A Qualitative Evaluation of the Building Community Resilience Process and National Collaborative

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We conducted a qualitative evaluation using semi-structured interviews with 24 BCR partners across five U.S. sites. Guided by the four components of the BCR process – shared understanding, state of readiness, cross-sector partnerships, and community engagement – interviews examined implementation strategies, challenges, and lessons learned. Transcripts were analyzed inductively through iterative coding and thematic analysis. Findings show that the BCR process strengthened cross-sector collaboration, expanded shared language around adversity, and enhanced community engagement. Partners emphasized readiness, trust-building, and centering community voice as key to sustaining resilience efforts. The BCR process provides a flexible framework for aligning systems and community priorities to address the Pair of ACEs and promote collective resilience and health equity. Policies that invest in multisector collaboration, community leadership, and structural reforms are essential for scaling resilience approaches and addressing the systemic drivers of childhood and community adversity. Figures Figure 1 Figure 2 Figure 3 Introduction The Building Community Resilience (BCR) process is a continuous improvement model designed to foster cross-sector collaboration to address the root causes of childhood and community adversity. 1 Informed by research and practice, the BCR process (Fig. 1) provides communities with tools and strategies to build integrated systems of care based on four central components: (1) creating a shared understanding of adversity, (2) assessing system readiness, (3) developing cross-sector partnerships, and (4) engaging families and residents in collaborative solutions. BCR was first developed as a model to address the long-term impacts of adverse childhood experiences (ACEs), such as abuse and neglect, parental substance abuse and incarceration, which are often compounded by community conditions such as concentrated poverty, poor housing conditions, and homelessness. From this, the BCR model devised the framework "Pair of ACEs" to address these dual burdens. By applying this framing, the BCR model helps communities establish a shared understanding, identify root causes, and mobilize stakeholders to act on both individual and structural drivers of adversity. First proposed as a model, in practice implementers began to apply the components as a continuous process rather than in a stepwise fashion as a model might suggest. Therefore, throughout this paper, we will refer to BCR as a process in keeping with how interviewers applied within their collaboratives and initiatives. Launched in 2015, the BCR national collaborative made up five networks across the U.S. including: the Greater Cincinnati Region; the State of Oregon; the Washington, D.C., Maryland, and Virginia (DMV) region; Newark, Delaware; and Dallas, Texas. In 2017, the Delaware collaborative was dissolved, and a team covering the state of Missouri, based in St. Louis and Kansas City, joined the national network. Child health systems initially led the networks but quickly expanded to include partners from public health, education, child welfare, public safety and criminal justice, local businesses, housing, and economic development. BCR teams comprise local cross-sector partners working together to address the root causes of childhood and community adversity, collectively creating integrated systems of care. Supported by the Center for Community Resilience (CCR) at George Washington University, teams engaged in peer learning and applied BCR as an adaptive, ongoing process rather than a static model. This paper evaluates the implementation of the BCR process during its initial national pilot, highlighting how diverse communities applied the framework, the challenges they faced, and lessons learned for scaling cross-sector resilience approaches. Understanding the Pair of ACEs The combination of adverse childhood experiences and adverse community environments, known as the Pair of ACEs, helps to frame the reinforcing effect of systems (public and private) combined with social determinants and policies on individual experiences and behaviors (Fig. 2). 2 Interactions at the community level, include policies that make up the 'soil' in which communities are rooted in to create cycles of adverse childhood and community experiences by race and place. ACEs have a direct and dose-dependent link to poor adult health outcomes. 3 Early exposure to ACEs can impair brain development, affect executive function, and alter gene expression. 4 ACEs often occur in the presence of adverse community environments, such as neighborhoods with concentrated poverty, limited access to economic mobility, and under-resourced schools and infrastructure. 1 , 5 Addressing ACEs requires policies and practices that sustain these conditions through vicious cycles as measured by lack of funding and investment that would provide access to resources, and economic, social and health supports. These patterns of systemic disparity is associated with health, wealth and social disparities that are often described as social determinants of health. 6 Understanding the association of systemic determinants aligns with the science of social determinants of health research demonstrating how inequitable policies and power structures, rather than solely individual behaviors, drive population-level disparities. 7 Plough 8 emphasizes that building resilience at the community level depends on transforming the systems and policies that perpetuate vulnerability, requiring multisector collaboration grounded in equity and shared accountability. The Pair of ACEs framing helps community stakeholders focus on solutions that are structural, place-based, and historically informed. 9 Paired with the BCR process, the approach emphasizes the need for cross-sector collaboration to build resilience at both individual and community levels. Defining Community Resilience Community resilience can be defined with two key characteristics. First is the sustained ability of community systems to prepare for, withstand, and recover from acute shocks while addressing and preventing inequities associated with chronic adversity. Second is the community's ability to cope, strive, and be supported through equitable access to buffers. These buffers address and relieve sources of chronic stress and adversity while also building assets that help residents thrive. 2 , 10 Methods Site Selection and Recruitment Interview participants were recruited from BCR sites that undertook each component of the BCR process between 2016 and 2022. The Delaware site was excluded from evaluation since its participation in BCR was limited to 2015–2017 and did not produce initiatives with long-standing impact. Researchers recruited core partners from the five sites included in the study: Washington, DC; St. Louis/Kansas City, Missouri; Oregon; Greater Cincinnati, Ohio; and Dallas, Texas. For the first round of recruitment, purposive sampling was used to identify BCR partners with key roles in their local site activities and/or leadership. Individuals positioned to speak to the conception of their local partnerships and how their BCR network evolved were prioritized. A total of thirteen invitations were initially sent, with at least two partners from each site invited to participate in the first round of interviews. A snowball technique was then used to recruit additional partners to participate in the study. Invitations were extended to a total of 24 current and former members of the five sites identified for the study. Data Collection Using the BCR process as the conceptual framework, the research team at CCR developed a semi-structured interview guide composed of open-ended questions organized around the four components of the BCR process: shared understanding, state of readiness, cross-sector partnerships, and community. During the interviews, participants were prompted to reflect upon each phase of the BCR process, with questions on topics such as implementation strategies, challenges, opportunities, and factors and conditions that influenced site implementation or outcomes. Data for this study were