Community Engagement to Enhance Child Survival and Early Development in Low- and Middle-Income Countries: An Evidence Review

"There is evidence that programs working collaboratively or those that achieve shared leadership with the community can improve critical health behaviors, increase knowledge, improve practices, affect social norms, lower disease incidence, and reduce poor health outcomes and mortality, even in low resource settings where social conditions and practices could otherwise result in poor child health."

This is one finding from an exploration of the research literature on the role of community participation in contributing to improved population-level infant and child health outcomes, mediated through improved household practices or better care-seeking behaviour. The review was conducted by one of the evidence review teams (ERTs) participating in the June 3-4 2013 Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change. It was hosted by the United States Agency for International Development (USAID), in collaboration with the United Nations Children's Fund (UNICEF) and the National Institute of Mental Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Centers for Disease Control and Prevention, The Communication Initiative, and the American Psychological Association. The summary below is part of a special issue of the Journal of Health Communication that is a product of the Evidence Summit.

The authors conducted a systematic review of the effectiveness of community mobilisation and participation that led to behavioural change and one or more of the following: child health, survival, and development. The level and nature of community engagement was categorised using two internationally recognised models: (i) the Clinical and Translational Science Awards Consortium's Community Engagement Continuum (2011), which was developed by the U.S. Centers for Disease Control and Prevention (CDC) to categorise the level of community engagement in the studies reviewed; and (ii) the Integrated Model of Communication for Social Change (IMCSC) framework, used here to examine the community-centred processes and approaches as applied in the studies in order to assess the relevant contribution of these processes to achieve behaviour and social changes leading to measurable child health outcomes. Based on that analysis, only studies where the methods of community participation could be categorised as collaborative or involving shared leadership were eligible for analysis. The authors identified 34 documents from 18 countries that met the eligibility criteria.

In brief, the researchers found that studies characterised as collaborative showed clear emphasis on collective action - e.g., local capacity building or training as part of mobilisation strategies - but did not undergo an initial process of community dialogue. In contrast, studies describing initiatives featuring shared leadership typically used a comprehensive community action cycle. In such a cycle, there are "expressions of shared ownership; the degree and equity of participation, including information equity; equitable access to resources; a sense of collective efficacy among community participants; engagement through social capital (community structures and systems that support the intervention); and value for continuous improvement. The presence of these attributes leads to a shift in locus of authority to the community."

To provide a snapshot on the findings, the researchers looked at how the studies included in the review applied the following categories of communication and other approaches to promote social and behavioural change: media (mass, social, interpersonal communication, and folk), community mobilisation, educational programmes, opinion leadership, economic incentives, and policy/legislative changes. Twenty-nine of the 34 articles reviewed described community mobilisation as part of the intervention design. Education programmes and opinion leadership were also commonly applied as part of the intervention package. Twenty-two articles described education as part of the package, and 16 addressed opinion leaders. Seven articles described incentives as part of the intervention package; 4 included social marketing; 6 included a media component; and 6 reviewed included a policy component.

Having reviewed the evidence, these researchers reflect in the discussion section of the paper on the dearth of evidence on community participation in child health and development. For instance, they point out that there is a small number of articles that describe process evaluation, "which is critical to addressing the means of community mobilization." In cases where they did find "process evaluation and a substantial level of community engagement, the articles did not specify whether it was the researchers' intention to contribute to community empowerment or capacity. Overall, this seems to be an understudied component of child health programming, and an area for further exploration."

While calling for further research, the authors of this paper acknowledge complexities, such as the fact that "[c]ommunity mobilization interventions are by intent highly localized. Thus the character of the intervention will necessarily vary. The diversity of responses highlight that there is no one right approach or outcome of engagement, but rather it is the norms, cohesion, and collective efficacy that communities foster around new knowledge that is critical for the behavioral transformations." As they explain, this type of variety complicates evaluation of the methodology, because there are so many indicators and mechanisms of action to consider.

"An important conclusion from the review is the need to strengthen both the design and the analytic approaches in future studies to better demonstrate any impact on outcomes including mortality and child development, as well as the underlying processes giving rise to change."