Co-Developing Community-Based Participatory Research (CBPR) Guidelines in Hong Kong: An Example of a Mental Health Literacy Promotion Project

Abstract

Although community-based participatory research (CBPR) is context and cultural-specific, existing CBPR guidelines were developed in the West and may not be suitable for East Asian contexts given different cultural backgrounds. Moreover, most CBPR mental health literacy promotion projects have been conducted in the West, with limited examples in East Asia. Therefore, the objectives of the current study were to co-develop CBPR guidelines with stakeholders in Hong Kong and to illustrate this with an example of a mental health literacy promotion project. We conducted seven focus group discussions with seventeen older adults in the community and eleven social workers from partnering non-governmental organizations. Subsequently, we formed a panel with community stakeholders to co-analyze and co-interpret the data and findings. Using the grounded theory approach, we identified six guidelines pertinent to CBPR practice in East Asian communities: 1. Highlighting an ‘acceptance and openness’ mentality in CBPR training; 2. Navigating the hierarchical culture to facilitate an equal partnership; 3. Breaking the project into smaller action tasks to facilitate design and implementation; 4. Fostering collective harmony through team-building activities and informal gatherings; 5. Encouraging open discussion of mental health; 6. Leveraging informal networks in mental health literacy promotion. Our discussion focuses on the methodological insights of practicing CBPR in Hong Kong and its implications in East Asian communities, along with the cultural differences compared to the West.

Keywords

community-based participatory research CBPR mental health literacy guidelines Hong Kong East Asia

Introduction

Community-based participatory research (CBPR), a research approach that emphasizes collaboration with the community, has grown in popularity and respectability among health researchers in recent years. Community members are not subjects of a study but equal partners in every research stage (Israel et al., 2005, 2018; Kegler et al., 2016; Minkler & Wallerstein, 2003; Wallerstein & Duran, 2010). Compared to traditional researcher-driven studies, CBPR integrates community-based practice, tacit knowledge, and cultural knowledge into evidence-based practices to address locally identified priorities and outcomes, enhancing an intervention’s validity (Wallerstein et al., 2019). Many CPBR interventions are guided by the ten principles proposed by Israel and colleagues in 1998 (Israel et al., 1998, 2018). The ten principles are (i) recognizes community as a unit of identity; (ii) builds on strengths and resources within the community; (iii) facilitates collaborative, equitable partnership in all research phases and involves an empowering and power-sharing process that attends to social inequalities; (iv) promotes co-learning and capacity building among all partners; (v) integrates and achieves a balance between research and action for the mutual benefit of all partners; (vi) emphasizes public health problems of local relevance and ecological perspectives that attend to the multiple determinants of health and disease; (vii) involves systems development through a cyclical and iterative process; (viii) disseminates findings and knowledge gained to all partners and involves all partners in the dissemination process; (ix) requires a long-term process and commitment to sustainability; and (x) addresses issues of race, ethnicity, racism, and social class, and embraces cultural humility (Israel et al., 1998, 2018). In 2008, Wallerstein and colleagues developed a conceptual logic model of CBPR processes that led to outcomes; the model identified four dimensions of CBPR characteristics, which are contexts, group dynamics, intervention, and outcomes (Wallerstein et al., 2008). However, the principles and the conceptual logic model describe the ideology of CBPR from a macro perspective, while micro-practices vary in context and culture (Israel et al., 2018; Yau et al., 2024). Therefore, different local adaptations have emerged to guide CBPR implementation in specific cultural contexts. Existing guidelines exist in the United States (Grills et al., 2018; Marquez et al., 2022) and the United Kingdom (Centre for Social Justice and Community Action & National Coordinating Centre for Public Engagement, 2022). However, these guidelines might not be applicable in East Asian communities because of significant cultural differences. For example, Western culture values individual uniqueness and equality, while East Asian culture values collectivism, relationship interdependence, and hierarchy (Ivancovsky et al., 2018). To our knowledge, no guidelines have been developed in East Asian societies.

With no existing guidelines developed in East Asian societies, a literature search was conducted to examine the practice of CBPR projects in Asian populations and evaluate how that differed from Western CBPR projects. In a CBPR study conducted in Taiwan for teenage boys in the juvenile justice system to examine how at-risk youth view their lived experiences, the study highlighted the need to develop individual participants’ introspective skills for project advancement (Hsiao et al., 2020); however, introspective skills were not highlighted in Western CBPR guidelines. In another CBPR intervention that was conducted among Koreans to improve hepatitis B virus (HBV) screening and vaccination, the findings highlighted that egalitarian and trust between academic researchers and community members were built up through reciprocal training sessions; for example, researchers provided research training to community members while community members provided training on key cultural elements of the community to researchers (Ma et al., 2012, 2018). However, such practice was less prevalent in Western examples. In another CBPR project conducted in Japan that addressed community health breakdown, their findings highlighted the key to having government officials in the project for success, as government officials were powerful in fostering collaboration between different stakeholders (Yamashiro & Kita, 2023). However, government officials might not always be involved in Western CBPR practice. These examples show that the micro practice of CBPR varies across cultural populations despite applying the principles. Due to the lack of CBPR local adaptations in East Asian communities, the no ‘one size fits all’ guideline argument suggests developing one specific to cultural contexts (Israel et al., 2018). Therefore, the first objective of this study was to use a bottom-up strategy to develop CBPR guidelines for practitioners in East Asian communities.

