· People (socioeconomics and demographics, health status and risk profiles, cultural and ethnic characteristics)

· Location (geographic boundaries)

· Connectors (shared values, interests, motivating forces)

· Power relationships (communication patterns, formal and informal lines of authority and influence, stake holder relationships, resource flows)

(Adapted from VHA, 1993).

Similarly, we can define the community from a broader sociological perspective by describing the social and political networks that link individuals and community organizations and leaders. Understanding the nature and boundaries of these networks is critical to planning engagement efforts. For example, tracing individuals’ social ties may help those who are initiating a community engagement effort to identify leaders within a community, understand community patterns, identify high risk groups within the community, and strengthen networks within the community (Minkler, 1997).

Beyond the collective definitions of community that researchers and organizers can apply, an individual also has her or his own sense of community membership. The presence or absence of a sense of membership in a community may vary over time and is likely to influence participation in community activities. This variation is affected by a number of factors. For example, persons at one time may feel an emotional, cultural, or experiential tie to one community; at another time, they might believe they have a contribution to make within a different group. At yet another time, they may see membership in a third distinct community as a way to meet their own individual needs (Chavis et al., 1990). Of course, they may also have this sense of belonging to more than one community at the same time. Before beginning an engagement effort, it is important to understand that all these potential variations and perspectives may exist and influence the work within a given community.

Concepts of Community Engagement

The CDC/ATSDR Committee for Community Engagement developed a working definition of community engagement. Loosely defined, community engagement is the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people. It is a powerful vehicle for bringing about environmental and behavioral changes that will improve the health of the community and its members. It often involves partnerships and coalitions that help mobilize resources and influence systems, change relationships among partners, and serve as catalysts for changing policies, programs, and practices (Fawcett et al., 1995).

In practice, community engagement is a blend of social science and art. The science comes from sociology, political science, cultural anthropology, organizational development, psychology, social work, and other disciplines with organizing concepts drawn from the literature on community participation, community mobilization, constituency building, community psychology, cultural influences, and other sources. Several of these concepts from the social science literature are presented here. The equally important artistic element necessary to the process, however, involves using understanding, skill, and sensitivity to apply and adapt the science in ways that fit the community and purposes of specific engagement efforts.

Insights from the Literature

Studies of participation in voluntary and community organizations have allowed social scientists and other researchers to develop organizing concepts about communities and the ways in which they are mobilized (Florin et al., 1990; Fawcett et al., 1995; Hanson, 1988-89; Thompson et al., 1990). Findings in the literature have helped to shed light on why community engagement is useful and how we can engage people to most effectively address public health issues. What follows are brief descriptions of some of the organizing concepts found in the literature that guide approaches to successful community engagement. Additional resources on these and other concepts not included here may be found in the Bibligraphy.

Social Ecology

Social ecological theories provide insight into elements of individuals’ lives that contribute to health promotion. Such theories seek to describe the concept of community in terms of a "dynamic interplay among individuals, groups, and their social and physical environments" (Stokols, 1996, p. 286). Researchers in this area help to integrate approaches to disease prevention and health promotion (which focus on modifying individual health behaviors) with environmental approaches (which focus on the physical and social environment). From the social ecology perspective, "the potential to change individual risk behavior is considered within the social and cultural context in which it occurs. Interventions that are informed by this perspective are directed largely at social factors, such as community norms and the structure of community services including their comprehensiveness, coordination, and linkages, in addition to individual motivations and attitudes." (Goodman et al., 1996, p. 34).

Social ecology theory as it informs health promotion suggests that community engagement efforts need to be focused at multiple levels — (1) individuals; (2) social network and support systems; (3) the range of organizations that serve and influence individuals and the rules and regulations that these organizations apply; (4) the community, including relationships among organizations, institutions, and informal networks; and (5) "public policy, regulations, ordinances and laws at the state and national levels" (Goodman et al., 1996, p. 35).

Several core concepts summarize the contributions of social ecology theories to community engagement efforts (Stokols, 1996, p. 285-286):

· Health status, emotional well-being, and social cohesion are influenced by the physical, social, and cultural dimensions of the individual’s or community’s environment and personal attributes (e.g., behavior patterns, psychological dispositions, genetics).

