Addressing diversity and complexity in the community engagement literature: The rationale for a realist review

Enhanced or hindered research benefits? A realist review of community engagement and participatory research practices for non-communicable disease prevention in low- and middle-income countries

INTRODUCTION

Community engagement and participatory research are widely used and considered important for ethical health research and interventions. Based on calls to unpack their complexity and observed biases in their favour, we conducted a realist review with a focus on non-communicable disease prevention. The aim was to generate an understanding of how and why engagement or participatory practices enhance or hinder the benefits of non-communicable disease research and interventions in low- and middle-income countries.

METHODS

We retroductively formulated theories based on existing literature and realist interviews. After initial searches, preliminary theories and a search strategy were developed. We searched three databases and screened records with a focus on theoretical and empirical relevance. Insights about contexts, strategies, mechanisms and outcomes were extracted and synthesised into six theories. Five realist interviews were conducted to complement literature-based theorising. The final synthesis included 17 quality-appraised articles describing 15 studies.

RESULTS

We developed six theories explaining how community engagement or participatory research practices either enhance or hinder the benefits of non-communicable disease research or interventions. Benefit-enhancing mechanisms include community members' agency being realised, a shared understanding of the benefits of health promotion, communities feeling empowered, and community members feeling solidarity and unity. Benefit-hindering mechanisms include community members' agency remaining unrealised and participation being driven by financial motives or reputational expectations.

CONCLUSION

Our review challenges assumptions about community engagement and participatory research being solely beneficial in the context of non-communicable disease prevention in low- and middle-income countries. We present both helpful and harmful pathways through which health and research outcomes are affected. Our practical recommendations relate to maximising benefits and minimising harm by addressing institutional inflexibility and researcher capabilities, managing expectations on research, promoting solidarity in solving public health challenges and sharing decision-making power.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Community Dynamics and Engagement Strategies in Establishing Demographic Development and Environmental Surveillance Systems: A Multi-Site Report from India

BACKGROUND

Six diverse Demographic Development and Environmental Surveillance System (DDESS) sites were established in urban slum, urban resettlement, peri-urban, rural, and tribal areas located in Northern, North-East, Eastern, and Southern regions of India from June 2020 to March 2022. Understanding the community dynamics and engaging people in the community is critically important in the process of establishing DDESS. We ascertained the barriers, challenges, and facilitators during the establishment of multiple DDESS sites across India.

METHODS

This was a cross-sectional descriptive mixed-methods study.

RESULTS

Multiple barriers and challenges encountered were reported in the process of community engagement (CE), such as geographical inaccessibility, language barriers, adverse weather, non-responsiveness due to perceived lack of individual benefit or financial gain, fear of contracting COVID-19, COVID-19 vaccine hesitancy, etc. Facilitators in the CE process were pre-existing links with the community, constitution of community advisory boards, community need assessment, concomitant delivery of outreach health services, and skill-building facilities.

CONCLUSION

Most community barriers in the development of DDESS sites in resource-limited settings can be overcome through a multipronged approach, including effective community engagement by focusing on demonstrating trust at the local level, enlisting community mobilization and support, utilizing pre-existing community linkages, initiating community diagnosis, and meeting perceived community health needs.

A realist review protocol on communications for community engagement in maternal and newborn health programmes in low- and middle-income countries

BACKGROUND

Community engagement (CE) has been increasingly implemented across health interventions, including for maternal and newborn health (MNH). This may take various forms, from participatory women's groups and community health committees to public advocacy days. While research suggests a positive influence of CE on MNH outcomes, such as mortality or care-seeking behaviour, there is a need for further evidence on the processes of CE in different settings in order to inform the future development and implementation of CE across programmes. Communication is an integral component of CE serving as a link between the programme and community. The aim of the realist review described in this protocol is to understand how, why, to what extent, and for whom CE contributes to intended and unintended outcomes in MNH programming, focusing on the communication components of CE.

METHODS

Realist review methodology will be used to provide a causal understanding of what communication for CE interventions in MNH programming work, for whom, to what extent, why, and how. This will be done by developing and refining programme theories on communications for CE in MNH through a systematic review of the literature and engaging key experts for input and feedback. By extrapolating context-mechanism-outcome configurations, this review seeks to understand how certain contexts trigger or inhibit specific mechanisms and what outcomes this interaction generates when communication in CE interventions is used in MNH programming.

DISCUSSION

A realist philosophy is well-suited to address the aims of this study because of the complex nature of CE. The review findings will be used to inform a realist evaluation case study of CE for an MNH programme in order to ascertain transferable findings that can inform and guide engagement activities in various settings. Findings will also be shared with stakeholders and experts involved in the consultative processes of the review (through workshops or policy briefs) in order to ensure the relevance of these findings to policy and practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022293564.

Community mobilization to strengthen support for appropriate and timely use of antenatal and postnatal care: A review of reviews

Background

Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies and parents/families to receive quality care and support from health services. Community-based interventions may improve the accessibility, availability, and acceptance of this vital care. For example, community mobilization strategies have been used to involve and collaborate with women, families and communities to improve maternal and newborn health.

