WHO recommendation on  community participation in programme planning and implementation

Women participating at National Safe Motherhood Day in India.

WHO recommendation on  community participation in programme planning and implementation

 

Recommendation

Community participation in programme planning, implementation and monitoring is recommended to improve use of skilled care during pregnancy, childbirth and the postnatal period for women and newborns, increase the timely use of facility care for obstetric and newborn complications and improve maternal and newborn health.

Mechanisms that ensure women's voices are meaningfully included are also recommended.

(Strong recommendation, very low quality of evidence)

 

Publication history

First published: May 2015

Updated: No update planned

Assessed as up-to-date: May 2015

 

Remarks

  • Additional research is required

 

Background

In 2003 the World Health Organization (WHO) published "Working with individuals, families and communities to improve maternal and newborn health", (1) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (2) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons - over and above what happens in clinical services - why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter's health promotion components(2) were translated into MNH programme language and 12 promising interventions - identified through reviews of country experiences and the literature - were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

Community participation is recognized in a number of legal instruments and key WHO policy documents and is considered within the IFC Framework and other WHO strategies to be a fundamental component of MNH strategies. Yet evidence is limited about the effect of community participation, here broadly defined as members of a community involved in planning, designing, implementing and monitoring strategies and interventions. Levels of participation can vary, e.g., providing views versus full decision-making. Interventions can also vary, e.g., consultations with communities, community representation on health facility management committees and meetings between community representatives, local authorities and health service managers.

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the "WHO handbook for guideline development", guided by the GRADE approach.(3) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(4)

A systematic review was conducted on interventions to involve communities in MNH programme planning and implementation.(5) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • What interventions to involve communities in MNH programme planning are effective in increasing birth with a skilled birth attendant/institutional birth and improving other key maternal and newborn health outcomes?

 

Evidence summary

Evidence on interventions to involve communities in MNH programme planning and implementation was based on literature identified through the MASCOT/ MH-SAR mapping, through a systematic review conducted by Marston et al. (2013)(5) and through an additional supplementary search conducted by Marston et al. (2014) to capture newborn health programmes. 12 studies were included. One programme was primarily aimed at increasing use of skilled care for obstetric complications.(6, 7)

Participation processes and mechanisms varied between studies. There was not sufficient evidence to determine which of the strategies or which combination of strategies were most effective. On the scale of types of participation, most of the studies fell into the level of involving communities. Two others worked at sharing leadership between the community and the services.

In summary, mixed quantitative evidence was found, often from studies with weak designs. Participation in planning takes many different forms, and it is difficult to compare the different strategies. Some interventions involved a package of measures including participation, and in these cases, the specific effects of participation cannot be separated out. However, the GDG noted that while the evidence was assessed as very low quality and inconsistent, there is positive reporting from different programmes in different contexts and on different outcomes, which provides an indication that there is potential for participation in planning to have an impact on care-seeking outcomes.

For the outcome of birth with a skilled birth attendant or facility birth, the quality of the evidence was rated as very low.

Two cluster RCTs (Bjorkman and Svensson, 2009; Bhutta et al., 2011) and one quasi-experimental study (reported in Malhotra et al., 2005) reported on this outcome. Both cluster RCTs report increased facility births, statistically significant in rural communities of Uganda (Bjorkman and Svensson, 2009) and not statistically significant in rural communities in Pakistan (Bhutta et al., 2011). The quasi-experimental study conducted with adolescents in Nepal (Malhotra et al., 2005) reports an increase in facility births at both sites but a greater increase at the control site than the study site. Very low-quality evidence.(8-11)