collected through in-depth interviews with BCR partners from the participating sites. One researcher from CCR facilitated interviews via videoconference, with support from two student researchers. Interviews were conducted between July and September 2022, with each interview lasting approximately one hour. All interviews began with introductions (when relevant) and a brief description of the study's purpose. Participants were then invited to ask questions before providing verbal consent to participate in the interview. Following the consent procedure, facilitators proceeded with the interview using the semi-structured interview guide. To transition to a new section of the interview, facilitators also presented a visual with a brief description of the corresponding phase of the BCR process. All interviews were audio-recorded, with the participants' permission. Data Analysis Audio recordings were transcribed verbatim using transcription software. Following transcription, the research team reviewed transcripts for accuracy. At this time, the transcripts were cleaned; transcription errors were corrected, and identifiable information was removed. Two research team members were directly involved in coding and analysis for this study. In preparation for analysis, the research team read the transcripts to familiarize themselves with the data, noting key phrases, words, and ideas expressed by BCR partners. An inductive coding approach was employed for the early codes, which were derived from margin notes and initial team discussions. The data analysis team employed a multi-step approach to develop the codebook, undertaking three iterations of coding to enhance code validity and reliability among coders. During each iteration, team members coded a subset of the transcripts, then met to review the coded transcripts and discuss code disagreements until a consensus was reached. The codebook was revisited through each iteration of coding to add, update, or clarify code definitions or code applications. Both semantic and latent codes were created. The data analysis team reviewed the coded transcripts and then organized them according to the four BCR components. Results BCR partners reflected key strengths and opportunities for improvement on various aspects of BCR technical assistance, tools, and peer learning opportunities. The findings are organized according to the four elements of the BCR process. Building Shared Understanding Technical assistance provided by CCR, tools, and peer learning activities helped BCR partners develop shared values, mission, vision, and goals as the 'foundation' of their local work. Through BCR's support, local partners identified shared values and a purpose that would underpin their collective work: equity and a commitment to address the Pair of ACEs. The Pair of ACEs became an "organizing principle," and the Pair of ACEs image is a critical tool for building and communicating shared understanding with local stakeholders (Ellis, 2022). One BCR partner described how the Pair of ACEs framing helped expand the perspective of those working to support children and families. "…for us, [the Pair of ACEs] really is the organizing principle that kind of leads to the understanding of how we best support children, families, and communities within the context of all their lives, and how to support them best. Prior to that, I would say all of us in one way or another, were more focused on the very prescriptive types of programs and services…" Local BCR partners were able to enhance opportunities for community engagement, strengthen coalition-building by centering on community voice, and gain a deeper understanding of the community and historical context relevant to current issues. Together, these efforts ensured that collective strategies were rooted in and responsive to the lived realities of the communities they served. Prioritizing community narratives and the language to describe the experience of trauma ranging from abuse and neglect, within the context of collectively endured stressors such as racism, poverty, community and gun violence, Medicaid cuts, and limited access to behavioral health care, was essential for each site. Centering the narratives of community enabled coalitions to frame and communicate local efforts more precisely. The process of learning from community voice was a long, iterative process. One BCR partner highlighted how the Pair of ACEs framing helped bridge the communication gap between different stakeholders. "…BCR [gave us] the language that helps makes it easier for people to kind of be on the same page. …because you have to have that language to talk to big systems, and so many times systems don't listen to community. Because there's a gap in the language, there's a gap in the narrative." State of Readiness Institutions and systems can create what BCR partners called "authorizing environments" to address the Pair of ACEs in communities. This refers to the leadership environments and policy directives that legitimize and support resilience-building work. However, institutions and systems could also choose to prioritize the needs of institutions over those of individuals. While BCR partners acknowledged that aligning community priorities and financing was beneficial for the larger community's readiness for change, they also emphasized that the type of financial resources available and the ability to distribute them equitably were crucial for sustaining resilience work. As one DC partner explained: "Because our development team is so dynamic, they help the rest of the team to understand fundraising. And we've been able to leverage the strengths and expertise of our team members to pursue funding opportunities… We have tried to take a different approach in the way we pursue resources, so that we can maximize the flexibilities that we need to do the work the way we want to do it." The alignment of community priorities can occur more gradually through raising public awareness. It could also happen when there is an opportune moment in political feasibility, typically characterized by a shift in policy or political momentum on an issue the local network sought to address. One BCR partner from the Missouri-Kansas City community described how BCR's "Significant U.S. Social & Criminal Policies Over Time" tool helped center their work on racial equity as part of the community environment (Figure 3). "And we were called out several times on how can you, of all places be in St. Louis, where your funding for [BCR partner] was off the backs of Michael Brown's murder? How could you talk about trauma and community trauma and never mention racism, historical trauma, structural racism, and those things? And so we were struggling entirely as an organization to figure out how to do that. And then again, it comes down to [the Significant U.S. Social & Criminal Policies Over Time tool], this timeline is a framework of how to help us tell a story based in fact, where you just cannot deny that it was important to center racial equity." Regardless of the state of readiness for change within the larger community, BCR partners built their own state of readiness by learning from other communities in the BCR national network, fostering local partner relationships, engaging with the community, and quickly adapting to new approaches when something wasn't working. As one individual articulated, "Readiness doesn't mean you hit the ground running. Readiness means you just go slow to go fast. And readiness means you think you're ready, and you pivot, because what you thought would happen, does not happen. You kind of duct tape the whole project together….It's built by listening." Building Cross-Sector Partnerships BCR partners affirm that relationships among cross-sector stakeholders are foundational to achieving meaningful change. While many stakeholders may represent or be affiliated with organizations, the network of partners is ultimately formed through interpersonal relationships. As one BCR partner described, "It's a community of people, not a community of organizations… it's the relationship with people with that shared passion to do something." Specific actions such as supporting one another during "eras of disappointment and discouragement" and lifting each other's work to confer power and legitimacy