Reciprocal Relationships: Something for Everyone
Reciprocal relationships based on mutual goals, respect and trust are key to maintaining working relationships and getting reliable research results. Yet relationship building is not a concept taught in academia. These skills are often learned the hard way, with singular solutions found for case–by–case scenarios. Several journeys to identify the components, barriers and rewards of reciprocal relationships are discussed.
reciprocal relationships, research collaboration, academic–community partnerships
Problems with maintaining a healthy working relationship are fodder for advice columnists and many day–time television program hosts. They have plenty of advice on how to recognize when a relationship is not working and what to do about that. Even Dr. Phil has written a book on rescuing relationships (McGraw, 2000), and has reminded us that, of course, both parties need to want to repair the relationship.
Establishing effective working relationships is not for the faint hearted. Despite the plethora of advice out there on how to repair damaged relationships, the building and maintenance of good relationships is difficult. Although numerous examples of common–sense advice on relationship–building do exist, relationships still go bad and still need constant work. And this is true of all relationships, whether they be personal interactions, business partnerships, or research collaborations.
When research collaborations are done right there are great rewards. From start to finish, a successful partnership must include: a project that is locally driven and supported by all partners; complementary skills and knowledge among the partners; project synergism that results in something neither partner could do alone; recognized and consistent leadership; a dedicated core of workers; adequate resources for implementation and evaluation; plans for dissemination to other communities; and community–based change agents working to maintain the progress obtained during the collaboration (Heaton, Day, and Britten, 2016).
These partnership components are ideal but not always achievable. The struggles to final achievement are illustrated in the 12 narratives discussed [End Page 55] here that focus on Community–Academic Partnerships in Research and Public Health. These narratives illustrate well that relationship building and maintenance is a continuous process. They take us through a journey of self–discovery, goal setting and readjustment, near misses, incremental successes, and ever renewing hope and perseverance. Their discoveries provide us with a blueprint of essential components of the creation of successful community–academic partnerships in research and public health. And they remind us that, although we still have a long way to go, the journey is worth taking.
Essential Components of Reciprocal Partnerships
The authors are all enthusiastic, passionate, and most were inexperienced at forming community–academic partnerships at the start of the project. The same can be said for many of their community partners. But they are not naïve. They all approached difficult issues in healthcare disparity with a willingness to help and an understanding that the project was too big to be done alone. They all sought to establish common ground with their community–based partners. They sought out and spoke to persons of authority and listened to their needs and wants. They negotiated with community and academic advisors and granting agencies for time and money. They developed trust. They developed respect. They forged a bond between themselves and the community members. And then they went to work.
One serious barrier to a reciprocal partnership is lack of confidence on the part of the community members. Bravo et al. worked hard to blur the lines between researchers and promotoras by working together to formulate research questions of interest to all in health prevention strategies in the Hispanic community. However, all of the partners still struggle against the immediate relapse back into prior relationships once outside the research setting. This is a major barrier but recognition is the first step of overcoming that barrier.
Cultural differences are both a barrier and an opportunity. Farrar spent 4 years immersed in the Amish community, willingly taking longer than originally anticipated to complete her research. But she is still surprised at the continuance of cultural misinterpretations on the part of healthcare providers and realizes that she herself still needs to learn more about the Amish culture. Her journey, although off to a good start, will be a long one.
Faculty members have more research experience than graduate students but that does not make their journey smooth. Saksena and McMorrow found willing community partners who saw opportunity with enthusiastic academic partners, a new technology, external funding, and a community of Congolese refugee women that would benefit from having its “voice” heard. Despite these many positives, the loss of the original community leader led to an undervaluation of the contributions of the researchers. The researchers’ willingness to be flexible with their time and resources also appears to have reduced the respect from the new community leadership as evidenced by the fact that they were often made to wait until other work was completed or were asked to change dates and times of planned activities at the last minute. Respect must be mutual and everyone’s contributions must be viewed as valuable.
There are special problems that arise when researchers study their own community. Raynor and Penkin have the advantage of understanding both sides of the community–academic partnership. Their dual perspectives brought a clarity to the discussion of priorities but it also introduced unanticipated struggles with ethical questions about privacy and trust. Their description of how they recognized, addressed, and resolved the issues provides both academic and community partners with a sterling example of problem solving.
Not all community–academic partnerships are as clear–cut as originally imagined. Pallai piloted a writing workshop that promotes the creation of patient narratives about illness, told by patients with assistance from medical students in writing them down. The plan was to help the medical community by showing students how to better relate to their patients and their illnesses. However, this medical community possessed two communities: the student community and the patient community. The patient community unilaterally shared their [End Page 56] stories with the students. But the students failed to share their stories, and even denied ever being ill, which is highly unlikely. It is a rare person who has never suffered with at least a cold, flu, or stomach cramps. For fuller engagement the students will have to be asked what they would like to learn from these interactions. Students have much to learn and give but often focus only on learning. With negotiation and relationship building they will learn that they can teach as well.
