From the Journal of Health Care for the Poor and Underserved
23.4, November 2012
Gayenell S. Magwood, PhD, RN
Jeannette O. Andrews, PhD, APRN, BC, FAAN
Jane Zapka, ScD
Melissa J. Cox, MPH
Susan Newman, PhD, RN, CRRN
Gail W. Stuart, PhD, APRN, BC, FAAN
Scholars committed to advancing knowledge development and improving health care
outcomes through practice and research must work in the complex social, political,
and cultural context of health care delivery. Evolving priorities include a renewed
emphasis on prevention and management of chronic illness; elimination of health
disparities; a call for reciprocal translational research models from the bench to the
bedside and community settings and vice versa; and development of novel approaches
for knowledge dissemination. The development and institutionalization of best practices
for community based participatory research (CBPR) are essential. Research agendas
and innovations promoted by both the National Institutes of Health (NIH) Roadmap
initiative1 and NIH commitment to Clinical and Translational Science Award (CTSA)2,3
development increasingly require transdisciplinary and community alliances. Actualizing
and sustaining authentic partnerships pose challenges at multiple levels (i.e.,
individuals, partnership dyads, organizations, and policy).
Previous reports have introduced models and lessons learned.4–7 Building on this work, this Report from the Field describes the evolution of a Center for Community
Health Partnerships (CCHP) at the Medical University of South Carolina (MUSC). The report traces developments and evolving structures and processes in this Center’s journey to institutionalize commitment to community-academic partnerships aimed at ultimately improving the health of our citizens and reducing disparities.
Evolution of the Center. Individual innovators at MUSC and local community organizations began working together decades ago to improve the health of community constituencies. Early on in this process, College of Nursing faculty and individuals from community health centers, schools, faith-based organizations, and other community organizations began collaborating to address health needs in underserved populations.
South Carolina (SC), like other Southeastern U.S. states, has alarming rates of diabetes, obesity, hypertension, cardiovascular disease, infant mortality, and uninsurance.8,9 Notably, racial and ethnic minorities in SC are disproportionately affected by these conditions and experience worse health outcomes and differences in health care quality.8,10
Typically, these early collaborations evolved from individuals in the academic and community settings who had a prior history of working together, perceived each other as credible partners, and shared mutual interests. Community members contributed expertise on the contexts of the health issues and potential real-world solutions, while academic members contributed expertise on evidence-based approaches and evaluation strategies. Over time, these community-academic partnerships became more formalized with memorandum of understandings (MOUs) as funding was received for targeted projects. Many of these initiatives formed formal and informal advisory boards and/or coalitions.11 Key characteristics of some of these initiatives are summarized in Box 1.
Strategic Plan to Build Skill and a Critical Mass
Over time, a critical mass of researchers, clinicians, and community partners, who were dedicated to innovative community-academic partnership models, formed and the need for a concerted systems level approach to partnerships became evident. As part of an explicit Strategic plan, the College of Nursing’s Dean and faculty began work to establish a formal center, the Center for Community Health Partnerships. Infrastructure development included expert consultation with other NIH funded centers; ongoing dialogue with community partners; and a series of capacity-building workshops on research methods and grant-writing. The College of Nursing committed to the hiring of an experienced health services research methodologist and a biostatistician.
A core group met weekly to adapt a research framework building on the lessons learned via early community collaborations. Consensus was reached to integrate common theoretical underpinnings and evidence-based practice.12–15 An ecologic perspective was adopted to guide the CCHP16–18 (see Figure 1) The Center for Community Health Partnership Model (see Figure 1) integrates and adapts the Chronic Care Model19,20 within a social ecological perspective. This perspective reflects the understanding that activity must function within and between many systems levels. CCHP activity reflects interaction of institutional environment (i.e., structures, policies, personnel), along with the community resource systems are vital for the impact on policy and, ultimately, sustainable health outcomes. Details of the CCHP Model are described elsewhere.15,21
Promoting Infrastructure and Institutionalization
During the evolution of an organized CCHP, the core group generated mission and vision statements guided by its model. The College of Nursing provided financial resources for hiring a director, program coordinator, and administrative assistant. In view of the University’s interest in community partnerships and the rich tradition of community-engaged activity in the College of Nursing, the CCHP received formal recognition as a University Center in 2008. Subsequent CTSA funding in 2009 further enhanced the University’s position for broad impact by engaging in activities with the community addressing local and state health issues. The CTSA’s are exemplars of a growing commitment by the NIH to support community engagement’s role in translational research. The collaborative benefits facilitate the development of transdisciplinary and community research teams with unique and complimentary perspectives that create, implement, and translate effective culturally sensitive primary and secondary prevention and treatment interventions in community settings.
