Mobilizing Established School Partnerships to Reach Underserved Children During a Global Pandemic

The CBPR conceptual model includes 4 dimensions (contexts, group dynamics and equitable partnerships, intervention and research design, and outcomes) with embedded subdimensions and relationships between the dimensions (Fig 1). Developed in 2011,²⁰  it was revised in 2013 to better capture evolving discoveries of the science of CBPR. The 2013 CBPR model details the dimensions and subdimensions of the process and outcomes, which have been extensively reported elsewhere.²¹  In brief, the first dimension, context, and its subdimensions, including social determinants (economic, social, and cultural), are described as shaping the nature of the research and the partnership. The second dimension is group dynamics and equitable partnerships, which describe how the practice of partnership creates equitable partnerships. The model reveals that group dynamics and equitable partnerships interact with contextual factors to impact the intervention and research design. The intervention and research design dimension highlights the importance of integrating community partners’ voices, cultural norms, and knowledge into the research design, research methods, intervention development, and translation of knowledge for dissemination and implementation.²¹  The bidirectional learning between communities and academics continues to build partnership synergy. Finally, ongoing interaction between the context, group dynamics, and partnership processes and integration of community into the intervention and research design lead to the fourth dimension, outcomes. Outcomes include intermediate system and capacity changes for both the community and research institution, such as changed policy and practices, different power relations in which community voices are heard, sustainability of community-centered interventions, and cultural revitalization and renewal, which collectively improve health and social justice outcomes. The model stipulates that partnership is dynamic, and participating stakeholders may experience tensions due to loss of funding, new leadership, differences in partners’ interpretation of events, and other external and internal factors.²¹ 

Using case studies as examples, we describe how the dimensions of the CBPR conceptual model (context, group dynamics, intervention and research, and outcomes) have been operationalized in the 2 school-academic partnerships. The first case study is a rural school-academic partnership established between the University of Washington (UW) and the Yakima Valley community. The second case study is a Tribal school-academic partnership established between the Johns Hopkins Center for American Indian Health (JHCAIH) and a Native American community.

Washington State is one of the major geographic areas in the United States where farmworkers reside,²²  and the Yakima Valley has the largest farms in number and size in Washington State.²³  Latino peoples make up a majority of the population in rural agricultural communities in the Yakima Valley,²⁴  and many are employed in agricultural and food packaging industries.²²  In addition, the population includes contracted seasonal workers from within and outside the United States, who move through distant geographical sites during farming seasons. Most of the Latino population in the Valley is Mexican American (95%).²⁵ 

In contrast to Southwestern areas of the United States, the Mexican settlement in the Yakima Valley is a historically recent phenomenon. Large-scale Mexican immigration to the Yakima Valley began during World War II, when the high demand for agricultural labor led to the enactment of the Bracero Program (1942–1964).²⁶  The program brought >35 000 Mexican laborers to Washington State to work under contract.²⁶  Despite the end of the Bracero Program in 1964, immigrants have continued to move to the Yakima Valley to find employment or to unite with family members and friends who have settled in the area. With this case study, we describe the process of designing a community-wide intervention to address childhood obesity in these communities through a rural school-academic partnership.

The Center for Community Health Promotion was established in 1998 to address the health needs of the Yakima Valley.²⁷  Projects that have included CBPR principles span the period from 1998 to the present. Close partnerships with the community enabled the team to create programs that were adopted regionally and nationally. For example, a project focused on pesticide education developed a preschool curriculum on avoiding pesticide exposure, which has been adopted by Head Start programs throughout the region.²⁸  More recently, a community-wide, family-focused nutrition and PA program has been adopted in 4 towns in the Yakima Valley.^29,30 

From its inception, our partnership with the Yakima Valley was grounded in CBPR principles of bidirectional learning. During community advisory board (CAB) meetings, we covered and discussed various areas of the research process, institutional review board process, requirements of the funded grant, and the partners’ roles and responsibilities to ensure that the work could be conducted equitably and collaboratively. These discussions led to the development of a CAB-facing curriculum on the research process consisting of the following 5 modules: (1) the role and importance of scientific design, (2) documentation and analysis of activities, (3) dissemination of the results, (4) program sustainability, and (5) budgeting. This curriculum helped CAB members to expand their knowledge of research, and 4 CAB members are now advising other projects as community investigators, infusing communities’ perspectives in research projects.

