A Contribution to Measure Partnership Trust in Community-Based Participatory Research and Interventions With Latinx Communities in the United States

Purpose of the Study

Our research team sought to measure partnership trust as a CBPR outcome hypothesizing that CBPR-related activities and processes can promote partnership trust and other desired outcomes of CBHOs and their stakeholders (Tumiel-Berhalter et al., 2011). The specific aim of this study was to refine a bilingual (i.e., English and Spanish) CBPR-PTS using CCCI, by collaborating with English- and Spanish-speaking stakeholders of a CBHO (PASOs).

Literature Review

CBPR is considered a trust-building process (Lucero, 2013), yet there are few measures of partnership trust as a CBPR outcome (DHHS, 2013). The cultural and linguistic adaptation of quantitative measurement instruments is highly relevant in cross-cultural research. Therefore, instruments used to measure trust in partnerships between Latinx stakeholders of CBHOs must be conceptually equivalent across languages. Particularly considering that a major threat to the analysis of survey data collected across language or cultural groups is that the items do not function similarly when administered across groups (Willis & Miller, 2011). A previous study (Carrasco, 2003) showed that some correctly translated questions still pose conceptual problems for Spanish-speaking respondents. For this purpose, CCCI has emerged as an extension to cross-cultural research, incorporating qualitative evaluation steps (Kudela et al., 2004; Levin et al., 2009; Merenda, 2005; K. Miller et al., 2005). In this study, we applied CCCI methods to pretest and evaluate a newly developed CBPR-PTS in English and Spanish.

Lucero (2013) argued that the CBPR literature has overlooked the trust development process and that trust has been conceptualized as a dichotomous outcome, thus denying its multidimensionality. Sandoval et al. (2012) conducted a literature review and concluded that most studies described CBPR processes and methods but not outcomes (Cargo & Mercer, 2008; Schaufeli & van Dierendonck, 1992). The DHHS (2013) stated that despite the relevance of trust as a community engagement outcome, gaps remain in understanding how the influence of CBPR in fostering trust can be measured. Thus, comprehensive, valid, and reliable tools are needed that measure partnership trust from the perspective of those who perceive historic mistrust (Costa & Anderson, 2011;M. C. Miller, 2012; Sandoval et al., 2012), as well as from a multidimensional, rather than a binary (i.e., whether a person trusts someone), perspective (Dietz & Den Hartog, 2006; Egede & Ellis, 2008).

Lucero (Lucero, 2013; Lucero & Wallerstein, 2013; Lucero, Wright, & Reese, 2018) and M. C. Miller (2012) advanced the understanding of partnership trust in the context of CBPR qualitatively, and their findings represent a basis for our study. In the absence of an existing theoretical framework on CBPR partnership trust to inform our CBPR-PTS instrument development in a previous study (Moore de Peralta et al., 2020), the research team decided to adapt Dietz and Den Hartog’s (2006) MMTM by shifting it from an intraorganizational focus to a CBPR focus (Figure 1). The MMTM was selected because, in this model, trust is conceptualized as a dyadic (i.e., trustor and trustee) and dynamic process consisting of attitudinal and behavioral elements and requiring inputs or determinants that foster trust. In our study, CBPR processes, methods, and context-specific conditions that foster collaboration and provide the opportunity to trust the partnership represent these determinants (Lucero, 2013; Oetzel, 2009).

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Figure 1

Partnership Trust Process as a CBPR Outcome: Modified Version of the Intraorganizational Trust Multidimensional Integrated Framework

In the previous study (Moore de Peralta et al., 2020), the research team identified all partnership trust determinants in the literature, categorized and defined them into the six input categories of the MMTM including items from Lucero’s (2013) CBPR trust study about the type and perceptions of trust, and the relevant factors that influence trust development in the context of CBPR; Wallerstein and Duran’s (2010) CBPR conceptual logic model; Costa and Anderson’s (2011) formative and reflective indicators of team trust; M. C. Miller’s (2012) psychometric analysis and exploration of trust, group characteristics and health among community-based and congregation-based groups; Oetzel’s (2009) intercultural communication concepts; and the Centers for Disease Control and Prevention’s (2008) partnership trust survey. Finally, the research team conducted a literature review to determine whether the MMTM has been previously used to inform partnership trust instrument development, and we did not find empirical evidence of this. Therefore, our study could be the first to use the MMTM to inform the development of a CBPR-partnership trust measurement tool.

