The architecture and effect of participation: a systematic review of community participation for communicable disease control and elimination. Implications for malaria elimination

Abstract

Background: Community engagement and participation has played a critical role in successful disease control and elimination campaigns in many countries. Despite this, its benefits for malaria control and elimination are yet to be fully realized. This may be due to a limited understanding of the influences on participation in developing countries as well as inadequate investment in infrastructure and resources to support sustainable community participation. This paper reports the findings of an atypical systematic review of 60 years of literature in order to arrive at a more comprehensive awareness of the constructs of participation for communicable disease control and elimination and provide guidance for the current malaria elimination campaign.

Methods: Evidence derived from quantitative research was considered both independently and collectively with qualitative research papers and case reports. All papers included in the review were systematically coded using a pre-determined qualitative coding matrix that identified influences on community participation at the individual, household, community and government/civil society levels. Colour coding was also carried out to reflect the key primary health care period in which community participation programmes originated. These processes allowed exhaustive content analysis and synthesis of data in an attempt to realize conceptual development beyond that able to be achieved by individual empirical studies or case reports.

Results: Of the 60 papers meeting the selection criteria, only four studies attempted to determine the effect of community participation on disease transmission. Due to inherent differences in their design, interventions and outcome measures, results could not be compared. However, these studies showed statistically significant reductions in disease incidence or prevalence using various forms of community participation. The use of locally selected volunteers provided with adequate training, supervision and resources are common and important elements of the success of the interventions in these studies. In addition, qualitative synthesis of all 60 papers elucidates the complex architecture of community participation for communicable disease control and elimination which is presented herein.

Conclusions: The current global malaria elimination campaign calls for a health systems strengthening approach to provide an enabling environment for programmes in developing countries. In order to realize the benefits of this approach it is vital to provide adequate investment in the 'people' component of health systems and understand the multi-level factors that influence their participation. The challenges of strengthening this component of health systems are discussed, as is the importance of ensuring that current global malaria elimination efforts do not derail renewed momentum towards the comprehensive primary health care approach. It is recommended that the application of the results of this systematic review be considered for other diseases of poverty in order to harmonize efforts at building 'competent communities' for communicable disease control and optimising health system effectiveness.

Figure 1

Selection process from database search to final analysis.

Figure 2

Key periods of health systems development within the primary health care context.

Figure 3

Summary of the percentage of included papers outlining community participation that originated in each PHC period.

Figure 4

Summary of considerations for community participation programmes relating to knowledge & perceptions of disease.

Figure 5

Reciprocity of disease vulnerability and community participation.

Figure 6

Summary of considerations for community participation programmes relating to vulnerability versus resilience.

Figure 7

Summary of considerations for community participation programmes relating to stigma.

Figure 8

Summary of considerations for community participation programmes relating to incentives.

Figure 9

Summary of considerations for community participation programmes relating to intervention acceptability.

Figure 10

Summary of considerations for community participation programmes relating to gender roles and power relationships.

Figure 11

Summary of considerations for community participation programmes relating to cultural norms and social mechanisms.

Figure 12

Summary of considerations for community participation programmes relating to access.

Figure 13

Summary of considerations for community participation programmes relating to urban versus rural implementation.

Figure 14

Summary of considerations for community participation programmes relating to community characteristics.

Figure 15

Summary of considerations for community participation programmes relating to disease epidemiology and complexity of interventions.

Figure 16

Summary of considerations for community participation programmes relating to the process by which communities are engaged to participate.

Figure 17

Summary of considerations for community participation programmes relating to the congruence of external targets and local priorities.

Figure 18

Summary of considerations for community participation programmes relating to political environment.

Figure 19

Summary of considerations for community participation programmes relating to government advocacy and support.

Figure 20

Summary of considerations for community participation programmes relating to decentralisation of power and resources and use of community assets.

Figure 21

Summary of considerations for community participation programmes relating to health authority commitment to primary health care.

Figure 22

Summary of considerations for community participation programmes relating to multi-sectoral collaboration and integration of programme into broader development goals.

Figure 23

Summary of considerations for community participation programmes relating to financial and human resources.

Figure 24

Summary of considerations for community participation programmes relating to techno-financial support of locally embedded development agencies.