Our first CBPR project began in 2013, when the community reached out to Center for Community Health Promotion with concerns of a high prevalence of childhood obesity in the Yakima Valley. A partnership grant from the National Institutes of Health allowed us to create a CAB representing diverse sectors of the community, including school stakeholders, and implement a community analysis in 4 towns in the Yakima Valley to assess the community needs for nutrition and PA.^31,32  Using the findings, the CAB and the researchers codesigned the intervention trial and launched them in 2 school districts.³³  On completion of the trial, intervention components were turned into programs and resources and were adopted by schools, community organizations, and 4 towns in the Yakima Valley.

The CAB and researchers reflected on the findings from the community analysis through a half-day retreat. Using a strengths, weaknesses, opportunities, and threats analysis, we identified internal and external needs and resources in the 4 towns. Then each CAB member anonymously voted to select the intervention and the comparison school districts.

Using an iterative approach, the CAB and the researchers codeveloped 4 different sets of interventions (named A, B, C, and D). Each set of interventions included multilevel programs that could be implemented within the time line of the study and had potential for dissemination and long-term sustainability. These options were presented at a community-wide town hall forum for voting. The winning intervention, called Together We STRIDE, consisted of the following: (1) a family event at the school district that builds social cohesiveness; (2) a series of multigenerational nutrition and PA classes for students, parents, and grandparents led by community health workers outside school; (3) teacher-led nutrition education and brief PA breaks in the classrooms, and (4) an “open streets” event (called ciclovía) to promote PA.³³ 

This rural school-academic partnership has been transformative for both the community and the academic institution. Findings from the evaluation revealed dose-response among students in the intervention group; students participating in more intervention components had a greater reduction in the mean BMI z score (P = .008).³⁴  The completion rate of the multigenerational nutrition and PA classes was 72%. The ciclovía is an open streets event that temporarily closes streets to motorized traffic so they can be used by individuals for PA, such as biking, walking, jogging, and dancing. The CAB secured permits to close the streets, and ∼180 individuals attended the first ciclovía.³⁵ 

The school-based activities were adopted by all participating schools. The multigenerational nutrition and PA classes were adopted by community organizations, and the ciclovía was adopted by the intervention town as part of its annual event. Although the original purpose of the ciclovía was to create more safe places for PA, the event has also served to build a sense of collectivism in the community, outreach to other towns and the Tribal Yakama Nation, and disseminate the learning to other communities through a planning guide.^29,30 

In 2017 and 2018, the ciclovía was a research intervention, whereas in 2019, the event became a community-adopted program, administered by the community, with the research team supporting its evaluation. Community attendance doubled from 189 people per hour (126 children and 63 adults) in 2017 to 394 people per hour (277 children and 117 adults) in 2019, which is >4% of the town’s population.^29,30  This rate of attendance is higher than ciclovías in urban settings, where <1% of the population participate.³⁶  Active transportation, such as bicycles, were promoted during the ciclovía, and children on bicycles increased from 11 (8 boys and 3 girls) in 2017 to 31 (18 boys and 13 girls) in 2019. Throughout the years, participation among Native Americans from the Yakama Nation noticeably increased, suggesting potential appeal to this community when adopted as a community-wide event. Approximately 30% of the surveyed participants reported that they were from neighboring communities and became aware of this event through outreach by the community to organizations in the neighboring communities. To facilitate the adoption of ciclovías by other communities, the CAB created a planning guide that describes the implementation steps and supporting tools to accomplish the plan.³⁷ 

The partnership also led to changes in academic institutions. For example, UW’s Institute of Translational Health Sciences (UW’s clinical and translational science award) created a bidirectional community-academic matching program in which the goal of the partnership was to move away from a latching relationship to participatory research that focuses on responding to the community’s priorities.³⁸  In addition, the Institute of Translational Health Sciences revised its vision to ensure that community engagement resources were available to research teams and programs across the translational science spectrum to support research partnerships that prioritized community input.

