Value of CE Pedagogy for Learners, Communities, and Partnering Organizations

CE pedagogy can help advance health equity by enabling learners to gain deeper knowledge of social determinants of health and gain insights on the societal context of effective strategies to address and reverse the effects of health and social injustices, stereotypes or structural racism, and similar biases [Reference Tai, Sia, Doubeni and Wieland24,Reference Doubeni25]. Implementing CE curricula thus benefits learners and their careers by equipping them with a deeper understanding of root causes of inequities and their impact on health and wellness. It may also improve the abilities of practitioners to quickly recognize and address emerging community concerns to avoid embedding mistrust in the community. Notably, a well-designed, implemented, and evaluated CE educational program may advance community objectives and reduce the risk of re-traumatization in communities. CE education can also provide community partners or members with opportunities to participate in training, enhance capabilities in communities, and spur community-led action or research by enhancing engagement with academic partners [Reference Piasecki, Quarles, Bahouth, Nandi and Bilheimer11,Reference Ziegahn, Joosten, Nevarez, Hurd and Evans26]. From the perspective of academic institutions and other partnering organizations, CE education can help train a well-prepared workforce for advancing community impact and health equity goals [Reference Hays, Ramani and Hassell27]. When designed and implemented strategically through a shared vision, CE curricula informed by a framework as proposed can enable organizations to strengthen their community relationships [Reference Driscoll28,Reference Beere29].

Value for Competency-Based Education

Education is accomplished at multiple levels and has traditionally been guided by learning objectives, competencies, and grading standards [Reference Ruiz, Mintzer and Issenberg30–Reference van Houten-Schat, Berkhout, van Dijk, Endedijk, Jaarsma and Diemers32]. Undergraduate medical education has moved toward milestones and passing scores. This evolution is also seen in public health education, with graduate training moving to competencies and concepts built around lifelong learning [Reference Abedini, Abedin and Zowghi33]. That evolution dovetails with principles of CE as described earlier [1,2]. CE learning should recognize that one is never entirely "competent" in identifying and working on community priorities. It should be approached as a lifelong process and from a place of humility to promote growth and connectedness to the community. The knowledge and experiences can translate into enhanced skills of co-learning with community partners to advance health equity through activities in education, research, public health programs, and healthcare delivery. Some proposed competencies for CE have been described in the extant literature [Reference Piasecki, Quarles, Bahouth, Nandi and Bilheimer11].

Approach for Informing Recommendations on CE Pedagogy

To support recommendations for curriculum development, we searched the peer-reviewed and grey literature for CE educational programs. Many of the authors, some with community partners who are coauthors of this article, lead CE initiatives in CTSAs and at cancer centers and collectively provided resources and insights with input from community partners. Additionally, we conducted direct outreach to other selected academic centers.

We based recommendations, partly, on educational theories, health equity frameworks, and emerging consensus on principles of CE [1,2,Reference Ahmed, Young, DeFino, Franco and Nelson5,Reference Ahmed and Palermo13,Reference Abedini, Abedin and Zowghi33–40]. Insights were drawn from a report by an Association of American Medical Colleges (AAMC) panel on public and population health in medical education [Reference Johnson, Fair, Howley, Prunuske and Cashman14].

Elements of CE Pedagogy

Learning is iterative and not a linear process, although core cognitive domain content is helpful prior to practical experiences. The proposed curricula framework is amenable to being adapted across a varied set of learners in academic and nonacademic settings. The proposed framework applies to precollegiate, undergraduate and graduate students, faculty, employees engaged in CE, and community members.

Core content on CE delivered using both traditional didactic and experiential methods should be considered an essential component of curricula at all levels of clinical and public health training and practice and related fields [Reference Ahmed and Palermo13]. Core competencies should include: 1) social determinants of health and historical injustices; 2) CE principles and community knowledge and relationships; 3) resource sharing and communication; 4) personal traits for successful CE, including cultural humility; 5) elements and value of community-engaged research; 6) program evaluation for CE; and 7) dissemination and advocacy in CE [Reference Piasecki, Quarles, Bahouth, Nandi and Bilheimer11]. The importance of sustainability and trustworthiness should be interwoven throughout the curriculum [2,Reference Ziegahn, Joosten, Nevarez, Hurd and Evans26,Reference Wilkins41,42].

