community engagement strategies to reduce health inequalities: a multi-method systematic review of...
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Community engagement strategies to reduce health inequalities:
a multi-method systematic review of complex interventions.
James Thomas, Ginny Brunton, Alison O’Mara-Eves
EPPI-Centre, Social Science Research Unit, Institute of Education, University of London
• This project was funded by the UK National Institute for Health Research (NIHR) Public Health Research Programme. The views and opinions expressed by authors in this presentation are those of the authors and do not necessarily reflect those of the Public Health Research Programme, NIHR, NHS, or the Department of Health.
• This report is in press with Public Health Research.• Project conducted by a team of researchers at the
Institute of Education, London School of Economics, and University of East London. All authors declare no conflicts of interest.
Funding and conflicts of interest
Project AimsRQ1. What are the range of models and approaches underpinning community
engagement? RQ2. What are the mechanisms and contexts through which communities are engaged? RQ3. Which approaches to community engagement are associated with improved
health outcomes among disadvantaged groups? How do these approaches lead to improved outcomes?
RQ4. Which approaches to community engagement are associated with reductions in inequalities in health? How do these approaches lead to reductions in health inequalities?
RQ5. Which types of intervention work best when communities are engaged? RQ6. Is community engagement associated with better outcomes for some groups when
compared to others? (In particular, does it work better or less well for children and young people?)
RQ7. How do targeted and universal interventions compare in terms of community engagement and their impact on inequalities?
RQ8. What are the resource implications of effective approaches to community engagement?
Aims of this presentation
• What are the theories underpinning community engagement interventions to reduce health inequalities?
• How do these relate to the effectiveness (including cost effectiveness) and implementation of such interventions?
• How do these findings shape new understandings of community engagement?
What is ‘Community Engagement’?
Brief: Community engagement for health inequalities =
‘approaches to involve communities in decisions that affect them’…
’…groups with distinct health needs and/or demonstrable health inequalities’
‘Health inequalities’ = gaps in the quality of the health of different groups of people based on differences in social, economic, and environmental conditions. (Marmot et al. (2010) Fair society, healthy lives: the Marmot review.)
Go ask the ‘experts’…
“I’m here because I’m interested in getting a good definition of community engagement…”
“…Well when you find one let us know”
Connected Communities: Communities, Cultures and Health & Well-Being Research Development Workshop (Cardiff, September 2011)
Community engagement: Panacea…or Pandora’s box?
• Encourages social justice, public accountability and better interventions
• Can “give a voice to the voiceless”: those who are socially excluded and disengaged from services
• Theory behind recommendations for community engagement often not linked to empirical evidence
• Much uncertainty about processes
• Fragmented, questionably poor quality evidence base supporting the effectiveness and cost-effectiveness of community
Community engagement to reduce inequalities in health: a systematic review
Conceptual framework
Statistical synthesis
Synthesis of process evals
Economic analysis
Aim of Conceptual Framework (Synthesis 1)
• To identify the range of models and approaches underpinning community engagement (CE); and
• To identify the mechanisms and contexts through which communities are engaged.
Protocol: Community engagement
The public Populations: • specific health needs• socioeconomic disadvantages
Communities:• of geography• of interests
Reasons for engaging
People invited for;• Ethics and democracy• Better services and health
People engage for;• personal gains: wealth & health• community gains• ideologies
Dimensions of engagement, e.g.• engaged in strategy/ delivery• state/ public initiated• degrees of engagement • individuals/ organised groups
Models of engagement, e.g.• consultations / service development• community development• grants for advocacy and support• controlling local facilities (e.g. sport centre)
Outcomes• Personal development: numbers & inequalities engaged, valued and connected• Community development: social capital• Programme development: communities’ influence on service/ delivery/ access• Health: overall, disadvantaged groups, health inequalities• Economics: time & cost of engagement, services developed, costs saved
ImplementationProcess evaluation of community engagement
Process evaluation of community’s intervention
Method of synthesisPrevious systematic reviews
Literature searching
Inclusion/exclusion screening
Reading key located literature for barriers/facilitators of successful CE
Coding
Analysis
Conceptual FrameworkSynthesis
Data extraction/synthesis methods
• Narrative format– Described the models, context and mechanisms of the participants,
interventions and approach to community engagement
• Barriers to, and facilitators of, implementation – Taken from the process evaluations using a formally developed tool – Conducted after the tool had been piloted on a sample of studies
• Findings from meta-analysis and cost-resource analysis
• Iterative ‘drawing together’ of all the above
Results: Included studies
• In total, 943 located potential systematic reviews elicited a total of 7,506 primary study titles and abstracts.