Native communities endure greater health, education, and economic inequities compared with other US ethnic groups, which stem from historical trauma, current and modern-day oppression, and underfunding of health services provided by the Indian Health Service.^39–42  Thus, public health strategies situated within Native populations are wise to develop prevention models targeting determinants of health at the whole community level and the larger socioeconomic context.^43,44  Native leaders and academic partners call for approaches that consider societal-level factors (such as poverty and unemployment), that are explicitly committed to local capacity building, and that are strengths based.^44–46  With this case study, we describe the process of designing a youth entrepreneurship education program as a primary prevention approach to reduce risk for substance use and suicide among Native American adolescents through a Tribal school-academic partnership.

The JHCAIH has a ≥40-year continuous track record of conducting CBPR in partnership with Native communities, including proving the efficacy of oral rehydration therapy for infant diarrhea and of pediatric vaccines for Haemophilus influenzae, type B meningitis, rotavirus, and pneumococcal disease.⁴⁷  These 4 interventions prevent ∼3 to 5 million child deaths a year worldwide.⁴⁷  JHCAIH upholds the highest standards of science and data quality, balanced by a community-engaged process. Stigmatization and a lack of trust of the outside research community are barriers to conducting research with Native communities. JHCAIH’s long-standing Tribal-academic research partnership is a testament to its model for creating and maintaining equitable relationships and public health solutions.

Community leaders from a Tribal community shared with JHCAIH partners sentiments of hopelessness among their youth, driven by an underresourced socioeconomic context, which may be contributing factors to high rates of youth substance use and suicide.^48,49  In response, Tribal-academic partners embarked on ≥20 years of qualitative and quantitative research to understand the factors perpetuating these inequities. This research revealed the following driving impacts: (1) low educational achievement and higher school drop-out rates, (2) hopelessness about the future, and (3) negative peer influences on youth substance use, suicide, and other high-risk behaviors.^50–57 

A CAB of Tribal youth, adults, and leaders was formed with key stakeholders, including local school administrators and Elders, to reflect on these data and explore avenues for intervention development. The principles and values of CBPR shaped the exchange of ideas between community and academic partners and the structure of the resulting intervention and evaluation design. CAB members described how youth struggle to see the practical side of education and have little incentive to stay in school, resulting in low high school graduation rates, low college matriculation, and diminished future career opportunities. In addition, CAB members lamented the lack of formal businesses and job opportunities and widespread unemployment and underemployment. CAB members discussed how entrepreneurship has a well-established foundation within their community, through which economic and employment opportunity gaps have been bridged. For example, Tailgate is a daily outdoor market with local individuals selling food, goods, and services not offered through large-scale businesses on the reservation. Thus, Tribal school-academic research partners established the following key goals for an intervention: (1) to teach entrepreneurship education blended with life skills; (2) to promote school connectedness, including a commitment to academic performance, school values, and codes of conduct; and (3) to foster relationships between youth, positive peers, and caring adults.^57,58  Together, we reviewed existing best practices in entrepreneurship education and developed life-skills content from a previous curriculum developed by JHCAIH that focused on communication, problem-solving, decision-making, and emotion regulation.⁵⁹  Tribal community health workers were chosen as facilitators to broaden the pool of caring adults with whom adolescents could connect and to build the local workforce and economy, thereby further strengthening the program’s community-level impact and potential for sustainability.

The resulting youth entrepreneurship education intervention consists of 16 lessons taught by 2 adult facilitators to mixed-sex groups of youth. The first 10 lessons are taught during a summer overnight camp. The last 6 lessons are taught through workshops during the academic year. More than 60 hours of applied lesson content is delivered through discussion, games, skill-building activities, and multimedia over ∼8 months. Several lessons are taught by local Tribal entrepreneurs, community leaders, and Elders, who teach about their culture and promote positive Native identity. At program culmination, youth present their small business plans and are awarded seed funding for startup.

