case study in community collaboration

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73 Community Engagement and Collaboration | Case Studies

Below we have curated a number of case studies of community engagement within the KMb and research context for you to review. Each case study has associated thought questions for you to work through in order to increase your learning in relation to these real-world examples.

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J Child Adolesc Trauma
v.12(2); 2019 Jun

Meeting Complex Needs Through Community Collaboration: a Case Study

Stephanie m. robinson.

Hotel Dieu Grace Healthcare, Windsor, Canada

Michelle M. Gallagher

This case study focuses on complex trauma in a refugee family. It explores the barriers faced while supporting a family presenting with complex and multifaceted needs. It reviews the roles, processes and participation of practitioners from Service Coordination (case management) and Treatment (therapeutic intervention) perspectives. This case study also examines the gaps in existing services for new immigrant and refugee populations within a community and provides recommendations for closing these gaps.

Introduction

Canada is a multi-cultural society. Canadians are a diverse mosaic of different languages, religions and races. According to Statistics Canada ( 2013 ), there are over 6 million foreign-born individuals living in Canada, totaling over 20% of the population. While not all foreign-born individuals have come to Canada under refugee status, recently the Government of Canada has welcomed 25,000 immigrants from Syria due to conflict in that country which contributed to a refugee crisis. Further, it is reported that approximately half of all refugees are youth under the age of 18 (Ellis et al. 2008 ).

The purpose of this case study is to discuss an Integrated Intervention used with a complex refugee family that experienced violence and trauma in their home country before seeking asylum in Canada. This paper will review the ways in which a Children’s Mental Health Agency (forthwith known as “the Centre”) worked to overcome known barriers to mental health service provision for refugees. It will also discuss clinical dilemmas, identified learnings, successes, and proposed changes to assist future clients who need support from the community.

Intervention

Service coordination – first author’s perspective.

In January 2015, the first author was assigned to be the Service Coordinator for a unique and challenging case. As a Service Coordinator at the Centre, her role involves assessment, referral and case management until discharge from the Centre. The formalized family meeting (known as the Service Coordination Assessment), encompasses an orientation to the Centre, discussion of the family’s concerns and review of the available treatment options. By the end of this biopsychosocial assessment, the Service Coordinator and the family agree to the treatment referrals that seem to fit their needs best. While the service coordinator typically has limited contact with the family after the Service Coordination Assessment is completed, the first author remained heavily involved throughout the course of this family’s interaction with the Centre.

Prior to the meeting, the service coordinator reviewed the intake packages which indicated that the family was new to Canada and had experienced horrific trauma in their home country. These traumas involved murder, sexual assault and discrimination. The father had tragically been murdered, leaving a single mother to care for the children whose ages ranged from 6 to 16. The intake packages also described symptoms being experienced by all of the children, including: depressed mood, physical complaints, sleeping and eating difficulties, enuresis, and school issues (including, academic, social and coping difficulties). In addition to the complex trauma and mental health concerns, the family members did not speak English. Some members of the family spoke French, but their first language was Swahili, and therefore, an interpreter would be required.

The first author researched the available services in the community for newcomers. There were several settlement agencies that support new Canadians. She attempted to locate a professional Swahili and English-speaking interpreter for the family meeting, but was unsuccessful, and therefore, planned to use a step-sibling with limited English skills for interpretation purposes. This was less than ideal but no other option was available at the time.

The children and their mother attended the Centre for the initial appointment, but the English-speaking step-sibling was not present. Instead, the family brought their Settlement Worker who spoke Swahili and English. The first author learned that this Settlement Worker had made the family aware of the Centre. The family members presented as confused and scared. The family was brought down to the first author’s office where the children huddled together and chose to share seats. The mother’s affect was notably flat, as evidenced by her discussion of traumatic events while showing little to no emotion in her voice and expressions.

The Settlement Worker explained that she became aware of the family and their story a few months prior, and realized quickly that they needed mental health support. She explained that her agency provided education to newcomers, but it did not provide mental health support. The Settlement Worker provided further details about the family and helped the mother and children to answer the service coordinator’s questions. While explaining some of the tragedy that had occurred in their home country, the mother shared some violent pictures she had taken when her husband was murdered. No one in the family reacted negatively to the pictures being taken out of the mother’s purse, appearing desensitized.

Once the family had shared their story and answered the first author’s questions, treatment recommendations were made. The service coordinator recommended that the children be referred for trauma-focused Individual and Family Counselling- High Risk. The high risk designation was intended to reduce the length of wait before services. The first author also suggested that another agency that specializes in treatment for survivors of sexual assault be involved. The family explained that they did not have transportation to get to and from the Centre for appointments. They had arrived today with the Settlement Worker, but she was not able to assist with transportation on an ongoing basis. The Settlement Worker also advised that she could not commit to ongoing interpretation for counselling sessions, as she is not a trained interpreter.

The first author recognized that this was a family who desperately needed help. The mother’s flat affect and the family’s apparent desensitization were concerns, somewhat predictable given all the family had been through. Despite being in Canada for a few years, they also seemed not well connected in the community and had few supports. The parent shared that she did not have money for food, clothing or transportation. The parent was asked to sign releases of information so that the first author could follow up with other community resources on her behalf. She expressed concern about signing the releases, but once it was explained that they would assist the Centre in helping her, she signed.

After the Service Coordination Assessment, an email was sent to Centre staff explaining that a recently referred family was in desperate need of help with basic needs, including clothing and food. A collection for the family was organized. Over the next few weeks, the first author’s office was filled with donations of new and used children’s clothing, outerwear, purses, shoes, pull-ups and gift cards. The family appeared appreciative when these items were delivered.

In the following months, there were several meetings with the Centre’s management team and the service coordinator to develop an innovative strategy to support this complex family and overcome barriers. The first author had connected with a therapist from a local Sexual Assault Treatment Agency. Given the overwhelming nature of this family’s needs and the risk for vicarious traumatization, the Centre’s management team arranged for the treatment team (once assigned) and the service coordinator to consult and receive clinical supervision with a well-known trauma expert in the province.

The first author searched the community for a Swahili-speaking social worker, who, if available, could perhaps provide counselling services to the mother while the Centre supported the children. The first author found one Swahili-speaking social worker in the community, who graciously offered to help, but then realized her Swahili Language skills were lacking. The service coordinator contacted a local agency that helped facilitate language services, but they only employed Swahili language aids, not interpreters. They explained that language aids are not professionally trained, and therefore are not recommended to be used for therapeutic treatment. It was discovered that the Centre had access to a Language Line, but it was thought that involving a third person and passing a phone receiver back and forth would also not be conducive for ongoing therapeutic treatment. It seemed that the community had a gap in terms of Swahili language services. Another person from the community came forward to help. She was a secretary at a settlement agency, who spoke English and Swahili. She offered to assist with translation for the family’s counselling sessions. Again, this informal interpreter was less than ideal, but there seemed to be no other choices.

In further consultation with the Centre’s management team, a preliminary treatment plan was developed in June 2015. It was determined that the youngest child was most appropriate to receive counselling from the Sexual Assault Treatment Agency, and therefore, her file would be closed to the Centre. The other children would receive counselling with Centre staff that had trauma training and/or French-language skills, and that the informal Swahili interpreter would participate in those sessions. One of the French-speaking staff is the second author who will elaborate on the treatment plan and therapeutic intervention below. A plan was developed for the youngest child to be provided counselling sessions at the Centre, even though her sessions would be facilitated by the sexual assault therapist. It was hoped that if the family only had to attend one agency, this would be easier and less confusing for them.

The first author learned of a community agency that supported Francophone families and was able to locate an individual through the agency who could assist with the family’s transportation needs. This individual was fluent in French and English. Her role was initially to provide transportation to and from counselling sessions at the Centre. This individual’s role later included French language interpretation for some. The first author learned that another community agency was offering a summer lunch program for low income families. Through this program, the treatment team obtained healthy lunches for the family every day that they attended the Centre for sessions throughout the summer.

A case conference occurred in July 2015, involving the mother, Centre staff and all involved community partners. The preliminary treatment plan was discussed, with which all parties were in agreement. The first treatment sessions were booked in the coming weeks on a weekly basis. In discussions with management and the treatment team, it was arranged for the family to use an available group room as their personalized waiting room when they attended the Centre for appointments. This would allow the family to eat their lunches without interruption and would provide a central meeting location while they transitioned to and from the treatment providers’ offices. The Sexual Assault Therapist was provided a treatment room at the Centre for her sessions. The treatment team was given the opportunity to continue the phone consultation sessions with the trauma expert on a weekly basis.

Through the course of treatment, the Centre accessed several other community agencies to support this family including financial, housing, medical and legal services. The Centre purchased groceries for this family and delivered the food to their home on several occasions, when they could not afford food. The family was connected with a Swahili-speaking child protection worker, who offered further advocacy and support to the family. As well, the team consulted with the children’s schools to ensure that there were no concerns for them in that environment. For the treatment team, knowing that these efforts were being made to meet the family’s basic needs allowed for increased comfort in delving into the mental and emotionally-laden work of exploring and processing their trauma experiences.

Treatment – Second Authors’ Perspective

The introduction of any case traditionally stays with the practitioner throughout the length of treatment. The details provided about this case were vague initially, but the impression of the significant trauma experienced by the family was impactful right from this initial introduction. While the Centre deals with some of the most intensive and high-needs children and families within the community, this felt different from the start.

As mentioned, the clinicians slated to be involved with the case were invited to a case conference to be provided further detail about the family’s experiences prior to gaining refugee status and immigrating to Canada. The information from other community agencies suggested that while the family was not thriving they were indeed surviving, though in need of mental health supports.

The initial introduction to a member of the family was meeting the family’s matriarch. She attended the conference in July 2015, along with members from a variety of community agencies that were already involved. At this meeting the importance of clear introductions given the number of individuals involved was evident. Given the nature of the work that would be done there was an identified need to have clearly defined boundaries and roles for the multiple agencies involved. This conference ended with scheduling several treatment appointments with the children and staff providing examples of what the mother could tell her children regarding the purpose of their attending the Centre. The goal was to decrease feelings of anxiety about their engagement in services.

The family (mother and all children receiving treatment) arrived for their first treatment appointment and appeared excited and apprehensive. All appointments for the children were blocked together given the limited access to interpretation and transportation. Attempts were made to predict and proactively plan for issues such as comfort, hunger and boredom for those who were waiting for their respective therapist and the sole translator. The family had access to snacks and activities such as puzzles, colouring and fidget toys each week.

The Centre was committed to supporting this family and the practitioners who worked with them. For example, decisions regarding some aspects of service provision were left to the individual practitioners. In consideration of language skills and of strengths with the adolescent population, a decision was made to work with a dual-therapist model. As well, per consultation with the trauma expert, each of the children were provided with small gifts geared toward their interests (a doll for the youngest daughter, stuffed animals for the middle children, and a fuzzy blanket for the oldest child) during initial appointments. These were meant to be items of comfort that could aid in the transition from home to an unfamiliar agency such as the Centre from 1 week to the next. These would be termed transition objects, though they were used intermittently by the children as such.

The initial appointment with the adolescent client evoked a sense of surprise and confusion in comparison to the case presentation on paper. Staff had conducted brief research on the country of origin in an attempt to avoid any significant cultural missteps. However, the adolescent presented in a very Westernized manner in terms of clothing and demeanor. She often used French ‘slang’ that was more common to Canada during conversations. She was, above all else, open and clear about the reasons she believed she was attending the Centre. Therapy sessions were conducted in French (a second language to the co-therapists and client alike) and as such patience was needed as topics were translated that could present complexities in expression even in ones’ native tongue.

While the limited access to interpretation services created a lengthier visit for the family as a whole, this also allowed for observation of the interactions between family members between their appointments. This allowed the team to tailor the approach based on clearly observable behaviours and expressed needs. Specifically, observing the experiences of each family member as an individual within the family system aided in selection of family session activities and general approach by the group. This case continually reaffirmed the idea that each person and family system responds to experiences very differently as a whole and as individuals within the family system, and that any approach must be tailored specifically to their presented needs.

Clinical Approach

Over the course of approximately one year, the treatment team met with the family on a near-weekly basis. The appointments were a mix of individual or family sessions dependent on client and clinician availability. If one child’s therapist was unavailable, the group would often engage in a family session to decrease the expressed and exhibited disappointment of being ‘left out’. The involvement of multiple therapists facilitated this approach and allowed for greater continuity of sessions for the family. Given the myriad of people that had come into and out of this family’s life over the course of their experienced traumas, immigration to Canada and subsequent period of settling, it was seen as important that the family experience as much continuity and consistency as possible with the Centre.

The case as a whole was approached with a trauma-informed lens, specific to the presenting needs of the client(s). A multi-modal approach was utilized including: attachment-focused, solution-focused, play therapy, narrative therapy and cognitive behavioral therapy. Each child was considered both individually and as part of the family system. This was important as the family experienced several of their traumas together, but their reported responses have varied widely since the initial incident. A key component to the use of multiple therapists was the debriefing period. This occurred on two levels: peer-to-peer and clinical supervision with the trauma expert.

The peer-to-peer debriefing was a significant aid in developing a more rounded understanding of the family’s experiences. This allowed the treatment team to put together a more complete timeline of the family’s initial and subsequent traumas. This form of debriefing also helped in normalizing some of the experiences of each clinician.

The clinical supervision was paramount in expanding the treatment team’s understandings of the family’s experiences and responses. The supervision included a review of each session and discussion regarding possible linkages within the case and plans for next steps. The supervisor also provided multiple opportunities for self-reflection that allowed for clinician growth. The use of effective clinical supervision and support was vital in ensuring that the practitioners themselves did not experience secondary trauma or compassion fatigue given the profound violence of the family’s trauma experience.

Individual sessions emphasized the development of rapport and comfort for a lengthy period of time. As well, the children and family themselves were consulted and their lead was followed in terms of readiness for the initiation of a trauma assessment and subsequent treatment. This progression was particularly challenging and was a point of difficulty for several of the clinicians. It was not unusual for the group to have a consensus that the children were ‘ready’ for trauma-related work but there continued to be considerable concern for parent/caregiver readiness. Ongoing impact of the family’s trauma was being reported by the family’s matriarch.

Despite the Centre’s best efforts to facilitate treatment and minimize the impact of these challenges, the language barrier, cultural difference and other unknown factors may still have contributed to this not being feasible. The clinical team felt that for the children’s progress to continue there was significant need for consistent parent support and readiness. Efforts were made to engage the mother, but challenges relating to her need for tangible items like money, in combination with the previously identified barriers, made these efforts even more difficult. This consequently impeded the trauma-specific work with the younger siblings. With consistent attention to the client’s level of comfort and emotional regulation, discussions regarding the experienced trauma were broached with the adolescent. This was done because it was determined that parental readiness was not as significant a concern given the adultified role this youth played within the home. As such, a trauma assessment and a narrative were started with the adolescent.

Yet again, translation proved to be complex. Typically this activity with an adolescent would also include delving further into the experience of each symptom in terms of frequency, duration, intensity and triggers. However, due to limitations in session length the language-barriers the activity was simplified slightly. The adolescent/adult list of symptoms was used with the child approach of stickers and simplified questions related to frequency and views regarding perceived size of concern. Once the identification of symptoms was complete, the next step was a rating of severity for the adolescent whereby she was tasked with placing her identified triggers in order. Interestingly, the symptoms which were identified as the most distressing were not necessarily those previously identified as having the greatest level of severity of occurrence.

It is important to note that these symptom identification and rating tasks were done in separate appointments. They were also accompanied with a wrap-up activity geared toward emotion re-regulation. Cues were taken from the adolescent, who was quite open with how she felt, what she thought would be helpful and the impact of the discussions on her mood. Work on the trauma narrative began following the symptom assessment and examination of the client’s willingness to engage with the therapists.

When treatment was nearing the 1 year mark there was a case conference to discuss further ways to support the family with community partners present. At this meeting, Centre staff were notified of the mother’s expressed intent to terminate her involvement with counselling services for her children. As such, a termination session was planned. Due to the abrupt termination of services the trauma narrative was not completed with the adolescent. Discussion occurred with the eldest child about the availability of services and supports from other agencies (due to aging out) in the future should she wish. The termination session was designed to be a celebration of the work done with the family. Practitioners provided small gifts for the family and each clinician wrote a small note to their client to wish them well.

Discussion and Recommendations

Clinical dilemmas.

Throughout the course of this family’s involvement at the Centre, the team encountered various clinical dilemmas, particularly related to the barriers of communication and transportation. From the point of intake, it was difficult to obtain a consistent Swahili interpreter. Members of the team were able to communicate effectively with the children in French, but it remained quite difficult to communicate with the mother, since her French- and English-language skills were limited. This contributed to the children progressing in treatment while little or no emotional support or treatment was being provided to the mother. This was in direct contradiction to the general practice at the Centre. In this case, meeting the mother’s mental health needs was highly challenging.

Another clinical dilemma was the occasional utilization of the oldest child for translation purposes. There was an interesting dynamic, because the oldest child reported not wanting to interpret consistently, but then was also resistant at times to someone outside the family providing translation services when it was available. Using a family member for interpretation is discouraged in the literature. The oldest child was at the Centre to access her own mental health treatment, not to translate for others. Also, via translation she was privy to sensitive adult information.

An additional clinical dilemma related to communication was the practice of signing consents and releases. When involved staff discussed consent forms, releases of information and the risks/benefits of treatment with the mother, someone translated the information in Swahili. The first few times, the mother stated that she understood and signed. As time passed, the mother seemed to grow concerned about the number of forms she was signing. Towards the end of treatment, the mother was quite uncomfortable signing any forms, even if staff went to great lengths to assure her why that information needed to be requested. As a result, once the initial releases expired, staff were no longer able to consult with other involved community agencies.

There were also many sessions that the mother did not attend. If it was a week that the therapists had prepared a family activity, she was unable to participate. Although staff had arranged a consistent transportation provider, the mother was not always at the pick up site. Staff speculated that this could be due to the mother not being actively engaged in her children’s treatment (due limited understanding or frustration over perceived lack of progress), or the mother’s potential disinterest in participating in family sessions. As a result, staff were put into a situation where they needed to go against the Centre’s policy of having the guardian in the Centre at all times in case of emergency. Many sessions occurred with just the children and their driver who became somewhat of a surrogate caregiver throughout the course of treatment.

