Community participation in rural primary health care: Intervention or approach?

MAIN FINDINGS:

The authors include 37 studies assessing the link between community participation and health outcomes in developed and developing countries. The studies adopted a range of study designs, but the authors found very few high-quality studies. The authors included studies of various approaches to community participation, such as the instrumental approach, the developmental approach, the contributions approach and the empowerment approach. Overall, results suggest a positive effect of community participation on some health outcomes, including better access to health services and more relevant and culturally appropriate services. However, the authors note that because of the quality of the evidence few, if any, of the reviewed studies are able to prove this link. The only included studies that assess community participation as an intervention are the ten studies that adopted an instrumental approach. While these studies reported various positive outcomes, including increases in decision-making power, increased numbers of people receiving treatment, and reduction in road fatalities and smoking rates, they were all based on studies which are not suitable for causal attribution. The results do not yield conclusive evidence on whether any of the conceptual approaches to community participation are preferable to achieve particular health outcomes. The authors highlight a number of limitations, calling for a cautious interpretation of the findings. First, the evidence base is very weak: most of the studies lacked sound methodology and good reporting. Second, the authors acknowledge that the search was not exhaustive and did not include grey literature. Finally, they stress the need for more studies using rigorous designs and focusing on appropriate outcomes, to better assess the link between the different approaches to community participation and health outcomes.

BACKGROUND:

Community participation is widely understood to mean local people with common interests coming together to identify their needs and devise ways to fulfil those needs (Zakus and Lysack, 1998). However, in practice there is not much consensus on whether community participation comprises community development, community mobilisation, community involvement, or community capacity building. Previous evidence suggests that community participation in rural primary health care can contribute significantly to community health development, making the health service more accessible, relevant and acceptable, fostering improvements in the socio-economic conditions of the poor. Through this review the authors assess the benefits of community participation, and they examine different approaches to community participation and the extent to which it can be externally engineered.

RESEARCH OBJECTIVES:

The objective of the review is to assess and synthesise existing evidence on the causal link between community participation and health outcomes.

METHODOLOGY:

The review included studies assessing the effect of community participation on health outcomes in rural primary health care in developed and developing countries. The authors confined their selection to published articles written in English. The authors conducted a systematic search of the published literature, including the databases PubMed, Medline and Web of Science, covering the period 1997–2008. They also searched conference papers and hand-searched relevant publications. Next, the authors assessed the quality of included studies using the scale developed by the National Health and Medical Research Council. Finally, they grouped included studies by their conceptual approach to community participation and produced a narrative synthesis of the results.

QUALITY ASSESSMENT:

The review assesses the quality of included studies and states clearly which studies are subject to low risk of bias. However, the review has some major limitations. The search is not sufficiently comprehensive, because it covers only peer-reviewed studies written in English. The inclusion criteria do not set any clear requirements in terms of study design. The review does not address heterogeneity of results or include any sub-group analysis for low-income countries only. The authors acknowledge many of these weaknesses and do not make any strong policy recommendations.