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To conduct a process evaluation of the Restoration Center Los Angeles, a community-academic partnered planning effort aimed at holistically addressing the unmet mental health needs of the Los Angeles African American community.
Semi-structured interviews with open-ended questions on key domains of partnership effectiveness were conducted with a random stratified sample of participants varying by level of involvement.
Eleven partners representing grassroots community agencies, faith-based organizations, service providers, and academic institutions.
Common themes identified by an evaluation consultant and partners relating to partnership effectiveness, perceived benefits and costs, and future expectations.
Findings underscore the importance of considering the potential issues that may arise with the increasing diversity of partners and perspectives. Many of the challenges and facilitating factors that arise in academic-community partnerships were similarly experienced between the diverse set of community partners. Challenges that affected partnership development between community-to-community partners included differences in expectations regarding the final goal of the project, trust-building, and the distribution of funds. Despite such challenges, partners were able to jointly develop a final set of recommendations for the creation of restoration centers, which was viewed as a major accomplishment.
Limited guidance exists on how to navigate differences that arise between community members who have shared identities on some dimensions (eg, African American ethnicity, Los Angeles residence) but divergent identities on other dimensions (eg, formal church affiliation). With increasing diversity of community representation careful attention needs to be dedicated to not only the development of academic-community partnerships but also community-community partnerships.
Community-based participatory research (CBPR) approaches have been heralded as a promising means toward the elimination of health disparities.1 The CBPR approach focuses on the equitable involvement of community and academic partners throughout the research process with the aim of improving hypothesis generation and evaluation, community-informed interventions, and translation and adoption of research findings.2 Hence, one of the key areas of focus within CBPR is the development and cultivation of relationships between outside researchers and community members.3,4 A central issue within CBPR is how to balance the diverse, sometimes conflicting, needs and priorities of academic and community members so that synergistic collaborations that promote co-learning, mutual capacity building, and more relevant and actionable knowledge can be formed.2
Interestingly, relatively less attention has been paid to the partnership building process between community members who often represent diverse segments and perspectives of the local community. Although subject to less investigation, CBPR does underscore the importance of recognizing the multiple voices of a single community.5 A core principle of CBPR is to identify and work with existing communities of identity and to fortify the sense of community through collective engagement.3 However, there has been limited examination of the participatory process when existing communities of identity overlap on some dimensions but diverge on others. In the case of African Americans, though largely connected by a shared collective history and ethnicity, they also reflect diverse experiences. African Americans are characterized by a growing heterogeneity in socioeconomic status, cultural beliefs and religious participation.6–9 For example, even though religion continues to be important in the lives of many African Americans, there is increasing variation in formal religious affiliation. A large majority, nearly 80% of African Americans, still claim a formal affiliation with the Christian Protestant church.8–11 However, 12% of African Americans are unaffiliated with any formal religious institution. Nevertheless, even among unaffiliated African Americans, three in four report that religion is either somewhat or very important in their lives.6 Rare are investigations on community-academic partnerships that involve community partners who represent diverse institutions and religious experiences within African American communities. Most evaluations in the CBPR literature in African American communities have focused either on the process of forming community–academic partnerships or on strategies to engage faith–based communities around health issues.10,11
The purpose of the present evaluation is to examine the partnership process of the Restoration Center Los Angeles (RCLA) which brought together a wide range of partners to engage in a two-year planning effort to create a set of recommendations to address mild-to-moderate depression and substance use problems affecting the South Los Angeles African American community. The planning effort centered on developing a set of guidelines for the creation of Restoration Centers that would address unmet mental health needs by building on existing community- and faith-based strengths and services, and by integrating the importance of supporting the wellness and resiliency of the individual, family, and community. The initial leadership group included founding partners who served as representatives for each of the following perspectives: community service providers, community grassroots organizations, faith-based organizations, and academia. Each partner entered into the RCLA planning process with different histories, traditions, and working styles.
