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Developing an Infrastructure to Cultivate Equitable and Sustainable Community-Academic Research Partnerships: Meharry Community Engagement Core

Objectives Achieving health equity and reducing racial and ethnic health disparities require intentional community engagement efforts by academicians. Primary among these efforts is the acknowledgement of research-related mistrust. Efforts to build trust must begin with recognition of the invaluable knowledge and experience community stakeholders possess. Methods The Meharry Community Engagement Core builds on the foundation provided by Meharry Medical College, a Historically Black College and University, to achieve its mission to improve health and health outcomes through long-term collaborative research partnerships with community stakeholders. Early in its development, the Core actively engaged community stakeholders throughout all research phases. Results Early successes include achieving community feedback on research priorities, policies, and procedures and developing partnerships that span the research spectrum. Core work to date is promising and may serve as a model for addressing research-related mistrust and efforts to build trust.


INTRODUCTION
Community engagement in research is critical for achieving health equity and reducing racial and ethnic health disparities. Engaging communities may increase trust in research and research participation, 1 resulting in improved health and health behaviors. 2 A primary goal is community involvement in the research process at all stages, allowing community stakeholders to be equitable partners. These collaborative relationships must leverage the expertise of stakeholders in areas such as the provision of services and resources needed to reduce racial and ethnic disparities and achieve health equity 3 . Additionally, they should acknowledge that community stakeholders may be hesitant to engage in research due to a number of reasons, including mistrust in research and limited recognizition of the benefits of research. 4 An understanding of the role Historically Black Colleges and Universities (HBCUs) may play in achieving health equity and reducing health disparities through community engagement in research may be gained by reviewing their histories and contributions. 5 Most were founded in the midto-late 19th century in response to social inequities, and theirprimarymissionwastoeducatenewlyfreedslaves.They were strategically positioned in African American communities to preserve the culture, improve the condition of the community, and educate and equip community leaders in all fields. 6 The long-standing relationship between HBCUs and the community are, in part, due to HBCUs' bold efforts in each of these areas. These economic, educational, and social anchors in communities put HBCUs in a novel position to understand cultural, social, and structural norms and other community concerns related to research, largely mistrust, which is essential in building and sustaining community-academic research partnerships. However, a long history of mistrust exists between communities and academic institutions. 7 The existing barriers for research partnership developmentbetweenHBCUsandlocalcommunitiesmaybe fewer today, and where present, less engrained, given community awareness of HBCUs' community-serviceoriented missions. 5 Meharry Medical College (Meharry) is well-known for its service to African Americans, other racial and ethnic minorities, and underserved populations. 8 Meharry focuses on improving health equity and reducing health and health care disparities through patient care, medical education, and research initiatives. 9 Founded in 1876 and chartered in 1915, it is the first medical school dedicated to the education of African Americans in the Southern United States. 9 As one of the nation's oldest HBCUs and academic health science centers, Meharry educates health care providers, medical, dental, and biomedical researchers and public health and health policy experts. Meharry is one of the nation's top producers of primary care doctors who work in underserved areas, reflective of the motto, "Worship of God Through Service to Mankind," and mission of educating, practicing, and researching to improve overall well-being.
The Meharry Community Engagement Core (Core) was conceptualized and launched in 2017 through funding from the Research Centers in Minority Institutions Program in Health Disparities Research from the National Institute on Minority Health and Health Disparities. The Core is led by researchers with considerable experience in community-engaged, public health, and clinical research. The Core purposefully builds on the networks developed through the history of education, service, and practice of Meharry to achieve its vision: to eradicate health and healthcare disparities through long-term, collaborative, mutually beneficial community/academic research partnerships. The partnerships exist to actively engage community in all phases of research activities and to enhance community-engaged research at Meharry. Furthermore, the partnerships facilitate and support efforts to achieve health equity and reduce racial and ethnic disparities in health and health outcomes.
This manuscript highlights how the Core has intentionally engaged community stakeholders in all research phases and the short-term impact of these efforts.

