HSOA Jou r n al of Com m u n i t y Medi ci ne an d Pu bl i c Heal t h Car e The Los Angeles Healthy Community Neighborhood Initiative: A Ten Year Experience in Building and Sustaining a Successful Community-Academic Partnership

Background: Developing effective Community-Academic Partnerships (CAPs) is challenging, and the steps to build and sustain them have not been well documented. This paper describes efforts to form and sustain the Healthy Community Neighborhood Initiative (HCNI), a CAP to improve health in a low-income community in South Los Angeles. Methods: Moderated, semi-structured discussions with HCNI community and academic partners were used to develop a framework for CAP formation. Results: We identi¿ed two key features, shared values and respect, as critical to the decision to form the HCNI. Five elements were identi¿ed as necessary for building and sustaining the HCNI: trust, transparency, equity and fairness, adequate resources and developing protocols to provide structure. We also identi¿ed several challenges and barriers and the strategies used in the HCNI to mitigate these challenges. Conclusion: We developed a framework to incorporate and reinforce the key elements identi¿ed as crucial in building and sustaining a CAP in a low-income community.


Introduction
A growing interest in community engaged research approaches to establish and sustain healthier communities and improve population health [1][2][3][4] has produced an increasing number of research studies that involve key community stakeholders in all aspects of the research process: from the identi cation of health priorities to study design, implementation, data analysis and dissemination [5]. Community engaged research may occur at a variety of levels of intensity ranging from the use of Community Advisory Boards (CABs) to fully engaged Community-Based Participatory Research (CBPR). Israel and colleagues [5] have de ned CBPR as "a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings, to jointly explore answers to complex socio-medical questions. " We also frequently use of the term "Community-Partnered Participatory Research" (CPPR) to emphasize partnering with communities rather than merely possessing a location within the community to conduct research [6][7][8]. e idea of community and academia partnering in the research process leads to the need for a better understanding how to build and sustain such partnerships. ere are several examples in the literature of "how to" build a Community-Academic Partnership (CAP) [9][10][11][12][13][14][15][16][17], but developing e ective CAPs is challenging [18], and the steps to build and sustain these CAPs have not been well documented. Most reports of CAPs have instead focused on discussing accomplishments [19][20][21][22], while a few studies have reported on selected elements of successful collaborations, such as building trust and team-building activities [23,24]. ere is a clear need for a better understanding of possible e ective strategies [1]. e HCNI is a pilot project started in 2005 consisting of community-academic partnerships between 2 community organizations and 2 academic institutions: Los Angeles Urban League (LAUL), Healthy African American Families Phase II (HAAF), Charles R Drew University (CDU), and University of California Los Angeles (UCLA). e overall goal of HCNI is to identify and address health-related questions posed by the residents in Park Mesa Heights, a low-income community in South Los Angeles. e initiative initially focused on a 70-square block area documented to have some of the poorest health outcomes for preventable chronic disease and some of the highest rates of premature morbidity and mortality among African Americans and Latinos in Los Angeles County [25].
trust, transparency, equity and fairness, adequate resources and developing protocols to provide structure. We also identi¿ed several challenges and barriers and the strategies used in the HCNI to mitigate these challenges. Conclusion: We developed a framework to incorporate and reinforce the key elements identi¿ed as crucial in building and sustaining a CAP in a low-income community. Keywords: Building partnerships; Community-academic partnership; Community-based participatory research; Memorandum of understanding; Sustaining partnerships HCNI: 70-square block area In 2005, the LAUL and United Way of Greater Los Angeles produced " e State of Black Los Angeles, " a report that measured the equality index, an objective tool to assess overall well-being of racial/ethnic minority groups in Los Angeles County (LAC) in six domains: economics, housing, health, education, criminal justice, and civic engagement [25]. e report indicated that African Americans in LAC fair worse than any other racial/ethnic group in all areas except civic engagement. e results presented in the report prompted community organizations to actively address these concerns. e HCNI partners recognized to improve the health of the community, each element of the report needed to be addressed simultaneously. e residents of the 70-square block area are disproportionately a ected by hypertension, obesity, diabetes, hyperlipidemia, and heart disease and face many barriers to implementing health promotion strategies and accessing health care for these conditions. e problem is magni ed because addressing these health problems requires more than a focus on health care. Most health outcome interventions do not address any social determinants of health and those that do, typically focus on one domain independent of the others [25]. is paper uses in-depth qualitative analyses to describe the formation and evolution of the CAP for the HCNI, a project designed to address health disparities in this community in South Los Angeles. We provide lessons learned in building a sustainable CAP and o er insights into strategies for stakeholders interested in forming and nurturing e ective CAPs.

