Young Men’s Health Matters: Implementing a Community-Academic Partnership in an Urban Federally Qualified Health Center

Abstract

Community-based participatory research (CBPR) approaches are being leveraged more and more in efforts to improve health equity. Informing the building of community-academic partnerships, CBPR draws on the community’s expressed needs and engages stakeholders in future intervention development. To date, however, little has been published on such efforts targeting the health of young Black men (ages 18-24), despite this population’s disproportionate need. In this paper, we describe the formation of a community-academic partnership in a federally qualified health center, with the goal of improving the health of young Black men in Detroit, Michigan. After conducting a needs assessment, we built upon existing networks to form a Community Advisory Board (CAB). We held three community forums during which CAB members highlighted key health issues in their community and described how they could be addressed. We developed a plan for future research and community engagement based on community input. Finally, we provide insights on community engagement strategies, forum structure, setting boundaries, trust-building, and valuable information in addressing the inequities in health that affect young Black men.

• What do we already know about this topic?

• Community-based participatory research (CBPR) approaches are increasingly leveraged to drive health equity programs.

• How does your research contribute to the field?

• This paper provides a framework for maintaining, sustaining, and evaluating community-based partnerships and how these partnerships can influence research practice early on in addressing equitable care and health promotion among racial-ethnic minority males.

• What are your research’s implications toward theory, practice, or policy?

• Fostering community engagement through the active participation of stakeholders is critical to the success of healthcare interventions, evidence-based practice, and policy change.

Introduction

Eliminating health disparities experienced by young Black men (ages 18-24) is an important public health objective. ¹ The literature has demonstrated a disproportionate burden of health and social conditions carried by these young men, who identify as Black and come from a vast array of lived experiences and cultural and ethnic backgrounds from the African diaspora. ² Studies have shown that the health and social inequities experienced by this group are diverse. ² They include, but are not limited to, lack of access to care and insurance, the inability to see a provider due to cost, lack of healthcare knowledge (eg, reproductive health related to pregnancy and condom effectiveness), poor education, high rates of unemployment and other risky health practices such as unsafe sex and alcohol and substance misuse.^{2 -4} Additionally, higher death rates have been seen among this group, including homicide, suicide, and HIV diseases.^{2 -4} Yet, efforts to engage this population with equitable health-supporting services are lacking. Several social determinants of health (e.g., socioeconomic conditions) and gender (the impact of masculinity and manhood) must be considered to address these disparities.^2,5,6 Given the divergent health and social needs compared to other groups, interventions must adopt a holistic, community-based approach to effectively engage, and build rapport with these young men.

Community-based participatory research (CBPR) methods are increasingly leveraged to drive health equity programs. Yet, there is limited literature on effective strategies for building partnerships aimed at improving the health of young men. ⁷ CBPR underlines the importance of building trust and reciprocal engagement between community members and academic investigators to sustain successful partnerships. ⁸ CBPR is equitable and involves all partners within the community in all aspects of the research and development process. ⁹ At the beginning stages, it enables all partners to contribute their expertise with shared responsibility, ownership, and commitment that enhances understanding of the phenomenon. ⁹ This approach may build upon existing networks within communities, such as community health centers, advocacy groups, and grassroots volunteer organizations. ¹⁰ Therefore, the use of such a model would prove beneficial in understanding, first-hand, the health inequities of young Black men.

This paper describes the development of a community-academic partnership aimed at addressing young Black men’s healthcare needs in Detroit, Michigan. The preliminary goals of this partnership were to (1) establish connections within a larger network of support, (2) form a community advisory board to provide an informed perspective on young men’s health, and (3) develop a community-academic plan for improving the wellbeing of young Black men. This included tasks such as identifying and prioritizing health issues, defining future research questions, and ensuring program sustainability. A prior needs assessment was performed to enhance the service delivery of adolescents and young adults at this organization. ¹¹ During that time, it was found that approximately 900 adolescents and young adults accessed care at just one of their specialty clinics. Of these, 95% were Black and 80% were female. ¹¹ Research has confirmed that Black men are less likely to seek primary care or receive reproductive health services than women.^12,13 Additionally, it is well known that FQHCs play a significant role in improved geographic access in delivering comprehensive, high-quality primary health services to individuals of all ages in underserved settings. ¹⁴ The results from this assessment served as a guideline to promote the development of efficacious, community-driven, and culturally responsive interventions with Black youth, with an emphasis on this population to reduce gaps in care and, as a result, birthed the Young Men’s Health Matters Program (YMHM). ¹¹

The impetus to make this happen started with building a community-academic partnership which was spearheaded by three initial community forums to aid in the development of YMHM. Ultimately, this is the first of a series of papers that will report on the process of forming and outcomes of the program and its impact on health disparities and a marginalized group within an urban setting (Detroit).