Objective

To synthesize existing reviews of evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC and PNC.

Methods

Six databases (MEDLINE, Embase, CINAHL, PsychINFO, Cochrane Library, PROSPERO) were searched for published reviews that describe community mobilization related strategies for ANC and/or PNC. Reviews were eligible for inclusion if they described any initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low- or middle-income country (LMIC), published after 2000. Included reviews were critically appraised according to the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Evidence Syntheses. This review of reviews was conducted following JBI guidelines for undertaking and reporting umbrella reviews.

Results

In total 23 papers, representing 22 reviews were included. While all 22 reviews contained some description of community mobilization and ANC/PNC, 13 presented more in-depth details on the community mobilization processes and relevant outcomes. Seventeen reviews focused on ANC, four considered both ANC and PNC, and only one focused on PNC. Overall, 16 reviews reported at least one positive association between community mobilization activities and ANC/PNC uptake, while five reviews presented primary studies with no statistically significant change in ANC uptake and one included a primary study with a decrease in use of antenatal facilities. The community mobilization activities described by the reviews ranged from informative, passive communication to more active, participatory approaches that included engaging individuals or consulting local leaders and community members to develop priorities and action plans.

Conclusions

While there is considerable momentum around incorporating community mobilization activities in maternal and newborn health programs, such as improving community support for the uptake of ANC and PNC, there is limited evidence on the processes used. Furthermore, the spectrum of terminology and variation in definitions should be harmonized to guide the implementation and evaluation efforts.

fM-aM Detection of the SARS-CoV-2 Antigen by Advanced Lateral Flow Immunoassay Based on Gold Nanospheres

The SARS-CoV-2 global pandemic created an unprecedented need for rapid, sensitive, and inexpensive point-of-care (POC) diagnostic tests to treat and control the disease. Many POC SARS-CoV-2 lateral flow immunoassays (LFAs) have been developed and/or commercialized, but with only limited sensitivity (μM-fM). We created an advanced LFA based on gold nanospheres (GNSs) with comprehensive assay redesign for enhanced specific binding and thermal contrast amplification (TCA) on GNSs for signal amplification, which enabled fM-aM detection sensitivity for SARS-CoV-2 spike receptor-binding domain (RBD) proteins within 30 min. The advanced LFA can visually detect RBD proteins down to 3.6 and 28.6 aM in buffer and human nasopharyngeal wash, respectively. This is the first reported LFA achieving sensitivity comparable to that of the PCR (aM-zM) by visual reading, which was much more sensitive than traditional LFAs. We also developed a fast (<1 min) TCA reading algorithm, with results showing that this TCA could distinguish 26-32% visual false negatives for clinical commercial LFAs. When our advanced LFAs were applied with this TCA, the sensitivities were further improved by eightfold to 0.45 aM (in buffer) and 3.6 aM (in the human nasopharyngeal wash) with a semiquantitative readout. Our proposed advanced LFA with a TCA diagnostic platform can help control the current SARS-CoV-2 pandemic. Furthermore, the simplicity and speed with which this assay was assembled may also facilitate preparedness for future pandemics.

Venous thromboembolism in non-COVID-19 population during the pandemic: a nationwide multicenter retrospective survey

Impact of pandemic on the incidence of venous thromboembolism (VTE) in non-COVID-19 patients is undetermined. Thus, a nationwide multicenter retrospective survey was conducted to evaluate the disease burden in non-COVID-19 population. This multi-center survey involved 94 hospitals from 24 provinces in the mainland of China, and collected data on non-COVID-19 patients admitted to the radiology departments due to VTE between January 24 and April 16, 2020. Baseline characteristics, VTE risk factors, clinical manifestations and the treatments were compared with those in the same period of 2019. 3,358 patients with VTE from 74 hospitals were included in this study (1,458 in 2020, 1,900 in 2019). Most aged ≥ 50 years (80.6% in the pandemic, 81.2% in 2019). The number of patients aged 30-39 years increased from 3.9% in 2019 period to 5.8% in the pandemic (p = 0.009). Among the VTE risk factors, the rate of decreased activity increased significantly in the pandemic, and was much higher than that in 2019 (30.7% vs 22.6%, p < 0.0001). Under the risk of decreased activity, patients with comorbidities chronic diseases, especially diabetes, showed significantly a higher incidence of VTE (30.4% vs 22.0%, p < 0.0001). In the pandemic period, fewer patients were treated with anticoagulation alone (33.5% vs 36.7%, p = 0.05), and more underwent inferior vena cava filter (IVCF) implantation, compared with those in 2019 (66.5% vs 63.2%, p = 0.046). The pandemic increased the VTE risk of decreased activity among the non-COVID-19 population. Patients with comorbidities, especially diabetes, have a significant higher risk of VTE during the pandemic.