help strengthen relationships and trust. For example, one leader reflected on the discouragement they felt during national backlash against anti-racist education and social-emotional learning, but emphasized how being part of the BCR collective reenergized them: "When I've become discouraged about the pushback that I see, I've become reenergized and re-encouraged by being with colleagues as part of [local collaborative]. I really see the collective awareness of the need to persevere. That can be contagious, and I need it to be contagious." BCR partners point to a set of characteristics that lead to practical collective actions. The strongest partners, they said, value relationships and collaboration and are motivated to contribute to the collective efforts. Just as important is their commitment to not only the collaborative work, but also "the inner work" of self-reflection, continuous learning, and humility, as well as accountability. An essential question for each person is described by one BCR partners as follows: "What are you doing on your own personal journey, to make sure that you're not perpetuating harm when you get in front of folks, or when you're sitting at a table in a meeting that you're making decisions?" BCR's emphasis on cross-sector partnership enhanced local networks' intentionality in cultivating partnerships grounded in trust. Partners identified two key factors that strengthened their local networks. The first was the transparency in being open about their mission, vision, values, expectations, capacity, strengths, and resources, particularly their commitment to racial equity. Such transparency helped partners understand both what they could contribute and what they could expect from collaboration. In Cincinnati, for example, transparency extended to the coalition's structure – shifting it from activity-based committees to system-focused channels. They then identified practice gaps and determined what the field most needed, such as training, resources, screening tools, advocacy, or communities of practice, and built on one another's strengths to meet those needs. The second key factor was the diversity of members in the local network. BCR partners emphasized that it is vital to have diversity in backgrounds, identities, skill sets, passions, sectors, and professions. BCR's technical assistance and tools prompted local networks to ask who should be at the table but was not yet present, a question that underscored seeking diversity across several different dimensions (e.g. race, skill sets, service offerings, etc.) as an ongoing process rather than a one-time achievement. In practice, sector diversity was evident across sites, with four out of five sites having four or more sectors in their network. Commonly represented sectors included education, arts and culture, community-based organizations, medical/health care, and behavioral/mental health. This cross-sector diversity expanded the range of perspectives represented and strengthened the network's capacity to act collectively. One BCR partner explains the thought process behind their approach to engaging partners. "… it's a slow process and the hope is to put the BCR message out there, and folks who are interested and willing have, and that's how we've grown: through openness and invitation. And now we're getting to a point where, okay, who's still not at the table, and it's been seven years? And why not? What are we doing?" BCR partners also described several challenges to collaborating effectively. First, while the relationship-based foundation for their local network strengthens the collective actions, it is also an approach that is slow and iterative, making it much more difficult for some to scale up the network in size. The reliance on interpersonal relationships also meant that when people transition roles within an organization, whether they move away or change jobs, the network's loss is greater and more challenging to recover. Second, there is a sense of competition for resources among organizations working to meet similar needs in the community, and the hyper-focus on the "survivability" of individual organizations could prevent meaningful partnerships. One BCR partner recalls an early experience of having to dissolve their advisory group due to a "tendency for organizations to be looking out for themselves, rather than working collectively". The key to overcoming the sense of competition is effective communication, which enables the first component – building a shared understanding. BCR partners stated that they listened to and communicated with stakeholders, resulting in a shared understanding of values and expectations. Engaging Community Prompted by the Engaging Community component of the BCR process, some partners engaged members of their local communities from the outset and incorporated community voice into the work "every step of the way." There are BCR networks that brought on community members for paid or voluntary advisory roles. Some BCR partners hired community members for staff positions. All with the acknowledgement that community voices are valuable and the intention of making their work community-driven, particularly for agenda-setting and prioritizing opportunities. For these BCR partners, community members are not an "afterthought". "But the process of how we're yielding our power to community members, to people from those groups, young or adult leaders who have a leadership capacity…consultant capacity, we treat them as a consultant because 'We are consulting with you. Your service is important and valuable.'… we're gonna demonstrate that." On the other hand, BCR partners that brought in community voice later in the process reported struggling with creating meaningful leadership opportunities for community members in ways that respect their time and uplift their expertise, without being extractive or tokenizing. As one BCR partner stated, "But we also recognize that … we had to do it in a meaningful way that wasn't creating a token position for somebody who wasn't really going to have a meaningful voice within their work that we did. And I would say that we're still struggling a little bit with that … we've been much more intentional about identifying who is sitting on our steering committee and who is missing." Discussion Although initially presented as a model, the four components of Building Community Resilience function as a continuous improvement process, with multiple components employed concurrently. For example, "Who should be at the table?" is regularly asked among network partners when assessing capacity and capability to address an emerging issue. Community engagement is most effective when conducted continuously, integrated into all aspects of collective action, and sustained over time. While the larger community's state of readiness fluctuates, local networks continually build and adapt their internal capacity for systems change in response to shifting contexts. Building Shared Understanding, though essential at a coalition’s outset, remains critical for maintaining partnerships and meaningfully engaging communities over time. This qualitative evaluation study has limited generalizability but offers valuable insight into how partners applied BCR tools and why certain approaches succeeded while others posed challenges. In the absence of quantitative measures to capture impact the Table illustrates how the BCR process supports communities in initiating and strengthening collective efforts to address the Pair of ACEs. Table 1. Evidence of Practice and Policy Change Across BCR Collaborative Sites Location / Team Initiative / Intervention Outcomes / Impact Policy or Funding Influence Cincinnati, Ohio Integration of parent coaches into pediatric primary care practice Reduced child behavioral issues and decreased parent reports of household stress Demonstrates translation of trauma-informed practices into pediatric primary care systems. Missouri Advocacy campaign to address maternal mortality and racial disparities Secured Senator Roy Blunt’s (R) support for maternal mortality initiatives Resulted in a $50 million appropriation to HRSA and CDC in the FY2019 Labor, Health and Human Services, Education, and Related Programs Appropriations Bill, specifically targeting Black maternal mortality. 