Academic–community collaborative partnerships have gained increasing acceptance as a model to assess and intervene on complex health problems in disadvantaged communities. True partnerships are instrumental to community-based participatory research (CBPR) methods, which strive to engage community members in all phases of research or intervention projects.1,2 The early wave of CBPR partnership studies were carried out in urban contexts in the USA. They produced promising evaluation findings,3,4 and the CBPR model has since been employed in research among minority groups in the USA and in other countries.5,6 Continuing evaluation of partnerships in international settings is crucial to shaping and expanding their potential in empowering communities and addressing health inequities worldwide.
Trust is a key factor to evaluate in academic–community partnerships and an important construct to measure in order to gauge their success.7,8 Due to a history of exploitative research in disadvantaged communities in the USA, mistrust of academic institutions has been highlighted as an impediment to partnership formation and sustainability. Mistrust between community partners themselves is also important to consider, yet this aspect of partnerships received less attention in scholarly writings. In socially and economically excluded communities, mistrust may be the outcome of structural conditions that force community partners to compete over scarce resources.
We describe an academic–community partnership formed to improve the mental health of youth in a disadvantaged urban community in Beirut, Lebanon. Based on a qualitative evaluation, we highlight the challenges encountered in forming and sustaining the partnership under economic and political conditions that promote conflict and lower trust between community partners. Drawing on lessons learned from the evaluation, we emphasize the importance of focusing on positive community features as a way to slowly work against mistrust and to move the work of the partnership forward.
The partnership was created in June 2005 between academic members in the Faculty of Health Sciences at the American University of Beirut and community partners from Burj el-Barajneh Palestinian refugee camp (BBC). BBC is an urban slum on the outskirts of Beirut that is inhabited by more than 16,000 long-term Palestinian refugees. Like neighboring urban communities, BBC exhibits high levels of social disorganization and low levels of trust.9 Findings from an urban health study carried out in 2003 revealed that, compared to Lebanese adolescents, those living in BBC were more likely to be school drop-outs and to report poor self-rated health,9 a subjective measure that reflects mental health status. Since its formation, the partnership took on the challenge of designing and implementing an intervention to improve the mental health of adolescents in BBC and to enhance their school attachment. The partnership was named the Community Youth Coalition (CYC).
Community representatives in the CYC included independent volunteers, representatives of local non-governmental organizations (NGOs), and representatives of the United Nations Relief and Works Agency (UNRWA). UNRWA was established in 1948 to provide education and health services to Palestinians who became refugees after the creation of the state of Israel. As the majority of Palestinians in Lebanon receive their formative education in UNRWA schools, it was crucial to include representatives from the agency in the partnership. Most local NGOs represented in the CYC run youth cultural, educational, or vocational programs for which they obtain funding from various international donors.
The need to evaluate the progress of the partnership was brought forth by community members themselves at the end of the first year of collaborative work. In response, a subcommittee was formed to plan for and implement the evaluation. In the summer of 2006, in-depth interviews were conducted with 18 CYC members who were either independents or represented one of 11 different partnership organizations. The interviews were tape recorded and transcribed verbatim; analysis of the transcript data was carried out following standard qualitative methods. Two salient, and somewhat conflicting, themes emerged from the analysis. CYC members projected a high level of commitment towards achieving the goals of the partnership. However, despite the high commitment, they exhibited low levels of trust towards other community partners.
With respect to the first theme, independent, NGO, and UNRWA representatives all expressed a strong sense of obligation towards enhancing the wellbeing of youth in their community and indicated that their participation in the CYC fits naturally with the work they do in their respective organizations. They highlighted that their commitment to the goals of the partnership stems from their belief that the wellbeing of youth is key to the wellbeing of the Palestinian refugee community as a whole:
This project is very important to me. We are not only dealing with the mental health or education of youth. In my opinion, we are dealing with the future of a whole community.
Member commitment to the welfare of youth in their community was strong and explained their sense of duty to contribute their time and expertise to the partnership. In addition to what community members themselves stated during interviews, an examination of minutes and running notes collected between 2005 and 2006 revealed that a core group of community members consistently attended meetings and actively contributed to the decision-making process and to building the partnership infrastructure. It is worth noting that, during its first year, the partnership operated on zero funding and none of the members or their respective organizations received any compensation for their contributions.
The second emergent theme highlights that the partnership operated under conditions of pervasive mistrust between members. Whereas initial suspicions of the academic partner were recalled during interviews, members primarily spoke about their mistrust of other community representatives in the CYC. They elaborated that, while trust improved slowly and conflict subsided over time, mistrust will not completely dissipate in the partnership due to long-standing structural factors in the community. These factors relate to the fact that NGOs in BBC are demanded to constantly secure international donor funding in order to sustain youth service projects. The system of international funding, which focuses on services and does not encourage collaborative long-term planning, has created stiff competition between NGOs and contributed to lowering trust over time. A community member described the situation as follows:
We have a problem [in BBC]. All our organizations operate on funding from international donors and foundations … The conflict between NGOs is very difficult to get rid of because, while everyone wants what is best for youth, there is strong competition over international funding.