· The same environment may have different effects on an individual’s health depending on a variety of factors, including perceptions of ability to control the environment and financial resources.

· Individuals and groups operate in multiple environments (e.g., workplace, neighborhood, larger geographic communities) that "spill over" and influence each other.

· There are personal and environmental "leverage points" that exert vital influences on health and well-being.

Cultural Influences

The literature on cultural influences suggests that health behaviors are influenced directly by elements of one’s culture. As a result, social norms and other elements of community culture provide a potential tool for disease prevention and health promotion. Culture involves "the integrated pattern of human knowledge, belief, behavior, and material traits characteristic of a social group" (Braithwaite et al., 1994, p.409). Another way to understand this concept is to think of culture as the "luggage" we always carry with us — "the sum of beliefs, practices, habits, likes, dislikes, norms, customs, rituals . . . that we have learned from our families" (Spector, 1985, p. 60). Cultural identity influences "the group’s design for living, the shared set of socially transmitted perceptions about the nature of the physical, social, and spiritual world, particularly as it relates to achieving life’s goals" (Airhihenbuwa, 1995, p. 5). Therefore, those who wish to work with community members should carefully examine the differences and similarities in cultural perceptions, so that engagement activities are appropriate for that particular cultural context. This appropriateness, often referred to as cultural sensitivity, means that programs are developed "in ways that are consistent with a people’s and community’s cultural framework" (Airhihenbuwa, 1995, p. 7).

An individual’s culture influences his or her attitude toward various health issues, including perceptions of what is and is not a health problem, methods of disease prevention, treatments for illness, and use of health providers. As Spector (1985, p. 59) notes: "We learn from our own cultural and ethnic backgrounds how to be healthy, how to recognize illness, and how to be ill . . . meanings attached to the notions of health and illness are related to basic, culture-bound values by which we define a given experience and perceptions." Individuals initiating community engagement activities should understand belief systems held by community members, especially if they are different from their own. Cultural experiences also can influence how individuals and groups relate to each other and to people and institutions of other cultures. Efforts to address these elements of a community could concentrate on affecting the landscape of information and ideas in which that community operates.

Community Participation

Concepts concerning community participation offer one set of explanations as to why the process of community engagement might be useful in addressing the physical, interpersonal, and cultural aspects of individuals’ environments. The real value of participation stems from the finding that mobilizing the entire community, rather than engaging people on an individualized basis or not engaging them at all, leads to more effective results (Braithwaite et al., 1994). Simply stated, change "... is more likely to be successful and permanent when the people it affects are involved in initiating and promoting it" (Thompson et al, 1990, p. 46). In other words, a crucial element of community engagement is participation by the individuals, community-based organizations, and institutions that will be affected by the effort.

This participation is "a major method for improving the quality of the physical environment, enhancing services, preventing crime, and improving social conditions" (Chavis et al., 1990, p.56). There is evidence that participation can lead to improvements in neighborhood and community and stronger interpersonal relationships and social fabric (Florin et al., 1990). Robert Putnam notes that social scientists have recently "...unearthed a wide range of empirical evidence that the quality of public life and the performance of social institutions...are...powerfully influenced by norms and networks of civic engagement." Moreover, "researchers in...education, urban poverty,...and even health have discovered that successful outcomes are more likely in civically engaged communities" (Putnam, 1995, p.66). For example, Steckler’s CODAPT model, for "Community Ownership through Diagnosis, Participatory Planning, Evaluation, and Training (for Institutionalization)," suggests that when community participation is strong throughout a program’s development and implementation, long-term program viability, i.e., institutionalization, is more likely assured (Goodman et al., 1987-88).

The community participation literature suggests that:

· People who interact socially with neighbors are more likely to know about and join voluntary organizations.

· A sense of community may increase an individual’s feeling of control over the environment, and increases participation in the community and voluntary organizations.

· Perceptions of problems in the environment can motivate individuals (and organizations) to act to improve the community (Chavis et al., 1990).

