R E S E A R C H A R T I C L E Open Access
Factors affecting effective community participation in maternal and newborn health programme planning,
implementation and quality of care interventions
Lisa Howard-Grabman1*, Andrea Solnes Miltenburg2 , Cicely Marston3and Anayda Portela4
Abstract
Background:Community participation in in health programme planning, implementation and quality
improvement was recently recommended in guidelines to improve use of skilled care during pregnancy, childbirth and the postnatal period for women and newborns. How to implement community participation effectively remains unclear. In this article we explore different factors.
Methods:We conducted a secondary analysis, using the Supporting the Use of Research Evidence framework, of effectiveness studies identified through systematic literature reviews of two community participation interventions;
quality improvement of maternity care services; and maternal and newborn health programme planning and implementation.
Results:Community participation ranged from outreach educational activities to communities being full partners in decision-making. In general, implementation considerations were underreported. Key facilitators of community participation included supportive policy and funding environments where communities see women’s health as a collective responsibility; linkages with a functioning health system e.g. via stakeholder committees; intercultural sensitivity; and a focus on interventions to strengthen community capacity to support health. Levels of participation and participatory approaches often changed over the life of programmes as community and health services capacity to interact developed.
Conclusion:Implementation requires careful consideration of the context: previous experience with participation, who will be involved, gender norms, and the timeframe for implementation. Relevant stakeholders must be actively involved, particularly those often excluded from decision making. Current limited evidence suggests that the vision of community participation as a process and the presence of a focus to strengthen community capacity to participate and to improve health may be a key factor for long term success;
Keywords:Community participation, Maternal and newborn health, Quality improvement, Health programme planning and implementation
* Correspondence:[email protected]
1Training Resources Group, Inc., 4301 Wilson Boulevard, Suite 400, Arlington, VA 22203, USA
Full list of author information is available at the end of the article
© The Author(s). 2017Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Background
Community participation in health is:‘a process whereby people, both individually and in groups, exercise their right to play an active and direct role in the development of appropriate health services, in ensuring the conditions for sustained better health and in supporting the em- powerment of community to help development’p.10 [1].
Involving communities in assessing their own needs and in developing strategies to meet those needs can increase intervention ownership and sustainability, while respon- siveness to community needs in planning and imple- mentation of health programmes can help improve health equity, service delivery, and uptake of care [2–4].
Various reviews and World Health Organization (WHO) Guidelines have highlighted the importance of commu- nity participation for improved health [5–9].
The WHO commissioned systematic reviews of health promotion interventions involving community participa- tion. We performed a secondary analysis on two of them here [10]: 1) quality improvement of maternity care ser- vices where community members participate in pro- cesses to review the quality of health services either as informants or as partners with health providers in plan- ning and implementation to improve quality; and 2) ma- ternal and newborn health programme planning and implementation, where community members are in- volved in planning, designing, implementing and moni- toring strategies and interventions. Based on these reviews, community participation in quality improve- ment and in health programme planning and implemen- tation is now recommended by WHO to improve use of skilled care during pregnancy, childbirth and the postna- tal period for women and newborns, increase the timely use of facility care for obstetric and newborn complica- tions and improve maternal and newborn health [10]. In addition to the available evidence on the impact of par- ticipation, it is also important to understand which factors influence implementation of community partici- pation interventions for maternal and newborn health.
This article addresses this question, exploring stake- holder perspectives and experiences of the two commu- nity participation interventions, and identifying barriers and facilitators to successful implementation.
Methods
We analysed the studies included in systematic reviews of published and unpublished grey literature used to in- form WHO health promotion guidelines for maternal and newborn health [10]. The methods for the review are described in the WHO document.
The systematic reviews included articles published be- tween 2000 and 2012 initially identified from a system- atic mapping of maternal health research in low- and middle-income countries [11]. Studies included RCTs as
well as any other study design that included at least one data collection point prior to the intervention and one during or after the intervention. Studies reporting quali- tative data were included. The systematic reviews them- selves are not the topic of this paper.
We extracted data from 16 studies that could shed light on factors influencing implementation using an adapted ‘SURE (Supporting the Use of Research Evi- dence) framework’[12]. The framework includes a com- prehensive list of barriers and facilitators to implementing health systems interventions including stakeholder knowledge and attitudes, health service de- livery factors, and social and political considerations.