Although there has been a growing recognition of applying CBPR in addressing mental health issues (Collins et al., 2018), limited research has been found on mental health literacy promotion. To our knowledge, only four studies of mental health literacy promotion projects using the CBPR approach have been published: three from the United States (Caplan & Cordero, 2015; Langdon et al., 2016; Stacciarini et al., 2011) and one from Australia (Hurley et al., 2020). These studies show to potential application of CBPR to promote mental health literacy because the interventions are culturally adapted in design and implementation and more sensitive to community members’ needs than traditional top-down interventions. This supports the argument that mental health intervention should be unique for different cultural populations (Burke et al., 2013; Subudhi, 2014). However, to our knowledge, no CBPR mental health literacy promotion projects have been conducted in East Asian societies. Therefore, the second objective of this study was to implement a CBPR mental health literacy promotion project in Hong Kong, a geographical center in East Asia (Ma et al., 2021).

The current guidelines for CBPR were created in the West and may not be suitable for East Asian contexts. Additionally, most CBPR mental health literacy promotion projects have been conducted in the West, with limited examples in East Asia. Therefore, this article aimed to address the gaps by co-developing CBPR guidelines with stakeholders in East Asian communities, illustrated with an example of a mental health literacy promotion project. These East Asian communities include China, South Korea, and Japan (Li, 2025). This study was conducted in Hong Kong, one of the special administrative regions of China. Hong Kong inherits traditional Chinese cultural heritage, language, and traditions (Song, 2023). Hong Kong also shares similar cultural characteristics with South Korea and Japan, for example, having a strong emphasis on respecting elders, authority figures, and social hierarchies, which could be seen in family structures and social interactions (Kim & Lee, 2023; Yang, 2024). We examined the following research questions: 1. What guidelines are pertinent to CBPR practice in East Asian communities? 2. How does the practice of CBPR differ between East Asian and Western communities?

Method

Research Context

Our CBPR mental health literacy promotion project is integral to the ‘Jockey Club Holistic Support Project for Elderly Mental Wellness’ (the JC JoyAge Project) (https://research.jcjoyage.hk/), a Hong Kong-wide collaborative stepped-care intervention for older people with mild to moderate common mental disorders (Liu et al., 2022). The project started in 2016 as a pilot project in four districts in Hong Kong and expanded to cover all eighteen districts since 2020. The mental health care system and knowledge in Hong Kong are not as developed as in Western countries like the United States. Significant barriers, such as a shortage of mental health professionals and uneven distribution of services, are prevalent (Liu et al., under review; Saxena et al., 2007). Stepped-care intervention is currently delivered by 19 non-governmental organizations (NGOs) in 52 community centers. To promote mental health literacy, the project provides free Mental Health First Aid – Older Adults Version training to community members 50 years or older at risk of depression to become JoyAge Ambassadors. Ambassadors were recruited by the community centres and identified as at-risk by social workers (indicated by the Patient Health Questionnaire-9 (PHQ-9) score 0–4) (Costantini et al., 2021). The training sought to equip the ambassadors with knowledge and skills to enhance their resilience in aging. In return, these ambassadors agreed to volunteer in community programs to promote mental wellness in their community. More than 6000 ambassadors have been trained since 2020. In May 2021, we invited these ambassadors and social workers to co-develop district-based CBPR projects to promote mental health literacy. When ambassadors and social workers indicated their interest, we facilitated the development of project implementation teams comprising ambassadors, NGO social workers and academic researchers in district action committees to initiate the co-development process. Sufficient interest from ambassadors and social workers was generated in five districts to co-develop a series of CBPR mental health literacy promotional activities. Each district action committee comprised 5–20 ambassadors, 1–2 social workers from the NGO community center, and 1–2 academic researchers and had monthly meetings. In the first monthly meeting, both ambassadors and social workers received training on the theoretical principles of CBPR and the concepts of mental health literacy provided by academic researchers. In the subsequent meetings, ambassadors brainstormed ideas and voted to decide which mental health literacy promotion project idea to implement. Although conflicts and diverging interests sometimes emerged, decisions were reached by consensus after extensive discussions. Social workers provided resources and administrative support, while academic researchers provided research expertise. Ambassadors, social workers, and academic researchers co-worked as equal partners in the project. A variety of mental health literacy promotional activities and outputs were designed and implemented by ambassadors; examples include public outreach (art and handcraft workshops to introduce ways to enhance mental health, street booths in the community to conduct Patient Health Questionnaire-9 (PHQ-9) for mental health assessment) (Costantini et al., 2021), multimedia production (videos that motivate the audience to self-care, videos about exercise learning), and promotional materials production (postcards with encouraging phrases and photos of community taken by community members, a year calendar showing different symptoms of depression, a leaflet introducing depressive symptoms and mental health resources in the community, a postcard encouraging people living alone to seek assistance from the community), etc. The project is still ongoing. Table 1 summarizes the mental health literacy promotional activities and outputs as of April 2024.

Table 1.