Forming a Community-Academic Partnership

Using a CBPR approach, the open-forum style discussions allowed us to discover topics important to the community through dialogue between community members, community leaders, and academic partners. Individuals from the community formed the Community Advisory Board (CAB) with the expressed goal of providing support to the community-academic team, helping to identify issues within the community, voicing their thoughts to develop future research plans, and applying their community knowledge throughout the YMHM program.

Description of the Partners

The community-academic academic team was formed with Detroit Community Health Connection, Inc. (DCHC), which is in Detroit, the state’s largest urban area and the seat of Wayne County. Wayne County is the most heavily populated county with just over 1.8 million residents, with 24.2% living below the poverty level. DCHC is Detroit’s second oldest federally qualified health center (FQHC), beginning its 35th year of operation, with seven clinics strategically located throughout the city. In all, DCHC provides comprehensive primary health care, regardless of insurance status, to almost 15 000 patients annually. Its patients are primarily Black or African American (82%). More than half of its patients are uninsured and over a third receive their insurance through Medicaid.

For this community-academic partnership, the team consisted of DCHC’s Director of Outreach, a Black male, from the community, whose experience extended to organizing outreach campaigns for thousands, coordinating events, communicating health and wellness information to the public, and developing and maintaining partnerships for the organization at the local and regional levels. DCHC’s executive and clinical leadership included the Chief Executive Officer, Chief Medical Officer, Associate Medical Officer, Chief of Staff, and clinical leadership, the Director of their Adolescent Health Center. The project also included community health workers and healthcare staff. The academic team consisted of undergraduate and graduate students from nursing, public health, and business programs at a large university under the supervision of the academic faculty lead.

As an FQHC, DCHC receives its primary funding from the Health Resource Services Administration (HRSA) ¹⁵ and provides health care to the underserved in its community. HRSA has a strict set of requirements that include having a sliding scale fee available to their patient population (based on their ability to pay). Additionally, clinics must operate under a governing board that includes 51% of its board members as patients, have established collaborative relationships within the community, conduct needs assessments, and maintain data on performance measures defined by the Uniformed Data System (UDS).^{14 -16} Within the scope of this partnership, patient and community advisory boards (CAB) are a new strategy (different from governing boards) to engage patients and the community with clinic leadership. ¹⁷ The governing board itself is tasked with different responsibilities (e.g., ensuring compliance with all state and federal laws, budget approval, monitoring organizational assets, evaluating the Chief Executive Officer, and strategic planning). Community advisory boards are endorsed by such agencies as HRSA and are listed as a component for Patient-Centered Medical Home Certification and Medicare and Medicaid reimbursement, of which DCHC is affiliated. ¹⁷ The rationale for the creation of this community advisory board is historic, as it allows the opportunity for shared practices and for health services to be tailored to the community’s needs. ¹⁷ The activities described in this paper for forming a community advisory board to assist with the initiatives to reduce health disparities in diverse populations follow the requirements of the Health Resource Services Administration for Federally Qualified Health Centers and does not include research practices for which protection of human participants or an Institutional Review Board-approved protocol is applicable.

Formation of the Community Advisory Board

DCHC had identified the issue of men’s health, with a specific emphasis on young Black men, as a need in the community prior to the project development via a community needs assessment conducted in January 2019. ¹¹ CAB members were recruited from community advocacy groups, community-based organizations, and DCHC-affiliated health centers using flyers, email, social media, and word-of-mouth strategies. These efforts were overseen by the Director of Outreach at DCHC. Recruitment extended to all interested individuals within the community. We implemented several retention strategies to ensure that CAB members were satisfied with their efforts. External funding was granted to assist with a convenient meeting space and scheduling flexible meeting times for each forum. In addition, the community partner was given a stipend, and each member received an incentive payment of $25 per meeting, emphasizing the CAB’s progress and goals throughout the program.

