Chapter 2. Begin Your Partnership: The Process of Engagement

Abstract

Community Partnered-Participatory Research (CPPR) is based on and utilizes community engagement as its central method and principle. In this chapter, we explain the key differences between engaging the community vs merely involving the community. The chapter also reviews the plan-do-action cycle of work that is used in each stage of CPPR. We define five key values of CPPR: respect for diversity, openness, equality, redirected power (empowerment), and an asset-based approach. In addition, we present 12 operational principles, which guide work throughout every stage of all CPPR initiatives.

Introduction

Developing and sustaining effective partnerships for health research is an over-riding goal across all stages of Community-Partnered Participatory Research. To the extent that partnered research may be one solution to addressing health disparities, implementing successful partnerships is itself an important goal.

This chapter reviews what partnership is, what distinguishes authentically engaged from merely involved partners, the key principles of equitable partnerships, and partnership development strategies. Of course, partnerships are developed within specific projects and thus are not fully separable from a discussion of the stages of partnered work.

Community-Partnered Participatory Research (CPPR) is research that is jointly designed by community and academic partners for community benefit. CPPR builds community capacity for participating in and using products of research, while at the same time building academic capacity to partner effectively and integrate community perspectives into high-quality research.

Developing a partnership that can conduct such research is itself a partnered research task, which follows the Vision, Valley, and Victory stages. (Figure 2.1) The shared Vision of the partnership is built on the core values outlined below. The Valley is the process of developing and sustaining the partnership as it goes through the work of its various initiatives. The Victory is the recognition that the partnership is engaged in effective and equitable work that also builds community capacity for such work.

Fig 2.1.

Vision, Valley, Victory

The Engagement Ring: Plan, Do, Evaluate

Once academic and community stakeholders move beyond involvement to create an authentic partnership, they become engaged. For us, the process of becoming engaged in a community-academic partnership became even more meaningful (and even more fun) when we realized it is not unlike the process of becoming engaged to the person who will be your spouse.

In both types of “engagement,” commitment and mutual trust are paramount. And in both types of engagement, a promise is made. When you enter into a romantic engagement, you promise to marry. When you enter into a community-academic research engagement, you promise to work together to achieve the results you both want.

We visualize the process as an engagement ring. The ring has three diamonds: plan, do, evaluate. Each of the diamonds represents an integral part of the work that the partners have promised to do together, through each stage of a particular project or initiative, following authentic partnership principles. (Figure 2.2)

Fig 2.2.

Plan, Do, Evaluate

Plan, Do, and Evaluate drive each stage of a CPPR initiative, focusing the team’s efforts on what is to happen, how it will happen, and how the results should be evaluated.

• Plan: What should happen? How?

• Do: Let’s make it happen!

• Evaluate: What did we accomplish?

The setting of the diamonds within a ring suggests another reality: that the work process is cyclical and non-linear, with planning, doing, and evaluating influencing each other both within a given stage (Vision, Valley, or Victory) and, as we will see later, across stages. Further, like successful marriages, successful partnerships require hard work, patience, faith and kindness to make it through the inevitable conflicts toward enjoyable and productive initiatives. Together, we can make it work!

The Difference Between Involvement and Engagement

Traditional academic research projects that are described as “community-based” typically involve the community as an advisor or as a broker for recruiting subjects, without partnering with the community on its own terms to support joint leadership and benefit. Such community-based projects tend to be time-limited and narrowly focused on a single problem or issue. While developing knowledge, they usually do not build community capacity to solve wider problems, or to implement the lessons of their research. And, because the community is not engaged in the work or the solution, the benefits even to the local community can be short-lived.

Authentic partnership with the community that is designed to develop change strategies with the community follows a different path and, we suggest, has a different outcome. With a fully engaged community-academic partnership, the locus of control (traditionally centered in an academic or research organization) shifts toward the community. Every aspect of the project – from framing the issue to gathering and owning the data to evaluating the results to sharing the findings with others– is designed to respect, honor, and include all partners. The ultimate goal of the partnership is to solve not only the problem at hand, but to allow the community itself to solve a wide range of issues. It is evident that community ownership of research fosters community-driven change.

