Implementing capacity-building initiatives addressing health equity through community–academic partnerships: A qualitative study

Abstract

Background

Capacity-building is a common goal of community–academic partnerships, but there are literature gaps in the components of capacity-building efforts that support success and how implementation science can contribute to these efforts. We studied the core components and implementation determinants of capacity-building initiatives carried out through Chicagoland CEAL community–academic partnerships.

Methods

We conducted seven focus group discussions with 26 community organization representatives and researchers exploring six capacity-building initiatives. We used Juckett et al.’s typology to summarize the initiatives’ core components and grouped emerging themes on implementation determinants according to the domains and constructs of the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation science framework.

Results

The core components of the capacity-building initiatives varied widely in their use of didactic, practical application, knowledge-sharing, and technical assistance activities, but the implementation barriers and facilitators showed greater consistency. Bridging factors: Findings demonstrated the importance of developing mutually beneficial, trusting relationships among community–academic partners with clear goals. Innovation factors: Tailoring capacity-building activities to populations’ needs and adapting over time were notable facilitators. Outer context: Flexible funding supported implementation, while social climate and local infrastructure limitations were barriers. Inner context: Barriers included competing priorities, space limitations, and staff availability.

Conclusions

Our findings on core components, barriers, and facilitators can promote the equitable implementation of capacity-building initiatives carried out by community–academic partnerships. Our study addresses calls to place greater emphasis on health equity and attention to context in the field of implementation science. Our findings further strengthen the literature on the EPIS framework through practical application.

The core components, barriers, and facilitators of the Chicagoland CEAL capacity-building initiatives explored can inform efforts of community–academic partnerships to promote health equity.

Implications.

• Practice: Community–academic partnerships using capacity-building should strive for a mutually beneficial relationship founded in trust with good communication channels and ensure their capacity-building initiatives are tailored to needs and adaptable, with clear goals.

• Policy: Policy-makers should address structural factors (e.g. historical disinvestment) that were barriers to the capacity-building initiatives, and funders should include unrestricted, flexible funding that allows for capacity-building activities to grow organically.

• Research: Researchers using the Exploration, Preparation, Implementation, Sustainment framework should build on our illustration of how community–academic partnerships can serve as bridging factors and on outer context barriers (i.e. social climate, local infrastructure) not explicitly addressed in the framework.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic accentuated longstanding health disparities facing historically minoritized groups. Black and Hispanic populations experienced higher rates of infection, hospitalization, and death compared to their White counterparts [1]. Research on health equity and social determinants of health has increased exponentially with growing awareness of these issues, which the pandemic brought front and center [2, 3]. Health equity refers to a commitment to reduce and eliminate disparities in health and social determinants by striving for the highest possible standard of health for everyone, with special attention on those with the greatest health risks [4].

Partnerships between communities and researchers (i.e. community–academic partnerships; CAPs [5]) play a critical role in efforts to achieve health equity [6]. Engaging communities in all stages of the research process equitably through such approaches as community-based participatory research (CBPR) can help address the structural issues underlying health challenges and create sustainable change [6, 7]. One common desired objective of CAPs is capacity building [5], which has numerous definitions [9]. The World Health Organization (WHO) defines capacity-building as “the development of knowledge, skills, commitment, structures, systems, and leadership to enable effective health promotion” [10]. Capacity-building within CAPs is necessary for establishing the infrastructure for conducting research that is collaborative and of mutual benefit [11]. Capacity-building can help avoid tensions and inequities within the collaborative relationship by putting community and academic partners on a more equal playing field [12]. Capacity-building can also serve as a natural extension to ongoing CAP work, as it allows community organizations and researchers to learn from each other’s strengths and experiences [13].

The WHO notes the value of pursuing capacity-building efforts both within organizations and among community members [10]. Within organizations, capacity-building can include staff training, the provision of resources, the design of policies/procedures, and the development of structures for health promotion planning and evaluation. Organizational capacity building provides needed skills and structures so that organizations can implement specific programs or identify new health risks and respond as needed. Within communities, capacity-building can include awareness-raising about health risks, the generation of strategies for community identity/cohesion, health literacy education, the provision of access to external resources, and the development of structures for community decision-making. Community capacity-building allows community members to take action to address their needs and facilitates the creation of social and political support for successful program implementation [10].

While capacity-building is a widely used strategy with a long history of seeking better health outcomes [14], there are gaps in the literature on the components of capacity-building initiatives that contribute to success. These initiatives can involve a myriad of activities which are difficult to measure and whose value is often underestimated [14]. Although numerous efforts have been made to determine the optimal activities or formula for capacity building, a universally accepted best practice or gold-standard method has yet to be established.

