INTRODUCTION

The Centers for Disease Control and Prevention define community engagement as “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” (64, p. 3). Key principles of this collective work include “fairness, justice, empowerment, participation, and self-determination” (64, p. 4). Levels of community engagement start with outreach to and consultation with community members and advance to the involvement of community members in projects, collaboration in the implementation of those projects, and, ultimately, shared leadership (64).

Collaboration and partnership with communities facing health challenges can improve the conditions that affect health, reduce illness, and save lives. A meta-analysis by O'Mara-Eves and colleagues (51) identified 131 controlled studies of public health initiatives that engaged members of disadvantaged communities. The researchers found benefits for health behaviors, health consequences, participant self-efficacy, and social support, with larger effect sizes for “interventions that engage community members in the delivery of the intervention,” employ “skill development or training strategies,” and involve “peers, community members or educational professionals” rather than health professionals (51, pp. 13, 17). Key attributes of successful community engagement include basing efforts on needs identified by affected communities, mobilizing the assets and strengths of communities, establishing a stable infrastructure sharing funding and authority over projects, focusing on meaningful outcomes, and fostering mutual trust and respect (44, 47, 62, 69).

This body of research and guidance has important implications for schools and programs of public health and their academic mission of education, research, and practice to promote public health. Educators can partner with community organizations to help students learn how to listen to individuals who are experiencing serious health burdens and then teach students how to work in partnership to address these burdens. Researchers can work with communities to frame research questions, implement studies, and translate results into action. Practitioners can work with health departments, community organizations, and residents on initiatives to tackle health problems directly.

In pursuing this work, schools and programs of public health should be aware of the legacy of the public health field's past treatment of disadvantaged communities as well as the barriers to successful community engagement today. Even beyond human rights abuses such as the Tuskegee Syphilis Study, researchers at schools and programs of public health have strained relationships with communities through invasive surveys (60), inadequate consent processes (59), and research projects that raise community hopes but vanish after publication. At times, even well-intentioned studies have become foci of discontent, ripe for misinformation and misunderstanding. Other barriers include insufficient support within schools of public health and underappreciation of faculty and staff who pursue community engagement.

In this article, we provide a road map for successful community engagement by schools and programs of public health. We first describe best practices and emerging innovations in community engagement for the curriculum, research studies, and practice programs. This article does not cover the related emerging concept of academic health departments, although many of the principles can inform these efforts. We discuss key facilitators of successful academic efforts, including leadership, infrastructure, and culture. Finally, we review major challenges to overcome, including mistrust, imbalance of power, and unequal sharing of credit.

EDUCATION

By defining public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy,” the Institute of Medicine placed collaborative action at the core of the field (36, p. 1). It follows that to prepare students for careers in public health, schools and programs of public health should provide instruction in effective community engagement. Schools and programs of public health can introduce students to community engagement theories, principles, and methods through a variety of mechanisms, including academic courses, workshops, practicum experiences, and extracurricular education.

Theory-based courses present the pedagogical components of community engagement in order to prepare students for community engagement activities. Examples of such courses include Community Engagement in Public Health Practice & Research at the Drexel University Dornsife School of Public Health; Individual, Community, and Population Health at the Boston University School of Public Health; Applying Theory to Public Health Research and Practice at the Emory University Rollins School of Public Health; and Community Capacity, Competence, and Power at the University of North Carolina (UNC) Gillings School of Global Public Health. At the Johns Hopkins Bloomberg School of Public Health, students take a series of online modules as well as onsite courses to prepare for community engagement activities.

The community experience of health disparities has long been a focus for the Consortium of African American Public Health Programs, which includes Charles Drew University of Medicine and Science, Florida A&M University, Fort Valley State University, Howard University, Jackson State University, Meharry Medical College, Morehouse School of Medicine, and Morgan State University. The first accredited public health program offering Master of Public Health (MPH) and Doctor of Public Health (DrPH) degrees at a historically black university, Morgan State developed a course called Community Needs and Solutions in response to the lead paint poisoning of Freddie Gray.

