Community engagement: improving health and wellbeing and reducing health inequalities

Background

Community engagement is a highly complex area with several important purposes. These include empowering people within local communities to gain more control over their lives and to play a part in decisions that affect their health and wellbeing.

The focus of community engagement in this guideline is to maximise local communities' involvement in planning, designing, developing, delivering and evaluating local initiatives to improve health and wellbeing and reduce health inequalities. In this guideline 'initiatives' covers all strategies, programmes, services, activities, projects or research programmes that aim to improve health and wellbeing and reduce health inequalities.

The committee noted that community engagement can be an end in itself, leading to a range of important health‑related and social outcomes, such as improved self‑confidence, self‑esteem, social networks and social support.

Many local authorities have considerable experience of involving local communities in tackling a range of issues in different ways. The committee also recognised the significant role that community and voluntary organisations play (both directly and indirectly) in community engagement activities to improve health and wellbeing and reduce health inequalities.

The committee noted the importance of not seeing local communities simply as recipients of health and wellbeing services but, rather, as active participants with a vital contribution to make to improving health and wellbeing and reducing health inequalities.

The committee was aware that many statutory organisations are looking for new ways to get local communities involved in activities to improve their health and wellbeing and to tackle the wider determinants of health. This includes, for example, agencies involved with increasing breastfeeding rates or reducing childhood accidents. But members were concerned that these well‑intentioned activities will only be effective if properly planned, designed, implemented and resourced.

The committee recognised that there are running costs associated with engaging local communities. Whether peer and lay roles are paid or unpaid is a local decision. However, unpaid roles are not actually 'free'. For example, it is important to identify and provide incentives for volunteers, such as learning and training and other development opportunities (see the section on learning and training). Volunteers' expenses also need to be paid.

The committee discussed that although planning for such costs may be challenging, community engagement need not necessarily cost more overall, but is about a different way of working using existing resources.

The committee recognised the difficulties that small community and voluntary organisations face in getting funding from local government and non‑governmental organisations. It also recognised that they need other help to get involved (this includes training and resources).

The committee was aware that many public health workers, including community development workers, are highly skilled at working with economically or geographically disadvantaged communities to bring about social change and improve their quality of life.

Community engagement activities and approaches

Many successful community engagement activities are undertaken across the country. Various terms and conceptual frameworks are used. But the committee agreed that Public Health England's guide to community-centred approaches for health and wellbeing provides a useful framework for understanding how different approaches work and deciding on the most appropriate activities to use locally.

Members noted the need to make community engagement an integral part of local strategies and initiatives for health and wellbeing and discussed the need for resources to achieve this. The committee also discussed the benefits of an asset-based approach, in which local communities themselves identify and solve issues that affect their health and wellbeing. This is in contrast to models that focus on outside agencies identifying their needs and fixing problems.

When statutory bodies and local communities work together they face many barriers and challenges. These vary depending on local circumstances but may include: cultural differences; statutory agencies being unwilling to share power and control of services; lack of time for statutory organisations to develop relationships and build trust with local communities; and a lack of suitable venues for activities.

The committee acknowledged that people may not want to get involved in community activities. Members also recognised that some people, particularly from disadvantaged communities, may need help to participate. This involves overcoming barriers such as having English as an additional language.

The committee noted that if disadvantaged communities have well established social networks, a 'bridge' is needed between these and other networks run by community, voluntary and statutory organisations. It also recognised that there is very little infrastructure in place for networking in some local communities – and that establishing such a network may take time.

Given the limited evidence base in this area, the committee considered that a central source of information on effective approaches to community engagement would be helpful. Members felt this would be particularly useful if local organisations could use it to share their learning.

Health and social inequalities

Community engagement is an important way to improve health, address the social determinants of health and reduce health inequalities. Members recognised that extra effort is needed to help some local communities to get involved. The committee recognised the importance of ensuring a fair allocation of resources to local community engagement activities to benefit those most at risk of poor health.

The committee noted that most evidence on community engagement came from studies of interventions to promote health among disadvantaged communities. But it also recognised that looking at populations in isolation may not reflect the dynamics of how local communities interact to improve their health and wellbeing.

Social media is becoming a commonplace way to communicate and share information among 'virtual communities' and it is a potentially efficient way of helping people to get involved. But the committee flagged that using social media could also increase health inequalities.

Evidence

Over recent years, there has been a significant increase in published evidence on community engagement. There is also a growing informal evidence base about how initiatives work in practice. But the latter is difficult to capture and formally evaluate.

There is good evidence that community engagement improves health and wellbeing. A recent review (Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis [O'Mara-Eves et al. 2013]) suggested that community engagement interventions are: 'effective in improving health behaviours, health consequences, participant self‑efficacy and perceived social support for disadvantaged groups'.