There are also gaps in the literature on how implementation science (i.e. the application and integration of research into policy and practice [15]) can inform the delivery of capacity-building initiatives addressing health equity through CAPs. Determinant frameworks in the field of implementation science can provide valuable insight into the influence of context (including barriers and facilitators) on the success of an implementation effort [16]. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework is particularly well suited to understanding initiatives delivered through CAPs. The EPIS framework includes four domains: (i) the outer context: the environment external to the organization, which can include the service and policy environment and characteristics of patients or consumers; (ii) the inner context: characteristics within organizations (e.g. leadership, organizational structures, internal policies, etc.); (iii) innovation factors: characteristics of the innovation or evidence-based practice and/or its fit at the system, organization, provider, and patient levels; and (iv) bridging factors: the interconnectedness and relationships between the outer and inner contexts, which can be reciprocal [16]. The EPIS framework is unique among determinant implementation science frameworks in that it conceptualizes CAPs as a construct within its “bridging factors” domain, viewing CAPs as helping to link the organizational (i.e. “inner”) context and the context beyond the organization (i.e. “outer”). While studies have reported on experiences implementing capacity-building initiatives through CAPs to address health equity [11, 17], we identified only two studies that drew on EPIS to frame their explorations of capacity-building initiatives [17, 18]. No studies to our knowledge have directly applied EPIS domains and constructs to understand determinants of capacity-building initiatives through CAPs.

The current study addresses these literature gaps by centering on the Chicagoland CEAL program. Funded by the National Institutes of Health, the Chicagoland CEAL program began in 2021 as part of the federal government’s response to the COVID-19 pandemic. Initially, its primary goal was to increase vaccination rates among Black and Latinx populations in metropolitan Chicago, leveraging CAPs. Community organizations serving Black and Latinx populations through social service programs were approached for participation, which led to the creation of the program’s CAPs (see [19] for more details). Following the program’s initiation, in response to frustrations from the community organizations about over-prioritizing vaccinations, the program broadened its focus towards using CBPR and implementation science to improve health equity and address social determinants of health [19–21]. Many of the CAPs began using capacity-building to enhance the knowledge, skills, and/or networks of organizational leadership and staff and/or community members to support their shared efforts.

In Year 3 of the program, we set out to explore these Chicagoland CEAL capacity-building initiatives in hopes of understanding: (i) the core components of the capacity-building initiatives, and (ii) determinants (i.e. barriers and facilitators) encountered during implementation of the initiatives using the EPIS framework [22, 23]. We sought to shed light on the key features of capacity-building initiatives through CAPs and how they can best be implemented to inform the work of researchers and practitioners using CAPs to promote health equity.

Methods

Chicagoland CEAL Program

The Chicagoland CEAL program is comprised of academic researchers and community organizations collaborating to improve equity in health outcomes and engagement in research for historically marginalized communities in the Chicago metro area. The academic partners include the University of Illinois Chicago, Loyola University Chicago, Northwestern University, Rush University Medical Center, Sinai Urban Health Institute, the University of Chicago, and Equal Hope.

Study Design, Population, and Procedures

Using a qualitative study design, we conducted seven virtual focus group discussions, each lasting 60–90 minutes, hosted on Zoom. Participants included 14 representatives from the community organizations and 12 researchers (representing 4 academic partners) who played a role in designing and/or delivering six capacity-building initiatives. Each focus group was moderated by the first author and supported by another research team member not involved with the capacity-building initiative being discussed, who took notes. The first author was not directly involved in any of the CAPs and thus brought an external, unbiased perspective to the research. Table 1 summarizes the partnerships for the initiatives and the focus groups conducted with each; three of the initiatives used the same research partner.

Table 1.

Descriptions of researcher and community organization partnerships and focus groups