This case emphasized the importance of recognizing all the successes that have occurred. First, the ability and willingness of the service coordinator to advocate for the family, to remain involved for a longer period of time, to meet the family’s basic needs and to develop a creative approach that enabled the family to remain engaged for a full year.

Second, the team found that the ongoing flexibility within the Centre was an area of significant contribution to success. This case demonstrated the importance and ability to place emphasis on the needs of the client and to facilitate services around those needs. While this sounds simple, it can be challenging given the pressure on many agencies to decrease wait lists, increase measurable outcomes and decrease length of treatment. Specifically for this case, flexibility included the use of a personalized waiting room, engagement of a specialized therapist from another community agency, facilitation of that therapist’s services being provided at the Centre, and the use of a multi-therapist model.

The ability to meet the family’s basic needs in session (organization of transportation, provision of snacks/meals) and out of session (donations, provision of groceries, gifts of winter wear) was understandably important. Based on comments from the family, it would seem that the Centre’s ability to provide these tangible items played a role in developing the rapport and engagement of the family’s matriarch. This was crucial to the children’s attendance and participation.

Finally, significant portions of the sense of success for this case can be connected to the regular access to peer and clinical supervision. The risks of compassion fatigue and secondary trauma are well identified within the literature. With this in mind, and given the extensive traumas experienced by this family as a whole and individually, the level of support for the clinicians internally (within the treatment team) and externally (access to a trauma expert and regular access to the management team as needed) was paramount. These supports allowed each practitioner to provide more to the clients: more support, more engagement and more energy.

Proposed Changes: Agency and Community

While success was experienced with this family, the impact of this case has simultaneously demonstrated that there is room for change. In some ways it felt as though the team encountered a gap in available supports and services at each turn. A common commentary from team members emphasized experienced confusion, frustration and disappointment as well as a recognition of how much more challenging this would be for individuals who do not fully understand the systems, the culture, the language or the expectations being placed on them. With this in mind, several areas of change within the Centre and the community have been identified.

Within the Centre, identified needs included the development of a toolkit and system for handling complex new immigrant families. The needs of new refugee and immigrant families are becoming bigger, and the world is seemingly becoming smaller. There is a responsibility as practitioners, and as an agency as a whole, to be prepared to meet the needs of the families presenting for services. Further, easy access to up-to-date information about language services, settlement agencies, transportation supports and ways to meet families’ basic needs for food, shelter and financial support will be imperative. Additionally, as was noticed with this family, the provision of tangible items can be of extreme importance in laying the foundation for trust and therapeutic rapport in preparation for the work related to mental and emotional health. It will be important that these families experience decreased wait times.

As well, further education for staff about working with complex new immigrant and refugee families is important. Ideally this education would occur for any staff member with whom the family could have contact. Education is also crucial in relation to the warning signs and potential impacts of vicarious trauma. As an agency, the Centre is seeing an increase in new immigrant and refugee referrals with tremendous experiences of trauma. Professionals will hear these stories repeatedly. A clinician’s ability to support themselves and their colleagues and to be supported by management will, in many cases, influence their ability to truly support their clients.

Within the community, identified needs included increased cohesion between community agencies. As mentioned previously, the difficulty experienced by the practitioners in navigating the settlement, legal, financial and mental health systems serves to clearly identify the multitude of potential barriers for families. Additionally, when the individuals and families that are navigating these systems have experienced a significant trauma (including the overall experience of immigration; L. Kirmayer, personal communication, April 29, 2016) there will be another layer that adds to the complexity of engaging in the system for these families. As such, it will be imperative that community agencies develop methods to ensure consistent, proactive and responsive communication and collaborative work to meet the needs of these families as part of their circle of care. This could also include community-wide engagement with a variety of agencies in a proactive way such as developing a committee that meets regularly to anticipate potential areas of increased need and to be responsive as patterns become apparent. As well, based on the team’s experience there would be significant benefit to the inclusion of consultation related to cultural competency prior to a family beginning services and throughout their engagement.

Finally, the team’s experiences identified a significant gap in availability of translation and interpretation services. Engaging as a community to identify areas of language need and to invest in the necessary training or recruitment within these areas would be vital. As well, emphasis would need to be placed on developing methods to ensure that the translators are not experiencing any vicarious symptoms as a result of their roles given the amount of triggering information they would be likely to hear.

Basic needs come first . It is essential for an individual or family to feel their basic needs are met before they will be able to dedicate significant mental and emotional energy to resolving or processing any experiences of trauma or other impacts of their experiences. As such, helping a low income client/family with accessing basic needs may be necessary before clinical intervention can occur.
Language matters . Finding a well-trained professional interpreter is crucial. While family members/informal interpreters may be the only option, these individuals should only be used in an emergency or as a last resort.
Staff well-being must be considered . Mitigating compassion fatigue, vicarious traumatization and burnout is critical for workplaces where employees support trauma survivors (immigrants, refugees or other). The ability of a staff to support these clients will inevitably be impacted by their own mental state. The risk for secondary trauma, compassion fatigue and burnout will be high for staff carrying larger case loads comprised of highly traumatized individuals/families. Further, staff who are trained and feel confident in their skillset will be better able to support these populations long-term.
Children do not exist in silos . A child exists within their environments (home, school, community). As such, family work is extremely important when supporting traumatized children. The implications of the experienced trauma on members of the family will influence the environment in which the child lives.
This process is about the client, not the practitioner or their policies . Assessment and treatment with traumatized newcomers can be time consuming and progress may occur very slowly. Innovative interventions must be tailored specifically to clients depending on their needs. While the emphasis is increasingly being placed on outcomes and decreased wait times, it is important that individuals and families be met where they are at instead of rigidly insisting they conform to agency expectations. This will contribute to better outcomes.

Compliance with Ethical Standards

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ellis, B. H., MacDonald, H. Z., Lincoln, A. K., & Cabral, H. J. (2008). Mental health of Somali adolescent refugees: the role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology . [ PubMed ]
Statistics Canada (2013). Immigrations and ethnocultural diversity in Canada . Retrieved from: http://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-010-x/99-010-x2011001-eng.pdf .

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Case Study of a Collaborative Approach to Improving Community-Based Services for People with Low Income: Community Caring Collaborative

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Published: 2021

Introduction

This case study describes the Community Caring Collaborative (CCC), the backbone organization of a network of community organizations and individuals focused on improving the lives of people and families with low incomes in Washington County, Maine. The CCC supports 45 nonprofit and state government organizations in a variety of ways and brings them together to solve emerging issues facing Washington County.

This case study is part of the State TANF Case Studies project, which is designed to expand the knowledge base on innovative approaches to help people with low incomes, including TANF recipients, prepare for and engage in work and increase their overall stability. Mathematica and its subcontractor, MEF Associates, were contracted by the Administration for Children and Families (ACF) to develop descriptive case studies of nine innovative state and local programs. The programs were chosen through a scan of the field and discussions with stakeholders. TANF practitioners and staff of other programs can learn about innovative practices through the case studies. The studies also can expand policymakers’ and researchers’ understanding of programs that support people’s success in work and highlight innovative practices to explore in future research.

The purpose of this case study is to describe the CCC in detail and highlight its key features: where it operates and its context; whom it serves; what services the CCC provides; how it is organized and funded; how it assesses its performance; and promising practices and remaining challenges. The case study concludes with a spotlight section on Family Futures Downeast, a two-generation program designed by the CCC and its partners.

Key Findings and Highlights

The CCC’s main approach to serving people with low incomes is to build collaborative community initiatives to address emerging needs.
The CCC’s primary services are convening groups of community service providers or members to build trusting relationships, collaborate, and share information; incubating programs to address emerging community needs; providing training and technical assistance to partner staff on various topics, including how to implement CCC-incubated programs with fidelity; and operating core programs that support multiple partners; for example, programs that remove financial barriers for partners’ participants or cross-sector initiatives.
Promising practices include building collaboration across diverse organizations, designing and implementing participant-centered programs, building the capacity of partner organizations, and providing flexible funding for activities designed to remove barriers.

To select programs for case studies, the study team, in collaboration with ACF, first identified approaches that showed promise in providing employment-related services to individuals and linking them to wraparound supports, such as child care and transportation. The next step was to hold initial discussions with program leaders to learn more about their programs and gauge their interest in being featured in one of the case studies. Once the list of programs was narrowed, the project team, in collaboration with ACF, selected the final set of case study programs to reflect diversity in geography and focus population.

Two members of the research team visited the CCC office in Machias and an FFD program location in Calais. The two-and-a-half day visit took place in February 2020. The team conducted semi-structured interviews with five staff members from the CCC, four staff members from FFD, and nine staff members from the partner organizations. Team members also conducted in-depth interviews with two participants of the FFD program, reviewed anonymized case files for two other FFD participants, and observed two convenings at the CCC office. The team held a follow-up telephone call with a program leader in July 2020 to learn how the CCC responded to the COVID-19 public health emergency.

Eddins, K., and K. Joyce (2021). “Case study of a collaborative approach to improving community-based services for people with low income: Community Caring Collaborative .” OPRE Report #2021-71, Washington, DC: U.S. Department of Health and Human Services.

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Sylvia is a Consulting Director of the Tamarack Institute’s Collective Impact Idea Area and also supports Tamarack’s Community Engagement Idea Area. She is passionate about community change and what becomes possible when residents and various sector leaders share an aspirational vision for their future. Sylvia believes that when the assets of residents and community are recognized and connected they become powerful drivers of community change. Sylvia is an internationally recognized community-builder and trainer. Over the past five years, much of Sylvia’s work has focused on building awareness and capacity in the areas of Collective Impact and Community Engagement throughout North America.

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Six Case Studies About Collaboration by the National Park Service

Click here to access a PDF publication, Leading in a Collaborative Environment: Six Case Studies Involving Collaboration and Civic Engagement , published in 2010 by the National Park Service.

Learn about common collaborative themes that emerged from six case studies related to historic and protected lands, including a sacred burial ground, a recreational park, and a national preserve and park. The publication offers suggests strategies on what to do before convening, what it takes to be an effective leader through a collaborative process, and how to build team capacity and relationships.

Publication credit: Jacquelyn L. Tuxill and Nora J. Mitchell, eds. Leading in a Collaborative Environment: Six Case Studies Involving Collaboration and Civic Engagement. Woodstock, VT: Conservation Study Institute, 2010. (For more information: www.nps.gov/csi ).

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Case Studies

The Managing by Network Case Study Program has been part of Managing by Network since 2009.

Federal employees have the opportunity to speak to a success, failure, challenge, opportunity, work-in-progress or vision relative to their work in partnerships and community collaboration.

Our Case Study Catalog showcases the work of federal agencies with more than 500 partner organizations: nonprofits; cooperating associations; local, state and other federal agencies; businesses; universities; museums; local schools; international organizations; and professional alliances.

More than 220 presentations provide models of informal and formal partnerships; of community collaboration with a range of stakeholders; of site-based conservation efforts and landscape-scale alliances.

Case Studies by Year

Kayla Blades, BLM, Grants Management Specialist, Idaho State Office, ID. What is the FASS-ination? An Appreciative Inquiry Approach .

Linda Naoi Goetz, BLM, Archaeologist, Interior Region 7, Upper Colorado Basin, WY. Kemmerer Historic Preservation Commission: Creating a Legacy for the Future .

Chris Otahal, BLM, Wildlife Biologist, Barstow Field Office, CA. Amargosa Vole Recovery Team Partnership .

Jesse Engebretson, EPA, Social Science Researcher, Office of Research and Development, Great Lakes Toxicology and Ecology Division, MN. Unsheltered Homelessness in Parks and Protected Are as in Northern California
Liz Smith-Incer, NPS, RTCA Field Office Director for Mississippi and Puerto Rico, MS. Africatown Connections Blueway: Healing Begins by Reclaiming Our Heritage & Happiness
Andrea Carson, USACE, Small Programs Planner, Regional Environmental Justice Coordinator, CPCX Division Liaison and Regional Silver Jackets Coordinator, Great Lakes & Ohio Division, PA. Making the Connections: Aligning Internally to Partner Externally .

USDA Forest Service

Danielle Bauman-Epstein, USDA FS, Program Specialist - Grants and Agreements, Six Rivers National Forest, CA. Youth Workforce Development: Two Tribal Partnerships
Shanna Klein smith, USDA FS, Writer-Editor, National Forest System, Policy Office, ID. Mature and Old-Growth Forests: Partnerships for Success.
Dessa Dale, USDA FS, Public Engagement Specialist, Mountain Planning Services Group, Regions 1 - 4, MT. Developing a Framework of Support around Partnerships and Relationships for Land Management Planning .
John Langdon, USDA FS, Partnership Coordinator, Uwharrie & Croatan National Forests, NC. Croatan Fireshed Partnership
Lacey Hill Kastern, USFWS, Western Lake Superior Coastal Program Biologist, Region 3 Ecological Services, WI. Lake Superior Collaborative: Enhancing a Partnership in the Wisconsin Lake Superior Basin .
Lauren Miller, USFWS, Social Scientist, R8 Science Applications, NV. Establishing a Climate Network .

John Langdon, USDA FS, Partnership Coordinator, Uwharrie & Croatan National Forests, NC. Croatan Fireshed Partnership.

Matthew Fockler, Socioeconomic Specialist, Great Basin Zone (NV, ID, UT), Reno, NV. Two Mississippi: A Case Study in Private / Public Collaboration

Heather Coleman, Deep Sea Coral Research and Technology Program Manager, Office of Habitat Conservation, NOAA Fisheries, Silver Spring, MD. EXPRESS: EXpanding Pacific Research and Exploration of Submerged Systems (PDF). Resources: EXPRESS website

Laura Rear McLaughlin, Chief, Stakeholder Services Branch, NOAA/Center for Operational Oceanographic Products and Services, Silver Spring, MD. An Evolution of Water Level Partnerships at NOAA Center for Operational Oceanographic Products and Services (CO-OPS)

Leslie Wolf, NOAA (MbN Class of 2016), Hydrologist, California Coastal Office, West Coast Region, CA; Mary Burke, North Coast Regional Manager, CalTrout. Strong Collaborative Process - A Case Study: The Redwood Creek Estuary Collaborative

Teresa Tucker, Planning & Compliance Lead (Environmental Protection Specialist), Mount Rainier National Park, Ashford, WA. Engaging the Public in Planning : Fryingpan Creek Bridge Replacement Project; Mount Rainier National Park: Nisqually to Paradise Draft Corridor Management Plan (ArcGIS Storymaps)

Connie Chan-Le, Park Ranger, USACE-Los Angeles District, South El Monte, CA and Henry Csaposs, Park Ranger, Los Angeles District, South El Monte, CA. A Second Chance in the Desert: Building partnerships and solutions at Mojave River Dam

Daniel Meden, Biologist, St Paul District (Regional Planning and Environmental Division North), USACE Bettendorf, IA. Iowa River Sustainable Rivers Program

Philomena West, Assistant Deputy Area Budget Coordinator, Washington Office Research and Development, Fort Washington, MD. A View from the WO: Forest Service Cross Deputy Area Projects (CDAPs) and What It’s Like Working for a National Office

Jo Anna Lutmerding, Biologist, U.S. Fish and Wildlife Service Headquarters, Migratory Bird Program, Falls Church, VA. Artificial Lighting at Night: What it means for bird conservation and navigating a path forward

Margaret Rheude, Wildlife Biologist, Midwest Regional Office - Migratory Birds, Bloomington, MN. Urban Chimney Swift Conservation: Non-randomizing our acts of conservation

Wayne Nelson-Stastny, Missouri River Recovery Project Leader, Missouri River Coordination Office, Yankton, SD. The Missouri River: A River of Connections, A River of Change .

Marina Tomer, Research Coordinator, South Central Climate Adaptation Science Center, Norman, OK. Leveraging Partnerships to Close the Science-Usability Gap .
Nina Hemphill, Aquatic Habitat Management Program Lead, California State Office. Water Quality and Fisheries - Working with Tribes.

Judith Downing, Emergency Management Specialist, Public Information Officer, National Headquarters, Fire and Aviation Management, National Incident Management Organization, CA. Community Wildfire Liaison Programs: What Makes Them Successful.

Max Forgensi, Lands and Minerals Program Manager, Pike-San Isabel National Forests & Cimarron and Comanche National Grasslands, CO. Long-term sustainable management for high-use recreation areas.

Reid Armstrong, Public Affairs Specialist, Arapaho and Roosevelt National Forest and Pawnee National Grassland, CO. Sparking a R/Evolution in Information Delivery

Tracy Schwartz, Historian, Portland District, OR. Willamette Falls Locks Transfer and Section 106 Consultation

Sarah Gray, Program Assistant, Portland-Vancouver Urban Refuge Program, OR. Nurturing Diversity and Increasing Trust through Youth Employment

Sergio Pierluissi, Regional Partners for Fish and Wildlife Coordinator, Midwest Regional Office, MN. Path to the Uplands Partnership

Sean Vogt, Lahontan Cutthroat Trout Recovery Coordinator, Ecological Services Office, NV. Modernizing Recovery Efforts of Lahontan Cutthroat Trout

Charles Cuvelier, Superintendent, George Washington Memorial Parkway, VA. Evolution of a Partnership

Jennifer Moore, Coral Recovery Coordinator, NMFS Southeast Regional Office, FL. Mission: Iconic Reefs

Krystyna Bednarczyk, Environmental Policy Advisor, Office of Environment & Energy, Environmental Policy Division

Karen Nelson, Office of Science Quality and Integrity (OSQI); Youth and Education in Science (YES) office. WI. Growing our Practice: Inward and Outward Journeys
Marcia deChadenedes, BLM, Collaborative Action & Dispute Resolution (CADR) Program Lead, HQ-210: Division of Decision Support, Planning, and NEPA, CO. San Juan Islands Terrestrial Managers Group

Gorge Refuge Stewards

Jared Strawderman, Gorge Refuge Stewards, Stewardship & Community Engagement Coordinator, Ridgefield National Wildlife Refuge Complex Stevenson, WA & Sarah Williams Brown, USFWS, Community Engagement Specialist, Portland-Vancouver National Wildlife Refuges, Ridgefield, WA. Urban Wildlife Conservation Program: Conserving the future with communities and partners in the Portland-Vancouver Metro area
Ali Weber-Stover, NOAA WCR, Natural Resources Management Specialist, California Coastal Office, Santa Rosa, CA. Bay Restoration Regulatory Integration Team (BRRIT): Facilitating multi-benefit restoration projects in the San Francisco Bay through enhanced collaboration. With Valary Bloom, USFWS Senior Fish and Wildlife Biologist, San Francisco Bay Delta Fish and Wildlife Office, Sacramento, CA
Brian Rast, USACE, Lead Silver Jackets Coordinator, Project Manager, Kansas City District, Planning Branch, Kansas City, MO. Partnerships and the Infinite Game of Flood Risk Management.
Katie Noland, USACE, Social Scientist, Levee Safety Center Risk Communication Team, Washington, DC. U.S. Army Corps of Engineers Partnership Pains and Gains Developing the Levee Safety Program Guidance
Betsy Koncerak, USDA FS, Grants Management Specialist, Pacific Northwest Region, Malheur National Forest, John Day, OR. A Peek Into the Life of a Grants Management Specialist.
Donna Mattson, USDA FS, Partnerships Team Supervisor, Washington Office, Enterprise Program, Elgin, OR. Dynamic Approach to Sustainable Recreation Strategy Development .
Kelsey McNicholas, USDA FS, Partnerships and Community Development Coordinator, Chattahoochee-Oconee National Forest, Gainesville, GA. Restoring Ourselves Restoring Our Lands: Empowering Educators to Examine Our Role in Equitable Access to Public Lands
Leslie Hay, USDA FS, Southwestern Region Wildlife Program Leader, Southwestern Region, Regional Office, Albuquerque, NM. J aguar Conservation and Partnerships: One Goal, Many Roads .
Valary Bloom, USFWS Senior Fish and Wildlife Biologist, San Francisco Bay Delta Fish and Wildlife Office, Sacramento, CA. Facilitating multi-benefit restoration projects in the San Francisco Bay through enhanced collaboration. With Ali Weber-Stover, NOAA WCR, Natural Resources Management Specialist, California Coastal Office, Santa Rosa, CA.
Jess Collier, USFWS, Fish Biologist, Green Bay Fish & Wildlife Conservation Office, New Franken, WI. Great Lakes Basin Road-Stream Crossing Inventory .