"When people share a strong sense of community they are motivated and empowered to change problems they face, and are better able to mediate the negative effects over things which they have no control," Chavis et al., (1990, p. 73) write. Moreover, "a sense of community is the glue that can hold together a community development effort" (Chavis et al., 1990, p. 73-74). This concept suggests that programs that "...foster membership, increase influence, meet needs, and develop a shared emotional connection among community members" (Chavis et al., 1990, p. 73) can serve as catalysts for change and for engaging individuals and the community in health decision-making and action.

Community Empowerment

The literature suggests that a critical element of community engagement relates to empowerment — mobilizing and organizing individuals, grass-roots and community-based organizations, and institutions, and enabling them to take action, influence, and make decisions on critical issues. It is important to note, however, 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 can provide important tools and resources so that community members can act to gain mastery over their lives.

Empowerment takes place at three levels: the (1) individual, (2) organizational or group, and (3) community levels (Rich et al., 1995; Fawcett et al., 1995). Empowerment at one level can influence empowerment at the other levels (Fawcett et al., 1995). At the individual level, it is generally referred to as psychological empowerment (McMillan et al., 1995; Rich et al., 1995). Individual level empowerment can be described along three dimensions: (1) intra-personal — an individual’s perceived personal capacity to influence social and political systems; (2) interactional — knowledge and skills to master the systems; and (3) behavioral — actions that influence the systems (Rich et al., 1995). This concept of psychological empowerment has been found to relate to an individual’s participation in organizations, the benefits of participation, organizational climate, and the sense of community or perceived severity of problem.

At the group or organizational level, the literature distinguishes between: (1) empowering organizations, which "...facilitate confidence and competencies of individuals;" and (2) empowered organizations, which influence their environment (Rich et al., 1995). The degree to which an organization is empowering for its members may be dependent upon the benefits members receive and organizational climate as well as the levels of commitment and sense of community among members (McMillan et al., 1995).

Community level empowerment (i.e., the capacity of communities to respond effectively to collective problems) occurs when both individuals and institutions have sufficient power to achieve substantially satisfactory outcomes (Rich et al., 1995). Individuals and their organizations gain power and influence by having information about problems and "an open process of accumulating and evaluating evidence and information" (Rich et al., 1995, p. 669). Empowerment involves "the ability to reach decisions that solve problems or produce desired outcomes," requiring that citizens and formal institutions work together to reach decisions (Rich et al., 1995).

Capacity Building

Another set of organizing concepts that can help guide approaches to effective engagement involves the process of capacity building. In essence, the literature on capacity building states that before individuals and organizations can gain control and influence and become players and partners in community health decision-making and action, they may need resources, knowledge, and skills above and beyond those they already bring to a particular problem (Fawcett et al., 1995). Participation in community engagement efforts can offer people the possibility of developing these skills.

The kind and intensity of capacity building that may be needed to sustain community engagement efforts is not entirely known; too often, community leaders can be caught up in "selling" the engagement effort without an accurate idea of the resources needed to actually support it over the long term (Florin et al., 1993). For example, people and organizations in the community might need technical assistance and training related to developing an organization, securing resources, organizing constituencies to work for change, participating in partnerships and coalitions, conflict resolution, and other technical knowledge necessary to address issues of concern to the community.

Coalitions

Engaging the community will very often involve building coalitions of diverse organizations. A community coalition can be defined as "a formal alliance of organizations, groups, and agencies that have come together to work for a common goal" (Florin et al., 1993, p. 417). Coalitions are usually characterized as "formal, multi-purpose, and long-term alliances" that "fulfill planning, coordinating and advocacy functions for their communities" (Butterfoss et al., 1993, p. 316, 318). They can be helpful in a number of ways, including maximizing the influence of individuals and organizations, exploiting new resources, and reducing duplication of effort. While the literature reveals that coalitions have not been systematically studied and contains little data to support their effectiveness, funding sources have been giving serious commitment to developing coalitions as an intervention to address health issues (Butterfoss et al., 1993).

