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
Funding and conflicts of interest
• 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.
Project Aims
RQ1.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’…
Connected Communities:
Communities, Cultures and Health & Well-Being Research Development Workshop
(Cardiff, September 2011)
“I’m here because I’m interested in getting a
good definition of community engagement…”
“…Well when you find one let us know”
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
Economic
analysis
Statistical
synthesis
Synthesis of
process evals
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
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
Process evaluation of
community engagement
Implementation
Dimensions of engagement, e.g.
• engaged in strategy/ delivery
• state/ public initiated
• degrees of engagement
• individuals/ organised groups
People invited for;
• Ethics and democracy
• Better services and health
The public
Process evaluation of
community’s intervention
Models of engagement, e.g.
• consultations / service development
• community development
• grants for advocacy and support
• controlling local facilities (e.g. sport centre)
Reasons for
engaging
Populations:
• specific health needs
• socioeconomic disadvantages
People engage for;
• personal gains: wealth & health
• community gains
• ideologies
Communities:
• of geography
• of interests
Method of synthesis
Previous systematic reviews
Analysis
Literature searching
Conceptual
Framework
Synthesis
Coding
Inclusion/exclusion screening
Reading key located literature for barriers/facilitators of successful CE
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).
Community Engagement in Interventions: Conceptual Framework
Community engagement
(Health) intervention
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
Motivations
Community
Participation
Conditions
Actions
Impact
Definitions
Motivations
Community
Participation
Conditions
Actions
Impact
(Health) intervention
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
Motivations
Community
Participation
Conditions
Actions
Impact
Motivations
Community
Participation
Conditions
Actions
Impact
The public
Populations
• With specific
needs
• Socioeconomically
disadvantaged
Communities
• Of interests
• Of geography
Need/Issue
• Felt
• Expressed
• Comparative
• Normative
Definitions
(Health) intervention
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
The public
Populations
• With specific
needs
• Socioeconomically
disadvantaged
Communities
• Of interests
• Of geography
Need/Issue
• Felt
• Expressed
• Comparative
• Normative
Definitions
Motivations
Community
Participation
Conditions
Actions
Impact
Community
Participation
Conditions
Actions
Impact
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
Motivations
(Health) intervention
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
The public
Populations
• With specific
needs
• Socioeconomically
disadvantaged
Communities
• Of interests
• Of geography
Need/Issue
• Felt
• Expressed
• Comparative
• Normative
Definitions
Motivations
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
Motivations
Community
Participation
Conditions
Actions
Impact
Conditions
Actions
Impact
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
(Health) intervention
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
The public
Populations
• With specific
needs
• Socioeconomically
disadvantaged
Communities
• Of interests
• Of geography
Need/Issue
• Felt
• Expressed
• Comparative
• Normative
Definitions
Motivations
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
Motivations
Community
Participation
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
Conditions
Actions
Impact
Actions
Impact
Mediators of
Community
Engagement
• Communicative
competence
• Empowerment
• Attitudes
toward
expertise
Context
• Sustainability
• Context of the
‘outside world’
• Government
policy & targets
Conditions
(Health) intervention
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
The public
Populations
• With specific
needs
• Socioeconomically
disadvantaged
Communities
• Of interests
• Of geography
Need/Issue
• Felt
• Expressed
• Comparative
• Normative
Definitions
Motivations
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
Motivations
Community
Participation
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
Conditions
Actions
Mediators of
Community
Engagement
• Communicative
competence
• Empowerment
• Attitudes
toward
expertise
Process Issues
• Collective
decision-making
• Communication
• Training support
• Admin support
• Frequency
• Duration
• Timing
Context
• Sustainability
• Context of the
‘outside world’
• Government
policy & targets
Interventions
• Acceptability
• Feasibility
• Cost
Conditions
(Health) intervention
Actions
Impact
Impact
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
The public
Populations
• With specific
needs
• Socioeconomically
disadvantaged
Communities
• Of interests
• Of geography
Need/Issue
• Felt
• Expressed
• Comparative
• Normative
Definitions
Motivations
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
Motivations
Community
Participation
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
Conditions
Mediators of
Community
Engagement
• Communicative
competence
• Empowerment
• Attitudes
toward
expertise
Context
• Sustainability
• Context of the
‘outside world’
• Government
policy & targets
Conditions
(Health) intervention
Actions
Process Issues
• Collective
decision-making
• Communication
• Training support
• Admin support
• Frequency
• Duration
• Timing
Interventions
• Acceptability
• Feasibility
• Cost
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
Actions
Impact
Community Engagement in Interventions: Conceptual Framework
Community engagement
Definitions
The public
Populations
• With specific
needs
• Socioeconomically
disadvantaged
Communities
• Of interests
• Of geography
Need/Issue
• Felt
• Expressed
• Comparative
• Normative
Definitions
Motivations
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
Motivations
Community
Participation
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
Conditions
Mediators of
Community
Engagement
• Communicative
competence
• Empowerment
• Attitudes
toward
expertise
Context
• Sustainability
• Context of the
‘outside world’
• Government
policy & targets
Conditions
(Health) intervention
Actions
Process Issues
• Collective
decision-making
• Communication
• Training support
• Admin support
• Frequency
• Duration
• Timing
Interventions
• Acceptability
• Feasibility
• Cost
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
Actions
Impact
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…
Service
outcomes Social outcomes
Information
Consultation
The public
Participation
Peers
Health improvements
Health inequalities
Health outcomes
Empowerment
Patients
Community development
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
Theories of change identified in the
theoretical synthesis
1. Empowerment
2. Collaboration or consultation in intervention
design
3. Lay-delivery
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
Communityobserved
problem
Communityperceived causes
of problem
Community
mobilises into
action
Communitydesigned
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
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
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)
Theory of change for lay-delivered
interventions
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
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)
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
Statistical significance
• 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
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 2254yrs
Sex
– 60% (n = 79) mixed sex
– 37% (n = 49)
predominantly female
– 2% (n = 3)
predominantly male
Results: Health topic
Health Topics (N=131 studies)
18
18
16
14
14
13
13
12
12
10
8
6
4
2
0
8
7
6
6
6
5
5
4
4
3
2
2
1
1
1
Results: Overall meanVariation
effect
amongst
In general,
interventions
are effective!
studies needs to be
explained
Heterogeneity
Outcome
Pooled
95% C.I.
n
τ2
Q statistic
I2
effect size
estimate
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
.44***
.23, .65
7 .067
42.67***
85.94
Participant social
support
*** p < .001
Statistical significance indicates the effect size estimate is significantly different from zero
Note. 95% CI = 95% confidence interval
n = number of effect sizes
τ2 = between studies variance
Attempts to explain variation
• 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
Moderator of effect on health
behaviours: Theory of change
Direct comparisons
• 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)
Moderator of effect on health
behaviours: Marmot Review themes
Outcomes
Health behaviours a
Marmot Review theme
Mean ES
95% CI
n
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
.23**
.06, .40
17
Best start in life
.05
-.29, .39
7
Prevention of ill-health and
injury
.12
-.06, .30
14
Health consequences b
Modifiable health risks
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
The protocol of the review is available to download at
http://www.phr.nihr.ac.uk/
EPPI-Centre
Social Science Research Unit
Institute of Education
University of London
18 Woburn Square
London WC1H 0NR
Tel +44 (0)20 7612 6397
Fax +44 (0)20 7612 6400
Email [email protected]
Web eppi.ioe.ac.uk/
Thank you!
James Thomas [email protected]
Ginny Brunton [email protected]
Alison O’Mara-Eves [email protected]