Starting from the categories within the broad SURE framework the authors identified further, specific themes of interest from the primary empirical data presented in the included articles and from the author discussion and conclusions from those articles.
Results
Description of included studies
Table 1 shows characteristics of included studies. 16 pa- pers reported on 13 separate programmes: seven in Asia (India N= 1; Bangladesh N= 1; Pakistan N= 2; Nepal N = 1; China N = 1, Indonesia N = 1), three in East Africa (Tanzania N = 1; Uganda N = 1; Kenya N = 1) and three in Latin America (Peru N = 2; Honduras N= 1). Implementation approaches for community par- ticipation varied. They included forming stakeholder committees [13–21], mobilizing communities to take ac- tion [14, 22–25], community based monitoring of health outcomes or services [17–19, 25, 26], community out- reach activities to increase awareness of health issues [13, 16, 27] and facilitating stakeholder dialogues [19, 28].
Many of the studies were complex, multiple intervention programmes that combined community participation with health system strengthening and some also combined multiple approaches to participation. There was no con- sistent definition of ‘community’and some studies did not define‘community’at all.
Community participation did not always fit neatly into one category, ranging from communities being the recipi- ents of health messages to high level engagement where community members and groups played active roles in decision-making, planning and implementation [29]. In six programmes, community members participated at different levels at different points during the intervention [17, 18, 22, 23, 25, 26, 28]. Communities were involved in designing programmes from the beginning in only two cases [19–21]; in four programmes, communities provided input on interventions [25–28]; and in seven, programme teams designed the programme and chose the interven- tions. The communities were then asked to adapt and implement them [13–18, 22–24]. Women participated at
Table1Characteristicsofstudiesanddescriptionofinterventions NoStudySettingCPa TimeframeApproachLevelGeneraldescriptionofinterventionoraim ofthestudy 1PurdinS,etal.(2009).Reducing maternalmortalityamongAfghan refugeesinPakistan Pakistan:HangudistrictofKhyber PakhtunkhwaProvince(ruralrefugee settlements)
P&I1980–2007`Communityoutreachand stakeholdercommitteeOutreachProvisionofreproductivehealthservicesfor Afghanrefugeesthroughestablishmentof BasicHealthUnitsandBasicEmergency ObstetricCarefacilities.Camp-basedhealth committeesincludedcommunityrepresentatives whoattendedbi-monthlymeetingswithhealth stafftodiscussprojectactivitiesandprovide feedbacktoprovidersonservicesprovided.The BasicHealthUnitstafftrainedCommunityHealth Workersandcommitteemembersincluding menonsafemotherhoodandreproductive healthtopicstoeducateothersintherefugee community. 2AhluwaliaI,etal.(2003).Anevaluation ofacommunity-basedapproachto safemotherhoodinnorthwestern Tanzania(SeealsoAhluwalia,2003)
Tanzania:Kwimba Missungwidistricts(rural)P&I1998–2000CommunitymobilizingOutreach, Consult, Involve
AspartofaCommunityBasedReproductive HealthProject(CBRHP)strengtheningof communitylevelserviceswasdonethrougha specialactivitycalledtheCommunityCapacity BuildingandEmpowermentProject.The projectaimedforlocalproblemsolving through1)training,technicalassistance,and supportfor(villagehealthworkers)VHWswho providededucationalhousevisitsontopics suchasrecognitionofdangersignsandbirth preparedness;[2]developingcommunity- basedplansfortransportationtohealth facilitiesand[3]increasingparticipationby communitymembersinplanningand decision-makingthroughcommunitymeetings, aimingtoidentifyandsolvelocalhealth problems. 3AhluwaliaI,etal.(2010).Sustainability ofcommunity-capacitytopromote safermotherhoodinnorthwestern Tanzania:whatremains?(Seealso Ahluwalia,2010)