Methods
Our team used CBPR/CPPR methods to build a foundation for the Healthy Community Neighborhood Initiative (HCNI), a CAP to improve the health of residents of a low income, bi-ethnic neighborhood in South Los Angeles (LA). Our project has been approved by both Charles R Drew University and University of California, Los Angeles Institutional Review Boards. e data presented in this paper did not require additional IRB approval since it was part of the internal evaluation of the project.
Description of partners e LA Urban League (LAUL) is a non-pro t community organization founded in 1921 focused on advancing equal opportunities on behalf of African Americans, Latinos and other minority youth and adults. Its mission is to enable these groups to secure economic self-reliance, parity, power and civil rights and a high quality of life through advocacy. LAUL employees have expertise in many of the social determinants of health, including education, employment, housing and criminal justice.
Healthy African American Families (HAAF) Phase II is a non-pro t community serving organization founded in 1992. ey facilitate health research and health promotion activities through education, training, and collaboration. HAAF has over 25 years of history partnering locally and nationally with community, academia, researchers, and government [26].
Charles R Drew University (CDU) is located in the diverse and underserved area of South Los Angeles. CDU was chartered in 1966 as a post-graduate school in response to the Watts rebellion, and the medical education program was established in 1978 as a satellite of the UCLA School of Medicine. e CDU mission is to provide education, research, and clinical service in the context of community engagement.
e University of California, Los Angeles Clinical and Translational Science Institute (UCLA CTSI) is comprised of four partner institutions-Cedar-Sinai Medical Center, CDU, LA Biomed/Harbor-UCLA, UCLA-Westwood-and a network of community partners. e CTSI's central mission is to translate evidence-based research into e ective clinical practices, public health initiatives and policies that address the greatest health needs of LA County.
Formation of the partnership Based on the ndings from " e State of Black Los Angeles, " the LAUL's Deputy Neighborhood O cer for Health (DM) initiated a series of neighborhood discussions on health with key community stakeholders, including HAAF (LJ), and academic partners at CDU (KN). During initial meetings to establish the partnership, each partner discussed his or her organization's or institution's goals and the team worked to develop a shared vision and set of goals for the project and for building the partnership. is core group of leaders was subsequently joined by other members of the UCLA CTSI. Once the team established a shared vision, the partnership became more de ned. Leadership meetings included all partners and were held weekly to review study design, develop protocols and surveys, analyze results, and review dra products (e.g., scienti c abstracts, community reports, presentations and manuscripts). e team also held quarterly community LAUL Health Collaborative stakeholder/advisory meetings to provide feedback and get further input. Additional weekly meetings and/or calls with coauthors were held for manuscript preparation. Meetings were held at HAAF or LAUL o ces, or occasionally other local community sites. To date, the HCNI study team consists of approximately 17 members, not including undergraduate, graduate and professional student interns. e partnership was uniquely positioned to launch the HCNI for numerous reasons. Several of the community and academic partners worked together on community research and outreach projects for as many as 10 to 15 years prior to the formation of the HCNI, which established a foundation of respect, trust and familiarity. is decreased the time required to build trust and familiarity in a CAP. Moreover, the community partners have spearheaded or collaborated on nationally recognized work on the theory and practice of CBPR/CPPR [6,[8][9][10][27][28][29][30]. Despite these prior activities, sustaining the work going forward is always challenging.
Creation of a shared vision rough the process described above, the team developed a shared vision of the HCNI and a set of goals for the CAP, speci cally, to work with the community to improve health and health care in the context of a multifaceted intervention that also includes housing, employment, education and safety. e goals were to understand the health needs, health-related behaviors, health care use and clinical outcomes of residents living within a de ned area of South LA.