Vermont Agency for Natural Resources

Kathryn Wrigley, VT ANR, Forest Recreation Specialist, Forestry Division, State Lands Program, Essex Junction, VT. Leveraging Partnerships to Help Manage Backcountry Site Hazard Trees.
Tye Morgan, BLM, Planner and Environmental Specialist, Medford Field Office-Ashland Resource Area, Medford, OR. Virtual Public Meetings: A Prequel Case Study
Jennifer Day, Regional Coordinator, Great Lakes Regional Collaboration Team, Ann Arbor, MI. Government Collaboration: Building Collaboration for One NOAA Internally to Facilitate One NOAA Externally
Evan Sawyer, Drought Coordinator (Natural Resource Management Specialist) NOAA Fisheries, West Coast Region, California Central Valley Office, Sacramento, CA. Sacramento River Science Partnership: Partnering to develop a shared understanding
Alicia King, Public Affairs and Partnership Staff Officer, Chugach National Forest, Anchorage, AK. Partnership Engagement in Inclusion & Diversity Festival Planning
Ricardo Lopez, Forest Engineer, Angeles National Forest, Arcadia, CA. Angeles National Forest Collaborative Transit to Trails
Elizabeth (Liz) Munding, NEPA Planner, Coconino National Forest, Red Rock Ranger District, Sedona, AZ. Oak Creek Watershed Restoration Project: Pullouts, Protection and the Public .
Lisa Shores, Management Analyst, Office of Regulatory and Management Services; Directives and Regulations, Washington, DC. Embracing Obligation & Increasing Opportunity
Kevin Kalasz, Fish and Wildlife Biologist/Coastal Program Coordinator, South Florida/Everglades, South Florida Ecological Services Field Office, Big Pine Key, FL. Pine Rockland Conservation Business Plan: It Takes a Community .

Mary (MJ) Byrne, Special Assistant to State Director for RAC, Partnerships, Ed. & Interp., Youth, Volunteering, Idaho State Office, ID. Turning Relationships into Partnerships (including Every Kid Outdoors and Hands on the Land / Teachers on the Land)

Katy Kuhnel, BLM, Outdoor Recreation Planner, Challis Field Office, Idaho State BLM, ID

Rebecca Wong, BLM, Monument Manager, Berryessa Snow Mountain National Monument, CA

Katy Kuhnel, Outdoor Recreation Planner, Challis Field Office, Idaho State BLM, ID. Making Community Connections

Ally Lane, Fish Biologist, West Coast Region, CA, Bridging Data Gaps Through Interagency Coordination

Karl Honkonen, Watershed Forester, Northeast Area/State & Private Forestry, NH. Saco Watershed Collaborative

Rachel Neuenfeldt, Partnership and Community Engagement Specialist, Wayne National Forest, OH, Forest Plan Revision Through Partnerships

Jeanne Stevens, Tribal Relations Specialist, Coconino National Forest, AZ, Springs Monitoring & Restoration Initiative

Leigh Goldberg , Scholar-in-Residence, One Tam Case Studies
Caroline Kilbane, Outdoor Recreation Planner, AZ, Lake Havasu Shoreline Sites

Florida Fish and Wildlife Conservation Commission

Sarah Barrett, Biological Scientist IV and Brie Ochoa, Species Conservation Planning Biologist III, FL, Management Plan Development in the Sunshine

Marin County Parks

Kevin Wright, Government and External Affairs Coordinator, CA, Yard Smart Marin: Think Before You Spray
Rebecca Ingram, Social Research Associate, Pacific Islands Fisheries Science Center, HI, Building a Network of Partnerships to Support NOAA’s Integrated Ecosystem Assessment
Mary Biggs, Resource Assistants Program Liaison, WO, DC, Strengthening Partnerships. Creating Opportunities. The USDA Forest Service Resource Assistants Program
Debra-Ann Brabazon, USFS, Forest Fire Prevention Education Officer/Fire Information, MI, Engaging Youth: Lessons Learned Along the Path of Growing Relationships
Coeli Hoover, Research Ecologist, NH, Cat Herding: A Tale of Two Documents
Dawn McCarthy, Recreation Team Leader, OH, The Baileys Mountain Bike Trail System: Improving Communities Through a Collaborative Vision
Brooke Burrows, Wildlife Refuge Specialist, MN, Minnesota Valley Trust and the Minnesota Valley National Wildlife Refuge & Wetland Management
Laurie Fairchild, Private Lands Biologist, MN, What to Do When You're Stuck: One Approach to Reimagine and Reconnect Resource Accomplishments with Realities on the Ground
Todd Jones-Farrand, Science Coordinator, LCC, MO, The Rise and Fall of a Landscape Conservation Cooperative: Lesson for Large-Scale Collaborative Efforts
Lisa Van Alstyne, Chief, WSFR Policy Branch (F&W Administrator), VA, When a Good Idea Goes Bad: Taking a Risk on an Alternative Approach in WSFR
Edd (Sherman) Franz, Outdoor Recreation Planner, CO, Community Collaboration: Bureau of Land Management Recreation Program
Anne Mullan, Endangered Species Biologist, OR, Gravel Mining and ESA Salmonid Recovery: Collaboration in the Willamette River

NPS/Greater Yellowstone Coordinating Committee

David Diamond, Executive Coordinator, Greater Yellowstone Coordinating Committee, MT, Greater Yellowstone Coordinating Committee (GYCC): A Case Study of More Than 50 Years of Federal Partnership

Partnership and Community Collaboration Academy

Mary Reece, Manager, Program Development Division, AZ, New Mexico Unit of the Central Arizona Project: An Arranged Marriage
Dave Cunningham, Partnership Specialist, MT, Friends of the Little Belts
Danny McBride, USFS, Regional Partnership Coordinator, Intermountain Region 4, UT, Utilizing Partners to Build Partnerships & Capacity
Erick Stemmerman, Administrative Staff Officer, Olympic National Forest, WA, Storrie Fire Settlement
Cindy Corsair, Fish and Wildlife Biologist, RI, A Tale of Two Cities: Urban Wildlife Refuge Partnerships in New Haven, CT and Providence, RI
Heidi Keuler, Fish Habitat Biologist, WI, Fishers and Farmers: Watershed Leaders Network
Susi von Oettingen, Endangered Species Biologist, NH, Tracking Migrating Roseate Terns: UsingPartners to Find a Needle in a Haystack

Case Study Catalog

2nd nature: a partnership with the national park service and latin america youth center, laura harvey.

Laura Harvey NPS Education Specialist National Capital Region Washington, DC 2nd Nature: A Partnership with the National Park Service and Latin America Youth Center

A Delicate Balance Between Multiple Uses: Sheep vs. Sheep, Andrea Jones

Andrea Jones USFS District Ranger Rio Grande National Forest La Jara, Colorado A Delicate Balance Between Multiple Uses: Sheep vs. Sheep

A Peek Into the Life of a Grants Management Specialist, Betsy Koncerak

Betsy Koncerak USDA FS Grants Management Specialist, Pacific Northwest Region (R6) Malheur National Forest Oregon A peek into the life of a Grants Management Specialist.

A Second Chance in the Desert: Building partnerships and solutions at Mojave River Dam, Connie Chan-Le and Henry Csaposs

Connie Chan-Le and Henry Csaposs, USACE, Park Rangers, Los Angeles District, CA. A Second Chance in the Desert: Building partnerships and solutions at Mojave River Dam. (PDF) Connie Chan-Le and Henry Csaposs USACE Park Rangers Los Angeles District California A Second Chance in the Desert:...

A Tale of Two Cities: Urban Wildlife Refuge Partnerships in New Haven, CT and Providence, RI, Cindy Corsair

Cindy Corsair FWS Fish and Wildlife Biologist Southern New England-New York Bight Coastal Program Rhode Island A Tale of Two Cities: Urban Wildlife Refuge Partnerships in New Haven, CT and Providence, RI

A Tale of Two Projects: What I Learned About Collaboration, Matt McCoy

Matt McCoy BLM Assistant Field Manager Four Rivers Field Office, Boise District Boise, Idaho A Tale of Tw o Projects

A View from the WO: Forest Service Cross Deputy Area Projects (CDAPs) and What It’s Like Working for a National Office, Philomena West

Philomena West USDA Forest Service Assistant Deputy Area Budget Coordinator Washington Office Research and Development Maryland A View from the WO: Forest Service Cross Deputy Area Projects (CDAPs) and What It’s Like Working for a National Office

Adapting Project Design to Local Conditions, Mike Johnson

Mike Johnson BLM Zone Social Scientist New Mexico and Arizona State Offices Adapting Project Design to Local Conditions: Learning on the Fly in an Interagency Collaborative Effort

Adventures in FACA: How USFWS Developed Its Voluntary Guidelines for Wind Energy Development, Rachel London

Rachel London USFWS Fish and Wildlife Biologist Ecological Services Arlington, Virginia Adventures in FACA: How USFWS Developed Its Voluntary Guidelines for Wind Energy Development Additional Resources: USFWS Land Based Wind Energy Guidelines

Africatown Connections Blueway: Healing Begins by Reclaiming Our Heritage & Happiness, Liz Smith-Incer

Liz Smith-Incer NPS RTCA Field Office Director for Mississippi and Puerto Rico Mississippi Africatown Connections Blueway: Healing Begins by Reclaiming Our Heritage & Happiness

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Community Collaborative Life Stages

Life Stage Map

Collaboratives typically go through a common series of life stages. These are described below, along with a rough indication of their duration.

Develop the Idea (3-6 months)

Community collaboratives evolve out of pressing social needs and some initial thoughts about how to address them. The realization that collaboration is necessary to attack the problem at scale may be recent. Or, it may have come about when a prior set of partnerships has failed to yield significant results.

But whatever its origins, a collaborative needs to learn how to pull together. Therefore, when successfully completed, the "Develop the Idea" stage is characterized by an energized, cohesive core group of partners. This nucleus also develops a clear sense of the issue they want to address and a short list of additional players who should be involved. Typically, the lead convener, i.e., organization or individual(s) that will coordinate the collaborative process, is identified during this stage.

Spearheaded by this lead convener, new or refocused collaboratives often have to immediately address challenges. Not least of these is raising sufficient funds to start to build the staff necessary to support the collaborative process. When raising funds, collaboratives may find funders hesitant because their work is functionally more like overhead than program work. Its impact is indirect and the lines of accountability are less clear. Nonetheless, collaboratives need to identify local stakeholders in the short term who are interested in sustaining the collaborative throughout the "plan" phase.

When done well, this stage begins the formal process of developing a roadmap, which is a detailed action plan for the future, and begins to attract additional players to the collaborative.

Key discussion questions for this stage

Is my community's history with collaboration positive or negative? How can we use either situation to our advantage?
What pressing issue or opportunity has brought us together? Will this idea galvanize leaders across sectors in my community?
Is this issue capable of attracting resources both for direct-service providers and dedicated collaborative capacity?
What do we know about this issue? What data is out there to help us better understand the issue?
How does the issue identified by the collaborative fit into the broader context of our community? Are other efforts under way? Are there opportunities for partnership with existing collaboratives? In what ways is our work needed and additive to existing work?
What core group of people simply has to be at the table to make needle-moving change occur on this issue?
Is there a trusted, neutral, influential leader - usually an organization - that is coordinating and facilitating the collaborative? Note: This may be your organization.
How can we foster genuine community partnerships to help us understand the issue and create the necessary support for the interventions needed?

Checklist of key tasks to complete

Bring a core group of stakeholders to the table. (i.e., those interested in and able to drive the early planning and whose engagement is fundamental to the success of the collaborative)

Include decision makers and funders relevant to the issue in the community: Participants should be either chief executives of organizations or trusted deputies who can take responsibility for the issue and can influence chief executives.
Start to discuss which key participants need to be at the table: Consider reaching out to the local United Way, mayors or senior city officials, school superintendents, child welfare agencies, relevant nonprofit service providers, area Chambers of Commerce, community foundations, advocates, researchers and the like.
Ensure that this early planning group includes the core decision makers within the community, without becoming unwieldy.
Understand that the collaborative will evolve and gain more members during later stages.

Conduct landscape research as needed to understand how to build the collaborative to be effective within the community context.

Use or undertake research to understand what else is happening in the community, such as the cultural and political landscape and other initiatives or collaboratives focused on similar or related topics.
Determine if a new collaborative is actually needed; sometimes the right path is to reinvigorate an existing collaborative.
Engage in conversations with relevant community leaders, residents (including youth, if applicable), business leaders and owners, and funders.
Aim, ultimately, to understand how the collaborative fits in the broader community context.

Frame the challenge and the problem(s) you will address.

Based on the results of the landscape review, complete a visioning process with the broader group to further define the core focus of your collaborative.
Consider creating a high-quality research report, one that can clarify the problem in local terms, gather baseline data for your community, and create a focal point for the public launch.

Identify funding sources for dedicated capacity of the collaborative

Identify a committed source(s) of funding to sustain the collaborative throughout the Plan phase, during which time there will be no success stories to attract resources.
Understand current funding condition of collaborative members to determine if some of their current resources can be repurposed to support the collaborative. Please refer to " Capacity and Structure - Funding Examples " for examples of how other collaboratives have raised funds.

Work to secure the right leadership and operational support for the collaborative.

Select a lead convener organization that will provide significant administrative capacity and resources for the collaborative.
Most importantly, select a lead convener with the trust and respect of the community; one that is both sufficiently neutral and has the ability to convene a broad group of decision-makers. Please refer to " Capacity and Structure - Examples of Collaborative Structure " for more information on selecting a lead convener.

Create the community engagement and participation plan.

Conduct a series of meetings, forums, and calls to engage other potential stakeholders, such as nonprofits, government agencies, advocates, and community members with an interest in the issue involved.
Determine how and when residents, parents, or youth can be involved to ensure that the collaborative has authentic engagement. Please refer to " The Next Generation of Community Participation " for guidance on engaging your community, examples of how other collaboratives have engaged their communities, and community engagement questions to ask yourself during each life stage.

Engage in peer learning and secure technical assistance, if possible.

Understand what other communities are doing to solve similar problems; read about other collaboratives, set up relevant calls, visit other collaboratives, and get involved in peer learning opportunities.
Use existing knowledge in this process, an effort that will likely save time and resources.
Seek out the support of experienced intermediaries to support this kind of work.

Potential roadblocks

While this is one of the most exciting times for a collaborative, challenges also exist. Common roadblocks are listed below, along with suggestions and resources for addressing them.









		Voices and Choices Unified New Orleans Plan

Plan (1-2 years)

The Plan stage is all about developing the process by which the collaborative will map its path to achieving results and then measure its progress. This takes some intensive upfront effort. For instance, this stage typically entails at least monthly—and sometimes more frequent—meetings of the core stakeholder group. It is this group's task now to put in place the collaborative's structure, finalize agreement on the community-wide goal(s), gather the appropriate benchmark data, and set the metrics for measuring success.

During this stage, it is critical to make sure the right people are at the table, across all sectors and interest groups, and working effectively towards the goal. Clear decision-making processes and a sense of mutual accountability are two critical pieces to make sure the group is aligned. Effective collaboratives can differ on the decision-making processes they use, varying from highly formal (with memorandums of understanding (MOUs) and bylaws) to largely informal, where collaborative work is difficult and lengthy, usually requiring at least three to five years of committed effort to see results. This length of investment combined with needle-moving aspirations make mutual accountability all the more important, given that collaborative's formations are based on the belief that all members are necessary to achieve success. Though accountability will look different depending on the collaborative's structure, two key things can promote mutual accountability: 1) choose metrics that correspond to the collaborative's performance rather than to partners' individual outcomes and 2) provide leadership opportunities (e.g., subcommittee chairs) in order to create a sense of ownership on behalf of partners.

This group should include a funder that is committed to supporting the collaborative in the early years. While one source of funding may have been sufficient to sustain the collaborative during this stage, going forward, members will need to develop a sustainable funding strategy to cover the cost of the staff managing the collaborative. The collaborative also needs to make sure there are funds available for their partners' work on the problem(s) they are trying to address. (Please refer to the " Capacity and Structure - Funding Examples " for examples of how collaboratives have obtained sufficient funding to implement their visions.)

During this stage, a concrete action plan should be developed, one that specifies the measurable outcomes the collaborative wants to achieve and the major interventions required to reach them. The roadmap breaks down each goal into actionable steps. It also provides guidance and timing for who will be accountable and when. This roadmap requires collaboratives to indicate how community resources, programs, and systems will be aligned and the data metrics that match up with each desired outcome. Collaboratives also should continue to partner with future beneficiaries of this work to develop the roadmap.