Table 2.1 is a side-by-side comparison of key features of research approaches that involve the community vs engaging the community. Both can yield valuable research data, but the paradigms are based on different values and principles and are likely to yield to different results in the community.

Table 2.1.

Community involvement vs community engagement

Historical Approach: Involve the Community	New Approach: Engage The Community
Directs a program toward a community without a community-centered process.	Honors the project’s collaborative nature every step of the way. Academic members are part of the community; community members are part of the research team.
Builds consensus for or obtains opinions on predetermined actions.	Leverages shared ownership of issues framing and action plan development into shared action.
Follows through and reports back primarily to funders/partners; work is done “for” rather than “with” the community until after major decisions are made.	Reports equally to both community and funders/partners, and ensures that work is done “with,” not “for” the community
Operates under a timeline for deadlines regardless of how the work takes shape.	Recognizes that trust and ownership are not developed quickly; time may be required to build meaningful relationships.
Relationships are managed to ensure goal attainment	Develops shared agendas, action plans and methods of evaluation with the community.
Delivers information and education to the community – with a predetermined agenda, action plan and method of evaluation.	Promotes joint approaches to building networks, achieving consensus and cultivating leaders.
Follows more traditional and pre-designed methods of building coalitions, consensus and identification of leaders.	Promotes joint decisions and ensures balance in decision-making.
Provides resources and technical assistance for the duration of the work.	Creates sustainable resources that can be utilized now and in the future to address community-defined issues; builds on and expands community capabilities.
Involves a top-down hierarchy in decision-making.	Involves a level playing field for getting the work done.
Creates distinct and separate identities for academic and community members.	Unites all partners into a strong, shared partnership.
Centralizes resource management within the academic partners.	Shares resources and resource management equally with community and academic partners.
Methods include:	Methods include:
Needs assessments	Asset assessments
Task forces led by academics	Community task forces led by many
Acknowledgment of individual efforts; encouragement of competition	Acknowledgment of collective group efforts; encouragement of cooperation
Information and teaching workshops	Information sharing and knowledge exchange workshops
Segregated academic and community leaders	Academic-community partnered leadership partnered community groups
Prescribed research steps	Jointly formulated action plans
Academic-directed operations and management	Joint operations and implementation

Core Values of Engagement

Community partnered participatory research reflects five core values of equitable relationships: respect for diversity, openness, equality, empowerment (redirected power), and an asset-based approach to the work. We discuss these values and then the operational principles that flow from them.

Respect for Diversity

To some extent, nearly every research effort must address diversity issues. Even traditional academic projects include individuals who differ in academic disciplines and background, age, gender, skills, and personal and career goals. Almost any research effort is a partnership.

However, diversity increases exponentially with the addition of community partners. Communities add so much diversity – in racial and ethnic backgrounds, income levels, work and life experiences, living conditions, communication style and expectations – that the challenges of working together can seem overwhelming.

We have found that the key to working together is to respect and honor our diversity. That means respecting and honoring the academic skills and know-how brought to the table by the academic partners, while simultaneously and equally respecting and honoring the life skills, community know-how and policy influence brought to the table by the community partners.

Openness

During the course of a project, it may become clear that goals and expectations that are very important to one individual or group are less important to others. This hurdle can best be overcome through mutual openness and exchange of perspectives. Definitions and assumptions should be questioned and clarified by each group. Personal, organizational and community histories should be shared. Openness and the practice of listening carefully to each other (facilitated by team leaders who ensure that each participant’s voice is heard) build mutual respect and trust. Respect and trust cannot be assumed; they are earned by hard work and consistent engagement, even when the community and academic partners have similar ethnic and cultural backgrounds. (Figure 2.3)

Fig 2.3.

Building trust

Equality

Academic researchers are selected, trained and encouraged by the promotion process to take an expert’s approach to issues (eg, we know what the problem is; here’s what we’re going to do about it; here’s the budget, here’s the timeline and, later, here’s what we’ve accomplished). Unfortunately, the result can be a “solution” that fails to address community needs, recognize community strengths, or honor community values and culture. Moreover, this type of self-oriented thinking may alienate community members who may perceive it – no matter how erudite or technically knowledgeable – as blind, narrow, selfish, arrogant, and patronizing.