Procedures
A focused discussion group with HCNI core members was convened in June 2013 at HAAF o ces in South LA to summarize the early phases of the HCNI project. A HCNI core member is de ned as a person who has been involved in HCNI since its origination in 2005. A semi-structured set of questions guided the discussion including topics such as the history of HCNI, the partnership's successes and challenges, and strategies used within the partnership to overcome barriers and successfully sustain a community-academic research partnership.
ese topic areas are aligned with critical realism concepts to better understand how the HCNI partnership participatory research methods has added value to the research process [2,31]. e discussion was approximately two-hours and digitally recorded. e recording was de-identi ed and transcribed by an outside rm and reviewed by an HCNI co-investigator, independent from the discussion group process, to create themes. A trained facilitator took notes during the discussion. ese notes formed the basis of three subsequent two-hour focused discussion groups with all current HCNI study team members, including core members who participated in the rst group discussion. e trained facilitator took notes at these subsequent series of team meetings which distilled lessons learned in building and sustaining the HCNI CAP and using grounded theory developed a set of recommendations around forming and sustaining a CAP as previously described [8,10,32]. To account for group dynamics and allow di erential expression of opinion, one-on-one, semi-structured, 30-minute interviews were conducted with three randomly selected HCNI core members that participated in the initial focused discussion group. e interviews were held at each member's respective o ce by a trained interviewer who also took notes. All interviews were digitally recorded. Members of the HCNI team (KMK, KN, AB, LJ, DM and AW) analyzed the core members' one-on-one transcripts and larger group summary notes for emerging themes and lessons learned from the partnership [32]. ese analyses identi ed the themes that helped to form the HCNI, approaches to sustaining its development and growth and strategies for mitigating challenges. e HCNI partnership then used these themes to develop a framework for forming and sustaining CAPs to improve health and reduce disparities.
Results e focused discussion group and subsequent review by the larger study team highlighted the key elements used to guide the HCNI partnership. e members of the HCNI team strongly endorsed the importance of CAP principles as a framework for initiating and expanding the collaborative. Table 1 lists the CAP Key emes and provides examples of strategies consistent with each key theme that was used in HCNI to promote the partnership. e discussants and reviewers cited several important characteristics of the project partners and the partnership itself that were essential to building and sustaining the HCNI collaborative (Table 2), including mutual respect, consistent and committed leadership, and a shared vision. Characteristics of the partners that the discussants identi ed as instrumental to the partnerships success included consistent and committed leadership with a shared vision and the fact that many of the original members continued to partner. Even when there was turnover at an organization, having representatives from the institution or agency who understood the project and could take on a leadership role ensured continuity. ere was transparency about the needs of each member of the partnership. Each member of the partnership was asked to be explicit about his or her individual goals and the goals/needs of the agency or institution represented. At each step, the group tried to emphasize and prioritize the needs of the community. ere was also an e ort to ensure that the core missions of the community organizations were not undermined by participating in the project. At the same time, there was sensitivity to salient outcomes for academic partners, among them funding, 3. Value community "resident experts." (Example: Promote community members to lead/co-lead manuscripts and grant proposals; co-teach in an academic setting) 4. Establish community advisory boards, but recognize while they are important they are not suf¿cient for true CAPs. (Example: A Health Collaborative was established to provide feedback and insight from various community organizations with expertise in health, education, safety, employment and housing) 5. Understand how to collaborate and build effective relationships: commitment = time, patience, physical presence and assistance in building the communities' capacity for understanding, participating in and bene¿ting from research. (Example: Identi¿ed and committed time and resources to goals of each partner, e.g., Supported CBO activities that addressed the needs of the communities they served such as health fairs, community presentations; joint podium and poster presentations at academic meetings; support for and collaborations on academic and community grant applications; jointly developed projects, such as training guides, resource manuals, surveys, worksheets, reports for community) 6. Faculty need to be briefed/educated by community leaders and vice versa. 8. Respect community's time, effort, insights (recognized with payment for services/%effort, authorship, etc., -same as academia). (Example: In-kind contributions of time from the CBO and academic leaders and staff members; space provided in-kind by community partners and academic partners; hired academic staff who could facilitate meetings and work collaboratively with CBO staff; funding to support CBOs and academic partners) 9. Build on existing community resources. (Example: Trainings on depression awareness, community safety, Cardiopulmonary resuscitation (CPR), and biomarker data collection) 10. Funding source should be committed to maintaining close contact throughout the project. (Example: Awarded funds for HCNI through UCLA CTSI whom also provide academic staff support that work collaboratively with CBO staff) 11. For meetings, alternate sites, establish ground rules, maintain community and academic co-chairs (consider two community co-chairs to one academic co-chair if needed to balance power dynamics). (Example: Regular meetings -mostly in the community; initially in person, subsequently alternated face-to-face meetings with telephone calls; agendas for subsequent meeting discussed at the end of each meeting and circulated several days prior to the meeting; occasionally requested in person meetings to address important or challenging issues (e.g., to modify protocols or develop responses to IRB queries) or culmination of an internship or to celebrate important milestones (e.g., completion of data collection) 12. Mentorship: Use a model where community members are co-mentors for entry-level academic faculty who are learning skills to conduct respectful partnered research with and in communities with balanced input from both academic and community sides of the research program. (Example: Identi¿ed "trainees" from the community and from the academic sector; included undergraduate and graduate students as interns; mentored non-junior faculty members new to community-partnered research methods) publications and presentations, and academic promotion. Finally, because many of the community and academic partners had prior experience with CBPR and/or CPPR, the process of engagement was more e cient, and those with more experience were able to mentor less experienced colleagues. e focused discussion group further identi ed ve themes, which were related to the success of building and sustaining the HCNI partnership.