Mental Health Literacy Promotional Activities in Each District in Hong Kong

District	Activity/output	Objective	Description
Central & Western	Public outreach	• Raise awareness of mental health among the general public • Build connection with the community	Three art and handcraft workshops were organized using a mobile van to introduce ways to promote individuals’ and family members’ mental health
Sham Shui Po	Multimedia production	• Raise awareness of the importance of mental health during the COVID-19 pandemic and lockdown	Two videos were filmed to motivate the audience to engage in self-care activities
	Outdoor visits	• Raise awareness of mental health among the general public	Two visits were organized to explore the relationship between mental health and Chinese medicine
	Public outreach	• Identify older adults at risk in the district• Build connections with the community• Disseminate mental health knowledge and resources in the district	A street booth was set up to conduct Patient Health Questionnaire-9 (PHQ-9) assessment and share mental health information with community members
	Talks with designated themes	• Mitigate the impact of grief and bereavement on individuals’ and family members’ mental health	A guest speaker was invited to deliver a talk on grief counseling skills
		• Educate the audience about life and death as a natural process• Update the audience on knowledge related to life and death	A guest speaker was invited to deliver a talk on life and death
Tseung Kwan O	Community resources booklet	• Spread information about community resources and self-care tips to carers	A booklet was published to introduce the condition of carer stress, promote help-seeking and provide information about relevant resources
	Multimedia production	• Raise awareness of self-care among peers	Five videos were filmed to demonstrate various physical exercises and showcase attraction sites in the community
	Promotional materials production	• Raise awareness of mental health among the general public	Nine postcards with encouraging phrases and scenic photos taken by community members were designed and distributed
	Public outreach	• Identify older adults at risk in the district• Build connections with the community• Disseminate mental health knowledge and resources in the district	Four different street booths were set up to conduct PHQ-9 assessment and share mental health information with community members
Wan Chai	Promotional materials production	• Educate the public about the symptoms of depression	A yearly calendar that highlighted the symptoms of depression was designed to encourage timely detection and early intervention
		• Spread mental health knowledge and resources in the district	A leaflet was produced to educate the public on the symptoms of depression in older people and mental health resources in the community
	Promotion integrated into regular members’ meetings at centers for older people	• Spread mental health knowledge and empower peers through the sharing of personal stories	Nine 15-min sharing sessions of mental health knowledge or peers’ personal stories were incorporated into the monthly meetings at the centers for older people
	Public outreach	• Identify older adults at risk in the district• Build connections with the community• Spread mental health knowledge and resources in the district	Four different street booths were set up to conduct PHQ-9 assessment and share mental health information with community members
Wong Tai Sin	Multimedia production	• Raise awareness of mental health among peers	Eight videos were filmed to demonstrate various physical exercises and showcase attraction sites in the community
	Online and face-to-face mass programs	• Raise awareness of mental health among peers	Four events were organized to facilitate the exchange of mental health knowledge and self-care tips among peers
	Promotional materials production	• Introduce and connect the public to community support services	A leaflet was produced to introduce community support services and the CBPR group to the general public
		• Raise public awareness and encourage people living alone to seek assistance in the community	A poster depicting the pain and suffering of isolated older adults was designed to create resonance with the general public
	Public outreach	• Identify older adults at risk in the district• Build connections with the community• Spread mental health knowledge and resources in the district	Four different street booths were set up to conduct PHQ-9 assessment and share mental health information with community members

Data Collection

We used focus group discussions to co-create CBPR guidelines with ambassadors and social workers from the five CBPR districts. We organized seven focus group discussions; four were conducted with seventeen ambassadors and three were conducted with eleven social workers. We recruited ambassadors and social workers actively involved in the CBPR project through purposive sampling, by verbally inviting them during the monthly district action committee meeting. They then indicated their availability by signing up on an online link. The focus groups were conducted face-to-face in NGO community centres. Table 2 provides the number of participants in each focus group and their profiles. Subgroups of ambassadors were formed based on their availability. The focus group questions for ambassadors and social workers differed slightly in terms of language used to prompt participants’ insights. However, both groups shared major questions, including ‘What are your experiences in CBPR,’ ‘What are the important elements in practicing CBPR,’ and ‘How does CBPR promote mental health literacy?.’ At the beginning of the focus group discussion, we recapped the essence of CBPR and mental health literacy promotion, we used layman terms such as ‘bottom-up mental health literacy promotion project’, ‘equal partnership between three stakeholder groups’, and ‘community-members initiated projects’ to ensure participants understand the foucs group questions. Table 3 shows the focus group discussion questions for ambassadors and social workers, respectively. Academic researchers facilitated all focus group discussions and stopped focus group discussions when data saturation was achieved (Mwita, 2022). Following the focus group discussions, we invited ambassadors and social workers to participate in the data analysis and interpretation process. Three ambassadors and four social workers from different focus groups and districts expressed their interest in participating to ensure multiple perspectives were considered. They joined with four academic researchers to form a panel. Table 4 shows the profile of the panel members. Ambassadors and social workers co-authored this manuscript and disseminated the study findings to their districts and the wider community.

Table 2.