• Searches of other sources provided an additional 1,961 primary study
titles and abstracts.
• Duplicate removal, retrieval and screening of full-text reports resulted in the final inclusion of 361 reports of 319 studies in the map.
• Also purposively selected process-only and background discussion papers that provided key examples of community engagement processes (n=33).
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivationsCommunity Participation
Community Participation
Definitions
Impact
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivationsCommunity Participation
Community Participation
Definitions
Communities• Of interests• Of geography
The public
Populations • With specific
needs•
Socioeconomically disadvantaged
Need/Issue• Felt• Expressed•
Comparative• Normative
Impact
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivationsCommunity Participation
Community Participation
Definitions
Communities• Of interests• Of geography
The public
Populations • With specific
needs•
Socioeconomically disadvantaged
Need/Issue• Felt• Expressed•
Comparative• Normative
People engage for:• Personal gains:
wealth / health• Community gains• Responsible
citizenship• Greater public
good / ideology
People invited for:• Ethics and
democracy• Better services and
health• Political alliances • Leveraging
resources
For intervention design:• Social learning• Social cognitive• Behavioral
Impact
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivations
Community Engagement in Interventions• Main focus• Secondary focus• Incidental focus
Activity and Extent of Community Engagement• Involved in
intervention: ‐ Design‐ Delivery• Community:‐ Leading‐ Collaborating‐ Consulted‐ Informed
Community Participation
Community Participation
Definitions
Communities• Of interests• Of geography
The public
Populations • With specific
needs•
Socioeconomically disadvantaged
Need/Issue• Felt• Expressed•
Comparative• Normative
People engage for:• Personal gains:
wealth / health• Community gains• Responsible
citizenship• Greater public
good / ideology
People invited for:• Ethics and
democracy• Better services and
health• Political alliances • Leveraging
resources
For intervention design:• Social learning• Social cognitive• Behavioral
Impact
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivations
Community Engagement in Interventions• Main focus• Secondary focus• Incidental focus
Activity and Extent of Community Engagement• Involved in
intervention: ‐ Design‐ Delivery• Community:‐ Leading‐ Collaborating‐ Consulted‐ Informed
Mediators of Community Engagement•
Communicative competence
• Empowerment
• Attitudes toward expertise
Context• Sustainability• Context of
the‘outside
world’• Government
policy & targets
Community Participation
Community Participation
Definitions
Communities• Of interests• Of geography
The public
Populations • With specific
needs•
Socioeconomically disadvantaged
Need/Issue• Felt• Expressed•
Comparative• Normative
People engage for:• Personal gains:
wealth / health• Community gains• Responsible
citizenship• Greater public
good / ideology
People invited for:• Ethics and
democracy• Better services and
health• Political alliances • Leveraging
resources
For intervention design:• Social learning• Social cognitive• Behavioral
Impact
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivations
Community Engagement in Interventions• Main focus• Secondary focus• Incidental focus
Activity and Extent of Community Engagement• Involved in
intervention: ‐ Design‐ Delivery• Community:‐ Leading‐ Collaborating‐ Consulted‐ Informed
Mediators of Community Engagement•
Communicative competence
• Empowerment
• Attitudes toward expertise
Context• Sustainability• Context of
the‘outside
world’• Government
policy & targets
Process Issues• Collective
decision-making
• Communication