Setting

An ongoing community–academic partnership between Clemson University and PASOs, a CBHO based at the University of South Carolina’s Arnold School of Public Health that delivers participatory health-promotion programming with Latinx families and communities, facilitated the application of CBPR principles to the design and implementation of this study. PASOs (which means “Steps” in Spanish) was established in 2005, to build a stronger state by supporting Latinx communities through education, advocacy, and leadership development. CHWs are the core of the organization since they assist community participants (CPs) in navigating complex health and social service systems and provide feedback to partner organizations. PASOs provides culturally tailored educational workshops to promote the health and well-being of South Carolina Latinx families; helps navigate the health care, social service, and early childhood resource systems; partners with mainstream organizations so they can provide more effective health and social services to the Latinx population; and conducts leadership development for grassroots Latinx leaders.

Procedures

Sample

The stakeholder sample included four groups of participants aged 18 years and older and residing in Richland County, South Carolina, as follows, CPs (n = 5), volunteer CHWs (n = 5), organizational partners (OPs, n = 6), and PASOs staff CHWs (staff CHWs, n = 5). The CBPR-PTS was made applicable to all stakeholders by adapting the questions to their different degrees and nature of involvement with PASOs (program design and/or research) and levels of linguistic skill and education. To apply the MMTM framework dyadically, it was necessary to determine who represented the trustor and the trustee when considering PASOs’ type of collaborations and stakeholders (Figure 2). The CPs were depicted as the trustor party for all other stakeholders. The volunteer CHWs mediate most of the interactions between the CPs and the other stakeholders; as such, they were depicted as trustees for the CPs and trustors for the OPs and PASOs’ staff CHWs and leaders. The OPs were depicted as trustees for the CPs and volunteer CHWs and as trustors for the staff CHWs and leaders. PASOs’ staff CHWs and leaders are considered trustees for all other stakeholders.

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Figure 2

Defining Roles in CBPR Partnership Trust: The Case of PASOs Stakeholders

Instruments

The team used the first version of the CBPR-PTS, to develop a second version of the survey by translating it to Spanish, and then back-translating it to English (Moore de Peralta et al., 2020). The team also pilot tested the Spanish version of this second version of the CBPR-PTS with four of the volunteer CHWs. After the team applied the pilot testing–suggested changes, the final version of the survey instrument consisted of 19 scales ranging from two to 18 items per scale for a total of 185 items. These items corresponded to the nine dimensions of partnership trust as per the modified MMTM (Figure 1). Supplemental Table 1 presents the details of all the survey scales, including the number of items, two example items, the type of scale, and to which MMTM dimensions (9) and constructs these items are connected.

The team evaluated the constructs’ face validity (Gravetter & Forzano, 2012) of the second version of the CBPR-PTS to determine whether the constructs covered the meanings and concepts as intended using CCCI. The team used Willis’s (2011) framework to develop the CCCI questionnaire for the interviews. This framework assesses the type of issues that could affect survey participants’ responses. Table 1 shows examples of the most recurrent issues that might affect survey responses related to the original survey questions (OSQs = 28) that were analyzed for specific issues and the corresponding CCCI questions.

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Table 1

Examples of Potential Issues That Might Have Affected Survey Questions and Were Addressed Using CCCI

Potential issues (Willis, 2011)	Original survey question	CCCI questions
Attitude may not exist: Respondent may be unaware of the occurrence or not of some of the assumptions of this question	3.6. Has PASOs asked you to participate in the design and implementation of health or early childhood research or programs conducted by this organization in your community? □ Yes □ No. Jump to Table 11 □ Prefer not to answer	• “What comes to mind when you think of situations when you were asked to collaborate with a PASOs programs or research on health or early childhood?” • “In your own words, what is a program?” • “How would you define research?” • “Can you think of an example of PASOs research or programs you collaborated with?”
Incomprehension of a specific term: The term memorandum of understanding [MOU] might not be clear or evident in its meaning for several respondents	3.3. Is there any standard procedure (e.g., MOU, contract, etc.) to collaborate with PASOs? □ Yes □ No □ Not sure	• “What is to you an MOU?” • “How would you express that in your own words?” • “How would you name that in Spanish?”
Missing time periods/unspecified: The respondent may have difficulties recalling when its involvement with the organization started	3.1. For how many years have you been collaborating with PASOs?	“What comes to mind when you think of the beginning of your relationship (collaboration) with PASOs?”
Social acceptability of responses: The politically correct response may be implied in the question asked	4.7. PASOs has increased efforts to allow greater involvement of community participants in decision making	“What comes to mind when you think of ways that you participated in the decision-making process concerning any aspects of PASOs’ programs?