Figure 2 presents the fundamental structure, processes and outcomes of the CCHP. As noted, the goal is to activate a community of informed learners committed to the transformation and improvement of health outcomes for disparate communities. The processes targeted to achieve these goals include: 1) strengthening the capacity for existing and potential academic-community partnerships by developing systems-level communication exchange and dissemination mechanisms, identification and sharing of resources, and CBPR training and education; 2) facilitating partnerships that ask the appropriate questions and reach the appropriate people by coordinating and linking partners and resources, and providing partnership training, education, and support; 3) stimulating the discovery, translation, and dissemination of research in community settings with formal mentoring, training programs, interest group formation, and technical assistance; and 4) establishing mechanisms that sustain the progress of community-based initiatives with the institutionalization of processes and products.
To address the goals and enable the processes needed, the CCHP established a structure to organize activity. The structure of the CCHP consists of two advisory boards and five cores (administrative, partnership, mentoring and consultation, research and evaluation, and dissemination). Boxes 2 and 3 describe key roles and responsibilities of the two advisory boards and five cores. Additional information about the CCHP organizational structure and operations can be found at https://sctr.musc.edu/index.php/ce-about-us/organization.
Implications and challenges in moving the CCHP forward. In moving forward and sustaining momentum, the CCHP faced several challenges. A major hurdle involves the implementation of institutional policies that are reflective of community equity in our projects, such as Institutional Review Board (IRB) approval processes for community co-investigators, processes for obtaining community consent prior to implementation of community projects, and equitable funding allocation to our community partners.
As a recipient of the inaugural NIH Partners in Health Award in 2008, the CCHP established internal supportive resources and processes to provide technical support to community partners who receive (or plan to receive) federal funding directly (i.e., build skills for obtaining federal-wide assurances, and negotiating facilities and administrative costs). This seemingly bureaucratic, but critical process required patient discussion and creative strategies between partners.
Other challenges include the facilitation of transdisciplinary buy-in and support, especially in a health sciences university where the majority of research is conducted at the bench or the clinical setting, as compared with the community. Due to tenure and promotion requirements and timelines, some academic colleagues, although interested in CBPR approaches, are concerned about the time commitment required to build community relationships and to develop processes to promote equity in research. Another challenge is to maintain the balance of community interests and needs with feasibility of CCHP resources and faculty time. Community members frequently request assistance from faculty with program evaluation, grant writing, and technical support for existing projects. Faculty often serve multiple roles in research, practice, and education, and lack time to “add on” new unfunded projects that may or may not enhance their academic trajectory and require considerable personal time. Currently, we do have several faculty who support these community requests as volunteer work during evening and weekend hours, yet the capacity to continue and/or expand this
support is limited.
Although we have demonstrated improvement in linking partners together for better coordination and leveraging of their resources, we remain challenged with collecting and maintaining inventories of academic-community partnerships across the campus and community. A goal is to have a systematic database that is generated either by new IRB applications or grant funding that identifies academic-community partnerships.
Community partners work together to collect a community inventory, yet multiple complexities of ownership and scarce resources among local community organizations are all ongoing challenges.