Profile of Study Participants in Each Focus Group

	ID	Sex	District	Duration in the CBPR project (May 2021–April 2024, a maximum of 3 years)	Role
Focus group discussion 1	1	Male	Shum Shui Po	2 years, 10 months	Ambassador
	2	Female	Tseung Kwan O	2 years	Ambassador
	3	Male	Tseung Kwan O	2 years	Ambassador
	4	Female	Central & Western	3 years	Ambassador
Focus group discussion 2	5	Male	Wong Tai Sin	2.5 years	Ambassador
	6	Male	Wong Tai Sin	3 years	Ambassador
	7	Female	Wong Tai Sin	2 years	Ambassador
Focus group discussion 3	8	Female	Tseung Kwan O	3 years	Ambassador
	9	Female	Wan Chai	2.5 years	Ambassador
	10	Female	Tseung Kwan O	3 years	Ambassador
	11	Female	Tseung Kwan O	3 years	Ambassador
Focus group discussion 4	12	Male	Shum Shui Po	1 year	Ambassador
	13	Female	Shum Shui Po	1.5 years	Ambassador
	14	Female	Wong Tai Sin	1.5 years	Ambassador
	15	Female	Shum Shui Po	3 years	Ambassador
	16	Male	Shum Shui Po	3 years	Ambassador
	17	Female	Shum Shui Po	2.5 years	Ambassador
Focus group discussion 5	18	Female	Wong Tai Sin	2.5 years	Social worker
	19	Female	Wan Chai	2.5 years	Social worker
	20	Male	Central & Western	1 year	Social worker
Focus group discussion 6	21	Female	Shum Shui Po	8 months	Social worker
	22	Female	Shum Shui Po	1 year	Social worker
	23	Female	Shum Shui Po	9 months	Social worker
Focus group discussion 7	24	Female	Wong Tai Sin	2.5 years	Social worker
	25	Female	Wan Chai	2.5 years	Social worker
	26	Male	Central & Western	1 year	Social worker
	27	Male	Tseung Kwan O	3 years	Social worker
	28	Female	Tseung Kwan O	1 year	Social worker

Table 3.

Focus Group Discussion Questions

Focus group discussion questions for ambassadors	Focus group discussion questions for social workers
1. What are your experiences in CBPR?	1. What are your experiences in CBPR?
2. What are the important elements in practicing CBPR?	2. What are the important elements in practicing CBPR?
3. How does CBPR promote mental health literacy?	3. How does CBPR promote mental health literacy?
4. What are the challenges and difficulties in the CBPR process?	4. What are the challenges and difficulties in the CBPR process? (from the perspective as an individual social worker and from the organization)
5. How do you overcome the challenges and difficulties?	5. How do you and your organization overcome the challenges and difficulties?

Table 4.

Profile of Research Panel Members

Panel member	Sex	District	Duration in the CBPR project (May 2021–April 2024, a maximum of 3 years)	Role
1	Female	Wong Tai Sin	1.5 years	Ambassador
2	Male	Shum Shui Po	3 years	Ambassador
3	Female	Shum Shui Po	3 years	Ambassador
4	Female	Wong Tai Sin	3 years	Social worker
5	Male	Shum Shui Po	2 years	Social worker
6	Male	Tseung Kwan O	3 years	Social worker
7	Male	Central & Western	2 years	Social worker
8	Female	–	3 years	Academic researcher
9	Female	–	2 years	Academic researcher
10	Female	–	2 years	Academic researcher
11	Male	–	2.5 years	Academic researcher

Each focus group discussion lasted 60 to 90 minutes and was audio-taped and transcribed verbatim. All participants were assured of the confidentiality of the study data and that their anonymity would be preserved. They provided written informed consent. All focus group discussions were conducted in Cantonese. Illustrative quotations in this article have been translated into English by the authors.

Data Analysis

We adopted a grounded theory approach based on the works of Strauss and Corbin (1998) in data analysis: open, axial, and selective coding (Strauss & Corbin, 1998), using Microsoft Word as our primary tool. First, in open coding, we started by reading each transcript line by line and applying initial codes to any meaningful text pertinent to the research question. At this stage, quotes describing participants’ views, opinions, and experiences about the CBPR project were highlighted. A sample quote highlighted during this coding process was from a social worker: “One of the drivers is to train them (ambassadors) to be ready and open to experience such a different model.” This was coded as “provide training.” Second, in axial coding, we identified preliminary themes by categorizing the initial codes. Following the previous example, when an emergent pattern indicated that both ambassadors and social workers identified specific contents of training, we classified and categorized these codes into the emergent theme “highlighting an ‘acceptance and openness’ mentality in the CBPR training” We compared the codes and these emergent themes within the research team to ensure reliability. We developed the paradigm model to explain the relationships between conditions and phenomena. Third, in selective coding, we selected and reviewed the themes to develop a theoretical explanation that captures the phenomenon under study.

During the opening coding process, four academic researchers (JHYY, HSK, WYF, MWSL) independently coded the same transcript and then discussed the labels applied to generate a code book, which included a set of codes with a brief definition. The four academic researchers then independently coded the remaining transcripts and developed the paradigm model after discussion. The paradigm model involved the whole panel (academic researchers, ambassadors, and social workers) in refining/defining/naming the themes and interpreting them to ensure the relationships between categories and themes are well established and validated to enhance the credibility of study findings (Strauss & Corbin, 1998). We follow The Standards for Reporting Qualitative Research (SRQR) to report our research (O’Brien et al., 2014) (Supplemental Table 1). We collected samples until the emerging concepts and categories reached saturation, at which no additional new data were found from each stakeholder group (Chen & Boore, 2008).

In this CBPR study, we, as researchers from an academic institution, need to be mindful of the power differences present in the research setting. Ambassadors and social workers from the community often view academic researchers as having authority and expertise, which could impact their contributions in focus groups. Throughout the research process, we fostered a collaborative and inclusive environment, promoting open dialogue and reflection during focus groups. When it comes to disseminating our study findings, academic influence and privilege are evident, as academics are trained and expected to produce peer-reviewed articles, where the academic language may not be familiar to community members. To maintain a balanced community-academic collaboration, we actively engage in open discussions with ambassadors and social workers, emphasizing the collective knowledge generated in the project as a result of collaboration among all stakeholders.

Results

Our data revealed six guidelines pertinent to CBPR practice in East Asian communities; Guidelines 1–4 concern generic CBPR practice, while Guidelines 5–6 are specific to mental health literacy promotion.