In a CPPR initiative, successful community-academic partnerships are based on absolute equality of authority and decision-making power. Such partnerships recognize that both community and academic participants bring to the table skills and know-how that are essential to a project’s success. Consequently, both community and academic participants must contribute actively as partners from the beginning of the project – including the initial steps of defining the issues to be addressed, obtaining funding, and developing an action plan.

Once the project is underway, community members should participate in every activity and should co-author all articles and other reports on the project. It will be necessary to review participation over the duration of the project to ensure that all members – community and academic – are feeling respected, heard, powerful and trusted. Even in established partnerships, the maintenance of equality and trust is an ongoing process requiring examination, reexamination, reflection, and checking-in.

While equality of community and academic partners is essential, “equal” does not mean “the same.” The skill sets and knowledge base of members of a community-academic initiative can be complementary or overlap, and views may be similar or different – whether between academic and community participants or within academic and community participants. Further, equal representation in products does not necessarily mean that all members must participate in each product or contribute in the same way. Those decisions can be made by the members themselves during the course of the project. They can decide who wants to work on what, as long as there is equal representation and participation for community and academic partners.

Redirected Power (Empowerment)

“Empowerment” is a central goal of many community-based research projects. However, we suggest that this term should be carefully reconsidered because it tends to suggest that one group has power and the other does not, and that an initiative is designed to give the “weaker” group power. In our view of partnered research, “empowerment” does not mean that one group bestows power on another, or that one is powerful and the other is weak. Communities, for instance, already have power, which may include: well-developed social, religious, political, educational, and business networks; community-based organizations; and knowledgeable, committed individuals who live and/or work in the community. However, communities may lack the resources or know-how to harness their power to achieve specific goals within a research-based initiative, or to assure that a research project is conducted in such a manner as to build community capacity.

In a CPPR initiative, we use the term “redirected power” to suggest the key power-sharing goal. Under this terminology, each group is encouraged to learn from the other and to build on existing strengths. Power is redirected to allow community and academic voices to be considered equally in decisions, and hence in the partnership as a whole. Academic researchers learn how to focus on issues of importance to the community, improve data-gathering methodology (thereby increasing both the quantity and reliability of the data gathered) and increase the effectiveness of interventions. Community members learn how academic rigor and methods can be used to enable them to build credibility and to develop analytical skills that can be applied to a wide range of problems. Both groups learn to respect each other’s strengths and to use that respect to build the impact of the partnership and products outside the project in community policy sectors.

How is power redirected in Community-Partnered Participatory Research? Achieving equality among community and academic members takes hard work; it may not come naturally. Academic members may feel at ease in research discussions, whereas community members may shy away from expressing themselves even when they have an opinion and are given the floor. Part of the hard work requires setting up mechanisms to make each decision transparent to the diverse members of the partnership. This can mean technical assistance to bring key principles or concepts to light for community members, or field trips or walking tours in the community for academics so that they can appreciate the strengths and constraints of the community context that they may be hearing about in meetings.

Redirection of power is thus a two-way process that appreciates the strengths and advantages of formal and informal power of all partners, and brings transparency to the sources of that power such that both sides grow and take advantage of the full partnership strength. Within this overall process, both community and academic members can be alert to thinking of when and how to promote the shared communication that enables joint decisions—bearing in mind what each member of the partnership brings to the table, and the traditions and styles of participation that apply across and within the core community and academic groups. While grass roots community members may need support to understand the implication of design decisions, for example, clinician scientists will need support to understand how a particular health issue or intervention plays out in the community.

Asset-based Approach

The asset-based approach we use to implement our partnerships also represents a core value because it affects all aspects of the partnership development and project work.

Both academic and community members can fall into a conceptual trap: focusing exclusively on weaknesses and problems. For both groups, the trap exists because community needs can be very apparent. Academic members may see a problem and view themselves as purveyors of the solution. Or they may become over-cautious, perhaps feeling that they have been too aggressive in defining the problem, and may then back down, which can be viewed as rejection or arrogance. Community members can feel that the problem exists because the community is poor, or the situation is hopeless. They may feel that the academic members just don’t understand the issues, or that the team is “oil and water.” We call this “deficit-based” thinking. (Figure 2.4)

Fig 2.4.

