Over 13 months, there were 101 full coalition meetings across the eight communities, ranging from nine to 16 meetings per community. Most coalitions met once per month for 60 to 120 minutes. During various phases and the emergence of the novel coronavirus 2019 disease (COVID-19), some coalitions opted to meet semi-monthly. All coalitions adopted a virtual meeting format beginning in April 2020 due to the emergence of COVID-19. A total of 429 individuals attended at least one coalition meeting with a range of 23–79 individuals per coalition. The average number of attendees at each coalition meeting per community ranged from 10–29 individuals.
Five central themes emerged from ethnographic analysis that served as facilitators and barriers to realizing specific CBPR principles within the coalition formation and early EBP implementation phases: 1) importance of trust, familiarity and mutual support; 2) magnitude of shared goals; 3) power dynamics between research site and community; 4) meeting structure matters; and 5) need to consider the socio-political context of the community in planning and implementation. Each theme is described below along with direct statements from the ethnographers and identification of the CBPR principles linked to each theme [Table 2]. Each of these overarching themes sometimes served as a facilitator and other times as a barrier to actualizing the CBPR principles, as described in our characterization of the themes and illustrative statements from the ethnographies.
Table 2
Themes & Relevant CBPR Principles
Theme | Linked Principles |
1. Importance of trust, familiarity and mutual support | • Principle 2: Build on strengths and resources within the community • Principle 3: Facilitate a collaborative, equitable partnership in all phases of the research • Principle 4: Promote co-learning and capacity-building among all partners • Principle 5: Integrate and achieve a balance between research and action to mutually benefit all partners |
2. Magnitude of shared goals | • Principle 1: Recognize the community as the unit of identity • Principle 5: Integrate and achieve a balance between research and action to mutually benefit all partners |
3. Power dynamics between research site and community | • Principle 3: Facilitate a collaborative, equitable partnership in all phases of the research • Principle 5: Integrate and achieve a balance between research and action to mutually benefit all partners • Principle 7: Involves systems development through a cyclical and iterative process • Principle 8: Disseminate findings to all partners and involve all partners in dissemination |
4. Meeting structure matters | • Principle 3: Facilitate a collaborative, equitable partnership in all phases of the research • Principle 4: Promote co-learning and capacity-building among all partners • Principle 7: Use of a cyclical and iterative process • Principle 8: Disseminate findings to all partners and involve all partners in dissemination |
5. Need to consider community socio-political context | • Principle 6: Emphasize public health problems of local relevance and ecological perspectives that recognized the multiple determinants of health and disease • Principle 10: Addresses issues of race, ethnicity, racism, and social class and embraces “cultural humility” |
Theme 1: Importance of trust, familiarity, and mutual support
Trust, familiarity, and mutual support among coalition members serves as a facilitator supporting the demonstration of Principles 2, 3, 4 & 5.
The coalition is incredibly collaborative and are constantly offering ways to support each other. There is no feeling of competition for funding or resources between the organizations [represented by coalition members]. They appear unified in their goal of supporting their shared community [Community #4, November 2020].
Working within a familiar and supportive environment fosters collaboration and capacity building among coalition members and enables them to build on their knowledge and strengths, both individually and within their organizations.
This meeting demonstrated how the coalition may be moving from a combative “storming” phase to a more peaceful “norming” phase. As coalition members presented their intervention updates they highlighted how other coalition members had collaborated or contributed to progress. Coalition members demonstrated appreciation for each other’s efforts [Community #3, November 2020].
Similarly, a trusting relationship between the HCS Community Engagement Facilitator and coalition members created space for shared ownership of the work and balanced research and community priorities necessary to implement interventions. Facilitation skills supported the presence of Principle 5 and trusting relationships opened space for feedback from coalition members.
They (CEFs) are truly facilitators…allowing the coalition to take ownership and share updates, while sharing research site updates in clear, accessible language. The participation from various coalition members and the constructive feedback provided to the research site staff shows a clear investment from coalition members in the materials and findings of the study [Community #6, August 2020].
Another ethnographer noted the facilitators focused on building strong community relationships with coalition members and community organizations, which require expanding coalition membership to bring in new voices and share additional resources:
The coalition members speaking up now were not the ones speaking up in the beginning and were not even present at the table. It is exciting to be hearing from peer recovery coaches, and volunteers not just town officials. The CEF’s facilitation skills and local relationships/knowledge are key in this change I believe [Community #2, May 2020].
Conversely, a lack of trust, familiarity and mutual support served as a barrier to the demonstration of these principles. In the absence of familiarity and trust, coalition members tended to prioritize their own organizations, and they were less engaged in collaboration and/or learning about others and their strengths or focusing on the good of the larger community:
Coalition members listened to each other’s ideas and were respectful. However, the very vocal organizations seem to want to prioritize their suggested interventions. Additionally, coalition members still seem to be unfamiliar with one another as observed when [coalition member] referenced [other coalition member] as “the gentleman from [local organization]”; there do not seem to be set standards for referencing other coalition members [Community #1, July 2020].