Academic partner	Community organization	Focus groups (number of participants) collection
Sinai Urban Health Institute: Community-engaged research center partnering with community members/leaders and organizations to identify, contextualize, and address health inequities with a particular focus on Chicago’s West and South Side communities	Breakthrough: Building connections, developing skills, and opening doors of opportunity in education, health, and wealth in partnership with residents of Garfield Park.	1 focus group with academic partners (n = 4) 1 focus group with CO representatives (n = 2)
Northwestern University: Multidisciplinary team of health scientists working to leverage expertise in Team Science, Population Health, Behavioral Health, and Preventive Medicine, to improve equity and transparency to Community-Engaged Research.	Phalanx Family Services: Dedicated to providing wrap-around services that offer vital resources and programming designed to empower individuals and families to live healthy, productive lives in the Far South Side of Chicago.	1 focus group (n = 4) (2 CO representatives and 2 academic partners)
Loyola University: Works with community organizations to expand knowledge in the service of humanity through learning, justice, and faith.	Cicero Community Collaborative: A community collaborative dedicated to enhancing the quality of life in the Cicero community by connecting youth and families to the programs and services they need. Youth Crossroads: An agency offering services towards the prevention of problems for youth in their communities, including creating a network of referral resources. Serving families from Berwyn, Cicero, Stickney, and neighboring towns.	1 focus group (n = 5) (4 CO representatives and 1 academic partner)
University of Chicago: Working alongside civic partners who provide experience-based insights to achieve a stronger understanding of pressing urban issues and develop pragmatic, thoughtful policies to help solve them.	Woodlawn Community Food Pantry: Serves as a source of nutritional assistance, with support from the Greater Chicago Food Depository. These include supplying free healthy food options and nutritional education and trainings in the Woodlawn Area to reduce stress in the community regarding the availability of food to families, children, and senior citizens.	1 focus group (n = 4) (2 CO representatives and 2 academic partners)
	Windsor Park Evangelical Lutheran Church Food Pantry: Partners with the Greater Chicago Food Depository to be a reliable food source for many individuals on the South Side of Chicago. Specifically, this pantry connects neighbors with healthy food across the South Shore neighborhood. They also increase knowledge about, and access to, fresh produce by running an urban community garden.	1 focus group (n = 4) (2 CO representatives and 2 academic partners)
	St Moses the Black Parish Food Pantry: Provides fresh produce, meat, and dry goods to over 500 households every week with the help of dozens of volunteers and the Greater Chicago Food Depository. This pantry serves the South Side of Chicago, particularly those in the Greater Grand Crossing neighborhood.	1 focus group (n=3) (2 CO representatives and 1 academic partner)

Abbreviation: CO=community organization.

Each CAP decided how they wished to structure the focus groups. In five of the initiatives, the community organization and researcher partners were together for the first portion of the focus group and then moved into separate breakout groups to share additional feedback on the partnership towards the end. For one initiative, separate focus groups were conducted with the community organization and research partners.

The focus group guide addressed background context on the partnership and the community organization; the impetus to launch the CAP and capacity-building initiative; the structure of the initiative, barriers and facilitators to implementing the initiative; and recommendations for future capacity-building initiatives addressing health equity using CAPs (sample questions are in Table 2). Focus groups were recorded and transcribed verbatim. The five researchers who conducted the focus group discussions wrote analytical memos immediately after the focus groups to record their reflections and thoughts on emerging themes [24].

Table 2.

Sample focus group questions

With community organizations and researchers together: • [To the community organization] How would you describe your organization? What is your organization trying to achieve? • What led to this partnership between [insert researcher/community organization]? What are you trying to achieve? • How would you describe the capacity-building initiative you have worked on together? What strategies have you used when implementing the initiative to enhance its success? • What has gone well? What has not gone well? How have you tried to address challenges that came up? • What recommendations do you have for others who may be developing and/or implementing similar initiatives through partnerships between researchers and community organizations? With community organizations and researchers in separate groups: • What has been your role with designing and implementing the capacity-building initiative? • What has gone well with your working relationship with [insert researcher/community organization]? What has not gone well? How have you tried to address challenges that have come up? • To what extent would you like the partnership with [insert researcher/community organization] to continue?

Analysis

We used a rapid qualitative analysis approach to facilitate coding, visualization, and interpretation of the data [25, 26]. A rapid analysis approach was selected so that we could apply our findings directly to the ongoing capacity-building initiatives of Chicagoland CEAL CAPs. We developed a qualitative analysis matrix [26, 27] to align with the questions in the focus group guides, with space to add columns to the matrix as needed. While all coauthors (i.e. researchers and community partners) were invited to conduct the analyses, community partners requested that the research team conduct the analyses given time constraints. The first author generated the analysis matrix and trained three members of the research team, each with previous qualitative coding experience, on how to fill in the analysis matrix using the transcripts. This analysis team met regularly to discuss the analysis process and ensure consistency in how the matrix was being completed. Alongside the analysis matrix, 12 analytical memos contributed to the analyses.

To understand the initiatives’ core components, we summarized CAP activities according to Juckett et al.’s typology of core intervention components of capacity-building initiatives [28]: (i) didactic activities (i.e. coursework, readings, and/or self-paced modules); (ii) mentorship and expert consultation (i.e. continued support, one-on-one or group meetings); (iii) practical application activities (i.e. small projects or field placements involving implementing an innovation under real-world circumstances); (iv) knowledge-sharing activities (i.e. group meetings encouraging networking, reflection, and discussion of implementation experiences/reflections); and (v) technical assistance (i.e. support for how to deliver an innovation/implementation strategy).

