By Amie Ashcraft, PhD, MPH | January 6, 2015
Research Manager, West Virginia University
I grew up in Bridgeport, West Virginia. We had what passed for a Mexican and a Chinese restaurant. We had a convenience store with a drive-thru where you could buy smokes, beverages and live bait—everything needed for a fishing trip.
By local standards, my town was not at all rural. There was even a shopping mall in Bridgeport. The town was not quite so small that everyone knew everyone else, but it was small enough that if you were getting into trouble, you could be sure that word would eventually get back to your parents.
It wasn’t until I got a summer job in college with Energy Express, a reading and nutrition program for children, that I experienced truly rural areas of my state—undeveloped, mountainous areas where cell phone service still doesn’t reach and access to clean water and indoor plumbing are daily challenges for some.
Like most members of our younger generations, I couldn’t wait to leave West Virginia. I longed for new experiences and diverse people and different ways of thinking. And so, like many before and after me, I took my college education and left the state.
Growing up in Bridgeport, almost everyone looked like me: White. I can count on one hand the number of people of color in my entire high school (around 800 students). I had never even known anyone who was Black.
My environment changed dramatically when I went to grad school in Richmond, Virginia. In that city, about 80% of the residents were Black and about 20% were White.
I thought I wanted to focus on lab-based social psychological experiments on stereotyping. Instead, a series of serendipitous events led me to Dr. Faye Z. Belgrave and the Center for Cultural Experiences in Prevention (CCEP) at Virginia Commonwealth University. As a graduate student (and later as a staff member), I joined their prevention work with Black adolescents in public schools and youth-serving organizations around Richmond.
I pretty quickly went from making my first friend of color to joining an all-Black staff at the CCEP. I often felt conspicuous, awkward and socially clumsy. I regularly had to justify and defend to both colleagues and community connections why I (a White girl from a middle-class background) was interested in working in poor communities largely comprised of people of color. Some accepted and appreciated my sincere interest, while others waited to hear from other trusted community members that I was an okay person to deal with.
Despite the challenges, I learned a great deal about connecting with community members and community-based organizations. In my later work, I went on to apply what I’d learned from my involvement with the CCEP and inner city public housing communities around Richmond. New projects took me to neighborhoods such as the Bayview community of San Francisco, the town of East Palo Alto and the city of San Jose, all in California; Pittsburgh, Pennsylvania; and several different counties around West Virginia.
I returned to West Virginia in 2013 and began working on a project implementing and evaluating a sexual health prevention intervention for adolescent girls ages 14-19. We worked in urban, suburban and rural areas in West Virginia, Pennsylvania and Ohio. After all of my time working in urban and suburban settings, I assumed I would have a lot to learn about working with rural youth.
It was especially important to me to get it right. My home state continues to face significant challenges and health disparities in adolescent sexual health. While national teen pregnancy rates are at an historic low, West Virginia has one of the highest rates in the country (see here and here for the data). State rates of chlamydia and gonorrhea have risen drastically from 2009-2012 (32.8% and 76.8%, respectively) with the greatest number of cases in youth ages 15-24.
This is particularly concerning given that a large portion of the state is rural and many residents have no health insurance. Many have limited access to health care due to lack of transportation and the often long distances to medical facilities.
Additionally, Appalachian social and cultural norms play a major role in health decisions. West Virginians and other residents of Appalachia are deeply proud of their heritage. They resent those who label them with stereotypes of ignorance and indigence based on where they live. Family bonds tend to be very strong and distrust of outsiders is high. Thus, many of these rural residents are reluctant to discuss sensitive and private physical and mental health matters with those outside the family, including physicians. Seeking medical assistance is often a last resort. (See this article for a qualitative exploration of these issues specific to West Virginia.)
Such an environment may limit adolescents’ access to accurate preventive health information and care, particularly in the area of sexual and reproductive health, which has traditionally been considered a private topic. In my field, most research and interventions to date have focused on suburban and urban adolescents. Research that takes into account the unique challenges of rural adolescents is urgently needed.
At this point I’ve come full circle. After living away from West Virginia for 14 years, I’ve returned to my home state and am working on projects to reduce unplanned pregnancy and sexually transmitted infections in adolescents. And you know what? I didn’t have as much to learn as I thought I did.
Through a combination of strong mentorship, my own trial and error and the application of my experiences growing up in Appalachia, I’ve learned some things about developing successful community partnerships over the years that have been useful in shifting my research focus from urban to rural settings.
One major thing I’ve learned is that strategies that work in inner city communities are not as different as one might imagine from those that work in rural communities. These strategies still basically boil down to trust, reputation and following through on commitments.