Some of the existing CE-related educational content [12,Reference Johnson, Fair, Howley, Prunuske and Cashman14,43–Reference Meurer, DeNomie, Morzinski, Nelson and Meurer45] focus on specific activities or models (e.g., CBPR) [Reference Ahmed and Palermo13,Reference Levin, Bowie, Ragsdale, Gawad, Cooper and Sharfstein15,Reference Chung, Kahn, Altshuler, Lane and Plumb46,Reference Israel, Coombe and McGranaghan47], and others on service-learning (or critical service-learning), which is the predominant form of pedagogy in academic health institutions [Reference Mitchell36,43,Reference Rosing and Hofman48–Reference Heffernan52]. As discussed later, fidelity to CE principles in service-learning pedagogy is not explicit. It thus may not be suitable as the sole source of community-engaged education in its current form.

Several essential elements to CE pedagogy can be drawn from the existing literature. First, the core set of CE principles should be integral to curricula design [1,2]. Second, because CE is an ongoing and dynamic process, a lifelong learning approach is needed. Third, effective CE strategies require enhanced relational knowledge and emotional intelligence for successful relationship building that promotes respect, trust, and prioritization of community ownership over individual exigencies. Fourth, community members should be involved in designing the course and included as faculty, which can increase the focus of training programs on community values and priorities and community-identified strategies [Reference Ziegahn, Joosten, Nevarez, Hurd and Evans26].

Thus, it is essential to have clearly defined roles for community members, either as teachers or facilitators, and not simply involve them as "subjects" of the educational program to promote co-learning with community partners [Reference Ziegahn, Joosten, Nevarez, Hurd and Evans26]. This bidirectional design enables the development of a shared vision in community-engaged programs and reinforce the construct of community ownership, which should encompass dissemination of products of research or other initiatives through peer-reviewed publications or conference presentations. Learners must understand the importance of timely return of results to the community and the inclusion of community members both in interpreting the findings and as coauthors.

Overall, CE pedagogy should have: 1) a preparatory phase; and 2) experiential learning such as observerships or supervised activities. An example of that approach is the PARE (Preparation, Action, Reflection, Evaluation) model (Table 1) [43]. Similarly, Kolb’s Experiential Learning Theory proposes four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation [Reference Kolb53,Reference Kurt54]. Thus, the design should incorporate adult learning principles, including experience, mentorship, self-direction, and self-motivation [Reference Abedini, Abedin and Zowghi33,Reference Merriam35]. Consequently, learning can be self-directed through online modules, individually or in groups, using in-person or virtual platforms. Experience suggests that in-person training and interactions may foster greater community involvement and reinforce relational and reflective skills. We recommend using Universal Design for Learning principles to help make the experience inclusive and accessible for all learners [55].

Table 1. Modified PARE (Preparation, Action, Reflection, Evaluation) Curricula Planning Approach

Learners and Faculty Considerations

CE learners vary from precollegiate to faculty, community members, and employees of community-based organizations and private and public agencies. As described earlier, learners acquire CE skills through experiential programs working with community members to understand co-learning and co-creation and community assessment and prioritization. Thus, educators need to have a strong foundation in CE principles and practice, which implies that curricula implementation may begin with ‘training the trainer [Reference Piasecki, Quarles, Bahouth, Nandi and Bilheimer11].’ Ideally, educators should have deep knowledge of the community and have community relationships to guide learners and avoid deepening of mistrust during experiential learning [Reference Meurer, DeNomie, Morzinski, Nelson and Meurer45].

