Community Engagement in Family Planning in the U.S

Abstract

Context

Community engagement may include activities that involve community members in the design, implementation, and evaluation of services. The objective of this systematic review was to evaluate the evidence on this kind of community engagement in U.S. family planning programs, including its effects on various health outcomes, its perceived value, and the barriers and facilitators to implementation.

Evidence acquisition

Using an analytic approach drawn from U.S. Preventive Services Task Force, multiple databases were searched for articles published from 1985 through February 2011 that described studies about community engagement related to family planning. In 2011, relevant articles were reviewed, summarized, and assessed for potential bias using a standardized abstraction process. An updated, targeted review for the 2011–2014 period was conducted in early 2015.

Evidence synthesis

Eleven papers related to family planning were included. All were qualitative, descriptive, and at high risk for bias. Engagement strategies involved various methods for developing educational materials, program development, or program evaluation. All studies reported benefits to community engagement, such as more-appropriate educational materials or more community support for programs. Barriers to engagement included the substantial time and resources required. Four more articles were identified in the targeted, additional search.

Conclusions

Community engagement is described as beneficial across the included studies, but the body of evidence for community engagement in family planning is relatively small. Given the high value ascribed to community engagement, more research and documentation of the various approaches taken and their relative strengths and weaknesses are needed.

Context

Community engagement is a core principle of public health practice. NIH and CDC define community engagement as “a process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people.”¹ Engagement can take many forms and purposes, ranging from single consultative meetings and focus groups with community members, to maintaining substantive, ongoing relationships with them and ensuring real leadership roles for community members in a project. Experience shows that community engagement also varies widely in the intensity of the partnerships formed, the degree of trust and equality among partners, and the influence that the engagement process has on a project’s directions. The United Kingdom’s (UK’s) National Health Service and WHO are among those who have espoused community engagement as a means of improving health and promoting equity and social justice.^2,3

Within the Title X family planning program, community engagement is a statutory requirement. Grantees are required, at a minimum, to obtain community input on the development, implementation, and evaluation of their programs, and particularly for the review and approval of informational and educational materials, to improve the suitability of those materials to their intended audiences.⁴ Although specific to the Title X family planning program, this requirement reflects values espoused by the broader public health community. Questions about the role and value of community engagement are pertinent to all family planning providers, particularly those that serve marginalized or underprivileged populations. We undertook this review to provide U.S. family planning providers a synthesis of published evidence and approaches related to community engagement for their own program development purposes.

Evidence Acquisition

The review relied on a set of six key questions (KQs) and an analytic framework that guided other reviews in this series (Table 1).⁵ The first three KQs relate to whether community engagement was associated with specific outcomes associated with the goals of most family planning programs, including those that were long-term (KQ1, e.g., reduced unintended pregnancy); medium-term (KQ2, e.g., more consistent use of contraception); and short-term (KQ3, e.g., higher satisfaction with services). The other three KQs relate to any unintended consequences of community engagement (KQ4), as well as barriers and facilitators to clients’ participating in community engagement (KQ5) and to healthcare centers conducting it (KQ6). Based on analytic frameworks developed by the U.S. Preventive Services Task Force (USPSTF), Figure 1 shows the logical relationships among the population of interest; the interventions of interest; and short-, medium, and long-term outcomes.⁶ The numbered lines in the framework map to the key questions addressed in the review. For this particular review, we added a short-term outcome related to improved informational materials and approaches. That outcome was the primary goal of many identified community engagement studies, but it was not adequately represented in this common analytic framework. All summary measures and statements reporting relevant outcomes were considered for review. Given that most identified studies were process evaluations and qualitative in nature, we eventually focused the synthesis of evidence on the reported qualitative outcomes.

Table 1.

Key Questions of the Systematic Review and Definition of Outcomes

Key question no.	Question
1	Does community engagement result in improved long-term outcomes of family planning services?
2	Does community engagement result in improved medium-term outcomes of family planning services?
3	Does community engagement result in improved short-term outcomes of family planning services?
4	Are there unintended negative consequences of community engagement in family planning program development and review?
5	What are the barriers and facilitators facing clients in participating in community engagement activities?
6	What are the barriers and facilitators facing health centers in adopting and implementing community engagement activities?

