The objective of this qualitative study was to determine the critical factors that facilitate the development, effectiveness, and sustainability of community—academic partnerships from the perspectives of the community partners. Many social, economic, and political factors have contributed to an increased emphasis on community outreach by academic health centers (AHCs). Decreases in clinical revenue due to increased managed care systems, increases in competition for research funding, and changes in graduate medical education subsidies have placed the traditional missions of AHCs at risk.1,2 Simultaneously, federal, state, and private funders are demanding greater institutional accountability. Blumenthal and Meyer have noted that the transformation of health care markets has influenced AHCs to reexamine and reestablish their community and societal connections.1 Also, as social, economic, and health problems in our communities have escalated in recent years, AHCs and universities have been challenged to refocus their efforts from the generation of specialized knowledge to the application of their expertise to address social problems.3 White and Connelly4 and Schroeder et al.5 question whether academic institutions improve the health of the public and whether their social missions reach underserved populations. Some AHCs have responded by implementing more community outreach activities to prepare students to be responsive practitioners in their communities and to fulfill their institutions' social missions.
Despite structural barriers in academic institutions to establishing and sustaining community—academic partnerships, interest in their development has increased. A 1996 study examining available structures for service found that 15 of the 31 universities sampled had recently formed task forces or councils to examine their outreach participation.6
In addition, several studies have reported on the factors that facilitate or hinder effective community—academic partnerships from the AHCs' perspective. Maurana and Goldenberg7 state that leadership, partnership, and empowerment are essential components for building effective community—academic partnerships. Leadership must formulate a common mission, and build trust and consensus; partnership fosters teamwork, communication, and resource sharing; and empowerment focuses on individuals' and institutions' strengths and fosters self-determination.7 However, in order to understand these partnerships and assess the factors that facilitate or hinder effectiveness and sustainability, it is essential to obtain the perceptions of community members who have participated in community—academic partnerships. These community members possess critical experience and knowledge that are needed to inform the future development of community—academic partnerships. We sought the input of community members in order to understand their perspectives on community—academic partnerships.
For this study, we interviewed 25 community partners representing eight community—academic partnerships at five AHCs. The sample of five AHCs for this study was selected from a previous survey conducted by one of the co-authors (CM) that assessed perceptions of academic institutions about community—academic partnerships. The three selection criteria for inclusion in the original study were: (1) AHCs that had participated in federal and foundation grants that had a significant community-based component (e.g., Area Health Education Center grants or W. K. Kellogg Foundation Community Partnership grants), (2) AHC medical schools that had received the Association of American Medical Colleges' community service award, and (3) AHCs that had developed university-wide structures (i.e., centers, offices, or task forces) for coordinating partnership initiatives with communities. The findings of that survey were reported in an unpublished dissertation.6
To identify partnerships and participating community members, we telephoned the faculty or administrative contact persons who had completed the original survey, explained the inclusion criteria, and asked them to recommend partnerships from among those that had been reported on their surveys that we could request to participate in our study. The selection criteria for inclusion of the partnership in the present study were (1) evidence of a defined organizational structure and governance relationship, (2) operational for at least two years, (3) high and varied levels of academic involvement, (4) extensive and varied levels of community involvement, and (5) visibility. We contacted the primary academic person involved with the partnership (if this was a different person than the primary contact), received his or her consent to speak with the community partners, and asked that the person inform the community partners that we would be requesting an interview. We then contacted the community partner, explained the study, and scheduled the interview.
We developed interview questions with input from community and academic representatives of community—academic partnerships. Between June 1998 and April 1999, we conducted 23 in-person interviews involving eight partnerships at community sites and two interviews by telephone. Each interview was scheduled at a time and place that was convenient for the interviewee, and we provided copies of the questions to interviewees before the interview. Respondents were guaranteed confidentiality and assured that any report of findings would be generic and not attributed to specific individuals, communities, partnership projects, or academic institutions. The interview consisted of a series of open-ended questions and was tape-recorded if the respondent agreed. If the respondent did not agree to be tape-recorded, the interviewer took notes and dictated the responses as close to verbatim as possible immediately following the interview. Only three respondents requested that they not be tape-recorded. The interview guide focused on (1) factors that have helped and/or hindered the development and effectiveness of the community—academic partnership, (2) organizational structures of the partnerships, (3) outcomes of the partnerships, (4) funding and sustainability of the partnerships, and (5) future challenges for the community—academic partnerships (see the Appendix).
After reviewing the interview data, we determined that three of the partnerships did not meet our selection criteria and excluded those interviews from the analysis. Therefore, our analysis involved 17 interviews representing five partnerships at five AHCs.