Curricula Resources

There are many resources about CE for learners [Reference Doubeni, Fancher, Juarez, Riedy and Persell6,Reference Johnson, Fair, Howley, Prunuske and Cashman14]. An authoritative text on CE principles, first published by practitioners in the field in 1997 and updated in 2011, is essential reading for learners and practitioners alike [1]. NAM publications on CE can also provide an excellent background for learners [2]. Other resources include examples of community-engaged research projects [12,Reference Wieland, Weis, Olney, Aleman and Sullivan56–Reference Brewer, Balls-Berry, Dean, Lackore, Jenkins and Hayes59], narratives about pitfalls in CE [Reference Israel, Schulz, Parker and Becker4], toolkits for community-academic or healthcare-public health collaborations [Reference Michener, Aguilar-Gaxiola, Alberti, Castaneda and Castrucci60–Reference Wilkins and Alberti62], materials on community health indicators [40,Reference Aguilar-Gaxiola, Ahmed, Franco, Kissack and Gabriel63], social-ecological model [37], and frameworks on health equity [39], social determinants of health [Reference Tai, Shah, Doubeni, Sia and Wieland8,38,Reference Solar and Irwin64], and program evaluation [65]. A 1938 lecture by Stampar on rural health provides an excellent overview of reasons and benefits of CE and the interconnectedness among social, economic, and health inequities [Reference Stampar66]. The Centers for Disease Control and Prevention (CDC) hosts many publicly available community-level data resources such as PLACES [67], which is derived from Behavioral Risk Factor Surveillance System data [Reference Razzaghi, Wang, Lu, Marshall and Dowling68,Reference Holt, Matthews, Lu, Wang and LeClercq69]. Mature CBPR programs, including the Rochester Healthy Community Partnership [Reference Wieland, Asiedu, Lantz, Abbenyi and Njeru57,Reference Wieland, Weis, Hanza, Meiers and Patten70] and the FAITH! (Fostering African American Improvement in Total Health) programs at the Mayo Clinic [Reference Brewer, Balls-Berry, Dean, Lackore, Jenkins and Hayes59,Reference Brewer, Morrison, Balls-Berry, Dean and Lackore71,Reference Brewer, Woods, Patel, Weis and Jones72], can provide a solid and authentic model of CE experiences.

Critical service learning is a widely used nontraditional pedagogy of experiential learning through involvement in community-oriented activities with varying levels of structured experiences and reflections [Reference Mitchell36,43,Reference Rosing and Hofman48–Reference Heffernan52]. While not synonymous with CE, some elements of critical service-learning are consistent with the intent of community-engaged education [Reference Levin, Bowie, Ragsdale, Gawad, Cooper and Sharfstein15,Reference Heffernan52]. The service-learning model carries a community deficit framing (service learning) and infers potentially inaccurate connotations that learners deliver services desired or needed by the community. It can thus potentially perpetuate “town and gown” perceptions among community members. Instead, CE education should emphasize humility and apply core principles of bidirectionality with an emphasis on understanding community assets and ownership and, in the context of community-engaged education, community members as teachers. Thus, the structure of critical service learning should be reconceptualized to integrate didactics on CE principles with examples of the intended purpose of CE and outcomes before the community experience, which in turn should be followed by an evaluation that emphasizes lessons learned rather than services learners purported provided.

Curricula Components

Ideally, CE training should be required for all learners and for employees in organizations seeking to collaborate with communities. The content and activities should be designed and implemented collaboratively with community partners to reflect local needs and assets [Reference Piasecki, Quarles, Bahouth, Nandi and Bilheimer11,Reference Ziegahn, Nevarez, Hurd, Evans and Joosten23]. The structure should encompass didactics, experiential learning or “field” work, personal reflection, and educational outcomes assessment incorporating community member perspectives [Reference Piasecki, Quarles, Bahouth, Nandi and Bilheimer11]. Modules could be posted online and on institutional learning platforms for new and existing employees and set as required training with regular refreshers. Content could be provided online for community members and as part of orienting community advisory board members along with regular refresher training.