There was good evidence from the effectiveness reviews and expert papers that collaborations and partnerships and peer and lay roles are effective approaches to involving communities in local health and wellbeing initiatives.

There was good evidence from the effectiveness reviews that community engagement activities lead to more than just traditional improvements in health and behaviour. For example, they also improve people's social support, wellbeing, knowledge and self‑belief. The committee agreed that these wider outcomes need to be taken into account. Members also agreed that future research should place greater emphasis on individual and community wellbeing and these kinds of social outcomes.

It was not possible for the committee to draw specific conclusions on which community engagement approach should be recommended for a particular population in a particular set of circumstances. However, the reviews present evidence for potential options.

Evidence on the use of social media came from a search strategy designed to find studies about community engagement, not social media or online social networks. The committee was unable to make a recommendation on online approaches due to the lack of evidence. But members agreed to make a research recommendation on the use of social media to further explore this method of engagement (see recommendation 4 in the section on recommendations for research).

There was good evidence that different approaches are used to target different types of health or wellbeing issues. Peer and lay roles were most often used in initiatives targeting individual behaviour change (such as physical activity, healthy eating or substance misuse). Collaborations and partnerships were more often used in initiatives focused on improving general community wellbeing, (for example, by setting priorities for health and wellbeing initiatives or regeneration of deprived areas).

The effectiveness reviews revealed variation in how much people were involved in community engagement projects, from early development through to delivery and evaluation. This variation provided an opportunity to indirectly compare the effects of different levels of engagement across studies: generally, the more stages of a project people were involved in, the greater the benefits. Members agreed that getting local communities involved as much as possible is essential for the success and sustainability of initiatives to improve health and wellbeing and address health inequalities.

The committee noted there was good evidence from expert papers that communities that received local services driven by statutory priorities were less empowered, over time, to contribute to local decisions than communities that worked in partnership with statutory services (see expert paper 4).

As a result, the committee did not make any recommendations on using consultation approaches alone to get local communities involved in health and wellbeing initiatives.

The committee noted that studies of community engagement activities and processes did not always exactly describe the populations involved and the actions being taken. This proved a challenge when trying to interpret which components of an activity were linked to successful outcomes.

The committee highlighted the complex nature of the evidence. In particular, members pointed to the inter‑relationships between inputs and outputs of community engagement. They also pointed to the problems involved in making direct comparisons of initiatives that differed in many ways – and not only in the community engagement approach adopted.

The committee recognised that some of the wider health outcomes – such as empowerment and social capital – were important in their own right. That is to say, such outcomes should not be treated as 'intermediate' in a simple linear causal chain between the 'intervention' (that is, the community engagement approach) and the recipients (that is, the local population).

In the absence of a method to capture a more complex system, with outcomes occurring at individual and community level, the committee agreed that the economic analysis would oversimplify the scope of community engagement activities and outcomes. The committee also noted that the benefits local communities themselves may value, such as gaining a sense of belonging and empowerment, or expanding their social networks and support, may be overlooked in formal evaluations.

To ensure that outcomes of importance to the community are captured, the committee made recommendations on involving local communities at every stage of the evaluation process.

The committee noted that the effectiveness reviews focused on context‑specific evidence from Organisation for Economic Cooperation and Development (OECD) countries. This meant that evidence from non‑OECD countries and qualitative evidence from outside the UK was not included. So potentially effective or innovative approaches – along with any findings – from other sociocultural settings but still applicable to the UK may have been missed.

Volunteers play a valuable role in community engagement activities to improve health. But members also recognised that community organisations do not always have the resources to support volunteers and there was not enough evidence to make a recommendation on how this support could be provided.

There was good evidence from expert papers that community engagement can help both local authorities and health bodies meet their statutory obligations on tackling inequalities and getting communities involved in local initiatives (see expert paper 3). But members also noted that the term 'community engagement' may be misunderstood, and that opportunities to maximise the benefits may therefore be missed. Similarly, the committee noted that some people or organisations the guideline is for may not be aware of their potential role in community engagement initiatives.

Health economics

The committee recognised the opportunity costs of prioritising community engagement activities over other public health activities. Members also valued the wider health benefits of community engagement, such as improved social support and social networks, wellbeing, knowledge and self‑belief. In addition, they recognised the indirect benefits, in terms of increasing participation in other healthcare and wellbeing programmes.

The committee noted that attempting to assess the cost effectiveness of community engagement approaches posed a number of significant challenges. These include the following problems:

The committee noted the cost‑effectiveness evidence identified in the literature reviews was mixed. There was evidence from 5 studies suggesting that community engagement is cost effective. Two studies suggested it is not cost effective and 4 studies were inconclusive. The 2 studies that covered disadvantaged groups reported that community engagement approaches targeting low-income groups and families are cost effective.