The EPIS framework guided the analysis process regarding implementation determinants given its attention to bridging factors—specifically, CAPs [22, 23, 29]. Our study focused on perceptions of determinants during the implementation phase of EPIS [30], as the capacity-building initiatives were ongoing during the time of data collection. Using the analysis matrix and analytical memos, the first author—who had previous experience using the EPIS framework [31]—generated a meta-memo summarizing emerging themes. The meta-memo grouped the themes by sub-construct and construct according to the four domains of the EPIS framework (i.e. innovation factors, bridging factors, inner context, and outer context). A valence was assigned to each construct/sub-construct to indicate whether it was perceived to be a facilitator (+), a barrier (−), or a facilitator for some initiatives and a barrier for others (+/−). Findings were presented by salience of first the domain, then construct, and then the sub-construct. Where a theme did not appear to align with any EPIS framework constructs, other constructs in the literature were used. The meta-memo was reviewed and discussed in detail with both the smaller research team and the wider team of researchers and community partner collaborators to achieve goodness, i.e. when emerging themes are authentic representations of the data [32]. We also conducted member checking [32] with the researchers and community organizations to ensure that the data presented would be an accurate and valid representation of their experiences.

Ethical Considerations

This study was approved by the Chicago Area Institutional Review Board (CHAIRb), protocol 2022-1173. Written informed consent was waived.

Results

Initiative Overview

The populations of interest across the six initiatives included staff members from the community organizations (i.e. “organizational staff”) for four initiatives, both organizational staff and community members (i.e. high school students and parent ambassadors) for one initiative, and community members (i.e. high school students) for one initiative (Table 3). The initiatives themselves took notably different forms, except for the three University of Chicago CAPs, which used the same core components. Some initiatives did not use didactic activities, whereas others used biweekly workshops, structured curricula, and/or training in research tasks (e.g. survey administration). Some CAPS focused primarily on technical assistance (e.g. connecting community organizations with other partners), whereas others focused more heavily on mentorship and expert consultation (e.g. using peer mentors to support implementation) and practical application activities (e.g. hosting health events, carrying out needs assessments).

Table 3.

Overview of the capacity-building initiatives carried out by Chicagoland CEAL community–academic partnerships (CAPs), described according to the five core components of capacity-building initiatives put forth by Juckett et al. [28]

CAP	Population of interest	Core components of initiatives
		Didactic activities	Mentorship and expert consultation	Practical application activities	Knowledge-sharing activities	Technical assistance
Sinai Urban Health Institute—Breakthrough	High school teens recruited by organization	Structured eight-session curriculum covering: data, community health, and advocacy	Peer mentors support implementation Leading figures in research and practice serve as guest speakers	Participants generate a final presentation based on real-world issues	Debriefing meetings between faculty lead and organizational lead after each session	Community partner supported with recruitment and CAP worked together for challenges that arose.
Northwestern University—Phalanx	Organizational staff and affiliates	Co-designed biweekly workshops focused on building research capacity	Provided bidirectionally that supported a shared vision on the value of research and how it may be utilized by this blended team.	Hosting health events, designing surveys, and generating tailored programming for the community.	Weekly meetings to plan and debrief biweekly workshops	Researchers provided training and technical assistance on data collection and reporting practices, while community partner provided technical assistance in working directly with community members.
Loyola University Chicago—Cicero Community Collaborative & Youth Crossroads	High school teens and parent ambassadors	Training in ethics, survey administration for students, and parent ambassadors	Faculty lead provided guidance on developing and implementing the needs assessment	Parent ambassadors carrying out need assessment	Faculty lead and community partner met regularly during survey development and dissemination	Faculty lead grounded the needs assessment survey in science
University of Chicago and (1) Woodlawn Community Food Pantry; (2) Windsor Park Evangelical Lutheran Church Food Pantry; and (3) St. Moses the Black Parish Food Pantry	Organizational staff and community members	None	Consultation on how to host health events	Hosting health events	Debriefing meetings after each event	Researchers promoted connections with other partners

Barriers and Facilitators to Implementation

Findings are presented according to the four EPIS domains in order of salience: (i) the relationships between community organizations and researchers (i.e. bridging factors); (ii) the capacity-building initiatives (i.e. innovation factors); (iii) the broader contextual context (i.e. outer context); and (iv) the community organization context (i.e. inner context). Figure 1 shows how the themes that emerged align with the constructs and domains of the EPIS framework, with valence assigned. Appendix 1 provides definitions for the constructs.

Figure 1.