While some interventions may address and support co-learning, there were instances where organizations were more interested in interventions strictly promoting their own organization:
“The idea of a navigator at each organization who would communicate with other organizations would be a space that facilitated co-learning. However, [local organization] and [local organization] are struggling with how to promote capacity building at both partners instead of just advocating for their own organization.” [Community #3, August 2020].
Theme 2: Magnitude of shared goals
Shared goals among coalition members appeared to be a critical facilitator for the presence of Principles 1 and 5 at coalition meetings. Coalitions with shared goals seemed to instinctively promote the idea of the community as their collective unit of identity and demonstrated openness to changes and true partnership based on coalition and community needs:
“A coalition member shared that sentiment that they want and need feedback from the community and other organizations in order to be as effective as possible in their outreach. They shared that while their agency is housing the position, they are serving the community which was powerful.” [Community #5, December 2020].
A mutual understanding and set of shared goals were also very important between the research site and the coalition in terms of promoting trust. Ethnographers identified this as critical to moving forward:
The research site…explains the expectations of the study from the start of the coalition, the charter outlined the expectations of the coalition membership and provided the members an opportunity to vote on their commitment to the coalition by agreeing to the charter [Community #2, February 2020].
Conversely, in cases where the coalition did not share goals with the research site, coalition engagement and movement toward the study goals waned:
The coalition currently does not believe that this project is beneficial to them. There is a clear feeling that the work they will be doing is replicating work that is already occurring in the community. The research site is not doing a good job of explaining how the community can use the money from the grant to fill in gaps [Community #2, February 2020].
Theme 3: Power dynamics between research site and community
Power dynamics between the research site and coalition members emerged as both a barrier and facilitator to operationalizing Principles 3, 5, 7 and 8. Coalition members displayed stronger engagement when the research site and coalition shared power and space in meetings:
The facilitator does a good job of allowing the coalition to take ownership of several action items and present their own opinions on various barriers and services in the community. The discussions are not formally structured but seem to work well for this group; people appear comfortable providing feedback regardless of their organization or expertise. The meeting agenda guides the coalition in terms of expectation and meeting topics but otherwise the conversation flows naturally with some facilitation from [CEF]. [Community #1, May 2020].
Strategies such as facilitated discussions to uplift coalition members’ voices addressed the inherent power imbalance between the coalition and the research site, and encouraged an equitable relationship between the parties. One ethnographer noted,
All participants were asked to introduce themselves and identify their hopes and concerns about the study. This led to an open discussion of shared goals and potential issues from the community perspective. This activity created an environment where community voices were elevated, so that the process was not driven entirely by the research team. All of the hopes/issues were written on a board at the front of the room for everyone to see and reflect on [Community #4, February 2020].
Power sharing was evident when coalition members serving in champion roles began leading meetings, presenting information to and engaging with their peer coalition members rather than relying on the Community Engagement Facilitator or other study staff to lead this process. In one coalition,
The data and communications champions are taking on a bigger role in presenting updates to the coalition. In these two instances, the community-facing team takes more of a backseat and coalition members are beginning to take on more ownership of these activities. [Community #6, April 2020].
Power dynamics were also a barrier to Principles 3, 5, 7 and 8. When the research site did not actively include coalition members’ feedback and voices, coalition members were less invested in the work. An ethnography notes, “The iterative process was lacking. After learning that several of their selected intervention strategies were not approved by the HCS research team, the coalition did not engage in problem-solving activities. Instead, the meeting had a very negative, demobilizing energy” [Community #4, July 2020]. Since the research site inherently holds power as the purveyor of study funding, it was important for community-facing teams to address this imbalance and create space for coalition member voices as part of incorporating the CBPR principles, while being transparent about which decisions were in the purview of the coalition, and which were ultimately up to the research site. Coalition members occasionally called attention to the impact of power dynamics between the research site and coalition that highlighted the relationship as a barrier to Principle 5:
There seems to be tension between the research site and coalition members. The breakout room I was in discussed that the coalition feels dictated by [research site] instead of led by the coalition. They explained there is not transparency and clarity between the two parties, and if the community had real ownership of the coalition, they could get this work done more efficiently. [Community #7, December 2020].
Theme 4: Meeting structure matters
As a community-engaged study, the coalition meeting structure served to facilitate engagement, collaborative partnerships, and a sense of ownership among coalition members. When meeting time was structured, coalition meetings demonstrated principles 3, 4, 7 and 8. As described in theme 3 related to power dynamics between research site and community above, having a structure that included content experts on the coalition as champions also helped to navigate the power dynamic between the research site and the coalition. One ethnographer noted how using content champions and creating space for coalition member updates increased engagement and ownership by members:
Coalition members shared updates from the subgroups. Each update was clear and comprehensive. Due to the large amount of discussion that occurred after each subgroup updates, it appears the coalition members are beginning to feel invested and responsible for the progress being made. There is some sense of “ownership” over each of the subgroups, which is shared by several coalition members, but all appear comfortable commenting on the various subgroups’ work.” [Community #1, May 2020].
