BHD421 Module 1 Case-
Module 1 – Case
PLEASE READ ATTACHMENTS FOR REQUIRED READING BEFORE STARTING ASSIGNMENT
INTRODUCTION TO COMMUNITY HEALTH
Assignment Overview
Understanding conceptually a community is critical to understanding this course. After reading the appropriate articles and websites listed on the Background page you should have a good understanding of what is a community and some of the differences between community health and public health.
Case Assignment
In responding to the questions below, I want you to immerse yourself into this course and try to think out of the box. Research points or questions you may not understand running key words through Google or another search engine. Remember, we dont require examinations at TUI University but we do want you to demonstrate through the written word that you understand the key concepts presented in the course.
Please briefly answer the following questions:
Which factor do you believe most affects the health of the community? Generally, these factors are classified as physical factors, social and cultural factors, community organization, and individual behavior. Please justify your response.
Define community, community health and public health. Discuss the domains of personal and community health within the context of the community.
Discuss and explain community health practices and what are their relationship to promoting a healthy community.
Explain health disparity and their causes? Identify the problems related to health disparity.
Discuss and explain a particular Social Determinant of Health that you consider to be the most important that can be improved by changing or modifying public policy as described by Richard Wilkinson and Michael Marmot in the WHO (2008) “Closing the gap in a generation” article.
Please submit your Case Assignment by the end of Module 1. Please refer to the Trident calendar for exact due dates. Please contact me at any time should you have any questions.
Assignment Expectations
You are expected to consult the scholarly literature in preparing your paper; you are also expected to incorporate relevant background readings.
Your paper should be written in your own words. This will enable your instructor to assess your level of understanding.
In order to earn full credit, you must clearly show that you have read ALL required Background materials.
Be sure to cite your references in the text of all papers and on the reference list at the end. For examples, look at the way the references are listed in the modules and on the Background reading list. Remember, any statement that you make that is not common knowledge or that originates from your synthesis or interpretation of materials you have read must have a citation associated with it. For guidelines on in-text citations, visit the following website: https://owl.english.purdue.edu/owl/resource/560/02/
Proofread your paper to be sure grammar and punctuation are correct and that each part of the assignment has been addressed clearly and completely.
Your assignment will not be graded until you have submitted an Originality Report with a Similarity Index (SI) score <15% (excluding direct quotes, quoted assignment instructions, and references). Papers not meeting this requirement by the end of the session will receive a score of 0 (grade of F). Papers with a lower SI score may be returned for revisions. For example, if one paragraph accounting for only 10% of a paper is cut and pasted, the paper could be returned for revision, despite the low SI score. Please use the report and your SI score as a guide to improve the originality of your work.
Length: This Case Assignment should be 3-5 pages (double-spaced) in length and should include 4-5 peer reviewed references, not counting the title and references page.
Note: Wikipedia is not an acceptable source of information.
RESEARCH ARTICLE
Community Participation in Health Systems
Research: A Systematic Review Assessing the
State of Research, the Nature of
Interventions Involved and the Features of
Engagement with Communities
Asha S. George*, Vrinda Mehra, Kerry Scott, Veena Sriram
Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United
States of America
* [emailprotected]
Abstract
Background
Community participation is a major principle of people centered health systems, with consid-
erable research highlighting its intrinsic value and strategic importance. Existing reviews
largely focus on the effectiveness of community participation with less attention to how com-
munity participation is supported in health systems intervention research.
Objective
To explore the extent, nature and quality of community participation in health systems inter-
vention research in low- and middle-income countries.
Methodology
We searched for peer-reviewed, English language literature published between January
2000 and May 2012 through four electronic databases. Search terms combined the con-
cepts of community, capability/participation, health systems research and low- and middle-
income countries. The initial search yielded 3,092 articles, of which 260 articles with more
than nominal community participation were identified and included. We further excluded
104 articles due to lower levels of community participation across the research cycle and
poor description of the process of community participation. Out of the remaining 160 articles
with rich community participation, we further examined 64 articles focused on service deliv-
ery and governance within health systems research.