Tanzania:Kwimba Missungwidistricts(rural)P&I2006CommunitymobilizingOutreach, Consult, Involve
Thisstudyreportsonafollow-upstudyof Ahluwalia(2003)withtheaimtoexaminethe remainsoftheCBRHPasdescribedabove. Activitiescontinuedfrom2001to2006without projectsupport.Apostprojectassessmentwas conductedwithfocusontheCBRHP components,includingcommunitysupported transportsystems;villagehealthworkers;and changesinselectedmaternalhealthserviceuse indicatorsatthedistrictlevel. 4BhuttaZ,etal.(2011)Pakistan:2townsinSindhwith 1400villages(rural)P&I2006–2008Stakeholdercommittee andCommunitymobilizingOutreachCommunity-basedinterventionpackage principallydeliveredthroughtrainingofLady HealthWorker(LHW)andDais(traditional healthworkers)andpromotionofliaison betweenthemtogetherwithfacilitationof thecreationofvoluntarycommunityhealth committees(CHC).Inadditiontoadvocacy workwithcommunityeldersandlocal
Table1Characteristicsofstudiesanddescriptionofinterventions(Continued) politicalleaders,theCHCswereencouraged toorganizeanemergencytransportfundand theuseofvehiclesusinglocalresources.The CHCsfacilitatedtheLHWsinaccessing womenandinconductinggroupeducation sessionsintheinterventionvillages. 5PaxmanJ,etal.(2005).TheIndiaLocal InitiativesProgram:AModelfor ExpandingReproductiveandChild HealthServices India:4northernstatesinKolkata,the hillsoftheHimalayas,Punjabplains, andmountainsofHimachalPradesh (urban&rural)
P&I1999–2003StakeholdercommitteeInvolveNGOshelptoorganizeorstrengthena reproductiveandchildhealthcommittee composedofinfluentialcommunitymembers. Thecommitteesrecruit,trainandoverseethe workofcommunityhealthvolunteers(CHVs), raisemoneyforhealthactivitiesandsupport, andenlistsupportoflocalgovernment,social andreligiousleaders.CHVsprovidedhealth informationtohouseholdsandkepttrackof theirhealthstatus,providedsomebasic healthservicesincludingsomefamily planningmethods,organizededucational activitiesandreferredclientstoadditional servicesoutsidetheircommunities.CHVs trackedhealthstatusmakinguseofapictorial maptofacilitateusebypeoplewithlimited literacyskills,whichhelpedprojectstaffto monitorperformance. 6KaufmanJ,etal.(2012).Improving reproductivehealthinruralChina throughparticipatoryplanning
China:DafangandZhenningcounties inGuizhouProvince,LuopingCounty inYunnanProvince(rural)
P&I2002–2006CommunityoutreachInvolveTheGenderandHealthEquityNetwork (GHEN)projectaimedtoimprovehealth furtherforpoorruralwomenbyincreasing women’sparticipationinplanningand resourceallocationthroughcapacitybuilding throughtrainingoftownshipwomen’s representativesandlocalofficialsingender andhealth.Women’shealthpromotion groupsanddemonstrationhouseholdswere established.Demonstrationhouseholds collectedinformationonlocalhealthservice needsandsharedthiswiththehealth promotionteamwhocommunicatedto higher-levelhealthauthorities.Womenand theirfamiliesweretaughthowtopreventand treatcommonhealthproblemsandweremo- tivatedtouseservices.Healtheducationactiv- itieswereorganizedatleastoncepermonth. Countyandtownshipsupervisionmeetings wereheldonceeverytwomonthstoprovide direction,identifyandsolveproblems. 7HarkinsT,etal.(2008).Thehealth benefitsofsocialmobilization: experienceswithcommunity-based IntegratedManagementofChildhood
Peru:Chaodistrict(peri-urban)and Honduras:SanLuisdistrict(rural)P&I2004–2005Stakeholdercommittee, communityoutreachInvolveMultiplegovernmentagencies,privatesector andnon-governmentalorganizationsalong withrepresentativesofcommunity-based organizationsestablishedorstrengthened existingcommitteesthatweretaskedbythe
