An implementation model that draws on experience from a diverse array of settings describes eight stages of community engagement: 3
- Step 1: Aim – Stakeholders define the focus of the community engagement intervention. In order to do so, leaders must be selected to champion community engagement.
- Step 2: Type of engagement activity – Stakeholders determine in what aspect of the health system community engagement will take place. This should include consideration and discussion of what systems and processes are already in place.
- Step 3: Participants – Stakeholders identify community participants for engagement activities. The selection process for participants will differ significantly depending on the type of engagement activity that is planned.
- Step 4: Preparedness to be involved in community engagement – The stakeholders who will be interacting with community members should receive necessary training and education.
- Step 5: Engagement models – Considering the types of engagement activities, stakeholders should determine how community input will be collected (shared decision making, focus groups, public inquiries, etc.)
- Step 6: Measurement of community engagement – evaluate and measure the community engagement activities with a focus on both process and outcome
- Step 7: Barriers – Identify and address barriers to community engagement (i.e. cost, culture, population-specific limitations).
- Step 8: Facilitators – Identify and harness facilitators (i.e. government support, key groups).
Simply acknowledging that community input is welcomed in the planning, provision, and governance of health services is not enough to catalyze effective engagement. Formal systems must be implemented to encourage, solicit, and respond to community members’ concerns, suggestions, and needs. While there is no single best way to engage communities, a range of methods are available for health systems to facilitate community engagement. This continuum includes simple, passive mechanisms to solicit feedback such as suggestion boxes or complaint lines as well as more active methods such as community ownership, sign-off, and decision-making. While deeper community engagement is preferable and will yield the most person-centered services, it may be helpful for health systems to begin by implementing more basic forms of engagement and planning strategies for scaling to more active engagement.
One common method for formally integrating community engagement in the health system is the use of a village (or regional/district level) health committee. Village health committees have been shown to play a variety of roles in LMIC. These committees stand at the intersection between community engagement, social accountability, and facility management organization and leadership. A systematic review of leadership committees in LMIC found a number of common functions of such committees. Although these functional are all ideal, they may not be functional or feasible in all community committees: 4
- Governance – to strengthen the accountability of the health facility to the community and public
- Co-management – of health facility resources and services
- Resource generator – in the form of material resources, labor, and funds for health facility
- Community outreach – to help the health facility reach into the community for the purpose of health promotion and improving health-seeking behavior
- Advocacy – to act as a community voice to advocate (e.g. to local politicians and health managers higher up the health system) on behalf of the health facility
- Social leveler – to help mitigate social stratification by empowering marginalized sections of the community/public
Community advisory boards often fulfill similar functions but may focus more on facility management and oversight opposed to community engagement. These boards may also engage in community-based participatory research or approval of research.5 Other systems for community engagement include community meetings, feedback forms at facilities and/or community centers, and the integration of community members in health system planning and management activities. By valuing the voices, opinions, and expertise of end users, health services will be more acceptable, accessible, and appropriate to the communities they serve.
One example of robust community engagement is Patient and Family Advisory Councils (PFACs), a strategy that can improve patient-provider respect and trust by establishing and recognizing community members as key contributors to the health systems. In PFACs, community members meet with providers to discuss quality improvement and facility interventions to improve patient care. The following step can be taken to establish and sustain PFACs:
- Establish a PFAC team within the facility – The providers in the PFAC should be champions for community engagement in the health system. Roles and responsibilities for the providers within the PFAC include a leader to manage the PFAC, a logistics coordinator, a community recruitment coordinator, and a scribe.
- Define the mission, vision, and goals of the PFAC – These components will eventually be discussed and formed by the community members as well, but it may be helpful to establish the baseline mission, vision, and goals between provider members to ensure alignment.
- Meeting logistics – the providers should consider how and when PFAC meetings are held. Some important considerations to ensure inclusion include transportation, reimbursement, and child or elder care.
- Identify patient and family advisors & recruitment – The PFAC team should next consider how they want to select community members. It is important to include patients who have some familiarity with the practice and are willing to contribute their feedback. Providers can be asked for suggestions. The best methods for contacting potential members will depend on context but may include: email, patient portals, regular mail, notices in newspapers, or through community-based organizations.
- Invitations and first meeting – Identify and consolidate materials to orient patients to the goals of the group. During the first meeting, important topics include: introductions, discussion and feedback on the mission, vision, and goals, establishing topics or agendas for the next few meetings.
- Ensure sustainability – some suggestions for ensuring that PFACs are sustainable include: allocating staff time and resources to PFACs, sharing information on feedback from the PFAC and how it was incorporated with communities, recognize and actively appreciate the contributions of community members to these groups, ensure that patient members are diverse and represent all segments of the population.6
More detailed information on PFACs, as well as sample resources for roles and responsibilities and discussion questions can be found here.