Cultivating community-academic partnerships in all research phases
The Institute of Medicine issued a report highlighting work needed to support progress in clinical and translational research. One of the seven recommendations was that community engagement should be integrated into all stages of clinical and translational research. 10 The Core aims to create an environment that promotes community engagement through a collaborative approach, equitably involving partners in all research processes, while recognizing the unique strengths of each partner. Purposeful community-academic relationships may change perspectives, address social, cultural, and structural norms, and alter structural barriers in community-academic partnerships. 3 As part of its launch, the Core actively sought ways to identify community stakeholders to partner in diverse roles. To date, approximately 100 community stakeholders have agreed to partner with the Core in one or more ways. Partnership opportunities include collaboration on community health events, research design and implementation, and dissemination of research findings, focused on reducing racial and ethnic health disparities. In addition, stakeholders have agreed to serve in specific roles as community advisory board (CAB) members, research advisors, research team members, and participants in Meharry research studies. Relative to these partnership opportunities and roles, examples of specific contributions and related outcomes are highlighted below.

Community stakeholder feedback on research priorities
The CAB formalizes the community-academic partnership by providing opportunities for community members to have representation in research activities. 11 For the Core, the CAB also plays a critical role in developing and shaping research priorities. Composed of representatives from various community and faith-based organizations and chaired by coauthor NR, the CAB provides insight into underlying relationship dynamics and fosters trust between the community and Core. This approach focuses on promoting empowerment and capacity building in the community. To date, the CAB has provided insight and direction in a variety of ways, including the development of the Core mission and vision statements, identification of Core marketing strategies, and selection of research dissemination methods. Notably, during the first CAB meeting, a discussion was held, and a consensus was reached that the Core should prioritize trust-building activities to lay the groundwork for impactful community-academic research partnerships. This perspective and guidance increases the likelihood that the negative factors impacting trust are addressed in all Core activities.

Trust as a foundation for community-academic partnerships
In community-academic partnerships, power dynamics and feelings of vulnerability 3 often exist and challenge the formation of equitable partnerships, which undergird communityengaged research efforts. Developing trust is an important factor in translating and expanding the reach of research. 1 While HBCUs are well known for their service to racial and ethnic minorities, they too must be intentional about efforts to increase community trust in research and, in some instances, these institutions are held to higher standards in this regard. 5 Building on the CAB recommendation of prioritizing trust, the Core implemented a workshop with the goal to strengthen and develop relationships between Meharry researchers and community stakeholders. The major workshop activity was the completion of the "Give-Get" grid, 12 an activity that gleaned and compared expectations of community stakeholders and researchers relative to these relationships. Summative data statements from stakeholders and community-based organizations (CBOs) included CBO expectations that researchers share research findings and allow community stakeholders to gain access to research data. These statements reflect what have been long-standing challenges to community-academic research partnerships, while communication and open-access were identified as building blocks to create trust in the community-academic partnership. These and other outcomes provided direction for collaborative principles and practices to guide the Core's partnership activities in support of building and sustaining community trust in research.

Promoting research relevance among community stakeholders
It is vital to address research relevance when building trust with community stakeholders, 13 who often believe research is conducted on them rather than with them, leaving them uninformed on how the results may be beneficial. 14 The Core is addressing this through community presentations and trainings. The presentations are guided, informal conversations about how research impacts everyday life. An example often used is the YMCA's Diabetes Prevention Program. 15 The YMCA developed a community-based, nationwide program to prevent diabetes by providing participants the tools to implement behavioral changes. The program was based on research that showed healthy eating, increased physical activity, and losing weight may reduce participants' risks for developing or prevent the onset of type II diabetes. 16 The first training was conducted as part of the aforementioned community-academic workshop. Presentation content included the importance of research participation among racial and ethnic minorities to ensure research findings are relevant for these groups. The role of research in reducing health disparities was highlighted along with the benefits of community-engaged research (e.g., increased community relevance and potential for sustainable widespread implementation). Post-training, 74% of attendees agreed that their interest in community-academic partnership participation had increased and 79% reported a greater understanding of what community stakeholders and academic researchers may contribute to partnerships. The Core cannot directly correlate these results to participants' increased perceptions of research relevance. However, highlighting research relevance as part of formal research training may be a straightforward method to positively influence trust perceptions when community stakeholders question research relevance.
The second training, "Introduction to Research," was developed in response to the CAB's directive of prioritizing trust and the need to increase the capacity of community stakeholders to actively and meaningfully engage in research efforts. The training includes: (1) an overview of health research; (2) a description of health research and how it may be used to address racial and ethnic health disparities; (3) definitions and examples of basic and applied research; and (4) a summary of ethical and safe research practices. Community members and the CAB provided feedback on order, design, content, and imagery. The feedback provided from community members and the CAB guided the final revisions.

