Community Engagement, Equity, and Cross-Sector Public Health Practice

Abstract

In this topical review, we integrate 3 concepts—public health practice, community engagement, and cross-sector governance—to consider the following question: What is the underlying relationship between public health and cross-sector governance according to which the field can understand the role of community engagement in achieving health equity? We begin with an overview of public health practice and the practice of community engagement. Next, we position these practices in the broader turn toward cross-sector governance. The integration of these themes reveals that common tools for community engagement fail to address questions about how services should be funded, how resources should be distributed, and which members of the community have a claim to services. We therefore suggest that distinguishing between community engagement for equity and equitable community engagement is a first step toward deepening dialogue about the role of public health in achieving health equity.

During the past 10 years, renewed commitments to community engagement have been made at every level of public health practice. In 2020, the World Health Organization identified “undeniable benefits to engaging communities in promoting health and wellbeing.” ¹ At the national level, in 2011, the Centers for Disease Control and Prevention (CDC) published the second edition of The Principles of Community Engagement, ² and in 2022, the National Academy of Medicine published a conceptual model to advance health equity through assessment of meaningful community engagement. ³ It is now common practice for state public health departments to fund efforts by local public health authorities to engage with communities. Although the potential benefits of community engagement are manifold, so are the meanings and practices of community engagement. In this topical review, we integrate concepts—public health practice, community engagement, and cross-sector governance—to consider the following question: What is the underlying relationship between public health and cross-sector governance according to which the field can understand the role of community engagement in achieving health equity? We begin with an overview of public health practice and the practice of community engagement. Next, we position these practices in the broader turn toward cross-sector governance. Finally, we distinguish between community engagement for equity and equitable community engagement as a first step toward deepening dialogue about the role of public health in achieving health equity.

Public Health and the Practice of Community Engagement

As with other applied fields (eg, public administration, education), the field of public health was institutionalized in universities and professionalized in associations in part to respond to problems associated with industrialization and urbanization. In the years leading up to the first public health degree—established in 1918 at the Johns Hopkins University School of Hygiene and Public Health—“[t]hree possible approaches for public health education were debated—the engineering or environmental, the sociopolitical, and the biomedical.” ⁴ A little more than 100 years later, in 2021, Galea and Vaughan ⁵ considered “three core purposes of public health—a focus on the conditions of the world around us, on eliminating health inequity, and on those who are marginalized and vulnerable—foundational to the field.” In July 2023, the board of directors of the Association of Schools and Programs of Public Health submitted a letter asking the US Department of Homeland Security to consider public health a STEM (science, technology, engineering, and mathematics) discipline. The letter stated that public health “has been a STEM focused discipline since its inception [in 1915].” The authors noted that public health education

includes instruction in epidemiology, biostatistics, public health principles, preventive medicine, health policy and regulations, health care services and related administrative functions, public health law enforcement, health economics and budgeting, public communications, and professional standards and ethics. ⁶

A recent introductory public health textbook described public health practice as involving “the delivery of public health services at the global, national, state, and local levels—everything done to prevent disease and promote health.” ⁷ The sheer scope of these definitions—from health equity to biostatistics and communications to law enforcement—can make it difficult to locate the relationship between the theoretical foundations and practice of public health.

The practice of public health within each of the subfields involves what philosophers discuss as epistemological assumptions. These epistemological assumptions inform answers to questions about what it is possible to know. Can we know facts about society objectively? How universally applicable is the knowledge that we produce? And, by extension, how valuable is local knowledge? ⁸ These epistemological assumptions also inform the claims that we make about our methodological choices. Debate about the validity of methods often stems from the tension between positivist approaches, which aim to discover social laws that govern our lives independent of subjective human experience, and phenomenological, interpretive, or social constructivist approaches, which consider context and the ways in which individuals experience and act upon this context. Public health practitioners work against the background of these tensions and often find themselves faced with contradictory assumptions in their everyday practice (Box).

Box.

Distinguishing positivist from nonpositivist research.

Many researchers do empirical work without sharing the assumptions of positivism. Not all quantitative research is positivist and not all qualitative work is nonpositivist. What makes research positivist is the claim that, like the laws of physics, the circumstances that people find themselves in can be attributed to predictable social laws,9,10 thereby eclipsing the role of community engagement in social change. Qualitative work that claims to describe social laws can be positivist, and quantitative work can incorporate local context in a nonpositivist way. For example, a public health researcher who uses national and local-level data to demonstrate that a community has unequal access to health care relative to the rest of the country, and then engages this community to investigate solutions based on their experience, is doing science in a nonpositivist way. A researcher who gathers the same data, does not engage the local community, and then reports that unequal access to health care in this community is a social fact that reflects predictable social laws is doing science in a positivist way.