In addition to offering dedicated courses, schools and programs of public health can incorporate community engagement concepts and case studies in multiple classes across curriculum by involving community leaders and residents as guest lecturers, panelists, and case-based learning discussants (7). Such activities provide students with broad exposure to community voices and experiences on a wide range of public health topics.

Critical Service-Learning

A best practice for integrating community engagement activities into academic courses and degree requirements is known as critical service-learning. A form of experiential education, critical service-learning is a pedagogy that develops students’ public health skills and competencies simultaneously through field placements that address community-identified concerns. Critical service-learning focuses on social change through intentional efforts to examine power, privilege, and systems of oppression. The use of critical service-learning pedagogy has enhanced the curriculum by providing students with opportunities to engage in real-world public health practice, an approach that has been linked with improved learning outcomes (48). This pedagogy is viewed as a fundamental tenet for educating health professionals in the social determinants of health (49).

Teaching critical service-learning courses requires skilled facilitation. Without adequate training in critical reflection, service-learning may reinforce a false sense of superiority in students (sometimes referred to as the savior syndrome) (22), may function as a charity model, and may fail to lead to social change (12).

When successful, critical service-learning shifts the dynamics of the learning environment by including community partners as coeducators. Community partners are involved in identifying and shaping service-learning projects, educating students about societal issues, reflecting on the historical context of oppressive structures in communities, and providing feedback on the students’ actions (15). A key goal of critical service-learning is to strengthen relationships among faculty, students, and community partners (see the sidebar titled Principles of Critical Service-Learning).

Practicum Requirement

Many degrees in public health include a practicum requirement of 100 hours or more of field work. This requirement is a community engagement opportunity for schools and programs of public health. As with critical service-learning, these experiences should include regular opportunities for reflection and learning. At the UNC Gillings School of Global Public Health, for example, the MPH Practicum includes both a two-credit practicum preparation course and a one-credit practicum reflection course.

Social Justice and Racism

Emerging innovations in education related to community engagement include teaching about social justice and racism. National organizations including the American Public Health Association and the Association of Schools and Programs of Public Health as well as many schools and programs of public health have declared that racism is a public health crisis. However, to date, few schools and programs have offered courses that focus on the US history of structural racism and racial inequity (24).

Across schools and programs of public health, students have protested and advocated to close gaps in teaching about the impact of racism, demanding more than basic discussions of diversity and embracing activism to make their point. At the University of Washington School of Public Health in 2013, students participated in an antiracism training that led to a call for a new required competency on racism. After an incident between a staff member at the school and campus police raised concerns of racial profiling, the school adopted in April 2016 a new requirement for students to “recognize the means by which social inequities and racism, generated by power and privilege, undermine health” (32).

At the University of California (UC) Berkeley, the student-led course Decolonizing Bodies in Public Health explores institutional racism, white-savior narrative, human rights injustices, and colonial ideologies (http://decolonizingph.weebly.com/). Inspired by this UC Berkeley course, students at the University of Michigan School of Public Health hosted a Decolonizing Public Health Teach-In in 2018, which led to the development of a course titled the Historical Roots of Health Inequities. At the Johns Hopkins Bloomberg School of Public Health, a collective of students, faculty, staff, and alumni formed LEAD (Liberate, Eradicate, Activate, Dismantle), which offered a workshop series on anti-oppressive frameworks in 2018.

In 2019, a member of a white supremacist group was convicted of first-degree murder in the stabbing death of a black man at a bus stop at the University of Maryland. In response, the University of Maryland School of Public Health expanded the concept of addressing racism as a public health issue directly by introducing a series of teach-ins hosted by subject matter experts sharing their research, practice, and expertise to inform antiracist practices on campus. The university's administration went further to post a message from the Office of Diversity & Inclusion in support of these efforts stating, “Words aren't enough. We have to act! We must learn to be antiracist in the face of racism whenever and wherever it occurs” (63). As the nation works to address the ongoing impacts of racism on health, such courses can serve as opportunities to inform and inspire effective community engagement programs.