11 National (Pair of ACEs Network) Use of the “Pair of ACEs” graphic to frame community adversity and resilience Elevated awareness of ACEs and trauma-informed approaches in policy settings Led to Congressional briefings co-led by Sen. Heidi Heitkamp (D-ND) and Rep. Danny Davis (D-IL); informed multiple policy and appropriations efforts promoting ACEs prevention, trauma-informed practice, and racial equity. 12 Oregon Development of Block of Humanity, a community-informed, place-based consortium addressing social determinants of health in Salem. 13 Established cross-sector collaboration among providers and agencies to meet social, economic, and educational needs Informed state funding for Resilience Hubs: $10 million awarded to 87 organizations statewide to address acute (wildfire) and chronic (housing, food, and health access) adversities. 14 Note. Table summarizes practice and policy impacts achieved by members of the BCR collaborative through place-based and advocacy efforts demonstrating translational application of community resilience frameworks at local, state, and federal levels. Implications for the Field Our findings demonstrate that the BCR process is a valuable approach to help place-based networks grow collectively and become more effective in addressing adverse childhood experiences within the context of adverse community environments. Over the past decade, BCR sites have translated this process into tangible achievements, including securing federal and local funding streams, influencing policy change, aligning systems across sectors, and adapting the model within local public health departments. 2 These accomplishments provide hard evidence of impact and demonstrate how the BCR approach transitions from theory to practice. Paired with the Pair of ACEs image, the BCR process enables local networks to effectively communicate their goals, values, and plans to a variety of stakeholders, fostering growth in relationships and trust with cross-sector partners and community members. By monitoring both external and internal readiness, networks can adapt strategies authentically to advance systems change. Prioritizing cross-sector partnerships and community voice enhances their ability to act collectively and leverage shared strengths. A decade of implementation shows that diverse coalitions strengthen relationships, build trust, and sustain resilience even amid shifting political and financial contexts. References Ellis WR, Dietz WH. A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model. Academic Pediatrics . 2017;17(7):S86-S93. doi:10.1016/j.acap.2016.12.011 Ellis W, Dietz WH, Chen KLD. Community Resilience: A Dynamic Model for Public Health 3.0. J Public Health Manag Pract . 2022;28(Suppl 1):S18-S26. doi:10.1097/PHH.0000000000001413 Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. 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Health Affairs . 2020;39(4):562-566. doi:10.1377/hlthaff.2020.00238 Social services hub planned for downtown Salem building. opb. Accessed October 14, 2025. https://www.opb.org/article/2024/04/17/social-services-hub-planned-for-downtown-salem-building/ Oregon Department of Human Services : Resilience Hubs and Networks Grant : Emergency Management : State of Oregon. Accessed October 14, 2025. https://www.oregon.gov/odhs/emergency-management/pages/resilience-grants.aspx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 21 Apr, 2026 Reviewers invited by journal 14 Apr, 2026 Editor assigned by journal 09 Dec, 2025 First submitted to journal 05 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":1168567,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8196885/v1/8743f6dfbb80c7ebaa75d0c3.jpg"},{"id":98222238,"identity":"41e1956a-139d-4c60-98f3-4d12993cdff9","added_by":"auto","created_at":"2025-12-15 11:41:17","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":528938,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8196885/v1/c990d7918dcdb717690461d1.jpg"},{"id":98222240,"identity":"d1564dc9-7112-4784-ab35-198094a5200b","added_by":"auto","created_at":"2025-12-15 11:41:17","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":746773,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8196885/v1/4ad7e413cf65794a731fdaab.jpg"},{"id":98444919,"identity":"b2856ba7-4db2-42c4-bf74-7a4e4ee5a45f","added_by":"auto","created_at":"2025-12-17 17:18:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2860989,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8196885/v1/be9b8860-aa4c-40d3-b78f-366b2dcf2f92.pdf"}],"financialInterests":"","formattedTitle":"A Qualitative Evaluation of the Building Community Resilience Process and National Collaborative","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe Building Community Resilience (BCR) process is a continuous improvement model designed to foster cross-sector collaboration to address the root causes of childhood and community adversity.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Informed by research and practice, the BCR process (Fig.\u0026nbsp;1) provides communities with tools and strategies to build integrated systems of care based on four central components: (1) creating a shared understanding of adversity, (2) assessing system readiness, (3) developing cross-sector partnerships, and (4) engaging families and residents in collaborative solutions.\u003c/p\u003e\u003cp\u003eBCR was first developed as a model to address the long-term impacts of adverse childhood experiences (ACEs), such as abuse and neglect, parental substance abuse and incarceration, which are often compounded by community conditions such as concentrated poverty, poor housing conditions, and homelessness. From this, the BCR model devised the framework \"Pair of ACEs\" to address these dual burdens. By applying this framing, the BCR model helps communities establish a shared understanding, identify root causes, and mobilize stakeholders to act on both individual and structural drivers of adversity. First proposed as a model, in practice implementers began to apply the components as a continuous process rather than in a stepwise fashion as a model might suggest. Therefore, throughout this paper, we will refer to BCR as a process in keeping with how interviewers applied within their collaboratives and initiatives.\u003c/p\u003e\u003cp\u003eLaunched in 2015, the BCR national collaborative made up five networks across the U.S. including: the Greater Cincinnati Region; the State of Oregon; the Washington, D.C., Maryland, and Virginia (DMV) region; Newark, Delaware; and Dallas, Texas. In 2017, the Delaware collaborative was dissolved, and a team covering the state of Missouri, based in St. Louis and Kansas City, joined the national network. Child health systems initially led the networks but quickly expanded to include partners from public health, education, child welfare, public safety and criminal justice, local businesses, housing, and economic development.\u003c/p\u003e\u003cp\u003eBCR teams comprise local cross-sector partners working together to address the root causes of childhood and community adversity, collectively creating integrated systems of care. Supported by the Center for Community Resilience (CCR) at George Washington University, teams engaged in peer learning and applied BCR as an adaptive, ongoing process rather than a static model.\u003c/p\u003e\u003cp\u003eThis paper evaluates the implementation of the BCR process during its initial national pilot, highlighting how diverse communities applied the framework, the challenges they faced, and lessons learned for scaling cross-sector resilience approaches.\u003c/p\u003e\n\u003ch3\u003eUnderstanding the Pair of ACEs\u003c/h3\u003e\n\u003cp\u003eThe combination of adverse childhood experiences and adverse community environments, known as the Pair of ACEs, helps to frame the reinforcing effect of systems (public and private) combined with social determinants and policies on individual experiences and behaviors (Fig.\u0026nbsp;2).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Interactions at the community level, include policies that make up the 'soil' in which communities are rooted in to create cycles of adverse childhood and community experiences by race and place.