The committee had concerns about the quality of the published studies, especially how they were conducted. Members felt the evidence was weak on the potential wider benefits, and the mixed findings made it difficult to interpret. As a result, this evidence was supplemented with several bespoke cost–consequences analyses and a rapid review of relevant social‑return‑on‑investment studies.

The committee considered that a cost–consequence analysis was the most appropriate type of economic analysis, given the wide range of outcomes relevant to community engagement. The evidence from this analysis suggested that individual empowerment and the development of a feeling of belonging or 'social capital' provide direct health benefits.

The committee also agreed that evidence on the social‑return‑on‑investment analysis should be considered because it is used to analyse 'value' beyond the financial cost (although some of the value it captures may have been paid for). Just as importantly, it aligns well with the concept of community engagement as: 'the process of getting communities involved in decisions that affect them (Community empowerment and health improvement: the English experience [Popay J; 2006]).

The committee noted the evidence reviews identified multiple examples of community engagement. The 3 case studies selected for cost–consequence analyses (see the cost–consequence analysis report) were chosen to represent the different types of theoretical approach identified in the original Evidence for Policy and Practice Information and Co‑ordinating Centre (EPPI) review ('Community engagement to reduce inequalities in health: a systematic review, meta‑analysis and economic analysis').

The committee noted the studies reported a range of benefits, including health benefits, from relatively low cost interventions (albeit based on retrospective estimates that may be incomplete). Health effects included: improved cancer awareness and mental wellbeing, increased breastfeeding rates, reduced postnatal depression, reduced childhood accidents and fewer cases of asthma. They also included improved access to health services and increased uptake of interventions known to be cost effective.

The committee noted, as with any economic analysis undertaken during guideline development, the results are subject to uncertainty and numerous assumptions. In terms of its impact on health and wellbeing, members agreed that appropriately resourced community engagement is probably cost effective. But they highlighted the need for better research on cost effectiveness and that this should include any associated opportunity costs.

The committee considered that the costs involved in recruiting, training and providing ongoing support for volunteers could be offset by the value of the activities provided by the volunteers (as evidenced in the cost–consequences analyses). This view is supported by a national report highlighted by the committee (Cabinet Office's Volunteering in the public services: health and social care). This estimated that for each £1 of investment in volunteer support, small voluntary organisations gained between £2 and £8 of value from their volunteers.

In addition, the Cabinet Office calculated that the monetary value of volunteering, in terms of improvements in the wellbeing of the volunteers themselves, was £13,500 per person per year (Department for Work and Pensions' Wellbeing and civil society: estimating the value of volunteering using subjective wellbeing data). Given this evidence of value for money, for both the volunteers and wider society, the committee believed it was important to support and sustain volunteering.

The committee noted that although the costs and benefits are picked up in different sectors, the public sector system as a whole is likely to benefit.

The committee believed that community engagement does not necessarily need extra money. Rather it considered community engagement to be a different way of working using existing resources. Indeed, the committee viewed the wide ranging benefits and virtuous cycle (such as volunteers going on to secure paid employment) as having the potential to make better use of scarce resources. In that regard, the committee considered community engagement good value for money.

Based on all the evidence presented, the committee is confident that community engagement offers economic benefits for communities.

Evidence reviews

The guideline recommendations are based on the best available evidence. Listed below are the evidence statements that provide the best available evidence and are directly linked to the recommendations. Evidence from the health economics work underpins all recommendations in this guideline. The complete list of evidence statements includes an overview of the economic evidence.

Gaps in the evidence

The committee's assessment of the evidence, stakeholder and expert comment on community engagement identified a number of gaps. These gaps are set out below.

1. Studies of the effectiveness of collaborations and partnerships, including those involving older people and those covering recently established communities.

(Source: evidence review 1)

2. Studies that identify and evaluate the components of community engagement.

(Source: evidence reviews 1, 2 and 3)

3. Studies of effectiveness and cost effectiveness that compare using community engagement with not using this approach.

(Source: evidence reviews 1 and 7)

4. Studies on what comparators to use in a community engagement study.

(Source: evidence reviews 1 and 7)

5. Studies of community engagement in a rural environment.

(Source: evidence review 4; primary research report 1)

6. Studies of community engagement addressing reproductive health, parenting or violence prevention.

(Source: evidence review 1)

7. Studies that outline the unintended or harmful effects of community engagement.

(Source: evidence review 4)

8. Studies of community engagement approaches that have failed.

(Source: primary research report 1)