A number of partners had collaborated previously on engaging the local community around depression and other health related initiatives.12 From this prior collaborative work, a local variant of CBPR, called community partnered participatory research (CPPR) was developed. The CPPR approach has a structure and a set of principles that ensures equal participation and leadership of community and academic partners.13 The CPPR model provided an important origin and guiding set of principles for some RCLA partners. Our faith-based RCLA partners brought the historical and collective role of the church in community activism and in providing for the physical and spiritual needs of the community. Faith-based organizations, in particular the Black church, have well-established infrastructures with long traditions, methods, and approaches to mobilizing resources and people to meet the needs of the community.14,15 It quickly became evident that the RCLA partnership needed to develop a working style that could accommodate the diverse perspectives and traditions represented so that effective planning could be accomplished. Thus, an early product of the leadership group was the development of a diversity statement that acknowledged and reinforced the importance of attending to diverse perspectives in the RCLA planning process (for more details see Chung et al, in this issue). In addition, guardians of each of the four perspectives (ie, community grassroots, faith-based, service providers, and academia) were appointed and given voting power for major decision-making processes.
The initial leadership group created a larger RCLA planning committee that supported three workgroups which were charged with developing a set of plans within their respective topic area: 1) mental health and substance abuse needs and services; 2) wellness and resiliency programs; and 3) policies and operations. Each workgroup was asked to respond to questions such as: “What are the mental health services most needed in the African American community?” and, “How can we integrate a faith based perspective into Restoration Centers given the diverse faiths of our community?” A set of recommendations were developed and presented and approved in several open community forums held at the California Endowment, the West Angeles Church of God in Christ, and the Holman United Methodist Church. The final set of recommendations focused on providing services for mild to moderate depression and substance abuse in a one-stop-shop setting that integrated or colocated holistic wellness approaches (for further details see Chung et al, in this issue). This article describes a post-hoc retrospective evaluation of the RCLA partnership, which was conducted shortly before the last community forum in which the final set of recommendations was reported.
Thirty-five RCLA members participated in planning committee or workgroup meetings between August 2007 and July 2008. The members were stratified into four exclusive categories based upon level of participation in planning committee meetings (ie, low to high attendance). Eighteen RCLA members randomly selected from these strata were contacted by phone with a maximum of three call attempts. A final sample of 11 RCLA members participated in face-to-face semi-structured interviews during October and November 2008.
The interviews were conducted by an evaluation consultant from outside the project at a location convenient for participants and lasted approximately 30–60 minutes each. The consent form was read to each participant who then gave oral consent before the interview was consulted. Each participant received a $10 gift card for their participation. The interviews were tape recorded and each was loosely transcribed and then common themes were identified. The semi-structured interview was based upon a conceptual framework for understanding and assessing the effectiveness of the CBPR partnership process.16 Key domains of the interview included: expectations and perceived effectiveness of the group; facilitators and barriers that affected group effectiveness; perceived benefits and costs of participation: and future expectations of the group’s effectiveness (see Table 1 for interview protocol). These domains are considered intermediate measures of partnership effectiveness.
The 11 tape recorded face-to face interviews were transcribed and analyzed by the evaluation consultant. Transcripts were analyzed for the common themes around partnership development, facilitators, barriers, benefits, and achievements. All identifiers were removed so that the raw responses could be interpreted by a subset of RCLA members. If any coded responses were unclear, the evaluation consultant edited the transcripts for further clarification and interpretation. All aspects of the evaluation and manuscript development were done in partnership with representatives from community, service providers, faith-based, and academic partners. Community partners refer to nonacademic representatives from community grassroot organizations, service providers, and faith-based organizations unless explicitly stated otherwise.
The RCLA members expressed a range of motivations for initiating their involvement in the project. Approximately half of the participants were drawn to the project because of the content (ie, focus on mental health/substance abuse) or the concept (ie, holistic approach to mental health needs). Other participants were motivated by the nature of the work (ie, community-based), the expectation that a one-stop-shop that met community needs would be established, and the potential to engage in a healthy relationship with academic researchers.