Avoid the blame game

A successful community-academic partnership completely rejects and overturns deficit-based thinking and instead relies on its opposite: asset-based thinking and problem solving. In a mature partnership, while members see community problems realistically, they are equally realistic about seeing community strengths. They recognize that both academic and community members bring assets that, when united, can not only resolve a specific issue, but can lay the groundwork for resolving future issues, and build resiliency and capacity. A successful community-academic partnership is “asset-based,” and builds and celebrates capacities. Table 2.2 compares the two approaches. While asset-based thinking and problem solving comes naturally to some people, academic clinicians, trained within a hierarchical structure and often mentored through a critical, or “analytical” style, are accustomed to identifying problems and rushing to the rescue, rather than thinking first of strengths and waiting for the collective or collaborative solution to emerge from active sharing and problem solving over time. While asset-based thinking is relatively simple to define, our experience is that it requires work and skill-building to develop. This can be a key focus of capacity-building exercises during the project.

Table 2.2.

Deficit-based vs asset-based thinking

Deficit-Based	Asset-Based
Talks about what is missing before discussing the community’s strengths. Hears what the community says but still “marches to its own drum” in defining need.	Uses the strengths of the community to define issues; views problems as potential growth opportunities.
Engages in a cycle of problem identification. Skips new opportunities to address the issues and prepare a plan. This perpetuates learned helplessness and hopelessness in finding solutions, or can create “solutions” that miss the mark.	Leverages personal and organizational passion, intention and resources throughout the cycle of problem identification and action planning.
Stays in the acknowledgment stage too long, which can lead to repeating what has been historically done before.	Encourages capacity building and resolution, which supports self-motivated, forward-looking growth.

Guiding Principles for Community-Partnered Participatory Research

Our Guiding Principles are designed to translate the core values discussed above into day-to-day guidance of partnership activities. These principles have guided and been modified by our years of partnership experience. Community-academic research partnerships require flexibility and commitment from all participants. Community needs must be met, community capacity enhanced, and community culture respected – all while maintaining the highest academic standards.

The principles listed below are designed to help support authentic partnerships while still maintaining academic rigor, combining these strengths to have a solid footing of relationships, programs and data to support community benefit.¹ These principles can be used as a basis for leadership training and for development of a formal memorandum of understanding, discussed more fully under point 2 below.

1. Each activity is co-planned by community and academic leaders who have equal decision-making power

In most clinical research projects, academic members tend to dominate decision-making. They are more familiar with clinical standards and procedures, and most grants are awarded to academic/clinical organizations, which gives them control over funding. Community-academic partnered projects, however, succeed only if decision-making is shared equally. Therefore, all committees and decision-making bodies should be co-led by one academic member and at least one (if possible, more than one) community member.

In addition, voting power should be equalized. For example, even if the number of community or academic team members differs on a given committee or working group, their voting power should be the same. Or, if there is a tie, the deciding vote should be given to the community. Another approach is to enlist a neutral facilitator who is responsible for monitoring and ensuring equal participation. A neutral facilitator is someone who is not involved in the project that monitors group meetings or is brought in to mediate during disagreements. Academic and community members may choose a facilitator jointly, although in our experience, it has worked well to defer to the community members’ preferences for a facilitator.

2. Each project is guided by a written agreement (a memorandum of understanding) that outlines goals and rules of engagement, including ownership and review of products and data

The agreement should be written early and should cover project goals, ownership of data (you should expect that data will be owned jointly), review of products (joint review responsibility should be specified), leadership structure (as noted above, project committees should be co-led by academic and community members), leadership expectations, resources to be contributed by each participant, responsibilities, and dispute resolution. After ratification by participants, the agreement should be reviewed regularly to ensure that the project is on track and the leaders are adhering to the agreed-upon guidelines.

