Evidence Synthesis Packet - Review Team-2: Community Empowerment

What are the effective means to facilitate and empower communities to organise and advocate for interventions to achieve behaviour and social changes that are needed to accelerate reductions in under-five mortality and optimise healthy and protective child development to age five? This was one of the questions posed by the United States Agency for International Development (USAID), which in 2013 convened a team of experts to conduct a systematic review of the evidence on a range of topics. In order to address this question, evidence review team 2 (ERT2) started from the following definition of community empowerment: "creating interactive/participatory processes that will gradually lead the community from being dependent on external support and resources, towards reaching a stage the community has freedom of choices, and ability to create their own choices, demand their rights and development opportunities." The papers considered for this reviewed described: (i) programmes that measured behavioural change and/or health outcome), and (ii) papers that were considered relevant and demonstrated substantive community involvement, i.e., either collaborated with the community or practiced shared leadership.

The findings and recommendation are presented by types of community engagement within the following health areas: (i) healthy timing and spacing of pregnancy, (ii) nutrition, (iii) newborn, (iv) water, sanitation, and hygiene (WASH)/pneumonia, (v) malaria, (vi) prevention of mother-to-child transmission of HIV (PMTCT), and (vii) immunisation.

An excerpt from the report follows related specifically to findings one of these areas: PMTCT:
"The evidence review process resulted in a disappointing view of the role of community engagement and empowerment strategies on improving infant health outcomes through the prevention of maternal to child transmission of HIV. Only one article from South Africa remotely met the evidence inclusion criteria. It demonstrated that a community based intervention can have an impact. However, the power of this result is limited because the community aspect of this program was essentially the replication of 'clinical-style' services delivered in a community outreach setting (the lowest level of community engagement). Likewise, the study was not designed to be able to document impact on preventing HIV transmission to infants beyond providing counseling to mothers.

The paucity of findings in this category is surprising given the number of community-based interventions that present at international conferences and are described in country program portfolios on this same topic. There were no articles in the literature review describing impacts of positive mothers clubs, community counseling services, or community activity kits (such as Soul City's materials or the Malawi BRIDGE Hope Kit PMTCT supplement, which are only two examples among several).

The limited number of articles in this category speaks to a number of obstacles that the public health community confronts in its ability to document the impact of interventions that are based in complex community environments. Community based interventions are challenged to set up pre-/post-monitoring systems that show an impact and refer to a comparable control community to document causality. Similarly it is hard in a true community setting outside of an 'operations research' environment to report impact on outcomes that require biomedical markers. The struggle to find an appropriate denominator in a community setting adds another challenges to assessing the true scale of impact that a community based approach can have. This challenge is especially apparent for relatively 'rare' events such as PMTCT which are more uniquely observed in a village or community setting, but for which patterns emerge on a larger aggregated scale.

The fundamental limitation of this work comes from the very nature of what it is - programming designed to engage and respond to community priorities and needs. These needs are informed by the perceived importance of competing factors. The majority of public health programs are 'direct-to-consumer.' The good ones are based on existing data, theories, and past experience. Politics, funding levels, project cycles and personalities all influence their implementation. The best programs conduct performance monitoring to satisfy stakeholders that progress is being made as intended - but often the program implementers do not have the framework, training nor skills to compile documentation to meet the rigors of a peer-reviewed publication process. Time is another resource that is often in short supply for documentation...

While these barriers to reporting impact are real, they cannot be used as an excuse for not better documenting the vibrancy and effective results that community empowerment programs inspire. The same creativity that inspires dynamic and exciting community engagement programs must be channeled into finding credible and innovative ways to document program effects....It is now incumbent on communities to share their evidence. Their stories must be told."

Click here for the 25-page report in PDF format.