Description of the Forums

The Director of Outreach was instrumental in reaching out to several community organizations and leaders around Detroit via email and word of mouth to gain interest in the advisory board. Information about the CAB was also posted in the community organizations’ newsletter and the academic partners’ quarterly newsletter. A total of 52 community members expressed interest via email or were referred to come in person by a friend to participate in the CAB forums. Ultimately, 36 individuals actively participated, 92% of the group were men and 8% were women. There were no formal selection criteria, although it was encouraged for CAB members to be living or working in Detroit, with an emphasis on shared identity, culture, history, or lived experience as Black men. A document to review the CAB’s responsibilities and purpose was provided to all members. Partnership goals included (1) engaging in open forums with comprehensive discussions regarding certain health issues and underlying problems contributing to these adverse outcomes in young Black men, (2) utilizing current and or seeking grant funding to organize an event in Detroit based upon the group’s recommendations, and (3) cooperate with the academic partner to properly deploy resources and deepen the roots of the community-academic partnership. Other discussed items included governance (eg, committee work and voting), roles of the stakeholder committee, distribution of work, and the communication process to the staff and executive leaders of the FQHC. Members were encouraged to invite other individuals and organizations who were passionate about working with young Black men and improving health equity. On average, each forum included 15 CAB members. Members represented local businesses (e.g., barbershops), non-profits, health centers, mental health agencies, literacy programs, faith-based organizations, and youth organizations (see Figure 1). Areas of expertise of members included counseling, project management, marketing, public speaking, legal, non-profit, technology, writing, and youth leadership.

Figure 1.

Areas of expertise reported by Community Advisory Board (CAB) members.

Three forums were held between June and October 2019 in community centers and at another partnering non-profit organization. Information on the premise of the meetings, project goals, the importance of partnership (e.g., quality vs. quantity) involving the community representative of the population it serves and how the forums fit within the larger planning of a research project were presented to the CAB. By the second forum, roles and basic steps to the decision-making processes were decided. Decision-making committees worked cooperatively and had to receive 75% supermajority support from the forum attendees to be established. Once the larger body separated into working groups to discuss forum questions, granular details were planned out for future meetings, and those decisions needed only a 50% simple majority inside of the respective groups. Many attendees (80%) returned to subsequent forums. Members also participated in team building activities and decided the themes and overall purpose of the group.

The Director of Outreach and two research assistants, from the academic team (young Black men between the ages of 18-24), who were previously involved in the community organizations, facilitated these forums. Each facilitator was trained extensively in group facilitation skills courses. This included prior experience with in-person and virtual group interviews, offering ideas to build trust, offering non-judgmental feedback to the group, and managing time, discussion, and group dynamics. All had prior experience in working with youth and young adults as well as local nonprofits in Detroit. The facilitators asked open-ended questions to initiate dialogue (e.g., “What are the main issues within our community?” and “What do young men need to be educated about most in the community?”). Additionally, to increase audience engagement and feedback, an online interactive anonymous poll was used during the first and second forums to initiate discussion on sensitive topics such as mental health among the group members. During the discussion and presentation portion of the forums, CAB members answered open-ended questions using Poll Everywhere on their mobile devices. Because of the advanced interactive nature of the platform, responses were captured in real-time and populated visually in a word cloud on a Google slide screen.

The first forum asked CAB members to identify the main issues in their community, identify important community partners, and determine the desired outcome for the forums. The goals of subsequent forums were to follow up on the main issues to gain a better understanding of the community’s needs and assets. Many participants described their experience in the forums as analogous to a therapy session, where they felt they could freely talk and open up in a trusting environment with community members and facilitators. Having research and community facilitators from the community itself was seen as an important part of the forums’ success.

The three forums yielded important information regarding the expansion of community partnerships and the development of future goals. CAB members recommended that faith-based organizations and church leaders should be included in community discussions surrounding young men’s health. Church pastors were viewed as necessary partners, given their role and influence within the community. Other community resources shared by the CAB revolved around neighborhood events (e.g., barbeques and jazz events) and community programs such “Brothers Also Read, a literacy program, and the Barbershop Tour: Taking a Cut Out of Life”—a traveling men’s panel hosted by a national men’s organization.