The CAB endorsed using a 2:1 (intervention/control) randomized controlled design for the evaluation of psychosocial, behavioral health, educational, and economic outcomes from baseline to 2 years of follow-up.^60,61  The evaluation was reviewed and approved by the participating Tribal Council and Health Advisory Board, the Indian Health Service, and JHCAIH research review boards.^60,61  A memorandum of understanding (MOU) was secured with all local high schools to refer youth aged 13 to 16 years for participation.

Results revealed that fewer intervention versus control participants used marijuana at 6, 12, and 24 months post intervention (19.6% vs 28.0% [P = .032], 20.4% vs 31.8% [P = .01], and 24.1% vs 31.4% [P = .047], respectively).⁶²  Positive impacts among intervention participants were observed at 6 months for missing school because of feeling unsafe (P = .021) and at 24 months for fighting at school (P = .003).⁶²  In addition, significant improvements in the intervention versus control group were sustained at 12 months for entrepreneurship knowledge (P = .008) and economic confidence and security (P = .006).⁶³  Additional outcomes from this research include transformative systems-level and capacity-building changes within the participating Tribal community, including sustainability of the intervention in a school-based setting, and cultural revitalization and renewal, which collectively improves health and social justice outcomes. For example, a complementary business incubator, a café, and a marketplace were launched to provide a workspace and meeting area for product creation and idea generation among youth program graduates, with on-site and virtual retail opportunities and apprenticeships in customer service, hospitality, and culinary arts. Youth apprenticeships offered opportunities to hone entrepreneurship and job skills while directly contributing to community economic development.

Since launching, the café has grown to become a profitable healthy foods restaurant and employs full-time employees, of whom several are youth program graduates. The café has its own food truck, expanding business to include catering and special events. Similarly, the marketplace has become a center for local artisans to sell products and goods, buying and selling products from >400 Native adolescent and adult entrepreneurs to date. The café and marketplace are now a vital community gathering place and a strength- and cultural-based economic asset for the Tribe. In addition, an MOU formalized the youth entrepreneurship education program as part of the standardized freshmen year curriculum. Now, all youth entering high school in this Tribal community learn this curriculum from JHCAIH facilitators and receive course credit. The continuation of positive relationships between these youth and adults in the community builds and sustains feelings of emotional safety, which could additionally buffer against risk factors for substance use and suicide.^64,65  In addition, intergenerational relationships and youth holding a purpose and role within their Tribe continually reinforce collective Native values centered on the importance of community.⁶⁶  Finally, a version of the program has been developed for adults and serves as both job-skills training and job creation as many adult graduates go on to sell their goods and products in the marketplace.

The established research infrastructure and capacity of the school-academic partnerships increased the partners’ readiness to respond rapidly to the needs of the global COVID-19 pandemic. Although all CBPR processes and practices are critical for building authentic partnerships, we highlight key processes under the group dynamics and intervention and research dimensions that specifically emerged when partnering with schools in the return-to-school program.

UW’s Reopening Schools and Educating Youth project is a school-academic partnership with one large school district (with 14 elementary schools) that includes predominantly Hispanic families in the Yakima Valley. The project’s aims are as follows: (1) to identify the community’s social, ethical, and behavioral needs and resources for students to return to school and maintain on-site learning; (2) to evaluate the effectiveness of a testing program on student attendance by using a cluster randomized controlled trial (RCT); and (3) to assess implementation outcomes of the testing program with school stakeholders, parents, and children. The testing program is administered and managed by the school district through the Washington Department of Health’s Learn to Return program by using BD Veritor for symptomatic and weekly asymptomatic testing of students on-site by trained staff.

JHCAIH’s Project SafeSchools partners with Native American communities in the Southwest. The project’s aims are as follows: (1) to understand the barriers and facilitators to school reopenings and the impact of school closures on youth from multiple stakeholder perspectives; (2) to measure the acceptability, feasibility, reach, and impact of surveillance testing for COVID-19 in schools; and (3) to understand the social, emotional, mental, educational, and physical health impacts of returning to school among caregivers and youth 4 to 16 years of age. The project is guided by CABs. Each school decides its own testing strategy in collaboration with Tribal partners and local and state public health departments. Testing data are collected by schools for only those participants who give their consent and then shared with the research team for analysis through data-sharing agreements.