ese ve themes were recognized as the "glue" to sustaining the CAP. Some of these themes were also included in the HCNI memorandum of understanding (MOU), a contract de ning the CAP for the project.

Building trust
Trust was a critical element of the partnership's success. Several factors promoted trust within the partnership: experience participating in CAPs as described above, a long history of leadership and service within the community, and pre-existing relationships with mutual respect between the partners.
"I think another one of the strengths that assisted this project is the longstanding partnerships that had worked on many other projects together and committed and everybody that was here had a certain set of ethics that they are familiar with and work with…it was the trust that they have amongst themselves and the commitment that they had that helped it [HCNI] to foster and move forward. " -Academic Partner Obtaining local funding to support the partnership Recognition of mutual bene¿ts • Recognized these needs also had relevance for community members whose employment prospects could be enhanced *CBPR/CPPR = Community-Based Participatory Research/Community-Partnered Participatory Research, a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings, to jointly explore answers to complex socio-medical questions. An emphasis on partnering with communities rather than possessing a location within the community to conduct research.
A central component to building community trust was developing and maintaining community awareness of, and interest in, the project. It was also essential to leverage existing resources from each of the partners in e orts to build trust within the community. e team emphasized an asset-based approach to working with the community that involved identifying and leveraging resources from a range of community stakeholders to support the HCNI.
"…one of the things that kept going on the agenda, that we kept going back to is making sure that the instrument [survey] was culturally appropriate…we brought in a cross-section of the community and sort of ran things by them for them to take a look at and got some interesting and salient points along the way, which I think was a good thing to do so we don't get so far down the road and then nd out from the community that this was a mess. " -Community Partner "But I think one of the things that we really enjoyed…was the fact that if we got it right and we got into the community and did it right, that we would have people on board with us that by word of mouth and by our behavior in community, that that would move this project forward and actually get it out there and let people see it…when we talked about this project, people really receive it with open arms. " -Community Partner Transparency ere was transparency about the needs of each member of the partnership, and at each step, the group tried to ensure that the core missions of the community organizations were not undermined by their participation.
is transparency required each partnership member to share their goals as they aligned with the project. When the goals did not align, transparency was achieved through honest discussions of how new goals not previously endorsed by the project could be aligned with the project. When goals did not align with the project, transparency was maintained with discussions highlighting the importance of the shared project goals while remembering that lack of endorsement of a partner's new goals were not intended as personal slights. e partnership thrived when individuals were encouraged to bring new ideas to the group for discussion even when there was no assurance they would be accepted as new goals.
"…what the goal was there was this large project that [CP1] described and that was an opportunity for people to come in and contribute… however, a lot of people came in and saw this as their opportunity. Came in with the perspective that my independent project desires, wishes, and needs are of primary importance…I want to drive the whole project around me and my project. But it has to be, everybody has to put their personal agendas as secondary to the primary project and primary goal…those people eventually dropped o " -Community Partner "…we had to look saying who's really working on the bus and who needs to be o the bus? So that's when we had to have meetings with [AP5] and [AP6], the person that we had to get o [the bus] because it just wasn't working. It was really bringing the morale of the rest of the group down every time we met because there was always an issue. " -Community Partner Equity and fairness A critical element in creating equity and fairness in the partnership was through shared leadership. e partners recognized the diversity within the CAP by identifying one or more rotating leads for di erent components of the project, who would put forth a plan and bring it back to the rest of the group. is process was iterative and elicited an ongoing, layering discussion that helped the larger group reach decisions on project related issues. e team emphasized egalitarian processes and peer governance, which fostered a willingness and openness to questioning each other and discussing competing priorities-a process the partners described as maintaining a "balance between trust and skepticism" [33].