Table1Characteristicsofstudiesanddescriptionofinterventions(Continued) IllnessinChao,PeruandSanLuis, HondurasprojectwithdisseminatingkeyIntegrated ManagementofChildhoodIllnesshealth messagestotheirvariousconstituencies throughtheirnetworkswiththeaimof involvingfamiliesandcommunitiesin maternalandchildhealthapproaches. Membersofthecommitteeweretrained andtheyinturncapacitatedcommunity members.Thecommitteescouldbe creativeabouthowtheydisseminatedthe messages.Thecommitteewasresponsible fororganizingthetrainingandeventsand thesupportinglogisticsfortheiractivities. 8SoodS,etal.(2004).Measuringthe effectsoftheSIAGAbehaviorchange campaigninIndonesiawith population-basedsurveyresults
Indonesia,West-JavaP&I1999–2004CommunitymobilizingInvolveSocialmobilizationcampaignconsistedofa massmediacomponentthattargeted husbands(SuamiSIAGA),birthattendants (BidanSIAGA),andcommunities(Warga SIAGA)andvillages(DesaSIAGA)withradio andtelevisionspotsandshowsthatmodeled thedesiredattitudesandbehaviorsof“alert” husbands,midwivesandcommunitiesthat supportthehealthoftheirmothersand babies.Therewasalsoacommunity participationcomponentforthe“alertvillage” thatbuiltonatraditionalconceptofthevalue ofcommunityhelp.Thiscomponentaimedat motivatingpeopletoestablishlife-savingsystems intheirvillages(transport,emergencyfunds,blood) 9Mathur,etal.(2004).Youth ReproductiveHealthinNepal–is participationtheanswer?(Seealso Malhotra,2005) Nepal:NawalparasiandKawasoti Districts(ruralTerai)&twourban suburbsofKathmandu
P&I1998–2004StakeholdercommitteeShared LeadershipAyouthcenteredparticipationprojectwas initiatedthroughaformativeresearchprocess, whichincludedaneedsassessmentonhow issuesofyouthreproductivehealthwere relevantinthecommunitiesofinterest.The projectstafffacilitatedanactionplanning processthroughwhichresultsoftheneeds assessmentweresharedwithcommunity members.Theprojectestablishedtwo community-basedadvisorygroups,the AdolescentCoordinationTeam(ACT)andthe ProjectAdvisoryCommittee(PAC)consisting ofadults.Thiswasfollowedbyformationof separatetaskforcesconsistingofyouth representativestodevelopinterventionsand aninterventionplan.Thetaskforcesthen cametogethertointegratetheirplansafter seekingadvicefromresourcepeopleinthe community.Thiswasfollowedby implementationoftheinterventions.This studydocumentstheprocessandresults oftheproject.
Table1Characteristicsofstudiesanddescriptionofinterventions(Continued) 10Malhotra,etal.(2005).Nepal:The DistributionalImpactofParticipatory ApproachesonReproductiveHealth forDisadvantagedYouth(Seealso Mathur,2004) Nepal:NawalparasiandKawasoti Districts(ruralTerai)&twourban suburbsofKathmandu P&I1998–2004Implementationplanning throughyouthinvolvement taskforces
Shared LeadershipThisstudyreportsontheimpactof participatoryapproachesinimprovingyouth reproductivehealthasreportedbyMathur (2004).Theauthorsexaminewhetherthe participatoryorthenon-participatoryintervention approachismoresuccessfulinreducingthegaps betweenthedisadvantagedandtheadvantaged inaccesstoyouthreproductivehealthservices andinoutcomes. 11KasejeD,etal.(2010).Evidence-based dialoguewithcommunitiesfordistrict healthsystems’performance improvement
Kenya: 6districtsinNyanzaProvince:Nyando, Siaya,Kisumu,Rachuonyo,Suba, Bondo(urban&rural) P&I,QI2005–2007Stakeholdercommittees, facilitationofdialogue, communitybasedmonitoring