• Training support
• Admin support
• Frequency• Duration• TimingInterventions• Acceptability• Feasibility• Cost
Community Participation
Community Participation
Definitions
Communities• Of interests• Of geography
The public
Populations • With specific
needs•
Socioeconomically disadvantaged
Need/Issue• Felt• Expressed•
Comparative• Normative
People engage for:• Personal gains:
wealth / health• Community gains• Responsible
citizenship• Greater public
good / ideology
People invited for:• Ethics and
democracy• Better services and
health• Political alliances • Leveraging
resources
For intervention design:• Social learning• Social cognitive• Behavioral
Impact
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivations
Community Engagement in Interventions• Main focus• Secondary focus• Incidental focus
Activity and Extent of Community Engagement• Involved in
intervention: ‐ Design‐ Delivery• Community:‐ Leading‐ Collaborating‐ Consulted‐ Informed
Mediators of Community Engagement•
Communicative competence
• Empowerment
• Attitudes toward expertise
Context• Sustainability• Context of
the‘outside
world’• Government
policy & targets
Process Issues• Collective
decision-making
• Communication
• Training support
• Admin support
• Frequency• Duration• TimingInterventions• Acceptability• Feasibility• Cost
Community Participation
Community Participation
Definitions
Communities• Of interests• Of geography
The public
Populations • With specific
needs•
Socioeconomically disadvantaged
Need/Issue• Felt• Expressed•
Comparative• Normative
People engage for:• Personal gains:
wealth / health• Community gains• Responsible
citizenship• Greater public
good / ideology
People invited for:• Ethics and
democracy• Better services and
health• Political alliances • Leveraging
resources
For intervention design:• Social learning• Social cognitive• Behavioral
Impact
Beneficiaries• Direct- Engagees• Indirect- Community- Service providers- Intervention - Government- Researchers
Outcomes• Empowerment• Self-esteem, skills• Social capital• Mutual learning•
Attitudes/knowledge
• Health
Potential harms• Social exclusion• Cost overrun• Attrition• Dissatisfaction
(Health) intervention
Community engagement
Community Engagement in Interventions: Conceptual Framework
Actions ImpactConditionsMotivations
ActionsDefinitions ConditionsMotivations
Community Engagement in Interventions• Main focus• Secondary focus• Incidental focus
Activity and Extent of Community Engagement• Involved in
intervention: ‐ Design‐ Delivery• Community:‐ Leading‐ Collaborating‐ Consulted‐ Informed
Mediators of Community Engagement•
Communicative competence
• Empowerment
• Attitudes toward expertise
Context• Sustainability• Context of
the‘outside
world’• Government
policy & targets
Process Issues• Collective
decision-making
• Communication
• Training support
• Admin support
• Frequency• Duration• TimingInterventions• Acceptability• Feasibility• Cost
Community Participation
Community Participation
Definitions
Communities• Of interests• Of geography
The public
Populations • With specific
needs•
Socioeconomically disadvantaged
Need/Issue• Felt• Expressed•
Comparative• Normative
People engage for:• Personal gains:
wealth / health• Community gains• Responsible
citizenship• Greater public
good / ideology
People invited for:• Ethics and
democracy• Better services and
health• Political alliances • Leveraging
resources
For intervention design:• Social learning• Social cognitive• Behavioral
Impact
Beneficiaries• Direct- Engagees• Indirect- Community- Service providers- Intervention - Government- Researchers
Outcomes• Empowerment• Self-esteem, skills• Social capital• Mutual learning•
Attitudes/knowledge
• Health
Potential harms• Social exclusion• Cost overrun• Attrition• Dissatisfaction
What are the underlying mechanisms/contexts?