Other examples of intentional meeting structure, such as breakout rooms, also facilitated a sense of ownership among the coalition:
The break-out groups were a great way to start allowing community members to work and learn from each other. The different facilitators in each room provide a different capacity for co-learning. The community faculty member is a skilled facilitator who frames [their] breakout session in a series of questions to receive the most information around the data presented as possible. This promotes co-learning as the research site provides the data and the coalition discusses the reality of what the data shows and how useful the data are to the coalition and the work they are trying to accomplish [Community #8, April 2020].
The structure and use of meeting time were important factors for whether Principles 3, 4, 7 and 8 were demonstrated. In contrast, limitations in meeting structure due to study timeline restrictions posed challenges to engagement. “All updates are followed by discussion to provide feedback and suggestions although this space is not often taken advantage of. Due to the timing challenges experienced in today’s coalition meeting, the spaces for discussion did not feel like enough time.” [Community # 1, November 2020]. The COVID-19 pandemic created new structure challenges due to remote meetings. Several ethnographies noted the barriers related to remote meeting structures and how they posed challenges for engagement and decision making: “Had we not been on Zoom, it would have been easier to gage the coalition members (who were off camera) responses” [Community #5, September 2020]; “The meeting was planned to be shorter in length than normal due to Zoom fatigue” [Community #6, May 2020]; “It is a bit hard to do consensus on Zoom” [Community #2, June 2020].
Theme 5: Need to consider community socio-political context
Coalition meetings often included discussions about ongoing social and political issues such as racial equity, economic stability, stigma, insufficient affordable housing and other factors that impact community members’ access to prevention, harm reduction and treatment for opioid use disorder. Framing opioid use disorder within the existing local community, state and national sociopolitical contexts was highly important to stakeholders. At times, coalition members facilitated conversations around principles 6 and 10, and emphasized the importance of incorporating an equity lens into their work. One ethnographer notes,
In this coalition meeting the CDM shares a PowerPoint with local overdose data. A coalition member is concerned that there is no data for Black Americans being shown in demographics graph. The coalition member shared their concern because they know Hispanic and African American populations are being hurt. She is astonished that there have been zero deaths in two years among African Americans. [Community #5, June 2020].
Coalition members engaged in conversations that focused on stigma, a lack of affordable housing and the COVID-19 pandemic. These discussions prompted meeting leaders to focus on relevant local public health issues in coalition meetings:
The coalition discussed how stigma prevents many in the community from accessing Naloxone. They also mentioned barriers and regulations that dictate which organizations can distribute Naloxone and how that needs to be tracked. The coalition considered these factors when brainstorming interventions, and they were leaning towards expanding Naloxone. A coalition member shared that their agency has been trying to get NaloxBoxes for a while and COVID-19 put a halt on that effort. They added that it is difficult to get places to put out the boxes in public because of stigma, people say that the boxes ‘invite those people here’” [Community #2, June 2020].
Discussions of stigma and community social context could also facilitate actualization of other CBPR principles such as co-learning and capacity building across stakeholders. For example, one ethnography noted, “There was a lovely example of co-learning in today’s meeting when one coalition member shared appropriate language with the coalition encouraging everyone to read through it and think about the language used to discuss Substance Use Disorder” [Community #2, October 2020].
When discussions about sociopolitical context arose in coalition meetings, ethnographers noted their importance and relation to coalition efforts or community engagement. However, many ethnography tables often stated, “this principle was not discussed during this meeting.” Principle 10 related to race, ethnicity and class was discussed less frequently than related to principle 6, addressing public health issues of relevance, which were naturally addressed due to the study focus. A frequent note in the ethnography about Principle 10 was “this principle was not addressed during this meeting.” Typically, ethnographies identified a lack of focus on these principles as appearing due to time constraints, which presented a significant barrier to consistently addressing these issues in coalition meetings. One ethnographer noted the limited time given to these topics in a coalition meeting,
A passionate conversation occurred around the need to address housing stability for individuals with opioid use disorder, particularly in light of COVID-19 and the approaching winter months. While the discussion was well-intended and expressed appreciation of interconnections in individual’s lives, little progress was made due to time constraints. This issue will continue to be discussed in a smaller group moving forward.” [Community #7, November 2020].
Some coalitions determined that the better way to address these issues were via subcommittees or other small groups focused on race, equity and social justice, and then brought discussions back to the larger coalition once a potential strategy had been identified in the smaller group.