Useful Concepts for the Practice of Community Engagement
The social science and public health fields provide us not only with useful definitions of community and ideas about community engagement but also with a wealth of concepts that are relevant to the practice of engagement. Here, we explore some of the most important.
Culture and Community Engagement
One of the more useful of the hundreds of definitions of culture is this one from the anthropologist Christie Kiefer (2007): “a complex integrated system of thought and behavior shared by members of a group — a system whose whole pattern allows us to understand the meanings that people attach to specific facts and observations.” Culture shapes identities and fosters notions of community, and it shapes how individuals and groups relate to each other, how meaning is created, and how power is defined. Furthermore, culture shapes ideas about partnership, trust, and negotiation. Therefore, culture shapes the process of community engagement, and effective engagement requires an understanding of culture (Blumenthal et al., 2004; Dévieux et al., 2005; Silka et al., 2008).
In particular, researchers and practitioners need to understand the cultural dynamics of specific groups and institutions in order to build relationships, identify ways to effectively collaborate, and build respect and trust. This is an ongoing effort for all involved in the community engagement process (Harrell et al., 2006; Minkler et al., 2004; Shoultz et al., 2006; Sullivan et al., 2001). Communities are not homogeneous entities; they are made up of diverse groups with different histories, social structures, value systems, and cultural understandings of the world.
There is no question that culture and health are intimately connected. Indeed, culture influences perceptions of illness and suffering, methods of disease prevention, treatments for illness, and use of health services. Both medical and public health literature recognize the connection between health and culture (Airhihenbuwa, 2007; Fisher et al., 2007; Krumeich et al., 2001; Resnicow et al., 1999), but the solution to bridging cultural boundaries is often presented as acquiring “cultural competency,” or having knowledge of a group’s cultural differences and typical behaviors or beliefs. This is inadequate, however. As anthropologists have demonstrated, culture is dynamic and complex, and cultural competence is more than identifying how a group is thought to differ from prevailing standards or norms of behavior and belief (Carpenter-Song et al., 2007). Focusing on the meanings that individuals share and on the explanatory models they use to discuss their health problems provides a richer understanding of these individuals and can yield a cultural understanding that is rooted in their real lives rather than in stereotypes. This meaning-centered approach can also help reveal how community conditions are determined by social, economic, and political forces rather than simply by individual choices (Carpenter-song et al., 2007; Kleinman et al., 2006; Kumagai et al., 2009; Silka et al., 2008).
To achieve successful collaboration with a community, all parties involved need to strive to understand the point of view of “insiders,” whether they are members of a neighborhood, religious institution, health practice, community organization, or public health agency. Key to developing such understanding is recognizing one’s own culture and how it shapes one’s beliefs and understanding of health and illness (Airhihenbuwa, 2007; Hahn, 1999; Harrell et al., 2006; Kleinman, 1980; Minkler, 2004). For example, community-engaged programs and research often involve people from universities or health institutions working with community groups in areas labeled “low income” or “at risk.” Acknowledging diversity in background, experience, culture, income, and education and examining how society produces privilege, racism, and inequalities in power should be central to the process of community engagement. Such an approach can help partners better understand and address the roots of health issues and guard against reproducing repressive patterns within their partnerships (Chávez et al., 2008; Chavez et al., 2007; Jones et al., 2000; Krieger et al., 1999; Yonas et al., 2006).
Done well, the community-engaged approach can enable partnerships to develop programs and research “in ways that are consistent with a people’s and a community’s cultural framework” (Airhihenbuwa, 1995). When researchers and organizers work collaboratively with community organizations throughout a project, they can produce effective, culturally appropriate programs and robust research results.
The practice and theory of community organizing provide useful insights into mobilizing the community to engage in health promotion. The foundation for community organizing is the principle of social action, bringing people together — often, but not exclusively, from the same neighborhood — to pursue a shared interest (Braithwaite et al., 1994).
When pursuing social action, a key question is who represents the community. Often, the most empowered members of a community will quickly move to the forefront, regardless of whether they are truly the most representative (Geiger, 1984). Similarly, engagement leaders may want to work with those who can most readily deliver what they want (such as research participants and data sources), but these persons may not be representative of the community. Facilitating community organization cannot be allowed to serve the needs of individual partners at the expense of the larger community (CARE: Community Alliance for Research and Engagement, 2009).
