I thank my colleague Joydeepa Darlong for drawing my attention to this important article,[1] where Wilson, Lavis and Guta have tackled the ‘Tower of Babel’ that is community organisations involved in health. Their approach was to conduct a scoping literature review and use the findings to develop a classification or taxonomy for this type of intervention. Although they searched no less than 18 databases, they found only 186 articles that enabled them to identify characteristics of community-based organisations or networks. The most common issues were HIV, mental health, addictions and unspecified populations. The great majority of the literature came from high-income countries.

Community organisations involve local people in the planning and implementing of policies that affect them, and thus enable a key principle of the Declaration of Alma-Ata.[2] Five criteria have been proposed for a community organisation:

1. Organised to some degree.
2. Separate from government.
3. Non-profit distributing.
4. Self governing.
5. Voluntary, at least to some degree.

In around one-quarter of cases the methodology of the included articles was entirely theorybased; a further quarter were based on case studies; and the remaining half were based on qualitative methods or quantitative surveys.

This is a very useful study, and describes some of the important features that a community organisation may, or may not, have. I was rather surprised, however, to find that women’s groups, which have been widely used and evaluated for maternity care,[3] did not make it on to the list. Likewise, there seems no mention of peer support in the community for conditions such as diabetes. I am the chief investigator on an NIHR study on leprosy, and there is absolutely no mention of the extensive networks of self-help groups that have come into existence for this condition around the world. In fact many of these groups have expanded to include other conditions and other severely marginalised people. Still less, is any mention of microeconomic interventions, many of which are relevant to health as well as social and wealth outcomes.

I guess all this adds to the evidence that community groups cover a very wide range of conditions and methods. It is perhaps more useful to articulate the principles that are involved in a particular case, rather than to use a portmanteau term such as ‘community group’ or ‘community network’.

And what are these principles?

First, seek to empower local people so that the facilitator or mentor of the group becomes increasingly redundant.

Second, create peer leaders to act as role models and peer educators.

Third, encourage local innovation and originality.

Fourth, if the intervention is largely health related, ensure that this is coupled to the health system.

Fifth, any organisation is political, so do the political work that is necessary to establish the community.

Sixth, and by extension of the previous point, engage not just the target population, but also the power structures that influence the community within which the target group is situated.

Seventh, ensure that the practical means for group activity are available; for example, if the group is highly dispersed, then consider information technology.

These are the main principles that I have found in the literature. I strongly encourage News Blog readers to add or subtract. However, based on my experience I would like to add two further requirements. First, If making an investment, do not withdraw the investment suddenly, but rather phase it out. Second, do not assume that the intervention to create a self-sustaining network will always work well. For example, a network may internalise bad habits and behaviour, just as it can promote good behaviour. An intervention targeted at one marginalised group may arouse resentment among others in the community. So always evaluate, preferably with an independent evaluator, and take a wideangle lens when doing so.

Richard Lilford, ARC WM Director

References:

1. Wilson MG, Lavis JN, Guta A. Community-based organizations in the health sector: A scoping review. Health Res Policy Sys. 2012; 10: 36.
2. International Conference on Primary Health Care. Declaration of Alma-Ata. 1978.
3. Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in resource-limited settings: systematic review and metaanalysis. Lancet. 2013; 381(9879): 1736-46.