The transcribed interview notes were entered into a qualitative-analysis software program. We performed content analysis8 of the data in which the data were read several times and apparent themes and patterns were identified and named in a process of open coding. Open coding involved closely examining the data, breaking them down into discrete categories, comparing similarities and differences, and asking questions about the phenomena we were investigating.9 Using a systematic, inductive identification of themes and patterns in the interview data, we categorized the primary patterns of ideas and concepts that emerged from the data.10
Nine major factors that community respondents thought strongly influenced the effectiveness of community—academic partnerships emerged from the data analysis: (1) creation and nurturing of trust; (2) respect for a community's knowledge; (3) community-defined and prioritized needs and goals; (4) mutual division of roles and responsibilities; (5) continuous flexibility, compromise, and feedback; (6) strengthening of community capacity; (7) joint and equitable allocation of resources; (8) sustainability and community ownership; and, (9) insufficient funding periods. These themes were discussed in varying ways by all the respondents.
Creation and Nurturing of Trust
We had had students come into our community before and do case studies and projects and the community had really gotten fed up with this because a lot of times, you raise the hopes of folks and then after you get your information, the community never sees you again and people wonder, “I thought they were going to help us and that never happened.” So the community was really disillusioned with the university.
Respondents indicated that one of the most significant obstacles to communities' working with AHCs was the communities' lack of trust in the universities. Respondents from a given community did not assume that they would be treated fairly and actually benefit from the relationship with the AHC, and respondents stated that they did not think the university would necessarily act in the best interest of the community. Many community respondents indicated that a baseline level of trust had been lacking prior to developing the community—academic partnership. Community respondents reported that prior to the partnership and during the initial stages of the partnership, trust had been nonexistent, because they had never had a relationship with or had had negative past experiences with the AHC. A respondent captured this opinion when he stated that the past relationship between the community and the university was “null and void.” Community respondents reported that prior to the AHC partnership, they had thought of the university as “that place up the road,” a “place that had a sports team,” or a “place their children might go to school.” These community respondents had had no or very few experiences actually working with the university or the AHC on shared objectives to improve conditions in their community. One community respondent reported that any benefit the community had reaped in the past had primarily been a “trickle down effect with very little trickling down.” Community respondents described their relationship with the AHC before the partnership as having been fraught with tension and negative perceptions. Some of the mistrust was due to racial differences. One African American respondent stated that black people had no reason to automatically trust white people who came into the community. Another spoke about the community's negative reaction to having white people from the university come into an African American community with a “great white hope” attitude.
These community respondents thought that establishing and building trust was the first and most essential priority in the beginning of a community—academic partnership. They stated that developing trust was critical, but that it was also a long, slow, and sometimes arduous process. When community and AHC partners began to work together, community members did not make any assumptions about the trust level among the participants. Community members took a skeptical approach, waiting to see how the AHC behaved. When the partnership involved an AHC from a primarily white university and a predominantly nonwhite community, several respondents commented that it was very important to maintain a dialogue about racism and not shy away from the issue.
Community members also stated that the only way for the AHC partner to build trust was through substantive activities that demonstrated to the community sincerity and a willingness to work with the community on projects. Further, respondents stated that AHCs particularly and universities in general had to be prepared to come into the communities to work, spend time, and slowly build trust over a period of time. The community respondents stated that only when they saw the AHC partners willing to work with the community and not just collecting information and “pick[ing] people's brains” in order to publish papers would the level of trust increase.
However, even after a certain level of trust between the community and the AHC had been achieved, it remained extremely fragile, and the AHC needed to continually work to sustain the trust it had earned.
Respect for a Community's Knowledge
There is not a recognition of what the community can actually provide in the educational setting. The university does not work with community about what the learning objectives should be for a student and let the community evaluate the student's performance. Its very difficult to move the academic partner from seeing itself as the expert … very difficult for it to share its teaching job with the community.
Community respondents articulated a strong conviction that if community—academic partnerships were to succeed, recognition and respect for their knowledge and experience was essential. Respondents stated that it was often a challenge to convince AHCs that community members and organizations had areas of expertise and strength that could be tapped. They stated that AHC partners tended to see themselves as the “expert” and underestimate the community's knowledge about issues and needs. Since academic institutions are designated centers of intellectual activity and knowledge, it is not surprising that this issue surfaced. Respondents from the communities acknowledged that the AHCs had definite areas of specialized knowledge, but the respondents perceived themselves also to have unique knowledge about their community that academic partners often failed to take into account.
Community respondents also expressed the opinion that the knowledge academic partners possessed and presented to the community was not always applicable, and that it was from a distant, theoretical perspective. One community respondent explained,
Theories are wonderful but oftentimes they don't relate to anything that's real out here. And the university doesn't seem to recognize this and when it comes out and finds that the community isn't responding favorably to the theory because it doesn't make any sense, the university gets offended.