Community organizing is based on the principles of empowerment, community competence, active participation, and “starting where the people are” (Nyswander, 1956, as cited in Minkler, 2005, p. 27). As Labonte et al. (1996) state, imposing one’s own notions of health concerns over the community’s risks several disabling effects. These include being irrelevant to the community, creating feelings of powerlessness in the community, complicating individuals’ lives, and channeling local activism away from important challenges toward less important ones.
Community organizing recognizes that, in order to change, we all must feel a need for change, and that we are more likely to do so when we are involved in group learning and decision making (Minkler, 1990). An important element of community organizing is helping communities look at the root causes of problems while at the same time selecting issues that are “winnable, simple, and specific” and that can unite members of the group, involve them in achieving a solution, and further build the community (Minkler, 1990).
Community engagement requires participation of community members in projects that address their issues. Meaningful community participation extends beyond physical involvement to include generation of ideas, contributions to decision making, and sharing of responsibility. Among the factors that motivate people to participate are wanting to play an active role in bettering their own lives, fulfilling social or religious obligations, feeling a need for a sense of community, and wanting cash or in-kind rewards. Whatever people’s motivations, obtaining meaningful community participation and having a successful, sustained initiative require that engagement leaders respect, listen to, and learn from community members. An absence of mutual respect and co-learning can result in a loss of time, trust, resources, and, most importantly, effectiveness (Henry, 2011; Miller et al., 2005; Minkler et al., 2009).
The “social exchange” perspective provides insight into motivations for participation; it uses the framework of benefits and costs to help explain who participates and why. From this perspective, organizations and individuals are involved in an “exchange system” and voluntarily share resources to meet their goals (Levine et al., 1961). Community members and organizations will participate if they perceive that the benefits of participation outweigh the effort required (Butterfoss, 2006; Butterfoss et al., 1993; Wandersman et al., 1987).
The potential benefits of participation for community members, academics, and health professionals include opportunities for networking, access to information and resources, personal recognition, learning, a sense of helping to solve community problems, improved relationships among stakeholders, increased capacity for problem solving, and contact with hard-to-reach populations (Butterfoss, 2006). Costs include the time and energy required to build relationships and other infrastructure and the lessening of control over initiatives (Staley, 2009).
Recently, literature has shifted from a focus on a social exchange model to other challenges and facilitators of community participation (Shalowitz et al., 2009). Some of these writings are based on experience rather than theory, but they may lead to the development of improved theories of participation (Michener et al., 2008; Williams et al., 2009).
Robert Putnam (2001) initiated an important debate about the degree to which Americans volunteer for and participate in group and community activities with the publication of Bowling Alone. In the book, Putnam argued that the willingness to volunteer and participate in public life waxes and wanes over time but that overall it has declined in recent decades. If there is indeed a trend away from civic engagement, it would affect efforts to engage communities in improving health.
Regardless of whether one agrees with Putnam’s assessment, it is essential to recognize that the community’s time is valuable and limited. Furthermore, developing relationships with individuals and community organizations, identifying common interests, and developing a shared sense of needs and shared ways to address those needs can take engagement leaders and stakeholders an enormous amount of time. Given the expanded roles that community members are being asked to play in the development of social programs and in research, we must consider how to compensate them for their participation, and we should involve them in this process.
The costs, benefits, and perceived risks of participation can sometimes be changed with collaborative planning and decision making. For example, academic partners have traditionally presumed ownership of any data or other tangibles resulting from research, but if the benefits of participation are to outweigh the costs and the principles of community engagement are to be met, the community should be involved early on in identifying what assets the research will produce and the rights of each partner to use those assets (see Yale Center for Clinical Investigation/Community Alliance for Research and Engagement, 2009).
Developing a constituency, or developing relationships with community members who have a stake in and support public health and health care, involves four “practice elements”:
- Know the community, its constituents, and its capabilities.
- Establish positions and strategies that guide interactions with constituents.
- Build and sustain formal and informal networks to maintain relationships, communicate messages, and leverage resources.
