Community development and public health are often viewed as parallel efforts – twin silos of separate work which just happen to have some goals in common.
But they are in fact profoundly interconnected, and new evidence suggests that practitioners and funders in both fields could benefit from building tighter organizational relationships that give community-based organizations more agency in their interactions with the public health sector. A pair of recent studies illuminate problems with the current state of those interactions and offer case studies for how to improve these vital relationships. By examining these studies, we can better understand the transformative potential of integrating community-based approaches into public health strategies, particularly for marginalized populations.
Historical and ongoing health disparities have shaped the relationship between public health and community development, creating a deep-seated mistrust between communities and health departments. The medical establishment’s history of mistreating Black Americans from experiments on enslaved people and forced sterilizations to the Tuskegee syphilis study has left many marginalized communities wary of public health initiatives. This mistrust persists even among Black medical professionals and is compounded by contemporary experiences of discrimination in healthcare. Studies show that medical mistrust stems not only from past mistreatment but also from ongoing inequities in healthcare. Black Americans are consistently provided less-modern and less-effective care, undertreated for pain and discharged earlier than White patients. This mistrust extends beyond interactions with doctors and hospitals to also erode confidence in public health officials and programs – which are crucial to solving upstream causes of health disparities.
Barriers: Distrust and Disempowerment
One study conducted during the COVID-19 pandemic surveyed community-based organizations (CBOs) and large metropolitan health departments to identify barriers and opportunities for fostering robust community partnerships in public health.
The study highlighted not just the deep-seated mistrust discussed above, but also a subtle contrast in views toward it: Public health officials are significantly more optimistic about how much progress they are making to build trust in marginalized communities than are the groups that actually work in those communities. Nearly half of public health departments surveyed said that “trust was mixed but that progress had been made.” But when a similar question was put to CBOs, just 28% said trust levels are mixed but improving, while 18% said they are getting worse.
Oddly, while public health officials appear more optimistic about their rate of progress, they are more cynical about the current state of affairs than their community counterparts: While only 18% of CBO respondents reported high levels of trust between communities and health departments, a far lower 11% of public health department respondents said they enjoy a high level of community trust.
Public health efforts often operate in silos, isolated within health departments and lacking integration with broader community initiatives. This issue is compounded by funding that is often disease-specific and doesn’t align with the varied needs of CBOs. A reported 91% of CBOs were asked for input on community concerns in the past year – but only 29% are actually involved in setting priorities, and just 15% have an actual say in funding decisions. This indicates a severe lack of shared decision-making between CBOs (who say trust levels are a bit better, but not growing very quickly) and health departments (who believe they are less trusted but are building trust faster).
The study authors leave it to the reader to imagine how public health workers’ apparent overestimation of how effectively they’re combating mistrust might connect to the frustrations community representatives report with being cut out from actually shaping policy implementation beyond being asked for their thoughts.
Opportunities: Case Studies for Effective Community Partnerships
Another study explored the potential for partnerships between public health NGOs and community power-building organizations. The study underscored the significant disconnect between these sectors through qualitative interviews with representatives from 22 national public health NGOs and 13 community power-building organizations. Major findings included a lack of mutual understanding, where public health NGOs and community power-building organizations share similar goals but lack collaboration. A language divide often exacerbates this disconnect; while both sectors aim to improve community health, they employ different methods and terminologies that hinder effective communication and partnership.
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Public health NGOs often focus on traditional health issues, while community power-building organizations address broader social determinants such as housing, worker rights and environmental justice. This divergence in focus contributes to the advocacy gaps observed, as public health NGOs typically do not engage in advocacy around upstream determinants of health. This lack of engagement is often due to restrictions on advocacy activities, especially for those NGOs that receive government funding, which can prohibit them from participating in certain types of advocacy. This limitation stands in contrast to community power-building organizations, for which advocacy on these broader issues is central to their missions.
The lingering confusion within each group about what precisely the other exists to do may have been compounded by what community power-building organizations saw from governments and other public health actors at the height of pandemic-era lockdowns. As the authors put it (emphasis added):
Some perceived public health as backing away from the bold, structurally focused policy stances that it adopted early in the COVID-19 pandemic, such as halting evictions and enacting worker protections. Community power–building organizations had learned that these policy stances were possible and questioned why they are deemed less necessary for their continually affected members now than at the height of the COVID-19 pandemic.
Bridging the Trust Gap
If public health actors want to build trust and break down barriers, the researchers suggest, they should make community groups a formal part of their process rather than informal or ad-hoc sources of consultation. They might establish state and local community advisory councils where CBOs participate in regular meetings to inform and guide public health decision-making. They might also dedicate flexible funding to these organizations whose programmatic work supports better organized communities and meets health-related social needs. Simplifying procurement and reporting processes, creating training and technical assistance programs for CBOs, increasing diversity among public health workers, and providing sustainable funding for community health workers were highlighted as crucial steps.
The studies also recommend creating a coordinated infrastructure for public health NGOs to support community power-building campaigns. Developing co-learning spaces to understand each other’s frameworks and approaches, and supporting narrative change by linking public health advocacy to broader social justice movements are also crucial.
What Does This Look Like?
The studies highlight successful community-led initiatives during the COVID-19 pandemic, such as the Black Boston COVID-19 Coalition and the Arkansas Coalition of Marshallese, which effectively utilized culturally relevant outreach to improve vaccination rates. The Black Boston COVID-19 Coalition advocated for a mass vaccination site in the heart of the Black community in Boston, ensuring that community members were employed to support the effort. Much of the initiative’s success was attributed to its culturally resonant messages and personal relationships, grounded in the trust created by the community-based employees, leading to higher community engagement and trust in vaccination efforts.
Concentrated immigrant populations bring unique cultural dynamics that can be pivotal in public health outreach. In Arkansas, for example, where there is a significant population of immigrants from the Marshall Islands, the researchers report a successful, similarly bespoke outreach effort to the Black Boston COVID-19 Coalition. The Arkansas Coalition of Marshallese focused outreach on mothers, leveraging the matriarchal structure of Marshallese culture to disseminate information effectively and encourage vaccination. This culturally tailored approach resulted in increased engagement and vaccination among the Marshallese, a group that had been disproportionately affected by the pandemic.
Moving Forward
National organizations that wish to enhance their efforts in promoting health equity through community development can learn much from this research. These organizations can facilitate trust-building initiatives through transparent, ongoing dialogues with community members and CBOs. Establishing state and local community councils to formalize these relationships, and ensuring community voices are integral to decision-making processes are crucial steps. Advocating for more flexible and integrated funding models will allow CBOs to address a wide range of community needs. Providing support to CBOs in measuring the community health impact of these interventions will be necessary for public health to continue to defend these investments. Simplifying procurement and reporting processes can help them access and utilize funds more effectively.
Fostering partnerships between public health NGOs and community power-building organizations can help bridge advocacy gaps and drive systemic change in areas such as housing, worker rights, and environmental justice. Developing training programs and providing technical assistance can build CBOs’ capacity to engage in public health initiatives. Increasing diversity within public health roles and ensuring sustainable funding for these roles will enhance cultural competence and long-term community engagement.
These studies underscore the importance of integrating community-based approaches into public health strategies to achieve health equity – and to help create a public health system that truly serves all communities. This transformation is not only essential for addressing current health disparities but also for building resilient, empowered communities capable of driving long-term change.
Justin Sackey is a Health Equity Intern at NCRC.
Photo via New York National Guard on Flickr.
