Models and Frameworks | Principles of Community Engagement

The social ecological model conceptualizes health broadly and focuses on multiple factors that might affect health. This broad approach to thinking of health, ... Skipdirectlytositecontent Skipdirectlytopageoptions SkipdirectlytoA-Zlink SkipdirectlytoA-Zlink SkipdirectlytoA-Zlink PrinciplesofCommunityEngagement-SecondEdition SectionNavigation CDCHome Facebook Twitter LinkedIn Syndicate ModelsandFrameworksforthePracticeofCommunityEngagement Minus RelatedPages DownloadFullDocumentCdc-pdf[PDF–2.6MB] ThisChapterCdc-pdf[PDF–998KB] Inadditiontotheconceptsjustsummarized,theliteratureprovidesmodelsandframeworksforunderstandinghealthpromotionandhealthresearchthatcanbehelpfulinthepracticeofcommunityengagement.Wecoveranumberofthosehere. TheSocialEcologicalModelofHealth Thesocialecologicalmodelconceptualizeshealthbroadlyandfocusesonmultiplefactorsthatmightaffecthealth.Thisbroadapproachtothinkingofhealth,advancedinthe1947ConstitutionoftheWorldHealthOrganization,includesphysical,mental,andsocialwell-being(WorldHealthOrganization,1947).Thesocialecologicalmodelunderstandshealthtobeaffectedbytheinteractionbetweentheindividual,thegroup/community,andthephysical,social,andpoliticalenvironments(Israeletal.,2003;Sallisetal.,2008;Wallersteinetal.,2003). Boththecommunityengagementapproachandthesocialecologicalmodelrecognizethecomplexroleplayedbycontextinthedevelopmentofhealthproblemsaswellasinthesuccessorfailureofattemptstoaddresstheseproblems.Healthprofessionals,researchers,andcommunityleaderscanusethismodeltoidentifyfactorsatdifferentlevels(theindividual,theinterpersonallevel,thecommunity,society;seeFigure1.2)thatcontributetopoorhealthandtodevelopapproachestodiseasepreventionandhealthpromotionthatincludeactionatthoselevels.Thisapproachfocusesonintegratingapproachestochangethephysicalandsocialenvironmentsratherthanmodifyingonlyindividualhealthbehaviors. Stokols(1996)proposesfourcoreprinciplesthatunderliethewaysthesocialecologicalmodelcancontributetoeffortstoengagecommunities: Healthstatus,emotionalwell-being,andsocialcohesionareinfluencedbythephysical,social,andculturaldimensionsoftheindividual’sorcommunity’senvironmentandpersonalattributes(e.g.,behaviorpatterns,psychology,genetics). Thesameenvironmentmayhavedifferenteffectsonanindividual’shealthdependingonavarietyoffactors,includingperceptionsofabilitytocontroltheenvironmentandfinancialresources. Individualsandgroupsoperateinmultipleenvironments(e.g.,workplace,neighborhood,largergeographiccommunities)that“spillover”andinfluenceeachother. Therearepersonalandenvironmental“leveragepoints,”suchasthephysicalenvironment,availableresources,andsocialnorms,thatexertvitalinfluencesonhealthandwell-being. Toinformitshealthpromotionprograms,CDC(2007)createdafour-levelmodelofthefactorsaffectinghealththatisgroundedinsocialecologicaltheory,asillustratedinFigure1.2. Thefirstlevelofthemodel(attheextremeright)includesindividualbiologyandotherpersonalcharacteristics,suchasage,education,income,andhealthhistory.Thesecondlevel,relationship,includesaperson’sclosestsocialcircle,suchasfriends,partners,andfamilymembers,allofwhominfluenceaperson’sbehaviorandcontributetohisorherexperiences.Thethirdlevel,community,exploresthesettingsinwhichpeoplehavesocialrelationships,suchasschools,workplaces,andneighborhoods,andseekstoidentifythecharacteristicsofthesesettingsthataffecthealth.Finally,thefourthlevellooksatthebroadsocietalfactorsthatfavororimpairhealth.Exampleshereincludeculturalandsocialnormsandthehealth,economic,educational,andsocialpoliciesthathelptocreate,maintain,orlessensocioeconomicinequalitiesbetweengroups(CDC,2007;Krugetal.,2002). TheCDCmodelenablescommunity-engagedpartnershipstoidentifyacomprehensivelistoffactorsthatcontributetopoorhealthanddevelopabroadapproachtohealthproblemsthatinvolvesactionsatmanylevelstoproduceandreinforcechange.Forexample,anefforttoreducechildhoodobesitymightincludethefollowingactivitiesatthefourlevelsofinterest: Individual:Conducteducationprogramstohelppeoplemakewisechoicestoimprovenutritionalintake,increasetheirphysicalactivity,andcontroltheirweight. Interpersonalrelationships:Createwalkingclubsandworkwithcommunitygroupstointroducehealthymenusandcookingmethods.Promotecommunitygardeninggroups. Community:Workwithlocalgrocerystoresandconveniencestorestohelpthemincreasetheamountoffreshfruitsandvegetablestheycarry.Establishfarmers’marketsthatacceptfoodstampssothatlow-incomeresidentscanshopthere.Workwiththecityorcountytoidentifywalkingtrails,parks,andindoorsiteswherepeoplecangotowalk,andpublicizethesesites.Iftheareaneedsadditionalvenuesforexercise,buildcommunitydemandandlobbyfornewareastobebuiltordesignated.Workwithlocalemployerstodevelophealthierfoodchoicesonsiteandtocreateotherworkplacehealthprograms. Society:Advocateforthepassageofregulationsto(1)eliminatesoftdrinksandhigh-caloriesnacksfromallschools,(2)bantheuseoftrans–fattyacidsinrestaurantfood,or(3)mandatethatapercentageofthebudgetforroadmaintenanceandconstructionbespentoncreatingwalkingpathsandbikelanes. Long-termattentiontoalllevelsofthesocialecologicalmodelcreatesthechangesandsynergyneededtosupportsustainableimprovementsinhealth. TopofPageTheActiveCommunityEngagementContinuum TheActiveCommunityEngagement(ACE)continuumprovidesaframeworkforanalyzingcommunityengagementandtherolethecommunityplaysininfluencinglastingbehaviorchange.ACEwasdevelopedbytheAccess,QualityandUseinReproductiveHealth(ACQUIRE)projectteam,whichissupportedbytheU.S.AgencyforInternationalDevelopmentandmanagedbyEngenderHealthinpartnershipwiththeAdventistDevelopmentandReliefAgencyInternational,CARE,IntraHealthInternational,Inc.,MeridianGroupInternational,Inc.,andtheSocietyforWomenandAIDSinAfrica(Russelletal.,2008).TheACEcontinuumisbasedonareviewofdocuments,bestpractices,andlessonslearnedduringtheACQUIREproject;inapaperbyRusselletal.(2008)thecontinuumisdescribedasfollows: Thecontinuumconsistsofthreelevelsofengagementacrossfivecharacteristicsofengagement.Thelevelsofengagement,whichmovefromconsultativetocooperativetocollaborative,reflecttherealitiesofprogrampartnershipsandprograms.Thesethreelevelsofcommunityengagementcanbeadapted,withspecificactivitiesbasedonthesecategoriesofaction.Thefivecharacteristicsofengagementarecommunityinvolvementinassessment;accesstoinformation;inclusionindecisionmaking;localcapacitytoadvocatetoinstitutionsandgoverningstructures;andaccountabilityofinstitutionstothepublic.(p.6) TheexperienceoftheACQUIREteamshowsthatcommunityengagementisnotaone-timeeventbutratheranevolutionaryprocess.Ateachsuccessivelevelofengagement,communitymembersmoveclosertobeingchangeagentsthemselvesratherthantargetsforchange,andcollaborationincreases,asdoescommunityempowerment.Atthefinal(collaborative)level,communitiesandstakeholdersarerepresentedequallyinthepartnership,andallpartiesaremutuallyaccountableforallaspectsoftheproject(Russelletal.,2008). TopofPageDiffusionofInnovation EverettRogers(1995)defineddiffusionas“theprocessbywhichaninnovationiscommunicatedthroughcertainchannelsovertimeamongthemembersofasocialsystem”.Communication,inturn,accordingtoRogers,isa“processinwhichparticipantscreateandshareinformationwithoneanotherinordertoreachamutualunderstanding”.Inthecaseofdiffusionofinnovation,thecommunicationisaboutanideaornewapproach.Understandingthediffusionprocessisessentialtocommunity-engagedeffortstospreadinnovativepracticesinhealthimprovement. Rogersofferedanearlyformulationoftheideathattherearedifferentstagesintheinnovationprocessandthatindividualsmovethroughthesestagesatdifferentratesandwithdifferentconcerns.Thus,diffusionofinnovationprovidesaplatformforunderstandingvariationsinhowcommunities(orgroupsorindividualswithincommunities)respondtocommunityengagementefforts. InRogers’firststage,knowledge,theindividualorgroupisexposedtoaninnovationbutlacksinformationaboutit.Inthesecondstage,persuasion,theindividualorgroupisinterestedintheinnovationandactivelyseeksoutinformation.Indecision,thethirdstage,theindividualorgroupweighstheadvantagesanddisadvantagesofusingtheinnovationanddecideswhethertoadoptorrejectit.Ifadoptionoccurs,theindividualorgroupmovestothefourthstage,implementation,andemploystheinnovationtosomedegree.Duringthisstage,theusefulnessoftheinnovationisdetermined,andadditionalinformationmaybesought.Inthefifthstage,confirmation,theindividualorgroupdecideswhethertocontinueusingtheinnovationandtowhatextent. Rogersnotedthattheinnovationprocessisinfluencedbothbytheindividualsinvolvedintheprocessandbytheinnovationitself.Individualsincludeinnovators,earlyadoptersoftheinnovation,theearlymajority(whodeliberatelongerthanearlyadoptersandthentakeaction),lateadopters,and“laggards”whoresistchangeandareoftencriticalofotherswillingtoaccepttheinnovation. AccordingtoRogers,thecharacteristicsthataffectthelikelihoodthataninnovationwillbeadoptedinclude(1)itsperceivedrelativeadvantageoverotherstrategies,(2)itscompatibilitywithexistingnormsandbeliefs,(3)thedegreeofcomplexityinvolvedinadoptingtheinnovation,(4)the“trialability”oftheinnovation(i.e.,theextenttowhichitcanbetestedonatrialbasis),and(5)theobservabilityoftheresults.Greenhalghetal.(2004)expandeduponthesecharacteristicsofaninnovation,adding(1)thepotentialforreinvention,(2)howflexiblytheinnovationcanbeused,(3)theperceivedriskofadoption,(4)thepresenceofaclearpotentialforimprovedperformance,(5)theknowledgerequiredtoadopttheinnovation,and(6)thetechnicalsupportrequired. Awarenessofthestagesofdiffusion,thedifferingresponsestoinnovations,andthecharacteristicsthatpromoteadoptioncanhelpengagementleadersmatchstrategiestothereadinessofstakeholders.Forexample,acommunity-engagedhealthpromotioncampaignmightincluderaisingawarenessabouttheseverityofahealthproblem(knowledge,thefirststageinRogers’scheme),transformingawarenessintoconcernfortheproblem(persuasion),establishingacommunity-wideinterventioninitiative(adoption),developingthenecessaryinfrastructuresothattheprovisionofservicesremainsextensiveandconstantinreachingresidents(implementation),and/orevaluationoftheproject(confirmation). TopofPageCommunity-BasedParticipatoryResearch Community-basedparticipatoryresearch(CBPR)isthemostwell-knownframeworkforCEnR.Asahighlyevolvedcollaborativeapproach,CBPRwouldberepresentedontherightsideofthecontinuumshowninFigure1.1.InCBPR,allcollaboratorsrespectthestrengthsthateachbringstothepartnership,andthecommunityparticipatesfullyinallaspectsoftheresearchprocess.AlthoughCBPRbeginswithanimportantresearchtopic,itsaimistoachievesocialchangetoimprovehealthoutcomesandeliminatehealthdisparities(Israeletal.,2003). Wallersteinetal.(2008)conductedatwo-yearpilotstudythatlookedathowtheCBPRprocessinfluencesorpredictsoutcomes.UsingInternetsurveymethodsandexistingpublishedliterature,thestudyfocusedontwoquestions:WhatistheaddedvalueofCBPRtotheresearchitselfandtoproducingoutcomes?Whatarethepotentialpathwaystointermediatesystemandcapacitychangeoutcomesandtomoredistalhealthoutcomes?Throughaconsensusprocessusinganationaladvisorycommittee,theauthorsformedaconceptuallogicmodelofCBPRprocessesleadingtooutcomes(Figure1.3) ThemodeladdressesfourdimensionsofCBPRandoutlinesthepotentialrelationshipsbetweeneach.Theauthorsidentify: “contextualfactors”thatshapethenatureoftheresearchandthepartnership,andcandeterminewhetherandhowapartnershipisinitiated.Next,groupdynamics…interactwithcontextualfactorstoproducetheinterventionanditsresearchdesign.Finally,intermediatesystemandcapacitychanges,andultimately,healthoutcomes,resultdirectlyfromtheinterventionresearch. Modelssuchastheseareessentialtoeffortstoempiricallyassessorevaluatecommunityengagementpracticesanddisseminateeffectiveapproaches. TopofPageTranslationalResearch