Guideline 1: Highlighting an ‘Acceptance and Openness’ Mentality in the CBPR Training

Compared to the training developed in Western CBPR projects highlighting skill acquisition, local participants emphasized cultivating an ‘acceptance and openness’ mentality for adopting a bottom-up, egalitarian, and collaborative approach. Professionals traditionally high up in the hierarchy must step back because CBPR requires a more unconventional and facilitative approach emphasizing values such as humility, trust, respect, and open-mindedness for all stakeholders. One social worker expressed the importance of adjusting her mindset in the decision-making process when her leadership role shifted to a more supportive and facilitative one:

I have to constantly adjust my mindset and remind myself to take a step back; this mentality is critical… It is because there are times that I feel my role is being challenged in the CBPR project… for example, the ambassadors initiate the meetings by themselves; they seek my help just for venue booking but do not invite me to join the meeting… I don’t feel comfortable with it... (Social worker, FGD7)

Therefore, training aimed at facilitating an ‘acceptance and openness’ mentality should focus on improving readiness. Another social worker commented:

One of the points is about the ‘acceptance.’ We all (academic researchers, social workers, ambassadors) have to accept that we are feeling stones while crossing the river... All of us are like guinea pigs to try on a new model… All of us are trying on something that we have never experienced. The mindset of acceptance is important; it allows us to try on a mode different from the traditional one. We are all in an experimental stage. (Social worker, FGD7)

The social worker expressed the importance of the ‘acceptance and openness’ mentality, defined as embracing the diversity in perspectives and practices on an unconventional approach, further facilitates the collaborative process in CBPR. From our experience and observation, social workers who are equipped with an ‘acceptance and openness’ mentality could impact the group’s development. The social worker of Wong Tai Sin is comparatively more open-minded and accepting, leading to the Wong Tai Sin district progressing more efficiently compared to other districts. Unlike traditional top-down volunteer programs or interventions, CBPR employs a bottom-up approach that necessitates all stakeholders to rethink and reconstruct their working relationships from the ground up. When professionals choose to step back, meaning that they acknowledge the importance of valuing local knowledge, local participants feel respected and valued, which empowers them to voice out their thoughts and actively engage in the CBPR process. By fostering a mentality of acceptance and openness, stakeholders can better adapt to the unpredictable nature of CBPR and simultaneously develop an appreciation for the unintended outcomes that emerge from this joint endeavor.

Guideline 2: Navigating the Hierarchical Culture to Facilitate an Equal Partnership

CBPR projects in the West often form equal partnerships before the project commences. The partnership is based on the partners’ abilities and strengths by inviting community organizations and members to submit a brief proposal to indicate their level of involvement and responsibility for the project (Marquez et al., 2022). Conversely, a hierarchical and top-down mode of practice and ideology is prevalent in the social service industry in East Asia (Sainsbury, 2003). An equal partnership might not be easy to form initially as community organizations and ambassadors expect the project to be professional-driven and top-down, as indicated by three ambassadors in this project:

We could not take the lead because we lack professional knowledge and experience. (Ambassador, FGD3)

I wonder, when we have already prepared everything, do we need approval from you (the academic institution) or the NGO to proceed. (Ambassador, FGD3)

Equal partnership is impossible because the relationship between academic researchers, social workers, and us is like a pyramid. You (the academic institution) are at the top level. You are the leader. You provide us with funding, professional knowledge, and information. We are just like followers of the order from you (the academic institution) or the social workers. (Ambassador, FGD4)

Hence, when developing CBPR locally, we emphasize partners’ interests more than their strengths and abilities and, as the CBPR project evolves, ambassadors gradually gain independence and start to exercise their self-determination. We found that ambassadors who show enthusiasm for the CBPR project were motivated to navigate the hierarchical culture. For example, the ambassadors in Sham Shui Po are actively involved in promoting mental health literacy through the CBPR project. They have raised concerns about the bureaucratic procedures for organizing mental health literacy activities in the district and are striving to foster a more collaborative partnership. On the other hand, the ambassadors in Central & Western display less enthusiasm for the CBPR project. They are accustomed to a top-down approach, making it difficult to establish a mutually beneficial partnership. Social workers might find it challenging to re-position themselves and readjust their roles (as mentioned in the first quote in Guideline 1). Forming equal partnerships locally takes time; stakeholders must navigate the hierarchical culture by aligning expectations and clarifying roles and responsibilities.

Guideline 3: Breaking the Project into Smaller Action Tasks to Facilitate Design and Implementation

Western culture is based on critical thinking, personal expression, and discovery; sufficient space for discussion and view sharing on a CBPR project is encouraged in the design phase and before implementation (Centre for Social Justice and Community Action & National Coordinating Centre for Public Engagement, 2022). In the local context, community members are used to respecting authority, following directions and instructions, and being task-focused and action-oriented. Breaking the project into small action tasks and accumulating successful small-task experiences facilitates stakeholders’ co-working experiences on a CBPR project:

I hope there is a conclusion and timeline every time in the meeting. When are we making things happen? We hope to take practical action! We discussed our agenda in the meeting, but we just omitted the details like when we will hold the street booth… when to do this and when to do that…this becomes meaningless. (Ambassador, FGD2)

This quote highlights that local community members do not enjoy discussion; instead, they favor practical actions. In Tseung Kwan O, Sham Shui Po, and Wong Tai Sin, ambassadors divide the project into smaller, achievable tasks, improving the feasibility and practicality of CBPR initiatives. This approach allows community members to find value in their contributions and promotes active engagement. Conversely, ambassadors in Wan Chai encounter difficulties in implementing the CBPR project, possibly due to a lack of meaningful engagement in the tasks at hand. In addition, a social worker mentioned how a bottom-up mental health promotion activity facilitated ambassadors’ understanding:

We can start with trying on small-scale promotional activity first; that will be better. Based on this point, they will learn our concept or mode. For example, the mobile van lets them experience what a bottom-up mental health volunteer is. (Social worker, FGD5)

In Central & Western, ambassadors ride on the NGO’s mobile van publicity service to reach a wider community through art and handcraft workshops, the co-working approach allows ambassadors to gradually accumulate resources, such as networks, knowledge, and experience through the ‘learn by doing’ process. These small tasks’ experience facilitates subsequent project design and implementation on a larger scale.