Results
Most articles were led by authors in high income countries and many did not consistently list
critical aspects of study quality. Articles were most likely to describe community participa-
tion in health promotion interventions (78%, 202/260), even though they were less
PLOSONE | DOI:10.1371/journal.pone.0141091 October 23, 2015 1 / 25
a11111
OPEN ACCESS
Citation: George AS, Mehra V, Scott K, Sriram V
(2015) Community Participation in Health Systems
Research: A Systematic Review Assessing the State
of Research, the Nature of Interventions Involved and
the Features of Engagement with Communities.
PLoS ONE 10(10): e0141091. doi:10.1371/journal.
pone.0141091
Editor: Xia Li, Harbin Medical University, CHINA
Received: July 18, 2015
Accepted: October 5, 2015
Published: October 23, 2015
Copyright: 2015 George et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information file.
Funding: This work is supported by the Future
Health Systems Consortium (http://www.
futurehealthsystems.org). This document is an output
funded by the UK Aid from the UK Department for
International Development (DFID) for the benefit of
low and middle income countries. However, the views
expressed and information contained in it are not
necessarily those of or endorsed by DFID, which can
accept no responsibility for such views or information
or for any reliance placed on them.
http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0141091&domain=pdf
http://creativecommons.org/licenses/by/4.0/
http://www.futurehealthsystems.org
http://www.futurehealthsystems.org
participatory than other health systems areas. Community involvement in governance and
supply chain management was less common (12%, 30/260 and 9%, 24/260 respectively),
but more participatory. Articles cut across all health conditions and varied by scale and
duration, with those that were implemented at national scale or over more than five years
being mainstreamed by government. Most articles detailed improvements in service avail-
ability, accessibility and acceptability, with fewer efforts focused on quality, and few designs
able to measure impact on health outcomes. With regards to participation, most articles
supported communitys in implementing interventions (95%, n = 247/260), in contrast to
involving communities in identifying and defining problems (18%, n = 46/260). Many articles
did not discuss who in communities participated, with just over a half of the articles disag-
gregating any information by sex. Articles were largely under theorized, and only five men-
tioned power or control. Majority of the articles (57/64) described community participation
processes as being collaborative with fewer describing either community mobilization or
community empowerment. Intrinsic individual motivations, community-level trust, strong
external linkages, and supportive institutional processes facilitated community participation,
while lack of training, interest and information, along with weak financial sustainability were
challenges. Supportive contextual factors included decentralization reforms and engage-
ment with social movements.
Conclusion
Despite positive examples, community participation in health systems interventions was
variable, with few being truly community directed. Future research should more thoroughly
engage with community participation theory, recognize the power relations inherent in com-
munity participation, and be more realistic as to how much communities can participate and
cognizant of who decides that.
Introduction
Rationale
The Alma Ata Declaration in 1978 framed community participation as central to primary
healthcare [1]. It has also been enshrined as an important principle within rights based
approaches to health that has an intrinsic value in and of itself [2]. Since these landmark agree-
ments underpinning community participation, considerable experience has been built regard-
ing it, with ample debate and reflection regarding its definition, rationale and outcomes [311].
Community participation can be instrumental as working with communities can help make
interventions more relevant to local needs, informed by local knowledge and priorities, and
therefore more effective. More fundamentally, depending on the social processes involved, it
can also be transformative, helping to empower and emancipate marginalized communities. At
the same time, community mobilization without attention to power relations can distort partic-
ipation from its developmental aims, exacerbate existing patterns of exclusion and further
entrench inequities.
Within the last ten years, the role of communities in health systems in low and middle
income countries (LMIC) increased in prominence as reviews highlighted the importance of
demand side issues [12, 13]. Subsequently, effectiveness trials and systematic reviews
Community Participation in Health Systems Interventions
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Competing Interests: "The authors have declared
that no competing interests exist."
demonstrated the health impacts of community health workers [1416], womens groups [17,
18], and community initiatives that supported empowerment through micro-finance [19], rais-
ing the profile of community-level interventions as an area for further research and investment.
Moving beyond improving health practices, service access and intervention implementation,
attention to how communities play an essential role in governing health systems through vil-
lage health committees [20] and other forms of community accountability [21] has also been
recently foregrounded in health systems research.
