Achieving Health Equity and Systems Transformation Through Community Engagement: A Conceptual Model

Introduction

Community engagement is not a single event or goal, but a complex process that changes across time and location. As that process takes place, it is equally complex to understand that the engagement is meaningful, impactful, and leads to promising outcomes. The Assessing Meaningful Community Engagement project of the National Academy of Medicine (NAM) Leadership Consortium, with funding from the Robert Wood Johnson Foundation (RWJF), is advancing an effort to identify measures of meaningful community engagement. With guidance from an Organizing Committee comprising experts in community engagement – including community leaders, researchers, and policy advisors – who are diverse in terms of geographic location, race/ethnicity, nationality, disability, sexual orientation, and gender, this project has developed the Assessing Community Engagement Conceptual Model, which centers community engagement and core engagement principles and identifies outcomes associated with meaningful community engagement that can form the basis for assessment or measurement efforts.

Four “petals” or “propellers” emanate from the center and radiate from left to right, reflecting major meaningful domains and indicators of impact. When community engagement takes place with core principles guiding its processes and activities, it propels strengthened partnerships and alliances, expanded knowledge, improved health and healthcare programs and policies, and thriving communities.

Impact in these domains and their associated indicators creates motion and catalytic action that leads to the fundamental goal of health equity and well-being through transformed systems, and is influenced by several contextual factors. Drivers of health, many of which align with the social determinants of health, expand far beyond “traditional” factors like health status and health care into factors that ultimately influence and impact well-being such as food, transportation, housing, community attributes, affordable childcare, and economic and racial justice, among many others. Drivers of change are the key levers that influence stakeholder action, including data-driven, evidence-based practice and policy solutions; the power and priorities of constituencies; market forces; policies; and financial incentives, to name a few. The relevant social, political, racial, economic, historical, and environmental context also underpins all community engagement efforts. The Organizing Committee believes that with meaningful community engagement it is not only possible to motivate health equity through transformed systems for health, but to also significantly transform and positively alter these contextual factors. As such, a feedback loop is created and reflected through the arrows that move from community engagement, the core principles, and the domains of meaningful engagement through to these contextual factors.  

Below is a description of the details and definitions of all the key components of the Assessing Community Engagement Conceptual Model. 

Community Engagement

Community engagement is the linchpin or central focus of the Conceptual Model. Engagement of the community, defined as “groups of people affiliated by geographic proximity… or similar situations to address issues affecting the well-being of those people” (CDC Principles of Community Engagement), represents both the start and the hub of movement toward outcomes. It is only with community engagement that it is possible to achieve and accelerate progress toward the goal of health equity through transformed systems for health.

Core Principles

The core principles identify attributes that are foundational to the process of community engagement. Those involved must ensure that community engagement is grounded in trust, designed for bi-directional influence and information flow between the community and partners, inclusive, and premised on culturally-centered approaches. The core principles also include equitable financing, multi-knowledge, shared governance, and ongoing relationships that continue beyond the project timeframe and that are authentic and enduring. Engagement should be co-created and participants should be considered co-equal. Principle-informed community engagement creates a readiness that can propel teams into productive motion and accelerate engagement outcomes and the ultimate goal of health equity and systems transformation.

Strengthened Partnerships & Alliances

The first assessment domain identified by the Organizing Committee relates to strengthened partnerships and alliances, which the Committee defines as how participants emerge from engagement with new, improved, or stronger relationships that are carried forward. Eight indicators for this domain are below.

Diversity and inclusivity

Diversity and inclusivity ask for constant consideration of the representation, inclusion and lived experiences of those who are and should be engaged in the efforts. Representation should be intentionally diverse, comprising multicultural, multiethnic, and multigenerational perspectives, particularly those not traditionally invited or involved in efforts to improve health and health care policies and programs. Perspectives should reflect the composition of the community, be based in the culture of the community, and reflect multidisciplinary expertise from the community. Diversity and inclusivity should also be reflected in intentional integration of the interests and, importantly, knowledge, resources, and other valuable contributions from all community members during conversations and deliberations.

Partnerships and opportunities

Partnerships and opportunities ensure that those who are engaged are fully benefiting from participation through deepened and mutually supported relationships. This indicator assesses if participants have benefitted from bi-directional mentorship or other forms of professional investment; gained access to new financial or non-financial opportunities; received certificates, degrees or otherwise benefited from skills development; or shared and connected to an expanded network of partners, influencers, and leaders.

Acknowledgement, visibility, recognition

Acknowledgement, visibility, and recognition reflects the degree to which community participants are seen and recognized as contributors, experts and leaders and are able to benefit from their participation. This indicator encompasses public acknowledgement of participant contributions, as well as recognizes the legitimacy of the partnership.

Sustained relationships

Sustained relationships require that the community, institutions and relevant disciplines maintain continuous and ongoing conversations that are not time-limited or transactional. The community should be engaged at the beginning of an effort and normalized as an essential stakeholder. Involvement and engagement of community should have depth and longevity.