Community-defined and -prioritized Needs and Goals
You have to let the people decide what the issues are and what should be addressed. Now I know a doctor who wants to go out in the community but he thinks he already has figured out what the community needs to do. He means well but it's never going to work. He hasn't even thought that what he thinks may not even be on their agenda.
The community respondents thought that the goals of community—academic partnerships should evolve from the community's own definition of its needs and priorities instead of from the university's unilaterally defining goals for the community. Respondents stated that even programs with good potential would fail if the community had not agreed that the programs should be implemented. The community's and the AHC's objectives were not always in agreement. According to the community respondents, those partnerships that took the time to arrive at a consensus about a project's goals based on equal input from the community and the AHC were much more likely to be effective. Community respondents' experiences with and investment in their particular community was perceived to be invaluable in determining the partnership's goals.
Several respondents thought that the community should be a “more equal” partner in community—academic partnerships, and they perceived the AHC to be the invited guest in the partnership. The process of goal setting involved careful negotiation in these communities. In one community the member stated that the AHC had come to the community with a preconceived notion that it needed to help reduce the incidence of chronic diseases. After the community became involved, however, the goals changed to increasing the police presence to reduce violence and drug use and developing recreational activities for families.
Mutual Division of Roles and Responsibilities
I think it has become more democratic over time. One of the things we fought for was to get everybody at the table meeting on a regular basis. So now at the beginning of the meeting we discuss all the issues and everyone has input into the decision-making process.
Community respondents thought that effective partnerships had to involve all key participants in the decisions about how roles and responsibilities were divided. When disagreement occurred, the partners discussed the issue and attempted to resolve it. Some partnerships dealt with this issue of power sharing and leadership by alternating roles and responsibilities between the academic and community partners.
Together we decided the first year it would be an agency person as chair then the second year would be a community person. Then we decided to have co-chairs and the community person would take the lead.
In another AHC—community partnership, respondents from the community thought the participating health professions students should function as tutors but not as the primary role models for a community of African American teenagers. In this partnership, the community partners recruited African American men from the community to serve as role models with whom the adolescents could identify more easily.
Continuous Flexibility, Compromise, and Feedback
Well, I think once we left our egos at the door it worked better. In the beginning it was really hard because there was a lot of ‘turfism.’ I mean like, ‘This is mine and I want to keep it.’ People didn't want to share so there were a lot of battles and things were at a standstill for a while.
Community respondents stated that community—academic partnerships worked most effectively when all issues were potentially open for negotiation. Decisions could not be made unilaterally, arbitrarily, or without discussion, input, and consensus from both the community and the AHC. This often required struggling with difficult or challenging issues until an acceptable and agreeable resolution could be reached. This can be a difficult process for any group, but it was particularly difficult for many communities and AHCs that lacked past experiences working together on projects. In many ways these partnerships were developing the framework for collaboration as they progressed. This was also a time-consuming process, and programs could not be implemented before these issues were resolved.
Interviewees reported that issues of power, authority, control, decision making, and accountability all had to be discussed, debated, and mutually resolved. Compromise required that participants be candid about their concerns, be willing to talk through problems, allow for input from all participants, and be open to innovative solutions. In one case a community respondent discussed a situation in which the community was experiencing problems with an AHC representative. The community requested that the AHC collaborate with the community to resolve this issue, but the issue was not resolved and the community partner elected to withdraw from the partnership until the AHC and community could come to an acceptable solution.
Strengthening of Community Capacity
Most of the communities wanted to be able to organize within themselves but they didn't have training and they didn't have anyone who had done that before to actually help them. So this partnership project provided not just a mechanism of just providing you help, but actually training you about how to solve your own problems so that even when the project was over and the organizations had to pull out, the community would be left with the leadership ability to take care of their own problems.
The community respondents articulated the opinion that an integral part of any community—academic partnership was the AHC's assistance with developing and strengthening the community's leadership and organizing skills so that, if and when the partnership ended, the community would be able to continue to improve itself. Several respondents stated that the AHCs should more strongly emphasize this component rather than a model of delivering services to the community. Although the community respondents were very positive about bringing health care services into the community, they thought increasing empowerment of the community should also be a goal of the partnership.
Several respondents commented that their partnership had as its goal building leadership capacity within the community. These partnerships not only helped the community to identify the problems they wanted to address, they also provided the community with the training and support that would allow the community to actually solve its own problems. Some of this training focused on providing people with the knowledge and skills to access the available organizational, governmental, and political resources to solve problems. One community respondent explained:
The training that they did with the communities is what really made the whole thing work … I did not know that you can empower people the way that training empowered me as a community leader. This is what really brought the community alive because we really didn't know how to solve the problems that were in the community. They taught us how to deal with agencies. They told us how to figure out who to see for what particular problem.
