Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis
TL;DR: A multimethod systematic review builds on the evidence that underpins the current UK guidance on community engagement to identify theoretical models underpinning community engagement and to explore mechanisms and contexts through which communities are engaged to identify community engagement approaches that are effective in reducing health inequalities.
Abstract: Background: Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base. Objectives: To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation. Data sources: Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included. Review methods: Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence. Results: The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework. Limitations: Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base. Conclusions: Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.
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TL;DR: There is solid evidence that community engagement interventions have a positive impact on a range of health outcomes across various conditions.
Abstract: Inequalities in health are acknowledged in many developed countries, whereby disadvantaged groups systematically suffer from worse health outcomes such as lower life expectancy than non-disadvantaged groups. Engaging members of disadvantaged communities in public health initiatives has been suggested as a way to reduce health inequities. This systematic review was conducted to evaluate the effectiveness of public health interventions that engage the community on a range of health outcomes across diverse health issues. We searched the following sources for systematic reviews of public health interventions: Cochrane CDSR and CENTRAL, Campbell Library, DARE, NIHR HTA programme website, HTA database, and DoPHER. Through the identified reviews, we collated a database of primary studies that appeared to be relevant, and screened the full-text documents of those primary studies against our inclusion criteria. In parallel, we searched the NHS EED and TRoPHI databases for additional primary studies. For the purposes of these analyses, study design was limited to randomised and non-randomised controlled trials. Only interventions conducted in OECD countries and published since 1990 were included. We conducted a random effects meta-analysis of health behaviour, health consequences, self-efficacy, and social support outcomes, and a narrative summary of community outcomes. We tested a range of moderator variables, with a particular emphasis on the model of community engagement used as a potential moderator of intervention effectiveness. Of the 9,467 primary studies scanned, we identified 131 for inclusion in the meta-analysis. The overall effect size for health behaviour outcomes is d = .33 (95% CI .26, .40). The interventions were also effective in increasing health consequences (d = .16, 95% CI .06, .27); health behaviour self-efficacy (d = .41, 95% CI .16, .65) and perceived social support (d = .41, 95% CI .23, .65). Although the type of community engagement was not a significant moderator of effect, we identified some trends across studies. There is solid evidence that community engagement interventions have a positive impact on a range of health outcomes across various conditions. There is insufficient evidence to determine whether one particular model of community engagement is more effective than any other.
281 citations
Cites background or methods from "Community engagement to reduce ineq..."
...The intervention ‘deliverer’ is the person who delivered the intervention, regardless o f their status as an engagee or professional [10]....
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...Data were extracted on models, approaches, and mech anisms of community engagement; health topic; participant characteristics; geograph ical and contextual details; costs and resources; and processes (the full data extraction to l is included in the report, [10])....
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...The search syntax strategies used are presented in Appendix A and the detailed screening and inclusion criteria are recorded in the full project report [10] and in a methodology paper [14]....
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...Full details of all these studies, with a detailed breakdown of the risk of bias assessment, can be found online at reference [10]....
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...This paper presents the results of a statistical an ysis that is one component in a broader project (reported in [10] )....
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TL;DR: The findings suggest that CE models can lead to improved health and health behaviours among disadvantaged populations if designed properly and implemented through effective community consultation and participation.
Abstract: Although community engagement (CE) is widely used in health promotion, components of CE models associated with improved health are poorly understood. This study aimed to examine the magnitude of th...
254 citations
Cites background or result from "Community engagement to reduce ineq..."
...Despite its potential for empowering disadvantaged populations, studies have shown that the majority of the health programmes use ‘top-down’ CE approaches, as opposed to ‘bottom-up’ participatory methods, which limit their impact upon health and health behaviours (44, 45)....
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...Overall, there is a lack of conclusive evidence on the role of CE in improving the health of disadvantaged populations and whether the identified improvements in health are due to the intervention itself, the CE approach, or both (45, 48)....
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...Overall, CE models identified in this review employed collaborative partnerships, bicultural CHWs, community participation, and power-sharing as key components of health interventions, a finding consistent with current evidence (45, 57, 80)....
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...CE model components impacting study outcomes The available literature on CE states that there is currently an evidence gap in understanding which CE components contribute to successful study outcomes (45, 48)....
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...(45) showed that the ongoing training of CHWs and the quality of relationships between them and the participants affected study outcomes....
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TL;DR: A range of levers for eliminating medical underuse and overuse are investigated, some of which could operate effectively (and be politically viable) across many different health and political systems whereas other levers must be tailored to local contexts.
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TL;DR: There is a clear need for research to better understand and evidence causal mechanisms and to explore the impact of social enterprise activity, and wider civil society actors, upon a range of intermediate and long-term public health outcomes.
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Cites background from "Community engagement to reduce ineq..."
...socs community-based solutions have gained prominence (Baum, 2008; O'Mara-Eves et al., 2013)....
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TL;DR: The Primary Health Care Performance Initiative has developed a framework to illustrate the relationship between key financing, workforce, and supply inputs, and core primary health care functions of first-contact accessibility, comprehensiveness, coordination, continuity, and person-centeredness.
Abstract: Primary health care (PHC) has been recognized as a core component of effective health systems since the early part of the twentieth century. However, despite notable progress, there remains a large gap between what individuals and communities need, and the quality and effectiveness of care delivered. The Primary Health Care Performance Initiative (PHCPI) was established by an international consortium to catalyze improvements in PHC delivery and outcomes in low- and middle-income countries through better measurement and sharing of effective models and practices. PHCPI has developed a framework to illustrate the relationship between key financing, workforce, and supply inputs, and core primary health care functions of first-contact accessibility, comprehensiveness, coordination, continuity, and person-centeredness. The framework provides guidance for more effective assessment of current strengths and gaps in PHC delivery through a core set of 25 key indicators (“Vital Signs”). Emerging best practices that foster high-performing PHC system development are being codified and shared around low- and high-income countries. These measurement and improvement approaches provide countries and implementers with tools to assess the current state of their PHC delivery system and to identify where cross-country learning can accelerate improvements in PHC quality and effectiveness.
147 citations
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TL;DR: Moher et al. as mentioned in this paper introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses, which is used in this paper.
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