Here are five strategies I’ve used in settings all along the continuum from the densest urban to the remotest rural communities. With a bit of modification, they seem to work well in every setting I’ve seen.
Get to know the people and organizations you’re working with. Do your homework to learn about the organization and its staff ahead of time. When interacting with staff and administration, remember their names. When appropriate, ask about their families, vacations and holiday plans.
Take extensive notes to help you remember. Make connections. If at all possible, spend time volunteering at the site to really learn about the organization. Participate in their events (e.g., food drive, fundraiser, health fair). Show your interest and commitment by being a regular presence (when appropriate, of course). Trust and respect will have to be earned, and that may take some time.
During my first foray into working with the Boys and Girls Club in one public housing community in Richmond—my first community partnership ever—I asked friends and colleagues for advice for how to present myself. I was advised to dress professionally and to have visible university identification on me so it was clear I was there in an official capacity.
I had no idea at the time that this was terrible advice and would immediately put everyone around me on guard.
I partnered with local Boys and Girls Clubs to connect with mothers and daughters I could interview for my dissertation. I found that my jeans and flip-flops got me a lot further than my suit and heels.
Although it seems a given, it’s worth mentioning that good manners and hospitality go a long way. When possible, take treats! The value of delicious food on the development of good will and cooperation cannot be overstated, and it is true for people of all ages.
Do not rely on email only. It took me awhile to realize this, and it may be a generational thing. I’ve found that it’s essential—especially when first connecting with a new potential partner organization—for people to hear my voice.
Part of the reason for this suggestion is practical in rural settings: many of the sites I’ve worked in around rural West Virginia have limited or no Internet access. Even at sites with fairly reliable Internet, staff members with email addresses may have limited opportunities to check their messages.
The other reason for this suggestion is interpersonal, and applies in urban, suburban and rural settings: it is critical to be able to infuse warmth, sincerity and humor into the conversation. It is vital to be able to gauge and react to the other person’s tone. And in that person-to-person interaction, it’s easier to remember to avoid lingo, jargon and acronyms.
Once the partnership is established, be sure to check in regularly. Check in by phone whenever possible, regardless of whether the partnership appears to be running smoothly or not. Some time and attention is needed on a regular basis to maintain the connection you’re developing in these communities and to ensure the work you’re doing together continues to be a priority for those involved.
As you’re getting to know the communities and the organizations with whom you want to partner, find out which community members are most influential. This is easier said than done, but their buy-in may be critical in connecting you to people, programs and resources. Their endorsement of your work may encourage others to support it, too.
Further, their input on your proposed methods can be invaluable to ensuring your project’s success. You may know the science and the stats, but they know the people and how to get things done. Consider setting up a Community Advisory Board that meets periodically to be sure that everyone is on the same page. Take their feedback and suggestions to heart.
I have found that these influential community members and thought leaders often emerge from unlikely places. On one of my projects, it was a mom in a public housing community who had provided child care for a large portion of the adolescent girls in the community I was trying to reach. She had become a confidante to many of them. Her support of the work I was doing encouraged girls and their mothers to participate in my research.
On another project, a local thought leader was a colorful former teacher and county circuit court clerk with strong social ties to and historical knowledge of the area. His connection to the local chapter of Bikers for Christ was crucial in garnering community support for a variety of projects, including our pregnancy and STI prevention work with youth. He had lived in the community all his life, and other community members trusted his judgment.
This is the tip I find is most often neglected. Many communities mistrust physicians, universities and other outsiders who want to conduct research or collect data from their members. When I worked in the Bayview neighborhood of San Francisco, one long-time staff member at a local community-based organization complained bitterly about his experiences over the years with researchers from a prominent area university. “All they want to do is take, take, take,” he told me. “They come in and pretend they’re going to do all these great things, and then they get what they want and we never hear from them again. And we’re still over here struggling and asking, ‘What about us? Hey! Remember us?’”
At the time I was naïve and surprised by his anger, but I’ve come to see that this is a common complaint of underserved populations and communities, and it is not without justification.
It’s just like the campsite rule: leave the community a better place than when you found it. There are lots of ways you can go about this. Share your findings in a manner that is accessible and approachable. When feasible, donate equipment or resources that can be useful (e.g., laptops or tablets used for data collection, free copies of the intervention you’re using). Do what you say you’re going to do and follow through on your promises and commitments (and if you cannot, clearly and honestly explain why and describe what will be done instead). Empower the staff, organizations, and communities you work with. Perhaps you can share data, time or expertise that will assist them in applying for their own funding. To the extent that you can, help develop their capacity to do their work even more successfully.
You are not only representing your immediate project or team when you develop a community partnership. You are also representing everyone who develops community partnerships in order to study health issues or effect change. Your efforts to develop successful ones now can pave the way for those who come after you.