These comments reflect the community's perspective that an AHC that solely provides services does not necessarily contribute to community empowerment. Strengthening and supporting the leadership that already exists in communities, however, has a greater long-term impact on a community's well-being.
Joint and Equitable Allocation of Resources
One of the challenges and negative points about this particular initiative that I wish would have been different, that I rate very low, is the amount of dollars that actually made it into the community you were working in. And then the red tape that the community had to go through to get those minimal and minute dollars.
All of the community partners voiced concern about the amount of financial resources necessary to carry out effective community-academic partnerships. Respondents stated that the budget was often determined when a grant application was written and the community-based organizations and the AHC submitted their budget projections for participation in the partnership. One of the respondents explained that, because relying on volunteers was not a viable solution, obtaining money for the programmatic and operational components of such partnerships was a challenge. The community partners' responses reflected different opinions about how money was allocated. Three partnerships did not think the money was allocated equitably between the community and the AHC, partially due to insufficient money and restrictions from the funders about how the money could be distributed. One respondent stated that money had been distributed to the AHC, then to other government agencies, and last to the community, with the result that very little money actually came to the community. Community respondents stated that the money they did receive provided only for refreshments for meetings and conference fees.
Even in partnerships where many positive things were occurring, the issue of money was controversial and had a negative impact on the quality of the partnership. One respondent stated:
The university got a large chunk of money because it served as the fiscal agent … it was just so saddening to see funders give hundreds of thousands of dollars to different grantees and then $3,000 gets to the community. You can't really expect to have true community change when the element of empowerment particularly from a monetary perspective never gets to the community for anything to be done. And you can't beat people over the head to come to meetings and say we used this money to help you.
Respondents thought that communities needed to be written into grant budgets at a much higher level, and that they should be able to request salaries for key positions such as community organizers, program coordinators, and administrative staff. They also stated that money was needed for community mobilization.
Sustainability and Community Ownership
I think we've been somewhat effective in the sense of mobilizing the bulk of the community around the issues. We were effective in training four or five leaders but not as effective in getting the whole community on board for an extended period of time. I think we should have concentrated more on mobilizing the entire community around its leaders.
Community respondents stated that the potential for sustaining the partnership projects depended on several factors. One key factor was a sense of community ownership of the project and the AHC's commitment to continued participation. A second factor for several partnerships was sustaining community leadership and community involvement. A third factor that community members discussed was the need to build relationships with other local organizations that could assist in the continuation of the project after the AHC partnership ended. Several respondents stated that they had considered what they would do if funding for their project was terminated. They were committed to sustaining the project despite the termination of funding.
However, the most critical factor facing community—academic partnerships identified by the community members was the need to obtain additional funding to carry out the projects. Several of the AHC—community partnerships had been successful in obtaining funding from other sources, while others had not yet attempted to secure additional funding. Sometimes communities secured the funding on their own. One respondent spoke about looking for a generous funding agency so that they could continue the operational component of their partnership:
The universities need to make sure there is something tangible left even if they have to pull out because the money has run out. Can these partnerships continue or can they even develop to the point where they can be trained to apply for grants?
Insufficient Funding Periods
I think the fact that hinders partnerships is that the period of funding was too short. By the time the project was really in the throes of understanding what it needed to do in the partnership, relationships were developing and we had to refocus our energies to how we survived rather than how do we continue to foster what we're doing.
Respondents were vocal about the difficulty of effecting real change in their communities during the brief period their partnerships were funded by most granting agencies. Community members spoke about the time required to establish trust, build relationships, determine goals, and obtain community buy-in, and the frustration of trying to accomplish these objectives in such a brief time period.
The funders give you a short period of time to do something and then the money's gone. You can't go snap your finger and get stuff rolling right away. You've got to work on those basic components of getting the community to accept, respect, and participate. That takes time. By the time you get it running good the money's gone so now you're struggling … you're just getting the people to trust you and now you're saying, ‘Oh by the way, it looks like we may not be here’ and community doesn't really understand that.
The communities' concerns about insufficient funding periods were perceived to be a significant issue that undermined the success of partnerships. Because of this particular concern among community members, sustainability, institutionalization, and alternate funding needed to be considered from the very beginning of the project, and it was helpful that both community and AHC participants commit to a long-term relationship regardless of funding.
The perceptions and experiences of the community partners in community—academic partnerships are critical to inform the further development and evolution of these partnerships. This study was an initial attempt to assess the community perspectives at five AHCs. The findings suggest that community members have many significant observations to share regarding their work with AHCs. If we are to continue to develop community—academic partnerships that are truly partnerships of equals, the observations of community members need to be heeded. Further research in this area, including a comparison of community and AHC perspectives, is clearly warranted to broaden and deepen our understanding of the dynamics of effective community—academic partnerships.