthesis of intervention outcomes from peer-reviewed journal articles to include any and all outcomes seen as arising from participatory processes in the published and gray literature. In a realist review, building a coherent and plausible explanation of the data through middle-range theory is as important as gathering evidence. Without such conceptualizing, our assessment would not have had a focus; we would have missed many configurations; and our conclusions would have been truncated. Partnership synergy theory was critical to helping shape the synthesis. Through the synthesis process using CMO configuring, we refined the theory by demonstrating that synergy is both an outcome and a context for partnership development—so that when synergy generated positive outcomes (e.g., enhanced trust or improved data collection), those outcomes generated new synergy. Expanding this logic, we demonstrated how partnership synergy created momentum over time, producing resilience in the face of obstacles as well as sustaining health-related goals, extending programs and infrastructure, and creating new and unexpected ideas and activities. The success of applying and refining this theory had to do with its having explanatory power across a broad range of PR practices. Regardless of the more specific drivers of such practices, such as knowledge utilization, self-determination, and social/environmental justice (Cargo and Mercer 2008
), partnership synergy appeared to be a universal feature of collaborative processes for those partnerships meeting our inclusion criteria.
In addressing the issue raised by authors of a number of previous reviews concerning the difficulty in measuring the extent of PR's impact on health disparity (Berkowitz 2001
; Kreuter, Lezin, and Young 2000
; Viswanathan et al. 2004
), our synthesis revealed that such disparity was reduced by the effects of enhancing programs themselves, as well as by so-called intermediate outcomes of participation. These latter outcomes, such as capacity building, self-empowerment, and infrastructure development, were sometimes described as having a more profound impact on well-being than did the intended outcomes of planned interventions. While a given intervention (e.g., for cancer prevention) increased the number of positive health changes (e.g., an increase in the number of diagnostic tests completed in an underserved community), the capacity and self-empowerment gained while partnering had an immeasurable long-term impact, altering the destiny of communities through acquired skills, self-determination, and empowerment.
In addressing the findings of the one previous systematic review of PR in health commissioned by the Agency for Healthcare Research and Quality (Viswanathan et al. 2004
), our findings confirmed what had been previously noted regarding improved research quality and capacity building in PR. We extended the assessment, however, to uncover new benefits for the outcome of productive conflict and negotiation; long-term synergy building (the positive outcome of one stage leads to a better context for the next); the ability to mitigate funding gaps, invoke sustainability, and extend programs; and create new unanticipated projects and activity. The evidence concerning conflict, disagreement, and negotiation in creating positive outcomes requires an explanation. The coalitions experienced stages of program and research planning in which stakeholders disagreed on, for example, the research agenda and/or aspects of intervention design and implementation. In such cases, disagreement was not necessarily antithetical to the group's synergy; on the contrary, it often increased synergy through successful negotiation and resolution. Disagreement was often an opportunity for the researchers to show their good intentions to work with the community—to listen, negotiate, modify their thinking and approach, and arrive at consensus—and in some cases allowed community members to learn about and gain appreciation for rigorous scientific methods. It also permitted approaches unlikely to work to be identified and abandoned at early stages. Such positive outcomes established trust and respect where they previously were not well established and deepened the stakeholders’ commitment to the project. Successful outcomes of conflict resolution in partnerships became a part of the partnership context for subsequent phases of research. Synergy, built on a series of successes, increased the chances for future success. We concluded that healthy conflict, resistance, negotiation, and consensus building are integral to establishing trust and rapport among stakeholders. Alternatively, unresolved conflicts, while rare in the documented data, led to disaffection and a breakdown in the trusting relationship between stakeholders.
Limitations and Directions for Future Research
A possible publication bias in primary studies toward reporting only the successful outcomes of partnerships is a potential limitation of this review. Thus although we sought, but did not find, disconfirming cases to challenge our demi-regularity statements, we are now interviewing PR stakeholders, because we hypothesize that such cases will likely be revealed only through qualitative interviews. In addition, although the realist approach can create a more encapsulating view of the evidence, the literature has not been written to be read with such a viewpoint. Therefore our theory-based approach leaves many questions unanswered, for which new research and, equally important, new reporting styles are needed. Such reporting styles need to describe more accurately the breadth and scope of PR impacts on research and health outcomes. In looking for the evidence corresponding to our threefold division of preexisting, generating, and accumulating factors, the area that is best reported in the literature pertains to the generating factors of PR. This is because the literature is marked by stakeholders themselves reporting what was generated from their collaborations. In contrast, better understanding the role of preexisting and accumulating factors for PR assessment requires further research. This may include realist evaluations of primary PR studies as well as qualitative interviews with both academic and community stakeholders to gain perspectives from their direct experience, and also prospective studies of new PR partnerships.
Because we had limited resources and were working with a large body of literature, we included in this review only community-based PR and not other forms, such as PR with institutions, health services, and policymakers. These diverse PR practices could be explored in a further review. Additionally, although the recruitment advantage in PR was shown to benefit all stakeholders, a critical view may reveal that some funding or research institutions’ reasons for pursuing PR are to increase enrollment in clinical trials, reduce refusals, boost sample sizes for surveys, acquire community support for random assignment to control groups, or increase knowledge translation activities only (Trickett 2011
). While these issues require serious attention, our results are applicable solely to “full participation” PR, which emphasizes equity and co-governance with community stakeholders who have formal power to challenge and change the research agenda. We also fully acknowledge that high-quality research with beneficial outcomes has emerged from collaborative research that did not meet these criteria for “full partnership” (e.g., Coady et al. 2008
; Hinton et al. 2005
), but our theoretical explanations in this article do not necessarily pertain to such studies.