RESEARCH

Most research in schools and programs of public health has historically excluded the involvement of nonacademic partners as collaborators. Systematic imbalances of power and privilege within the academy often limited the role of these partnerships to supporting predetermined research agendas and to assisting with study participant recruitment. We now know that research programs benefit greatly from community engagement, both in identifying key questions of importance and in implementing studies ethically and effectively (5). There is also much greater awareness that dissemination of interventions and the advancement of policies based on evidence require the experience, talent, and capacity of community agencies in the promotion of community change (58).

A common structure for engagement in research is the “community engagement core” in federally funded research centers. These programs generally serve to “communicate research findings and concepts to community partners and convey the voice of these communities to researchers within the center” (50). These efforts are highly variable. On the one hand, perfunctory meetings between community members and researchers can lead to little collaboration on research ideas. On the other hand, when researchers approach partnerships with an open mind and genuine interest in matters of concern to local residents, the result can be the codevelopment of important efforts for health.

Community-Based Participatory Research

One way to distinguish between low-value and high-value research collaborations is through the lens of community-based participatory research. This term represents an approach to addressing pressing issues germane to the beneficiaries of research, interventions, and policies that is based on a set of principles related to mutual respect, humility, and long-term relationships (see the sidebar titled Principles of Community-Based Participatory Research) (38, 66). This research has led to greater understanding and action to address community health challenges, as demonstrated through many examples (13, 34).

One of the earliest programs credited for the increased presence in the field of community-based participatory research is the W.K. Kellogg Community Health Scholars Program, which provided 40 postdoctoral fellowships to increase a cadre of trained faculty, many of whom are now faculty and leaders in organizations extending the reach and focus on community-based participatory research. From 2007 to 2012, this program furthered the capacity of community-based organizations to collaborate with academic researchers and practitioners to address their own challenges and to advocate for policies leading to reductions in health and health care disparities (9).

One best practice is for schools and programs of public health to provide intensive training in the skills of community-based participatory research. This training is often conducted with dyads of researchers and community organizations learning together. For example, Columbia University has a 10-session, 25-hour program for researchers and their partners, which includes the opportunity to receive pilot funding. Similar programs exist in public health schools and programs across the country. For example, the Division of Public Health Sciences at the Washington University in St. Louis has developed a Community Research Fellows Training program to “equip community members with the tools and resources to examine and address health disparities that exist among communities of color and medically underserved populations in the region” (43). Similarly, the Detroit Community-Academic Urban Research Center, a collaboration of community organizations in Detroit and academic researchers from the University of Michigan, established The CBPR Partnership Academy, a multifaceted training and mentoring program for new community-academic partnerships to build capacity for engaging in community-based participatory research approaches to eliminate health inequities (https://www.detroiturc.org/cbpr-partnership-academy.html). In Boston, staff from Strong Women Strong Girls and researchers from Harvard's School of Public Health participated in a year-long community-based participatory research academy. The result was a project to understand and address the mental health experiences and needs of women and girls in underserved communities (4).

Such collaborative training programs can help overcome a common point of failure for community-based participatory research: faculty who believe they have the requisite knowledge and experience to engage communities, when, in reality, they are not oriented sufficiently to the community's priorities to be effective (67).

Another best practice is to integrate the teaching of community-based participatory research in the curriculum, including support for students’ theses and dissertations. One example of a dedicated course is a seminar at the University of Michigan, led by an interdisciplinary team of faculty, which aims to provide instruction as well as to strengthen support for community-based participatory research across the university (26). There are similar courses at the University of Washington and at Johns Hopkins.

Schools and programs of public health should be aware that major funders are now investing in community-based participatory research. The Patient Centered Outcomes Research Institute has created funding opportunities to support training programs in community-based participatory research, and the National Institutes of Health and other federal agencies have acknowledged community-based participatory research as a method for identifying policy changes that promote health equity and for developing solutions to address health disparities.

PRACTICE

Public health practice refers to the actual work of health improvement. At the turn of the twenty-first century, public health schools began organizing academic efforts in and near communities that had complex relationships with sickness and disease prevention, in part because of the opportunity to study the causes of poor health (60). Today, the location of schools and programs represents a special responsibility to work with nearby communities to improve health outcomes, in addition to work that faculty lead in communities across the nation and around the world. The success of all these efforts depends on trust and respect, shared decision-making, and recognition of the strengths that each of the partners brings to the table (11).