3. Project leaders (academic and community) communicate regularly, use mutually accepted means of maintaining productivity, and recognize that conflicts and disputes are necessary to growth

Frequent, regular communications promote respect for both the project itself and all team members. A communications plan enabling both vertical and horizontal communications should be developed and followed. Action plans and timelines should be jointly developed and approved, and then should be monitored and updated to ensure progress. Meetings should be supported by an agenda and documented by minutes or recordings. Meeting leaders should be guided by standard rules of discussion and should respect all voices at the table, while adhering to the meeting agenda and project timeline. All participants should recognize that the process of respecting each participant’s viewpoint will necessarily result in conflicts and disputes. Some of these will be resolved; in other cases, it may be necessary to acknowledge the difference but to set it aside – to “agree to disagree” while still moving forward.

4. Project activities, methods, procedures, and rationale are fully accessible to and understood by all participants

Every aspect of the project approach should be thoroughly understood by both academic and community members. Academic members are usually responsible for explaining academic and clinical concepts (such as human subjects’ protection and data-gathering procedures) in a way that makes sense to all participants. Community members are responsible for ensuring that the agreed-upon approach is likely to work in the community, and for explaining to academic partners concepts and context that are important to the community and that might affect project goals. All members should be open to new ideas. Community members, for example, may be especially creative in translating concepts into community-relevant presentations that use stories, music, role-playing, and other forms of expression to enhance understanding. Community members may also develop unique scientific insights and contribute significantly to improving the project’s scientific basis, which may come as a surprise to academic members. Similarly, academic members are encouraged to join community members in creative forms of expression. Leaders should ensure that all members contribute to, understand, and support the project’s direction.

5. Since community partners usually require financial or inkind resources to participate in the project, academic partners should help to obtain such funding

Obtaining funding for a true academic-community partnership is challenging. Most funding is awarded to academic or clinical institutions, which automatically shifts the balance of power toward those institutions and away from an equal partnership. Moreover, the time academics devote to the project is often covered by project funds and/or their salaries, whereas the time community partners devote to the project must be shoehorned into already crowded schedules or done after work. Since academic partners are usually more experienced in obtaining funding, it is their responsibility to help ensure that community participation is appropriately funded, and to advocate with funding agencies for the need to structure grant opportunities to permit equal partnership. Joint participation in developing the proposal and presenting results to the funder should be built into the process.

6. All leaders respect and follow community values and time frames

Since academic-community partnered projects are intended to develop infrastructures for long-term collaboration, timeframes may exceed usual norms. The purpose of the collaboration is not only to address the immediate issue but to build community capacity to address a wide range of issues in the future. This requires an infrastructure that is based on a deep level of mutual trust and understanding. Creating such an infrastructure takes time. The project should be structured to allow members to “step on and off the bus” as needed as the bus travels to its final destination without impeding overall progress.

What is the best way to ensure that the departure of a participant or project leader does not impede progress? If the person is a gate-keeper to other individuals or agencies, introductions can be made to other leaders in the team to facilitate continued relationships. Also, any tasks that were delegated to the person should be shared with the group, so that leadership may decide to redistribute the tasks or put them off. Ideally, team members should be continually developed in leadership skills, in case they need to step into a leadership role. Also, co-leadership should be promoted whenever possible so that if one of the leaders leaves, there is already another leader who will provide continuity.

As partnerships develop, there may be opportunities to accelerate certain aspects of project design and implementation to meet funding goals (such as obtaining pilot data for new proposal submission) without risking the stability or equality of the partnership. However, careful cross-checking across community and academic leadership and “taking the temperature” of the community members is required.

7. All leaders are committed to achieving the highest standards of productivity, impact and accountability

Neither academic goals nor community values are abandoned. Academic leaders are responsible for maintaining the highest scientific standards. Abandoning such standards would not only imperil the success of the project and the possibility of future funding, it would also deny community members the chance to enhance individual and community capacity. At the same time, rigidity can be fatal to a community engagement project. Academic researchers should be open to the possibility of creative modifications to “business as usual.” Such modifications can change the nature of the project design, often to advantageous effect in terms of achieving a unique impact in the scientific field as well as greater community relevance. Community members are responsible for ensuring that all activities are respectful of, and responsive to, community values, and for suggesting viable alternatives to proposed approaches when they feel such values are in danger of being ignored. Further, community members are responsible for leading the effort to celebrate accomplishments, assure that products are directly relevant to the community, and monitor the overall strength-based framing of the project. Respect for both academic and community values is essential to the project’s success. Over time, respect for both community and academic values may become so ingrained that experienced partners may find themselves switching roles in monitoring each other.

