A Case Study on a University-Community Partnership to Eliminate Racial Disparities in Infant Mortality: Effective Strategies and Lessons Learned

Abstract

This case study discusses the implementation framework, effective strategies, and lessons learned of a university-community partnership addressing racial disparities in infant mortality. The partnership was successful at enhancing coordination within service delivery systems for maternal and child health programs. Results: the elimination of waiting list for services, maximizing federal and state reimbursement, the adoption of culturally-appropriate intervention practices, increasing racial diversity in the workforce, diffusing silos, and facilitating healthier relationships among service providers. Key lessons: activating the collective strengths among a network of diverse community stakeholders with shared interests, prioritizing black voices in the change process, and capacity building opportunities.

Introduction

Problem Description

In the United States, historically-disenfranchised racial and ethnic populations continue to experience poor outcomes on key national measures of health such as infant mortality. Nationally and in Wisconsin, black infants [based on race of the mother] are two to three times more likely to die before their first birthday compared to white infants (Mathews, MacDorman, & Thoma, 2015; Wisconsin Department of Health Services, 2015). Infant mortality is a marker of overall health and wellbeing in a community. Lower rates of infant mortality suggest that a community has the protective capacities to facilitate its members in achieving optimal health. Higher rates of infant mortality suggest that social, structural, and environmental safeguards in a community are ineffective at supporting community members to live at their optimal health capacity (Halfon & Hochstein, 2002). Efforts to address infant mortality are increasingly moving beyond health systems alone to focus on collaborative approaches that address health determinants, improve health, and build capacity in communities (Resnick, 2017; Lu et al, 2010).

In 2009, the University of Wisconsin School of Medicine and Public Health (SMPH or the university) established the Lifecourse Initiative for Healthy Families to address racial disparities in infant mortality in the state of Wisconsin. The Lifecourse Initiative is a university-community partnership that works to modify community conditions associated with poor birth outcomes and disparities. The initiative has three goals: (1) improve infant health; (2) support black women and their families; and; (3) eliminate racial disparities in birth outcomes. This case study discusses the implementation framework, effective strategies, and lessons learned of a university-community partnership seeking to eliminate racial disparities in birth outcomes.

Available Knowledge

The literature on university-community partnerships working to address US infant mortality in the black community builds on community based participatory research perspectives and other literature on university outreach to communities. For example, the benefits of community engagement have been documented as a tool for trust-building, understanding indigenous perspectives, conducting community assessment, formulating solutions, and capacity building (Baffour & Chonody, 2009; Holden et al, 2011). Salihu (2011) notes the importance of having significant representation of black voices in the community engagement process, pointing out that black leaders involved in infant mortality reduction efforts should have expertise in maternal and child health and that the change process is enriched by including black leaders cross-generationally, from early career professionals to more experienced professionals. Addressing racial disparities in infant mortality requires an acknowledgment of racism through conversation, challenging academic orientations, and re-directing community members and professionals serving those community members, which can be challenging tasks (Pestronk & Franks, 2003; Willis, McManus, Magallanes, Johnson, & Majnik, 2014). Partnerships engaging black communities on issues that impact black communities require engagement strategies that are grounded in trust, respect and effective communication.

The broader literature on university-community partnerships highlights facilitators of success in a partnership. These include support from university leadership reflected in formal strategic goals; an understanding of organizational capacity; enacting a trust-building process; respecting community voice; promoting community ownership; and ensuring learning opportunities for students (Calleson, Seifer, & Maurana, 2002; Plowfield, Wheeler, &; Raymond, 2005). Mulroy (2008) points out that university-community partnerships that promote evidence-based macro practice include an intent toward social justice, a focus on planning, decision-making and a civic engagement component that involves partnership development and community-oriented participatory research approaches. Developing and sustaining a university-community partnership can be challenging, as the work may require new ways of thinking, new change models and sometimes, new players (Salihu, 2011). Rubin (1998) notes that university partners can support partnership success by participating in community engagement training and receiving coaching assistance when working with communities. Beyond selecting an appropriate engagement approach and improving the skills of university representatives, partnerships that align with interests and goals of the broader university are much more likely to be supported and thrive (Calleson, Seifer & Maurana, 2002).