Five observational studies also report on this outcome. Two controlled before and after studies report significant increases in facility births in Kenya and China (Kaseje et al., 2010 Kaufman, Liu and Fang, 2012); the before and after studies report increased facility births following the intervention in Peru (Harkins et al., 2008); and in Pakistan, births in an EMoC facility increased in a refugee population (Purdin, Khan and Saucier, 2009). In Indonesia (Sood et al., 2004), study findings indicate facility births were significantly more likely in the group exposed to the intervention. Harkins et al. (2008) also reports an increase in use of skilled attendants at last birth in Honduras following a participation intervention. The community participation interventions are diverse and the level of participation in planning, implementing and evaluating programmes varies across the studies. Very low-quality evidence.(12-16)

For those studies where the focus was increasing access to skilled care for complications:

The pre and post intervention follow-up study in rural, poor communities in Tanzania (Ahluwalia et al., 2010) reports significant increases in births assisted by a trained person and occurring at a health facility over the three-year follow-up period. Very low-quality evidence.(7)

For the outcome of care with a skilled birth attendant or facility in case of maternal complications, the quality of the evidence was rated as very low.

Only the pre and post intervention study in Tanzania (Ahluwalia et al., 2003) reported on this outcome. In this programme, community mobilization was a small component of a larger more complex programme focused on training TBAs, preparing women for birth with a TBA, and mobilizing communities to understand danger signs. The study reports an increase in the number of pregnant women attending the district hospital treated for obstetric complications. Very low-quality evidence.(6)

For the outcome of ANC use, the quality of the evidence was rated as very low.

Two cluster RCTs (Bhutta et al., 2011; Bjorkman and Svensson, 2009) and one quasi-experimental study (Malhotra et al., 2005) reported on this outcome. The two cluster RCTs report non-significant increases in four or more visits in Pakistan (Bhutta et al., 2011) and number of ANC visits at the facility per month in Uganda (Bjorkman and Svensson, 2009). The quasiexperimental study of adolescents in Nepal (Malhotra et al., 2005) reports a decrease in mean percentage of women receiving ANC in the intervention group. Very low-quality evidence.(9-11)

Seven observational studies also reported on this outcome. The controlled before and after studies report increases but no significant differences between control and intervention sites (Kaseje et al., 2010; Kaufman, Liu and Fang, 2012). The before and after studies all report increased ANC use following the intervention (Ahluwalia et al., 2010; Paxman et al., 2005; Sood et al., 2004; Harkins et al., Peru, 2008; Purdin, Khan and Saucier, 2009). Studies were conducted in a range of countries from low income (Tanzania, Kenya) to middle income (Pakistan, Indonesia, China, India, Peru) and with varying populations including rural poor communities (Ahluwalia et al., 2010; Kaseje et al., 2010; Kaufman, Liu and Fang, 2012; Paxman et al., 2005; Sood et al., 2004), peri-urban migrant poor (Harkins et al., Peru 2008) and Afghan refugee women (Purdin, Khan and Saucier, 2009). The community participation interventions are diverse and the level of participation in planning, implementing and evaluating programmes varies across the studies. In some studies community participation is one small component of larger safe motherhood or maternal and newborn health programmes (Ahluwalia et al., 2010; Harkins et al., 2008; Paxman et al., 2005; Purdin, Khan and Saucier, 2008; Sood et al., 2004), while in others community participation was the main focus of the intervention, specifically communitybased monitoring via report cards (Bjorkman and Svensson, 2009), community dialogue (Kaseje et al., 2010) or more general participatory approaches to improve services for specific groups (Kaufman, Liu and Fang, 2012). All studies report ANC use but use different measures. Some report number of women reporting four or more visits (Harkins et al., 2009; Kaseje et al., 2010; Sood et al., 2004), others report complete ANC (defined as three or more visits) (Paxman et al., 2005; Purdin, Khan and Saucier, 2009), one reports prenatal care before 20 weeks (Ahluwalia et al., 2010) and other descriptive measures (Kaufman, Liu and Fang, 2012). Very low-quality evidence.(7, 12-14, 16-18)

For the outcome of postpartum visits for women, the quality of the evidence was rated as very low.