The understanding of the practice of community engagement in public health is similarly broad and often intersects with the foundations of public health identified by Galea and Vaughn. ⁵ CDC’s definition of community engagement includes at least 3 categories of public health practice:

“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.” . . . Community engagement can take many forms, and partners can include organized groups, agencies, institutions, or individuals. Collaborators may be engaged in health promotion, research, or policy making.^2,8

This definition of community engagement is notable for the broad spectrum of practices that it includes: health promotion, research, and policy making. Although health promotion, research, and policy making are interrelated—research informs both health promotion and policy making, policy making affects access to resources, and health promotion affects community perceptions of policy and research—each has a unique relationship to community engagement. Understanding the relationship between community engagement and policy will require that we position these practices in the broader context of cross-sector public health practice.

Community Engagement for Cross-Sector Public Health Practice

The spectrum of organizations advocating for community engagement, funding community engagement efforts, and engaging with communities is remarkable—spanning global governance organizations, local public health agencies, private foundations, and even private corporations. As with the spectrum of public health practices and community engagement, this broad spectrum of actors and the wide variation in their roles and values can make it difficult to see how community engagement represents an opportunity for change inspired by the everyday lives of community members. This difficulty is in part due to the complexities of the partnerships within which the practice of community engagement for public health is situated. ¹¹

Local public health agencies and community-based organizations are often simultaneously engaged in partnership with state and federal governments and local, national, and international nonprofit organizations. Local nonprofit organizations frequently depend on funding from foundations, global or national nonprofit organizations, or governments, and governments frequently rely on nonprofit organizations for service delivery. ¹² For example, at the national level, CDC is a federal agency that awards grants and cooperative agreements to state and local governments as well as nongovernmental organizations. ¹³ The Robert Wood Johnson Foundation is a national-level organization that awards grants to US-based nonprofit organizations. These various forms of partnership are sometimes referred to as cross-sector collaboration, network governance, or collaborative governance, and they are typically discussed in terms of a positive transformation away from government—from vertical to horizontal, from unilateral to collaborative, from publicly funded to jointly funded—or as an indication that the practice of governing has advanced from a less democratic to a more democratic stage.^12,14-17

The public organizations listed previously—the World Health Organization, CDC, and state and local public health agencies—are funded by governments. When practiced in this context, public health belongs to the broader field of public administration and governance. When practice is restricted to government, political theorists broadly refer to this category as “the state,” which, in some democratic theory, is seen as distinct from civil society (including voluntary associations based in communities) and the economy (also referred to as “the market”). These categories are also commonly described as sectors, including the public sector, nonprofit sector, and private sector (state, civil society, and economy, respectively).

Governance is a broader category than government and sometimes refers to the partnership between governments and nongovernmental organizations advocating for and implementing formal policy or working to achieve policy-related objectives outside of the formal policy-making process. Pierre described governance as having a dual meaning:

On the one hand it refers to the empirical manifestations of state adaptation to its external environment as it emerges in the late twentieth century. On the other hand, governance also denotes a conceptual or theoretical representation of co-ordination of social systems and, for the most part, the role of the state in that process. ¹⁸

Governance also includes the ways in which public health is practiced by nongovernmental organizations at the global, national, state, and local levels. For example, at the global level, the Grand Challenges for Global Health initiative from the Bill and Melinda Gates Foundation funds “innovation to solve key global health and development problems” and, as of June 2023, had awarded 2317 grants.^19,20 At the national level, the Robert Wood Johnson Foundation awards grants aimed at “building a culture of health” (https://www.rwjf.org). Public health might also include public–private partnerships, which typically involve collaboration between governments and for-profit organizations. For example, in 2015, the US Department of Health and Human Services’ Office of Disease Prevention and Health Promotion and CVS Health formed a public–private partnership. ²¹

The assumption that governance partnerships are necessarily democratic has been questioned by scholars concerned with the quality of engagement by governments and the intent of partnerships. ¹⁴ Ostrander ²² highlighted the overemphasis on government-initiated partnerships in collaborative governance and the potential for “cooptation, placation, lack of real authority, absence of diversity and overall lack of parity with government.” Although partnerships in public health often involve shared commitments or goals, including a commitment to community engagement, the quality of these relationships varies in substantial ways.^12,15-17 In addition, although nonstate actors, such as nonprofit or philanthropic organizations, are often assumed to have a democratic relationship with community, relationships with nonstate organizations also involve complex power dynamics.^23-25

The relationship between public health practices and communities is further characterized by the professionalization of community engagement, which has grown remarkably during the past 10 years, resulting in a dizzying array of tools and phrases.^26,27 In this context, it can be difficult for both practitioners and community members to engage with definitions and toolkits at more than a surface level. Questioning this professionalization is important because engaging in dialogue about the meaning of community engagement is a central element of the practice of community engagement. Meaningfully engaging in dialogue with community will necessarily involve meaningfully engaging in dialogue about the concepts and ideals that we appeal to when we suggest that communities should have a say in public health practice. This practice of community engagement makes it all the more important to recognize and acknowledge where our work falls on the spectrum of epistemological assumptions mentioned previously and the role that these assumptions play in how we value knowledge generated in the course of community engagement.