While there is growing consensus on the value of community participation in health sys-
tems, there is variation in how communities are defined and understood. While communities
are often defined as being geographic, such as in villages or neighborhoods, they are not neces-
sarily territorial, as they can also include social groups united by activities or interests (such as
savings or labor groups), and in a range of spaces (whether for example, international or vir-
tual). The Latin word communitas combines the terms with/together with gift, as a broad
term for fellowship or organized society. In this sense, communities are constituted by those
with a shared social identity; that is of members with the same set of social representations,
which are the meanings, symbols and aspirations through which people make sense of their
world [22]. These are not purely markers of affinity, but also governed by power relations [23].
In this sense, communities are also heterogeneous and constitute sites of social exclusion [24,
25]. These social conditions are not permanent. Communities are also sites of empowerment,
where unequal relations can be challenged [24, 26, 27].
While a defining element in assessing community participation is the level of control or
power that communities command in an initiative [28], the terminology that categorizes the
processes and conditions by which communities are involved also at times blurred, ranging
from mobilization to empowerment. Some view community mobilization as mainly externally
driven [29], while others define it as how communities plan, carry out, and evaluate activities
on a participatory and sustained basis to improve their health and other needs, either on their
own initiative or stimulated by others [30]. Beyond community mobilization lies community
empowerment, the expansion of capability to participate in; negotiate with; influence, control,
and hold accountable institutions that affect the wellbeing of the community. It is through
empowerment that communities gain mastery over their lives and change their social and
political environment to improve their health and quality of life [31].
While multiple reviews have argued the value of community participation [311], evalua-
tions have largely focused on health outcomes. None assess the extent to which community
participation figures in research on health systems interventions. Hence, the purpose of this
review is to examine the size and scope of community participation in health systems interven-
tion research in low- and middle-income countries. It is not the intention of the review to pro-
vide a comprehensive catalogue of the literature on community participation, as this has
already been done by others [3, 4, 9, 29, 32, 33]. Our aim is to review how published health sys-
tems research, as one aspect of the health systems policy and research community, is engaging
with community participation. The findings are one input towards further understanding and
supporting community participation as a part of strengthening health systems research and
interventions at community level.
Objectives
The review sought to understand the extent, nature and quality of community participation in
health systems interventions research in LMICs. Participants included community members
involved in health systems intervention research in LMICs. As this was largely a qualitative
review, specific comparison interventions or populations were not sought and a broad array of
Community Participation in Health Systems Interventions
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study designs were considered eligible, whether experimental, descriptive or exploratory/
explanatory. Domains of interest captured by the review include the nature, scale and duration
of the interventions that enlisted community participation; its health systems area; type of
health conditions and health outcomes derived. With regards to community participation, the
review documented extent and depth of community participation; definitions and frameworks
used; facilitators and challenges to community participation.
Methods
A review protocol was developed and shared among team members to guide the review.
Information sources
We conducted a literature search in June, 2012, of four electronic databases: Pubmed, Embase,
Scopus/ Web of Science, Global Health (Ovid). Each database was searched from 2000 onwards
for articles containing concepts related to community, capabilities, health systems research and
LMICs (Table 1).
Article selection
The titles and abstracts of all articles found through the electronic search were combined to
form a database and duplicates were removed. In step 1, the titles and abstracts of all unique
articles were examined independently by two reviewers, who assessed whether the article
should be included or excluded according to our inclusion and exclusion criteria (Table 2).
Articles on which there was a consensus for exclusion, based on the title and abstract, were
excluded automatically. All titles and abstracts assessed as meeting the inclusion criteria by the
reviewers and about which the reviewers felt uncertain or disagreed were reviewed by the lead
researcher (AG) and discussed with the team to develop consensus on inclusion or exclusion.
In step two, full-text versions of all the articles retained in the review were then accessed. These
articles were again assessed independently by the review team according to the inclusion and
exclusion criteria. All included full-text articles and articles for which there was uncertainty or
disagreement were again discussed as a group and assessed by the lead researcher before final-
izing the dataset.
Table 1. Concepts and associated terms used in literature search.