Effective public health practice recognizes the central importance of place. In 2008, the World Health Organization Commission on the Social Determinants of Health found that “inequities in health [and] avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness” (68, p. iii). This concept—that place matters—means that improving health requires addressing these structural issues in traditionally marginalized communities. In 2012, the Joint Center for Political and Economic Studies called for tackling the structures and systems that create and perpetuate inequality to fully close racial and ethnic health gaps. The Center's report emphasized the need to respect the significant knowledge of the local community and to allow residents to become leaders who mobilize their neighbors in advocacy for the welfare of their communities, from education and public safety to zoning regulations and environmental protection (41).

Schools and programs of public health can plant the seeds of successful practice efforts through mutual capacity building with community partners. Faculty and students can provide in-person training and webinars around such topics as data analysis, grant applications, and policy advocacy (31). Schools and programs of public health can also make research results and, where permissible, raw data available to community organizations for their own analysis and other uses. These efforts can lead to discrete collaborative efforts that build confidence for tackling larger challenges. One example is the Baltimore Equity Toolkit & Power Mapping dashboard developed by Lawrence Brown and his students at the Morgan State School of Community Health and Policy (http://www.equitybaltimore.org/). Community members helped faculty, staff, and students understand key local challenges and how they are experienced within homes and neighborhoods.

Collective Impact

One best practice is for schools and programs of public health to participate in efforts that embrace a collective impact approach, which recognizes that problems are too big to be solved by any one entity alone. Successful collective impact projects involve five key components: a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations (25) (see the sidebar titled Principles of Collective Impact).

In Baltimore, for example, a collective impact effort called B'more for Healthy Babies has involved more than 100 public and private partners to improve long-term health outcomes for families, particularly pregnant and postpartum women, infants, and children (3). For more than a decade, this collective has developed public education campaigns to promote safe sleep and reduce infant mortality, centralized home-visiting programs, enhanced state and local policies, and made improvements within partnering organizations to better address systemic challenges (3). Working together, academic partners at Johns Hopkins and the University of Maryland have conducted extensive data analysis as well as created materials for evidence-based behavior change campaigns. Rates of infant mortality and other adverse birth outcomes have improved substantially (3).

In Texas, the School of Public Health at Texas A&M University in 2015 convened a project focused on high-impact diseases—including diabetes, infectious disease, and asthma—and their consequences across 27 counties in South Texas. The effort, known as Healthy South Texas, has, along with local health care providers and community members, brought together faculty in nursing, public health, pharmacy, and medicine, and collectively they have developed and launched a series of initiatives to improve health (33).

Practice efforts in community engagement should provide a leadership role for community members (61). In East Los Angeles, for example, a partnership between the University of California Los Angeles Fielding School of Public Health and the local YMCA, two high schools, and a local arts and civic engagement organization permitted teens to enroll in an elective course focused on social justice, health disparities, and social advocacy. The teens then helped to lead a local health improvement project called Proyecto MercadoFRESCO, which resulted in the conversion of two corner stores that previously sold mostly unhealthy foods into stores that offered a variety of healthy food options (52).

INSTITUTIONAL SUPPORT FOR COMMUNITY ENGAGEMENT

The community engagement work of schools and programs of public health can be more than the sum of discrete efforts in education, research, and practice. One best practice is for leaders of schools and programs to demonstrate institutional support to grow and sustain community engagement over time through strategic planning, academic infrastructure, and resources.

Mission, Vision, and Strategic Plans

Schools and programs of public health can adopt mission and vision statements that embrace health equity and the principles of community engagement and then back them up with strategic plans that incorporate these concepts into key and urgent priorities. In the process of creating a strategic plan, schools and programs can seek community input into key goals, priorities, and metrics.

For example, the School of Public Health at UC Berkeley has set the strategic goal to “deeply engage with communities working to disrupt systemic health threats and inequities, partnering with them on the path to healthy populations” (8, p. 13). The Johns Hopkins Bloomberg School of Public Health strategic plan states, “No matter where we work or the size of the populations we work with, our success depends on listening to the community and developing authentic partnerships that are grounded in mutual trust and respect for shared values and goals” (39, p. 19).