University-community partnerships are a type of collaboration nested within the broader field of community practice; insights in this field also bare consideration. For example, greater emphasis on cross-sector representation and involving impacted populations has influenced how university-community partnerships engage stakeholders and view their roles. Some university-community partnership efforts are guided by social change strategies with deliberate approaches for improving economic conditions of stakeholders and shifting power dynamics within the community (Fisher, Fabricant & Simmons, 2004). Social change strategies target deep structural barriers and provide stakeholders with information, tools, and skills to become more empowered and transform their own conditions. Examples of this type of efficacy within stakeholders could be realized in greater voting power, re-directing resources, improving economic circumstances or preventing adverse policy decisions. These examples illustrate an increase in community authority. This is noteworthy as university-community partnerships tend to address local issues experienced by populations whom may lack access to resources, be isolated, and removed from decision-making structures. Wolf and Maurana (2001) documented the university-community partnership experience from the perspective of community participants, noting the importance equitable allocation of resources and that sustainable funding is necessary in change processes. To address issues related to power imbalance such as who makes decisions for whom, university partners sometimes rely on community advisory boards to ensure that mutual interests are being served and to garner buy-in from stakeholders to support action or research activities (Norris et al, 2007). As the field of community practice embraces new approaches for change, understanding how such approaches can be applied to university-community partnerships requires further investigation.

Rationale

Notably, there have been isolated examples of success at reducing infant mortality rates among blacks in particular communities such as New York City and Grand Rapids, Michigan, but gains have not been broadly realized in other areas of the US (National Institute for Children’s Health Quality, 2015; Francis, 2016). New strategies are needed to spread and deepen impact. An evolving approach in community practice, such as collective impact, could serve as a model for community change to address racial disparities in infant mortality. Collective impact is a structured approach for mobilizing stakeholders across systems and moving them toward coordinated action to achieve social change (Kania & Kramer, 2011). In a meta-analysis, Anderson et al, (2012) found that collaboration [coalition] strategies could be successfully applied to managing chronic disease and other health issues in clinically relevant and socially meaningful ways within local communities. Guided by developments in the field for addressing complex issues, collaboration and partnerships are now seen as important elements in a community change model for reducing health disparities but more knowledge is needed regarding implementation process and practical experiences with collaborative models. Wisconsin’s effort is ripe for understanding the dynamics of implementing a university-community partnership initiative to address racial disparities in infant mortality.

Aim

In this case study, we share effective practical strategies and lesson learned from Wisconsin’s experience implementing a university-community partnership to eliminate racial disparities infant mortality.

Methods

Context

The Racial and Ethnic Approaches to Community Health (REACH) guided the implementation framework of the Lifecourse Initiative (Tucker, Liao, Giles, & Liburd, 2006; Giles et al, 2010)—the focus of this manuscript. Formation of the Lifecourse Initiative and planning phase activities such as creation of a community coalition, capacity building, problem analysis, and development of an intervention strategy outlined in a Community Action Plan—were previously reported by Frey, Farrell, Cotton, Lathen & Marks (2013). This case study focuses on the Lifecourse Initiative’s experience with the first three stages of REACH’s implementation and evaluation phase from April 1, 2012 to March 31, 2014 (see Figure 1). Stage One addresses capacity building of the community coalition by ensuring readiness of members to take action. Stage Two places emphasis on executing planned targeted actions that can produce change within a population. Stage Three focuses on transforming community and system-level interventions through change among change-agents. At this stage, changes in knowledge, attitudes, beliefs or behavior among subset of the population (“change agents”) are intended to be promoted, spread and adopted by members within the broader population.

