Schools, Especially Those in Large Urban Districts, Have Multiple Levels of Administration, Which Require Multiple Levels of “Buy-In”
Researchers should be cautious in assuming that they have broad community input or support unless they have comprehensively explored multiple stakeholder layers, which are sometimes only evident by continually revisiting and re-engaging partners. The research team engaged partners at different vertical levels of administration, from the central district (e.g., assistant superintendent, Board of Education) to the local school (e.g., principal, cafeteria manager, teachers). The research team also engaged distinct horizontal stakeholder categories, each representing a different parallel arm (or division) of the organizational structure (e.g., Student Health and Human Services; Business Services Division, which contains the FSB).
To reach these vertical and horizontal stakeholders, we used a snowball process of asking for input about others who should be involved with intervention development. Inclusion of multiple categories of stakeholders led to both broad and deep insights. It was essential to use community members’ personal and working relationships to open doors and “pave the way” to reaching key stakeholders. We also had an “open-door policy” for CAB attendees, such that members could feel comfortable inviting other key people to meetings.
Multiple horizontal and vertical stakeholders needed to be engaged for the intervention evaluation. For example, FSB administrators at the central and local district levels approved of our request to obtain and copy school cafeteria sales records. However, their approval was contingent on cafeteria managers’ allowing records to be removed from the cafeteria for copying, and some managers did not feel comfortable with such procedures. Further, although we had approval from LAUSD’s institutional review board to collect student fitness data with parental consent, we had to navigate though the local school and back to the central district (Planning, Assessment and Research Division) to retrieve the data. Schools may not have the capacity to transfer such data and they cannot release data without guarantees that the appropriate permissions, consents, and data sharing agreements are in place. Hence, there is an essential need for engagement, buy-in, and understanding related to the project at multiple levels.
Communities, Just like Large Organizations, Have Multiple Levels of Stakeholders With Distinct Power Differentials, Requiring Cultivation of Separate Partnerships for Each Stakeholder Type
The need for three CABs arose out of distinct strengths of different stakeholder groups. Because the CCAB was already established and served a broad advisory function for several Center projects, it was uniquely positioned to guide project formulation, beginning at the proposal stage. Because the CCAB drew membership from the local community, it was invaluable in devising an intervention responsive to community needs and priorities.
The HLAB was composed primarily of higher level administrators in LAUSD and other county- and state-wide organizations focused on decreasing adolescent obesity. The HLAB could provide a broader and long-term outlook of addressing obesity both within and outside of LAUSD, and focused the study on solutions that would be sustainable and acceptable within the policy context. The HLAB’s larger picture perspective was complementary to the local perspective of the CCAB.
In working with the YCAB, it was important to understand the power differentials between youth and adults; youth may be reluctant to participate in an advisory board dominated by adults or persons with power in their school or community. Thus, we selected a relatively young YCAB facilitator (a graduate student) who was not connected with the school district; the facilitator was able to engage youth and maximize their creative input while building their capacity to look critically at health and community issues. To provide a forum for YCAB input in the face of real and perceived power differentials, the YCAB was engaged in a Photovoice project before the start of this research. Photovoice methodology is a CBPR tool for identifying health-related concerns in a community by giving voice through photographs to people who often are not heard.14
In their Teen Photovoice Project
, YCAB members used photographs to design posters about the availability of unhealthy foods in their schools and neighborhoods, a topic that they selected.15
Their insights provided one impetus for the current research.
Although the meetings of the three CABs often had similar agendas and content, the discussion and facilitation were geared to maximize each CAB’s strength. Although the CCAB’s strength was in its knowledge and understanding of the local landscape, HLAB members were recruited after the inception of the project to advise on obesity prevention from a county, state, and national perspective. YCAB members provided insight about adolescents, the primary recipients of the intervention. When the preliminary results of the pilot project were presented to each CAB, the CCAB suggested greater parent involvement and worked actively with project leadership to connect with parents; and the YCAB focused on alternative marketing strategies that are effective with youth (e.g., social networking, video). The HLAB suggested state policy changes that could support LAUSD’s obesity prevention initiatives, including working with the leadership team to help a California State Assembly member introduce a bill focused on improving school water availability.
Implementation of a Sustainable CBPR Intervention Requires Common Vision and Shared Priorities Among All Partners
The goal of the project was to develop and test an intervention that was feasible for school staff to implement on their own, cost effective, consistent with district and school priorities, and that LAUSD would ultimately choose to sustain. In the spirit of CBPR, the intervention was not designed to be a stand-alone program that an external entity would conduct in a school; the intervention required school resources and staff and needed to be integrated into the school’s daily working environment. Thus, it was essential that all partners were committed to program success and that school staff, especially in the cafeteria, were motivated to increase their daily workload to implement a program that they believed would ultimately improve students’ eating habits and health. For example, the intervention required that cafeteria staff offer cut fruit to students every day for a 5-week period, because the needs assessment indicated that students were less willing to eat (and more likely to discard) whole fruit. However, the intervention school cafeteria was understaffed, and the slicing of fruit would take staff an extra hour daily. Nevertheless, the pilot intervention showed great effects on fruit servings, and the cafeteria staff, who witnessed the power of the changes, decided to continue the program, even after the 5-week intervention period.
To Influence Policy Change, It Is Important to Understand Schools’ Political and Policy Environments
School districts often use policies or regulations to change school-level practices or environments. However, policy change does not always translate into practice. We found existing federal regulations and LAUSD policies that were consistent with project goals. Sometimes, community members were unaware of such policies or misinterpreted them; sometimes they were aware, but lacked the means, resources, or leadership to implement them. For example, when we attempted to offer free water with school lunches as part of our intervention, we found misunderstandings about whether this intervention component was in accord with federal, state, and district policies. Some stakeholders inaccurately believed that school beverage contracts prohibit serving free water in cafeterias, or that United States Department of Agriculture regulations forbid schools from serving water in cafeterias. Our clarification to constituents about current policy (and correction of misconceptions) allowed us to pilot test the provision of free water in the cafeteria as one strategy to address obesity in schools.
Translation of policy into practice requires understanding the community and working with community members who are directly affected by practice change. Our project complemented the policies of the LAUSD Board of Education, as well as the California state legislature, by aligning the intervention with district and statewide goals for obesity prevention. Interventions aligned with current policies (as opposed to inconsistent programs or programs that attempt to change policy themselves) may have a better chance of successful implementation.
Capacity Building as an Outcome of CBPR Applies to Both Community and Academic Partners
When working with academic researchers on a project, communities often receive direct and indirect services, including critical knowledge to build research expertise (e.g., research methodology, grant writing). Capacity building can also take the form of helping communities to overcome up-front costs or “one-time” hurdles that can prevent policy change. For example, the design of cafeteria signs and marketing materials enabled cafeteria staff to serve food more efficiently and comply with policies about posting point-of-sale nutritional information. Although the research project incurred up-front costs, the materials were still being used in the school cafeteria more than a year after pilot testing.
Capacity building enables community members to readjust roles and responsibilities to implement policy. For example, FSB staff members were willing to take on additional responsibilities to enact policy change once they received training and resources. Such capacity building can lead to long-term practice changes, as new roles and responsibilities become ingrained in organizational culture.
Less attention is traditionally dedicated to capacity building among academic partners. In the present project, academic partners experienced significant capacity building, in terms of gaining knowledge in implementing CBPR methods; obtaining opportunities for community-based training among health services researchers, fellows, residents, and students; and building platforms on which to conduct other research projects aligned with community needs.