Summary of themes (i.e. sub-constructs) by EPIS constructs and domain, with valence assigned (+ for implementation facilitators, − for barriers)

Bridging Factors: Relationships Between Community Organizations and Researchers

All partnerships were established as a mutually beneficial relationship, which was a key facilitator to implementation. Community organizations offered access to clients, spaces, and insider knowledge about community needs. Researchers offered access to external facilitators/consultants, research and organizational skills, “fresh eyes,” and credibility in the health space; as a community partner explained, “[The researchers] brought background, experience, and connections …That’s something that I can’t bring. It’s harder for me to bring the weight or clout.” A researcher from one initiative emphasized the reciprocal nature of the mutually beneficial relationship they developed:

I think there is a misconception in some research spaces that capacity building is coming down from the ivory tower and sharing knowledge about research methods. However, that’s just not how it is in reality. Capacity building is very much also learning from community partners and recognizing their expertise. (Researcher)

Establishing and sustaining trust was considered critical to building a strong foundation for the CAPs. In the words of a community partner, “Start with the basics and build a foundation by getting to know one another so that there’s trust … I cannot emphasize enough how important that core, trusting relationship is.” Community partners described several actions of researchers that supported the trust-building process, including taking time to get to know the organization and staff, being physically present at organizational events, communicating openly and transparently, acknowledging their positionality in relation to the work being done, taking the time to research related topics in lay terms, asking questions about the organization and community, and elevating the importance of community voices. The partners knew each other and felt confident that they were collaborating for the same reasons. Community partners explained:

It was important to have a representative who cares about the community. Our research partner wants to make sure we are heard. Most researchers are only in it for the data. (Community partner)

Everybody is a known quantity. Our research partner knows us. Our volunteers know them. (Community partner)

One community partner highlighted the importance of ensuring enough comfortability within a partnership to be able to speak openly about sensitive topics—i.e. to have “very hard conversations about race or unintentional biases”—so as to build a truly trusting relationship.

In addition to trust, the CAPs generally described using open communication strategies, which supported the implementation of their initiatives. They used a variety of means of communication, including email, Zoom calls, in-person meetings, and text messages for “a quick touch-base.” In a couple of cases, communication was a barrier. In one example, turnover in the roles of the research team caused a breakdown in communication, which left one client waiting for their stipend for an extended period. In another example, the research team had trouble reaching their community partner when needed; they lacked a clear point of contact who would respond reliably.

The relationships between community organizations and research partners were often described as facilitating interlinkages between the organizational (i.e. inner) and broader (i.e. outer) contexts. They helped strengthen the outputs produced by organizations in the inner setting to communicate more clearly with legislators and spark changes at the outer setting. For example:

We’re very fortunate to have the support of our research partner to help us give a true picture to the community about things that are happening and to help us tell that story. When we are engaging with our public officials, our alderman, the mayor, the governor, we have data to support what we’re saying in hopes that changes are made that provide the additional support needed in communities of color. (Community partner)

In some cases, researchers facilitated connections between organizations (i.e. inner setting) and other organizations or experts who could provide them with services or support (i.e. interorganizational networks at the outer setting). Leadership representatives in the community organizations helped research partners access organizational staff (i.e. inner setting) despite negative perceptions about researchers’ intentions in some communities (i.e. social climate).

Innovation Factors: The Capacity-Building Initiatives

All initiatives were described as intentionally tailored to address the needs of the communities and organizations involved. As one community partner succinctly stated, “It fits with our mission.” The way in which the initiatives were tailored to address needs varied. In some cases, the research partner came in with a more structured initiative but closely worked with their community partners to “hone in on what was going to be beneficial for our clients” (Community Partner). As another community partner explained, “They wanted to know what we thought would work.” In other cases, the community partners had an initiative in mind which was already tailored to their needs, which the research partner supported. In a unique case, the community organization and researchers together decided to create a capacity-building initiative that would benefit all parties—i.e. “a formal channel and avenue to build up research together and keep learning from one another and create a kind of shared language and understanding” (Researcher).

In addition to being tailored to community and organizational needs from the start, a key facilitator centered on ensuring the initiatives would be adaptable over time. All participants described making changes to their initiatives in response to shifting organizational and client needs, with several participants referring to the adaptations as “organic.” In one example, a CAP started by using a structured approach for the academic partners to impart research skills to organizational staff, but quickly recognized that the approach was not working; the more traditional, didactic style was perceived as sterile and not sufficiently engaging to community partners. The CAP decided to change course and began hosting bidirectional sessions led by researchers and community partners alike. Researchers led sessions on such topics as “Mixed Methods 101” and community partners led sessions on such topics as “Getting to know the Far South Side community.” In addition to formal topics, many sessions involved participatory group discussions and activities that intentionally involved reciprocal learning rather than a lecture-style approach. A community partner explained, “This is fluid learning on both sides. The plane is going up and flying at the same time. We’re navigating while we are learning.” In another example, an initiative geared at capacity-building among students drew on a structured approach but included flexibility to customize topics to students’ interests each year: “We really want to hear from youth participants, and we tried to evolve the program the best we can every year based on learnings from the previous year,” said a community partner.