Important challenges in the community were identified during these forums. During the first forum, five major issues were emphasized: socio-economic factors, behavioral health/substance abuse, lack of education, violence, and health (Figure 2). Reviewing these identified issues more in-depth, we summarize the following: Socio-economic factors were categorized into (1) the impact of community values, (2) Trust (e.g., having acceptable role models for advice), (3)Lifestyle (e.g., health behaviors), (4) the effect of incarceration on employment—neighborhoods and environment breed peer pressure, “what they see is what they want to imitate” (e.g., finding a job and the expected financial contributions to the home, growing up before their time). Pressing issues related to behavioral health/ substance abuse for young men included shame and embarrassment around mental health and associated symptoms, which are often not addressed until they become “serious.” In addition, young men have less access to mental health services. Peer pressure and easy access in the community may contribute to drug use/abuse and were identified as a coping mechanism to relieve stress. The discussion about the lack of education included being educated more on risk behaviors, sexual health, understanding sexual misconduct, financial literacy, and policing. Last, health topics included nutrition and understanding the long-term impact of chronic diseases.

Figure 2.

Top 5 issues identified by Community Advisory Board (CAB) members during open forums.

Overall, members reflected on the stigma associated with men’s sexual and behavioral health within churches and suggested that pastors may assist in changing attitudes. Additionally, members believe that including men of all ages in these discussions adds a diversity of thought and experience, which is important for future program development and “bridging the generational divide.” Future discussion-based forums should engage with young men using technology platforms to create a safe space for expressing their opinions.

Discussion

Community-academic partnerships offer a model for integrating both research and practice to develop public health programs that are both culturally sensitive and evidence-based. ¹⁸ However, differing perspectives can strain these partnerships if not integrated using the right approaches, thereby harming the development of effective solutions. ¹⁹ Thus, the chief purpose of this paper is to inform future research and community-academic partnerships operation by the principles integrated in this community-based participatory project.

The discussions between CAB members, the community, and academic partners, highlighted key shared beliefs and conversations around health, communities of color, and the fundamentals of CBPR (eg, power, privilege, participation, co-learning, mutual benefit, and advancement) harbored by stakeholders across different industries at the local level. We believe that these forums provided the space to address and prioritize issues that otherwise might have gone unnoticed by the FQHC agency and academic team. It also allowed the opportunity to network, strengthen community engagement and health practice, and alleviate health disparities within the city. The intention was to ensure that the health center is responsive to the needs of the communities it serves by involving the community. Throughout this process, the CAB consistently mentioned the importance of trust-building in obtaining honest, candid feedback in forums with young Black men. Establishing a partnership between young Black men and a health center in the city of Detroit allowed for more open dialogue regarding the health concerns of the priority population and collaboration to achieve health equity. This partnership, while new, is a big step toward addressing the disproportionate burden of health and social conditions among young Black men that have been largely ignored. Such partnerships are instrumental in the development of effective preventative health interventions and health promotion services for young Black men.

This partnership benefited from the purposeful involvement of community leaders with direct access to young men in Detroit. Our community-based approach was effective because it identified existing resources and structures within the community. For instance, issues surrounding behavioral and mental health require significant shifts in attitudes and sustained investment in financial and human resources. Thus resource-sharing was a significant outcome of this partnership. CAB members offered suggestions for addressing young Black men’s health needs using Detroit’s existing networks of support (e.g., mental health services, youth-based programming, barber services).

The next steps for YMHM include implementing a men’s health conference with several sessions as well as developing Ted Talks to discuss priority issues relevant to young Black men’s health. The events would provide a platform to provide input on the health crisis facing younger generations as well as continue formative assessments with the target population. YMHM had a fantastic response and attendance rate until the onset of the COVID-19 pandemic. Due to emerging health risks for everyone involved, the fourth in-person meeting was halted. This resulted in conversations on how to continue community engagement considering the present challenges, especially when in-person, face-to-face connections are essential for relationship building.

Conclusion

Partnerships between communities and academic entities have been critical in addressing complex issues among communities of color and hard-to-reach populations. ²⁰ Thus, the goal of YMHM is to continue operating under core components of CBPR while integrating strategies and discussions developed from the information provided by the CAB. By using effective communication, maintaining relationships, sustaining operations, and evaluating our approach, we can ensure that the state of health is being addressed with the input of all partners to yield the greatest impact for young Black men in Detroit. ²¹ Given that fostering community engagement through the active participation of stakeholders and leadership both internal (organizational wide) and external (thought leaders and the community) is critical to the success of healthcare interventions. Furthermore, partnerships such as these are essential in creating roadmaps and strategies to engage and empower the community and keep academic units informed about the realism of health challenges that exist in underserved communities.