5. Overcoming Competing Priorities and Institutional Differences

From the concepts of community set forth in Chapter 1 it is apparent that universities can be seen as communities that have their own norms, social networks, and functional sectors. How can we resolve the conflicts and misunderstandings that result when the operations and expectations of universities differ from those of their collaborating communities?

A. How do you work with a community when there are competing priorities and different expectations?

Karen Williams, PhD, John M. Cooks, Elizabeth Reifsnider, PhD, Sally B. Coleman

Challenge

A major priority for the University of Texas Medical Branch at Galveston when developing its CTSA proposal was to demonstrate community partnership with a viable, grassroots community-based organization (CBO). One of the coinvestigators listed on the CTSA proposal was a research affiliate of an active CBO, which was composed of persons representing practically every facet of life in the community. While focusing on its own organizational development, this CBO had identified eight community health needs for its focus and implemented two NIH-funded projects (Reifsnider et al., 2010). The CTSA coinvestigator wanted the CBO to be the community partner for the CTSA proposal, and the other CTSA investigators agreed. The brunt of the active work in the community outlined in the CTSA proposal became the CBO’s responsibility. However, although the CTSA work was within the existing scope of work for the community partner, certain invalid assumptions about the type of activities the CBO would do for the CTSA were written into the final version of the grant. Most important, no budget was presented to the CBO that showed support for expected deliverables.

The CBO was unwilling to commit to being a part of the CTSA until the proposal spelled out in detail what it was required to do for the funds. An official meeting took place between selected CBO members and CTSA investigators; after an informal discussion, CBO members gave the university members a letter requesting specific items in return for their participation. A formal response to the letter was not provided by the university partner; instead, the requested changes were inserted into the proposal and a revised draft circulated to community partners with the assumption that it would address their requests. This was not the understanding of the community partners, and this misunderstanding strained future relationships. The CBO felt that it had not received the answers it had requested, and the university coinvestigator believed that revising the proposal addressed the CBO’s requests. The miscommunication persisted for months and resulted in difficulty in establishing the operations of the CTSA once it was funded.

Action Steps

The issue was finally addressed when the university coinvestigator approached the CBO for help in writing another NIH proposal. At that time, it emerged that the CTSA-related issues had never been resolved and that the CBO felt its cooperation was being taken for granted. A meeting was held with the CBO president, another member, and two university researchers who were dues-paying members of the CBO. During this meeting, the misunderstanding was clarified and apologies were offered and accepted. Both the CBO and the university members realized that in a rush to complete grant-writing assignments, shortcuts had been taken that should have been avoided.

Take-Home Messages

• University partners should be clear in responding to written requests from a community for communication about specifics on research collaboration. Communications can be easily misunderstood by well-intentioned individuals. Asking for feedback should be routine practice.
• It is critical for partners to respect and include the input of the community they are trying to serve.
• The lines of communication must remain open until all issues are considered resolved by everyone involved.
• Transparency is always essential for all entities.

Reference

Reifsnider E, Hargraves M, Williams KJ, Cooks J, Hall V. Shaking and rattling: developing a child obesity prevention program using a faith-based community approach. Family and Community Health 2010;33(2):144-151.

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B. How do you overcome differences in financial practices between the academic institution and the community?

Karen Williams, PhD, Sally B. Coleman, John M. Cooks, Elizabeth Reifsnider, PhD

Challenge

Academic research institutions and community organizations often partner on research projects even though they may differ significantly in key ways, including organizational capacity and the types of knowledge considered useful for social problem solving (Williams, 2009). Although evaluation tools exist for assessment of organizational capacity and for setting priorities (Butterfoss, 2007), tools for assessing the “fit” between partnering organizations are scarce. This vignette describes the challenges faced by a CBPR partnership during the preparation and implementation of a joint grant proposal.

In October 2007, NIH announced the NIH Partners in Research Program. Each application was required to represent a partnership between the community and scientific investigators. Upon award, the grants were to be split into two separate but administratively linked awards. A community health coalition and university health science center that had worked together for several years submitted a joint proposal. Preparing the budget for the joint proposal highlighted power imbalances in the community-academic partnership. The university-based investigators’ salaries were large relative to the salary of the community-based PI, which was based on what he earned as an elementary school music teacher. To direct more funds to the community partner, the partnership minimized the university-based investigators’ time on the project and allocated all non-salary research funds to the budget of the community partner. This resulted in a 30% community/70% university split of direct costs. In addition, every dollar of direct cost awarded to the university partner garnered an additional 51 cents, because the university had negotiated a 51% indirect cost rate with NIH. However, the community partner received no indirect cost add-on because it had no negotiated rate with NIH. The irony in allocating program funding to the community partner was that this sharing gave the community partner more administrative work to do, even though the partner received no support from indirect costs.