An exciting opportunity to meet several of these challenges is to further refine the integration of the CCHP objectives to align with the CTSA award funded in 2009. The CTSA Community Engagement Core provides resources that will assist with CCHP activities, yet further expands our objectives and expectations. We have obtained initial success, as the CTSA funded our Community Engaged Scholars (CES) Program. The CES aligns objectives of the CCHP and CTSA Community Engagement Core with the mutual goal to increase the capacity of academic-community partnerships to conduct research. The CES is a 12-month fellowship for academic-community teams, with each team having at least one community partner and one academic partner. During the application process, the team develops a MOU and brief proposal describing a priority health issue and their proposed approach to address the issue. Members of the community advisory board (CAB) and scientific advisory board (SAB) review the applications. Six teams were selected during the first year, including inter-professional academic faculty from five of our six colleges and members from nine community organizations. The teams are provided didactic training on CBPR (monthly), mentorship (academic and/or community), and pilot funds for a formative CBPR project. The planned competencies of the teams at the end of one year are to: 1) understand the concepts and components of CBPR; 2) apply CBPR principles in the conduct of research; 3) incorporate CBPR principles and approaches in grant proposals; 4) communicate with audiences in both academic and community settings about CBPR principles and components; and 5) implement a pilot CBPR initiative. A task committee that includes academic and community members as faculty and mentors has developed the CES program. Institutional support has been received with this new innovative program as evidenced by CTSA funding in year one, and additional intramural funds for the next four years.
The immediate challenge now is sustaining and growing the CCHP during a period of significant dwindling resources, tight federal research funding, and increasing pressures on community organizations and leaders. It is clear that the CCHP must continue to be a critical element of the university’s strategic plan into the next decade. Faculty have been recruited and hired based upon their interest and expertise in community health. Student projects and programs are focused on supporting one of the many community-based programs. Clinical practice activities have developed models of care that reflect the work of the CCHP. Transdisciplinary collaborations that build on existing community-based research and have the potential to increase the overall health impact will be explored and sought. Just as academic health centers support the fundamental resources needed for basic and clinical research (e.g. labs, space, supportive structures such as Clinical Trials Office), infrastructure support from the larger university is also needed for community partnerships.
In summary, the Center for Community Health Partnerships has been a proactive initiative from the College of Nursing to address new paradigms and priorities in health care. It has served to focus faculty research and practice initiatives and to provide institutional direction for strategic planning with the goal of impacting the health of our region. As a university designated Center, the CCHP reflects a transdisciplinary approach to research that is consistent with national directions. We will continue to evolve, creating unique opportunities to expand upon existing community alliances and capacity. The potential is high given a key component of MUSC’s strategic plan, that is, to “promote community-campus partnerships in the public and private sector to reduce health disparities through education, research, and practice.”
The authors express their sincere gratitude for the collaboration and contributions of the following people. For contributions to this manuscript we acknowledge the assistance of Janet A. Grossman, PhD, APRN, BC, FAAN. We recognize the groundbreaking work of our community partners, Carolyn M. Jenkins, DrPH, APRN-BC-ADM, FAAN, Marilyn Laken, PhD, RN, Deborah Williamson, DHA, CNM, Brenda Nickerson, MSN, RN, faculty, and advocates in building community partnerships. It is impossible to name all of our community partners, however we do want to acknowledge our sustained leaders including Mrs. Florene Linnen (Georgetown Core Group); Mrs. Virginia Thomas (Charleston Diabetes Coalition); Mrs. Stacey Crawford Jarriel, Alisha Simmons, Juanita Brunson, Tammy McCottry Brown, Christina Hurman (Sister to Sister Project), and Gwen Gillenwater (disAbility Resource Center). Gratitude and admiration are extended to all of our community partners for their efforts. This project was supported by the South Carolina Clinical and Translational Research Institute, Medical University of South Carolina’s CTSA, NIH/NCRR Grant Number UL1RR029882. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or NCRR.