Most initiatives had goals that were clear to all partners involved. The goals included, among others, a desire to: ensure the perspectives of clients are “being heard”; ensure research is “activated”; enhance diversity and representation in the public health sphere; increase data utilization; enhance reporting of findings; carry out a community needs assessment; and increase organizations’ “self-sustainability” to expand their health services. For most initiatives, having clear goals supported the implementation process. In a couple of cases, a lack of clear goals served as a barrier to implementation. One research team, for instance, reflected on how they may not have been clear in communicating what they saw as the goals for the capacity-building initiative from the start: “Maybe we weren’t explicit enough about what we were trying to do.” The researchers reflected on how, as a result, a community organization is bound to default to their “primary mission” and put funding towards those efforts rather than capacity-building.

Outer Context: Broader Contextual Factors

Funding was noted as both a facilitator and barrier of the initiatives. A paramount benefit of the funding provided was its less restrictive nature, which allowed for flexibility in carrying out the capacity-building initiatives, including tailoring the initiative to the needs of organizations and clients and adapting as needed (innovation factors, described above):

It has been great because there hasn’t been too great of a restriction on how the funds could be used, so that’s what allows you to be able to set up a nice program. (Community Partner)

This is one of the only grants I’ve ever worked with that had some level of continued flexibility. And I just think that’s been so critical for us to really be responsive to the needs of the work that is to be done. (Researcher)

A community partner further reiterated the importance of funding being unrestricted to support things like infrastructure and “keeping the lights on.”

Funding was also noted as a barrier in some cases. Providing stipends to community partners, for instance, is expensive, and some community partners were therefore limited in the number of clients they could afford to pay. The funding structure was also awarded on a year-to-year basis, which made assurances of funding for the upcoming year unclear. As a researcher explained, “We haven’t known, ‘Is this going to be continuing?’ That’s a challenge on the academic side to make those commitments.”

Participants in this focus group study noted three forms of structural barriers affecting implementation within the communities in which the capacity-building initiatives took place—first, relating to the local infrastructure (i.e. the structures or resources existing in the community [33]). Some communities were described as having insufficient access to healthy food, information, and health insurance. In one example, a CAP described needing to be conscious of the amount of time they were requesting of their client populations for the initiative, since they did not want to “hold them from getting to their other financial priorities.” Transport issues were raised. For one initiative, client populations faced challenges with having transportation to attend activities—e.g. needing to spend “two to three hours by bus and train” or “relying on parents for transportation.” Second, safety concerns were noted, where clients faced challenges attending activities in certain areas, which made them “uncomfortable because of the negative experiences they had had around the neighborhood.”

Third, the social climate (i.e. beliefs of the larger community within which the initiatives took place [33]) was noted as hindering implementation. Community partners explained negative perceptions of researchers and health service providers among the communities in which their organization operates and the importance of researchers demonstrating their commitment to the communities to help counter this narrative:

In the African American neighborhood, people are wary of someone coming in to say, ‘We want to give you a shot for this or a shot for that,’ just simply because of the history that exists. Our community has had a history of organizations, corporations, politicians, or any people who come to the community and make promises. And they end up being promises unkept. If you say you’re going to do it, do it, cause they’re looking. And if it doesn’t happen, you know, ‘Here come these folks again …’ (Community partner)

Oftentimes in our communities, our residents don’t get to see the researchers. Our organization is considered a trusted partner for the South side or even in the city of Chicago. When you have the researchers a part of forums, a part of community talks, a part of community engagement, trust is built … When you talk about dispelling myths among communities mistrusting of researchers, that relationship-building is key. (Community partner)

Competing priorities and language considerations posed further challenges. Researchers sought to connect their community partners with other organizations but quickly discovered many of these other organizations were already overloaded with their own initiatives, rendering these connections more difficult: “The organizations and groups we’re connecting them with have all the resources, but they don’t have a lot of bandwidth” (Researcher). Some projects also faced barriers with youth involvement, given their competing priorities, such as school and extracurricular activities. For instance, one initiative planned to involve students in data collection for their needs assessment, but struggled with student availability, so it relied instead on parent ambassadors. Language barriers were a further concern for one initiative which worked in Latinx communities with numerous Spanish dialects spoken.

Inner Context: Community Organization Context

In all initiatives, the community organizations were depicted as open to and interested in the capacity-building initiative. For example, one initiative was sparked because the community partner “had an eye for research and an interest in research” (Researcher). However, community partners’ abilities to take the initiatives forward depended in part on other organizational characteristics. Competing priorities were barriers, as organizations were often described as being over-stretched with numerous initiatives on their plate simultaneously. As a researcher explained of a community partner, “There were capacity constraints—the capacity of time and ability to coordinate all of this … I think they’re overwhelmed.” In another example, an organization had so many existing programs that finding dates for activities or events was very difficult. The CAP described having to set their expectations that hosting activities for their initiative might have to consistently be “pushed back a couple of weeks.” Community partners and researchers alike described these types of challenges as follows:

The main challenge was calendaring. Everybody was committed. Everybody wanted to do it. It was just a matter of trying to fit it all together. (Community Partner)

It is important to recognize and understand how busy the organization already is. Hopefully the organization can move forward on the initiative without having to spend a lot more time, because there isn’t a lot of extra time. (Researcher)

Space limitations were also noted as a barrier within community organizations. There were physical limitations with some spaces (e.g. old buildings not being handicap-accessible). There were also challenges with finding spaces that would be safe for clients to access and challenges coordinating with other groups who also use the same spaces.