CollaborateAnevidence-baseddialoguemodelwas introducedtocommunitymembers,district healthmanagementteams,andservice providersthroughaseriesofthree,three-day workshops.Theinterventionpackageincluded thedevelopmentofcommitteesatthevillage, communityandhealthfacilitylevels;identify, trainanddeployCommunityHealthExtension Workers(CHEWs)asfacilitatorsofdialogueat thecommunitylevel,supportersofCHWs,and maintainersofacommunity-basedinformation system;identifyandtrainCHWstosupport householdsinhealthimprovementactivities, maintainvillageregisterandfacilitatedialogue athouseholdlevel;establishmentofvillage registersofallhouseholds;improvementand timelinessofanalysis,disseminationand utilizationofhealthmanagementinformation systemdata;analyzesuggestionscollectedfrom suggestionboxesonamonthlybasis;and,hold dialoguesessionsbasedondatafromthe communityandhealthfacilitieseverymonthat householdandcommunitylevelsandevery fourmonthsathealthfacilityandsub-district levels.Indialoguesessions,dataweredisplayed, discussedandconsensuswasbuiltonwhat wasacceptableandwhatneededtobe improved. 12BjorkmanM,andSvenssonJ(2009). PowertothePeople:Evidencefrom arandomizedfieldexperimenton community-basedmonitoringin Uganda
Uganda:50communitiesfrom9 districtsinallfourregionsofUganda (rural)
P&I,QI2004–2006Community-based monitoringCollaborate (most villages), Shared Leadership (some villages)
Withtheaimtostrengthenproviders’ accountabilitytocitizen-clientsanNGO- facilitatedapproachwasimplemented.First communitymemberswerepresentedwith baselineinformation(a“reportcard”)which wasasummaryofinformationgatheredfrom bothcommunitymembersandservice providersaswellasdatacollectedfrom serviceregisterstoreflectthestatusofhealth servicedeliveryrelativetootherprovidersand thegovernmentstandards.Duringcommunity meetingscommunitymembersdevelopeda sharedviewonhowtoimproveservicedelivery
Table1Characteristicsofstudiesanddescriptionofinterventions(Continued) andmonitortheproviders.Afacilitymeeting washeldwithhealthfacilitystafftopresentthe resultsofthehouseholdsurveyandcontrast theresultstotheresultsoftheinformation providedbyservicesproviders.Aninterface meetingbetweencommunityrepresentatives electedattheearliercommunitymeetingand healthserviceprovidersdiscussedproposed suggestionsforimprovementandcameto agreementonanactionplanandaplanfor howthecommunitywouldmonitorprogress. Aftersixmonths,healthfacilitystaffand communitymembersjointlyassessedand analyzedprogress. 13SinhaD(2008).Empowering communitiestomakepregnancysafer: aninterventioninruralAndrha Pradesh.
India:MominpetinRangareddy DistrictinAndhraPradesh(rural)QI2004–2006Communitymobilizingand communitybasedmonitoringShared Leadership (some villages)
Communityorganizersraisedawarenessof villagecouncilsandyouthorganizationsabout thepowerfulroletheycouldplayinensuring thatpublichealthfacilitiesprovidethe servicestheyarerequiredtodeliverand instructedthemonhowtouseamonitoring tooltocompareactualperformancewith expectedservicedelivery.Villagecouncils thenheldregularmonthlymeetingstowhich theyinvitedrepresentativesoflocal organizations,youthgroups,schools,mother’s committees,andcommunitylevelhealth workers.Participantsinthemeetingsreviewed serviceperformance,healthdataandservice utilizationstatistics,identifiedproblemsand workedtosolvethem.Whensolutionsdid notwork,theyinitiatedactionwithhigher authorities.Meetingswerealsoheldatthe lowerlevels.Youthleaders,initiallyyoung menbutlaterjoinedbyyoungwomen, organizedmeetingsinthevillagestoraise awarenessofyoungpeopletoholdproviders accountableforgoodservice.Eventually,the youngpeopleformeda“YouthCommitteefor RighttoHealth”thatmetmonthly. 14GabryschS,etal.(2009).Cultural adaptationofbirthingservicesinrural Ayacucho,Peru.
Peru:All17villagesintheSantillana district,Ayacuchoregion(rural)QI1997–2001FacilitationofdialogueConsult, CollaborateProgramcycleapproachtoengaging pregnantwomenandhealthprovidersinthe developmentofmaternityservicesthatmet bothserviceproviderandcommunity expectationsforqualitycare.Phase1:detailed formativeresearchbyprojectteamto understandperceptionsandpracticesrelated toreproductivehealthandhealthservices. Phase2:3facilitatedmeetingsofpregnant women,TBAs,CHWsandhealthprovidersto designabirthingservicethatwas`toall