People Don’t Behave the Way We Think/Know They Should Susan B . Rifkin, PhD. London School of Economics Colorado School of Public Health
Community Participation and Health: The Critical Questions 1. What is the contribution of community participation to improved health outcomes? 2. Why are we not able to adequately evaluate these contributions?
1. Answers 1. The answer to question one depends on the answer to question 2. 2. The reason we cannot adequately evaluate the contributions is because : 1. A. Our assumptions about the contribution that have not been thoroughly investigated. 2. Our evaluation frameworks are designed to answer the question of WHAT? not WHY? And HOW?
Critical Assumptions about CP and Health • Communities want to participate in health improvements. CHWs do if financial and career incentives are given. (Some examples say pride and recognition is also critical) • Community participation will ensure equity and equitable distribution of resources and ensure social justice and the right to health. (Mansuri and Rao, 2013 World Bank) (WB spent $85 billion on participation; found investment driven by ideology and optomism) • Community participation will create capacity building and empowerment. (McCoy et. al. 2012; Molyneux et. al. 2012) Yes, if very carefully nurtured and supported by money and influential people.
Frameworks for Evaluation • In health, most frameworks use Random Case Control Trials (RTCs) for evaluation. • The evaluation framework takes community participation as the intervention and improvement in health status as the outcome. • A growing recognition that this approach is limited to understand the effective of specific interventions on population health.(Shelton, 2014; Harvey, 2013) • Sanson-Fisher, et.al (2007) argue RCTs have limits when evaluation population health interventions. – Population availability – Time for follow up – External Validity – Contamination – Cost – Ethics and Informed Consent – Inhibition of innovative research questions
Critique of the RTCs for examining community participation and improved health outcomes (Rifkin, 2014) • Most evaluations examine CP as an intervention. However: • There are no standard definitions for “community” and “participation making it difficult for generalizable results. • The RTC framework reduces investigations to a simplified explanation for a complex and highly nuanced interaction between professionals and community lay people. • It is more valid and productive to view CP as a process (defined as “a usually fixed or ordered series of actions or events leading to a result ) rather than as a static, repetitive event.
Failures of Evaluation Frameworks • In a search for generalizability many evaluations ignore context. WB (2013) notes that one lesson of the research is that context is extremely important. • Planners and policy makers do not question the assumptions about the contribution of community participation to improved health. • Evaluations fail because they do not confront the killer assumption: People act the way we think/know they should. A recent example published in The Lancet provided evidence that an intervention of intense latrine building in a poor rural area in India when compared to a similar control area did not significantly reduce diahorrea deaths among children.(Clausen, et. al. 2014)
Realist Evaluation (Pawson, 2005): A way forward • Realist evaluation is a theory driven approach to provide evidence for policy makers and planners about What works and Why concerning complex interventions to improve health. • It uses mixed methods (quantitative and qualitative). • It focuses on explaining the relationship in which an intervention is applied, the mechanisms by which it is implemented and the outcomes which it produces
The Realist Approach • Start by stating the underlying assumption about how an intervention is supposed to work and the expectations for its outcome. • Analyze the Context, Mechanisms and Outcomes of the intervention • Use “middle range” theory which is tested on observable data not data abstracted for generalization • See the most appropriate theory(s) based on data as it is collected • Build on the findings that partner synergy is a universal feature • Seek unintended outcomes that may have critical influence on intended outcomes.
The Realist Approach ( con’t ) • Examines the relationship between interventions and outcomes in terms of continual change in an iterative approach • Rejects the checklist approach to evaluations and uses mixed methods to collect and analyze data • Seeks to identify the dynamics of program implementation not merely static indicators that may or may not be sustainable. • Relies on flexibility of application and investigation of the evaluation.
Take Home Messages • If we want to know how community participation contributes to health outcomes (good and bad) we need a framework that we will address the how and why of a health intervention. • The framework must start by planners and policy makers examining the context in which the intervention is to take place and the assumptions on which expected outcomes are based. In this case the contribution of community participation. • It is necessary to deal with the killer assumption about the generalizability of human behavior and remain flexible in order to adjust programs to concrete situations. In this context evidence shows that participation is best seen as a process not the intervention. • The bottom line is that the goal of the intervention improves the health of the intended beneficiaries. The goal is not to provide a generalizable approach which overides the value to the target groups.
References • Clasen, T. et. al. 2014 Effectiveness of a rural sanitation programme on diahrroea, soil-transmitted helminth infections, and child malnutrition in Odisha, India: a Cluster-randomised trail. The Lancet 2(11):645-653. • Harvey, G. 2013.The many meanings of evidence: implications for the translational science agenda in health care. International Journal of Health Policy and Management . 1(3):187-188 • Mansuri, G and Rao, 2013. V Localizing development: does participation work? Washington, D.C. , The World Bank. • Nilsen, P. (2006) The theory of community based health and safety programs: a critical examination Injury Prevention 12:140-145. • McCoy, D., Hall, J. and Ridge, M. 2012. A systematic review of the literature for evidence on health facility committees in low and middle income countries. Health Policy and Planning 27 :6: 449-466. • Molyneux, S, Atela, S, Angwenyi, V, Goodman, C. 2012. Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework. Health Policy and Planning 27: 7: 541-554.
Reference Con’t • Pawson, R., Greenhalgh,T., Harvey, G., Walshe. 2005. Realistic review-a new method of systematic review designed for complex policy interventions . Journal of Health Services Research & Policy 10 Suppl 1 ,: 21 – 34 Journal of Health Services Research & Policy Vol 10 Suppl 1, 2005: 21 – 34. • Rifkin, S. B. Examining the links between community participation and health outcomes: a review of the literature. Health Policy and Planning 2014. 29(6): ii98-ii106. • Sanson-Fisher, et. al. (2007) Limitations of Randomized Controlled Trials in evaluating population-based health interventions. American Journal of Preventive Medicine 33:2:155-161. • Shelton,J. 2014 Evidence-based public health: not only whether it works, but how it can be made to work practicably at scale. Global Health: Science and Practice. 2(3): 253-258.
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