Utilitarian perspective• Pragmatic• Health systems focused• Those who initiate
engagement define ‘the community’
• Underlying mechanism: ‘engagement’ may lead to better design/delivery
• Understanding what features of engagement improve effectiveness is critical
Social justice perspective• Community empowerment• Democratic right• Power shared/redistributed• Underlying mechanism: if
people are ‘signed up’ to the intervention/programme, participation and health improvements more likely
• Understanding how and why people ‘sign up’ is critical
The issue
The literature included in the review did not fall neatly into either one paradigm or the other…
The public
Patients
Peers
Community development
Consultation
Information
Participation
Empowerment
Service outcomes Social outcomes
Health outcomes
Health improvements
Health inequalities
Community empowerment
Need to bridge utilitarian and social justice rationales for empowerment
Unpacking ‘engagement’
1. Did the community identify the health need?2. Level of engagement in design
– Informed– Consulted– Collaborating– Leading
3. Level of engagement in delivery– Informed– Consulted– Collaborating– Leading
1. Empowerment2. Collaboration or consultation in intervention
design3. Lay-delivery
Theories of change identified in the theoretical synthesis
Theory of change for empowerment
Change is facilitated where the health need is identified by the community and they mobilise themselves into action.
Example: inner-city childhood immunisation initiative
Community- observed problem
Community- perceived causes of
problem
Community mobilises into
action
Community-designed
intervention programme
Intervention is more appropriate
and greater community
ownership than before
Outcomes (higher than they would have been due to empowerment)
Theory of change for collaboration or consultation in intervention design
Observed problem
Health service designs
intervention to tackle the problem
The views of stakeholders are
sought
Intervention is more appropriate
than before
Implement intervention (which has been altered by
stakeholders)
Outcomes (higher than they would have been due to stakeholder input)
The views of stakeholders are sought with the belief that the intervention will be more appropriate to the participants’ needs as a result. Example: healthy eating intervention
Theory of change for lay-delivered interventions
Observed problem
Health service designs intervention
to tackle the problem
Peers deliver the intervention
Delivery more empathetic,
credible, etc. than before
Outcomes (higher than they would have been due to
peer delivery)
Change is believed to be facilitated by the credibility, expertise, or empathy that the community member can bring to the delivery of the intervention.
Example: breastfeeding support
Outcome types
• Health behaviours (n=105)– e.g. breastfeeding, attend cancer screening
• Health consequences (n=38)– e.g. mortality, diagnosis
• Participant self-efficacy (n=20)• Participant social support (n=7)• Also a small number of community outcomes
and ‘engagee’ outcomes – not meta-analysed
• Significant statistical heterogeneity was expected in this review• “When operating across such a wide range of topics,
populations and intervention approaches, however, there is a disjunction between the conceptual heterogeneity implied by asking broad questions and the methods for analysing statistical variance that are in our ‘toolbox’ for answering them”
• Potential confounding variables or interactions amongst variables made it difficult to disentangle unique sources of variance across the studies
• Emphasis on magnitude of the effects and trends across studies
Statistical significance
The results
Results: Effectiveness studies (N = 131)
Countries– 4% (n = 5) UK– 86% (n = 113) USA– 4% (n = 5) Canada– 6% (n = 8) other OECD
Population/Health inequalities– 43% (n = 56) ethnic minorities– 26% (n = 34) low socioeconomic
position– 16% (n = 21) multiple health
inequalities
Age ranges– 60% (n = 79) young
people 11-21yrs– 50% (n = 65) adults 22-
54yrs
Sex– 60% (n = 79) mixed sex– 37% (n = 49)
predominantly female– 2% (n = 3)
predominantly male
Results: Health topic
Substance
abuse
Cardiovascu
lar dise
ase
Breastfeeding
Obesity prevention / w
eight reducti
on
Smoking cessa
tion
Public health
/ Health
promotion/ p
revention
Antenatal (prenatal) c
are
Cancer p
revention
Diabetes prevention/ m
anagement
Physical a
ctivity
Healthy eating/ n
utrition
Parenting
Immunisa
tion
Injury prevention
Smoking/tobacco
prevention
Child illn
ess and ill
health
Disabiliti
es & ch
ronic i
llness
Child abuse prevention
Hypertensio
n
Infant morta
lity0
2
4
6
8
10
12
14
16
1818
1413 13
12
87
6 6 65 5
4 43
2 21 1 1
Health Topics (N=131 studies)
Results: Overall mean effect
*** p < .001Statistical significance indicates the effect size estimate is significantly different from zero Note. 95% CI = 95% confidence intervaln = number of effect sizesτ2 = between studies variance
Heterogeneity
Outcome Pooled effect size estimate
95% C.I. n τ2 Q statistic I2
Health behaviours .33*** .26, .40 105 .093 604.62*** 82.80
Health consequences .16** .06, .27 38 .076 196.36*** 81.16
Participant self-efficacy .41** .16, .65 20 .278 480.44*** 96.05
Participant social support
.44*** .23, .65 7 .067 42.67*** 85.94
In general, interventions are effective!