Guideline 4: Fostering Collective Harmony Through Team-Building Activities and Informal Gatherings

Ambassadors tend to be more indirect, introverted, and slow to open up; an abundance of team-building activities and informal gatherings are needed to build their confidence in working as a group and improve group dynamics. Conversely, examples of CBPR projects in the West do not highlight improving group dynamics specifically. This might be because Western culture values individual uniqueness; community members often take the initiative to express personal opinions, while group dynamics build up naturally as the project evolves. Ambassadors expressed concerns about the challenges of working together if they do not know each other well beforehand:

All of us are from different backgrounds; everyone has their strengths. However, what is he good at? What is she good at? I don’t know… how could we work together if we do not know each other well beforehand? (Ambassador, FGD4)

If we know each other and are close with each other, I think that yields twice the result with half the effort.” (Ambassador, FGD2)

Meanwhile, a cohesive group that values harmonious and conflict-free collaboration is considered by both ambassadors and social workers as a protective factor or as the foundation of an equal and sustainable partnership. Furthermore, a harmonious group dynamic fosters an environment where community members feel safe and empowered to express their individuality and confidence to assume greater responsibilities, as expressed by one ambassador:

I’m uncertain about my ability. I rejected being the convener of an activity. However, she (another ambassador) keeps encouraging me. She said: “Just go! I will support you!”. It feels like this group is going up and down together!...This gives me great confidence! (Ambassador, FGD2)

In the local context, CBPR emphasizes interpersonal bonding, mutual understanding, and harmony. Team-building activities and informal gatherings that foster connectedness are as important as formal meetings in fostering collective harmony and functioning. Ambassadors from Wong Tai Sin take the initiative to organize numerous informal gatherings, such as hiking trips, to foster collective harmony and bonding, resulting in more effective progress in their CBPR project. In contrast, in districts like Central & Western and Wan Chai, where informal gatherings are scarce, the weaker bonding among ambassadors leads to less efficient progress.

Guideline 5: Encouraging Open Discussion of Mental Health

According to community members, many older adults have low mental health literacy due to a lack of education and discussion of the topic. Ambassadors considered the mental health definition so broad and vague that they did not know what and how to initiate mental health topics with peers, as articulated by one:

I think many older adults do not know what mental health is… the area is so broad and not specific at all. I think more training and discussion are needed (Ambassador, FGD 4)

When discussing how to promote mental health literacy in the community, a social worker commented:

We need a platform for all of us (social workers and ambassadors) to discuss mental health. Mental health is a vast area. We need a lot of discussion and information on the existing services available for mental health, which helps ambassadors identify what is lacking in their community. Ambassadors can, therefore, think about a subsequent mental health literacy promotion project starting from there. (Social worker, FGD 7)

In addition, we observed some discrepancies between community members’ enthusiasm for mental health literacy promotion and their perceived capacities in channeling their passion into actions since they often find themselves unequipped with the necessary knowledge, skills, and confidence to engage in mental health promotion efforts. Older adults in all five districts share a common lack of understanding of mental health literacy. Ambassadors tend to view mental health literacy solely in terms of happiness or unhappiness, overlooking the importance of recognizing mental health symptoms and knowing where to seek help as key components of mental health literacy. Therefore, there is a need for continuous education and a platform for discussing mental health with the public. Additionally, since mental health is a culturally specific construct, clarifying its meanings and perspectives within a local context can assist community members in conceptualizing the issue and formulating strategies more effectively.

Guideline 6: Leveraging Informal Networks in Mental Health Literacy Promotion

Community members in local CBPR groups often rely on informal networks, such as neighbors, family members, and friends, to share and obtain mental health information, as well as to identify mental health needs specific to the community. Apart from information sharing, informal networks provide a source of emotional support when facing mental health challenges, as evidenced by the ambassadors below:

I saw one of my neighbors has mental health problems… I hope to learn more about mental health to help her… (Ambassador, FGD 4)

Older adults like our age… children may have migrated, and we make friends with neighbors…. Our role becomes important. We have to explore our neighbors who are living alone, talk with them, and invite them to go out so that they don’t feel lonely and know that there are still many people who care about them. (Ambassador, FGD 1)

In recent years, many older adults in Hong Kong have experienced the migration of their children and grandchildren; hence, relationships with neighbors and friends have become a more significant part of their informal networks. We noticed that informal networks are notably robust in certain older districts in Hong Kong, including Wong Tai Sin, Sham Shui Po, Central & Western, and Wan Chai. Ambassadors in these districts have longstanding roots in the communities and maintain strong social connections with the district and their neighbors. In contrast, Tseung Kwan O is a relatively new town where ambassadors relocated after its development, resulting in fewer social ties. The formation of informal networks in Tseung Kwan O often occurs through participation in volunteer programs offered by NGOs. In local CBPR groups, the function of establishing and maintaining informal networks often extends beyond building collaborative efforts or providing psychosocial support. Instead, they act as a vehicle for mental health literacy promotion at the community level through information dissemination and social participation facilitation. The former refers to using informal networks as a starting point to circulate information related to mental health. The latter implies leveraging informal networks to identify potential participants for volunteering programs and other community activities, thereby increasing community members’ exposure to positive mental health messages. By capitalizing on the strength of informal networks, mental health literacy promotion efforts can be more effectively disseminated and integrated into the lives of community members who may have trouble utilizing mental health services due to the presence of structural barriers such as stigma.