Mutual value

Mutual value ensures that communities engaged are equitably benefitting from the partnership. This indicator requires balanced engagement between community and others involved in the partnership, as marked by reciprocity that considers how the community will benefit from, not just contribute to, the effort. The value exchange can be financial or non-financial, but must be defined by, not prescribed for, the community. Mutual value is grounded in the need for understanding and respect for the community and all partners. It requires valuing the knowledge and expertise of all individuals, agreeing to a shared set of definitions and language, and committing to bidirectional learning.

Trust

Trust is a core component of engagement. It requires showing up authentically, being honest, following through on commitments, and committing to transparency in order to build a long-lasting and robust relationship. Genuine partnerships grounded in trust require change on the part of all partners. Trust also requires that entities engaging communities commit themselves to being trustworthy. Mistrust among communities of representatives of health care and other systems is often an adaptive response to historical and contemporary injustice perpetrated by these systems. A foundational component of building trust with communities is demonstrating that community trust is warranted, will not be abused or exploited.

Shared power

Shared power is fundamental to strong and resilient partnerships with the community. Shared power reflects that community participants are involved in leadership activities such as co-designing and developing the shared vision, goals, and responsibilities of the partnership. It emphasizes that members of the community have influence and can see themselves and their ideas reflected in the work being done. Shared power includes true equitable partnership and governance structures that ensure community partners occupy positions of leadership, and wield demonstrable power equivalent to other partners. Shared power relies on collaborative and shared problem-solving and decision-making, joint facilitation of activities, and shared access to resources, such as information and stakeholders.

Structural supports

Structural supports for community engagement provides the infrastructure needed to facilitate continuous community engagement. This indicator asks about operational elements for engagement such as established and mutually agreed-upon financial compensation for community partners, requirements for equitable governing board composition, protocols to ensure integration of community partners into grant writing and management, and equitable arrangements for data sharing and ownership agreements, among others. These structural supports ensure the longevity of community engagement and the sustainability of the partnership over time.

Expanded Knowledge

The second domain, expanded knowledge, refers to the creation of new insights, stories, resources, and evidence, as well as the formalization of respect for existing legacies and culturally-embedded ways of knowing that are unrecognized outside of their communities of origin. When co-created with community, expanded knowledge creates new common ground and new thinking, and so can catalyze novel and more equitable approaches to the transformation of health and healthcare. Three indicators for this domain are below.

New curricula, strategies, and tools

New curricula, strategies, and tools are formal products of community engagement that encapsulate new knowledge and evidence in ways that allow it to be disseminated, accessed, replicated and scaled. This indicator looks for the development of new curricula, strategies, and tools that enable other partnerships to learn from, build on, and advance new practices in their community engagement.

Bi-directional learning

Bi-directional learning is when community and partners are able to collaboratively generate new knowledge, stories, and evidence that reframe how community is described and appreciated. This indicator looks for representations of community that are asset- and resiliency-based; for improved cultural knowledge and practices among  partners; and for broader cultural proficiency and respect for community differences across the partnership. Bi-directional learning equally values all forms of knowledge and wisdom, including stories and lived experience.

Community-ready information

Community-ready information is an indicator referring to the creation of actionable findings and recommendations that are returned to the community in ways they understand, value and can use.

Improved Health and Health Care Programs and Policies

The third domain of the Conceptual Model is improved health and health care programs and policies. This is the stated goal of many partnerships; however, creating programs and policies that address community needs and priorities requires alignment between those who administer programs, services, and policies and those who use them. Community engagement is essential to creating a productive context for developing solutions that are “fit to purpose,” as well as embraced and championed by those who they are designed to serve. Three indicators for this domain are below.

Community-aligned solutions

Community-aligned solutions come from and speak to the priorities of the community. This indicator looks for community-defined problems, shared decision-making, and cooperatively defined metrics. It also ensures that care models, communication, and solutions are tailored to the community setting and needs

Actionable, implemented, and recognized solutions

Actionable, implemented, and recognized solutions are important indicators of success. Results should be visible within and across communities. This indicator looks for solutions that are recognized and endorsed by community members and leverage the assets in the community and the partnerships that produced them; are referenced publicly or within academic literature; and show measurable adoption, growth, and reach.

Sustainable solutions

Sustainable solutions reference new interventions, programs, and policies that can extend past their initial period of support. This indicator looks for residual infrastructure and other resources that remain in the community to support sustainability and further adjust or refine solutions in the future, if needed.

Thriving Communities

As motion accelerates through strengthened partnerships and alliances, expanded knowledge, and improved health and health care policies and programs, assessing the impact of community engagement moves to the fourth domain: Thriving communities. Five indicators for this domain are below.

Physical and mental health

Physical and mental health reflect a “whole-person” view of health. Additionally, physical and mental health include a shared awareness and view of health and health-related activities; self-efficacy in managing health and chronic conditions; shared decision-making in health care treatments and priorities; increased confidence and capacity to make decisions that improve an individual’s own health; and increased resiliency.