Note. CCCI = cross-cultural cognitive interview; PASOs = Perinatal Awareness for Successful Outcomes.

Trustors’ Predisposition to Trust

The team included a probe in the CCCI instrument to explore whether a participant considers the length of one’s relationship with the organization when deciding whether to trust a CBHO (OSQs 2.1, 2.2). The respondents identified several factors as key elements that affected their decision to trust PASOs. However, none of the respondents mentioned length of time in the partnership. As a result, two NSQs were added to account for length of time in the partnership as a determinant of partnership trust (Table 3). Table 3 also presents other emerging factors (a to d) that were named by respondents as predictors of trust and that we included in an NSQ. The participants could select up to three reasons that motivate them to trust PASOs from this list, depending on the type of collaboration they have with the organization.

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Table 3

CCCI Questions and New Survey Questions for the MMTM Dimension Trustor’s Predisposition to Trust

Original survey question	CCCI question	Final decision or new survey question
Grade your agreement with the statements . . .  2.1. I have higher trust in organizations with which I have been affiliated for longer periods.  2.2. I have higher trust in organizations with which I have had greater interaction.	What comes to mind when you think of your relationship with organizations with which you trust most?	Which of the following ways of communication has been mostly used in your interactions with the organization? email exchange, phone conversation, face-to-face meetings, other, specify.
		I trust the organization because the interactions I had with them have been based on a respectful relationship, friendly relationship, mutual interest on the issues discussed.
	Emerging issues identified during the CCCI:  (a) Characteristics of people in the organization (Hispanic origin, honesty, sensitiveness, compassion)  (b) Characteristics and nature of the relationship (cooperation, mutual respect, common interests)  (c) Characteristics of the organization (transparent, efficiency, knowledge, consistency)  (d) Characteristics of the services provided (accuracy, delivery, usefulness, relevancy)	Select up to three of the following to end the phrase, I trust organizations because . . .  - The people in the organization are honest.  - The people in the organization are of Hispanic origin.  - The people in the organization are sensitive and compassionate.  - The relationship with the organization is based on cooperation/collaboration.  - The relationship with the organization is based on mutual respect.  - The relationship is based on common interest between me and my organization and the organization.  - The organization is transparent.  - The organization knows what they are doing.  - The organization gives a consistent message across personnel.  - The organization provides immediate responses (delivers).  - The organization provides accurate information and responses.  - The organization provides useful and relevant services to the community they serve.

Note. CCCI = cross-cultural cognitive interviewing; MMTM = multidimensional measure of trust model.

Trustees’ Characters, Motives, Abilities and Behaviors

OSQs 5.8 to 5.10 aimed to explore the reasons people collaborate with the organization, including recognition of the work performed by and the accountability of the organization. We detected a comprehension issue for OSQ 5.10, which is related to “perceived trustworthiness,” as the stakeholders stated that they were confused by the word “accountable” (Table 4). The CPs and volunteer CHWs described the word “as being related to transparency” possibly because all of the CPs and volunteer CHWs opted to complete the Spanish version of the survey where the word “transparente” was used because the word “accountable” has no direct translation in Spanish. Therefore, we found a translation issue affecting the comprehension of this item (Willis et al., 2005). In the NSQ, the team agreed to add a definition of accountability instead of using this term, as follows: I have stayed involved with PASOs because (1) they explain what they do to the community and (2) they are held responsible for what they do (Table 4).

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Table 4

Cross-Cultural Cognitive Interview Questions and New Survey Questions for the MMTM Dimension Trustee’s Character, Motives, Abilities, and Behaviors

Original survey question	Cross-cultural cognitive interview question	New survey question
5.10. I’ve stayed involved with PASOs because I think the organization is accountable	Why did you get involved with PASOs in the first place? And why do you keep collaborating with them?	I’ve stayed involved with PASOs because (1) they explain what they do to the community and (2) they are held responsible for what they do
12.3. Most staff and community health workers from PASOs would stand behind their beliefs [“An acceptance that a statement is true or that something exists” also meaning “trust, faith, confidence in someone or something”]	At one of the questions, we used the term beliefs (principles for the Spanish version) [(12.3) Most staff and CHWs from PASOs would stand behind their beliefs]. You responded that you “x” with that statement. What, to you, are “beliefs”? How did you come up with that answer? Is there any other word you would have rather use instead of “beliefs”?	Most staff and CHWs would stand behind the principles embraced in PASOs mission, even if this decision contradicts their personal principles or beliefs

Note. MMTM = multidimensional measure of trust model; PASOs = Perinatal Awareness for Successful Outcomes; CHW = community health worker.

