Chapter 5. Part 2. Overcoming Differences Between and Among Academics and the Community

American Indian youth are one of the demographic groups at highest risk for smoking (Johnston et al., 2002; CDC, 2006). Yet there is little research regarding effective interventions for American Indian teens to prevent or quit smoking. Unfortunately, American Indians have a long history of negative experiences with research. This ranges from being exploited by this research to being ignored by researchers. Specifically, they have been minimally involved in research on tobacco addiction and cessation in their own communities. This problem is compounded by the economic, spiritual, and cultural significance of tobacco in American Indian culture. In the late 1990s, the West Virginia University PRC and its partners conducted research on teen smoking cessation in North Carolina. This research was largely among white teens. North Carolina American Indian community members approached the researchers about addressing smoking among American Indian teens, focusing on state-recognized tribes.

CBPR approaches can be particularly useful when working with under-served communities, such as American Indians, who have historically been exploited. For this reason, CBPR approaches served as the framework for a partnership that included:

• The West Virginia University PRC,
• The North Carolina Commission of Indian Affairs,
• The eight state-recognized tribes, and
• The University of North Carolina PRC

The CBPR-driven process began with formation of a multi-tribe community partnership board including tribal leaders, parents, teachers, school personnel, and clergy. The researchers and the community board developed a document of shared values to guide the research process. Community input regarding the nature of the program was obtained from:

• Focus groups
• Interviews
• Surveys, and
• Informal discussions, including testimonials and numerous venues for historical storytelling

As the community and the researchers continued to meet, they encountered challenges. This was concerning the role and meaning of tobacco in American Indian culture. The researchers saw tobacco as the problem, but many community members did not share that view. This was a significant issue to resolve before the project could move forward. A major breakthrough occurred when partners reached a declarative insight that tobacco addiction, not tobacco, was the challenge to be addressed. From that day forward, the group agreed to develop a program on smoking cessation for teens. This program specifically addressed tobacco addiction from a cultural perspective. In addition, the community decided to use the evidence-based Not on Tobacco (N-O-T) program as the starting point. The N-O-T program was developed by the West Virginia University PRC. American Indian smokers and nonsmokers, N-O-T facilitators from North Carolina, and the community board all provided input into the program’s development. In addition, teen smokers provided session-by-session feedback on the original N-O-T program. Numerous recommendations for tailoring and modifying N-O-T resulted in a new N-O-T curriculum for American Indians. The adaptation now provides 10 tailored sessions (Horn et al., 2005a; Horn et al., 2008).

The N-O-T program as modified for American Indians continues to be used in North Carolina. There are ongoing requests from various tribes across the U.S. for information about the program. The initial partnership was supported by goodwill and good faith. The partnership between American Indians and N-O-T led to additional collaborations. This included a three-year CDC-funded CBPR project to further test the American Indian N-O-T program. This collaboration also altered the political and cultural norms related to tobacco across North Carolina tribes. Critically, grant resources were divided almost equally among:

• The West Virginia PRC,
• The North Carolina PRC, and
• The North Carolina Commission on Indian Affairs

Each organization had monetary control over its resources. In addition, all grants included monies to be distributed to community members and tribes for their participation. This statewide initiative served as a springboard. It helped begin localized planning and action for tobacco control and prevention across North Carolina tribes (Horn et al., 2005b).

• Act on the basis of value-driven, community-based principles, which assure recognition of a community-driven need.
• Build on the strengths and assets of the community of interest.
• Nurture partnerships in all project phases; partnership is iterative.
• Integrate the cultural knowledge of the community.
• Produce mutually beneficial tools and products.
• Build capacity through co-learning and empowerment.
• Share all findings and knowledge with all partners.

University and community partners often have different social, historical, and economic backgrounds, which can create tension, miscommunication, and misunderstanding. These issues were evident in a recent submission of a grant proposal. For instance, all of the university partners had advanced degrees, came from European-American backgrounds, and grew up with economic security. In contrast, the backgrounds of the community partners ranged from two years of college to nearing completion of a PhD. The community partners socioeconomic backgrounds were varied. All of the community partners were involved in a community-based organization and came from African American backgrounds.

There was extensive discussion and participatory process (e.g., data-driven dialogue and consensus about the final topic selected) during the proposal-writing process. Despite this, the community-university partnership was strained during the writing of the proposal. Time was short. The university partners volunteered to:

• Outline the contents of the proposal,
• Identify responsibilities for writing different parts of the proposal, and
• Begin writing

The proposal details (e.g., design, contents of the intervention, recruitment strategy, and comparison community) were discussed mostly through conference calls.

The university partners began writing, collating what others wrote, and initiating discussions of (and pushing for) specific design elements. Recruitment strategy became a point of contention and led to heavy discussion. The university partners argued that a more scientifically sound approach would be to recruit individuals from clinic settings. These clinic settings should have had no prior connections to those individuals. The community partners argued that a more practical and locally sound approach would be to recruit through their personal networks. No resolution came during the telephone calls. So, the university partners discussed among themselves the two sides of the argument. They decided to write the first draft with participants recruited from clinic settings (in accord with their original position). The university partners sent the draft to the entire group. This included the county health department and a local health coalition as well as the community partners, for comments.

The community partners did not respond to drafts of the proposal as quickly as the university partners expected. This expectation was based on the deadlines and administrative work that were required to get the proposal submitted through the university. This lack of response was interpreted by the university partners as tacit approval, especially given the tight deadline. However, the silence of the community partners turned out to be far from an expression of approval. Their impression was that the university partners did not really want feedback. This was based on the fact that the plan was already written, and time was getting shorter. They also felt that they were not respected because their ideas were not included in the proposal. The university partners, however, sincerely meant their document as a draft and wanted the community partners’ feedback about the design. They thought there was time to change some aspects of the proposal before its final approval and submission by the partnership. The following all contributed to the misunderstanding and miscommunication about the design:

• The tight deadline
• The scientific convictions of the university partners
• The reliance on telephone communications, and
• The imbalance of power between the partners

This process created significant problems that have taken time to address and to heal.

• Be explicit that drafts mean that changes can be made, and that feedback is both expected and desired. Figure out ways to be scientifically sound in locally appropriate ways.
• Have more face-to-face meetings, especially when discussing points about which there may be disagreement, because telephone conferencing does not allow for nonverbal cues and makes it more difficult to disagree.
• Acknowledge and discuss power imbalances and ensure that all partners’ voices are heard and listened to, create settings for open and honest discussion, and communicate perspectives clearly.
• Help partners understand when they are being disrespectful or might be misinterpreted. Discuss differences even after a proposal is submitted.
• Improve communication by establishing agreed-upon deadlines and midpoint check-ins, using active listening strategies, specifically requesting feedback with time frames, and facing issues directly so that everyone understands them.
• Provide community partners with time and opportunity for developing designs for proposals, and provide training for community partners if they lack knowledge in some areas of research design.
• Set aside time for university partners to learn about the community partners’ knowledge of the community and what expertise they bring to a specific project. Acknowledge expertise within the partnership explicitly and take advantage of it when necessary.

Conducting community-engaged research requires overcoming various hierarchies to achieve a common goal. Hierarchies may be created by differing economic status, social affiliation, education, or position in the workplace or the community. A Pew Research Center survey, described by Kohut et al. (2007), suggests a change in value. It suggests that the values of poor and middle-class African Americans have moved farther apart from each other in recent years. It also suggests that middle-class African Americans’ values have become more like those of whites than of poor African Americans. In addition, African Americans are reporting seeing greater differences created by class than by race (Kohut et al. 2007). It is widely known that perceived differences in values may influence interactions between groups.

Approaches to engage the community can be used as bridge builders when working with economically divided groups. The African-American Health Improvement Partnership (AAHIP) was launched in October 2005 in Durham, North Carolina, with a grant from the National Center (now Institute) for Minority Health and Health Disparities through a grant program focused on community participation. The AAHIP research team consists of African American and white researchers from Duke University with terminal degrees and research experience. The team also has health professionals/community advocates from the Community Health Coalition, Inc, a local nonprofit. The community advisory board (CAB) is composed of mostly African American community leaders. These leaders represent diverse sectors of Durham's African American and health provider communities. The first study launched by the AAHIP, which is ongoing, is an intervention, designed by the AAHIP CAB and its research team. It was designed to improve disease management in African American adults with type 2 diabetes.

At meetings of the CAB, decisions were to be made by a majority vote of a quorum of its members. Members of the research team would serve as facilitators who provided guidance and voiced suggestions. The sharing of information was understood to be key to the process. However certain dissimilarities created underlying hierarchies within the group (i.e., the CAB plus the research team). These were dissimilarities in educational level and experience between the research team and the CAB. These were also variations in socioeconomic status, positions, and community roles among CAB members. The research team assumed a leadership role in making recommendations. Notably, even within the CAB, differences among its members led to varying levels of comfort with the CAB process. The result was that some members did most of the talking while others were hesitant to make contributions. Many of the community leaders were widely known for their positions within the community and their accomplishments. These individuals were accustomed to voicing their opinions, being heard, and then being followed. Less influential members were not as assertive.

Faculty from North Carolina Central University, a historically black university in Durham, conduct annual evaluations. They do this to assess the functioning of the CAB and the research team. In particular they want to ensure that it is performing effectively and meeting the principles of CBPR. An early survey found that only about 10% of respondents felt that racial differences interfered with productivity. This survey also found 19% felt that the research team dominated the meetings. However, nearly half felt that the meetings were dominated by just one or a few members. More than 90% reported feeling comfortable expressing their point of view at the meetings. Although, it was suggested that there was a need to get everyone involved.

CAB members suggested ways to rectify the issues of perceived dominance, and all parties agreed to the suggestions. From then on, the entire CAB membership was asked to contribute to the CAB meeting agendas. This was done as a way to offer a larger sense of inclusion. At the meetings themselves, the chair made a point of soliciting remarks from all CAB members. The chair did this until they became more comfortable speaking up without being prompted. In addition, subcommittees were established to address important business. These made active participation easier because of the size of the group.

As seats opened on the CAB, members were recruited with an eye to balancing representation in the group by various characteristics. These characteristics included gender, age, socioeconomic status, and experience with diabetes (the outcome of interest). Overall, change was seen in the level of participation at meetings, with more members participating and less dominance by a few. Moreover, former participants in the type 2 diabetes intervention were invited to join the CAB and have now assumed leadership roles.

• Evaluate your process on an ongoing basis and discuss results as a group.
• Assure recognition of a community-driven need through strong and fair leadership.
• Make concerted efforts to draw out and acknowledge the voices of all participants.
• Create specialized committees.
• Engage participants in the choosing of new board members (especially former participants).