NIHhascreatedanewimpetustowardparticipatoryresearchthroughanincreaseinfundingmechanismsthatrequireparticipationandthroughitscurrentfocuson“translation”(i.e.,turningresearchintopracticebytakingitfrom“thebenchtothebedsideandintothecommunity”).Increasingly,communityparticipationisrecognizedasnecessaryfortranslatingexistingresearchtoimplementandsustainnewhealthpromotionprograms,changeclinicalpractice,improvepopulationhealth,andreducehealthdisparities.TheCTSAinitiativeistheprimaryexampleofanNIH-fundedmechanismrequiringatranslationalapproachtotheclinicalresearchenterprise(Horowitzetal.,2009). Thecomponentsoftranslationalresearchareunderstooddifferentlybydifferentauthorsinthefield.Inonewidelyusedschema,translationalresearchisseparatedintofoursegments:T1−T4(Kon,2008).T1representsthetranslationofbasicscienceintoclinicalresearch(phase1and2clinicaltrials),T2representsthefurtherresearchthatestablishesrelevancetopatients(phase3trials),T3istranslationintoclinicalpractice,andT4isthemovementof“scientificknowledgeintothepublicsector…therebychangingpeople’severydaylives”throughpublicandotherpolicychanges. Westfalletal.(2007)haveidentifiedthelackofsuccessfulcollaborationbetweencommunityphysiciansandacademicresearchersasoneofthemajorroadblockstotranslation.Theynotethatalthoughthemajorityofpatientsreceivemostoftheirmedicalcarefromaphysicianinacommunitysetting,mostclinicalresearchtakesplaceinanacademicsetting(Westfalletal.,2007).Consequently,theresultsofclinicaltrialsmaynotbeeasilygeneralizedtoreal-worldclinicalpractices. Onesolutiontothisdilemmaispractice-basedresearch(PBR):engagingthepracticecommunityinresearch.PBRhastraditionallybeenconductedinaprimarycaresettingusingacoordinatedinfrastructure(physicians,nurses,andofficestaff),althoughtherecentemphasisontranslationhascontributedtotheemergenceofmorespecializedpractice-basedresearchnetworks(e.g.,innursing,dentalcare,andpharmacy).Likealleffortsinengagement,developingPBRincludesbuildingtrust,sharingdecisionmaking,andrecognizingtheexpertiseofallpartners.PBRaddressesthreeparticularconcernsaboutclinicalpractice:identifyingmedicaldirectivesthat,despiterecommendations,arenotbeingimplemented;validatingtheeffectivenessofclinicalinterventionsincommunity-basedprimarycaresettings;andincreasingthenumberofpatientsparticipatinginevidence-basedtreatments(Westfalletal.,2007).“PBRalsoprovidesthelaboratoryforarangeofresearchapproachesthataresometimesbettersuitedtotranslationalresearchthanareclinicaltrials:observationalstudies,physicianandpatientsurveys,secondarydataanalysis,andqualitativeresearch”(Westfalletal.,2007,p.405). TopofPage Pagelastreviewed:June25,2015 Contentsource: AgencyforToxicSubstancesandDiseaseRegistry home PrinciplesofCommunityEngagement Foreword ExecutiveSummary Chapter1.LiteratureReview expand Introduction ConceptsofCommunity WhatIsCommunityEngagement UsefulConcepts TheEthicsofCommunityEngagedResearch ModelsandFrameworks ConclusionandReferences Chapter2.Principles expand Introduction BeforeStartinganEngagementEffort ForEngagementtoOccur ForEngagementtoSucceed Conclusion Chapter3.SuccessfulExamples expand SuccessfulEffortsinCommunityEngagement CACHÉ Health-e-AME ProjectSuGAR CHIC HealingoftheCanoe FormandoNuestroFuturo ImprovingAmericanIndianCancerSurveillance CANDOHouston TheDentalPractice-BasedResearchNetwork DEPLOYPilotStudy ProjectDULCE DeterminantsofBrushingYoungChildren’sTeeth Conclusion Chapter4.ManagingOrganizationalSupport expand Introduction TheFrameworks ExaminingtheStructuralCapacityNeeded ConclusionandReferences Appendix Chapter5.Challenges expand Introduction 1.EngagingandMaintainingCommunityInvolvement 2.OvercomingDifferences 3.WorkingwithNontraditionalCommunities 4.InitiatingaProject 5.OvercomingCompetingPriorities Conclusion Chapter6.TheValueofSocialNetworking expand Introduction SocialNetworksandHealth TheRoleofSocialNetworksinCommunityEngagement ElectronicSocialMediaandCommunityEngagement CautionsontheUseofSocialMedia ConclusionandReferences Chapter7.ProgramEvaluation expand Background ProgramEvaluation EvaluationPhasesandProcesses ApproachestoEvaluation EvaluationMethods EvaluatingtheCommunityEngagementProcess Challenges ConclusionandReferences Chapter8.Summary AppendixA:Acronyms CTSACommunityEngagementKeyFunctionCommittee PublicationDevelopment OrderaPrintCopy Facebook Twitter LinkedIn PDF ExitNotification/DisclaimerPolicy Close LinkswiththisiconindicatethatyouareleavingtheCDCwebsite. 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