In some cases, community partners and researchers alike described staff availability within the organization as a challenge. Some partners were depicted as lacking “the manpower,” being “maxed out,” and relying on volunteers who were “doing 16 other things at the same time,” which affected their ability to push the capacity-building initiatives forward.

Discussion

This study set out to understand the core components and implementation determinants of capacity-building initiatives carried out by Chicagoland CEAL CAPs. While the CAPs were established in response to the COVID-19 pandemic, when researchers and community partners alike were attempting to adapt to a changing landscape, the themes that emerged echo existing literature, highlighting the potential transferability of our findings to other CAPs. We found that the technical core components of the initiatives differed notably across community partnerships with academic institutions, echoing the literature on the myriad ways capacity-building approaches can take shape [14]. However, the “soft” or intangible aspects of the initiatives, which emerged during our assessment of implementation determinants, were largely consistent across projects. In the bridging factors domain, we found that CAPs need to develop mutually beneficial relationships with strong communication channels, founded in trust. In the innovation factors domain, our findings highlight that tailoring capacity-building activities to populations’ needs, adapting over time, and establishing clear goals play a key role in the successful delivery of the initiatives. These findings are consistent with existing literature on CAPs [18, 34–36] and our team’s earlier research during the COVID-19 pandemic [19]. Developing trusting relationships and adapting capacity-building activities to address community needs takes significant time and effort and continues to be a challenge for CAPs [37, 38], thus highlighting the ongoing relevance of our findings.

Many barriers and facilitators we identified at the outer and inner contexts—including negative perceptions of researchers and health service providers [39], local infrastructure issues, competing priorities within organizations, and space and staff availability limitations—have also been found in previous studies [17, 39] but remain essential for CAPs to identify and navigate when implementing capacity-building initiatives. The outer context findings, in particular, underscore how historical disinvestment in minoritized communities and structural racism can limit capacity-building efforts of CAPs and reinforce the central importance of tackling these structural barriers to support health equity [40]. Our findings on the funding structure at the outer context highlight the value of unrestricted and flexible funding with extended timeframes to allow capacity-building initiatives to grow organically. Funders are increasingly recognizing the need to provide sufficient funds to cover the indirect costs of organizations, including for capacity-building [41]. However, restricted funding remains the norm [42], emphasizing the ongoing relevance of these findings for funders.

Our study is novel through three main contributions to the literature on applications of the EPIS framework. First, our visual representation of the EPIS domains, constructs, and sub-constructs identified through this research, with valence assigned (Fig. 1) offers a practical example to novice implementation science researchers on how to map determinants by domain. Visualization tools have been noted as valuable for understanding complex phenomena in the field of implementation science [43]. Second, our findings add to the literature on the bridging factors domain of EPIS, which has been identified as “an urgent priority for implementation research” [29] but has received little attention compared to the other domains [23]. We identified several ways in which CAPs served as “bridges” between the inner and outer contexts—e.g. by the CAPs strengthening the research outputs of organizations (inner context) to better communicate with legislators (outer context) and by fostering relationships between organizations (inner context) and external experts (outer context). These findings offer an example of how CAPs can interlink the inner and outer contexts in practice. Third, we identified several outer context factors that are not represented in the EPIS framework. We drew on Watson et al.’s outer context definitions for social climate and local infrastructure [33] to address various “structural barriers” raised in the focus groups. In our study, social climate encompassed negative perceptions of researchers and health service providers within certain communities of the community organizations, which have been similarly found in other studies of CAPs [34]. These findings could support the development of future iterations of the EPIS framework.

Study limitations must be recognized. Most CAPs chose to host focus group discussions jointly with academic and community organization representatives, which promoted joint reflection but may have prevented full disclosure of viewpoints, given that the CAPs are still ongoing. We tried to address this by facilitating separate conversations with each partner at the end of the focus group. It is important to recognize the unique nature of most CAPs when considering the transferability of findings, though we expect the themes to be relevant to other contexts and populations. The CAPs presented in this manuscript had a range of capacities but were generally on the higher end of the spectrum and had resources through CEAL funding. Future studies should examine capacity-building initiatives carried out through CAPs with lower capacity and/or funding to further our understanding of how initiatives in these contexts address health equity. Finally, while this study has identified determinants during the implementation of the capacity-building initiatives, it does not specify the implementation strategies used and the causal mechanisms through which these strategies operate to achieve desired implementation outcomes [44]. Future studies should focus on addressing causal mechanisms to further advance the field of implementation science.