The members reported divergent expectations about the end goals of the project. Nearly half of the participants believed that the purpose of the project was to develop an executable plan or blueprint of the operations, programs, and services that would constitute a Restoration Center. In contrast, approximately one-third of participants expected that an actual Restoration Center would be created and established. A smaller subset of participants thought that the end purpose of the project was to strengthen collaborations between partners.
Correspondingly, participants differed in the degree to which they felt that their expectations had been met. Some participants (n=4) reported that the project fell short in meeting their expectations. For example, a participant described having unmet expectations given that the participant believed that the funding agency would provide the financial resources needed to establish a center upon the development and delivery of a plan. Other participants (n=4) had no expectations or were unsure about whether their expectations had been met. The remaining participants reported being satisfied with the results of the project but expressed that the project needed to continue to achieve further accomplishments.
One of the major accomplishments identified by many participants (n=7) was the facilitation of a planning process that involved diverse partners and perspectives (eg, theological, academic, community). One participant describing RCLA stated, “I think they have made quite a bit of accomplishments through their planning, getting the community involved, listening to the community, being a partner with research as well as community leaders.” Another participant talking about the accomplishments of RCLA explained, “Because it had a collective of people from different backgrounds, different cultures, different ways of looking at life, different disciplines…you’ve got the theological perspective, you’ve got the academic perspective, you’ve got the community perspective.” Participants said that staying committed to the project and producing a plan were major accomplishments. One participant responded, “…getting through the process, staying committed and coming together with a unified vision and plan.” Another remarked, “…just bringing the community and the different perspectives to the table and coming out with the same goal is a major accomplishment.”
Participants also noted the development of partner relationships and the level of engagement with the community as major accomplishments. Participants commented that relationships, partnerships, and real friendships had been formed and that trust was developed. In addition, the RCLA planning process was described as, “…getting community excited about the project.” Other accomplishments included gaining knowledge about the partnership process and the demonstration of the cohesiveness of the faith-based community.
Several factors were viewed as facilitating the accomplishments achieved by the RCLA planning process. The diversity of community input and individual commitments to the project were seen as contributing to the progress of the project. Although the diversity of community perspectives represented in the RCLA planning process was cited as a major accomplishment, it was also regarded as a significant challenge. For example, one participant responded, “We had academics, faith-based community, mental health all at the table. I think it was an excellent group, I really do. Unfortunately, everyone had a real strong opinion and couldn’t get past to come together as real partners.” Some participants commented on the diversity particularly exhibited among the community partners. For instance, a participant remarked that “…some significant cultural differences that weren’t addressed. There were different cultures. The diversity of African Americans, the diversity of the different groups that were at the table, the diversity of faith…I think that we underestimated those cultures and didn’t give enough attention to it. ”
Another factor that affected the process included concerns about the influence of pre-existing relationships between various community and academic partners that were established prior to the project as well as the occurrence of side interactions between different partners. Participants also said that disorganization, changes in leadership, and misunderstandings of the planning process impeded the partnership process. For example, a participant describing the challenges stated, “…the repetition of goals, of not being able to agree, no one being able to agree on how we should get started, how things should be in place, who should be the target population, and really how we can achieve the goals.” In addition, another factor that was cited as hindering the process was the scale of the project goals which was described as being too large.
Some participants commented on the nature and timing of the partnership process. One participant stated: “…it takes time for people to trust one another. That everyone really is considering each other’s interests and not in there just for their own interests, so I think that was one of the big challenges.” Despite these challenges, commitment to the process was viewed as a significant factor that facilitated persistence with one participant noting, “…sticking through something and pushing through something and fighting for what we believe in…we stayed.” Staying focused on the larger goal of the project was also identified as a significant factor to facilitate completion of process. For example, one participant said that the process was facilitated “once people realized they were working for the greater good and let go of egos, and sacrificed a little.”
Certain elements of the leadership committee were cited as factors that facilitated the planning process. In portraying the leadership committee a participant remarked, “I think leadership assisted in providing information. They were open. They listened. They took into consideration suggestions that were made, wanted to work with us. I think they made us feel that they were looking to our well-being.” It was also noted that “…when leadership committee members felt comfortable to speak up…” the process was facilitated.