Gayenell Magwood is Associate Professor in the College of Nursing at the Medical University of South Carolina (MUSC). Jeannette Andrews is Professor and Director of the Center for Community Health Partnerships at MUSC. Jane Zapka is Research Professor in the College of Medicine and College of Nursing at MUSC. Melissa Cox is Program Director, Center for Community Health Partnerships. Susan Newman is Assistant Professor in the College of Nursing at MUSC. Gail Stuart is Distinguished Professor and Dean in the College of Nursing at MUSC. Please address correspondence to Gayenell S. Magwood, PhD, RN, Associate Professor; 99 Jonathan Lucas, MSC 160; Charleston, SC 29425-1600; (843) 792-0685; firstname.lastname@example.org.
1. National Institutes of Health. About the NIH roadmap. Bethesda, MD: National Institutes of Health, 2001. Available at: http://commonfund.nih.gov/aboutroadmap.aspx.
2. Zerhouni EA. Translational and clinical science—time for a new vision. N Engl J Med. 2005 Oct;353(15):1621–3.
3. National Center for Advancing Translation Sciences (NCATS). About the CTSA program. Bethesda, MD: National Institutes of Health, 2011. Available at: http://www.ncats.nih.gov/research/cts/ctsa/about/about.html.
4. National Institutes of Health, CTSA Community Engagement Key Function Committee Task Force. Principles of community engagement (2nd ed.). Bethesda, MD: National Institutes of Health, 2011.
5. Boutin-Foster C, Phillips E, Palermo AG, et al. The role of community-academic partnerships: implications for medical education, research, and patient care. Prog Community Health Partnersh. 2008 Spring;2(1):55–60.
6. May M, Law J. CBPR as community health intervention: institutionalizing CBPR within community based organizations. Prog Community Health Partnersh. 2008 Summer;2(2):145–55.
7. Andrews JO, Newman, SD, Meadows O, et al. Partnership readiness for communitybased participatory research. Health Educ Res. 2012 Aug;27(4):555–71. Epub 2010 Sep 13.
8. United Health Foundation. America’s health rankings: a call to action for individuals and their communities (2011 ed.). Minnetonka, MN: United Health Foundation, 2011.
9. Agency for Health Care Research and Quality. Highlights from the national health quality and disparities report. Rockville, MD: Agency for Healthcare Research and Quality, 2010. Available at: http://www.ahrq.gov/qual/qrdr10.htm.
10. Smedley DB, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press, 2003.
11. Newman SD, Andrews JO, Magwood GS, et al. Community advisory boards in community-based participatory research: a synthesis of best processes. Prev Chronic Dis. 2011 May;8(3):A70.
12. Israel BA, Shulz AJ, Parker EA, et al. Critical issues in developing and following community-based participatory principles. In: Minkler M, Wallerstein N, eds. Community-Based Participatory Research (CBPR) for health. San Francisco, CA: Jossey-Bass, 2003; 56–73.
13. Israel BA, Schulz AJ, Parker EA, et al. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202.
14. Israel B, Eng E, Schulz A, et al., eds. Methods in community-based participatory research for health. San Francisco, CA: Jossey-Bass, 2005 Jul; 1–392.
15. Jenkins C, Pope C, Magwood G, et al. Expanding the chronic care framework to improve diabetes management: the REACH case study. Prog Community Health Partnersh. 2010 Spring;4(1):65–79.
16. Bronfenbrenner U. Toward an experimental ecology of human development. Ithaca, NY: Am Psychol. 1977;32:513–30. [Ed: no city needed if this is a journal]
17. Anderson ET, McFarlane J. Community as partner: theory and practice in nursing (4th ed.). Philadelphia, PA: Lippincott, 2006; 169–221.
18. McLaren L, Hawe P. Ecological perspectives in health research. J Epidemiol Community Health. 2005 Jan;59(1):6–14.
19. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998 Aug–Sep;1(1):2–4.
20. Barr VJ, Robinson S, Marin-Link B, et al. The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp Q. 2003;7(1):73–82.
21. The Medical University of South Carolina College of Nursing. Center for Community Health Partnerships model. Charleston, SC: Medical University of South Carolina, 2010. Available at: http://www.musc.edu/nursing/departments/researchoffice/cchpartnerships.htm.