The concept of coalition has its roots in political science. In parliamentary democracies, for example, a coalition government is formed by two or more parties when no single party has a sufficient mandate to represent the majority. In addition, in almost all kinds of governments, informal coalitions exist among factions that share general or specific policy or legislative objectives. The types of coalitions that might be necessary for engagement efforts can be viewed the same way. The experience of political theorists suggests that:

· Coalitions require a perception of interdependence; each party must believe it needs help to reach its goals.

· There must be sufficient common ground and a clearly articulated mission or purpose so the parties can agree over time on a set of policies and strategies.

· At the same time, coalition members typically have "primary" goals and perspectives that are distinct, if not conflicting; they agree on some issues but disagree on others.

· Coalitions require continuous and often delicate negotiation among participants.

· The distribution of power and benefits among coalition members is a major focus of ongoing concern; each member needs to believe that over time, he or she is receiving benefits that are comparable to their contributions (see discussion on Benefits and Costs below). (AED, 1993)

Benefits and Costs

A critical set of organizing concepts involves analysis of the benefits and costs of community engagement. The literature suggests that "participants will invest their energy in an organization only if the expected benefits outweigh the costs that are entailed" (Butterfoss et al., 1993, p. 322). It appears that an individual’s desire to join and continue a commitment to an engagement effort depends more on this benefit-cost ratio than on his or her demographic characteristics (Wandersman et al., 1987). Potential benefits include: networking opportunities, access to information and resources, personal recognition, skill enhancement, and a sense of contribution and helpfulness in solving community problems. Costs can run the gamut from the contribution of time required, to lack of skills or resources needed for participation, to basic burn out. By identifying the specific benefits and barriers to participation in the engagement effort, community leaders can put the appropriate incentives in place.

The social exchange perspective investigates the benefits and costs of participation to help explain who participates and why. The literature has long discussed health-related organizations as being involved in an "exchange system" whereby they voluntarily share resources to meet their respective goals or objectives (Levine et al., 1961). Similarly, social exchange occurs among community members, organizations, and others to overcome potential costs in an engagement effort — "a social exchange takes place in organizations such that participants will invest their energy into the organization only if they expect to receive some benefits" (Wandersman et al., 1987, p. 538).

Community Organization

The community organization literature provides insight on the kinds of engagement activities that may prove useful. This and related concepts offer a path to engagement through a "process by which community groups are helped to identify common problems or goals, mobilize resources, and in other ways develop and implement strategies for reaching goals they have set" (Minkler, 1990, p. 257). Organizing activities are a way of activating the community to encourage or support social and behavioral change (Bracht et al., 1990). This approach to bringing about change at the community level is based on principles of empowerment, community competence, active participation and "starting where the people are" (Minkler, 1990, p. 270).

Labonte and Robertson support the particular importance of "starting where the people are" by stating that "if we fail to start with what is close to people’s hearts by imposing our notions of health concerns over theirs, we risk several disabling effects..." (Labonte et al., 1996, p. 441). These include: being irrelevant to the community, exacerbating the community’s sense of powerlessness, further complicating individuals’ lives, and possibly channeling local activism away from broader challenges and into individual-level changes.

The community organization approach also reflects findings that individuals and communities: (1) must feel or see a need to change or learn, and (2) are more likely to change attitudes and practices when they are involved in group learning and decision-making (Minkler, 1990). An important element of community organizing is helping communities look at root causes of problems while at the same time selecting issues that are "winnable, simple, and specific," can unite members of the group, involve them in achieving a solution, and help build the community or organization (Minkler, 1990).

Community organizing can be an empowering process for individuals, organizations, and communities. At the individual level, community organizing activities provide individuals with the chance to feel an increased sense of control and self confidence and to improve their coping capacities (Minkler, 1990). These have been shown to have physical health benefits. Organizing activities also strengthen the capacity of communities to respond effectively to collective problems. Individuals, organizations, and communities can be empowered by having information about problems and "an open process of accumulating and evaluating evidence and information" (Rich et al., 1995, p. 669).