An abridged curriculum of a course taught at Stanford is provided in Appendix A. The course, co-developed and co-taught with community partners, includes facilitated discussions and peer-to-peer feedback to enhance co-learning among learners and community members. It also includes content on building self-awareness, and addresses competencies in professionalism and communication skills. Other examples are courses on community-engaged research hosted by the Tufts CTSA program [73] and by the Detroit Urban Research Center (DURC) with the University of Michigan [Reference Israel, Coombe and McGranaghan47]. The course materials provide practical examples of forming and working in community partnerships, including Memoranda of Understanding or Agreement. The Agency for Toxic Substances and Disease Registry (ATSDR) of the US Department of Health and Human Services has several online modules with course objectives and videos that are easily accessible to learners and faculty [12]. The AAMC Expert Panel on Public and Population Health in Medical Education report provides an example of a related curriculum [Reference Johnson, Fair, Howley, Prunuske and Cashman14], including a detailed evaluation framework based on the New World Kirkpatrick Model [74].

The Tufts CTSA course “Building Your Capacity: Advancing Research through Community Engagement” aims to help communities increase their capacity to participate in research efforts [73]. The DURC online course entitled “Community-Based Participatory Research: A Partnership Approach for Public Health” [Reference Israel, Coombe and McGranaghan47] focuses on researchers, “health and human service practitioners,” and members of community-based organizations. The DURC learning objectives encompass 1) rationale, definition, and core principles of CBPR; 2) strategies for forming, maintaining, sustaining, and evaluating CBPR partnerships; 3) data collection methods and interpretation; 4) methods for dissemination and translation of research findings; and 5) benefits and challenges for using CBPR for research and social change [Reference Israel, Coombe and McGranaghan47].

The approach and examples described above aim to provide faculty with the tools to develop the goal, learning objectives, and evaluation of learning outcomes (Table 1). For example, faculty could frame the overall goal of a CE curriculum as aiming to enable learners to effectively demonstrate the principles of CE in working with community members. The course can be divided into several modules preceded by learner assessment as described in the following sections. The content and context should guide the length of the training and whether it is a standalone course or integrated in related courses.

Learner Assessment

Learner assessment is essential to inform curricula adaptations to unique needs or areas of emphasis [Reference Black and Wiliam75,Reference Black and Wiliam76]. Individuals self-evaluate their current level of knowledge and experience to ascertain prior knowledge, experience, readiness, and capacity to embark on CE. Prior to practicums, it should be clear to the community who the learners are, goal, and how much time they are expected to devote to a particular project or community. This transparency can help clarify expectations and avoid potential disappointment and resentment from all parties involved, and ensures that the relationships last well beyond the project or any one individual [Reference Meurer, DeNomie, Morzinski, Nelson and Meurer45]. Although many communities welcome students and academic members, mistrust occurs or deepens when well-intentioned people at all levels overpromise and underdeliver on commitments. Additionally, creating narratives that are potentially stigmatizing for the community or mischaracterizing observations in the community can undermine trust building.

Course Pre-requisites

Prerequisites cover areas from many disciplines and should be tailored to local needs, such as rural or urban communities or a community of people with specific conditions such as substance use disorder. In general, prerequisites should cover core content related to health and wellness in communities (Box 2). The topics include overviews of essential functions of public health; health disparities and definitions of critical constructs involved, including various stratifications; community health indicators; social determinants of health or vital conditions of health frameworks along with social causation of disease; the history of social, health, and research injustices, including structural racism and intersectionality; and applicable health and behavioral theories specifically social-ecological model [Reference Tai, Shah, Doubeni, Sia and Wieland8,37–40,Reference Aguilar-Gaxiola, Ahmed, Franco, Kissack and Gabriel63,Reference Solar and Irwin64]. The prerequisites may be built into required readings or integrated into the core contents.

Didactic Component

The didactic component should cover the fundamental principles of CE with applications in research, clinical care, public health, and educational programs [Reference Israel, Schulz, Parker and Becker4,Reference Meurer, DeNomie, Morzinski, Nelson and Meurer45]. It should include community assessments and lessons learned on CE to highlight both benefits and potential harms or pitfalls as exemplified by the DURC course [Reference Israel, Coombe and McGranaghan47,Reference Del Pino, Jones, Forge, Martins and Morris77,Reference Jones and Collins78]. It should draw on core competencies to include content on understanding the role and limitations of community advisory boards and how the role of community members should be honored on CE projects. Content should also include understanding the organizational capabilities or toolkits needed for CE [1,12]. The time horizon for meaningful results and the importance of returning research results should be included.