Assigned Responsibility

Although people at a school or program of public health may be involved in community engagement activities, it is useful for “a single individual in central administration” to be responsible for sustaining and supporting these efforts over time (17). This individual can champion community-engaged learning opportunities in the curriculum; be available to make connections to community organizations for research initiatives and practice projects; and foster the development of student, staff, and faculty organizations that pursue community engagement. Many schools and programs of public health have deans for practice, who could assume this role. Other options include a dean for diversity, inclusion, and community engagement.

Offices, Centers, and Institutes

Offices, centers, and institutes that focus on community engagement can grow long-lasting partnerships over time. These structures can support service-learning, community-based participatory research, and a wide variety of practice efforts with a consistent and empowered set of community partners.

At the Johns Hopkins Bloomberg School of Public Health, the community engagement and service-learning center, known as SOURCE, was established in 2005 to engage the Johns Hopkins University health professional schools and Baltimore communities in mutually beneficial partnerships that promote health and social justice. SOURCE operates on a partnership model in which community organizations join a network that provides opportunities for mutually beneficial collaborations. SOURCE has also created opportunities for internships, service days, collaborative action projects, and other connections for thousands of students and more than 100 community organizations each year (45).

Over time, SOURCE has become more deeply involved in the core educational, research, and practice efforts of the public health school. Since 2012, for example, SOURCE has offered specialized training in service-learning pedagogy for faculty and community partners. Over several years, SOURCE developed and implemented a methodology to review and designate courses as service-learning courses. In 2019, the senior staff of SOURCE joined the school's faculty and now work closely with departments across the key domains of community engagement.

Beyond the designation of a responsible academic administrator and the establishment of a focused office to lead efforts in community engagement, another best practice is for schools and programs of public health to expect that every office and department will embrace the principles and activities of community engagement. Planned reviews of academic departments, for example, can include assessments of community engagement work, with input from community partners.

Community Advisory Boards

Schools and programs of public health can also encourage the development of community advisory boards and coalitions. These boards offer a formal mechanism for coordination across education and practice and provide a critical resource for community-based participatory research (57). The Johns Hopkins Center for Health Equity, for example, has an advisory board that is co-led by a faculty member and a community member; it includes representatives from 50 local and national organizations. The board meets on a quarterly basis to discuss methods of engagement and types of collaborations that may be beneficial to participating stakeholders and targeted communities. The community advisory board members participate in all phases of the Center's research and training programs, from formulation to dissemination, including the development of grant proposals; piloting and refinement of research procedures and materials; recruitment of study participants; training of staff and students; and authoring of manuscripts (20).

Similarly, the Urban Health Institute has a community–university coordinating council, which is made up of community representatives from the faith community, education, philanthropy, and local organizations as well as faculty and staff from across Johns Hopkins and other local universities. The council is cochaired by both a Hopkins representative and a community member and assists the Urban Health Institute in developing its work plan, reviews progress on the work plan, and provides budget recommendations.

Appointment and Promotion

Schools and programs of public health can promote community engagement by emphasizing its value in the academic promotion process. Aspiring researchers, educators, and practitioners can be guided through developing an academic career devoted to community engagement (14). Promotion committees can develop evaluation criteria for these activities based on those created by the National Review Board of the Scholarship of Engagement (40). These committees can obtain from community partners external review of candidates being considered for promotion and establish structures to reward faculty who lead service-learning efforts (28). As one example, the City University of New York School of Public Health developed promotion and tenure policies that incorporate teaching and service to community organizations (27).

Resources

Community engagement requires resources. School and program budgets can make funding available for community engagement activities, including critical service-learning, community-based participatory research, and collective impact efforts. Such funds can be structured as freestanding or matched with other external funding, and funders can require the appropriate sharing of resources with community partners themselves. For example, the Johns Hopkins Urban Health Institute launched in May 1999 after two years of planning that involved more than 150 community leaders, Johns Hopkins faculty, and staff. The Institute makes small grants and awards available to community partners, supporting more than 150 grants over time.