As an example, underlying The Strive Partnership's progress is its Student Roadmap to Success , which was developed during its Plan stage. The roadmap describes five life stages: early childhood, adolescence, early adulthood, transition from school, and postsecondary training into a career. The map has critical checkpoints at each stage - and indicators for tracking success all along the way. Using a common roadmap also allows The Strive Partnership's networks to better align their community of efforts. The genesis of the roadmap served as a forcing function for the alignment of partners. Indeed, its development was a critical part of the process for creating a shared vision, along with an agenda for moving forward. Though critical, it was not easy to gain consensus. Core partners grappled with the research and Cincinnati's data over several years before agreeing to this course of action. As in this case, data will often be necessary to bring shareholders into agreement concerning the vision and agenda of the collaborative.

When all of these elements are in place, the Plan stage comes to fruition with a campaign launch designed to rally the community around the efforts.

Do we have the right people at the table? Have we thought about what assets and perspectives each brings to the collaborative?
What exact change do we plan to see in five years? How will we measure our progress?
How will data be tracked and is there a data analyst or other resource available to support the collaborative in this regard?
What roles are needed to staff the collaborative? What resources are available to do this?
Do we have a funder(s) at the table willing to provide resources for the collaborative as it begins to implement its plans? What will it take to get funders on board?
Based on the assessment results, what are our collaborative's strengths and weaknesses? What steps do we need to take to address weaknesses?

Bring additional people to the table, as needed, and engage the community.

Determine what sectors need to be involved and approach relevant leaders identified in the Develop the Idea stage (e.g., funders, business leaders, government agencies).
Proactively address any changes in community leadership.
Review " The Next Generation of Community Participation - Community Engagement Examples " and make sure the collaborative continues to invest in engaging with residents and youth (if applicable).

Analyze and discuss the data around the problem.

Use data around the issue as a starting point to bring the collaborative to a common understanding and vision.
Please refer to " Capacity and Structure - Data and Continuous Learning Examples " for common uses of data and examples of how other collaborative have used data.

Finalize collaborative goals and build buy-in to the shared vision.

Ask the question: What are the few key goals for the community over the next five years regarding this issue? Examples include "changing dropout rates by XX% or increasing graduation rates by YY%." Such goals will often be characterized by a desired ultimate outcome (e.g., increased graduation rates) and several intermediate goals (e.g., increased slots in alternative schools) that lead to the overall result.
Determine the geographic boundaries of the goal or goals. Do they apply to the entire city, the metropolitan area, or a large neighborhood within the city (e.g., Manhattan in New York City)?
Get final agreement on the metrics that will be tracked.
Analyze the data to understand your goals and create a plan for data collection and analysis moving forward.
Create a clear leadership and governance process if not already established.
Devise a roadmap or logic model for what it will take to achieve the vision and targets.
Develop a clear action plan to create the various pathways required to achieve the goal and work to align the programs, interventions, resources, and advocacy efforts around what works.
Include milestones and metrics to help track success over the next phase; these should also measure organizational goals such as hiring X people in year two.
Clarify accountability for organization goals.

Understand evidence-based practices.

Research existing evidence-based practices and interventions that have been proven to address the issue you are trying to solve.
Determine if your community is currently using evidence-based practices where appropriate, and if you should shift towards those practices in any areas.

Get commitment or at least common agreement from participants on a timeline.

Ensure that participants are committed for the long term.

Secure funding (or at least a committed private funder) for the next few years.

Consider if funds can be obtained from an existing organization, the government or other efforts—if not, work to secure new funds sufficient to cover the collaborative's required capacity. (Please refer to " Capacity and Structure - Funding Examples " for examples of how other collaboratives have raised funds.)
Determine capacity required to manage the collaborative.

Secure the key staff required to support the work.

Repurpose or hire the first few staff members and start to define roles.(Please refer to " Capacity and Structure - Examples of Collaborative Structure - Dedicated Capacity ") for guidance on hiring dedicated collaborative staff and examples of how other communities have staffed their collaboratives.

Start to build out the data effort for continuous improvement.

Determine what data needs to be collected or reviewed to understand your community's progress against your goal.
Gather baseline data, where possible, to track your roadmap's key metrics.
Alternatively, develop a plan for how to collect that data in the future.

Develop a sustainability philosophy.

Consider long-term options for the collaborative (e.g. achieve goals and dissolve, reach milestones, and transfer to existing provider).
Determine funding required to pursue the options considered.

Launch a public campaign.

Develop a communications plan to guide how to build public interest and enthusiasm, and to manage perceptions.
Organize a launch event to announce the collaborative and its partners; share the goals, the roadmap and the benchmark data.
Develop related press materials detailing compelling data and local stories about the problem, as well as planned solutions and commitments from key leaders (e.g. the mayor or CEOs).
If you have created a research report during the Develop the Idea stage, consider publishing the report to both communicate the challenge, lay out the roadmap as a solution, and attract supporters and partners as a part of the public launch.

Common roadblocks in the Plan stage involve failure to reach agreement on goals and missing representation. Here are some suggestions and resources for addressing each.

Align and Improve (1-3 years)

The Align and Improve stage is where the rubber meets the road and, ideally, the collaborative starts to yield early results against the goals laid out in the roadmap. Indeed, it is during this stage that collaboratives builds momentum.

But staying on course entails making constant adjustments and improvements as the collaborative collects data and learns more about what works and what does not work in the community. These bends and twists in the road require that the collaborative's participants meet at least monthly to make decisions based on where the tracked data is leading them.

In some instances new programs may be required. However, for most collaboratives, this stage is more about improving the alignment of existing programs and resources. This steering activity continues as the collaborative develops, receives feedback through new data, and manages its continuous-improvement processes. Done right, this iterative phase will begin to improve the effectiveness of a community's existing programs and resources.

As the work progresses, it is a good idea to highlight early "wins" to maintain community support and excitement. Likewise, publicly recognizing participating organizations and their programs helps build cohesion.

Chicago's Pathways to Success exemplified the Align and Improve stage. Data has determined Pathways to Success' strategy since the question was asked: Who is at risk of not graduating? CPS initially relied on its partnership with the Chicago Consortium on School Research (CCSR) and later The Parthenon Group to profile the at-risk student and determine which interventions were successful in improving graduation rates. Pathways to Success then worked to move the community towards programs that have demonstrated success in helping students graduate. For example, consulting firm Parthenon found that 16 year-old first-time freshmen who attended Achievement Academies, the two-year schools for over-age students who have not met promotion criteria for high school admission, were almost twice as likely to graduate as their peers. As a result, Pathways to Success is looking to expand the academies to a four-year program. If successful, CPS can then roll out an intervention to other district schools and partners.

Finally, it is important to build longevity into the collaborative so that it can weather changes in leadership both inside and outside the collaborative. Because the issues addressed are complex and the process Is long term, many collaboratives will outlive the tenure of any single mayor, CEO, or executive director. Successful collaboratives embed their strategies and roadmaps throughout the systems in which they work, so that a change in any given leader does not halt progress. Building strong consensus around the roadmap or logic model—both internally and with key groups external to the collaborative—creates strong momentum that can carry new leaders with it. It may also be wise to brief the key candidates for elective office to be sure each one understands the collaborative's efforts, the roadmap, and the progress to-date prior to taking office, so that the collaborative leadership can understand where the public official stands.

What will it take to align our community's efforts with the roadmap? What are potential barriers? How will we overcome those barriers?
What is the data telling us about the work of the collaborative? Are we on track? Are metrics moving in the right direction? How can we improve? Are we starting to see early changes in our community, due to the work in the above stage (this assessment may be qualitative at this point)?
Do we have long-term financial commitments? If not, how will we fund this in the next few years?

Align existing programs in the community against the roadmap and create new programs if necessary.

Schedule regular meetings with relevant stakeholders (form sub-committees if the collaborative is focused on multiple goals).
Realign elements of your collaborative as needed, as you start to execute against the roadmap.

Advocate for or enact policy change in the community to change systems.

Develop a policy agenda/plan, in the event that you will need to influence other groups or organizations in your community to change policies.
Include policymakers in your community to help influence the flow of resources to what works.

Test, refine, and course-correct along the way.

Begin to collect and review relevant data points; determine what additional data points will be needed.
Meet regularly to maintain focus on what is working, while quickly modifying what is not working, based on data and findings.
Continue to proactively address any community leadership changes and to ensure the leadership group has all necessary stakeholders at the table.

Develop characteristics of success.

Ensure the vision and agenda are evolving as your collaborative learns.
Make sure leadership and governance structures are clear to everyone and effective.
Grow dedicated capacity and the structure as the collaborative's work expands.
Make sure your resources are adequate for the size and goal of the collaborative (and continuing to grow, if necessary).

Highlight early successes; give credit strategically to bolster the collaborative.

Determine how to share credit with specific organizations and when it should be given to the collaborative as a whole.
Develop an accompanying communications plan and build in regular opportunities to celebrate the success of your work with the public.

Ensure your collaborative's culture is in place and being cultivated.

Test to see if: participants are working together offline, personal relationships have been formed, institutional agendas have melted away, and people are acting for the common good. (Please refer to " Capacity and Structure—Examples of Collaborative Structure—Culture of the Collaborative " for more information on creating a collaborative culture that will promote success.)

Common roadblocks on the way to proper alignment and execution typically relate to difficulty aligning your community's work or challenges tracking the data. Here are some suggestions and resources for addressing these roadblocks.





		Unified New Orleans

Reflect and Adapt (ongoing, starting after Align and Improve)

Reflect and Adapt is the stage after the launch when collaboratives maintain a rigorous focus on improving their evolving work. By this point, a collaborative typically has gathered and analyzed significant amounts of data. Successes have taken place, along with the discovery of significant challenges. Given their track records, collaboratives often make one of two choices at this point: They either expand their goals, or they sharpen their approaches to the goals that have already been established.

During this stage, collaboratives also must confront the issue of long-term sustainability. What will happen to the collaborative in five to 10 years? What will be its legacy? Collaboratives must therefore begin to consider whether elements of their work can be spun off or institutionalized within other parts of the community. For example, with working models now in place, should collaboratives move their operations or aspects of their operations to government, schools, or to nonprofits? These are questions of not only scope and scale but of mission. And they must be answered amid continually changing political and funding landscapes.

Yet some things remain constant. The need to celebrate successes continues to be crucial as does the necessity of regularly reporting data results to the community. And as collaboratives successfully morph in response to changing needs, they usually find that community residents, parents, and youth become ever more active in shaping their daily decisions and future direction.

Project U-Turn , which is now more than six years into its work, is now at the Reflect and Adapt stage. Several key participants from the early steering committee have transitioned to new roles and been replaced on the committee. At the same time, the group has chalked up impressive policy wins, nearly doubling the number of slots available in alternative high schools. In the current era of fiscal austerity, much of the collaborative's work has shifted to protecting these gains and defining the next steps to further improve graduation rates. Many of the most senior participants, who had stepped back from the collaborative to let deputies push things forward, are now re-engaging to set the agenda for the next few years.

Are we starting to move the needle, i.e., see more significant changes in our data?
What is our five- to 10-year vision for this collaborative, particularly in our community context?
How do we manage our collaborative to maintain influence through turnover in participants, changes in political administrations and changing cultural trends?
Are we using data effectively to understand our progress, determine the appropriate adjustments, and improve our collaborative?

Continue to coordinate efforts and track data.

Maintain the active tracking of data and report back to collaborative planners and the community.
Continue to hold stakeholder meetings to execute against the roadmap.
Make system adjustments to ensure that the collaborative's impact is permanent.

Complete the continuous improvement loop between data and programming.

Use data actively to inform programming and to make major decisions about the collaborative's path forward.
Maintain accountability for reaching goals by continuously monitoring the data.
Make modifications and changes as needed, depending on the results of the data.

Continue to proceed with the roadmap and adjust the roadmap as collaborative members have a better sense of what works.

Be ready, for example, to expand or narrow the collaborative's focus to ensure that it is effectively addressing its goals.

Develop a long-term plan, specifically around sustainability.

Determine the required long-term programmatic elements of the collaborative, as well as its organization, infrastructure, and financial-support needs.
Decide whether the collaborative should "put itself out of business" by having its efforts appropriately institutionalized.

Ensure the community is still actively engaged in formal and informal ways.

Study examples of community engagement, specifically those described in " The Next Generation of Community Participation-Examples of Community Engagement ."

Roadblocks typical to the Reflect and Adapt stage revolve around maintaining progress and addressing long-term sustainability. Here are some suggestions and resources for addressing them.

Decide Next Steps: (after 4-6+ years)

It has been a long haul, but this is the stage at which the fruits of collaborative work are starting to show: You are making measurable strides toward your goals and congratulations are in order. Yet after a collaborative has been in operation for a significant period (of from four to six or more years), this is also the time to assess the ultimate success of the collaborative and determine a path forward.

Times change and the community may have too. Indeed, over the years, new external political conditions, new opportunities or even new challenges may have emerged. Now is the time for a collaborative to evaluate its role within today's context. As they take stock, many collaboratives face three options: whether to seek new ways to become more effective, whether to address other challenges or opportunities, or whether to end on a high note.

The variations on such future roles are numerous. For example, a collaborative might decide to:

Maintain its current structure and role, as long as it can continue to have significant impact.
Utilize its structure but change its mission to address new goals.
Institutionalize the gains made by embedding them within a public agency—such as a school or a health department—and transition out of existence.

Celebrations become most poignant in the last instance, but it remains critical to regularly mark successes and thank those involved no matter what the future holds.

Milwaukee's Teen Pregnancy Reduction Initiative is now working to decide its next steps, having reduced births to teen girls by roughly 30 percent over the last five years. The oversight committee of the initiative believes the data will continue to improve as positive messages are reinforced both in schools and in out-of-school programs for kids before they become teens. United Way of Greater Milwaukee will maintain its support of the collaborative, but having shown its unique ability to convene and staff effective collaboratives, it is now launching a related initiative to reduce infant mortality.

Have we achieved our goal? Is there more progress that could be made?
Will the gains be maintained if the collaborative were to disappear tomorrow?
If we decide to end operations, what is the best way to communicate this and thank the community and stakeholders who were involved?

Assess your progress to-date.

Determine if the interventions are working and if you have achieved your goals.
If unsure, discuss if you are on track and how you should proceed.

If you have achieved your goals, decide on a path forward (options include continuing, adapting to a new form or focus, or ending well).

Determine how to proceed over the next three to five years.
List the pros and cons of each option, including how and who it will impact in your community.
Formally create a roadmap forward based on your discussion of the options.

Ensure that institutionalized efforts are being supported.

Ensure that your efforts will live on in existing institutions (such as school districts, government agencies and nonprofits), in terms of funding, public support, and continuing impact.
Work to transfer the knowledge and processes that made the collaborative successful to the new host organization.

If ending, make sure to acknowledge successes.

Recognize the successes of the collaborative publically.
Honor the community and stakeholders who led the effort.

Taking stock can result in the following list of roadblocks. Here are some suggestions and resources for addressing them.


	Stakeholder engagement
	Community engagement
	Knowledge center, general resources for education-focused efforts
	Setting goals
	Range of resources for launching and sustaining community schools
	General guidance
	Case studies, general guidance	findyouthinfo.gov
	Parent engagement, research reports (i.e., dropout crisis)
	Community engagement
	Support for collaboratives focused on educational goals
	Support for collaboratives on community engagement
	Community engagement
	Sample documents about the foundation's efforts
	Range of resources for youth and education initiatives (case studies, tools, strategy guides, research)
	Research reports, policy briefs on youth-related topics
	Case studies, general guidance
	Range of resources for continuous improvement, general guidance

Building Back for Equity: Guidance to Inform 2021 Early Childhood Grantmaking

Social mobility in rural america: insights from communities whose young people are climbing the income ladder, youth unemployment: confronting the elephant in the room.

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Child sexual abuse: a case study in community collaboration

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1 University of Michigan School of Social Work, Ann Arbor 48109-1106, USA.
PMID: 11057707
DOI: 10.1016/s0145-2134(00)00171-x

Objective: This is an exploratory study that describes the process and outcomes of a Midwestern US community's approach to case management of child sexual abuse.

Method: Data were abstracted from 323 criminal court files. Specific information gathered included child and suspect demographic data, law enforcement and CPS involvement, child disclosure patterns and caretaker responses, offender confession, offender plea, trial and child testimony information, and sentences received by offenders. Both case process and outcome variables were examined.

Results: In this community, criminal court records reflect a sex offense confession rate of 64% and a sex offense plea rate of 70%. Only 15 cases went to trial and in six the offender was convicted.

Conclusion: Communities can achieve successful outcomes when criminal prosecution of sexual abuse is sought, but the child's testimony is not necessarily the centerpiece of a successful case. In this study, desired outcomes were a consequence of the collaborative efforts of law enforcement, CPS, and the prosecutor's office, which resulted in a high confession and plea rate.

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From Research to Real Life Podcast

Episode 2 | Research Health Equity and Community Engaged Research | From Research to Real Life Podcast

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In this episode our host, Gelise Thomas, JD, MS, Director of Research Health Equity for the CTSC sits down with the Yvonka Hall, MPA, Executive Director of the Northeast Ohio Black Health Coalition. Yvonka tells us stories about her life, her motivation behind the Northeast Ohio Black Health Coalition, applying lived experience to effective community engagement and impacting health equity, her Long COVID research with Dr. Grace McComsey, work with the CTSC, and more!

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Community Engaged Research

“I want to help you just as much as you can help me. And I think that that's part of the most effective community engagement, is that at the end, the community has helped me as much as I have helped them.”

-Yvonka Hall

Gelise Thomas : Hello everyone, and welcome to From research to Real Life. I'm Gelise Thomas, Director of Research Health Equity with the Clinical and Translational Science Collaborative of Northern Ohio. I’m incredibly excited to be hosting this episode focused on research health equity with our guest, Yvonka Hall. How are you doing today, Yvonka?

Yvonka Hall : I’m good, how are you?

Gelise : Fantastic. I feel I'm sitting here with a legend. We are at 1464 East 105th Street in Cleveland, Ohio, in a building formerly known as the Medical Associates Building. This building was designed in 1960 by Robert P Madison. The first licensed Black architect in the state of Ohio, and it was for Black doctors who were excluded from practicing at local hospitals. Our gracious host is Third Space Action Lab.