Community mobilisation approaches to preventing and reducing adolescent multiple risk behaviour: a realist review protocol

BACKGROUND

Adolescent multiple risk behaviour (MRB) continues to be a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, rather than targeting the wider environmental or structural context. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. Despite this, there are gaps in the current literature, theory and implementation that would benefit from a realist approach due to the suitability of this methodology to analysing complex interventions. The objective of this study is to understand 'how, why, for whom and in what circumstances and time periods' do community mobilisation interventions work to prevent and/or reduce adolescent multiple risk behaviour.

METHODS

This is a protocol for a realist review. The review will use a six-stage iterative process, guided by the RAMESES framework. We will systematically search PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies will be screened for relevance to the programme theory and included based on a priori eligibility criteria including (1) reporting a community mobilisation intervention (2) targeting two health risk behaviors (3) for adolescent populations. Two independent reviewers will select, screen and extract data related to the program theory from all relevant sources. A realist logic of analysis will be used to identify all context-mechanism-outcome configurations that contribute to our programme theory. The findings will be synthesised to produce a refined programme theory model.

DISCUSSION

The goal of this realist review is to identify and refine a programme theory for community mobilisation approaches to the prevention and/or reduction of adolescent multiple risk behaviour. Our aim is that the findings surrounding the programme theory refinement can be used to develop and implement adolescent multiple risk behaviour interventions and maintain collaboration between local policy makers, researchers and community members.

SYSTEMATIC REVIEW REGISTRATION

This realist review is registered on the PROSPERO database (registration number: CRD42020205342).

Comparison of infection control strategies to reduce COVID-19 outbreaks in homeless shelters in the United States: a simulation study

BACKGROUND

COVID-19 outbreaks have occurred in homeless shelters across the US, highlighting an urgent need to identify the most effective infection control strategy to prevent future outbreaks.

METHODS

We developed a microsimulation model of SARS-CoV-2 transmission in a homeless shelter and calibrated it to data from cross-sectional polymerase chain reaction (PCR) surveys conducted during COVID-19 outbreaks in five homeless shelters in three US cities from March 28 to April 10, 2020. We estimated the probability of averting a COVID-19 outbreak when an exposed individual is introduced into a representative homeless shelter of 250 residents and 50 staff over 30 days under different infection control strategies, including daily symptom-based screening, twice-weekly PCR testing, and universal mask wearing.

RESULTS

The proportion of PCR-positive residents and staff at the shelters with observed outbreaks ranged from 2.6 to 51.6%, which translated to the basic reproduction number (R₀) estimates of 2.9-6.2. With moderate community incidence (~ 30 confirmed cases/1,000,000 people/day), the estimated probabilities of averting an outbreak in a low-risk (R₀ = 1.5), moderate-risk (R₀ = 2.9), and high-risk (R₀ = 6.2) shelter were respectively 0.35, 0.13, and 0.04 for daily symptom-based screening; 0.53, 0.20, and 0.09 for twice-weekly PCR testing; 0.62, 0.27, and 0.08 for universal masking; and 0.74, 0.42, and 0.19 for these strategies in combination. The probability of averting an outbreak diminished with higher transmissibility (R₀) within the simulated shelter and increasing incidence in the local community.

CONCLUSIONS

In high-risk homeless shelter environments and locations with high community incidence of COVID-19, even intensive infection control strategies (incorporating daily symptom screening, frequent PCR testing, and universal mask wearing) are unlikely to prevent outbreaks, suggesting a need for non-congregate housing arrangements for people experiencing homelessness. In lower-risk environments, combined interventions should be employed to reduce outbreak risk.

A funfair without the candy floss: engaging communities to prevent diabetes in Nepal

OBJECTIVES

The World Health Organization estimates that 422 million people have diabetes, three-quarters of whom live in low- and middle-income countries. Global action plans to address non-communicable diseases (NCDs) recognise the centrality of community engagement to create an enabling environment within which to address risk factors.

STUDY DESIGN

In this article, we describe and critically reflect on a cocreated community engagement approach to address type 2 diabetes in the southern plains of Nepal. We coproduced the engagement approach with 40 artists from the Janakpur Women's Development Centre to create an environment for dialogue about diabetes and NCD risk between artists and the general public.

METHODS

We used participatory action research to produce contextually relevant interactive methods and materials. Methods included artists' peer research to inform creative workshops, a drama performed in 19 villages and a two-day funfair in a public park. We used qualitative and participatory methods to analyse the effect of this engagement and reflect on lessons learned.

RESULTS

Around 2000 people saw the drama, and around 4000 people attended the funfair. Community dialogue about prevention of diabetes was facilitated by drama and through games and songs at the funfair. Artists grew confident to interact with their peers and drama audiences about the causes of diabetes and prevention strategies. Despite crowds at the funfair, it was difficult to reach women because the venue was often used by men and boys, and patriarchal norms prevent women from free movement. Village interactions were able to engage a more mixed audience.

CONCLUSION

Innovative, asset-based community engagement about diabetes and other NCDs at scale is possible through locating, building on and strengthening community resources to address local health issues. Engagement could be enhanced by considering the gendered nature of community engagement spaces and by increasing opportunities for interaction between artists and the general public through more intimate and large-scale events.