Whereas competition led to mistrust across the board, the most evident schism in trust manifested between members from local NGOs and those who represent UNRWA. The partnership brought vying stakeholders together at the same table and the history of conflict and mistrust directed at UNRWA inevitably spilled into CYC meetings and influenced their dynamics. For some local NGO members, the meetings served as occasions to criticize UNRWA and to hold its policies responsible for the high rate of school drop-out among Palestinian adolescents. This put UNRWA representatives, who are from the BBC community, in a defensive and awkward position:
Since the first meeting I attended, I was put on the defensive as a representative of UNRWA. I think it is a little bit better now, but the conflict remains.
A quick background serves to contextualize this conflict as an outcome of larger structural conditions that govern life in BBC. For over 60 years, Palestinian refugees in Lebanon have been denied rights in the areas of education, health, employment, and property ownership.10 Whereas UNRWA provides free health and education services to Palestinians, there is an almost universal consensus that these services are inadequate and of poor quality.10 In order to compensate for inferior formal education, local NGOs in BBC run after-school remedial education programs. Members representing NGOs in the CYC indicated during interviews that they witness on a daily basis the failings of the UNRWA education system through their work.
In response to the strain imposed on the partnership because of this context, some members suggested making a practical change in CYC meeting structure—to reduce the number and length of full CYC meetings and to hold more frequent and longer small subcommittee meetings. Each of the subcommittees would include a small number of members who would meet in a more intimate setting and work together on achieving specific practical goals. In return, full CYC meetings would focus primarily on discussing the progress of subcommittee work and future directions. Members conjectured that bringing a few members closer together as a team in charge of achieving specific goals would build personal relations and a team spirit as the partnership begins to accomplish its overall goals. During in-depth interviews, most members expressed satisfaction with the new structure because of its potential to enhance trust and maintain momentum in the partnership.
The CYC presented a microcosm of the BBC community, reflecting both its strengths and weaknesses—a high level of commitment to enhancing the wellbeing of youth and a low level of trust between members. Structural conditions that heightened competition over international funding inevitably created an environment of conflict and mistrust in the BBC. Our qualitative evaluation highlights unique lessons that can guide future academic–community partnerships in similar urban contexts. When working collaboratively with communities, it is important to contextualize mistrust within the broader structural conditions that create conflict and competition between partners and to build on community strengths in order to push the work of the partnership forward. In the CYC, the high level of member commitment to enhancing the welfare of youth in the BBC community served as the driving force to sustain the partnership under structural constraints. One of the main accomplishments of the CYC was that it planted a seed for future collaborations between NGOs in the BBC and made a small break in the psychological barrier that has hindered joint work for many years. We hope that findings from this evaluation will inform the policies of international donors that provide small and short-term funding in poor urban communities. Gearing some of the funding to the establishment of collaborative partnerships promises to reduce competition, enhance trust, and empower communities.
References
- 1.Israel BA, Eng E, Schulz AJ, Parker EA. Methods in community-based participatory research for health. San Francisco: Jossey-Bass; 2005. [Google Scholar]
- 2.Minkler M. Community-based participatory research partnerships: challenged and opportunities. J Urban Health. 2005;82(2 Suppl 2):ii3–ii12. doi: 10.1093/jurban/jti034. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lantz PM, Viruell-Fuentes E, Israel BA, Softley D, Guzman R. Can communities and academia work together on public health research? Evaluation results from a community-based participatory research partnership in Detroit. J Urban Health. 2001;78(3):495–507. doi: 10.1093/jurban/78.3.495. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Metzler MM, Higgins DL, Beeker CG. Addressing urban health in Detroit, New York City, and Seattle through community-based participatory research partnerships. Am J Public Health. 2003;93(5):803–811. doi: 10.2105/AJPH.93.5.803. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Burhansstipanov L, Christopher S, Schumacher SA. Lessons learned from community-based participatory research in Indian Country. Cancer Control. 2005; Cancer, Culture, and Literacy Supplement: 70–76. [DOI] [PMC free article] [PubMed]
- 6.Mosavel M, Simon C, Stade D, Buchbinder M. Community-based participatory research in South Africa: engaging multiple constituents to shape the research question. Soc Sci Med. 2005;61(12):2577–2587. doi: 10.1016/j.socscimed.2005.04.041. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Schulz AJ, Israel BA, Lantz P. Instrument for evaluating dimensions of group dynamics within community-based participatory research partnerships. Eval Program Plann. 2003;26:249–262. doi: 10.1016/S0149-7189(03)00029-6. [DOI] [Google Scholar]
- 8.Cargo M, Mercer SL. The value and challenges of participatory research: strengthening its practice. Annu Rev Public Health. 2008;29:325–350. doi: 10.1146/annurev.publhealth.29.091307.083824. [DOI] [PubMed] [Google Scholar]
- 9.Khawaja M, Abdulrahim S, Afifi R, Karam D. Distrust, social fragmentation, and adolescents’ health in the outer city: Beirut and beyond. Soc Sci Med. 2006;63(5):1304–1315. doi: 10.1016/j.socscimed.2006.03.047. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Chatty D, Lewando Hundt G. Children of Palestine: experiencing forced migration in the Middle East. New York: Berghahn Books; 2005.