FHI 360’s global headquarters sit in downtown Durham, North Carolina, a mid-size city with a growing reputation for being hip, vibrant and diverse. Historically, Durham was known as the Black Wall Street – until urban renewal sent a highway through the middle of the black community in the 1960s. Where past and present meet, Durham has a housing crisis, urban deindustrialization, and persistent poverty that disproportionately affect Durham’s black residents, and its growing Latinx population. These social conditions, in turn, generate and perpetuate health disparities. The 2017 Durham County Health Assessment identified affordable housing, access to health care and insurance, and poverty as among the county’s top five health priorities.

There are many organizations, institutions and groups working together to create a culture of health for everyone in Durham. Our FHI 360 offices are within two miles of many including the historically black North Carolina Central University (NCCU), the Durham County Department of Public Health (DCoDPH), the Lincoln Community Health Center providing health care to the underserved, and Duke University and its affiliated health system.

Here I highlight four recent research efforts that show what we have learned about gaps and needs from projects, partnerships and relationships in Durham, North Carolina.

Facilitating cross-sector collaboration

In our five-year National Institutes of Health (NIH)-funded Linking Communities and Scientists project in Durham (LinCS 2 Durham), we convened a Collaborative Council that met monthly and included grassroots members of Durham’s black community as well as organizational representatives. Project partners included NCCU, DCoDPH, and the University of North Carolina Center for AIDS Research (UNC CFAR). You can read more about the LinCS 2 Durham research in this blog post.

In 2013 (the final year of the project), we asked the Collaborative Council members what they saw as the highest priority work we could do to address the health needs of those at risk for HIV. They said people at high risk for HIV had multiple health challenges, and that the things that put them at risk for all those health challenges overlapped. They said Durham needed ways to help people address all these risks and challenges in an integrated way.

With this feedback, our research team focused on how to support Durham’s organizations and partnerships in addressing structural barriers that can’t be addressed at the individual client or provider level. It became increasingly clear that fragmentation functioned as a barrier to information sharing and partnership. Addressing multiple needs is difficult when the services to meet multiple needs are fragmented. Service providers are hard pressed to keep up with their own workloads, let alone fully understand what other providers are doing and how they can most effectively work together.

As researchers and partners, we thought that mapping relationships – how organizations interact with each other – could help community leaders grasp the big picture and figure out new ways to address overlapping health challenges.

In an exploratory study co-led with Betsy Costenbader, we mapped the network of connections between HIV testing organizations and other health and social service agencies in Durham County. We surveyed 26 health and social service organizations, including six providing HIV testing services, about their relationships with each other and referrals. We made a visual network map of the relationships and mapped the geographic locations of organizations along with transportation routes and census data showing income disparities and racial composition of census tracks.

When we shared the study findings with participating organizations, they found that mapping the landscape of their relationships was a practical way to make cross-sector collaboration easier and to improve community health. They were very supportive of using this approach as a tool to monitor efforts to facilitate collaboration because it would allow organizations to assess how everyone is connected and what changes are occurring in the network over time.

Opportunities & gaps in cross-sector member networks

In 2016, we leveraged FHI Foundation funds to conduct an evaluation for the Partnership for a Healthy Durham, a long-standing DCoDPH-supported group that has collaboration and community problem-solving as core to their mission. With several hundred members and 60+ organizations participating in five committees, members said they found it difficult to stay informed of what the different committees were doing. But they also noted that the way relationships are built within the partnership makes the collaboration that does emerge stronger and makes collective action possible. As one member said, “We can work together well because we’ve already all been working together…we already have those relationships built, and the trust is already there.”

As part of our evaluation, we looked at how member organizations were networked, with 40 local organizations participating in the exercise. We found a mix of sectors across this network, with organizations providing medical care connected to those providing education, human and social services, and other services. We could also see that two organizations – the Boys and Girls Club and the Department of Social Services – played a key role in bridging clusters of organizations that would otherwise be disconnected from each other.

Understanding & respecting the patient viewpoint

From 2012 to 2013, with Patient-Centered Outcomes Research Institute (PCORI) funding, FHI 360 researchers conducted interviews and focus groups with more than 300 black men in Durham, to understand how to improve methods for conducting patient-centered research and to explore men’s experiences and opinions regarding health and health care in Durham. The men who participated in the study offered honest and insightful views of their health experiences, which were later captured in an ethnodrama (a dramatized, written play based on narratives from the focus groups).

The play, written and performed by Anita Woodley, a local performer experienced in health education, was free, open to the public, and recorded live. Among the important themes emerging from this work were cultural influences on diet and nutrition, inaccessibility or unaffordability of health insurance and health care, use of the emergency room as a primary interface with the medical establishment, hypermasculine gender roles and expectations, and experiences of poor service related to race or insurance status. The findings underscore the importance of understanding the life experiences and perspectives of those we ultimately hope to serve through policies and strategic planning.

You can read more about this research in this blog post.

Developing a community-driven response

In 2018 we once again leveraged FHI Foundation funds to provide evaluation, communications and stakeholder engagement support to help build a shared vision for the food system in Durham County that will benefit everyone. Convened by the Durham Mayor’s office, the Durham County Commission and the World Food Policy Center at Duke University, this community-based planning project is led by a Design Team that includes diverse voices and expertise (including community organizers, food justice advocates, and educators), with input and feedback from a Collaborative Council representing a diverse cross-section of Durham’s communities and coordination provided by the locally-based Community Food Lab.

Initial work was focused on developing a framework that emphasizes the importance of racial equity in a context of gentrification and expanding urbanization. This included discussion about the need to actively build relationships and a shared understanding about race equity among all those engaged. As of this writing, we are providing our first process evaluation report on the initial phase.

As the project moves into 2019, partners will take “the next most elegant step” (Brown, 2017) to develop a shared understanding of the existing Durham food system, and from there to develop a plan of action with the community and take action together to create food system change in Durham. We are excited to be part of this important community work.

Looking forward

We appreciate the opportunity to apply our research skills to challenges in our local community. Not only are the findings applicable in our “front yard” in Durham, NC, but they can also shape research efforts for addressing complex problems in diverse global settings.

Building on our ability to think globally, tell us: what more do you think we can do to act locally?


Photo caption: Major the Bull, Durham, North Carolina
Photo credit: Kate MacQueen

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