Figure 1:

REACH Policy Systems and Environmental Framework for Health Disparity Reduction

Intervention

Prior to formalizing the Lifecourse Initiative, an outreach arm of the university including faculty and public health advocates charged with addressing statewide health disparities gathered input from and convened meetings with stakeholders to identify and prioritize a health disparity issue in Wisconsin. The issue of infant mortality was identified because of its urgency, stakeholder buy-in for the issue, the opportunity to strengthen university relationships with communities, and interests in building university-community capacity. To launch the Lifecourse Initiative, the university provided direct funds via planning grants to support convening agencies in targeted Wisconsin communities to form a collaborative and to develop locally-tailored community action plans (see Figure 2). A needs assessment that included input from black residents was conducted in each target community. The needs assessment informed the development of actions plans. Carrying out recommendations in action plans was the next step in the Lifecourse Initiative. Initial two-year implementation grants covering the period April 1, 2012 to March 31, 2014 were awarded to convening agencies in each community to support the Lifecourse Collaboratives in advancing community-system strategies that addressed identified local needs.

Figure 2:

Lifecourse Initiative Funding Structure for Implementation and Evaluation Phase

Convening agencies were identified by local stakeholders and tasked with supporting the collaborative in their community to reach priorities identified in Community Action Plans. As convening agencies worked to address infant mortality at the systems-level, efforts were also moving forward to meet community needs at the individual level. During this period, the university worked with convening agencies on a process for identifying community-based organizations and local health departments interested in adopting and scaling up evidence based and promising practices that targeted black families. The Lifecourse Initiative’s goal was to launch and support the sustainability of multi-level intervention activities in each community. For example, ensuring the inclusion of fathers in the service delivery continuum and simultaneously working with child support enforcement to reduce system-level barriers that pose challenges for fathers.

Implementation Infrastructure

To support the implementation phase, the university continued to work with a Steering Committee comprised of key black leaders in each community, recruited a program officer [a black professional from the target community], contracted with university staff to assist with evaluation activities and launched a recruitment effort for a maternal and child health faculty leader. A leadership group of five individuals, which included two black professionals, was comprised of three university staff and two members from the university outreach group had responsibility for overseeing the initiative along with support from the Steering Committee. See Figure 3 for an organizational chart. The university released a special funding solicitation to support the work of Lifecourse Collaboratives. Emphasis was placed on funding organizations with an explicit mission to serve racial and ethnic populations and with boards and staff representation that reflected the mission.

Figure 3:

Lifecourse Initiative Organizational Chart

Within the Lifecourse Initiative, there was a growing recognition on the importance of the university having a deeper presence in communities to facilitate effective university-community relations, communication, and understanding local contexts. Closer contact with community partners would support appropriately aligning university resources to help meet the needs of each community. A regional office was established in 2013 to provide one-on-one coaching, technical assistance and consultative services to convening agencies and Lifecourse Collaboratives. The regional office was physically housed in one of the funded communities. Table 1 shows areas of support from the university to build capacity within local communities.

Table 1.

Technical Assistance through the Lifecourse Initiative

Area of Support	Funder	Regional Office/Evaluation Consultants
Grant monitoring and compliance	X
Convening meeting with content experts	X	X
Providing communication tools such as a media kit	X	X
Linking university content experts to communities	X	X
Feedbac k on strategy selection	X	X
Evaluation technical assistance		X
Developing and implementing community needs assessm ents		X
Program planning and development		X
Communication Engagement		X
Sustainability		X
Policy, system s and environmental change		X

Study of the Intervention(s)

To inform this case study, publicly accessible meeting notes from the Lifecourse Initiative Steering Committee were reviewed as well as progress reports and presentations prepared by convening agencies. Summary notes from conversations with black professionals working as part of the Lifecourse Initiative also informed this case study. A key strength of this case study is the illumination of perspectives from black professionals with direct experience in the field implementing and supporting a university-community partnership. These perspectives can offer valuable insights for planning and implementing future university-community partnerships.