\u003c/p\u003e\u003cp\u003eACEs have a direct and dose-dependent link to poor adult health outcomes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Early exposure to ACEs can impair brain development, affect executive function, and alter gene expression.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e ACEs often occur in the presence of adverse community environments, such as neighborhoods with concentrated poverty, limited access to economic mobility, and under-resourced schools and infrastructure.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Addressing ACEs requires policies and practices that sustain these conditions through vicious cycles as measured by lack of funding and investment that would provide access to resources, and economic, social and health supports. These patterns of systemic disparity is associated with health, wealth and social disparities that are often described as social determinants of health.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eUnderstanding the association of systemic determinants aligns with the science of social determinants of health research demonstrating how inequitable policies and power structures, rather than solely individual behaviors, drive population-level disparities.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Plough\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e emphasizes that building resilience at the community level depends on transforming the systems and policies that perpetuate vulnerability, requiring multisector collaboration grounded in equity and shared accountability. The Pair of ACEs framing helps community stakeholders focus on solutions that are structural, place-based, and historically informed.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Paired with the BCR process, the approach emphasizes the need for cross-sector collaboration to build resilience at both individual and community levels.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDefining Community Resilience\u003c/h2\u003e\u003cp\u003eCommunity resilience can be defined with two key characteristics. First is the sustained ability of community systems to prepare for, withstand, and recover from acute shocks while addressing and preventing inequities associated with chronic adversity. Second is the community's ability to cope, strive, and be supported through equitable access to buffers. These buffers address and relieve sources of chronic stress and adversity while also building assets that help residents thrive.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eSite Selection and Recruitment\u003c/h2\u003e\u003cp\u003eInterview participants were recruited from BCR sites that undertook each component of the BCR process between 2016 and 2022. The Delaware site was excluded from evaluation since its participation in BCR was limited to 2015\u0026ndash;2017 and did not produce initiatives with long-standing impact. Researchers recruited core partners from the five sites included in the study: Washington, DC; St. Louis/Kansas City, Missouri; Oregon; Greater Cincinnati, Ohio; and Dallas, Texas.\u003c/p\u003e\u003cp\u003eFor the first round of recruitment, purposive sampling was used to identify BCR partners with key roles in their local site activities and/or leadership. Individuals positioned to speak to the conception of their local partnerships and how their BCR network evolved were prioritized. A total of thirteen invitations were initially sent, with at least two partners from each site invited to participate in the first round of interviews. A snowball technique was then used to recruit additional partners to participate in the study. Invitations were extended to a total of 24 current and former members of the five sites identified for the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eUsing the BCR process as the conceptual framework, the research team at CCR developed a semi-structured interview guide composed of open-ended questions organized around the four components of the BCR process: shared understanding, state of readiness, cross-sector partnerships, and community. During the interviews, participants were prompted to reflect upon each phase of the BCR process, with questions on topics such as implementation strategies, challenges, opportunities, and factors and conditions that influenced site implementation or outcomes.\u003c/p\u003e\u003cp\u003eData for this study were collected through in-depth interviews with BCR partners from the participating sites. One researcher from CCR facilitated interviews via videoconference, with support from two student researchers. Interviews were conducted between July and September 2022, with each interview lasting approximately one hour. All interviews began with introductions (when relevant) and a brief description of the study's purpose. Participants were then invited to ask questions before providing verbal consent to participate in the interview. Following the consent procedure, facilitators proceeded with the interview using the semi-structured interview guide. To transition to a new section of the interview, facilitators also presented a visual with a brief description of the corresponding phase of the BCR process. All interviews were audio-recorded, with the participants' permission.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAudio recordings were transcribed verbatim using transcription software. Following transcription, the research team reviewed transcripts for accuracy. At this time, the transcripts were cleaned; transcription errors were corrected, and identifiable information was removed.\u003c/p\u003e\u003cp\u003eTwo research team members were directly involved in coding and analysis for this study. In preparation for analysis, the research team read the transcripts to familiarize themselves with the data, noting key phrases, words, and ideas expressed by BCR partners. An inductive coding approach was employed for the early codes, which were derived from margin notes and initial team discussions. The data analysis team employed a multi-step approach to develop the codebook, undertaking three iterations of coding to enhance code validity and reliability among coders. During each iteration, team members coded a subset of the transcripts, then met to review the coded transcripts and discuss code disagreements until a consensus was reached. The codebook was revisited through each iteration of coding to add, update, or clarify code definitions or code applications. Both semantic and latent codes were created. The data analysis team reviewed the coded transcripts and then organized them according to the four BCR components.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBCR partners reflected key strengths and opportunities for improvement on various aspects of BCR technical assistance, tools, and peer learning opportunities. The findings are organized according to the four elements of the BCR process.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eBuilding Shared Understanding \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTechnical assistance provided by CCR, tools, and peer learning activities helped BCR partners develop shared values, mission, vision, and goals as the 'foundation' of their local work. Through BCR's support, local partners identified shared values and a purpose that would underpin their collective work: equity and a commitment to address the Pair of ACEs. The Pair of ACEs became an \"organizing principle,\" and the Pair of ACEs image is a critical tool for building and communicating shared understanding with local stakeholders (Ellis, 2022). One BCR partner described how the Pair of ACEs framing helped expand the perspective of those working to support children and families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"…for us, [the Pair of ACEs] really is the organizing principle that kind of leads to the understanding of how we best support children, families, and communities within the context of all their lives, and how to support them best. Prior to that, I would say all of us in one way or another, were more focused on the very prescriptive types of programs and services…\"\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLocal BCR partners were able to enhance opportunities for community engagement, strengthen coalition-building by centering on community voice, and gain a deeper understanding of the community and historical context relevant to current issues. Together, these efforts ensured that collective strategies were rooted in and responsive to the lived realities of the communities they served.