Emphasis should be placed on understanding that prioritization should be done by or with the community and that the meaningfulness of outcomes is determined primarily from the community’s perspective. Locally relevant case studies, similar to those offered by ATSDR, should illustrate creating shared vision and outcome metrics, pitfalls and lessons learned, and how challenges may be overcome; this is particularly important if a practicum or field experience is part of the training [12].

Practicums

Didactics provide a foundation but should never be considered sufficient because CE does not happen from reading a paper or book, or from behind a computer [Reference Ahmed and Palermo13]. Facilitated experiences through practicums are essential for development and maintenance of CE skills. When done stepwise, CE practicums and experiences provide a guided intersection point for the learner with the community [Reference Meurer, DeNomie, Morzinski, Nelson and Meurer45].

Guided practicums enable learners to understand the community, learn from the community and understand the process of bidirectionality in acting on an issue (Box 1) [1,2]. An orientation session allows discussion about learning objectives and framing of the experience, and to have expectations laid out before the practicum and revisited during regular meetings between faculty and learners. Expectations on self-directed learning and availability for the program are crucial to a successful experience. A progress report generated around the middle of the program can allow discussion of the trajectory and potential adjustments. At the end of the program, an exit interview can assess accomplishments.

We emphasize that students embark on practicums only when both the student and the faculty (ideally with community member input) believe that the student is ready to interact with the community. This approach should be clarified and mutually agreed upon with the learners from the outset as part of the course orientation. The rationale is that sending students out to the community unprepared and unsupervised can jeopardize partnerships.

To teach the skills of seeking and incorporating community feedback and the return of results, we recommend that learners present their experiences or findings to the community members and/or community advisory boards and work with mentors to provide a final report back to the community involved in the learning experience.

Reflective Learning

Reflective exercises and facilitated discussions are essential to underscore the critical role of relationships in CE. Contemporaneously with structured didactics and practicums, self-awareness and reflective exercises help improve knowledge and skills and address misperceptions and even challenges related to CE. They reinforce the synergism across learning, action, and reflection [Reference Freire79]. Reflective learning exercises can adapt approaches used for understanding and teaching emotional intelligence, particularly those related to social change [Reference Abe34,Reference Basu and Clermont80–Reference Basu and Clermont80]. Keeping a reflective journal or field note during the experience is an excellent way to record thoughts and feelings about things that went well and those that did not go well or as expected. A formal debrief should be done in a safe environment focusing on lessons learned – what worked and what did not work and adaptations that were made. While this can be done as a one-on-one or self-guided exercise, it should ideally be conducted as a group exercise to share the lessons learned among learners.

Evaluation and Assessment Tools

Evaluation with formative and summative assessment should occur at various stages of the learning process to allow adjustments to be made [Reference Sadler83]. The course and learner experience should be evaluated by the learner, the facilitator, or the teacher with CE experience and community members [Reference Meurer, DeNomie, Morzinski, Nelson and Meurer45]. The evaluation framework of the AAMC Expert Panel is a good model for all participants in the course, including community members and faculty leads or facilitators (Table 2) [Reference Johnson, Fair, Howley, Prunuske and Cashman14]. A sample of evaluation areas is provided in Table 3, and an example is provided in the Tufts CTSA course [73].

Table 2. Examples from the Modified New World Kirkpatrick Evaluation Model

Abbreviations: CE = community engagement; CEnR=Community-Engaged Research.

¹Students, faculty, and community members who are learners of the CE education.

²Tools recommended include Center for Health Care Strategies, Inc.; Partnership Assessment Tool for Health; National Collaborating Centre for Methods and Tools Partnership Self-Assessment Tool; and The CDC’s Evaluation Guide: Fundamentals of Evaluating Partnerships [14].

³Some examples of community health indicators can be found in the Agency for Toxic Substances and Disease Registry (ATSDR) website including the Action Model [12].

Table 3. Sample evaluation components