OSQ 12.3 explored the trustor’s perceptions of the trustee’s trustworthiness (Table 4). We considered that some of the participants would provide a socially desirable response to this question (Arredondo et al., 2008). Respondents’ narratives revealed a general cognitive problem by differentiating between the concepts of “beliefs” and “principles,” where principles seemed to be the term most accepted by the participants. Some of the interviewees stated, “Beliefs are something more related with spiritual values” and “It is more like something, you believe in, and principles are more about what shaped you . . .” In addition, a volunteer CHW answered OSQ 12.3 by considering personal principles versus organizational principles. Since all of the volunteer CHWs are Latinx, we considered that the responses to this question might have presented a culturally specific error by been influenced by the participants’ cultural values personalismo (a personal connection) and simpatía (empathy and shared common interests; García et al., 2017; C. R. Martinez et al., 2012; Willis et al., 2005). Hence, we considered both personal and organizational principles in the NSQ to account for the participants’ consideration of the personal principles of those in the organization (Table 4).

Quality and Nature of the Trustee–Trustor Relationship

Table 5 includes OSQs 3.3, 4.6, 4.7, and 5.7; their corresponding CCCI questions; and the NSQs. In CBPR, an important component of the dimension “quality and nature of trustee–trustor relationship” is having formal agreements to establish the role of each party. We considered it was important to test the comprehension of the memorandum of understanding in OSQ 3.3. The participants’ responses differed across stakeholders, reflecting a general cognitive problem. For the CPs, a memorandum of understanding was defined as “a verbal agreement” or “what the organization is going to do.” The volunteer CHWs defined it as a “formal procedure that establishes what the organization would expect from them” and rejected the word “contract” as a synonym, stating that this word “. . . may involve paid services.” The OPs also disagreed with the use of the word “contract” in this context and suggested “partnership agreement” or acuerdo in Spanish. Additionally, the team discussed whether the existence of formal agreements is always a predictor of trust. In certain instances and with some groups, when trusting relationships exist, a formal agreement might be seen as a signal of mistrust, representing a culturally specific error (Willis et al., 2005). To address the ambiguity in the relationship between trust and formal partnership agreements, which could operate differently across cultures, we modified the term in OSQ 3 and preceded it with an NSQ (Table 5).

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Table 5

Cross-Cultural Cognitive Interview Questions and New Survey Questions for the MMTM Dimension Quality and Nature of Trustee–Trustor Relationship

Original survey question	Cross-cultural cognitive interview question	New survey question
3.3. Is there any standard procedure (e.g., memorandum of understanding [MOU], contract, etc.) to collaborate with PASOs? Yes /No/Not sure	What is to you an MOU? How would you express that in your own words? How would you name that in Spanish?	On a scale from 1 to 10, where 1 is total disagreement and 10 total agreement, grade your agreement with the following sentences:  I trust more organizations that use partnership agreements to be clear on both parties’ roles and responsibilities.  If I trust, I do not need any formal partnership agreement to know my or other parties’ role.
		Is there any written or verbal partnership agreement to collaborate with PASOs? (We understand partnership agreement as the mechanism through which both parties agree on which are their roles and what is it they will do together or separately). Yes /No/Not sure
To what extent do you agree with the following question: 4.6. PASOs has changed a research or community program because of information or an opinion I shared with them.	Was there any information that you provided to PASOs that resulted in a change or improvement in one of their programs or research studies?	Based on participants comments it looks that we needed to distinguish among different phases as follows: 1. Suggestion was made to modify a program or research. 2. Suggestion was considered by PASOs. 3. Suggestion led to some change. 4. Participants are aware of these steps.
To what extent do you agree with the following question: 4.7. PASOs has increased efforts to allow greater involvement of community participants in decision making.	What comes to mind when you think of ways in which you participated in the decision-making process of PASOs’ programs?	Involvement in decision making implies having participated at some point in the consideration and weighting of the positives and negatives of different options. We wonder how much you have been involved with the organization in the consideration of different options or alternatives. In a scale from 1 to 10 grade the level of participation in the following examples of decision-making processes, where 10 is full involvement and 1 is no involvement at all. I have participated in deciding  - the design of research or programs,  - selection of geographical areas to intervene,  - problems to prioritize, and  - strategies to adopt.
5.7. My PASOs’ supervisor closely follows up on my responsibilities.	What comes to mind when you think how PASOs’ supervisor(s) monitors your work activities? Could you name specific things/tasks they does? What did you answer in 5.7? Why?	I like that when my supervisor follows up on my work they use this opportunity to review my progress  - provide me feedback,  - provide me with support,  - help me with problem solving, and  - hold me accountable on the activities I was hoping to achieve.
		I like that when my organizational contact follows up on my actions they  - review my progress,  - provide me feedback,  - provide me with support,  - help me with problem solving, and  - hold me accountable on the activities I was hoping to achieve.