Purdin, Khan and Saucier (2009) showed that coverage of postpartum care within 72 hours of birth increased over time following the intervention in a setting with Afghan refugee women in Pakistan. Very low-quality of evidence.(14)

In addition to the critical and important outcomes, the GDG had requested information on the effect of the intervention on woman's satisfaction with services. Theree studies implied improved satisfaction but one assessed satisfaction and determined it could not be attributed to the intervention.

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/172427/2/9789241508742_tables_eng.pdf?ua=1

 

Implementation considerations

  • Participation in programme planning should ideally be implemented through either existing or adapted structures and platforms that enable planning at the local level (reflecting the local reality/needs) and input to planning at higher levels, with monitoring and evaluation and ongoing planning/replanning.
  • Discussion at the national and local levels is required for adaptation to context and to ensure a meaningful degree of decentralization and the appropriate level of budget and resources assigned to support the process.
  • Community participation in planning and implementation of MNH programmes is a dynamic process that can strengthen community capacity in many ways such as helping communities to effectively identify their assets, needs, and problems; plan together as a group; obtain and manage resources; problem-solve; use data to monitor progress and make decisions; and resolve or manage conflict. It takes time to build trust and for community members to develop the skills and processes necessary to plan and implement effectively as a group. However, once relationships and trust have been established and skills have been learned, they can be applied to address other community priorities. When engaging in these types of processes, those in supporting roles need to be aware of the changing context and adjust their support accordingly.
  • Strategies that have been pre-determined by programmes that then mobilize communities to implement them risk not being owned by communities and may be abandoned in the future. This approach also limits opportunities for communities to learn how to identify emerging priority challenges over time and plan together to address them to improve MNH and other health issues.
  • It is essential to have linkages between the different levels of the health system and between the different institutions involved in planning, implementation, monitoring and evaluation.
  • An enabling/supportive environment is considered a key facilitator of implementation where the public sector/local government is involved in the multiorganization partnership.
  • NGOs, which often have experience facilitating and organizing community involvement, can facilitate the process and provide technical support to develop communities' capacity to plan and implement interventions. The work should be linked to government services and embedded in ongoing processes, as appropriate to the local context. Community health workers can also play a vital role in linking communities and health services.
  • Ensuring women's participation is extremely important as women are key stakeholders and directly affected by the issues discussed. Innovative mechanisms may be needed to ensure inclusion of women and other key stakeholders who may otherwise be excluded. This may require reflection on existing power dynamics to find appropriate and effective ways to address any power imbalances that would prevent their voices being elicited or heard.
  • Facilitation of the process to ensure the discussion and interaction between the different actors and stakeholders is important. Programme implementation should include training facilitators in key MNH topics, data interpretation, communication, conflict resolution and management.
  • Data presentation must be comprehensible and the communication of health issues should be adapted for the audience, who may have no previous health sector experience. For instance, culturally appropriate materials available in a local language suitable for individuals with low literacy/numeracy skills should be developed where needed.
  • Health committees exist in many countries and can prove effective for monitoring progress, identifying and solving problems and re-planning as necessary. The purpose of the committee should be clear to all members and basic good group processes should be in place. It is important to review existing committees to see how they can become more effective, taking into account the extent to which community members are involved and how they can strengthen their planning and monitoring processes.
  • Formal written action plans should be developed, setting out clearly assigned roles and responsibilities to clarify agreements and hold communities and services accountable for their activities.

 

Research implications

The GDG identified several areas for future research:

  • Community participation is often one intervention in a complex package of interventions. While RCT design may be helpful to determine effectiveness and outcomes, alternative designs are needed to look at processes and to understand change.
  • Determining the most effective ways to share data that are accessible to those with low literacy and numeracy skills.
  • Establishing the gender considerations that are necessary in planning processes, such as when and how do men and women participate and under what circumstances and in what contexts it might be useful to have single sex versus mixed sex groups. How cultural beliefs and practices influence the planning processes (e.g., how issues such as causality are perceived).
  • How and when to share strategies that have been found to be effective in other settings with community planning groups.
  • How and when to include community participation at the programme design stage.
  • Determining the social effects of programmes where household decision-makers participate at a higher level while the pregnant women's level of participation is only to receive key messages.
  • Establishing the values and preferences of community members who participate in the planning and implementation of MNH programmes.
  • Assessing the impact of experiences in high-income countries and identifying the lessons learned.