\u003c/p\u003e\n\u003cp\u003ePrioritizing community narratives and the language to describe the experience of trauma ranging from abuse and neglect, within the context of collectively endured stressors such as racism, poverty, community and gun violence, Medicaid cuts, and limited access to behavioral health care, was essential for each site. Centering the narratives of community enabled coalitions to frame and communicate local efforts more precisely.\u003c/p\u003e\n\u003cp\u003eThe process of learning from community voice was a long, iterative process. One BCR partner highlighted how the Pair of ACEs framing helped bridge the communication gap between different stakeholders.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"…BCR [gave us] the language that helps makes it easier for people to kind of be on the same page. …because you have to have that language to talk to big systems, and so many times systems don't listen to community. Because there's a gap in the language, there's a gap in the narrative.\"\u003c/em\u003e\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eState of Readiness \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eInstitutions and systems can create what BCR partners called \"authorizing environments\" to address the Pair of ACEs in communities. This refers to the leadership environments and policy directives that legitimize and support resilience-building work. However, institutions and systems could also choose to prioritize the needs of institutions over those of individuals. While BCR partners acknowledged that aligning community priorities and financing was beneficial for the larger community's readiness for change, they also emphasized that the type of financial resources available and the ability to distribute them equitably were crucial for sustaining resilience work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs one DC partner explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"Because our development team is so dynamic, they help the rest of the team to understand fundraising. And we've been able to leverage the strengths and expertise of our team members to pursue funding opportunities… We have tried to take a different approach in the way we pursue resources, so that we can maximize the flexibilities that we need to do the work the way we want to do it.\"\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u0026nbsp;The alignment of community priorities can occur more gradually through raising public awareness. It could also happen when there is an opportune moment in political feasibility, typically characterized by a shift in policy or political momentum on an issue the local network sought to address. One BCR partner from the Missouri-Kansas City community described how BCR's \"Significant U.S. Social \u0026amp; Criminal Policies Over Time\" tool helped center their work on racial equity as part of the community environment (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"And we were called out several times on how can you, of all places be in St. Louis, where your funding for [BCR partner] was off the backs of Michael Brown's murder? How could you talk about trauma and community trauma and never mention racism, historical trauma, structural racism, and those things? And so we were struggling entirely as an organization to figure out how to do that. And then again, it comes down to [the Significant U.S. Social \u0026amp; Criminal Policies Over Time tool], this timeline is a framework of how to help us tell a story based in fact, where you just cannot deny that it was important to center racial equity.\"\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegardless of the state of readiness for change within the larger community, BCR partners built their own state of readiness by learning from other communities in the BCR national network, fostering local partner relationships, engaging with the community, and quickly adapting to new approaches when something wasn't working. As one individual articulated,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"Readiness doesn't mean you hit the ground running. Readiness means you just go slow to go fast. And readiness means you think you're ready, and you pivot, because what you thought would happen, does not happen. You kind of duct tape the whole project together….It's built by listening.\"\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003eBuilding Cross-Sector Partnerships \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eBCR partners affirm that relationships among cross-sector stakeholders are foundational to achieving meaningful change. While many stakeholders may represent or be affiliated with organizations, the network of partners is ultimately formed through interpersonal relationships. As one BCR partner described,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"It's a community of people, not a community of organizations… it's the relationship with people with that shared passion to do something.\"\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSpecific actions such as supporting one another during \"eras of disappointment and discouragement\" and lifting each other's work to confer power and legitimacy help strengthen relationships and trust. For example, one leader reflected on the discouragement they felt during national backlash against anti-racist education and social-emotional learning, but emphasized how being part of the BCR collective reenergized them:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"When I've become discouraged about the pushback that I see, I've become reenergized and re-encouraged by being with colleagues as part of [local collaborative]. I really see the collective awareness of the need to persevere. That can be contagious, and I need it to be contagious.\"\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBCR partners point to a set of characteristics that lead to practical collective actions. The strongest partners, they said, value relationships and collaboration and are motivated to contribute to the collective efforts. Just as important is their commitment to not only the collaborative work, but also \"the inner work\" of self-reflection, continuous learning, and humility, as well as accountability. An essential question for each person is described by one BCR partners as follows:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"What are you doing on your own personal journey, to make sure that you're not perpetuating harm when you get in front of folks, or when you're sitting at a table in a meeting that you're making decisions?\"\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBCR's emphasis on cross-sector partnership enhanced local networks' intentionality in cultivating partnerships grounded in trust. Partners identified two key factors that strengthened their local networks. The first was the transparency in being open about their mission, vision, values, expectations, capacity, strengths, and resources, particularly their commitment to racial equity. Such transparency helped partners understand both what they could contribute and what they could expect from collaboration. In Cincinnati, for example, transparency extended to the coalition's structure – shifting it from activity-based committees to system-focused channels. They then identified practice gaps and determined what the field most needed, such as training, resources, screening tools, advocacy, or communities of practice, and built on one another's strengths to meet those needs. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe second key factor was the diversity of members in the local network. BCR partners emphasized that it is vital to have diversity in backgrounds, identities, skill sets, passions, sectors, and professions. BCR's technical assistance and tools prompted local networks to ask who should be at the table but was not yet present, a question that underscored seeking diversity across several different dimensions (e.g. race, skill sets, service offerings, etc.) as an ongoing process rather than a one-time achievement. In practice, sector diversity was evident across sites, with four out of five sites having four or more sectors in their network. Commonly represented sectors included education, arts and culture, community-based organizations, medical/health care, and behavioral/mental health. This cross-sector diversity expanded the range of perspectives represented and strengthened the network's capacity to act collectively.