Participants acknowledged experiencing a variety of personal benefits resulting from their participation in the project. A substantial proportion of participants reported gaining knowledge or renewed awareness of group dynamics and process. One participant remarked, “…I think the thing that was reinforced for me was the fact that you don’t get to ignore culture. It doesn’t matter how significant the project is – you don’t get to ignore culture. And that if you’re going to enter into a project of diversity, that you’ve got to factor in time to understand the cultures that are at the table.” Some participants disclosed new insights or increased understanding about different cultures. For example, a participant commented, “I also learned that there is this whole other community out there. They’re taking care of their own, they’re figuring out ways to help their community and there’s lots to be learned from the people who work in the community.” Several participants said that involvement in the project provided new networking opportunities. Many participants acknowledged deriving personal benefit from the partnership process including, “…the structure of bringing people together, talking things over, being more open-minded.” Moreover, one participant remarked that, “…hearing those different perspectives and melding them into one and being able to go through the conflicts” was a benefit.
In terms of perceived organizational benefits, participants expressed a hope that involvement in the project would result in greater recognition of community needs and increased efforts to address them. Further along in the continuum, some respondents reported that their organization had desired that their affiliation with the project would lead to establishment of an actual center(s). Regardless, participants expressed that their organizations benefited by being “part of something that filled a gap,” ensuring “the communities’ voice has been heard,” and “helping the community since there isn’t a lot available in that area.” Participants also said that future anticipated opportunities for collaborative work (eg, publications, funding) was a benefit anticipated by some organizations.
With respect to personal and organizational costs associated with participation in the project, more than one-third of participants said that being diverted from other work was a cost. One participant said that misinformation had caused detrimental effects for his/her organization. In contrast, nearly a third of participants reported being unaware of or having no costs related to their participation.
The majority of participants (n=7) felt that the RCLA planning process should continue largely due to the expectation and needs of the community. One participant stated, “There are still a few planning aspects that need to take place, but let’s move on. I can’t say this enough - if an actual place doesn’t come out of this, it will really hurt me. It’s not good enough to begin something – you’ve got to finish it. We have a lot of Black people hurting.” Community members’ expectations for a tangible product in terms of establishing an actual Restoration Center was emphasized. A participant remarked, “…as much as we reminded them, it’s about putting together a plan, they were hoping that something would ultimately come out of it. I know the community and they’re gonna say, ‘This is something that we need, this something we’d like to see, and it would help us tremendously because we’re the ones that access those services on a regular basis.”’
The remaining four participants were unsure or expressed that the RCLA planning process should not continue in its current form and significant changes were needed. For example, a participant commented, “I’m not sure that this particular group could render something different eight months from now. There would have to be some significant changes in the group for us to…for time to render a different product.” Another participant offered more concrete recommendations, “Again, it’s got to be more structured. There have to be time limits that have to be enforced. Everybody has to have a clear understanding that this is a process that needs to end at some point. That everybody has an objective at the table and that they need to be understanding of the objectives and time, overall, of everyone at the table – respect that.”
Participants also noted the need for self-evaluation and evaluation of the group should the partnership continue. One participant said, “I think we should continue to have meetings to determine how we’re progressing. We should have meetings to see what we need to change…what’s going well, what’s working, what isn’t working.” Another participant stated: “I think that there’s no way in the world that we can say, ‘Don’t do anything else.’ I’m glad that I stayed with the whole process from beginning to end because I wouldn’t have been able to get that last outcome. I think people need to really redefine what they are willing to commit to and be involved in…and I think they really need…everybody needs to really think about…their agenda…personally and professionally, within…whatever they want…and to see if it is in alignment with what the Restoration Center would do and be about.”
The present evaluation examined the partnership process of the RCLA, which was a two-year planning effort to develop a set of recommendations to address the unmet mental health needs of the South Los Angeles African American community. Findings underscore the importance of considering the potential issues that may arise with the increasing diversity of partners and perspectives. In the case of the RCLA, a diverse set of community partners proved to be both its greatest asset and challenge. The RCLA members continually referred to the broad and diverse representation of individuals engaged in the planning process as a major accomplishment and benefit of the project. However, RCLA members also acknowledged that the diversity of community partners at times prevented further cohesion and progress within the partnership.