Note. MMTM = multidimensional measure of trust model; PASOs = Perinatal Awareness for Successful Outcomes.

We explored the construct “participation of all parties in decision making” (Lucero, 2013). This construct was addressed in OSQs 4.6 and 4.7 (Table 5). In OSQ 4.6, we wondered whether stakeholders have been involved in programming and research decision making at PASOs. This question was understood as asked, confirming the existence of the attitude or behavior of sharing information or opinions with PASOs’ stakeholders. However, based on the participants’ comments, we distinguished among the different phases of programming and research in an NSQ.

OSQ 5.7 referred to the participants’ perceptions of their supervisors’ monitoring behaviors. We concluded that social desirability was not an issue for OSQ 5.7. However, the team also explored the need to distinguish between different stages of opinion sharing by asking them to name specific tasks that were monitored by PASOs’ supervisor. The volunteer CHWs provided responses that suggested that they understood the concepts of monitoring and follow-up. However, they distinguished between meetings (coaching and feedback) and the cloud-based data collection and monitoring system used by PASOs’ supervisors (Apricot). The staff CHWs distinguished between monitoring styles. For instance, a staff member stated “. . . closely . . . yeah they follow up but it’s not constant and not super close either.” Therefore, we clarified this question by explicitly mentioning follow-up tasks. Additionally, since the OPs mentioned they perceived that OSQ 5.7 did not apply to them, we included an NSQ (Table 5).

Situational/Organizational/Institutional Constraints

OSQ 3.6 was intended to identify participation in research and programs to explore the construct of the community’s capacity for research. During the pilot testing, the volunteer CHWs were unsure if they had participated in research with PASOs. This answer could be considered an “understanding issue” or general cognitive problem as per Willis’s (2011) framework. Most of the CPs were not sure if they had participated in a research experience while collaborating with PASOs. Only the OPs provided responses suggesting they recognized research in the context of collaboration with PASOs. We concluded that a definition of research was needed in the new survey and that the best way to address this concept would be by separating it into different research-related activities in an NSQ.

Socioeconomic, Cultural, and Geographic/Environmental Aspects

Stakeholders’ socioeconomic, cultural, and geographic environments and their relationships with the organizations with which they interact (Wallerstein & Duran, 2010) mediate the integration of communities’ knowledge and experience in CBPR. We addressed the understanding of the expression “knowledge and experience of this community” in OSQ 5.4. The analysis of the responses showed that most of the stakeholders understood the question and could mention relevant examples. However, some of the OPs inquired about the community referred to in OSQ 5.4; thus, we specified the organization’s target community or population in an NSQ.

Trust as a Process

According to the MMTM, along with “trust the belief,” “trust the decision” is a key dimension of trust as a process. To explore the concept of “trust as a process,” we included OSQ 6.3 to determine whether the participant decided to trust PASOs based on proper knowledge of the organization’s mission and objectives. The responses revealed that all four types of stakeholders understood the concepts since most were able to explain PASOs’ mission and objectives. However, an emergent issue was that some of the staff CHWs were confused about the concept of “participation” as used in OSQ 6.3. In the words of a staff CHW, “I put agree but I am not a participant in their programs . . . but rather a staff member.” Hence, we decided to add other verbs in an NSQ. In addition to “participate,” we included other types of stakeholder involvement as follows: “My knowledge about the mission and objectives of PASOs influences my willingness to work, collaborate, and participate in their programs.”