Variation amongst studies needs to be explained
• Conducted moderator and regression analyses• Most of the analyses conducted on health
behaviour outcomes only because of small number of data points
• Not unexpected: none of the variables tested were statistically significant predictors of effect.
• Emphasis on trends across the data
Attempts to explain variation
Moderator of effect on health behaviours: Theory of change
• Most interventions were compared to a comparison condition that differed from the intervention in more ways than just community engagement
• For health behaviour outcomes, there were seven studies for which the only difference between the treatment conditions was the presence or absence of community engagement
• Analysis did not detect a significant difference between the studies with a direct comparison (effect size = .34) or indirect comparison (effect size = .33)
Direct comparisons
Moderator of effect on health behaviours: Marmot Review themes
Outcomes Marmot Review theme Mean ES 95% CI nHealth behaviours a
Modifiable health risks .24*** .11, .37 34
Best start in life .38*** .19, .56 24
Prevention of ill-health and injury .38*** .28, .48 47
Health consequences b
Modifiable health risks .23** .06, .40 17
Best start in life .05 -.29, .39 7
Prevention of ill-health and injury .12 -.06, .30 14
Other moderators tested
• Single component interventions tended to be more effective at improving health behaviours than multiple component interventions
• Universal interventions tended to have higher effect size estimates for health behaviour outcomes than targeted interventions.
Features of the interventions• Interventions conducted in non-community settings tended to be
more effective than those in community settings for health behaviour outcomes.
• Interventions that employed skill development or training strategies, or which offered contingent incentives, tended to be more effective than those employing educational strategies for health behaviour outcomes.
• Interventions involving peers, community members, or education professionals tended to be more effective than those involving health professionals for health behaviour outcomes.
• Shorter interventions tended to be more effective than longer interventions for health behaviour outcomes; this is probably confounded by levels of exposure or intensity of contact with the intervention deliverer.
Conclusions
• Overall, public health interventions using community engagement strategies for disadvantaged groups are effective in terms of health behaviours, health consequences, participant self-efficacy, and participant perceived social support.
• These findings appear to be not due to systematic methodological biases.
Conclusions
• However, unexplained variation exists amongst the effect sizes
• “…the evidence suggests that community engagement in public health is more likely to require a ‘fit for purpose’ rather than ‘one size fits all’ approach.”
Conclusions• Strengths
– Theories of change helped us to articulate proposed causal mechanisms
– Effects were evident despite substantial heterogeneity • Limitations
– Broad scope didn’t enable us to identify the ‘active ingredients’ of community engagement (i.e., which components work?)
– Lack of direct comparisons mean we don’t know how much of the effect is unique to community engagement
• More work to be done to understand more about which components contributed to effectiveness– Different methods of analysis may be required– Theories of change need further development
Acknowledgements
Co-authors:
David McDaid, Sandy Oliver, Josephine Kavanagh, Farah Jamal, Tihana Matosevic, Angela Harden
Thanks also to authors of and participants in the reviewed studies
EPPI-CentreSocial Science Research UnitInstitute of EducationUniversity of London18 Woburn SquareLondon WC1H 0NR
Tel +44 (0)20 7612 6397Fax +44 (0)20 7612 6400Email [email protected] eppi.ioe.ac.uk/
The protocol of the review is available to download at http://www.phr.nihr.ac.uk/
Thank you!
James Thomas [email protected] Brunton [email protected]
Alison O’Mara-Eves [email protected]