"For the local community that's a big piece because we as community, we're living the experience in the community. We know what the needs are but in order to develop something at the level that we needed to, we needed that academic side and [AP1], see that vision, was able to be the voice that we needed to navigate us through some of the challenges that we faced in terms of getting the expertise that we needed to be on board…" -Community Partner "I was saying too, if you came in and sat down at the table, you couldn't tell if there was somebody leading. It was an egalitarian process. And so community and the academic side, it was equal governance, people participation across the board. " -Community Partner Need for adequate resources e partnership was started with no formal funding; however, the partners collaborated to achieve short term projects within the community, o en linking to ongoing activities their agencies or institutions, such as health fairs, local presentations on health and well-being, and community-wide conferences. e team used these events to disseminate information on the collaborative, gauge community interest in the project, and identify community priorities for the collaborative. ese e orts were also central to building trust within the community by developing and maintain community awareness of an interest in the project. e team also emphasized a non-de cit, asset-based approach to working with the community that involved identifying and leveraging community resources to support the HCNI.
" at was another thing. ere was no money. Everybody was working for four years with no money. So everybody, we all came to the table volunteering but we' d known in the long range we would nd money or continue to look for money…it wasn't till a couple years ago that we got the CTSI funding to actually fund the project. " -Community Partner "…it was a lot of time and energy that was not, that we had not funding for, but everybody was really committed to it. So it was a challenge to make sure that we could continue doing the work without any funding to get it done. " -Academic Partner Developing protocols to provide structure A nal theme important to building and sustaining the CAP was the development of protocols, which provided structure to the process for achieving study goals and outcomes. For instance, the team developed protocols for sharing information, completing and distributing minutes, deciding on the next meeting's agenda at the end of each meeting, regular emails with the agenda and documents to be reviewed beforehand, etc.

Challenges and barriers to partnering
During the focused group discussion and the subsequent review by team members, several challenges and barriers were identi ed. Here we highlight the most salient challenges and barriers. e partnership consisted of individuals from diverse backgrounds who had expertise in a range of academic disciplines and community topics. Di erences in opinions and in styles of communication initially discouraged some members of the study from fully participating in the research process and early on, caused some study team members to leave the group. e partners worked to resolve this challenge by adopting peer governance and an egalitarian approach that encouraged all participants to voice their opinions and to question each other's assumptions respectfully.
Another challenge involved con icting goals and agendas among team members and organizations that led to disagreements between some of the partners. At times the team strayed from main goals of the collaborative and the speci c projects needed to achieve these objectives. is was especially problematic early on, before the MOU was established and nalized. Key to resolving this problem was referring back to the MOU to reiterate and prioritize the shared objectives of the partnership. is con ict resolution process was generally successful in addressing di ering agendas, but in one instance, a team member who could not reconcile personal goals with the partnership objectives was asked to leave the project a er many attempts to re-align competing priorities.
Another major barrier encountered was a lack of funding. is was a substantial challenge, as many of the team members were working in-kind on HCNI while maintaining full workloads in their agencies. e lack of consistent funding resulted in signi cant delays to many components of the project. However, the group took steps to overcome this challenge by applying for extramural and intramural funding. Eventually, the study team secured intramural funding from the UCLA CTSI and from the University of Southern California (USC)-UCLA Biodemography Center to assist with data collection, partnered analyses, manuscripts, intervention development and obtaining longer term funding for interventions.
A nal major barrier was the di culty nalizing the adult survey questions.
e survey was one of three parts of the adult health interview comprised of 1) the survey, 2) health screening, and 3) laboratory data collection conducted within the household. ere were protracted disagreements, limited sta and resources regarding the survey focus and which questions to include slowed progress by a year. e HCNI study team brought in new study team members to view survey in light of overall goals and community feedback and developed an iterative process to revise the survey. e new study team members elded several dra s with community and found survey was too long. is forced the team to revisit original goals from MOU to guide focus and shorten the survey.

HCNI outcomes
Despite the challenges and barriers described above, the approaches we outlined resulted in several products and accomplishments. ese include: the MOU; a partnered informed consent form; an IRB approved study protocol; training materials such as a manual of procedures, eld safety protocol documents for study sta , and patient result reporting protocols. e data collection elements developed jointly through the partnership included an adult survey, a manual for neighborhood observations, a community resource guide, and mapping of community assets and de cits. Discussion e HCNI's CAP was founded to address health and social inequities identi ed in communities in South LA. We identi ed several key factors that helped to build the CAP and to sustain the relationships between the partners over the past seven years [9,10]. Consistent with the ndings of Eriksson et al., [17] mutual respect and a shared vision led to shared goals and built a strong foundation for the partnership. e HCNI team built upon this foundation by incorporating ve key themes for building and sustaining the partnership: trust, transparency, equity and fairness, need for adequate resources and importance of developing protocols. ese mirrored the four themes of accepting di erent levels of participation in di erent phases, openly discuss mutual expectations, unmasking power and authority and allow the work to take the necessary time reported by Fröding and colleagues for using a CBPR approach to increase participation of community-academic partnerships to improve health and well-being in poor neighborhoods [16]. Lastly, we identi ed challenges and barriers to building and sustaining a partnership.