Every research project has multiple stages—including design, implementation, and evaluation of interventions—and each stage affects the others. The narrative by Schuch reports on how the intervention phase of a study to increase access to healthcare by the Hispanic immigrant community is affected when multiple partners are involved in the design stage. The interventions were developed by key informant interviews, focus groups, a Photovoice project, and community forums, as well as inclusion of community and academic partners. This led to the identification of multiple needs and goals. Balance between research and service goals was difficult to maintain, leaving all sides anxious. Communication was time consuming but critical to the project’s success. Connecting participants to health and social services was key to the sustainability of the project. Despite difficulties, the improvements in the health and wellbeing of underserved Hispanic immigrants was worth the effort.
When developing a community–academic partnership your time is not always your own. When Shirazi participated in a study on breast health in an Afghan community, she knew the importance of the community having control over the production of knowledge and being engaged in all phases of research. Community ownership of the entire program was key to its continuance following the termination of the study. What was unanticipated was the degree to which flexibility and patience were required. It took longer than anticipated to establish trust. Academic timelines were jettisoned as community members led the pace of interactions and adoption of acceptable interventions.
Sometimes less is more. Community–academic partnerships can happen unexpectedly when an overwhelming need is acknowledged for a project whose time has come. As part of an academic exercise Salm Ward et al. identified significant disparities in the infant mortality rate in Milwaukee where African American babies die at a rate nearly three times that of White babies and proposed a hypothetical research intervention. The community members who heard the presentation agreed with the students’ assessment and asked that the study be done. The students’ lack of experience probably helped them to fully engage community members in all phases of the study, from start to finish with everyone claiming ownership. This was a successful partnership and a research study that had an important impact in Milwaukee.
Community advisors have a special place in community–academic partnership heaven. They can assist academic researchers in identifying the community stakeholders who are often either voiceless or absent because they are not recognized as being a part of the community. Often special effort is needed to ensure that all stakeholders are heard from. Thomas et al. discuss a unique program in which disparate groups of stakeholders are brought together and engaged in personal storytelling designed to decrease stereotyping, promote understanding and communication, and show each other why they care. This development of mutual trust empowers all the stakeholders, both academic–and community–based, to participate as equal partners in identifying and reducing health disparities and improving health outcomes for everyone.
Protection of personal information from research subjects is not a new topic. However, in terms of community–academic partnerships, it is a topic that bears discussion. Collecting health data from community members places the academic researcher in a position of power with the possession of health information that is sensitive. Such is the case especially when working with persons with a positive HIV status or a mental health issue. Release of health status information can lead to social stigmatization should it become widely known that they are participating in research. Mason discusses the effect of stigma experienced by persons living with a positive HIV status or who are receiving mental health services has on their trust in their research partners. Ethical dilemmas such as these negatively [End Page 57] affect communication but, ironically, require more communication. Exchange of information between academe and the community requires trust and openness. This reminder of social responsibilities is well placed.
Sometimes disadvantages can be advantages in disguise. Normally developing a community–academic research partnership over a large geographic divide would seem foolhardy. In the collaborative described by Wilbricht the pros appear to outweigh the cons. Synergism allowed for emic media messages to be created and disseminated via local radio stations in a rural Native American and an Alaskan Native community. Distance dictated that many decisions were made locally, keeping control firmly in the community. The sincere interest and expertise of the researcher in the use of emic media provided expertise that allowed a project to be done that would not normally have been possible. The major cost was lack of control over the project, a price the researcher was gladly willing to pay for the ability to make a difference.
Some topics are so sensitive and potentially invasive that it takes extra measures to cement a community–academic partnership. This is the case with Elk’s study of culturally–based attitudes towards palliative care in two rural communities, one African American, and the other White. Not only is trust building important but so is the need to truly listen to what community members are saying. Focus groups, advisory boards and local champions of palliative care all played a role in ensuring that conclusions drawn from past studies of palliative care preferences in other communities were used only as a guide to what questions to ask, not to what the answers would be. Respectful listening and discussion led to improved cultural awareness and respect for cultural differences across the two different communities and with the academic researcher. In this case, allowing the community to direct the questions and conclusions ensured that results will be applied back to the community. With help from a researcher who provides research funds and expertise on research design, this community–academic partnership will go far.
These 12 narratives have shown that it is possible to develop community–academic partnerships that are truly win/win. Each has shared a personal journey and has not hesitated to point out pitfalls, barriers, and challenges as well as successes. They talk of finding ways for all voices to be heard, the sometimes difficult road to mutual respect, and why equitable sharing of resources is important. Other advice acknowledged in the 12 narratives include the empowering local champions; being flexible and taking the time needed; asking what can be changed and respecting that some things cannot be changed; sharing the power; and leaving assumptions at the door. These are all strong lessons and well worth remembering. But are these lessons enough to support the maintenance of these partnerships?
Sustainability is always the Holy Grail of research and of funding. Once these community–academic partnerships have accomplished their original goals, can the changes they have wrought be sustained and, perhaps equally important, can the relationships be maintained in order to extend the goals to others equally in need? A huge next step is to determine whether and how health care research that is successfully accomplished in one locality can be effectively translated to other settings. Given the power of accomplishment that we have seen here in these 12 community–academic partnerships that are done right, it is possible that such partnerships can indeed support new groups. And accomplish even more. Dr. Phil would be proud.
Conflicts of Interest. The author reports no conflicts of interest.