Conclusions

By focusing on the core components and implementation determinants of Chicagoland CEAL capacity-building efforts, this study addresses calls in the literature to advance our understanding of essential capacity-building initiative components, to place greater emphasis on health equity in the field of implementation science, and to give greater attention to context in implementation efforts [8, 14, 45, 46, 47]. Our findings on the importance of mutually beneficial relationships, trust, strong communication, initiative tailoring, adaptability, and clear goals can inform the work of CAPs using capacity-building to address health inequities, including those of the Chicagoland CEAL program. Furthermore, the Chicagoland CEAL CAPs have begun to account for the determinants identified in this study while developing interventions and strategies that will be implemented across all sites in Year 4 of the program using a CBPR approach.

Appendix 1: Domains, constructs, and sub-constructs^*

Domain	Construct	Definition of construct	Sub-constructs and their valence
Innovation	Innovation Fit	The extent to which the innovation/ EBP fits the needs of the population served or context in which it is implemented	+ Tailoring to needs
	Innovation Characteristics	Features or qualities of innovations to be implemented	+ Adaptability    +/− Clear Goals
Bridging factors	Community–academic partnerships	Active partnerships between researchers and key community stakeholders, who can represent multiple levels involved in implementation (e.g. system representatives, organizational leaders, providers, consumers), that can facilitate successful implementation and delivery/use of the innovation	+ Mutually Beneficial Relationship    + Trust    +/− Communication
Inner Context	Organizational Characteristics	Structures or processes that take place and/or exist in organizations that may influence the process of implementation	+ Receptive Context    − Competing Priorities    − Space Limitations
	Organizational staffing processes	The processes or procedures in place at an organization related to the hiring, review, and retention of staff involved in the active delivery of the innovation/EBP and/or its implementation	- Staff availability
Outer Context	Funding/ Contracting	Fiscal support provided by the system in which implementation occurs. Fiscal support can target multiple levels (e.g. staff training, fidelity monitoring, provision of the innovation/EBP) involved in implementation and delivery/use of the innovation	N/A
	Service Environment/ Policies	State and federal sociopolitical and economic contexts that influence the process of implementation and delivery/use of the innovation	N/A
	Interorganizational Environment / Networks	Relationships of professional organizations through which knowledge of the innovation/EBP is shared and/or goals related to the innovation/EBP implementation are developed/established	− Competing priorities
	Social Climate [28] (not part of EPIS)	Beliefs, values, customs, and practices of the larger community or system within which an intervention exists	N/A
	Local Infrastructure [28] (not part of EPIS)	The physical, technical, or service structures or resources in the larger service system or community which can influence implementation	− Resources    − Transport    − Safety
	Client characteristics	Demographic and individual characteristics of the target population.	− Competing priorities    − Language barriers

^*Definitions are from the EPIS framework [21] unless otherwise noted.

Funding

This research was, in part, funded by the National Institutes of Health (NIH) Agreement OT2HL158287 (SUB-OTA No. 6922-03-COVID-S020: Martin, Kershaw, Lynch, Margellos-Anast, Moskowitz, Silva, Thomas). This research was also supported by the NIH's National Center for Advancing Translational Sciences, UL1TR001422 (Hartstein). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies, either expressed or implied, of the NIH. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Conflict of interest statement

We have no known conflicts of interest to disclose.

Author contributions

MM conceived of this study with input from all authors. MM, AS, HMA, and DM are principal investigators on the Chicagoland CEAL program. KM, AD, SB, and AS conducted the focus group discussions. KM, AD, SB, and MH conducted data analyses. KM led the data collection and analysis and wrote the first draft of the manuscript. AB contributed to the framing of the manuscript. KM, AD, SB, MH, AS, DM, MDP, HM, AB, PN, AS, LB, MC, JD, EO, BH, BB, IM, NW, and MM contributed to data interpretation and critically revising the manuscript. The entire Chicagoland CEAL program and partners approved the research prior to its implementation and reviewed the manuscript. All authors approve of the final manuscript.

Human Rights

All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

This study was approved by the Chicago Area Institutional Review Board (CHAIRb), protocol 2022-1173. Written informed consent was waived.

Welfare of Animals

This article does not contain any studies with animals performed by any of the authors.

Transparency Statements

This study was not formally registered. The analysis plan was not formally pre-registered. De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author. There is not analytic code associated with this study. Materials used to conduct the study are not publicly available.