\u003c/p\u003e\n\u003cp\u003eOne BCR partner explains the thought process behind their approach to engaging partners.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"… it's a slow process and the hope is to put the BCR message out there, and folks who are interested and willing have, and that's how we've grown: through openness and invitation. And now we're getting to a point where, okay, who's still not at the table, and it's been seven years? And why not? What are we doing?\"\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBCR partners also described several challenges to collaborating effectively. First, while the relationship-based foundation for their local network strengthens the collective actions, it is also an approach that is slow and iterative, making it much more difficult for some to scale up the network in size. The reliance on interpersonal relationships also meant that when people transition roles within an organization, whether they move away or change jobs, the network's loss is greater and more challenging to recover. Second, there is a sense of competition for resources among organizations working to meet similar needs in the community, and the hyper-focus on the \"survivability\" of individual organizations could prevent meaningful partnerships. One BCR partner recalls an early experience of having to dissolve their advisory group due to a \"tendency for organizations to be looking out for themselves, rather than working collectively\". The key to overcoming the sense of competition is effective communication, which enables the first component – building a shared understanding. BCR partners stated that they listened to and communicated with stakeholders, resulting in a shared understanding of values and expectations.\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003eEngaging Community \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ePrompted by the Engaging Community component of the BCR process, some partners engaged members of their local communities from the outset and incorporated community voice into the work \"every step of the way.\" There are BCR networks that brought on community members for paid or voluntary advisory roles. Some BCR partners hired community members for staff positions. All with the acknowledgement that community voices are valuable and the intention of making their work community-driven, particularly for agenda-setting and prioritizing opportunities. For these BCR partners, community members are not an \"afterthought\".\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"But the process of how we're yielding our power to community members, to people from those groups, young or adult leaders who have a leadership capacity…consultant capacity, we treat them as a consultant because 'We are consulting with you. Your service is important and valuable.'… we're gonna demonstrate that.\"\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, BCR partners that brought in community voice later in the process reported struggling with creating meaningful leadership opportunities for community members in ways that respect their time and uplift their expertise, without being extractive or tokenizing. As one BCR partner stated,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"But we also recognize that … we had to do it in a meaningful way that wasn't creating a token position for somebody who wasn't really going to have a meaningful voice within their work that we did.\u003c/em\u003e \u003cem\u003eAnd I would say that we're still struggling a little bit with that … we've been much more intentional about identifying who is sitting on our steering committee and who is missing.\"\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough initially presented as a model, the four components of Building Community Resilience function as a continuous improvement process, with multiple components employed concurrently. For example, \u0026quot;Who should be at the table?\u0026quot; is regularly asked among network partners when assessing capacity and capability to address an emerging issue. Community engagement is most effective when conducted continuously, integrated into all aspects of collective action, and sustained over time. While the larger community\u0026apos;s state of readiness fluctuates, local networks continually build and adapt their internal capacity for systems change in response to shifting contexts. Building Shared Understanding, though essential at a coalition\u0026rsquo;s outset, remains critical for maintaining partnerships and meaningfully engaging communities over time.\u003c/p\u003e\n\u003cp\u003eThis qualitative evaluation study has limited generalizability but offers valuable insight into how partners applied BCR tools and why certain approaches succeeded while others posed challenges. In the absence of quantitative measures to capture impact the Table illustrates how the BCR process supports communities in initiating and strengthening collective efforts to address the Pair of ACEs.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"804\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 804px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eEvidence of Practice and Policy Change Across BCR Collaborative Sites\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation / Team\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitiative / Intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes / Impact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePolicy or Funding Influence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCincinnati, Ohio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eIntegration of parent coaches into pediatric primary care practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eReduced child behavioral issues and decreased parent reports of household stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eDemonstrates translation of trauma-informed practices into pediatric primary care systems.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eMissouri\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eAdvocacy campaign to address maternal mortality and racial disparities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSecured Senator Roy Blunt\u0026rsquo;s (R) support for maternal mortality initiatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eResulted in a $50 million appropriation to HRSA and CDC in the FY2019 Labor, Health and Human Services, Education, and Related Programs Appropriations Bill, specifically targeting Black maternal mortality.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eNational (Pair of ACEs Network)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eUse of the \u0026ldquo;Pair of ACEs\u0026rdquo; graphic to frame community adversity and resilience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eElevated awareness of ACEs and trauma-informed approaches in policy settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eLed to Congressional briefings co-led by Sen. Heidi Heitkamp (D-ND) and Rep. Danny Davis (D-IL); informed multiple policy and appropriations efforts promoting ACEs prevention, trauma-informed practice, and racial equity.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eOregon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eDevelopment of Block of Humanity,\u0026nbsp;a community-informed, place-based consortium addressing social determinants of health in Salem.\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEstablished cross-sector collaboration among providers and agencies to meet social, economic, and educational needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eInformed state funding for Resilience Hubs: $10 million awarded to 87 organizations statewide to address acute (wildfire) and chronic (housing, food, and health access) adversities.