Concept Search terms
Community "Community Networks"[Mesh] OR "Community "[text word] OR Communities [text word] OR "Community Health
Planning"[Mesh] OR "Community-Institutional Relations"[Mesh]
Capability/
Participation
"Capacity Building"[Mesh] OR Capability [text word] OR Capacity [text word] OR Capacities [text word] OR Capabilities
[text word] OR empowerment [text word] OR participation [text word] OR involvement [text word]
Health System
Research
"Health Services Research" [Mesh] OR "Community-Based Participatory Research" [Mesh] OR "Operations Research" [Mesh]
OR OR Qualitative Research [Mesh] OR "Evaluation Studies as Topic" [Mesh] OR "Evaluation Studies" [Publication Type] OR
"Health Care Evaluation Mechanisms" [Mesh] OR "Program Evaluation" [Mesh] OR "Health Care Quality, Access, and
Evaluation" [Mesh] OR "Health Services Research" [Mesh]
LMICs "Lower-middle-income economies"[tiab] OR low income economies[tiab] OR "Developing countries"[mh] OR "developing
countries"[tiab] OR "developing country"[tiab] OR "under-developed countries"[tiab] OR "under-developed country"[tiab] OR
"third-world countries"[tiab] OR "third-world country"[tiab] OR "developing nations"[tiab] OR "developing nation"[tiab] OR "under-
developed nations"[tiab] OR "third-world nations"[tiab] OR "third-world nation"[tiab] OR "less-developed countries"[tiab] OR "less-
developed country"[tiab] OR "less-developed nations"[tiab] OR low and middle income countries[tiab] OR lmic[tiab] OR low
income country[tiab] OR low income countries[tiab] OR lower income countries[tiab] OR middle income country[tiab] OR middle
income countries[tiab] OR lower middle income country[tiab] OR lower middle income countries[tiab] OR Afghanistan . . .
Zimbabwe[tiab]
doi:10.1371/journal.pone.0141091.t001
Community Participation in Health Systems Interventions
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Data collection process and data items
Continuing with step two, an abstraction form was created in Microsoft Excel to facilitate
extraction of information from each article on key aspects describing community participation
and health systems intervention research as listed under objectives earlier. We assessed study
drawing from the Critical Appraisal Skills Program and elements of rigor in health policy and
systems research [34, 35]. From these sources, we derived four broad categories in our assess-
mentsampling, data collection, analysis and trustworthiness. The review team piloted the
form independently by abstracting five sample articles. After collective review and discussion,
the form was further refined and the researchers reached a consensus on the abstraction pro-
cess for the remaining articles. The remaining articles were abstracted, with weekly meetings
held among the researchers to discuss findings as they emerged, challenges found during the
abstraction process and a consensus approach to resolving them. All questions and changes in
the abstraction process were documented in a shared document that was reviewed and dis-
cussed weekly.
Analysis
Findings were synthesized using a thematic approach, commonly used to summarize qualita-
tive and quantitative studies in systematic reviews [36, 37]. Articles were revisited multiple
times and abstracted findings synthesized into detailed outputs. These were then reviewed and
revised by the lead author (AG) in discussion with the team, following a process of constant
comparison. After drafting synthesized findings, authors revisited original articles to check
their interpretations.
Results
Article selection
Our search generated 3,803 articles, which after removing 711 duplicates, left a total of 3,092
articles. Next 1807 abstracts where both reviewers agreed on exclusion were excluded.
Abstracts where there was disagreement or uncertainty, or which were selected for inclusion
(1285) were re-checked and resulted in the removal of an additional 763 abstracts, leaving 522
Table 2. Inclusion and exclusion criteria.
Inclusion Exclusion
Health systems research which examines an interaction of parts (service
delivery, information systems, medical products/ technologies, human
resources, financing, governance, community/ households) and their
interconnections (ideas and interests, relationships and power, values and
norms) that come together for a purpose (health)
Basic scientific research, clinical efficacy or effectiveness of treatments/
technologies, measurement and social determinants of population health
Low and middle income country contexts Editorials
Community level health system interventions are those where communities
are substantially involved in their implementation or monitoring and evaluation,
ie going beyond initial consultations for design or formative research.
Community was defined as people residing together in a geographical area, a
village or a township, not inclusive of community based organizations and or
local administrators who worked in these geographic areas, but did not reside
in them.