Limitations

This paper is a single case study; a reflection on implementation experiences from engaged and motivated persons with experience in the field. We hope that it will be helpful to others in similar situations. In the future, a formal mixed methods study of the Lifecourse Initiative would be beneficial to overcome issues related to convenience sampling, bias, rigor, that may be present in this case study.

Results

During the initial implementation and evaluation phase, across the overall effort, the REACH framework set the tone for the Lifecourse Initiative toward increasing public awareness about the issue of infant mortality, building community buy-in among multi-sectoral partners, and positioning target communities for a coordinated response. Some communities benefited from existing efforts to address the issue of infant mortality and these were integrated, when possible, into Lifecourse Initiative activities. To demonstrate these points, an example of a single community experience is presented.

Community Exemplar

Kenosha, Wisconsin: The Division of Health within the Kenosha County Department of Human Services served as the convening agency. One of the distinct features of the Kenosha Collaborative was the inter-dependence between the public health department and community-based organizations. At the organizational level, some members of the collaborative contracted with the county to perform professional services. Collaborative partners represented 20 organizations across various sectors that consistently participated. Leaders from anchor organizations such as a community health center, community action agency, and a private family foundation representing a legacy of black civic leadership served to guide the development of the collaborative. In 2011, there were 174 black babies born in the City of Kenosha, representing 12% of the total 1,480 births (Wisconsin Interactive Statistics on Health Database, 2017). Given the proportion of black births in Kenosha and interests in expanding the reach of the system to engage more black families, collaborative members pursued a strategy to ensure that black expectant and new mothers and their families had access to services in the pre-and post-natal periods.

REACH Stage One--Capacity Building: A first step toward building capacity of the service delivery system was to convene service providers to explore options for improving access to services for black families. One consequence of partnership meetings was greater openness among service providers for discussing issues related cooperation and competition within the service delivery system. Frank discussions among service providers about turf, organizational mission/strengths, and shared interest in finding solutions for black families had utility in increasing organizational readiness toward collaborative action and eliminating silos.

REACH Stage Two--Targeted Action: Several key questions informed discussions among service providers: what services exist within the system, who is served by the system, what barriers exist within the system that are preventing more families from being served, and what are the opportunities for better coordination within the system. Service providers created a service map to increase their understanding about service availability, accessibility, utilization, and gaps. Several priorities were identified based on the mapping activity: (1) develop a process for connecting families to the appropriate services with respect to eligibility guidelines, (2) eliminate the waiting list for services, and (3) maximize state and federal reimbursement among providers.

REACH Stage Three--System Change: To more effectively work with the black community, there was a growing recognition among service providers that it was imperative to have a presence of black employees within the system at various levels. Efforts were made to recruit, hire and retain black representation in administrative, clinical, and peer-support positions within the health department and at community-based organizations with maternal and child health programs. Additionally, the system augmented the conventional program services by adopting evidence-based strategies specific to black families such as the Effective Black Parenting Program; a group-based intervention that builds parenting skills by addressing cultural issues unique to black families, improving parent-child interaction and preventing child abuse (Myers et al, 1992). A further action was taken to more effectively serve at risk families by implementing the Healthy Families America (HFA) service model, which is a home visiting program that focuses on improving parenting skills and practices (Harding et al, 2008). To ensure that families were aware of these innovative services, a range of community engagement strategies were utilized to bring awareness to the issue of infant mortality and resources in the community to support families. For example, the creation of diaper banks to assist families with limited income by providing health and service information and goods that could be helpful for families with infant children. In addition, a liaison position was created to connect the work of the collaborative to the faith community and promote community events such as resource fairs.