Third Space Action Lab was created to disrupt the vicious cycle of disinvestment and displacement that exploits low income communities of color. They are a grassroots research strategy and design cooperative dedicated to prototyping creative, place based solutions to actualize racial equity. The CTSC hosted its first Minority Health Townhall in 2023, in Third Space’s Reading Room, the only Black owned bookstore in Cleveland, where we've also purchased over 600 books to support our annual Health Equity Challenge Series.

Yvonka is the executive director of the Northeast Ohio Black Health Coalition, the first organization in the state of Ohio dedicated to addressing disparities in the Black community. Yvonka is a member of the CTSC's inaugural Community Advisory Board, Community Engaged Research Network, and READI, Set, BRACE Experience. Yvonka, thank you for being here with us today.

Yvonka : Thank you for having me.

Gelise : So let's get to it. From led to flavored tobacco to the environment. When we think about public health priorities. And someone was leading the charge locally and nationally to eliminate health disparities, you are synonymous with search engine results, which I'm sure you're aware of! A self-proclaimed agitator, can you tell us a bit about who you are and why you do what you do?

Yvonka : So I am Yvonka Hall, the Executive Director of the Northeast Ohio Black Health Coalition, the nationally recognized Northeast Ohio Black Health Coalition. We are the first coalition in the state of Ohio to focus exclusively on African-American disparities. Our work is to create equity by addressing the cumulative impact. So we look at everything around the air, the land and water. So the impact of racial, economic, environmental and social justice inequities. I started doing this work and think, you know, we all find our calling. And this was my calling. So I've been doing this work since I was six years old. and for people who know me, they know my story. But my mom was murdered in front of myself and my younger brothers. And I promised that I would use my life to help change the lives of others. And that has led to the creation of some cutting edge programs, and the ability to help change the lives and directions of many people in my community. That's important to me that that is why this work is important. The Northeast Ohio Black Health Coalition was birthed out of a – We hosted a local conversation on health disparities in 2004, here in Cleveland. And so what happened is we were the first people to host this local, effort on health disparities. And we divided, communities out into racial and ethnic groups. during these conversations, the groups were they went into rooms and decided to what they wanted to focus on, like, what do you want to focus on?

So the Hispanic/Latino community, the Asian/Pacific Islander community, the Native American community, all went into these roles. And there were people who went into another world and said, we want to talk about Black folks. And so when they came out, they came out with enough of some nonsense for me to say, we need to have an office just dedicated to the unique needs of the African-American community. And that is where the Northeast Ohio Black Health Coalition was born on 8/1/2011.

Gelise : Love it. From passion to purpose. So one translational science principle is prioritization of initiatives that address unmet needs. You just talked about some of those unmet needs. how do you use the Northeast Ohio Black Health Coalition to address some unmet needs?

Yvonka : So I think for the Northeast Ohio Black health population, our strength is being able to work with community partners, across the board to be able to help, to engage communities that are hard to reach, and translate information into a way that they understand because that hasn't always happened. So what has happened is, you know, projects come into the community with very little community input and then the community kind of feels left out, like their voice is never heard in these projects. Things get finished and they say, well, we didn't ask for that. That's not what we wanted. What we wanted was this. And so I looked at and I said, because of how I am able to pull together people and information, I can, help coalesce folks to, meet the community where they are and provide the services, in the capacity that the community needs, and then help translate it in a policy. Because at the end, if I don't do anything to change policies that disproportionately impact my community, now, I'm not doing my word.

Gelise : Absolutely. So you talked about listening to the community, hearing their voices and being that bridge, being a resource to make sure that policies are changed. How do you define trust and how have you built trust amongst the community?

Yvonka : Wow. So trust is, you know, looking at, you know, understanding how people receive information, how they perceive other folks, and kind of balancing out the mistrust, the things that have happened to cause the community to not trust folks that are coming in. I’m the community. So, you know, there's a quote that says, you know “Be with the community, you know, help them find their voice. And then at the end, they'll say they did it themselves.” And so for me, that person, they help them to be able to find their voice. And I think that that's what builds a trust is because they know that at the end, it isn't about me. It's about them. And I think we have to remember that in all of our aspects of research, and all of our community engagement pieces, that at the end of all of this, it's not about us. It's about how do we, what do we create in order for the community to do better when we leave? Because research doesn't last forever. And so, because it doesn't, you know, what are what are some of the things that we can use as earmarks that are benchmarks for long term change in communities?

Gelise : Thank you. Now, I've also heard you elevate the fact that the word equity is defined and understood differently by various people, how do you define equity and what does it look like for the work that you lead?

Yvonka : Wow. So so I think it's a whole -- So I think people define equity by their own experience. So if you have not had food then equity is to give me some food. Or to give me a sandwich. Like I'm hungry, give me something. But what happens is I think that because it's so many people trying to define something for my community, that my community has been left out of the equation. And so we have there is a, a picture that has people at a fence. It has these boxes. So it starts off the first one is, inequity. This next box is they give you a box that’s your size, and so that's equity. And then now they have one that they move the fence and the fence is justice. And so what I'm here to tell everybody is none of that is equity.

And none of that is equity because the, the not having the right box, having a box the right size, removing the fence didn't change the fact that that community is still being treated differently than the other community. So in that pictorial, the problem is the Black people are standing at a fence and then you move the fence. So now you move the fence and I'm still standing on the outside watching the other communities enjoy the game.

So my grandmother was born in 1931. In 1940, my grandmother went to a baseball game. She was nine years old. The African-Americans had to stand and watch the game, right. So that was not equity in 1940. So how could something that was not equity in 1940 all of a sudden be equity and justice? So if you really want to get to equity, put Black people in the stands, make room for us to have seats at the stand, in the stands, make room at the table for African Americans to have a voice that is true equity, making sure that people have their voices heard in all of these discussions that are going on about their community. And so in that case, make sure that Black people are part of the game. Make sure that if we if you were sitting in the stands, that we're sitting in the stands also, because I think that that's the other thing around that pictorial is that people don't understand when you're looking at it, you're looking at the people at the fence and don't realize that the people that are sitting in the stands are all white. And so change that around and you actually have equity and stop letting people hijack what equity is to you.

Gelise : Absolutely. In 2022, Black people made up 15% of participants in new drug and interventional clinical trials between 2010 and 2021, and 8.5% of participants in oncology or cancer clinical trials. We've seen the need to increase diversity in research, specifically clinical trials, in the headlines over the past couple of years and more recently in connection with the FDA's draft Diversity Action Plans guidance. In what ways has the trust that you earned and built helped advance research that the Northeast Ohio Black Health Coalition has led or supported?

Yvonka : Well, I think that because our strength is in our ability to work across these multiple sectors. So I'm able to translate things from the university to the community, and let them know where they fit in and why it's important for their voices to be there. And I think that that hasn't always happened. You know, I mean, in our community in particular. But I think that when we talk about research projects, we still have to remember that there's still this little thin balance around community engagement and research. Research is not community engagement. Research is research. Community engagement is community engagement. And so I think that a lot of times what happens is researchers say, oh, well, this research is community engagement. It's like No, you know, it's a whole different way to talk to the community about engaging them. And part of it is addressing the mistrust of the research establishment in the first place.

Being able to talk openly about Dr. Marion Sims, about Henrietta Lacks, about the Tuskegee Experiment that was not a study. It was definitely an experiment. To talk about all of the other experiments that have happened to communities of color, in particular African Americans. And not just experiments that took place 30, 40, 50 years ago, 60, 70, 80, 90, 100 years ago. But we actually have some stuff that has taken place, you know, within this lab in this century. You know, and so understanding how those things impact folks and then saying, okay, we understand that this happened because we have to admit that it happened fast, because I think that that's the other thing, is that people are like, is this going to happen to me again? But do you talk to them like I will walk you through this process? I will walk you through this process or any other any questions that you have I am here to answer them and I think it's being there for the community helps change their outlook on research.

Gelise : And what are some ways that the academic institutions and other organizations, health care systems, etc. can show that they are there for the community? And like you said that there is a distinction between research and community engagement and the acknowledgment of it?

Yvonka : Hire some Black people. So, you know, part of it is and now don't just hire housekeepers. Don't just hire your support staff. Hire people who are your administrators who are the people who are running programs, that look like the communities that you seek to serve. Because if you actually really seek to serve me, then you're going to have someone who looks like me, that’s talking to me about the things that are going on here. And so I think we had this whole thing around, if we make it 1%, if we do this 10% is make it right. Make it fair. Make sure that if you're going to talk to people about their disparities, that you're not talking about it from a second or third person, that you're bringing someone in that actually understands what's going on with the community. And that means training young people, getting young people involved, and an early age in elementary school. And then helping to walk them all the way through to get our future doctors, our future nurses, our future academicians. Like we need young African-Americans to know that there is a way this is different from what they have been seeing or what they see on TV. And I think that's like universities have an opportunity to change the dynamics that have played out around the engagement around the university.

My grandmother worked at the University in the cafeteria, and she wanted to be a nurse. Just think of what the university could have done for her to help her get into a nursing school could have changed her life, but instead she was a cafeteria worker. And in 1978, her yearly pay for the whole year working at the cafeteria ‘cause cafeteria workers worked at the cafeteria at the university, but didn't work for the university. Her whole paycheck for the whole year was $1,200. She made $1,200 for doing backbreaking work for 40 hours a week in the cafeteria. And we could have really, really changed her life because she wanted to be a nurse. We have so many young people with aspirations. I think part of enhancing research is to help the young people who have aspirations to see them come to fulfillment and then allow all of their dreams. I never dreamt that this would be me, that this would be my life. I mean, I came from a broken home. My mom, my mom was murdered by my dad. My parents were divorced. Like society said, there was nothing else for me. It was nothing else that I could offer for society. They had already painted a picture of what my life was to look like, and other people stepped in. And my neighbors, you know, my teachers, people from the community, they all stepped in and said, you got too much of a mouth for us to have you over here doing this. There’s something else for you. And I'm grateful.

Gelise : And Cleveland.com agrees! They honored you as a Homegrown Hero in 2020 for your work supporting families during the onset of the COVID-19 pandemic. How did you and your organization support members of the community during that time?

Yvonka : Hah, you don't even want to know. So, I just left California doing some work in California when we determined that something was here that we couldn't even, we had no idea about COVID. Like, what the heck is going on? From a research background and from looking at HIV and AIDS, I'm like, okay, it has to be something to address the potential of elderly people who are raising their grandkids, who have these comorbidities. If they die, what's going to happen to their grandchildren? So their grandchildren who have been raised with them and been sheltered? Because I was sheltered, I was protected, are going to end up in these systems. And how do we keep that from happening? We make sure we get them food. We made sure we get them PPE equipment, we make sure we get them dishwashing liquid, we make sure we get some games. We make sure that we give them everything they need for them to be safe in place. Right. And it's like, how do you do that with no money? And so I had this whole, you know, conversation with a higher being, like all night long. And it was like, you got to use your credit card. I'm like, no, go for somebody else for this assignment.

And so it became my assignment. And so my assignment was to use my credit card to go buy food for 125 children. And that's just the children, that's not the entire, that's not all the families. Right? that's not counting grandma, granddad or mom or dad or, we got these houses that got everybody. You got mom, dad, grandma, granddad. And so I put $10,000 on my credit card, and out of blind faith, did it the first time and asked for some volunteers. 100 people showed up. We started bagging up stuff. The next month, put the next $10,000 down. The first $10,000 have been paid off. People gave me money. I said, okay, paid that, paid it off. And then I would come to the door. We were finished. We were exhaling like, yeah, we're done with the food for the day. And they would say, it's a knock at the door. And I would go out on my front porch and it would be like 300 boxes of Cheerios where someone ordered a lot of stuff from Amazon, and it would just be out there. And so by our sheer efforts and determination, we send out 250,000 meals in two years to disabled children and their families and I am I'm grateful for every minute of it. It helped me to be a better person and help the organization to do some work that we had already been doing, but it kind of put a spotlight on, like, they're actually really doing the work. Because doing the work is more than just saying you're doing the work is actually doing the work. And so nobody was sitting up at me at night when I was like, putting gift bags together for the kids so they could have birthdays. I could I remember one day cutting up birthday cake because I'm like, who missed their birthday while we're going through all this. Sitting at night cutting up birthday cake so we can make sure that we send out a slice of cake to every child.

And then I remember going to a home and the mother said, “we're so happy that you came to deliver today!” And, she said, “because he's been waiting to see you!”, because he saw me the first time, and then he had this thing at me, and he was autistic, aged. So he's been practicing since you left. And I walked off. “Well, you know, what do you. What's going on?” and he said, “thank you!” and I was like butter, just melted. I'm, I'm a softy. Even though in this world, you know, I think people think that I'm, that I have Kryptonite, that I'm, you know, Superwoman. But I am a softy. especially for the little ones. I don't want to see kids go through what I went through. And if I can find a way to kind of be the bridge between getting them the things that they need and help in their lives, a change, for me, unlike some of these children, I don't know what it's like to have people who support them. And so I want to be the person where if they had an opportunity to change their life, that I could be the person that supports them.

Gelise : Incredible. What you do, what you're doing, what you will continue to do is just absolutely incredible. So thank you so much for doing what you do; for doing the work. I mentioned at the top of our conversation that you are a part of the CTSC ‘s Inaugural Community Advisory Board and Community Engaged Research Network. Can you tell us a little bit about your involvement so far. And just overall, what has been your, what kind of benefits have you received from being a part of the CTSC?

Yvonka : You know, I think actually when I first came in, I said, this is about to be some garbage. And I, I don't even know if this is going to work. I might be here for a minute and then I'm out of here. But I think being in a room and getting a chance to hear other voices that I have not met up with in the community, being able to talk to them and hear them talk about the programs that they're doing, the things that they're doing in the community. Meeting folks who have a like mind is important in this work. And then meeting people who have a difference of opinion than you because I, you know, in my work, I'm, you know, most of the people that I meet, you know, they sound like me, you know, and so many folks who don't necessarily sound like me, but they come at community in a whole different way. I think that that's what this piece has brought to me is that meeting people who are my counterparts, and that they're ready and willing to help with the elimination of disparities and they help make this community whole, like they found their niche. But we need each other in order for us to do this work. And I think that that's one of the things that the CAB has taught me is that this is not something that I can do singularly, as Yvonka Hall, because I think I can do a whole bunch because I think I can wear 50 hats, but I need my other counterparts in order for me to be able to actually do this work.

Gelise : Love to hear that, that it's been a good experience for you so far. Are there any relationships or connections or even collaborations that you're looking forward to as you move into year two of your service on the CAB?

Yvonka : I know I've talked to people about some of the other work that I do outside of here to kind of, goes into the work that we do here. Like, I'm actually part of the National Environmental Justice Advisory Council for the EPA, and, I'm the Chair of their farmworkers and pesticides group. And so we have a young lady as part of the CAB that actually works in a community that works with migrant workers. And I'm like, look, I have a report that's actually going to help change their lives, you know, what can you offer to this report? Because we want to make sure that the voice of our migrant workers here in Ohio was heard, because I've heard from New York and I've heard from Texas and I've heard from Florida. And I think that that's the other thing is that because we work in silos, that we all of us, we don't get a chance to hear everybody's voice. And so for me, if I'm in a room and I get a chance, I hear somebody say “I do such and such”, I'm like, okay, tell me a little bit more. And then, working with one of the young ladies that works with the LGBTQ Center about some of the work that they're doing over there.

How does that gel with the work that we're doing with the Northeast Ohio Black Health Coalition? And then just hearing her story, you know, talking about some of the things that are going on her life. And I think that that's one of the other things is that we know that we all have these stories to tell. We get into these, places and we become part of an organization and not so much individual. And so being able to have that individual feel like what's going on, what people individually. I think one of the questions out, one of the I was like, how do you feel about today? How do you feel about the weather? You know, and you get a kind of chance to, to hear, what other people are feeling and going through. Like, I love to travel. And so, you know, they're like, where you where are you at today? You, you know, are you here in Cleveland or are you somewhere else? And I'm like, I'm somewhere else, but I'm still working, you know? So no matter where I'm at, you know, that tablet is still with me, the laptop is still with me, and I'm still on go. So I'm still on the go for Cleveland. And looking at other people and seeing them feel the same exact way has been a great experience with the CAB.

Gelise : Excellent. Also glad to hear that. So for our listeners who aren't familiar with what Community Engaged Research is, Community Engaged Research is a process that incorporates input from people who the research outcomes will impact and involves those people or groups as equal partners throughout the research process. You talked a lot about that and the importance. This involvement could include co-designing research questions to solve problems, making decisions, influencing policies, and creating programs and interventions that affect their own lives. We've invited you to be a part of the Community Engaged Research Network. What influenced your decision to join that? As you know, you and I, we have a relationship prior to my time at the CTSC. What drew you in to becoming a member of the Community Engaged Research Network?

Yvonka : You. So I have had a relationship with you because we met in another light.

Gelise : And then it was “can you be a part of this, can you be a part of this.”

Yvonka : Yeah. Can you. And, and I said but you know what I think people who are, who I look at as saying this person has leadership qualities and potential, it can actually help really change some stuff. Those are the people I want to be at the table with, because there are so many people who only look at the four walls and they understand nothing about what happens outside. And I think one of the reasons why I was willing to join Gelise is because she does understand what's happening outside. If I'm sitting at a table and you're not willing to speak up for the community then I'm done, and I'm out of the table, I'm like, “Oh, we not speaking up for Black people here? Time to go!” because, you know, my voice has always been to use it to change the community, even if it meant losing a job or losing a position. Community always comes first. And so I don't think people outside of this understand that enough about me, you know? Is that they know - they don't understand that I lost my career, for speaking out about an issue that was going on in our community and so I'm willing to go the extra mile because I'm willing to fight with King Kong about my community.

I trust you. And that that wasn't one of the other things you. I get asked a lot to be part of all types of things. And so when I look at the table, I look at whether the person at the table is willing to talk about the community, willing to break from other voices that are at the table, because so often what happens is, you know, we get to these tables and everybody that all of a sudden was loud in the parking lot, you know, they get there and nobody's talking about the communities that they came here for. And so I didn't see that with you. And so that is what brought me, attracted me to the work that you're doing. It's because I see you as, an ally in this work. And we need people who are allies. And you're young, so you're going to be here when I'm long gone. Being able to carrying on this work. And so for me, I want to help, I want to help you just as much as you can help me. And I think that that's part of the most effective community engagement, is that at the end, the community has helped me as much as I have helped them.