Community capacity and connectivity

Community capacity and connectivity speaks to a growth in skills and capacity of community, both as individual members and as a whole, to act on its own behalf. This indicator highlights the connectivity between community members and between community members and available resources; how engaged and activated community members are; and the investments available to develop new community leaders (e.g., financial, educational, career).

Community power

Community power manifests in a sustained paradigm shift that ensures processes and procedures are favored, initiated, and guided by the community. Community power arises with an increased rate of new efforts in the community and new efforts that are defined, initiated, and owned by the community. Community power is also indicated by cultural change – including changes in community dynamics, such as expectations that they will be meaningfully invited to and want to participate in problem-solving and priority-setting and will experience true equity (e.g., social equity, racial equity, health equity, equity across the drivers of health).

Community resiliency

Community resiliency refers to the overall strength of a community and its internal capacity to self-manage. This indicator reflects the ability of the community to recognize and mount a locally relevant response to new adversities and to engage and advance culturally-effective strategies to strengthen the community over time. The inherent culture and strengths of the community should be both visible and valued. Importantly, resiliency must not be invoked as a backstop for initiatives that perpetuate trends of a lack of external investments, protections, and support for community. In other words, resilience is valuable for the internal benefits and strengths that it generates among community members; it is not, however, a replacement for adequate and tangible external investments in the resources that communities need to thrive.

Life quality and well-being

Life quality and well-being refer to improvements in the drivers of health (e.g., education, economic and racial justice, built environment). The ability to heal, to hold hope for the future, and to experience greater joy, harmony, and greater social equity are highlighted in life quality and well-being.

Development of the Assessing Community Engagement Conceptual Model

An analysis of the peer-reviewed literature and organizational websites for frameworks and conceptual models of engagement led the Assessing Community Engagement Organizing Committee to feel strongly that a conceptual model was needed to reinforce existing models. This new model should provide a paradigm for the factors needed to assess the quality and impact of outcomes of meaningful community engagement across various sectors and partnerships, and simultaneously emphasize health equity and transformed systems for health

This new conceptual model could be used by a range of stakeholders including federal, state, and local agencies; tribal communities; advocacy and community-based groups; funders, philanthropy, and financiers; academic institutions; care systems, health centers, and hospitals; and payers, plans, and industry. The Organization Committee additionally highlighted the important considerations for the conceptual model design and development process.

Ready to use the Assessing Community Engagement Conceptual Model?

The Organizing Committee encourages use and adaptation of the Conceptual Model in assessing community engagement efforts.

One size does not fit all, even within communities that share similar identities. That understanding guided the Organizing Committee’s development of the Assessing Community Engagement Conceptual Model to ensure it was flexible enough to measure engagement for a range of settings and purposes. While the petals can be viewed as linear and sequential, specific communities may want to focus on or adapt indicators to reflect the language, needs, and contextual factors of their community – especially considering the importance of intersectionality as individuals often belong to multiple and intersecting identities. A range of outcomes reflect the different priorities and interests of unique communities rather than assuming all communities want or need the same outcomes. In other words, different communities will want to focus on different outcomes. Each community and its partners should consider the terms and measurement areas presented in the model and collaboratively decide on how to define, apply, modify, or implement them to support their needs.

This collaborative approach reflects the need for equitable and continued engagement with those who have been traditionally left out of decision-making to open a pathway to true system-wide transformation for health – a goal that is not possible without embedding equity into the core components of engagement, not just its outcomes. The Assessing Community Engagement Conceptual Model places community and community engagement at the center, and all impact and influence accelerates toward meaningful outcomes that ultimately ensure health equity through transformed systems for health, conceptualized to broadly encompass community definitions of physical and mental health as well as well-being. The Organizing Committee considered an aspirational ideal of what matters, what should be measured, and what should be done to support meaningful community engagement. If “what is measured gets done,” the measures or metrics needed to assess outcomes of meaningful community engagement cannot be limited by what already exists in the literature.

The Assessing Community Engagement Conceptual Model focuses on the dynamic relationship between engagement and outcomes to support accountability for engagement that is meaningful to the communities themselves. That focus, however, does not ignore the importance of the various and multiple processes, strategies, and approaches used to engage communities. There are myriad toolkits, reports, articles, and examples in existence on how to engage communities, and more work is needed to better understand how these processes can lead to desired outcomes. Intention is not enough to ensure meaningful engagement: The fundamental question is not whether entities think they are engaging communities, but whether communities feel engaged. If stakeholders are not able to achieve meaningful community engagement based on mutually agreed-upon outcomes, modifying or changing the engagement process could be considered.

We want to hear from you!

Assessing community engagement involves the participation of many stakeholders. Click here to share feedback on these resources, or email leadershipconsortium@nas.edu and include “measure engagement” in the subject line to learn more about the NAM’s Assessing Community Engagement project.


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