Beyond the resources available within their own institutions, schools and programs of public health can advocate for policy changes to support community engagement. These changes could include accreditation requirements for critical service-learning opportunities, new federal funding priorities for community-based participatory research, and novel approaches to reimbursing collective impact initiatives and other community-based public health efforts that reduce health care costs.

CULTURE CHANGE

A key goal of institutional support for community engagement is to support an academic culture that embraces work with communities to achieve health improvement. Success requires overcoming a historic misconception of community health that emerged in the 1960s, when mental health professionals in New York saw the term “community” as synonymous with radical and racialized demands averse to the institutional interests of predominantly white academic institutions (2). In response, the institutions limited efforts to improve the health of surrounding neighborhoods, even to the extent of tying the hands of functional unit directors within schools and programs who were working on behalf of the community.

Today, schools and programs of public health can foster a cultural shift that embraces community voice and power sharing as fundamental to the success of academic efforts (24). This effort starts with attention to communication, both internal and external to the school or program. Because communication is malleable, operates on multiple levels of analysis, and fundamentally involves the coordination of meaning, it is a uniquely important focal point for change (53). Unlike the social determinants of health or the entrenchment of systemic racism, communication can be modified, both systematically and individually (53). Internal communication can inspire and lift up examples of effective community engagement as well as validate the importance of urgent health challenges facing communities. External communication as part of community engagement efforts in education, research, and practice can generate a new appreciation for problems and solutions and lead to meaningful change (35).

Workshops and Other Training

Interpersonal discrimination, whether implicit or explicit, impairs relationships and may serve as a barrier to effective community–academic partnerships. Workshops and other training can increase self-awareness of implicit racial and social class bias among faculty, staff, and students.

Schools and programs of public health can learn important lessons from interventions to reduce discriminatory behavior among health professionals and persons in other social sectors. Stereotype replacement, counter-stereotype imaging, individuation, and perspective are potential strategies to reduce individual-level prejudiced attitudes and behaviors toward socially marginalized groups. Interest is now emerging in bystander antiracism training, which prepares people to respond to incidents of interpersonal or systemic racism in the moment, as an organizational strategy because of its documented effectiveness and potential to change social norms toward intolerance of discrimination (1, 19).

The Undoing Racism workshops led by the People's Institute for Survival and Beyond are an example of training that can support effective community engagement. The organization's workshops seek to create change in knowledge and attitudes about structural racism, promote engagement in job-related racial equity activities, raise awareness about an organization's progress toward racial equity, increase understanding of factors that might be associated with personal engagement and progress toward organizational change, and expand knowledge about the role of race in the outcomes (1). Core to this program is the idea that racism has been consciously and systematically erected, and it can be undone only if people and institutions understand what it is, where it comes from, how it functions, and why it is perpetuated (1).

Improving Classroom Instruction

Schools can set in motion processes to examine their curricula to create opportunities to learn about community engagement and related topics, improve the classroom environment for students of diverse backgrounds, and support inclusive teaching practices (32).

Monitoring and Evaluation

The academic culture should embrace continuous improvement in community engagement efforts. Schools and programs of public health can pursue regular review and evaluation of community engagement efforts by monitoring the quality of training partnerships and the achievement of outcomes with an equity perspective (21, 30). However, there is a paucity of indicators and metrics for evaluating success in community engagement (46). A systematic search of six major literature databases through May 2015, focused specifically on community–academic partnerships, found few data on the characteristics of such partnerships and heterogeneity in descriptions of the processes used and the targeted outcomes. Recommendations from this review included using longitudinal or before-and-after data (6) and creating a systematic reporting structure of methods and characteristics to help with evaluation (23). Involving community members in the design and implementation of this oversight is an important element.

OBSTACLES TO SUCCESSFUL COMMUNITY ENGAGEMENT

In pursuing community engagement, schools and programs of public health should be aware of major obstacles to success, including mistrust by community members, imbalance of power, and unequal sharing of credit. Attention to these issues is critical to avoiding problems that can undermine progress.