Module Feature : We'd like to take a moment to introduce you to our Community Engaged Research Team with a special message from Dr. Shari Bolen.

Dr. Shari Bolen : Hello. My name is Shari Bolen, an internal medicine physician, professor of medicine and cardiovascular health researcher at the MetroHealth system and Case Western Reserve University. I am co-leading with Darcy Freedman, a professor in the Department of Population and Quantitative Health Sciences at Case Western Reserve University, the new Community Engaged Research Module of the Clinical and Translational Science Collaborative of Northern Ohio. With this new Community Engaged Research Module, we aim to develop a network of community and other partners to align in our efforts to translate research into practice and policy to advance health equity, to have the greatest impact in our research on health for all populations. We need to develop and maintain trusted partnerships and build capacity within our research groups to engage with these partners.

Therefore, in addition to building a network of partners, we have developed a number of services to enhance capacity and community engaged research, including a consult service where people can get questions answered about community engaged research, we have website resources around community engaged research and team science, we have a mentoring program that's starting soon for those new to community engaged research, we have co-learning events where researchers and partners can come together to learn more about specific community engaged research topics, we have community engagement studios for those interested in getting community input on their research, and voucher awards of up to $7,500 in funding to help with preliminary community engaged research efforts needed to obtain larger scale grant funding. If you are interested in learning more about how best to use some of the module infrastructure and resources, I encourage you to visit our website linked in the description, and submit a SPARCRequest to meet with our consult team, who can guide you through how we may be of service.

Gelise : Let's talk a little bit about your future academic community collaborations in terms of research, you've recently applied for, and were awarded a CTSC voucher to support a research project that focuses on COVID-19 with the CTSC's Principal Investigator, Dr. Grace McComsey, an internationally known HIV researcher and leader of one of 15 nationwide REsearching COVid to Enhance Recovery or RECOVER hubs. And you mentioned your RECOVER service. Black people make up 3% of participants in major COVID-19 vaccine clinical trials, while representing 21% of COVID-19 deaths. What can you tell us about your project and the importance of academic community collaboration to advance health equity?

Yvonka : So first, I can tell you that the RECOVER hub, I’m part of the RECOVER hub, and I actually chair the Health Equity Committee, I've actually worked into some other pieces. One of them was around, the neurological impact around COVID. But when we talk about this 3%, it’s 3% nationwide. But when we start looking, diving into what's going on in these individual cities, we have very few African Americans that are participating in Recovery studies. Although we look across the board at the number of African Americans who have been disabled as a direct result of COVID or have lost their lives. So on a personal note, I lost more than 65 friends with COVID during COVID. 65. 6-5. And these are people who are my age. You know, they graduated from high school the year before me, the year that I graduated, the year after -- they're gone, they're gone. And so, they when we talk about the years of potential life loss, like the years of potential loss, knowledge loss for our community, when we start losing people in our young, like the knowledge that they're able to pass on to their children and they're gone, you know, and so, looking at the looking at some of the reasons why African-Americans aren't in the study is what drove me to this whole thing. And so my piece is addressing implicit bias in medical settings and the impact of Long COVID, clinic and clinical trial access in African-American communities. That for me was important. I'm sitting on Zooms. I see very few African-Americans. Usually it's like me and two others, and so I'm like, if this is what this looks like, this RECOVER meeting, then what does a Recovery clinic look like?

And I'm sure it looks like one of the cities I visited today. And so for me, that we know that African-Americans, who are coping with undiagnosed or unrecognizable Long COVID symptoms and the importance of working with them to reduce, some of their barriers to timely, Long COVID access in clinical settings, like, I think the more we can get them involved in research studies to find out what's going on, the more we can help with other COVID things that, ‘cause COVID hasn’t gone anywhere, I think that's the other thing is that we're like, oh, COVID is gone. And it's like, where did it go to? We have, you know, a new version of COVID, FLiRT. And so we look at the number of people who have COVID currently, and our numbers look like what they looked like a couple years ago, but we're really still not talking about it. And so or just the impact, the medical impact, and why it was important for me to have this.

I'm a COVID Long Hauler. So if y'all see I'm having a hard time remembering words. And part of that was the whole thing around Long Haul, you know, is that my my piece was brain fog. but I also had an uncle when we all had COVID together. Me, I was the ten of us, who were together, had COVID. Three of my young nieces and nephews are autistic, and I wonder if it was directly related to COVID because they didn't start speaking when they should have. And I'm like, did they have brain fog and we don't know how to define it in children? That's one. The other is I had an uncle who when we had COVID, I talked to him one day and his arm was fine, it looked like mine. And the next day he was holding it and I said, “well, what's going on with your arm?” And he said, “I don’t know, you know, it's kind of hurting.” And I said, “well, you know, you need to go to the hospital.” He said “no, I'm not going.” The next day, his arm was in black, and the next day his arm was amputated. My uncle lost his arm from COVID because of the blood clot. There were people who lost toes, who lost fingers, who lost their sight. We don't talk about that. And so what I want to do is make sure that the people who have the stories that are untold, that they’re able to tell it and they can't tell it unless they're actually in a clinic to be able to tell the story of what's going on with them, so that we can help them to be able to to extend their life. And so that's why, this piece is so important to me.

Gelise : So what advice do you have for community members who would like to be a part of research? I mean, the stories that you just told really amplify the importance of being a part of clinical trials.

Yvonka : Yeah, I think to talk to them and say, let's help to alleviate the fear. If that means I have to walk you through it, if you have questions and you want to ask me about, you know, that I'm here for you. I just talked to someone and they said, you know, when do you turn off? And I said, you know, I don't actually turn off. You know, I've actually had people who would call me at 2:00 in the morning and say, oh, Yvonka I got a question. And I'm like, okay, well, what's the question? but I think that being here for people, to help them as they're kind of going through this journey. ‘Cause this is the journey. Being involved in a medical setting for African-Americans who've been so distrusting of medical settings and being involved in a research setting which has meant even more distrust is very hard. And so the, the stressors are there. How do we alleviate those stressors? How do we make research, not only important, and valuable, but fun for people who are, who feel like they're going under the knife because that's what people feel like. You know, if they're like, “oh, you want to sign up for this study?” And they're like, “uh-uh I don’t want to do it.” Okay, well, let me explain a little bit about it to you. And so for me, I have never had that problem. When I actually started off doing this work 30 years ago, 30 years ago, I was doing HIV research, and we wanted to do this whole piece around educating folks about the dangers around HIV, but encouraging them to get a test. My testing rate was 100%. The rate of follow-through at 3 and 6 months later, everybody else had dismal numbers and theirs were and mine were like 90, 95, 98%. And they said, well, why do your numbers look like, look different from everybody else's? And I said, because I meet people where they are, like, I'm like, I'll meet you at the McDonald's around the corner from your house. If I can't meet you at home, I'll come. I'll come to your work. We can come. We can come sit in the car. We can go sit at the lake, you know?

And then I would have folks where I would go to their house. And, you know, most people, when you go to their house and they offer you a drink, you say, I'm good, I don't want anything. And I remember going to a patient's house and she said, “I'm get ready to fry some chicken.” And I said, “you know how to cook?” And she said, “oh yeah I know how to cook.” I said, “okay, well, let's, let's, let's try this out.” And after that, every time she came to, she was looking for me. “Where’s Ms. Hall at, where’s Ms. Hall at?” And they say “your girl is here looking for you. She's here looking for you today.” And, she told me things that she would never have told her doctor. And so I was able to help with a better, with a better health outcome for her because I was able to go back to our doctor and say, look, this is what's going on. This is how you can better help her.

And I think that that that we have to understand that medical setting isn't just the doctor in the patient, it's the whole system in the patient. And that's why when I worked at the hospital, when I would work with residents, I introduced them to everybody they knew the housekeeping staff, they knew the staff that was, you know, doing the labs. They knew everybody. And they said, well, I don't have to know everybody. I said, because the patients know everybody. And the patients talk to everybody, because these other folks here live in the communities with these patients, and they're going to talk to them first so they know more about your patient than you do. And so they're able to come tell you some stuff that's going on with your patient. And they help with better patient care. And so what we saw was my program was phenomenal because, you know, they're like, look, we can't give you any more money because you spend everybody else's money in this research project because nobody else has money, because every week you coming back going “Okay. I'm finished. I don't have any money left. Like all my stuff is gone.” and everybody else is going: “You saw 50 people already?” and I'm like, yeah, my office is busy every day. So I think we just have to be human about it. And I think that that is the whole thing is that I’m me no matter what setting I’m in. I can't change who Yvonka Hall is.

But, you know, I think the other thing is that some people try too hard to be people who they aren't. But what we do know is that, you know, studies have shown that although if you are not of that community, if you're working with the community and you just kind of help understand the things that are going on, people understand it, that you're trying, and all we can do is try.

Gelise : Absolutely. So what advice, since you've worn both hats as a researcher and as a community member, would you have for our academicians, researchers, physician scientists as they try to infuse more research health equity into their programs and studies, and across their research teams? So you mentioned workforce development and how representation was important there. What is one thing that they could do today that would help increase diversity in research?

Yvonka : Well, well, I talked about workforce development. I talked about bringing students in, you know, bringing them in when they're young. I think it's just being themselves, you know, trying to work with the communities that some of them have never been in the community besides the work that they're doing. And so not wanting to say, I know it all, but going in and say, how can I help you to make your community a better place? What can I do for you that'll help change the conditions that are going on in our community? And not saying I know everything that can change our community, because that's what usually comes in, is I look, I came here with a cure for you, and it's like, well what’s wrong with me? You know? And I think it's, you know, not telling people that, oh, well, this is what's wrong with your community. It’s, you know, can I help your community to be better? What's not working? What can we do to help change the things that are going on the community from a research standpoint, from a policy standpoint, like what are some of the things that we can put in place to help your great, great great grandchildren? If we can do it for you, what can we do to change the conditions for them?

Gelise : So what can we do for you? What are some upcoming engagement opportunities? How can our listeners support the Northeast Ohio Black Health Coalition and all of the work that you do, research policy and beyond?

Yvonka : Well, we do lots of community, activities and engagements. They're on our website. So our website is www.NEOBlackHealthCoalition.org, or they can email us at [email protected]. And we have an annual conference that we do this year. It's it's always “The State of...”. And this year is The State of Reparations in the African-American Community, because that's a topic we don't all talk about. So it's an opportunity to talk about what does reparations look like in a health setting. Like when we talk about health care, what does it look like? And so it's an opportunity for people to just kind of understand some of the things that are going on and some of the voices from across the country.

Gelise : Yvonka, thank you so much for taking time to talk with me today to give our listeners all of the insights. Make sure to visit the websites linked in the description to learn more about research, equity, accessibility, diversity and inclusion, or READI; research health equity and our upcoming programing and webinars; community engaged research; and more about Yvonka Hall and the Northeast Ohio Black Health Coalition. Yvonka, thank you again.

Outro : From Research to Real Life is brought to you by the Clinical and Translational Science Collaborative of Northern Ohio. The views, recommendations and opinions expressed in this podcast are those of the presenters and not necessarily those of the CTSC or its partners.

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Published: 19 August 2024

Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia

Malizgani Paul Chavula ORCID: orcid.org/0000-0003-1189-7194 1 , 2 ,
Tulani Francis L. Matenga 3 ,
Patricia Maritim 4 , 5 ,
Margarate N. Munakampe 4 , 5 ,
Batuli Habib 3 ,
Namakando Liusha 6 ,
Jeremiah Banda 7 ,
Ntazana N. Sinyangwe 8 ,
Hikabasa Halwiindi 1 ,
Chris Mweemba 4 ,
Angel Mubanga 9 ,
Patrick Kaonga 7 ,
Mwimba Chewe 4 ,
Henry Phiri 9 &
Joseph Mumba Zulu 3 , 4

Health Research Policy and Systems volume 22 , Article number: 112 ( 2024 ) Cite this article

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Metrics details

Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia.

A qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance.

The principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.

Conclusions

Principled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.

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Introduction

Multi-drug-resistant tuberculosis (MDR-TB) infection is a major global public health concern, with TB remaining as one of the top 10 leading causes of morbidity and mortality, especially in low- and middle-income countries (LMICs) [ 1 ]. In 2022, the global MDR-TB burden estimate was at 410 000 cases (CI 370 000–450 000) and only 176 000 (43%) were initiated on treatment [ 2 ]. The burden of MDR-TB infection and disease is unevenly distributed globally, with LMICs disproportionally affected due to high poverty levels [ 1 ]. Zambia is among 30 other countries with the highest MDR-TB burden in the world [ 1 ]. In 2022, Zambia had an estimated burden of 1900 MDR-TB cases, but only initiated treatment in 362 cases in the same year (WHO 2023 Global TB Report). The country recorded a treatment success rate for MDR-TB of 79% for the same year, which was lower than the treatment success rate for drug-susceptible TB, which was at 92%. The sub-optimal treatment success for MDR-TB cases is attributed to the complexity of the TB bacterium called Mycobacterium tuberculosis, as it undergoes mutations, rendering it resistant to first-line drugs crucial for TB treatment, hence requiring a more comprehensive and multifaceted approach during treatment and care [ 3 ].

Studies have highlighted risks and susceptibility factors, which drive MDR-TB infection. These include gender, residence, history of previous TB treatment, lack of knowledge and poor adherence to treatment, treatment failure, presence of MDR-TB in the family and low economic status [ 5 , 6 ]. Further, treatment success is hindered by adverse events that may arise during treatment, including vomiting, skin rash, anaemia and peripheral neuropathy [ 7 ]. Drivers for unsuccessful treatment outcomes include social stigma, negative experiences of physical and emotional trauma, lack of social support and non-responsiveness to healthcare services [ 8 ]. Therefore, while MDR-TB is driven by various factors such as gender and social support, its successful treatment faces challenges from both side effects and patient experiences.

Prevention of MDR-TB infection is part of the global agenda of Sustainable Development Goal (SDG) 3 (Good Health and Well-being), thus, in practical terms, the aim is to dismantle inequalities and increase universal health coverage [ 9 ]. Many countries are adopting decentralisation of MDR-TB services through health systems strengthening as a critical way of ensuring timely service delivery to all people. Global partners and international organisations are playing a critical role in strengthening the health systems through resource mobilisation, and investment into improving infrastructure, diagnostics, health information and human resources for health development, to enhance service delivery [ 10 ].

Studies have revealed that decentralisation of MDR-TB healthcare services has had significant advantages including improved accessibility, and timely delivery of care particularly for rural areas [ 11 ]. In Bangladesh, decentralisation contributed to enhanced collaboration in localising MDR-TB medical services, adapting them to local preferences and needs [ 12 ]. However, governance issues such as fragmentation and poor coordination remain significant gaps limiting equitable resource distribution for MDR-TB services, including infrastructure inadequacy. Many other challenges, however, are faced by many countries in trying to combat TB and attain the WHO global target to eliminate TB by 2030, through the End TB Strategy [ 10 ]. In South Africa, healthcare providers reported anxiety over the abrupt introduction of MDR-TB care, limited support and inadequate communication and collaboration during the service implementation [ 7 ]. These challenges are exacerbated by socio-economic and political factors including declining funding towards TB services .

In 2017, Zambia’s Ministry of Health introduced a policy to decentralise MDR-TB services through the 2017–2021 National Strategic Plan for Tuberculosis and Leprosy Prevention, Care, and Control, which was aligned to the National Health Strategic Plan and the WHO Global End TB Strategy [ 13 ]. The MDR-TB service delivery has, since 2017, been decentralised from the two national-level hospitals to about 100 sites across all 10 provinces in the country, including regional and local hospitals. The Ministry of Health has been collaborating with local and international organisations to support the delivery of decentralised TB services. Some of the funding agencies working with the Ministry of Health in supporting the decentralisation process include the Global Fund, the United States Government through the United States Agency for International Development (USAID) and Centers for Disease Control and Prevention (CDC), WHO, Japan Anti-Tuberculosis Association (JATA) and many others. Local partners such as civil society organisations (CSOs), TB survivor groups, faith-based organisations and many others have also been key in enhancing the decentralisation process in the country. In line with this strategic direction, collaboration has the potential to create an opportunity to strengthen the health system through increasing coverage, expanding access and improving the comprehensive availability of MDR-TB services across the country.

Collaboration is a participatory process of engaging key actors in addressing complex problems that cannot be handled by a single entity. Some studies have been conducted in LMICs on collaborative governance of tuberculosis control programmes (West Africa and Bangladesh) [ 14 , 15 ]. The Ministry of Health in Zambia, in collaboration with partners, is implementing the decentralisation of MDR-TB services. There is inadequate evidence on the optimal implementation of decentralised MDR services in the country with available literature only focusing on the general TB and human immunodeficiency virus (HIV) programme collaborative activities [ 16 ]. Most studies conducted have not addressed how system context issues and capacity for joint action as aspects of collaboration affect the effective or successful decentralisation of MDR-TB services. This study sought to explore the role of collaboration in the implementation of the decentralisation policy of multi-drug-resistant tuberculosis services in Zambia.

Conceptual framework: integrative collaborative governance

To address the research question, we adopted an integrated framework for collaborative governance to analyse the findings according to Emerson et al. [ 17 ]. Collaborative governance is defined as “the processes and structures of public policy decision-making, and management that engage people constructively across the boundaries of public agencies, levels of government, and/or the public, private and civic spheres to carry out a public purpose that could not otherwise be accomplished” [ 5 ]. We adopted the integrative framework for collaborative governance by Emerson et al. [ 17 ] to analyse the role of collaboration in the implementation of the decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. The framework consists of key components (layers) including system context, collaborative governance regime, drivers and collaborative dynamics (principled engagement, shared motivation and capacity for joint action) [ 2 ] as shown in Fig. 1 . However, this paper focussed on exploring how collaboration dynamics namely principled engagement, shared motivation and capacity for joint action c hinder or support the implementation decentralisation policy of MDR-TB services in Zambia. The interaction and intersectionality of contextual actors including the political, social and legal environment are some of the key drivers influencing collaboration dynamics. The concept of principled engagement entails a process that unfolds over time, involving various stakeholders who may participate at different stages and in different settings, such as face-to-face or virtual meetings, cross-organisational networks or public and private gatherings. In this study, stakeholders engage through principled discussion to define the purpose, guidelines and roles necessary to govern the collaboration. The degree of shared motivation among actors influences the nature and pattern of collaboration in the delivery of MDR-TB services. Furthermore, capacity for joint action refers to the actor’s ability to collectively decentralise the delivery of MDR-TB services. The stakeholders collectively, through regular joint meetings, mobilise resources to facilitate implementation of MDR-TB services using existing networks and community structures [ 3 ].