 

Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015)full document and evidence tables

 

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

Newborn Health

 

Supporting systematic reviews:

Marston C, Sequeira M, Portela A, Cavallaro F, CR M. Systematic Reviews on community participation and maternity care seeking for maternal and newborn health

 

References

  1. Working with individuals, families, and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. [26 November 2014] http://wwwwhoint/maternal_child_adolescent/documents/who_fch_rhr_0311/en/.
  2. The Ottawa Charter for Health Promotion [website]. Geneva: World Health Organization; 1986. [30 March 2014] http://wwwwhoint/healthpromotion/conferences/previous/ottawa/en/.
  3. WHO Handbook for Guideline Development - 2nd edition. Geneva: World Health Organization; 2014. World Health Organization. 2014.
  4. WHO recommendations on health promotion interventions for maternal and newborn health 2015: World Health Organization; 2015.
  5. Marston C, Renedo A, McGowan CR, Portela A. Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review. PloS one. 2013;8(2):e55012.
  6. Ahluwalia IB, Schmid T, Kouletio M, Kanenda O. An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2003;82(2):231-40.
  7. Ahluwalia IB, Robinson D, Vallely L, Gieseker KE, Kabakama A. Sustainability of community-capacity to promote safer motherhood in northwestern Tanzania: what remains? Global health promotion. 2010;17(1):39-49.
  8. Iap2 public participation spectrum. Wollongong, Australia: International Association for Public Participation; [23 January 2015]. year https://wwwiap2orgau/documents/item/84.
  9. Björkman M, Svensson J. Power to the people: evidence from a randomized field experiment on community-based monitoring in Uganda. The Quarterly Journal of Economics. 2009;124(2):735-69.
  10. Bhutta ZA, Soofi S, Cousens S, Mohammad S, Memon ZA, Ali I, et al. Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. Lancet (London, England). 2011;377(9763):403-12.
  11. Malhotra A, Mathur S, Pande R, E. R. Nepal: the distributional impact of participatory approaches on reproductive health for disadvantaged youths. Washington, DC: The World Bank; 2005 [7 January 2015] https://openknowledgeworldbankorg/bitstream/handle/10986/13687/324190HNP.... 2005.
  12. Kaseje D, Olayo R, Musita C, Oindo CO, Wafula C, Muga R. Evidence-based dialogue with communities for district health systems' performance improvement. Global public health. 2010;5(6):595-610.
  13. Kaufman J, Liu Y, Fang J. Improving reproductive health in rural China through participatory planning. Global public health. 2012;7(8):856-68.
  14. Purdin S, Khan T, Saucier R. Reducing maternal mortality among Afghan refugees in Pakistan. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2009;105(1):82-5.
  15. Sood S, Chandra U, Mishra P, Neupane S. Measuring the effects of behavior change interventions in Nepal with population-based survey results. 2004.
  16. Harkins T, Drasbek C, Arroyo J, McQuestion M. The health benefits of social mobilization: experiences with community-based Integrated Management of Childhood Illness in Chao, Peru and San Luis, Honduras. Promotion & education. 2008;15(2):15-20.
  17. Sood S, Chandra U, Palmer A, Molyneux I. Measuring the effects of the SIAGA behavior change campaign in Indonesia with population-based survey results. 2004.
  18. Paxman JM, Sayeed A, Buxbaum A, Huber SC, Stover C. The India Local Initiatives Program: a model for expanding reproductive and child health services. Studies in family planning. 2005;36(3):203-20.

 

Citation: WHO recommendation on community participation in programme planning and implementation (2015). WHO Reproductive Health Library; Geneva: World Health Organization.