Discussion

This study addressed the research gap in co-developing CBPR guidelines with stakeholders in East Asian communities, whereas existing guidelines were developed in Western communities. Additionally, given that existing CBPR mental health literacy promotion projects have mainly been conducted in the West, this study served as the first mental health literacy promotion project in East Asia. We identified six guidelines pertinent to the CBPR practice in East Asian communities: 1. Highlighting an ‘acceptance and openness’ mentality in the CBPR training; 2. Navigating the hierarchical culture to facilitate an equal partnership; 3. Breaking the project into smaller action tasks to facilitate design and implementation; 4. Fostering collective harmony through team-building activities and informal gatherings; 5. Encouraging open discussion of mental health; 6. Leveraging informal networks in mental health literacy promotion. Our study enriches existing literature by co-developing CBPR guidelines in East Asian communities, illustrated with an example of a CBPR mental health literacy promotion project. We provide methodological insights into practicing CBPR projects in East Asian communities where cultural issues are considered.

CBPR is a brand-new concept and approach in East Asian societies. In Hong Kong, around 30% of adults aged 65 or above reported their highest education attainment as primary or secondary school (Census and Statistics Department Hong Kong Special Administrative Region, 2021). Historically, they are used to the traditional, hierarchical, top-down mode of following orders from management levels. Additionally, paternalism, an ideology or practice of managing others’ affairs in a controlling manner, has been prevalent in the social work profession (Sainsbury, 2003), a working mode that negates CBPR values. Due to the novelty of the working relationship, both social workers and community members are unfamiliar with the core values of CBPR, such as equal partnership, shared decision-making, and co-construction. Additionally, in our experience, social workers and community members may expect academic researchers to take the lead in CBPR projects like traditional researcher-driven studies. However, it is important for academic researchers to avoid being dominant and to involve all stakeholders equally to uphold the CBPR essence. Hence, as reflected in our data and observation, we emphasized the importance of fostering an ‘acceptance and openness’ mentality in CBPR training to address both operational and interpersonal challenges faced by stakeholders. Such mentality facilitates equitable partnerships between researchers, social workers, and community members by promoting mutual respect and embracing the diversity in perspectives and practices on an unconventional approach. Fostering an ‘acceptance and openness’ mentality is crucial for the successful implementation of CBPR initiatives in East Asian societies like Hong Kong.

In addition, we recommend breaking the project into smaller action tasks, as there are multiple advantages to doing so. On the one hand, this allows social workers and community members to experience co-construction and co-working; this coincides with chunking theory in cognitive psychology, where breaking a task into small and manageable pieces facilitates the learning process and working memory of an individual (Lu et al., 2024; Miller, 1956). The practice of chunking tasks into smaller, manageable pieces corresponds with traditional East Asian teaching methods that emphasize step-by-step learning and gradual mastery, which aligns with an East Asian proverb that says a journey of a thousand miles begins with a single step, emphasizing the significance of taking small and incremental actions to achieve success (Morris, 2018). On the other hand, it promotes meaningfulness (e.g., feeling worthwhile and valuable) for older adults volunteering from the role engagement perspective (Kahn, 1990; Lu et al., 2024). This is similar to the concept of capacity optimization, which highlights the importance of task-ability and preference match in volunteering satisfaction (Ludlow et al., 2018). Promoting meaningfulness resonates with the East Asian cultural emphasis on respect for elders and the value of role engagement. Older adults in East Asian society are often revered for their wisdom and experience, and involving them in meaningful tasks can enhance their sense of worth and contribution to the community (Chen et al., 2022). From our experience, local older adults favor practical actions over discussion despite discussion being encouraged and needed before implementing a CBPR project (Centre for Social Justice and Community Action & National Coordinating Centre for Public Engagement, 2022). Aligning the project structure with East Asian cultural values increases the likelihood of successful engagement and participation of older adults in CBPR initiatives. Our research highlights that older adults enjoy CBPR projects when they are broken into small action tasks. This allows them to contribute fully and feel valued, leading to increased motivation and ongoing involvement in the project.

Community members in East Asian societies emphasize collective harmony in groups and are slow to open up. In terms of relationship building in groups, Western culture and East Asian culture exhibit distinct approaches. Western culture prioritizes the creation of structure, norms, and group processes, while East Asian culture prioritizes interpersonal bonding and mutual understanding as the foundation for effective communication and coordination (Ginzburg et al., 2022). This aligns with the Confucian values of respect and harmony, which underpin social interactions in East Asian society (Onwurah, 2025). Moreover, fostering collective harmony in groups encodes social identity theory (Lu et al., 2024; Turner & Oakes, 1986), highlighting that social identity is a source of emotional ties to social groups and a sense of belonging. When older adults feel comfortable and confident to work in the CBPR group, they develop an alternative social identity from the district action committee as they perceive themselves as integral members of the CBPR group, contributing to a common goal. It enhances their motivation to continue volunteering and encourages them to sustain their engagement.