Utilizing REACH to address infant mortality, the Kenosha County Division of Health became more efficacious at enhancing coordination within the local service delivery system for maternal and child health programs. Stakeholders reported that collective efforts by community partners resulted in fewer of waiting lists for services, increased federal and state reimbursements, the adoption of culturally-appropriate practices, greater diversity in the workforce and facilitated healthier inter-agency relationships among service providers. The REACH framework fostered for the Kenosha Collaborative a conceptual understanding of an effective pathway for change in eliminating racial disparities in infant mortality, starting with improvements in the service delivery system. Given the community experiences in Kenosha and across other communities, lessons learned from the Lifecourse Initiative’s university-community partnership experience have been identified and are listed below.

Lessons Learned

Distributed leadership can foster positive and effective partnerships.

Distributed leadership recognizes that both university and community partners have unique and important roles to play in the change process (Harris, Leithwood, Day, Sammons, & Hopkins, 2007). Roles are based on individual or organizational strengths and position of influence. Roles must be acknowledged, understood and realized by all partners. Resources may be needed to assist partners to clarify and grow in their respective roles. Distributed leadership acknowledges that each partner has limitations and a multiplying effect occurs when partner strengths are aligned toward a common goal. The strength of distributed leadership is its assertion of viewing individuals and organizations as contributors and not distractors in the change process. Distributed leadership maintains that partners can be most effective when (1) they know and respect each other and (2) bring resources to the table that can be strategically and synergistically activated to achieve a common goal.

It is critical that the implementation structure support university-community interface and maintain consistency in structure.

A number of stakeholders found the structure of the initiative to be complex, making it difficult to understand themselves and communicate the structure to others. Some partners in both the community and university found it difficult to connect to an existing structure and operate effectively within their role. Changes within the initiative such as transitions in leadership or staff further compounded issues related to structure, roles and continuity as the initiative evolved. Further exacerbating this was the developmental and participatory nature of the initiative. Although stakeholders appreciated providing input, it was unclear exactly how decisions were made, how community input was considered and who had the final decision-making authority. More attention on communicating the structure of the initiative, clarifying roles and discussing the decision-making process is essential. In the future, additional time to formally assess infrastructure needs, determine an appropriate structure to align with the evolution of the initiative, and implement process improvement activities early on could be useful inputs for helping stakeholders understand and adjust to structural changes and develop strategies for course corrections.

Engage black voices and leaders in authentic and meaningful ways and ensure supports are in place for these leaders.

The explicit focus and prioritization of the health status of blacks fostered a sense of cooperation and willingness to engage. However, this work highlighted both the absence of and necessity for including indigenous leadership and diverse black voices at every stage of the process. The inclusion and contributions of black voices and leaders beyond political consideration within the initiative led to a recognition of the need to expand and empower black communities, organizations, and families. Notably, there was an increase in the contributions of black professionals and community residents in spaces of power that had not previously existed in the discourse. For example, the Lifecourse Initiative was intentional in its efforts to organize and engage diverse voices to inform maternal and child health planning committees. Yet, the dynamics of racism and implicit bias created barriers when black voices and leaders sought to operate with increased authority by challenging ways of understanding and conventional problem-solving techniques. Examples of having insufficient representation include meeting spaces not equipped to integrate contributions from community residents, gathering input to temper dissenting voices rather than an appreciation for broad input to enhance decision-making and funding preferences for managing large grants in favor of mainstream organizations that lack diversity over grassroots organizations led by people of color. The need for embracing diverse leadership and re-thinking how culturally different perspectives bring value to strategy development and carrying out action steps is critical. As university community partnerships work to be more inclusive, it is imperative to manage the process and its impact upon black leaders, especially among persons with roles and accountability in both university and community domains. To support meaningful engagement, university-community partnerships can solicit input from black voices at the outset, inquire about needs for establishing a successful partnership, identify how input from diverse black voices guides decision-making, and acknowledge the value of formalized liaison roles.

Honestly assess capacity and readiness to implement strategies.