8. Academic leaders are quick to seek help from community leaders in resolving conflicts

Since academic members tend to perceive themselves as experts, they may unconsciously adopt a high-handed or patronizing approach that may be offensive to community members. Community members, appropriately, perceive themselves as experts also – experts in the real-life circumstances of the community. Clashes are almost inevitable until (and even after) mutual appreciation is achieved. However, they can usually be resolved – and, to some extent, avoided – by close coordination and communication between academic and community leaders. Community leaders can often explain the issues underlying a conflict and suggest how best to address them.

9. Academic leaders work to understand community priorities and histories

Communities can have long histories and long memories. Community and academic perceptions may differ radically. For instance, community members may perceive a specific educational or research institution (including, perhaps, the institution supporting the research) as being racially or ethnically biased – and, as a result, may be suspicious of both individual and institutional intentions.

Academic members should become knowledgeable about community history, economic conditions, political structures, demographic trends, and experience with both their institution and prior research efforts. Both before and during the project, academic members should get out into the community. Efforts should be made to establish relationships, build trust, work with the formal and informal leadership, and seek commitment from community organizations and leaders to create processes for mobilizing the community.

Here again, close coordination with community leaders is essential. A community leader can: help make decisions on how to get oriented and involved in the community; facilitate open discussion; initiate and guide community contact efforts; and educate academic members about the project’s historical and social context.

10. Community input is formally recognized

Research results are normally disseminated in peer-reviewed journals and other publications. All such publications should be co-authored by both community and academic members. Academic members can facilitate this process by offering, before writing begins, a seminar on publication processes, procedures and expectations. A system for obtaining input from community co-authors should be agreed upon, which might include (in addition to written drafts) tape recorders, telephone dictation, and other ways to facilitate community input.

Other ways to recognize and honor community members include participation certificates, faculty appointments and office space. Or, the partnership could create a special designation, such as a “community scholar” or “community chair” position (with appropriate funding to cover time for research).

At the same time, it is important to recognize that academic publications may not serve community interests. Equal attention has to be paid to other forms of dissemination that will ensure the appropriate sharing of information with community members. This might involve presentations by community leaders at existing community gatherings, or the publication and dissemination of a community-friendly document or brochure.

11. Academic leaders ensure that their own institutional leadership understands and values the academic-community partnering process

Many of the skills required in a community-academic research partnership are undervalued by academic institutions and may even be seen as a sign of failure. For example, researchers traditionally need to demonstrate that they have “led” projects in order to be considered for promotion. But a community-academic partnership requires joint leadership, along with the flexibility, openness and willingness to compromise that such leadership entails. Another pressure is publication: academic institutions value the lead author role while partnerships value joint authorship.

Nonetheless, community-partnered participatory research is an area of growing academic interest. Academic pressures can be minimized if, before undertaking a community engagement project, academic participants take the time to educate their colleagues and department chairs about community engagement priorities and processes, emphasizing the value to both the community and the institution.

Senior academic leadership is particularly needed to create an appropriate environment for recruitment, advancement and retention of junior academic leaders with strengths in community engagement. For example, senior leaders can advocate or enable attractive recruitment, or explain the value of the work to deans, chairmen or promotional committees.

12. All leaders agree on the standards and tools for evaluating progress and impact

Once project goals are developed, academic and community leaders should agree on how to measure progress toward achieving the goals. The relationship between every project activity and the goal should be clearly understood by every team member. When possible, inputs and outputs should be measurable, and should be reported back to the team as well as to project leaders. Academic and community members should jointly accept responsibility for adhering to rigorous research procedures that serve the scientific and community purposes of the initiative. At the same time, implementing rigorous science within an engaged community partnership implies or requires intensive work to maintain community understanding and input into design and methods. (Figure 2.5)

Fig 2.5.

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