In East Asian cultures, the promotion of mental health literacy lags behind Western cultures. There is a lack of open discussion around mental health in East Asia, which makes it challenging to promote mental health literacy. The influence of Confucianism in East Asian societies imposes an expectation on individuals to maintain, protect, and preserve their faces and attain harmony with society to fit in. As a result, people tend to conceal mental illness status and are not used to discussing mental health publicly (Blignault et al., 2008; Yang et al., 2014; Yang & Kleinman, 2008; Zhang, 2012). Conversely, there has been increasing discussion and awareness of mental health in Western societies. This also explains why most mental health literacy campaigns and education programs are prevalent in the West while such promotion has been lacking in East Asia (Ryff et al., 2014). As a result, we encourage open discussion of mental health as the first step to enhancing mental health literacy. By promoting open dialogue to discuss mental health issues, individuals can gradually feel more comfortable seeking help and engaging in conversations about mental well-being. Furthermore, we suggest facilitating informal networks as the primary source of mental health promotion in East Asian cultures. Practical guidance to leverage informal networks includes establishing membership in existing community organizations, familiarizing and utilizing existing community events and services, and establishing trust and relationships with peers (Haase et al., 2025). This draws on social network theory, arguing that informal networks are essential in transmitting information, facilitating social support, and influencing behavior within communities (Pescosolido & Manago, 2017).

This study has several strengths. First, it enriches the existing CBPR field by adding insights from an East Asian perspective. Second, our guidelines were developed from a bottom-up approach - a co-creating process in which individual and organizational-level perspectives are included in data analysis and interpretation to enhance the credibility of the findings and data. Regarding implications for future research and practice, we suggest policymakers and service providers develop a bottom-up intervention following our guidelines and suggestions. In East Asia, older adults tend to be perceived as passive recipients of social services (Chui et al., 2018); our study revealed that there is enormous potential to engage older adults in CBPR or a bottom-up mental health literacy promotion setting; a paradigm shift is required from viewing older adults as passive social service recipients to active collaborators. Future studies can examine the association of the guidelines and the implementation of a CBPR project within or beyond the mental health literacy promotion focus.

There are limitations to this study. First, Guidelines 5-6 may not be generalizable to all CBPR projects because they are specific to mental health literacy promotion. However, Guidelines 1–4 concern generic CBPR practices, which should be applicable to other CBPR projects with different focuses. Future studies may consider using our proposed guidelines to apply the CBPR approach to different types of project and see how different guidelines are implemented. Second, our study samples were self-selected. They might have greater interest and passion to engage in a mental health literacy promotion project because they were recruited from a territory-wide mental health capacity-building project in Hong Kong. Third, older adults in our study were at risk of mental illness because of the inclusion criteria of the community mental health training program. Older adults with different characteristics, such as those with severe mental illness, may have different experiences in a CBPR project. CBPR projects are specific to the culture of the community members involved. Future studies may include participants from diverse backgrounds to explore how CBPR can be adapted to different populations. Fourth, our study focuses on older adults; the generalizability to populations with different socio-cultural backgrounds may have to be interpreted with caution. Fifth, our study did not consider gender-based hierarchy in dividing focus groups, which may influence group dynamics and impact open dialogue. Future studies may consider dividing focus groups based on participants’ backgrounds to mitigate the potential effect of demographic factors.

Conclusion

This study extends existing literature by co-creating CBPR guidelines with stakeholders in East Asian communities, illustrated with an example of a mental health literacy promotion project. We suggest applying our guidelines in future CBPR projects to enrich CBPR practices in various contexts.

Supplemental Material

Supplemental Material - Co-Developing Community-Based Participatory Research (CBPR) Guidelines in Hong Kong: An Example of a Mental Health Literacy Promotion Project

Supplemental Material for Co-Developing Community-Based Participatory Research (CBPR) Guidelines in Hong Kong: An Example of a Mental Health Literacy Promotion Project by Jessie Ho-Yin Yau, Hotinpo Sky Kanagawa, Wing-Yin For, Maggie Wai-Shan Lo, Stella Lai-Kuen Wong, Ken Tsz-Kin Ho, Alta Sze-Ki Cheung, Frankie Ho-Yin Ho, Donald Chak-Ling Lee, Isaac Long-Ching Sui, Tianyin Liu, Gloria Hoi-Yan Wong, Cheryl Hiu-Kwan Chui, and Terry Yat-Sang Lum in International Journal of Qualitative Methods

Footnotes

Acknowledgments

The authors would like to thank the CBPR project team (academic researchers from the University, social workers from local non-governmental organizations, and older adults in the community) for their help and support in this research.

ORCID iD

Jessie Ho-Yin Yau

Ethical Considerations

The Human Research Ethics Committee approved the study at The University of Hong Kong (reference number: EA210164).

Consent to Participate

All participants were assured of the confidentiality of the study data and that their anonymity would be preserved. They provided written informed consent.

Author Contributions

JHYY conceived the study idea, designed the study, collected data, and drafted the initial manuscript. HSK, WYF, MWSL, SLKW, and KTKH facilitated the implementation. ASKC, FHYH, DCLL, and ILCS provided feedback for important intellectual content. TL, GHYW, CHKC, and TYSL critically reviewed the manuscript. TYSL acquired the funding and supervised the research implementation. All authors approved the final manuscript version for publication.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by The Hong Kong Jockey Club Charities Trust to conduct CBPR projects with older adults in the community (AR190017).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data are available upon reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

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