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 804px;\"\u003e\n \u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Table summarizes practice and policy impacts achieved by members of the BCR collaborative through place-based and advocacy efforts demonstrating translational application of community resilience frameworks at local, state, and federal levels.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for the Field\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings demonstrate that the BCR process is a valuable approach to help place-based networks grow collectively and become more effective in addressing adverse childhood experiences within the context of adverse community environments. \u0026nbsp;Over the past decade, BCR sites have translated this process into tangible achievements, including securing federal and local funding streams, influencing policy change, aligning systems across sectors, and adapting the model within local public health departments.\u003csup\u003e2\u003c/sup\u003e These accomplishments provide hard evidence of impact and demonstrate how the BCR approach transitions from theory to practice.\u003c/p\u003e\n\u003cp\u003ePaired with the Pair of ACEs image, the BCR process enables local networks to effectively communicate their goals, values, and plans to a variety of stakeholders, fostering growth in relationships and trust with cross-sector partners and community members. By monitoring both external and internal readiness, networks can adapt strategies authentically to advance systems change. Prioritizing cross-sector partnerships and community voice enhances their ability to act collectively and leverage shared strengths. A decade of implementation shows that diverse coalitions strengthen relationships, build trust, and sustain resilience even amid shifting political and financial contexts.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEllis WR, Dietz WH. A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model. \u003cem\u003eAcademic Pediatrics\u003c/em\u003e. 2017;17(7):S86-S93. doi:10.1016/j.acap.2016.12.011\u003c/li\u003e\n\u003cli\u003eEllis W, Dietz WH, Chen KLD. Community Resilience: A Dynamic Model for Public Health 3.0. \u003cem\u003eJ Public Health Manag Pract\u003c/em\u003e. 2022;28(Suppl 1):S18-S26. doi:10.1097/PHH.0000000000001413\u003c/li\u003e\n\u003cli\u003eFelitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. \u003cem\u003eAm J Prev Med\u003c/em\u003e. 1998;14(4):245-258. doi:10.1016/s0749-3797(98)00017-8\u003c/li\u003e\n\u003cli\u003eJiang S, Postovit L, Cattaneo A, Binder EB, Aitchison KJ. Epigenetic Modifications in Stress Response Genes Associated With Childhood Trauma. \u003cem\u003eFront Psychiatry\u003c/em\u003e. 2019;10:808. doi:10.3389/fpsyt.2019.00808\u003c/li\u003e\n\u003cli\u003eWade R, Cronholm PF, Fein JA, et al. Household and community-level Adverse Childhood Experiences and adult health outcomes in a diverse urban population. \u003cem\u003eChild Abuse Negl\u003c/em\u003e. 2016;52:135-145. doi:10.1016/j.chiabu.2015.11.021\u003c/li\u003e\n\u003cli\u003eCamacho S, Henderson SC. The Social Determinants of Adverse Childhood Experiences: An Intersectional Analysis of Place, Access to Resources, and Compounding Effects. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2022;19(17):10670. doi:10.3390/ijerph191710670\u003c/li\u003e\n\u003cli\u003eBraveman P, Egerter S, Williams DR. The social determinants of health: coming of age. \u003cem\u003eAnnu Rev Public Health\u003c/em\u003e. 2011;32:381-398. doi:10.1146/annurev-publhealth-031210-101218\u003c/li\u003e\n\u003cli\u003ePlough AL. Building a Culture of Health: A Critical Role for Public Health Services and Systems Research. \u003cem\u003eAm J Public Health\u003c/em\u003e. 2015;105(Suppl 2):S150-S152. doi:10.2105/AJPH.2014.302410\u003c/li\u003e\n\u003cli\u003eBrown AF, Ma GX, Miranda J, et al. Structural Interventions to Reduce and Eliminate Health Disparities. \u003cem\u003eAm J Public Health\u003c/em\u003e. 2019;109(Suppl 1):S72-S78. doi:10.2105/AJPH.2018.304844\u003c/li\u003e\n\u003cli\u003eNorris FH, Stevens SP, Pfefferbaum B, Wyche KF, Pfefferbaum RL. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. \u003cem\u003eAm J Community Psychol\u003c/em\u003e. 2008;41(1-2):127-150. doi:10.1007/s10464-007-9156-6\u003c/li\u003e\n\u003cli\u003eSummary Of The Labor, Health And Human Services, Education, And Related Programs FY19 Appropriations Bill | United States Senate Committee on Appropriations. Accessed October 14, 2025. https://www.appropriations.senate.gov/news/minority/summary-of-the-labor-health-and-human-services-education-and-related-programs-fy19-appropriations-bill\u003c/li\u003e\n\u003cli\u003eLott R. Treating Children, Coaching Their Parents. \u003cem\u003eHealth Affairs\u003c/em\u003e. 2020;39(4):562-566. doi:10.1377/hlthaff.2020.00238\u003c/li\u003e\n\u003cli\u003eSocial services hub planned for downtown Salem building. opb. Accessed October 14, 2025. https://www.opb.org/article/2024/04/17/social-services-hub-planned-for-downtown-salem-building/\u003c/li\u003e\n\u003cli\u003eOregon Department of Human Services : Resilience Hubs and Networks Grant : Emergency Management : State of Oregon. Accessed October 14, 2025. https://www.oregon.gov/odhs/emergency-management/pages/resilience-grants.aspx\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-urban-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jurh","sideBox":"Learn more about [Journal of Urban Health](https://www.springer.com/journal/11524)","snPcode":"11524","submissionUrl":"https://www.editorialmanager.com/jurh","title":"Journal of Urban Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8196885/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8196885/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe aimed to evaluate the implementation of the Building Community Resilience (BCR) process during its initial national pilot and explore how communities applied the framework to address the root causes of childhood and community adversity. We conducted a qualitative evaluation using semi-structured interviews with 24 BCR partners across five U.S. sites. Guided by the four components of the BCR process \u0026ndash; shared understanding, state of readiness, cross-sector partnerships, and community engagement \u0026ndash; interviews examined implementation strategies, challenges, and lessons learned. Transcripts were analyzed inductively through iterative coding and thematic analysis. Findings show that the BCR process strengthened cross-sector collaboration, expanded shared language around adversity, and enhanced community engagement. Partners emphasized readiness, trust-building, and centering community voice as key to sustaining resilience efforts. The BCR process provides a flexible framework for aligning systems and community priorities to address the Pair of ACEs and promote collective resilience and health equity. Policies that invest in multisector collaboration, community leadership, and structural reforms are essential for scaling resilience approaches and addressing the systemic drivers of childhood and community adversity.\u003c/p\u003e","manuscriptTitle":"A Qualitative Evaluation of the Building Community Resilience Process and National Collaborative","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 11:41:09","doi":"10.21203/rs.3.rs-8196885/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-04-21T17:45:04+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-14T16:18:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-09T19:33:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Urban Health","date":"2025-12-05T13:54:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-urban-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jurh","sideBox":"Learn more about [Journal of Urban Health](https://www.springer.com/journal/11524)","snPcode":"11524","submissionUrl":"https://www.editorialmanager.com/jurh","title":"Journal of Urban Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"134bd7fa-153f-42b6-a06d-7ed516db22ea","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T11:41:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-15 11:41:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8196885","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8196885","identity":"rs-8196885","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}