Although the instruments commonly found in the practice of community engagement (eg, continuums, spectrums, checklists, toolkits) can instigate useful discussions, they can also give the false impression that the questions arising from the complexities of public health practice have been answered. The emphasis on instruments and tools in the professionalization of engagement potentially displaces deeper questions about public health and governance. When we argue for cross-sector public health practice, we make an implicit argument for a particular type of governance process for making decisions about how resources that affect health are distributed. Cross-sector governance for public health often involves questions related to social determinants of health, which involve policy decisions. These decisions include questions of how resources will be distributed, who will make decisions about this distribution, whose rights will be secured through this distribution, and the effects that this distribution will have on population health (Table). ²⁸

Table.

Questions involved in community engagement and cross-sector governance policy

Category of practice	Engagement questions	Cross-sector governance policy questions
Equitable community engagement (the quality of engagement)	1. What factors need to be addressed if your community is going to move toward equitable engagement? • Well-known factors include transportation, childcare, and translation. • Less well-known factors include engagement norms, hierarchies of types of knowledge, and assumed authority. 26	1. Who should be involved? (eg, community members, nonprofit organizations, for-profit organizations, coalitions) 2. At what level should they be involved? (eg, Centers for Disease Control and Prevention’s Community Engagement Continuum)
Community engagement for equity (the objective of engagement)	1. Will community engagement address sources of inequity in your community? 2. How is language excluding discussions of sources of inequity? For example, what does the word transformational tell us about the changes that we want to see? 3. What is it that we want to transform? 4. What specific changes do we want to see?	1. How should services be funded? (eg, tax dollars, fundraising, private sector donations) 2. According to what rights should resources be distributed? (eg, social rights, human rights, discretionary philanthropy) 3. What level of security are members of our community entitled to? (eg, food, housing, employment, health care)

Tools such as the IAP2 Spectrum of Public Participation ²⁹ and the CDC Community Engagement Continuum ² aim to address these first 2 questions about who should be involved and at what level. However, these tools tell us little about how services should be funded, how resources should be distributed, and which members of the community have a claim to services. How we answer these questions and the extent to which we answer these questions in relationship with community tell us a great deal about our underlying conception of the relationship between public health and equity in the practice of public health through cross-sector governance.

Community Engagement for Equity and Equitable Community Engagement

Although researchers and practitioners in public health frequently reference public participation and community engagement as a tool for ensuring equitable practice, the meaning of equitable practice is not always clear. Does the term describe the equitable practice of engagement or engagement as a strategy to achieve equity? CDC’s Practitioner’s Guide for Advancing Health Equity highlighted community engagement as a strategy to achieve health equity. ³⁰ In a research report on leveraging community expertise to advance health equity, Allen et al ³¹ highlighted the importance of authentic community engagement by “governments, health care and social service organizations, philanthropies, and others conducting health equity work.” In a report for the Robert Wood Johnson Foundation, Health Equity Solutions identified community engagement as a central element in addressing inequity and distinguished between transformational community engagement and transactional community engagement. ³² This distinction points to the importance of the quality of community engagement.

Distinguishing between types of community engagement can be valuable in some circumstances because it underscores the possibility for community engagement to further solidify unequal power dynamics and erode trust.^33,34 Practitioners have sought to overcome power dynamics through practices such as photovoice. ³⁵ However, as Johnston ³⁶ noted in her inquiry into photovoice as a mechanism for social change, “studies showed an overall lack of the ‘bigger picture’ of structural inequalities and available resources needed to enact social and policy change.” To bring this “bigger picture” into question, we distinguish between 2 interdependent concepts: equitable community engagement and community engagement for equity. Equitable community engagement recognizes how some voices and concerns have been systemically excluded ³⁷ and takes steps to ensure that a specific community engagement practice does not compound these exclusions. Community engagement for equity seeks to change the environment that has resulted in structural inequalities^38,39 that are repeated in the context of community engagement through concrete governance objectives, such as policy change, resource distribution, or education (Figure). With this in mind, we suggest that, when considering how community engagement and equity are related, it is important to distinguish between equitable community engagement (the quality of engagement) and community engagement for equity (the objective of engagement) (Table).

Figure.

Community engagement for equity and equitable community engagement. Community engagement for equity (the objective of engagement) and equitable community engagement (the quality of engagement) are distinct and interrelated categories of practice. The arrows represent the way in which policy objectives influence whose voice is heard and how the inclusion or exclusion of this voice in turn influences what policies are pursued.

Conclusion

Given the widespread emphasis on community engagement and cross-sector governance in public health, it is important that the field consider how these practices are related and how they both affect and are affected by systemic inequities. To this end, we suggest that public health consider (1) the questions involved in cross-sector public health practice, (2) the quality and objective of community engagement, and (3) the relationship between community engagement and cross-sector governance.