Review papers will not be abstracted through the form, but will be
reviewed as background material.
English language publication, with American and English spellings
Peer review journals
2000 onwards
doi:10.1371/journal.pone.0141091.t002
Community Participation in Health Systems Interventions
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articles for full-text examination (26 review articles and 496 studies). At the full-text reading
stage, an additional 236 studies were excluded after being examined by two reviewers, leaving
260 studies with some level of community participation in health systems research studies.
This included articles that aimed to engage communities more fully, but failed to do so (Fig 1
and S1 Table).
Article characteristics
We assessed geographic location of interventions and first author to assess where and who is
publishing research on health systems that involves community participation in LMIC con-
texts. When authors mentioned two different affiliations, we categorized them by the first affili-
ation mentioned. Despite the focus on LMIC countries, more than half of first authors were
based in high-income countries (58%, 150/260). Among LMIC articles, almost a half focused
on sub-Saharan Africa (45%, 117/260), even though just under a fifth were authored by those
based in sub-Saharan Africa (19%, 50/260) (Table 3). Very few articles were from LMIC coun-
tries in the Middle East and North Africa (n = 4, Yemen and Iran) or in Europe and Central
Asia (n = 2, Romania and Kyrgyzstan) and very few spanned multiple regions (n = 4).
In terms of study design, just over a half of the articles that included community participa-
tion in health systems research interventions were of an explanatory nature (54%, 140/260)
and only 7% (19/260) followed a probability design (Table 4). While more articles were either
qualitative (37%, 97/260) or combined qualitative and quantitative data (34%, 89/260), a signif-
icant number were also purely quantitative (28%, 74/260).
Synthesis of results for all health systems research articles with
community participation
In this section, we review how communities participated in interventions, who in communities
participated and the distribution of articles across health systems domains and health
conditions.
Extent of community participation: How communities participate?. The extent of com-
munity participation in health systems research interventions was assessed across five different
elements, depending on whether communities were involved in: (1) identifying and defining
the problems addressed; (2) identifying and defining the interventions developed to address
those problems; (3) implementing interventions; (4) managing resources for the interventions;
and/or (5) monitoring and evaluating interventions. To be included in this review, articles
needed to have community participation in at least one of the above five elements (Table 5).
Of those articles that had some degree of community participation in the health system
intervention under investigation, almost all detailed community participation in implementing
interventions (95%, 247/260). Very few were involved in the strategic decisions that framed the
research by identifying and defining the problems that needed to be addressed (18%, 46/260),
although just over half were involved in identifying and defining interventions (50%, 131/260).
Fewer articles detailed community participation in terms of managing resources (31%, 80/260)
or monitoring and evaluating (24%, 63/260). Only a minority involved communities in 3 steps
(55/260, 21%) or in 4 steps (12%, 31/260), with only 4 involving communities in all 5 steps.
We combined our assessment of the number of elements with the level of detail available on
community participation in the article to categorize articles as having rich community partic-
ipation. Those categorized as rich participation largely correlate with the increasing number of
elements, but not exactly (Table 6). For example, articles that may have only supported com-
munity participation in one or two elements of the intervention but provided a rich description
of this participation whether positive or negative where included, rather than those that had
Community Participation in Health Systems Interventions
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Fig 1. Flow chart detailing article selection
doi:10.1371/journal.pone.0141091.g001
Community Participation in Health Systems Interventions
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more than one element but with little description detailing what this meant for the communi-
ties involved.
Extent of gender analysis: Who in communities participates?. Among those articles
with rich community participation, just over half, 54% (84/156) disaggregated by sex. However,
those that did present information disaggregated by sex, did so regarding mainly related to
background data sources or population health outcomes. Extremely few articles detailed inter-
vention participation by sex [3840].
Almost a third, 32% (50/156), of articles targeted women or men or focused on sex specific
health conditions. A large number of these articles focused on sexual, reproductive, maternal
and child health issues, primarily focusing on women as beneficiaries. Only one article targeted
men in participatory way by supporting fathers clubs to promote child health [41].
Table 3. Geographic region of first authors vs. region of intervention.
