The model presented in this post was updated and published as an appendix to an article in Health Affairs. See the article here and the appendix here. Both the article and the appendix can also be downloaded from this website (here).
In this post, I am proposing a model linking community engagement, health improvement, and the building of community power. It’s informed by my review of the biomedical research on whether community power influences health, and how. The ‘whether’ was summarized in post three (the summary being that it does) and the ‘how’ was summarized in post five (backing up a number of theories proposed over the last 30 years).
There are numerous models linking community engagement to health improvement. The one we started from was first published in 2006 by Jennifer Popay, now a distinguished professor of sociology and public health at Lancaster University in the UK. I described Popay’s model in post one but the key thing to know is that it incorporates a theory of change that is supported by the research that we reviewed — that the type of outcomes possible depend on the depth of the engagement.
Our proposed model is below.
Classically, when the health sector engages communities, it’s either informing its members of something or consulting with them to get their views, perhaps on a health improvement initiative. At that level of engagement, only service outcomes and health outcomes are likely, and they’re usually modest (as indicated by the width of the relevant triangles at those points).
As the engagement deepens, such that community members are involved, collaborated with, or deferred to, ‘community outcomes’ begin to surface. Popay called these ‘intermediate outcomes’, the idea being that they were intermediaries to better service and health outcomes. We’ve called them ‘community outcomes’ because we think they matter in and of themselves, not just because they’re intermediaries to the outcomes that the health sector is classically interested in.
We’ve also separated the community outcomes into individual and social. As described in post three, deeper forms of engagement lead to changes in and between the community members involved. We have summarized the changes in community members as them having more skills, confidence, and a greater sense of empowerment. We have summarized the changes between community members as more trust, social cohesion, and a greater sense of collective empowerment.
The triangles for individual outcomes and social outcomes overlap. This is intentional because it’s generally accepted that changes amongst individuals lead to changes in the social fabric between them, and vice versa (see pages 15 and 122 of my research report).
The community outcomes are prerequisites to a community having power. While it’s not inconceivable that they might use that power to improve the health services available to them, as well as their health, it’s also likely that they’ll want to address other things in their neighborhood. Quite what those things are will differ from neighborhood to neighborhood so we’ve depicted it by saying that a community with power has the potential to hold policymakers and institutions accountable.
Under the levels of engagement, we’ve added the phrase, “While maintaining a focus on inclusion to overcome discrimination and marginalization”. We’ve added this because all too often community engagement involves reaching out to those within immediate reach, rather than doing the hard work of engaging those that have traditionally been discriminated against and marginalized. It’s important to note that people who have endured discrimination and marginalization may be distrustful of, if not angry with, formal systems, such as the health sector. Overcoming this – a process that is sometimes called healing – may become a significant part of the work.
We’re proposing this model because in our experience, telling leaders in the health sector that community power is important for health often leads to blank stares – people just don’t know what to do with that information. However, the health sector is constantly engaging communities, often on the basis of wanting to make a health intervention ‘culturally appropriate’. Our view – which, to be clear, is based on the evidence – is that every single one of those engagements is an opportunity to do something that has been shown to protect health and reduce the risks to health – build community power.
In fact, my contention is that given just how clear the evidence is, not doing so would be clinically negligent, if not morally bankrupt.
Those strong words bring me to the end of the narrative that I have drawn from my review of the biomedical research linking community power and health. My work continues, however. I’m currently looking at what public health practitioners (primarily in the US) need to embrace community power building as an integral part of what they do. Our working hypothesis is that the research has not been ‘translated’ for people in practice but I’m currently testing that through interviews of leaders in public health.
Until next time.
Pritpal S Tamber
- Throughout this post, I have used ‘we’ because a version of the above model was first drawn for an article that I wrote with Anthony Iton and Bob Ross of The California Endowment. That article is currently being reviewed by a journal. If it is published (and includes a version of the above model), I will update this post with a link to it.
- The terms used to describe the depth of engagement (in the horizontal arrow across the across the top) were taken from the Spectrum of Community Engagement to Ownership by Rosa Gonzalez of Facilitating Power, a document that I really like because of its incisive introduction and notes for practitioners.
- Although we have used the word ‘inclusion’ in the model, I am much taken by john a powell’s contention that inclusion is not enough as it assumes that the thing you’re being included in is the right shape for everyone (see the previous post)
- It is, of course, naive to assume that a community with power is able to use it to improve its circumstances. So much depends on the social position of the community members and their networks, culture, and political context, as well as how open policymakers and institutions are to change.
- To cite the above model, consider the following format: Tamber PS. A Model Linking Community Engagement, Health Improvement and Community Power [Internet]. London: Pritpal S Tamber Ltd; 2022 April 7 [cited on YYYY MM DD]. Available from: https://www.pstamber.com/a-model-linking-community-engagement-health-improvement-and-community-power
The photo behind the title is by Mike Hindle on Unsplash.