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In addition to the concepts just summarized, the literature provides models and frameworks for understanding health promotion and health research that can be helpful in the practice of community engagement.
The social ecological model conceptualizes health broadly and focuses on multiple factors that might affect health. Both the community engagement approach and the social ecological model recognize the complex role played by context in the development of health problems as well as in the success or failure of attempts to address these problems. The same environment may have different effects on an individuala€™s health depending on a variety of factors, including perceptions of ability to control the environment and financial resources. There are personal and environmental a€?leverage points,a€? such as the physical environment, available resources, and social norms, that exert vital influences on health and well-being.
To inform its health promotion programs, CDC (2007) created a four-level model of the factors affecting health that is grounded in social ecological theory, as illustrated in Figure 1.2. The first level of the model (at the extreme right) includes individual biology and other personal characteristics, such as age, education, income, and health history.
The CDC model enables community-engaged partnerships to identify a comprehensive list of factors that contribute to poor health and develop a broad approach to health problems that involves actions at many levels to produce and reinforce change.
Individual: Conduct education programs to help people make wise choices to improve nutritional intake, increase their physical activity, and control their weight.
Interpersonal relationships: Create walking clubs and work with community groups to introduce healthy menus and cooking methods.
Community: Work with local grocery stores and convenience stores to help them increase the amount of fresh fruits and vegetables they carry. Society: Advocate for the passage of regulations to (1) eliminate soft drinks and high-calorie snacks from all schools, (2) ban the use of transa€“fatty acids in restaurant food, or (3) mandate that a percentage of the budget for road maintenance and construction be spent on creating walking paths and bike lanes. Long-term attention to all levels of the social ecological model creates the changes and synergy needed to support sustainable improvements in health. The Active Community Engagement (ACE) continuum provides a framework for analyzing community engagement and the role the community plays in influencing lasting behavior change. The continuum consists of three levels of engagement across five characteristics of engagement. The experience of the ACQUIRE team shows that community engagement is not a one-time event but rather an evolutionary process.
Everett Rogers (1995) defined diffusion as a€?the process by which an innovation is communicated through certain channels over time among the members of a social systema€? .
Rogers offered an early formulation of the idea that there are different stages in the innovation process and that individuals move through these stages at different rates and with different concerns. In Rogersa€™ first stage, knowledge, the individual or group is exposed to an innovation but lacks information about it. Rogers noted that the innovation process is influenced both by the individuals involved in the process and by the innovation itself. Awareness of the stages of diffusion, the differing responses to innovations, and the characteristics that promote adoption can help engagement leaders match strategies to the readiness of stakeholders.
The model addresses four dimensions of CBPR and outlines the potential relationships between each.

Models such as these are essential to efforts to empirically assess or evaluate community engagement practices and disseminate effective approaches. The components of translational research are understood differently by different authors in the field. One solution to this dilemma is practice-based research (PBR): engaging the practice community in research. This broad approach to thinking of health, advanced in the 1947 Constitution of the World Health Organization, includes physical, mental, and social well-being (World Health Organization, 1947). The second level, relationship, includes a persona€™s closest social circle, such as friends, partners, and family members, all of whom influence a persona€™s behavior and contribute to his or her experiences. Establish farmersa€™ markets that accept food stamps so that low-income residents can shop there. ACE was developed by the Access, Quality and Use in Reproductive Health (ACQUIRE) project team, which is supported by the U.S. The levels of engagement, which move from consultative to cooperative to collaborative, reflect the realities of program partnerships and programs. At each successive level of engagement, community members move closer to being change agents themselves rather than targets for change, and collaboration increases, as does community empowerment.
Communication, in turn, according to Rogers, is a a€?process in which participants create and share information with one another in order to reach a mutual understandinga€? . Thus, diffusion of innovation provides a platform for understanding variations in how communities (or groups or individuals within communities) respond to community engagement efforts.
In the second stage, persuasion, the individual or group is interested in the innovation and actively seeks out information.
Individuals include innovators, early adopters of the innovation, the early majority (who deliberate longer than early adopters and then take action), late adopters, and a€?laggardsa€? who resist change and are often critical of others willing to accept the innovation.
As a highly evolved collaborative approach, CBPR would be represented on the right side of the continuum shown in Figure 1.1. Next, group dynamicsa€¦interact with contextual factors to produce the intervention and its research design.
Increasingly, community participation is recognized as necessary for translating existing research to implement and sustain new health promotion programs, change clinical practice, improve population health, and reduce health disparities.
In one widely used schema, translational research is separated into four segments: T1a?’T4 (Kon, 2008). This approach focuses on integrating approaches to change the physical and social environments rather than modifying only individual health behaviors. The third level, community, explores the settings in which people have social relationships, such as schools, workplaces, and neighborhoods, and seeks to identify the characteristics of these settings that affect health. Work with the city or county to identify walking trails, parks, and indoor sites where people can go to walk, and publicize these sites. These three levels of community engagement can be adapted, with specific activities based on these categories of action.
At the final (collaborative) level, communities and stakeholders are represented equally in the partnership, and all parties are mutually accountable for all aspects of the project (Russell et al., 2008).

In the case of diffusion of innovation, the communication is about an idea or new approach.
In decision, the third stage, the individual or group weighs the advantages and disadvantages of using the innovation and decides whether to adopt or reject it. In CBPR, all collaborators respect the strengths that each brings to the partnership, and the community participates fully in all aspects of the research process. Using Internet survey methods and existing published literature, the study focused on two questions: What is the added value of CBPR to the research itself and to producing outcomes? Finally, intermediate system and capacity changes, and ultimately, health outcomes, result directly from the intervention research. The CTSA initiative is the primary example of an NIH-funded mechanism requiring a translational approach to the clinical research enterprise (Horowitz et al., 2009). T1 represents the translation of basic science into clinical research (phase 1 and 2 clinical trials), T2 represents the further research that establishes relevance to patients (phase 3 trials), T3 is translation into clinical practice, and T4 is the movement of a€?scientific knowledge into the public sectora€¦ thereby changing peoplea€™s everyday livesa€? through public and other policy changes. They note that although the majority of patients receive most of their medical care from a physician in a community setting, most clinical research takes place in an academic setting (Westfall et al., 2007).
Like all efforts in engagement, developing PBR includes building trust, sharing decision making, and recognizing the expertise of all partners.
If the area needs additional venues for exercise, build community demand and lobby for new areas to be built or designated. The ACE continuum is based on a review of documents, best practices, and lessons learned during the ACQUIRE project; in a paper by Russell et al. Understanding the diffusion process is essential to community-engaged efforts to spread innovative practices in health improvement. If adoption occurs, the individual or group moves to the fourth stage, implementation, and employs the innovation to some degree. Although CBPR begins with an important research topic, its aim is to achieve social change to improve health outcomes and eliminate health disparities (Israel et al., 2003). What are the potential pathways to intermediate system and capacity change outcomes and to more distal health outcomes? Consequently, the results of clinical trials may not be easily generalized to real-world clinical practices.
Work with local employers to develop healthier food choices on site and to create other workplace health programs. During this stage, the usefulness of the innovation is determined, and additional information may be sought. In the fifth stage, confirmation, the individual or group decides whether to continue using the innovation and to what extent.

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