Integrated framework for collaborative governance Emerson et al. [ 17 ]

Study context

This study was conducted in selected health facilities in Zambia, where the burden of TB, particularly MDR-TB, is high. The contributing factors to the higher prevalence include poverty, rapid urbanisation, population growth and exposure to silica in mining settlements [ 17 ]. In response to this situation, the Ministry of Health (Zambia), in collaboration with partners, implemented the decentralised treatment and management of TB from two national health facilities (in Lusaka and Ndola) to other facilities in all 10 provinces. The decentralisation of TB services was implemented in alignment with the 2022–2026 Zambia National Health Strategic Plan for Tuberculosis, which stresses the significance of adopting the primary healthcare approach in eliminating MDR-TB by 2030 [ 12 ]. The study was conducted in various selected healthcare facilities, including provincial and district hospitals, both public and private across the nation (Lusaka, eastern, southern, western, central and Copperbelt provinces). The study sites were selected on the basis of their higher volumes of MDR-TB case notifications, with decentralisation of TB services already being implemented in these sites.

Study design

A qualitative case study design was adopted to investigate the influence of collaboration on decentralising drug-resistant tuberculosis services in Zambia. The application of this approach enabled a comprehensive analysis of the collaboration in the implementation process. We used a case study approach to get a detailed understanding of the collaboration within the context of MDR-TB. Case studies are useful when conducting a detailed exploration of an issue in its real-life context, such as collaboration in the implementation of MDR-TB, and was relevant to facilitate unpacking of substantive real-life contexts, interactions and complexities [ 18 ]. The study utilised this design to understand how collaboration influenced the success and challenges of the decentralisation process.

Data collection methods and sampling strategy

In this study, we employed key informant and in-depth interviews as methods of understanding collaboration for the implementation of decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. We conducted a total of 112 interviews with healthcare workers (18), community health workers (17), patients (32) and caregivers (21) in select healthcare facilities located in 10 selected districts and key informant interviews with facility, district, provincial, and nationallevel based managers (24). We engaged 10 trained research assistants who conducted various study activities under the supervision of the study team. The research assistants were divided into groups and collected data from the different facilities. Study participants were purposively sampled based on their involvement in the treatment and management of TB at different levels. Table 1 summarises the qualitative interviews per category of respondents.

Data management and analysis

The collected interviews were transcribed word for word and managed using NVivo software plus 14. We adopted an integrative collaborative governance framework focussing on collaboration dynamics to guide the analysis. A codebook was developed in NVivo and trained research assistants then used the NVivo software and coded the transcripts on the basis of the pre-determined coding framework. Subsequently, the coded projects were integrated into a unified project. The coding process enabled us to identify codes, which were later grouped into substantive themes. These substantive themes were later aligned with the respective domains under collaboration dynamics including principled engagement, shared motivation and capacity for joint action [ 19 ]. Our analysis approach was guided by the thematic data analysis method [ 19 ].

Trustworthiness of the study

To ensure the credibility and trustworthiness of the study, transcripts were coded by different coders. After coding, the authors verified the coded work to ensure that the quotes were representative of the developed codes. Additionally, quality assurance of transcripts was conducted through the sharing of transcripts with study team members and audio recordings. Furthermore, we held meetings with stakeholders who participated in the study to discuss the findings. However, this did not affect the interpretation of the themes as participants confirmed or could relate to these findings.

This section presents collaboration dynamics strategies shaping the implementation of the decentralisation policy of MDR-TB services. The results have been presented around the integrative collaborative governance domains, including principled engagement, shared motivation and capacity joint action, as highlighted in Table 2 below.

Domain 1: Principled engagement

Principled engagement was shaped by the global health agenda/summit meeting influence on decentralisation of TB, political will to support the introduction of decentilisation, engagement of stakeholders to initiate decentralisation, and a supportive policy environment for decentralisation of MDR-TB services.

Global health agenda/summit meeting influence on decentralisation of TB

The local government leadership interaction with the global community on health reignited the desire to create systems that increase access to health. Participants narrated that the global meeting on health for all heads of state on sustainable development was held. Goal number three was appreciated by heads of state, including the available leadership at the time. The notion of decentralising health governance, including the delivery of services, was adopted as part of the government’s agenda. The Zambian Government also committed itself to urgently address gaps in access to TB services. The Ministry of Health was tasked with finding mechanisms to address TB access-related challenges.

[In] 2015 there was a high-level meeting where heads of state were called at the UN summit and subscribed to the sustainable development goal number three and malaria, TB and HIV were picked globally for contributing as causes of mortalities, so the summit recognised the need to do something about it… (KII, government official 1).

Political will to support the introduction of decentralisation

The documented challenges on centralisation received government support, and this was a catalyst for decentralisation of TB services in Zambia. Some participants noted that there was a great push from the Ministry of Health that played a crucial role in preparing for decentralisation. Furthermore, the political will and ownership of appreciation of the value of decentralisation was also enhanced by the global agenda on health where the fight against TB was one of the priorities.

The government, through the Ministry of Health, emphasises zero cost on the part of the patient who has come to access TB services. There's caution to make sure that patient incur zero (or minimal) cost. So, when we look at these things and certainly say, how can we stop someone from travelling from [the provincial capital] all the way to UTH to seek treatment? (KII, TB government official 2).

Engagement of stakeholders to initiate decentralisation

The Ministry conducted capacity building to secure stakeholder buy-in for decentralisation, fostering community support and promoting integration, organisational capacity building, staff recruitment maintenance and ensuring a fertile climate for community support. Respondents indicated that obtaining explicit buy-in from critical stakeholders was necessary to foster a supportive environment through community sensitisation and capacity-building. Partnerships between the Ministry of Health and some implementing partners including local NGOs were essential to enhancing the provision of resources such as funding, equipment and training.

We built capacities, then we also conducted a lot of sensitisations, in promoting decentralisation, amongst other healthcare workers as well as amongst the patients, we assured the patients that service flow would continue smoothly, they shouldn’t be worried about those people who would be attending to them. They are capable (KII, government official 3).

Furthermore, organisational capacity was conducted to enhance institutional and structural health systems governance, and overall abilities to deliver quality services effectively and efficiently. Organisational capacity was conducted through recruiting and training new staff, equipping staff, improving infrastructure and increasing access to resources. As one interviewee stated:

So, now we actually started ah… are equipping, doing capacity-building to health workers in these other facilities which highlights the importance of investing in the development of human resources to improve the overall capacity of the healthcare system (KII, government official 4).

Supportive policy environment for the decentralisation process

The government, through the Ministry of Health, introduced policies including the 2017–2021 Zambia National Strategic Plan (NSP) on TB and Leprosy Management and Control in Zambia. To this effect, the Ministry of Health introduced the MDR decentralisation across the provinces in a phased approach. The services were decentralised first in Lusaka and the Copperbelt, and subsequently to other provinces including the Eastern, Western, North-western and Central provinces. However, little was mentioned about the impact that these policies had on operations at various levels.

There is a strategic document that we have called national strategic document for TB so that once again gives the overall guidance, and it runs for a period of 5 years so that is the mother document. The implementation part is the guideline, where everything is well documented and even algorithms are an extract from the guideline. Even when you go to the lab it will tell you an algorithm to use (KII, government official 5).

However, interviewees were of the view that the lack of stakeholder involvement during the decentralisation process may have contributed to the removal of critical policy and program features required for the successful implementation of the MDR-TB programme. They felt that engaging stakeholders, particularly healthcare practitioners, would assist them grasp the programme’s importance, build appreciation and allow for talks about how to incorporate the program into their daily activities. The absence of stakeholder participation in these talks may have resulted in missed opportunities.

I observed the relaxed support to decentralisation program by the district leadership, when you go to the district to do mentorship, our expectation was that the district leadership in most cases were supposed to be with us and just maybe even just participate for 10 minutes, even see what’s happening and have a word with a local team, but in most districts we did not see that, so this resulted in health workers not taking the program to be serious because health workers take the program to be serious when they see the top leadership is also involved (KII, government official 6).

Quarterly clinical expert committee meetings

Strengthened healthcare providers’ collaboration was recognised as a strategic approach to improving MDR-TB healthcare reform that could lead to improved patient outcomes. Expert committees were present at national, provincial and district levels. Peer-to-peer data reviews in the districts were felt to be effective. However, the capacity of provincial expert committees to go around districts providing technical assistance and facilitation for the implementation of decentralised services was reliant on the available services such as diagnosis and screening. This has led to a reduced number of visits in the last few years. The TB experts gave midweekly reviews of the performance of the decentralised MDR-TB services and identified strategies to improve them. Clinical expert committee meetings at national and provincial levels were held quarterly to review difficult cases and technical support provided on the best patient management strategies.

We also hold the quarterly clinical expert committee meetings where we review difficult TB cases pertaining to patients. Each district was given a chance to make a presentation on difficult cases that they have had in that quarter both for MDR and drug susceptibility so in that platform we build capacity, and we have a team of experts that now advise on how that patient can be managed and we have really improved in the treatment outcome for DR patients (KII, government official 7).

Domain 2: Shared motivation

Several factors influenced shared motivation in the decentralisation of MDR-TB, including actors having a common understanding, limited access to health facilities and emergency transport services, shared understanding of challenges in providing optimal patient monitoring and review, and their appreciation of the value of evidence-based decision-making in adopting the MDR-TB decentralisation.

A common understanding of the challenges faced by MDR-TB: limited access to health facilities and emergency transport services

The centralisation of TB services brought about patient discontentment regarding poor service delivery due to the poor accessibility of TB services. The patients were required to travel long distances to selected health facilities for treatment. Some patients with inadequate financial resources could not afford transportation fees to health facilities, accommodation and food while seeking care at the health facilities. The challenges contributed to socio-economic inequalities concerning access to health services. The respondents narrated that there was a great need for the government to adequately deliver these services, especially in provinces such as Eastern and North-western provinces where the decentralisation process was happening at a slow pace and had patients that still experienced difficulties travelling to health facilities.

I stayed in Lusaka for treatment for 5 months, the sixth month they said the remaining 1 month you should go and finish from home. So, when I came back home the medicine I got from Lusaka was not here the whole week and in the second week I found the medicine, and it happened that the cough came back again. When I thought of coming back to the clinic, I had no transport because where I live........ there is a distance (Patient with TB).

Centralisation also affected the emergency transport services as more patients were required to be taken to only two facilities in the country. Hence, before decentralisation, health facilities experienced challenges in referring patients. Sometimes, the unavailability of ambulances or transport limited the capacity of health facilities to deliver services to patients in time. During the decentralisation phase, more patients were attended to promptly because several health facilities across districts were offering services to patients with MDR-TB.

Before decentralisation, so, first a case could be identified by facility, and the facility would communicate to the district, then the district needed to find transport to take that patient to the central treatment centre, yet the district does not have any capacity to transport that patient (KII, government official 8).

The adoption of decentralisation facilitates opportunities for local health systems to collaborate with existing partners to provide emergency services to the nearest hospital. Compared with taking the patients to the two national treatment centres, the decentralised model reduces costs such as travel costs which were associated with TB management/services before decentralisation.

I can mention here that for us, we can’t afford a vehicle to go and pick up a client from a facility to the general hospital so our partners will provide the vehicle to move the patient and even if we want to go and visit a patient, our partners will provide transport/logistics (KII, government official 9).

Shared understanding of challenges in providing optimal patient monitoring and review

The centralisation of MDR-TB services was perceived to be affecting the monitoring and care of patients. Healthcare workers in the centralised system experienced heavy workloads due to huge numbers of patients, thus making the monitoring of patients challenging and sometimes impossible. Furthermore, seeing many patients and managing patient health information was problematic, furthering the gap in ensuring that patients are effectively monitored. The government and implementing actors recognised the multifaceted challenges and supported the decentralisation process to contribute to a reduction of the problem.

Patient overload, distance to the facility, poor record keeping and follow-ups were not being done and maybe even monitoring of these patients was difficult, so they figured out that if we decentralise maybe things will be done more orderly. So even patient care was compromised, so when they decentralised care and treatment improved because services were brought closer to home (KII, government official 10).

Appreciation of the value of evidence-based decision-making in adopting MDR-TB decentralisation

The capacity readiness assessment included evaluating the size and composition of health facilities, the availability of human resources, diagnostic and laboratory capabilities and the availability of data collection tools. These facilitated an understanding of facilities’ readiness to implement and manage MDR-TB treatment at the facility level. Key informants narrated that human resource for health were identified as a crucial factor, and facilities needed to have at least one medical doctor and a dedicated clinician or nurse trained in DR-TB management to handle the patients. Diagnostic services also had to be available to make an accurate diagnosis of MDR-TB. The decentralisation process was gradual, starting with larger hospitals in 2014 and fully decentralising to districts in 2018. There was also an imperative need for adequate drug stocks, which were crucial in ensuring that facilities could continue providing treatment and care for patients with MDR-TB. The success of the decentralisation process of TB services depended heavily on these preparatory measures, with manpower development being a key factor as one interviewee stated:

So, we did have a tool that was assessing certain things that should be in place for a site to be set to be related to start treating patients. It has to be a diagnostic site, it must have a preferred medical officer who’s also trained in drug-resistant TB (KII, government official 11).

Domain 3: Capacity for joint action

The capacity for joint action strategies included leadership roles in communicating the implementation plan, MoH initiating strategic partnerships in enhancing MDR-TB decentraliation, leadership capacity role in organiing training for healthcare workers, training of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.

Leadership capacity in communicating the implementation plan

The selected sites were assessed using a tool to ensure that each region had the necessary resources to treat patients with MDR-TB. This strategy allowed for a targeted and context-specific approach to implementing decentralised MDR-TB treatment in Zambia, rather than a one-size-fits-all plan. The communicating of the plan to all relevant implementing partners was crucial to ensuring that they were all informed and guided. Another KII participant stated:

We have to have different strategies for different provinces because the capacity of one province is not the same as the capacity of another province (KII, government official 12) I think one last important area where we are involved is to make sure that the community TB program is also supported and coordinated so that as a province, we do make sure that drug-resistant TB at the community level is implemented, where volunteers are supported. …. provide services on DRTB by for instance supporting DRTB patients at the community level. (…) even giving education at the community level for people who are coughing or people who may be on treatment but they are not getting any better so communities are involved, so in a nutshell that’s what I can say the degree to which am involved in DRTB program (KII, government official 17).

MoH initiating strategic partnerships in enhancing MDR-TB decentralisation

Strategic partner identification was critical to the successful execution of the MDR-TB decentralisation strategy. As a result, several partners were identified to assist with staffing specific facilities, sourcing equipment and providing assistance at the district or facility levels. It has been stated that increased collaboration in healthcare is a strategic approach to reform that can improve patient outcomes, such as reducing preventable adverse drug reactions, lowering morbidity and mortality rates and optimising pharmaceutical dosages.

The Ministry of Health alone cannot manage to sufficiently do a lot of things [on its own] but when you collaborate with other organisations, it helps because for example, the training which we have been having, they were supported by CIDRZ. So, then they will support those activities. In addition, when we are doing some of the community activities, they also support the communities (KII, government official 13).

Creating health partnerships extends to supporting the implementation of community-based activities. It was also important to assess which institutions were capable of offering preparatory services to assist with the decentralisation process. For instance, the [general hospital] was identified in the [province] as a training site to train health workers in MDR-TB diagnosis and treatment. For some areas, collaboration with external partners helped them not only train staff members but also led to the rehabilitation of structural facilities that would lead to a smooth decentralisation process of MDR-TB management.

The [general hospital] is a training and internship site… so we train a lot of interns in MDR TB, of course, our understanding is that as we build capacity, wherever they’ll go, they’ll carry that capacity… we trained pharmacy, trained lab, nurse, clinical people ahh we trained them and trained environmental health for public health purposes (KII, government official 14).

Leadership in organising and implementing the training for healthcare workers

The availability of trained human resources for health contributes to their increased knowledge and skills to improve the delivery of TB services. Some healthcare workers reported that after receiving the training, they were now more actively involved in the planning, implementation and monitoring of the delivery of TB services compared with the pre-decentralisation period. However, due to limited funding, several healthcare providers were not trained in the management of MDR-TB.

So, now we actually started…are equipping, doing capacity building to health workers in these other facilities, which highlights the importance of investing in the development of human resources to improve the overall capacity of the healthcare system (KII, government official).

Formation of multidisciplinary teams

The interviewees underscored that creating MDR-TB implementation teams was a crucial step in the decentralisation efforts, at the national, provincial, district, and health facility levels. In this regard, committees and expert teams were formed to spearhead the process. The National Clinical Expert Committee is composed of specialists in internal medicine, and infectious diseases including MDR TB, pharmacy, paediatrics, gynaecology, nutrition, social work and other supporting partners. Collaboration and teamwork were essential for ensuring successful decentralisation efforts, but it was not the same across regions and sites. As one interviewee stated:

You feel (the patient) is not responding well to treatment, there is a committee that the client is subjected to. They analyse the patient, analyse the drugs, should we switch, should we change maybe from second line treatment…third line treatment. That committee has been there maybe I don’t see any change I don’t think there is something that has changed if there are changes maybe it’s the number of times that probably this committee should sit…the number of times that this committee should look at the patients, discuss the patients… (KII, government official 14).

Collaborating with external partners in support decentralisation

For some areas, collaboration with external partners not only helped train health workers but also led to the rehabilitation of existing health facilities’ infrastructure, facilitating the smooth decentralisation process of MDR-TB services and management.

In 2017, we first started having visitations with NTLP to see what was on the ground… I think the major partner was FHI-360 under the challenge TB program. So, FHI-360 through the challenge TB program conducted the prevention and control training for the entire institution targeting all the workers in all the major departments… and providing infectious control guidelines and activities in each working space in the clinical area as well as in the non-clinical. They brought in partners under USAID and lobbied for us to have an MDR ward rehabilitated. That was done at UTH, here [Kabwe], Ndola and Kitwe, not sure about other provinces if something was done to that effect (KII, health facility staff 1).

Joint action in health infrastructural rehabilitation

Furthermore, the collaboration between the Ministry of Health and partners also contributed to improving infrastructure. For some areas, collaboration with external partners helped not only train staff members, but also led to the rehabilitation of structural facilities that would lead to a smooth decentralisation process of MDR-TB management. In some cases, new structures were built for MDR TB management. However, the support was limited as many health facilities required adequate health infrastructure development that remains unmet.