Within CBPR, partnership issues have mainly focused on the kinds of challenges created by the divergent views of academic versus community partners.17 In contrast, relatively less attention has been paid to how the diversity of community representation impacts the partnership process. Interestingly, many of the challenges and facilitating factors of academic-community partnerships mirrored many of the processes that manifested between various RCLA community partners. For example, issues related to differences in expectations, trust-building, and the distribution of funds influenced the partnership development process between RCLA community partners. Although RCLA community partners were unified by the common goal of addressing the unmet mental health needs in their community, there was substantial variation in the expectations of what kind of final product the planning process would yield (ie, proposed plan for a Restoration Center versus the actual establishment of a Restoration Center). These findings demonstrate that the immediate needs of the community can continue to pull partners toward more action-oriented outcomes even when opportunities are afforded for the specific purpose of strengthening partnerships. The RCLA planning effort was made possible in part because of the funding agency’s responsiveness to policy recommendations to support planning grants that help build infrastructure.18 Thus, even in the infrastructure development phase of CBPR, expectations and tensions around the balance between process versus action outcomes need to be effectively managed.
Findings also highlight the added complexity of the partnership process with the expansion of community representation. A core principle of CBPR is to identify and work with existing communities of identity and to foster a fortified sense of community through collective engagement.3 Although the challenges wrought with increasing diversity have been documented more generally,19 there is limited guidance on how to navigate differences that arise between community members who have shared identities on some dimensions (eg, African American ethnicity, Los Angeles residence) but divergent identities on other dimensions (eg, formal church affiliation). The non-overlapping dimensions of identity may be associated with divergent perspectives that can affect the partnership process (eg, prioritization of goals, perceptions of community relevant solutions). Findings indicate that with the increasing diversity of community representation careful attention needs to be dedicated not only to the development of academic-community partnerships but also to community-community partnerships.
Despite the challenges encountered, RCLA members considered the development of a final set of recommendations for the creation of Restoration Centers as a major accomplishment (see Chung et al, in this issue, for further details). Recommendations included designing Restoration Centers as one-stop-shops for mental health and substance abuse problems and to build wellness and resiliency. Restoration Centers would also serve to coordinate access to a range of community services to ensure holistic care, to provide outreach, education and training to increase community awareness and leadership to address mental health and substance abuse issues and to deliver direct services to fill gaps as needed. In addition, Restoration Centers would promote program design, implementation, and ongoing review that incorporate cultural awareness and competency and client and community participation. The final recommendation stated that the RCLA planning phase should be followed by a demonstration project of at least one Restoration Center to evaluate the acceptability and impact of the Centers and explore how they could be replicated and sustained in other areas of Los Angeles. Efforts were made to carry out this final recommendation by exploring whether a Restoration Center could be implemented by individual partner institutions and by approaching county government agencies and private foundations.
The RCLA members recognized the rarity with which such a diverse set of partners can be brought together to work collaboratively on a joint effort. Commitment and dedication to a greater good went a long way in aiding the RCLA partnership to weather some of the challenges common to CBPR partnerships. This was particularly evident during the final community feedback conference in which the set of recommendations were presented to the community at large. The RCLA members reported feeling energized by the community’s excitement and enthusiasm for the plan and expressed the need to continue the effort. The members and the community-at-large recognized the huge potential in having diverse partners at the table to jointly address the pressing needs of the community. When diverse partners are able to work in synergy, opportunities to develop new and improved solutions, more integrated and comprehensive programs, and stronger ties to the broader community are made possible.20 The RCLA experience illustrates some of the lessons learned by a diverse set of partners in their journey toward the actualization of the full potential of collaboration.
This research was supported by a grant from the California Endowment. We thank and are indebted to the many community, faith-based, service provider, and academic partners without whom this study would not have been possible.