Community stakeholder feedback on research procedures
The promotion of transparency between community stakeholders and researchers is a priority in community-engaged research efforts. 17 The lack of transparency may lead to community hesitation, which is rooted in mistrust of research, uncertainty of partnership direction, and doubt about partnership status. 18 Beyond convening a CAB to provide guidance on research priorities, our Core has engaged community stakeholders in developing new policies and procedures. For example, we have established the Meharry Research Partners database, which pairs research volunteers with Meharry research studies that interest them. Given the known concerns that racial/ethnic minorities have about research participation, 19 we obtained and incorporated feedback from community stakeholders on the database agreement and enrollment forms. The database agreement form describes how the database works and attempts to address some of the known trust-related research concerns (e.g., protection of personal information). The enrollment form includes basic demographic and healthrelated questions. Community stakeholders emphasized the need for plain language to describe medical conditions on the enrollment form and more information about research study safety monitoring on the agreement form. The Core did not assess changes in stakeholder trust as a result of being involved in developing these research procedures. However, inviting and incorporating their input, when possible, is a straightforward method to promote transparency, while simultaneously responding to community concerns that influence trust in research. 1

Community stakeholder feedback on research dissemination strategies
An important, yet often overlooked, community-engaged research principle is the dissemination of research findings to community, 20 a major criticism of community stakeholders. Community-academic partnerships often do not include efforts to develop and implement research dissemination strategies, thereby contributing to mistrust of research and low perceptions of its value. 21 The Core convened a CAB meeting to identify research dissemination strategies to share research findings with the community. The preferred strategies werethrough CBOs, followed byvideos, podcasts, and email. While not among the top strategies, radio and YouTube videos also were considered dissemination strategies.WiththeCAB'sassistance,CBOsarebeingidentifiedto disseminate research findings through their networks.
Thus far, the Core has implemented two dissemination activities. The first of these was to develop and implement an "Introduction to Research Dissemination" training for researchers. This training was developed by Core faculty and staff includes (1) an overview of the importance of research dissemination; (2) steps to develop a dissemination plan; (3) tips on how to identify and engage stakeholders; and 4) a video clip of a community stakeholder discussing the importance of research dissemination to the community. The inaugural training was attended by fifteen biomedical and basic researchers. Following the training, most researchers (80%) indicated that they knew how to measure dissemination efforts, and 90% would incorporate dissemination into their research.
In addition, the Core worked with the CAB to develop guidelines for researchers to discuss their research studies and provide results to the community via radio. The resulting Meharry Research Spotlight Series is a quarterly feature of a Fisk University-run radio station. Fisk University is an undergraduate HBCU that partners with Meharry on numerous education and research initiatives. The first airing introduced the Core and importance of research and research dissemination and the second featured the first of many researchers to present their research findings to the community. During the second airing, the Core hosted a radio listening party with community stakeholders to assess the impact of the dissemination activity on their research perceptions. The preliminary findings suggest that radio dissemination may increase knowledge, attitudes, trust, and participation related to research among those underrepresented in research. Moreover, the Core is currently working with the CAB to develop a website and quarterly newspaper editorial to supplement the radio segment.

RESULTS AND DISCUSSION
The Meharry Community Engagement Core is actively engaging community stakeholders in all research phases. Early successes include achieving community feedback on research priorities, policies, and procedures, and developing partnerships that span the research spectrum. This work is critical given that community engagement in research is integral to achieving health equity and addressing disproportionate disease burdens experienced by racial and ethnic minorities. The advantage of collaborations between communities and academicians in this regard is the potential to increase the breadth and depth of understanding burdens and how to best address them. 22 Though community engagement in all research phases helps to develop equitable community/academic research partnerships, integration and adoption by academic institutions may include the need to overcome various implementation challenges. For institutions that do not have an existing infrastructure to support community engagement, these challenges may include time, effort, funding, and preparedness. Engaging stakeholders may be a new concept for some researchers, as their training has not prepared them for engagement, which also may not be valued by their institution or its leadership. In such cases, it may be helpful to leverage existing national resources or activities. At minimum, communities should be included in developing research goals and objectives.

IMPLICATIONS
Since its launch, the Core has intentionally engaged community stakeholders in all research phases. While still early, the Core is experiencing promising outcomes. These successes are critical given that health and health care disparities and health in equities will continue to persist without meaningful community engagement. The outcomes reported here may serve as examples to other institutions seeking to promote health equity and reduce racial and ethnic disparities in health and health outcomes disparities through research.