Two subdimensions were identified under group dynamics: (1) formal agreements with schools and (2) recognition of community members as wisdom keepers. First, both of our partnering institutions created an MOU detailing the scope of work with input from our school partners. These documents were reviewed by the partnerships and revised until deemed appropriate by the communities to ensure mutual understanding. At UW, this document was signed at the district level because the school system is centralized, with the district having overarching supervision over all the schools. However, researchers should note that some school systems may be less centralized and that leadership at the school level may operate more independently. For example, the MOU in the JHCAIH case study was signed by the superintendent of the school district on behalf of the local high school. Second, it is important to recognize community members, leaders, and other stakeholders as wisdom keepers of the community. These partners often have identified solutions that can be expanded and scaled. When UW’s team needed to increase student and family buy-in to SARS-CoV-2 testing because of testing fatigue, CAB members participated in the development of promotional materials for local radio and television to create community awareness about the study. At JHCAIH, local leaders, health care and other treatment providers, school administrators, and parents were asked to join the CAB to advise on school-based testing strategies on the basis of previously successful programs in their communities.

Similarly, the following 2 subdimensions were identified under the intervention and research domain: (1) maintaining flexibility of the study design and (2) using a creative process to design interventions that are relevant and appealing to the community. First, both the UW and JHCAIH teams maintained flexibility in the study design, selecting evaluation designs that would be accepted by the community and benefit all participants regardless of the intervention assignment. Although RCTs are the gold standard in trial design, RCTs may not always be feasible or appropriate to employ in school-academic partnerships. For example, when ethical concerns were raised by union members in the comparison schools about not being offered the intervention (consisting of weekly COVID-19 testing for students and staff plus risk communication with comic books for students), the UW team revised the design and made testing available to both intervention and comparison groups, and comic books remained the only intervention with delayed distribution to the comparison group. With the change in the study design, the purpose of the study was revised to examine the effectiveness of the comic book on increasing adherence to COVID-19 testing during the school year among the study participants and its impact on COVID-19 transmission. Similarly, the JHCAIH team selected a mixed-methods study design, which included in-depth interviews with parents and youth and a longitudinal survey to best understand the social and emotional impacts of COVID-19 without putting undue time burden on participants. Second, UW’s team planned to implement education on the importance of a safe return to schools through preventive measures (eg, masks, hand-washing, social distancing), testing, and future vaccination to children by only using comic books (Fig 2). Reflecting on the concerns from adults, the partnership decided to create adult-facing health education materials with videos to complement the education of the children. Similarly, reflecting on the community’s values, the JHCAIH team employed and trained local Tribal members to conduct all data collection as part of their Return-to-School Diagnostic Testing Approaches agreement.

Native Americans and Latinos have experienced incredible disparities because of the COVID-19 pandemic. To support the safe reopening of schools, 2 academic institutions mobilized previously established school-academic partnerships and their research infrastructure to implement SARS-CoV-2 testing approaches in schools. These testing strategies identify cases rapidly, limit the spread of SARS-CoV-2, and prevent unnecessary school and work absences. These school-academic partnerships are grounded on CBPR processes and practices, which state that to achieve transformative, sustainable changes, partnerships must be equitable, include bidirectional learning, foster capacity changes in the school and academic system, focus on health outcomes, improve practices and policies, and promote health equity. Authentic partnerships should be the ultimate goal of research collaborations between schools and academic institutions, and the processes described in this article can serve as an initial platform to build capacity and a model to continue to strive toward that goal.

We acknowledge Brooke Walker, MS, who provided editorial review and submission of the manuscript.

CAB

community advisory board

CBPR

community-based participatory research

COVID-19

coronavirus disease 2019

JHCAIH

Johns Hopkins Center for American Indian Health

MOU

memorandum of understanding

PA

physical activity

RCT

randomized controlled trial

SARS-CoV-2

severe acute respiratory syndrome coronavirus 2

UW

University of Washington