Stages of Innovation
The concept of stages of innovation can be useful when dealing with the potential differences that might exist within a community as it changes over time. All individuals within a community are not necessarily at the same stage of readiness to change behaviors. This is an important notion to understand before and during a community engagement effort. Rogers offered one of the earliest formulations of this idea with his 1962 work, Diffusion of Innovations. In this book he states that all individuals do not adopt innovations at the same rate or with the same willingness. Stages of innovation, in general, can help implementors of engagement efforts to match strategies to the readiness of a community to adopt them. In applying these concepts to community development, for example, desired outcomes are predicated upon the community working through a number of phases, including raising awareness of the severity of a health problem, transforming awareness into concern for the problem, establishing a community-wide intervention initiative, and developing the necessary infrastructure so that service provision remains extensive and constant in reaching residents.


General Conclusions about the
Power and Userfulness of Community Engagement

There is a consensus in the literature that engaging and supporting the empowerment of the community for community health decision-making and action is a critical element in health promotion, health protection, and disease prevention. The impact of programs that target individual behavior change is often transient and diluted unless efforts are also undertaken to bring about systematic change at multiple levels of society (Braithwaite et al., 1994).

Scholars have described several trigger activities that might begin the community engagement process. Some of these trigger activities are tied to legislative or program mandates, while others involve special initiatives, such as those of public health departments, grant makers, health service providers, or existing community groups and coalitions. Once triggered, the community engagement process itself can take many forms. It can range from cooperation, where relationships are informal and where there is not necessarily a commonly-defined structure, to collaboration, or partnerships where previously separated groups are brought together with full commitment to a common mission (Mattessich et al., 1992).

The organizational concepts from the literature discussed in this section of the document lead to a number of general conclusions about what lies at the heart of successful community engagement efforts. These conclusions, which follow here, provide a useful segue to the community engagement principles outlined in Part 2.

· Community engagement efforts should address multiple levels of the social environment, rather than only individual behaviors, to bring about desired changes.

· Health behaviors are influenced by culture. To ensure that engagement efforts are culturally and linguistically appropriate, they must be developed from a knowledge and respect for the targeted community’s culture.

· People participate when they feel a sense of community, see their involvement and the issues as relevant and worth their time, and view the process and organizational climate of participation as open and supportive of their right to have a voice in the process.

· While it cannot be externally imposed on a community, a sense of empowerment — the ability to take action, influence, and make decisions on critical issues — is crucial to successful engagement efforts.

· Community mobilization and self-determination frequently need nurturing. Before individuals and organizations can gain control and influence and become players and partners in community health decision-making and action, they may need additional knowledge, skills, and resources.

· Coalitions, when adequately supported, can be useful vehicles for mobilizing and using community assets for health decision-making and action.

· Participation is influenced by whether community members believe that the benefits of participation outweigh the costs. Community leaders can use their understanding of perceived costs to develop appropriate incentives for participation.

The following table, based on the social science literature and the above conclusions, offers a set of specific factors that can positively influence the success of community engagement efforts. Planners and organizers of these efforts may find it useful to keep the factors in mind as they work through the engagement process and apply the principles detailed in Part 2.

Environmental
· History of collaboration or cooperation in the community
· Collaborating group (and agencies in group) seen as leader in community · Favorable political and social climate

Membership
· Mutual respect, understanding, and trust
· Appropriate cross-section of members
· Members see engagement in their self-interest — benefits of engagement as offsetting costs
· Ability to compromise

Process/Structure
· Members feel ownership — share stake in both process and outcome
· Every level in each organization in collaborating groups participates in decision-making
· Flexibility of collaborating group
· Clarity of roles and guidelines
· Ability to sustain itself in midst of changing conditions

Communication
· Open and frequent interaction, information, and discussion
· Informal and formal channels of communications

Purpose
· Goals clear and realistic to all partners
· Shared vision
· Unique to the effort (i.e., different at least in part from mission, goals or approach of member organizations)

Resources
· Sufficient funds
· Skilled convener

(Based on a review of the literature and excerpted from Mattessich and Monsey, 1992)

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For further information on community collaboration, visit the Public Health Practice Program Office Internet site at www.cdc.gov/phppo/ or contact Michael Hatcher at Mail Stop K39, 4770 Buford Highway, N.E., Atlanta, GA., 30341-3724 or email mth1@cdc.gov.