Partners sometimes overestimated their level of readiness and ability to perform. Unlike the planning phase involving a structured approach for assessment and prioritization, the implementation phase required operationalization of a shared governance model and execution of locally tailored strategies without a pre-designed script. Convening agencies were now tasked with designing logically linked actions, strategies and outcomes to achieve goals identified in their community action plan. Logic model and project work plans were tools for mapping out and delineating implementation strategies and associated tasks and actions. Concerns regarding local capacity were often identified in the proposal review process when logic models and work plans lacked specificity and coherence, but course corrections sometimes were difficult to implement. Future efforts could benefit from the use of formal readiness and capacity assessments throughout the social change and partnership process to ensure early feedback and greater responsiveness to reviewer comments. Similarly, a capacity assessment of the technical assistance provider should be conducted to determine their strengths, areas of development, needs and overall competence.

Utilize a technical assistance approach that is empowering.

To improve performance, technical assistance must be delivered in a way that supports reflection and fosters a culture of learning. Attributes of a technical assistance provider must include effective interpersonal skills to create an environment that encourages mutual exchange. The objective is to stimulate growth and development among those receiving technical assistance. Organizations and professionals working with technical assistance providers must also be open and committed to learning, receiving feedback and applying new skills. Both university and community partners could benefit from coaching assistance to support the expansion of capacity in the areas of partnership development and the design and implementation of health improvement efforts that are community-based and population-focused.

Discussion

Summary and Interpretation

The emphasis on distributed leadership within the Lifecourse Initiative was based on a fundamental belief that opportunities to address racial disparities in infant mortality would be enabled by activating diverse partners and networks within both university and community domains. This approach was consistent with recent population health improvement efforts that draw on the expertise of multi-sectoral partnerships (Roussos & Fawcett, 2010). Addressing the issue of trust in partnership is also an important aspect of developing positive rapport and healthy working relationships, especially with communities of color (Wolff & Maurana, 2001; Plowfield, Wheeler, & Raymond, 2005; Abdulrahim, El Shareef, Alameddine, & Hammad, 2015). Our case study provides one example of a practical approach towards achieving this goal. The intentional focus in this project on improving the health of black communities facilitated engagement of black leaders and voices in meaningful ways throughout the change process. Romero (2016) contends that the value of including those most affected leads to the development of informed and sustainable solutions grounded in the perspectives and experiences of real people who can provide insights on how to address barriers. University-community partnerships require thoughtfulness in planning such as appropriately determining when to partner, how to design the partnership, and intentionally planning for growth of all partners. Schiavo (2015) highlights the importance of in-person discussions between university-community partners for assessing if, when and how to pursue a partnership, also noting that organizations and leaders need skills to effectively partner. Each of these approaches were essential to the Lifecourse initiative.

Racial and Ethnic Approaches to Community Health (REACH) provided an effective framework for a university-community partnership to map out an overall change process to eliminate racial disparities in infant mortality. While partners conceptually understood how collaborations could influence change in communities, there were challenges in implementing strategies such as operationalization of coalition action theory and collective impact models (Butterfoss & Kegler, 2009; Kania & Kramer, 2011). Capacity building as a component of the REACH framework challenged the Lifecourse Initiative to understand the capacity of university and community partners by incorporating a formal assessment into the design and building capacity throughout the change process.

Conclusions

The Lifecourse Initiative called for a new way of university-community problem-solving between the University of Wisconsin School of Medicine and Public Health and communities in southeastern Wisconsin to eliminate racial disparities in birth outcomes. The strong focus on community engagement presented challenges and new opportunities. Using REACH, the initiative successfully mapped out an overall change pathway for eliminating racial disparities in infant mortality and improved local service delivery systems for maternal and child health programs. Next steps for the Lifecourse Initiative include ensuring spread and uptake of current strategies focused on service delivery systems and planning for sustainable long-term change through policy, system and environmental efforts that address root causes of racial disparities in birth outcomes.