Geographic region of first authors Articles with community participation (n = 260)
Low income 17% (43/260)
Lower middle income 12% (32/260)
Upper middle income 13% (33/260)
High income 58% (150/260)
No information 01% (2/260)
Geographic region of intervention Articles with community participation (n = 260)
Sub Saharan Africa 45% (117/260)
South Asia 19% (49/260)
East Asia and Pacific 18% (47/260)
Latin America and Caribbean 14% (37/260)
Middle East and North Africa 02% (4/260)
Europe and Central Asia 01% (2/260)
Multiple regions 02% (4/260)
doi:10.1371/journal.pone.0141091.t003
Table 4. Study inference.
Study
inference
Explanation Articles with community
participation (n = 260)
Probability Controlled (cluster randomized) trials 7% (19/260)
Plausibility Concurrent, non-randomized cluster trials 12% (32/260)
Adequacy Before-after or time-series in program recipients only 16% (41/260)
Explanatory Can be mixed methods, quantitative or qualitative;
focus on how a strategy led to effects on outcome
54% (140/260)
Exploratory Can be mixed methods, quantitative or qualitative;
focus on descriptions and relationships
11% (28/260)
doi:10.1371/journal.pone.0141091.t004
Table 5. Nature of community participation.
Nature of community participation (CP) Articles with CP (n = 260)
Identifying and defining problems 18% (46/260)
Identifying and defining interventions 50% (131/260)
Implementing interventions 95% (247/260)
Managing resources for intervention 31% (80/260)
Monitoring, evaluating interventions 24% (63/260)
doi:10.1371/journal.pone.0141091.t005
Community Participation in Health Systems Interventions
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Of the 106 articles with rich community participation that did not target women or men or
their sex specific health issues, 28% (30/106) did not discuss gender in any way, 35% (37/106)
mentioned gender in passing (one or two sentences), and only 28% (30/106) discussed gender
issues substantively.
Health systems domains. We assessed which health systems domains had interventions
that involved community participation, and identified eight different fields: (1) health promo-
tion, (2) inter-sectoral, (3) service delivery, (4) governance, (5) supply chain management, (6)
financing, (7) human resource management and (8) information systems (Table 7).
Involving communities in health promotion was most common, with 202 of the 260 articles
(78%) included in the review having communities participating in this domain. However, only
63% (128/202) of the articles that involved communities in health promotion included rich
experiences of community participation. Most of the health promotion articles in our review
included community participation in implementing the intervention, but were less likely to
have communities defining the problem that needed to be addressed, defining the intervention
in question, managing resources for it or monitoring/evaluating its results.
Involving communities in governance and supply chain management was not very common
(only 12% (30/260) and 9% (24/260) respectively), but when it occurred it was highly participa-
tory with 80% (24/30) and 83% (20/24) of the articles in these respective domains being classi-
fied as having high participation. Within the domain of governance, many of the articles
described how communities were engaged in decision making regarding the intervention, their
involvement in health planning processes or supervision of services. With regards to supply
chain management interventions, half of the interventions included related to community-
directed treatment for various communicable diseases, which involved communities in
Table 6. Number of elements of community participation.
Number of community participation (CP)
elements
Articles with CP
(n = 260)
Articles with rich CP
(n = 156)
Column subtotals Row subtotals
CP in 1 of the 5 elements 33% (86/260) 22% (19/86)
CP in 2 of the 5 elements 32% (84/260) 57% (48/84)
CP in 3 of the 5 elements 21% (55/260) 98% (54/55)
CP in 4 of the 5 elements 12% (31/260) 100% (31/31)
CP in all 5 elements 2% (4/260) 100% (4/4)
Total 260 60% (156/260)
doi:10.1371/journal.pone.0141091.t006
Table 7. Extent of community participation (CP) across health systems domains.
Health systems domains Articles with CP (n = 260) Articles with rich CP (n = 156)
Column subtotals Row subtotals
Health promotion 78% (202/260) 63% (128/202)
Inter-sectoral 35% (90/260) 71% (64/90)
Service delivery 30% (77/260) 69% (53/77)
Governance 12% (30/260) 80% (24/30)
Supply chain management 9% (24/260) 83% (20/24)
Financing 7% (19/260) 68% (13/19)
Human resource man