- Mobilize communities and constituencies for decision making and social action (Hatcher et al., 2008).
These four elements, which provide a simple, useful framework for thinking about the requirements of community engagement, will be revisited in Chapter 4’s discussion of the organizational support required for community engagement.
Building capacity to improve health involves the development of sustainable skills, resources, and organizational structures in the affected community. For engagement efforts to be equitable, effective, and sustainable, all stakeholders must be ready for collaboration and leadership. Thus, building capacity also includes fostering shared knowledge, leadership skills, and an ability to represent the interests of one’s constituents. Because capacity building is deeply rooted in the social, political, and economic environment, it cannot be conducted without an understanding of the specific environment in which it will take place (Eng et al., 1994). When carried out with context in mind, capacity building is an integral part of community engagement efforts, necessary for challenging power imbalances and effectively addressing problems.
The theoretical roots of “empowerment” as a critical element of community engagement can be traced back to Brazilian educator Paolo Freire (Freire, 1970; Hur, 2006). As articulated by Kenneth Maton (2008), empowerment is “a group-based participatory, developmental process through which marginalized or oppressed individuals and groups gain greater control over their lives and environment, acquire valued resources and basic rights, and achieve important life goals and reduced societal marginalization.” Ideally, empowerment is both a process and an outcome of community engagement.
Empowerment takes place at three levels: the individual, the organization or group, and the community. Empowerment at one level can influence empowerment at the other levels. Furthermore, empowerment is multidimensional, taking place in sociological, psychological, economic, political, and other dimensions (Fawcett et al., 1995; Hur, 2006; Maton, 2008; Rich et al., 1995). Community-level empowerment “challenges professional relationships to communities, emphasizing partnership and collaboration rather than a top-down approach” (Wallerstein, 2002, p. 74).
Empowerment theory stresses that no external entity should assume that it can bestow on a community the power to act in its own self-interest. Rather, those working to engage the community should, when appropriate, offer tools and resources to help the community act in its own interest. This could include helping to channel existing sources of community power in new ways to act on the determinants of health. Kretzmann et al. (1996) note that communities are usually assessed in terms of their problems, but they point out that this demeans and disempowers the community, relegating its members to the roles of dependents and recipients of services. They advocate for assessing communities in terms of their own assets, resources, and resourcefulness (Kretzmann et al., 1996).
Community engagement often involves building coalitions, defined by Cohen et al. (2002) as “a union of people and organizations working to influence outcomes on a specific problem” (p. 144). The goals of a coalition might range from sharing information and resources to advocating for specific policy changes (Cohen et al., 2002). Increasingly, funders have supported the building of coalitions for improving community health (Butterfoss et al., 1993; Green et al., 2001a; Hill et al., 2007).
The motivation to create coalitions comes from the recognition that they can accomplish what each partner cannot accomplish alone. Political science literature suggests that:
- Coalitions require that each party believe it needs help to reach its goals.
- The goals and perspectives of the members of a coalition will not all be shared. However, the coalition requires sufficient common ground that the parties can agree over time on a purpose, set of policies, and strategies.
- Coalitions require continuous and often delicate negotiation among their participants.
- The distribution of power and benefits among the members of a coalition is an ongoing concern; all members need to believe that, over time, they are receiving benefits that are comparable to their contributions (Sofaer, 1993).
Coalitions can help the engagement process in a number of ways, including maximizing the influence of individuals and organizations, creating new collective resources, and reducing the duplication of efforts. The effectiveness of coalitions has been evaluated on two distinct bases: how well the members work together, and what kinds of community-level changes they bring about. While noting that the research literature is inadequate for determining which factors are associated with the effectiveness of coalitions, Zakocs et al. (2006) suggest six possibilities: formalization of rules/procedures, leadership style, participation of members, diversity of membership, collaboration, and group cohesion.
Based on their review of the literature on coalitions, Butterfoss et al. (2002) developed community coalition action theory, which provides 23 practice-based propositions that address processes ranging from the formation of coalitions through the institutionalization of long-lasting coalitions. These propositions, which shed light on how to create and support effective long-term alliances, will be discussed in greater detail in Chapter 4.