Here we share some of our lessons learned from building and sustaining HCNI that may be useful to other community organizations and academic institutions interested in forming or nurturing partnerships.
Lessons learned e rst lesson was to carefully think through the members of the team. It is important to frequently review who is not at the table and who should be at the table [28,34,35]. Importantly, this should include not only key stakeholders who might be supportive but those who might be naysayers in order to have a spectrum of perspectives and insights that allow the team to think through the potential successes and pitfalls of the project and planned strategies. While recognizing di erent individuals will have di erent agendas, we strive to have each person leave their personal agendas outside the door when they work as part of the team. Having some community and academic partners with prior experience in CAPs promoted e ciency in the partnering process, as those with more experience were able to mentor less experienced colleagues. Within HCNI, this process helped build trust among the partners. In addition, leveraging each partner's existing resources helped build trust in the project with the community.
Aligning individual/organization-speci c goals and the group agenda through a project-speci c MOU helped to reinforce and prioritize the shared objectives of the partnership. is process helped to resolve con icts between partner organizations. Transparency among the partners helped to promote sensitivity to salient outcomes for each partner, such as publications, presentations, and academic promotion for academic partners and capacity needs for community partners. Resonant with the ndings of Fröding et al., [16] there were concerns that power di erentials between individuals at the table might impede discussions about issues within the partnership and an additional concern that di erent communication styles might contribute to separate discussions among partner members who did not feel comfortable approaching some members of the group. To address these concerns, the partners developed a shared leadership and peer governance structure that encouraged all participants to voice their opinions and to question each other's assumptions respectfully in a manner similar to that described by Jones et al. [36].
is process was described by the partners as "maintaining a balance between trust and skepticism" [33] that contributed to timely and e cient con ict resolution. In addition, the senior community and academic partners having a long history of collaboration further facilitated power sharing.
Another challenge was maintaining project continuity. Over time multiple transitions occur, some are temporary and some permanent. When there was turnover of HCNI representation at an organization, it was important for incumbent partners to connect the new team member to the primary goals of the project to ensure continuity as well as to recognize people may have to leave and may also rejoin during the course of the project [37].
Lack of resources was one of the biggest challenges in sustaining the partnership. In some instances, trying to achieve the mission of the respective partners while staying committed to HCNI signi cantly decreased productivity towards the study aims. However, the group took steps to overcome this challenge by appointing a working group within the partnership that consisted of community and academic team member who focused on obtaining extramural and intramural funding. e study team secured intramural funding from the UCLA CTSI and from the USC-UCLA Biodemography Center as noted earlier.
Lastly, developing protocols provided structure for the partners and the project. By having speci c protocols in place for sharing information, the conduct of meetings, etc., the CAP was able to work more e ciently to achieve project goals and outcomes and to celebrate small successes at each phase of the project. A unique but related challenge that emerged from the individual interviews with core HCNI members was the Institutional Review Board challenges for study approval. CAP projects such as HCNI revealed distinctive IRB requirements leading to multiple revisions to the study protocol before it was approved. A er approval, the project coordinator continued close communication with IRB to ensure all requirements were being met each approval period.
Based on our discussions, we developed a Community-Academic Partnership Framework (Figure 1) that includes the core themes that we believe are essential to building and sustaining the partnership. ese elements should be reinforced through the MOU and thus guide the partners in sustaining and strengthening their relationships and remaining aligned with the project goals and outcomes.

Conclusion
Building a CAP to improve community health is not an easy feat. It takes time, patience, and commitment to the process. HCNI was successful in building and sustaining a partnership that achieved some of the initial study goals, but it also bene ted from several years of prior collaborations. e next steps for the HCNI are to discuss the challenges and successes of the initial study goals, analyze the data collected, and use the data, in partnership with the community, to develop an intervention that will address the HCNI vision to impact policy for improving community health [38,39].