A second challenge arose that highlighted the difference in expectations between university and community partners. The grant required that community workers facilitate discussion groups. To accomplish this, the community portion of the budget had to pay to train community workers and trainees as well as cover costs such as meeting rooms, food, and materials. Inevitably, the community’s small pool of funds was exhausted, and some university funds were required. Getting community researchers and research expenses paid by the university took a month or longer. University faculty are accustomed to lengthy delays in reimbursement, but community members expect prompt payments. Both the community-based and university-based PIs were put in the uncomfortable position of having to continually ask those waiting for payment to be patient. Documentation procedures were not as extensive and wait times were shorter when community research funds flowed through the community organization.

Action Steps

It would have been administratively easier for the university partner to pay the community partner on a subcontract. However, this arrangement was prohibited by NIH because the purpose of the Partners in Research grant was to establish an equal partnership. In future CBPR projects, the community partner may consider subcontracting as a way to decrease administrative burden, even if it decreases control over research funds. Also, the university-based PI should have more thoroughly investigated the procedures for university payments, alerted community members to the extended wait times for payments, and advocated for streamlined procedures with university administration and accounting.

Take-Home Messages

• “Splitting budgets in half” is too blunt a tool for the delicate work of building equal partnerships. Exploring more nuanced mechanisms to balance power between community and academic partners is critical.
• Make no assumptions about the capabilities of the institution (university or CBO) or how it functions.
• University and CBO partners need to come to agreement on all processes and timetables that might be involved.
• Foster open communication with those affected to maintain organizational and personal credibility.

References

Butterfoss FD. Coalitions and partnerships in community health. San Francisco: Jossey-Bass; 2007.

Williams KJ, Gail BP, Shapiro-Mendoza CK, Reisz I, Peranteau J. Modeling the principles of community-based participatory research in a community health assessment conducted by a health foundation. Health Promotion Practice 2009;10(1):67-75.

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C. How do you harness the power and knowledge of multiple academic medical institutions and community partners?

Carolyn Leung Rubin, EdD, MA, Doug Brugge, PhD, MS, Jocelyn Chu, ScD, MPH, Karen Hacker, MD, MPH, Jennifer Opp, Alex Pirie, Linda Sprague Martinez, MA, Laurel Leslie, MD, MPH

Challenge

In some cases, several CTSA sites are clustered in a small geographic area and thus may be well suited to demonstrating how institutions can overcome competitive differences and work together for the good of their mutual communities. In the Boston metropolitan area, three CTSA sites, Tufts University, Harvard University, and Boston University, prioritized working with each other and with community partners.

Action Steps

To facilitate their collaboration, the three sites took advantage of the CTSA pro-gram’s Community Engagement Consultative Service, bringing two consultants to Boston to share insights about forming institutional partnerships in an urban area. Bernadette Boden-Albala from Columbia University in New York City and Jen Kauper-Brown from Northwestern University in Evanston, Illinois, visited Boston on separate occasions and shared their experiences in bringing together CTSA sites and community partners in their areas.

These visits helped to facilitate conversation among the three CTSAs about how to work together for the mutual benefit of the community. At the same time, the CTSAs each were having conversations with their community partners about the need to build capacity for research in the community. When a funding opportunity arose through the American Recovery and Reinvestment Act of 2009, the three CTSAs, along with two critical community partners, the Center for Community Health Education Research and Services and the Immigrant Services Providers Group/Health, decided to collaboratively develop a training program to build research capacity.

Of the 35 organizations that applied for the first round of funding, 10 were selected in January 2010 to make up the first cohort of community research fellows. These fellows underwent a five-month training course that included such topics as policy, ethics, research design, the formulation of questions, and methods. The community organizations represented in the training varied in size, geographic location, and the types of “communities” served (e.g., disease-specific advocacy organizations, immigration groups, and public housing advocacy groups specific to certain geographic boundaries). The program used a “community-centered” approach in its design, feedback about each session was rapidly cycled back into future sessions, and learning was shared between community and academic researchers. The first cohort concluded its work in 2010. Outcomes and insights from the project will feed the next round of training.

Although the CTSA sites in the Boston area were already committed to working together, bringing in consultants with experience in working across academic institutions helped them think through a process and learn from other regions’ experiences. The consultants affirmed that, by working together, academic medical centers can better serve the needs of their mutual community rather than the individual needs of the institutions. This was echoed by participants in the capacity-building program described above. One clear response from participants was their appreciation that the three academic institutions partnered to work with communities rather than splintering their efforts and asking community groups to align with one institution or another.

Take-Home Messages

• Research training programs need to model multidirectional knowledge exchange; the knowledge of community members must be valued and embedded into the curriculum alongside academic knowledge.
• Transparency, honesty, and sharing of resources (fiscal and human) among academic institutions and community groups are crucial to building trust.
• Academic institutions can and should work together on the common mission of serving their communities. Outside consultants can help facilitate multi-institutional collaboration.

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