They brought in partners under USAID and World Bank lobbied for us to have an MDR ward rehabilitated (KII, health facility staff 2).

This study explored how collaboration influences the effective decentraliation implementation of MDR-TB in Zambia to enhance access and care quality. The principled engagement was shaped by the global health agenda/summit meeting’s influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, supportive policy environment and quarterly clinical expert committee meetings. The study underscores the value of collaboration among stakeholders in policy development and implementation, shaping their joint capacity and shared motivation to train healthcare providers and engage communities, ultimately influencing successful treatment outcomes.

The study has revealed that the lack of TB service decentralisation in Zambia led to limited access, hindering eligible patients and clients from conveniently accessing care. However, a Pakistani study showed that expanding the centralised TB healthcare services contributed to increased adverse effects for rural and peri-urban populations [ 20 ]. The limited access to TB services in rural and peri-urban areas was attributed to limited or lack of healthcare infrastructure where patients could easily get tested. This highlights the major constraining factors that contributed to limited access to health facilities. They included emergency services transport for referring patients for MDR-TB services, constraining access to health facilities owing to long distances and challenges in providing optimal patient monitoring and review, as motivating factors.

The study suggests that a supportive decentralisation policy and governance environment plays a crucial role in health systems strengthening in MDR-TB in Zambia. The political leadership appreciated the pressing challenges, particularly poor access to MDR-TB services. Therefore, they advocated with political will for a policy shift from centralisation to decentralisation. Similarly, a South African study also showed that the health reform pertaining decentralisation of MDR-TB services was done to enhance access to care by placing TB care closer to communities, and improving TB-care success rates [ 21 ]. In addition, studies conducted on health policy and systems reforms also show how critical leadership and power are in driving collective decision-making on health system and policy development and reform [ 22 , 23 , 24 ]. The Ministry of Health realised that creating an enabling policy environment would contribute to addressing the limited access to MDR-TB services in Zambia. Therefore, taking services closer to the people promotes equity and contributes to dismantling health inequalities.

The supportive policy health environment spelt out the government’s agenda, direction and commitment to scaling up the decentralisation of MDR-TB services. This roadmap was essential not only in helping health managers, providers and partners understand the policy, but also in giving authority to key stakeholders to hold the government accountable for the status of the delivery of services. An Indian-based study showed that social accountability mechanisms empowered the community to collective negotiations resulting in demands for changes from the health leadership [ 25 ]. However, top leadership, in some cases, limited sustained momentum in the decentralisation process. This creates an impression whereby local health actors may fail to appreciate the health reform, contributing to a lack of ownership as they will only be waiting for the superiors to direct the implementation of the process. This study highlights that shared motivation is critical in making the stakeholders understand the programme, facilitate their buy-in and support the creation of the MDR-TB decentralisation structure and plan. Therefore, collaboration is key in facilitating stakeholder engagement through decentralised delivery of TB services to improve accessibility by clients to health facilities and the provision of quality services for a broader population.

Furthermore, this study has highlighted the importance of collaboration in the decentralisation of multi-drug-resistant tuberculosis services. Collaboration plays a crucial role in capacity-building and training among healthcare providers. In South Africa, trained human resources for healthcare are limited, thereby impacting optimal service delivery. Stakeholders, including NGOs’ collaboration and collective action, improved healthcare workers’ delivery of TB services through the provision of specialised healthcare and psychological social support [ 21 , 26 , 27 ]. Furthermore, through joint efforts, healthcare providers can receive specialised training to stay updated with the latest treatment options and management techniques, thus enhancing their proficiency in handling MDR-TB cases.

This study also highlighted that strategic partnerships are essential through capacity-building and training of healthcare providers by contributing to more effective patient care and enhanced treatment outcomes. This finding is in line with other studies, which suggest that collaborative efforts in delivering patient-centred decentralised approaches enable healthcare providers to navigate therapeutic options and provide effective care, ultimately contributing to improved treatment outcomes [ 4 ]. Collaboration helps healthcare workers to continue providing services through community structures [ 28 , 29 , 30 ]. However, inadequate human resources for health in Zambia is contributing to limiting healthcare provider’s involvement in the treatment of patients. Many healthcare facilities are not fully equipped to handle TB. In addition, they have a limited number of healthcare providers who have heavy workloads with marginal involvement of others in the management of patients.

Some studies have, however, shown that collaboration in delivering a patient-centred decentralised approach where healthcare providers collaborate in delivering TB services helps in navigating therapeutic options and enhances effective care [ 5 ]. Furthermore, this study shows that training healthcare providers is key to the decentralisation of TB services. The training equips the officers with specialisation on the latest treatment options in the operations and management of TB. Similarly, evidence from an African study found that equipping healthcare providers in the management of TB and adopting locally appropriate strategies enhances the implementation of the decentralisation policy [ 31 ].

Supportive collective community-based MDR-TB interventions were found to be crucial in creating awareness and improving patient treatment outcomes. It was apparent that community health actors, with the involvement of community health workers, contributed to improved awareness, enhanced case detection and strengthened referral systems and monitoring of patients [ 32 ]. The findings of the study show that there was inadequate involvement of community-based actors in the delivery of TB services, which might be contributing to low levels of knowledge and inadequate support from the community.

Limitations and strengths of the study

One of the limitations is the absence of stakeholders from supporting partners, including international organisations. This leaves a gap in understanding engagements during the decentralisation process. This could potentially limit the scope of the insights shaping decentralisation. Another limitation of this study is that we only focussed on collaborative dynamics to understand the key factors shaping the decentralisation policy of MDR-TB services, as it is crucial to provide in-depth knowledge of the key lessons influencing the implementation of these services. Despite this limitation, our study strength includes conducting inclusive interviews with stakeholders at the national, provincial, district and community levels, such as healthcare providers and managers at different levels, patients and caregivers, which facilitated an in-depth understanding of collaboration for implementation of decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. The collaboration of researchers with backgrounds in health, social science and TB programs enhanced the analysis and quality interpretation of the findings.

The decentralisation of multi-drug-resistant tuberculosis services in Zambia was propelled by collaborative efforts aimed at addressing access to multifaceted challenges arising from the centralised management of TB health services. Collaboration dynamics, including principled engagement, shared motivation and the capacity for joint action, played a crucial role in involving stakeholders to tackle issues such as limited access, transportation barriers and patient monitoring challenges. The shift in policy was grounded in evidence-based decision-making, influenced by political determination and facilitated by supportive policies. However, more capacity-building trainings are needed to increase the number of healthcare workers involved in the delivery of MDR-TB services. The study also identified associated healthcare challenges, including infrastructure and service delivery limitations. Therefore, enhancing stakeholders’ collaboration will create opportunities to expand the current infrastructure and support the optimal decentralised delivery of MDR-TB services.

Data availability

The study data can be requested from the authors. The articles for this review can be made available upon request.

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Acknowledgements

We would like to thank the Ministry of Health managers for facilitating easy data collection process. We also appreciate the participants for sacrificing the time in providing information on this study.

Open access funding provided by Umea University. We would like to thank the Ministry of Health through Global Fund of Zambia for providing financial support to implement this study.

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M.P.C., T.F.L.M., P.M., M.N.M., B.H. and J.M.Z. contributed towards the development of study design, review of data, analysis and synthesis. M.P.C. drafted the manuscript and all authors contributed towards its revision. All authors (M.P.C., T.F.L.M., P.M., M.N.M., B.H., N.L., J.B., N.N.S., H.H., C.M., A.M., P.K., M.C., H.P. and J.M.Z.) reviewed and approved the final manuscript.

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This study followed comprehensive ethical considerations. Ethics approval was sought from the University of Zambia Biomedical Research—UNZABREC (ref. no. 3003-2022) and protocol was further registered and approved by the Zambia National Health Research Authority. Informed consent was obtained from all participants to ensure confidentiality and clear information about the study’s purpose, risks and benefits. To protect research assistants and participants, health safety protocols, including provision of N95 masks, hand sensitising and ensuring that they maintain a safe distance during interviews, were followed.

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Chavula, M.P., Matenga, T.F.L., Maritim, P. et al. Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia. Health Res Policy Sys 22 , 112 (2024). https://doi.org/10.1186/s12961-024-01194-8

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3 Case studies demonstrate the power of modern enterprise content management

Customers in insurance, banking, and healthcare find benefits in replacing aging content management tools with modern systems..

From insurance to banking to healthcare, organizations of all stripes are upgrading their aging content management systems with modern, advanced systems that introduce new capabilities, flexibility, and cloud-based scalability. In this post, we’ll touch on three such case studies.

Global insurance company

A large insurance company adopted a cloud-based document management system to enable paperless operations around the world and simplify regulatory compliance. The organization had some tactical document management systems, but they were siloed and based on slow, outdated technology. Plus, all files were stored in U.S. data centers, creating obstacles for a globally dispersed user base.

After adopting Alfresco Content Services and Alfresco Governance Services running on Amazon Web Services (AWS), the insurer fully digitized its operations. The IT team worked closely with business users to build a solution “in which paper wasn’t part of the process,” the company’s SVP and CIO said.

The solution provides electronic file and records management capabilities that integrate seamlessly with the company’s core insurance applications, automating everything from document retrieval to records management . The solution is saving the company $21 million over five years thanks to massive reductions in paper, printing, and storage costs.

Large community bank

When a 28-branch community bank decided to sunset its document storage system, it needed a solution that would work with its cloud-based core banking system.

After identifying dozens of company requirements, the organization selected OnBase running on the Hyland Cloud. With support from Hyland Professional Services, the bank migrated 2.5 million documents, representing the past 15 years of business documents, to OnBase. Soon after, the bank added WorkView , Hyland’s low-code application builder, to create solutions and address new challenges with speed and agility.

“With WorkView, you can build workable solutions with almost no code at all. It’s enabled us like a force multiplier. We can accomplish so much with a small team,” said the bank’s enterprise process manager.

Among the benefits, the solution helped the bank’s lending department retire its manual, paper-based workflow in favor of more automated processing using OnBase workflows. The results have been significant: a mortgage loan process now takes less than 20 minutes to complete each day, down from two hours.

What’s more, during the COVID-19 pandemic, the bank was able to bring on remote, temporary workers to handle an onslaught of Paycheck Protection Program (PPP) applications.

“All the documents needed were visible in OnBase without relying on paper to complete the work,” said the bank’s senior vice president and director of operations and process improvements. “We couldn’t have managed the loan volume without OnBase in the cloud.”

Large pharmacy and healthcare firm

A large American retail pharmacy and healthcare company was looking to upgrade its aging knowledge management systems. Its executive leadership team directed the business to select a knowledge management platform with a modern, open-source approach that would reduce the company’s dependence on IBM, Oracle, and other proprietary solutions.

The company opted for Hyland’s Nuxeo Platform , an open-source and highly scalable platform that enables the provider’s customer care representatives to quickly access their customers’ current coverage details. It also gives the company the flexibility to introduce new solutions in the future without worrying about being constrained by proprietary technology.

Ultimately, the healthcare firm used Nuxeo to replace two aging platforms:

A mission-critical solution, previously based on IBM File Net, that’s used by more than 20,000 customer care agents to serve clients daily.
A content management solution based on Oracle Stellent for managing policies, procedures, and other business content.

Now, the company is confident its agents will be up to date on the latest information they need to do their jobs effectively, from patient details to urgent notices about drug recalls.

“We’re confident the Nuxeo Platform will enable us to inform our reps ASAP,” said a healthcare company rep. “This is critical not only for our business, but also for the well-being of the millions of people who use [our] services.”

To learn more, visit Hyland .

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Call for case studies and best practices on addressing tuberculosis in prisons

The World Health Organization (WHO) Global Tuberculosis Programme is launching a call for case studies and best practices on addressing tuberculosis (TB) in prisons. This includes provision of services for communicable diseases, with a focus on TB prevention and care provided within prisons, as well as on addressing TB in the context of mobility of people between police holding cells, prisons and the community.

An estimated 10.6 million people developed TB in 2022. Despite being preventable and curable, TB remains one of the world’s top infectious killers, accounting for over one million deaths annually. Prisons and other places of detention can be high risk environments for TB transmission due to overcrowding, inadequate infection prevention and control measures, and other determinants such as undernutrition, substance use disorders and inadequate access to health services. The burden of TB disease in prison populations is about 10 times higher than in the general population. In 2019, an estimated 125,105 people in prisons fell ill with TB worldwide, representing about 1% of the global incidence, and only about half of these detected, leaving a large gap of incarcerated people with undiagnosed or unreported TB.

The provision of high-quality health care in prisons, including TB prevention and care, is essential. People in prisons should access health care in the same conditions and of a similar quality as any other person living in the community, throughout their life course. Protecting the human right to health and ensuring universal health coverage are particularly critical in prison settings, where the provision of health services is not always prioritised.

WHO recommendations on TB (prevention, screening, diagnosis, treatment, testing for HIV and comorbidities, treatment support, and infection prevention and control) are applicable to all settings, including prisons. In addition, WHO has specific recommendations on systematic screening for TB disease in prisons and penitentiary institutions, for both prisoners and prison staff as well as systematic testing and treatment for TB infection, which may be considered for people in prisons as well as other at-risk groups including health workers, immigrants from countries with a high TB burden, homeless people and people who use drugs.

WHO has previously issued guidance on the management of TB in prisons, however there have been significant advances in TB prevention and care since this guidance was issued. The WHO Global Tuberculosis Programme is in the process of updating its guidance on TB in prisons. The purpose of the guidance will be to provide operational guidance on the prevention, management and care of TB in prisons, including when people are transferred between police holding cells, prisons and communities. The new WHO guidance on TB in prisons will also feature several case studies illustrating experiences and best practices in addressing TB in prisons.

These case studies may include examples of interventions that are provided within prisons and police holding cells, such as:

· TB screening and active TB case finding for people in prisons as well as prison staff;

· Short course TB preventive treatment and effective management and treatment of TB;

· Screening, diagnosis and care for co-morbidities or other health related risk factors, such as mental health conditions, substance use disorders, HIV, among other conditions;

· Contact investigation, outbreak management and TB infection prevention and control;

· Policies and practices that aim to address the social determinants of TB among people in prisons (such as employment, housing and linkages with social protection services);

· Collaboration between ministries of health and the ministries responsible for prisons and penitentiary institutions;

· Policies and practices on promotion of human rights and the human right to health;

· Building the capacity of prison health staff and inmates to effectively prevent and manage TB;

· Recording and reporting systems on TB in prison settings, and their linkages to the national TB surveillance system, and

· Policies or practices that ensure continuity of care when people with TB are transferred between prisons or from prisons to the community.

Through this call, WHO invites country officials, UN agencies, technical partners, and other governmental and non-governmental stakeholders within and beyond the health sector involved in the provision of health services within prison settings to submit examples of relevant case studies and best practices to this email address: [email protected] .

These case studies and best practices should be no longer than 500 words, should feature current examples implemented in the last ten years and should be structured as follows:

· Background

· Policy or practice implemented

· Results achieved as a result of this policy or practice

· Challenges identified during implementation (and solutions)

· Way forward/ next steps (as a conclusion)

The deadline for submission of case studies and best practices is Friday 30 September, 2024 .

All contributors to the selected case studies will be appropriately acknowledged in the WHO guidance on TB in prisons. We thank you in advance for your collaboration, and please do not hesitate to contact us in case of any questions.

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Case Study Solution for Improving Collaboration and
Community/University Collaboration in Health Care Planning: A Case
Community Case Studies
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Collaboration case studies

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73 Community Engagement and Collaboration
73 Community Engagement and Collaboration | Case Studies . Below we have curated a number of case studies of community engagement within the KMb and research context for you to review. Each case study has associated thought questions for you to work through in order to increase your learning in relation to these real-world examples.
Using collaborative coalition processes to advance community health
The case study interview transcripts were coded to highlight concepts related to the SCALE theory of change and the principles of Collaborative Equity and Justice (CEJ) shown in Table 1. Two evaluators coded two interviews together to ensure consistency in coding and to refine the code book. The codes were applied to all case study interviews.
Attributes of effective collaboration: insights from five case studies
A major strand of this literature on cross-sector collaboration is comprised of comparative case studies that seek, in the main, to identify the key success factors in and/or impediments to effective collaboration. For the most part, the case study literature reflects the experience of collaboration in the United States and Britain.
Engaging Your Community
Each chapter also includes a case study that draws on the information presented in the chapter. The case studies detail the collaboration and community engagement efforts of organizations in the field, and serve as a guide for how readers may themselves utilize the concepts and tools presented in this toolkit.
Meeting Complex Needs Through Community Collaboration: a Case Study
Abstract. This case study focuses on complex trauma in a refugee family. It explores the barriers faced while supporting a family presenting with complex and multifaceted needs. It reviews the roles, processes and participation of practitioners from Service Coordination (case management) and Treatment (therapeutic intervention) perspectives.
PDF Six Case Studies Involving Collaboration and Civic Engagement
that you give appropriate citations and bibliographic creditsRecommended citation: Jacquelyn L. Tuxill and Nora J. Mitchell, eds. Leading in a Collaborative Environment: ix Case Studies Involving Collaboration and Civic. For more information, contact: Conservation Study Institute 54 Elm Street Woodstock, VT 05091 Tel: (802) 457-3368 Fax: (802 ...
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1 College of Social Work, The Ohio State University, Columbus, OH 43210, USA. 2 School of Social Welfare, University at Albany, Albany, NY 12222, USA. 3 College of Social Work, University of South ...
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Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant ...
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Large community bank. ... 3 Case studies demonstrate the power of modern enterprise content management . By Paul Desmond. Aug 21, 2024 4 mins. Machine Learning Artificial Intelligence. news.
Call for case studies and best practices on addressing tuberculosis in
The World Health Organization (WHO) Global Tuberculosis Programme is launching a call for case studies and best practices on addressing tuberculosis (TB) in prisons. This includes provision of services for communicable diseases, with a focus on TB prevention and care provided within prisons, as well as on addressing TB in the context of mobility of people between police holding cells, prisons ...

73 Community Engagement and Collaboration | Case Studies

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Meeting Complex Needs Through Community Collaboration: a Case Study

Michelle M. Gallagher

Introduction

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Case Study of a Collaborative Approach to Improving Community-Based Services for People with Low Income: Community Caring Collaborative

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