Social groups that have often been marginalized—including ethnic minorities, religious and cultural minorities, sexual minorities, persons with low income, individuals who are incarcerated, and persons with physical and mental disabilities—and individuals working in community-based institutions serving these groups often mistrust public health professionals and researchers (54). This mistrust stems from historical events, beginning with the legacy of slavery and continuing with events such as the Tuskegee Syphilis Study (29) and the experience of Henrietta Lacks, the African American woman who was the unwitting source of the HeLa cancer cell line that led to many research breakthroughs (56).

Mistrust in institutions has been reinforced by centuries of discriminatory treatment in diverse settings, ranging from the educational system, to housing, employment, the criminal justice system, and health care. Ongoing discriminatory actions in diverse settings are manifested by physical violence, dismissive behaviors, denial of access to opportunities, lack of respect for persons and for their autonomy, bias and stereotyping behaviors in decision-making, poor communication, and lack of empathy when interacting with persons from at-risk groups and historically disadvantaged communities (18).

To overcome mistrust, public health researchers, practitioners, and policy makers can demonstrate trustworthiness in their interactions with community members and organizations. Trustworthiness has been defined as the ability to be relied on by others based on benevolence, integrity, and ability or competence (55). Organizational and interpersonal strategies enhance trustworthiness through open information systems, clear communication, person- and community-centered framing of messages, participatory approaches, and authentic leadership. Monitoring, reporting, and accountability also communicate trustworthiness.

Imbalances of power and power dynamics are embedded in the histories of intentional oppression and consequential social injustices (67). In academic and community partnerships, these differences in status and privilege manifest in unequal practices of agenda setting, distribution of financial resources, data ownership, and publication rights.

Establishing an equal partnership structure and a balance of power requires deliberate and ongoing open and honest communication between community and academic partners. The knowledge and diversity of opinions of community partners should be valued to the same degree as that of the academic partners; otherwise, the credibility and integrity of the relationship, as well as the health improvements of the community, will be in jeopardy (67). Public health researchers and practitioners should make efforts to engage stakeholders in problem-solving and decision-making by eliciting their opinions and preferences and negotiating mutually beneficial agreements. Aligning the priorities and incentives of diverse stakeholders can be time-consuming and challenging; however, public health professionals should be patient and flexible, communicating clearly the importance of certain decisions for the integrity of the research or the implementation of the program while also respecting the concerns of stakeholders and working with them to arrive at mutually agreeable decisions.

The culture, expectations, and processes of community organizations and universities frequently do not align. Researchers often apply for grants prior to engaging with community partners, and there is little coordinated effort following a study on dissemination. In a national study, 73% of researchers reported spending less than 10% of project effort on dissemination (10). Decisions about academic credit-sharing and the dissemination of research findings and products are often left to those within the university (58). These actions result in perceptions by the community that the academic partner will control the research process, perpetuating feelings of exclusion.

Nearly two decades ago, the Agency for Healthcare Research and Quality commissioned a study on the evidence and evaluation of community-based participatory research to provide guidance on best practices for promoting community-based research (65). A set of general recommendations emerged to advance relationships between researchers and communities. In addition to active community input in planning the intervention and interpreting the data, manuscript preparation and translation of research findings into policy changes were cited as important to building and sustaining partnerships between public health institutions and communities. Guidelines such as these minimize the chances of unilateral control and increase the likelihood of shared credit and balance around authorship, dissemination, and translation efforts (65).

CONCLUSION

Community engagement is more than a skill to be taught and more than a strategy for successful research; it is more than a pathway to health improvement. Community engagement reflects the values that animate the field of public health, particularly the concept of social justice. Schools and programs of public health can embrace teaching, research, and practice in community engagement, create structures to support these activities, and strive to overcome the difficult legacy of past failures and other barriers to success. This work is challenging but essential because progress advances equity and improves health in communities all around the world.

disclosure statement

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review.

AUTHOR CONTRIBUTIONS

M.L. created the outline for the article and wrote the first draft of the education section. J.B. wrote the first draft for the research section. A.G. wrote the first draft of the practice section. S.R. and L.C. wrote the first draft of the culture change section. J.S. wrote the first draft of the introduction, the institutional support section, and the conclusion. All authors participated in a critical review of the entire document, and J.S. prepared the manuscript for submission.