Involve minorities and the socially disadvantaged to help them to become healthier
By Alison O’Mara-Eves
These days, public health and health promotion interventions are particularly concerned with reaching and influencing minority and socially disadvantaged groups. Why? Because disadvantaged groups tend to have higher rates of certain health problems (such as diabetes, heart disease, cancer and perinatal mortality) than other members of society. Such systematic, modifiable differences in health are referred to as ‘health inequalities’. Addressing inequalities demands action. Disparities suggest significant potential for health improvement, if only the right approach can be found.
One answer may be community engagement, in which members of the community are involved in the planning, design, or delivery of a health intervention. Some research suggests that, if communities are ‘signed up’ to an intervention or programme, people are more likely to participate and better outcomes can result.
What type of community engagement works? In our project, we examined which approaches for minority or socially disadvantaged groups are most effective. It’s a big piece of work – a systematic review of 319 previous public health or health promotion interventions. Of these, we looked at the effectiveness of 131 interventions that addressed certain health issues, including smoking cessation, healthy eating, sexual health, and a range of others.
We have some good news: overall, the interventions that we looked at were generally effective at improving health behaviours (such as eating more fruit and vegetables) and health states (such as improved cholesterol levels). There were also benefits in terms of increased self-efficacy and social support in the studies that measured those outcomes. Plus, good relationships between members of the community and professionals providing an intervention appears to improve programme implementation. However, there is a limit to the conclusions that we can draw from this research. This is because the interventions were rarely compared to a condition in which the only thing that differed between intervention and comparator was the community engagement component. This means that we cannot isolate community engagement as the sole ‘active ingredient’—it could be a combination of features of these interventions that leads to improved outcomes.
To explore whether different ways of engaging people made a difference, we divided community engagement activities into three categories. The first is where a community identifies a health need for itself; for example where mothers, concerned that children were catching measles, lobbied other parents in their community to get their infants immunised. The second is where members of a community play a role in designing an intervention; for example advising on the route and public promotion of a cycle or walking path. The third broad grouping is where delivery is provided by peers or lay members of a community, such as support for breastfeeding, in which a community member visits a new mother’s house and offers advice; or where one or two members of a community deliver sex education to a small group of peers.
All of these models appear to be successful, our project found. (Again, we note that we were unable to isolate community engagement as the single active ingredient in the intervention, so here we focus on trends). There was a trend for peer- and lay-delivered interventions to be particularly effective, although that may be because these programmes are particularly intense, often small scale and typically one-to-one – in the case, for example, of breastfeeding home visitation interventions. They also tend to be short term, so you might expect a large effect from a programme like this providing an intense burst of support. Peer-related interventions also tend to be highly targeted at people with a specific need.
In contrast, the other two models – community empowerment and community involvement in design – are typically less intensive for the people receiving the intervention. Such interventions often address a broader community, such as the immunisation advocacy programme that addressed the locality. Such community-wide approaches – where the intervention lasts for perhaps years and it is not clear who has been exposed to the intervention – have impacts that are harder to assess. It would, therefore, be a mistake to conclude that the effectiveness of the peer-delivered intervention ranks it above alternative approaches, not least because one-to-one interventions are difficult to roll out at scale.
It seems, then, that implementing community engagement in a public health intervention requires a ‘fit for purpose’ approach; different types of engagement are likely to be more suitable for different health problems and different groups of people, and may even involve multiple ways of engaging members of the community. Although the designs of the evaluations included in our review mean that we cannot be conclusive that community engagement is the sole active ingredient in each of these studies, both theory and the observed trends across the literature suggest that engaging members of the community in the planning, design, and/or delivery of public health interventions is worth pursuing.
Dr Alison O’Mara- Eves is a research officer at the Institute of Education, University of London. The Institute is the lead organisation in this piece of research, undertaken in collaboration with the LSE and the University of East London, with funding from the NIHR Public Health Research Programme. Professor James Thomas, Dr O’Mara-Eves and Mrs Ginny Brunton will present the research findings at a SPHR@L Seminar on Thursday 10 October 10 at 5.15-6.30pm at the London School of Hygiene and Tropical Medicine.