Chapter 5. Part 5. Overcoming Competing Priorities and Institutional Differences

A major priority for the University of Texas Medical Branch at Galveston was to demonstrate community partnership in their CTSA proposal. They wanted a 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. This CBO 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. This CBO also 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. The CTSA work was within the existing scope of work for the community partner. However, there were certain invalid assumptions about the type of activities the CBO would do for the CTSA. These invalid assumptions 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. They could not commit until the proposal spelled out in detail what the CBO 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. A revised draft was also 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. At the same time, 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.

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. It also emerged 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. The CBO and university members realized that in rushing to complete grant-writing assignments, shortcuts were taken that should have been avoided.

• 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.

Academic research institutions and community organizations often partner on research projects. Though they may differ significantly in key ways. These ways include organizational capacity and the types of knowledge considered useful for social problem solving (Williams, 2009). Evaluation tools exist for assessment of organizational capacity and for setting priorities (Butterfoss, 2007). However, 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. The PI's salary 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. The partnership also 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. This is 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 the community partner was given even more administrative work. This was done 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. The community portion of the budget also covered 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. The community-based and university-based PIs were in the uncomfortable position of continually asking 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.

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. This is 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. This can be done 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. They should have alerted community members to the extended wait times for payments. They also should have advocated for streamlined procedures with university administration and accounting.

• “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.

In some cases, several CTSA sites are clustered in a small geographic area. Thus, they might demonstrate how institutions can overcome competitive differences to work together for the good of their mutual communities. In the Boston metropolitan area, three CTSA sites prioritized working with each other and with community partners. These sites were Tufts University, Harvard University, and Boston University.

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

These visits helped 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. They discussed the need to build capacity for research in the community. A funding opportunity arose through the American Recovery and Reinvestment Act of 2009. When this happened the three CTSAs, and two critical community partners, developed a training program to build research capacity. These two critical partners were the Center for Community Health Education Research and Services and the Immigrant Services Providers Group/Health.

Of the 35 organizations that applied for the first round of funding, 10 were selected in January 2010. These 10 made up the first cohort of community research fellows. These fellows underwent a five-month training course on 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. These were 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.

The CTSA sites in the Boston area were already committed to working together. However, bringing in consultants, who've worked 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. As opposed to these centers serving 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. Participants appreciated this approach over splintering their efforts and asking community groups to align with one institution or another.

• 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.