Figure 1.

Analytic framework and key questions guiding the systematic review of community engagement.

We limited the review to literature related to the development or evaluation of informational and educational materials or program services, to align with the scope of the Title X requirement. We excluded the substantial literature on participatory approaches to conducting clinical trials and other research in the formal review and excluded articles about community-level interventions. Our search included research based on experiences in Australia, Canada, Europe, New Zealand, and the UK; we excluded the substantial literature on community engagement in lower-resourced settings to enhance the relevance of this review to U.S. family planning providers.

Search terms applied specifically for this review included Medical Subject Headings such as consumer participation, community health planning, public relations, and community networks, as well as free-text terms such as community mobilization, community collaboration, and participatory (Appendix A). These were combined with family planning–specific terms (e.g., family planning, contraception) and those related to the various outcomes of interest (e.g., health behavior, intention, contraceptive behavior, utilization, pregnancy), to search for appropriate studies. Electronic searches were conducted of multiple databases, including PubMed/MEDLINE, CINAHL, PsycINFO, and POPLINE (Appendix B). Manual website searches were also conducted of 34 organizations, both U.S.-based and international, which were known to work on or include family planning and may have had additional gray literature reports to contribute to this review.

Information on the method of reviewing and abstracting data from studies, assessing study quality and risk for bias, and summarizing those are described elsewhere.⁵ Briefly, we used a system based primarily on the USPSTF to assess the level of evidence.⁶ We did not compute summary measures of association across studies because of diversity of interventions, study designs, populations, and outcomes.

Evidence Synthesis

The original search for this review was combined with that for community education, the results of which are synthesized elsewhere.⁷ As shown in Figure 2, the original, combined search yielded 14,357 unique abstracts across the examined databases, of which 4,006 were identified for further abstract review for this topic based on their title. We then excluded 3,983, with 23 selected for additional examination. Five of those articles were included, and supplementary PubMed/MEDLINE and hand searches identified six additional studies related to family planning, for a total of 11 articles. Appendix C provides detailed information on the study designs, interventions, and results.

Figure 2.

Flow diagram of the process of identifying articles to include in this review of community engagement in family planning programs.

None of the identified studies addressed KQ1 (long-term outcomes) or KQ2 (medium-term outcomes). Most addressed aspects of KQ3 (short-term outcomes), but none involved a comparison group, standardized measures of community engagement, or standardized measures of any short-term outcomes. Rather, all were descriptive and qualitative and therefore were rated at high risk for bias, according to USPSTF standards of evidence. None clearly described unintended consequences (KQ4). Many discussed some of the barriers and facilitators to community engagement (KQ5 and KQ6).

Most (nine) of the identified studies were based in the U.S., with two from the UK; publication dates spanned from 1987 to 2010 (Appendix C).^8–18 The methods of engagement employed were as follows: focus group discussions (nine studies)^8,10,12–18; key informant or individual interviews (five studies)^9,14–16; development of advisory boards (one study)⁸; community meetings/forums (two studies)^8,15; and surveys (three studies).^11,14,18 One study also used Photovoice, a form of consultation that asks participants to take photos to represent different themes and points of view and then uses those photos as the basis for discussion and greater understanding.^17,19 Collectively, these studies described engagement of various types of community members, including clients of health services, youth, parents, teachers, staff from service organizations, community leaders, and the general population. Formal examination of the external validity of this group of studies was not possible to assess, given the variety of populations involved, small number of included studies, and small sample sizes in most cases.

The goals of community engagement in these studies varied, including formative research for the development of culturally/linguistically relevant educational materials, market research to plan campaigns and advertising, development and evaluation of specific health services, and mobilization of public support for services. Two were also focused on assessing the feasibility of particular kinds of engagement. In the following sections, we briefly describe the findings of studies according to these broad aims.

Studies of the Development of Educational Materials

Among all five studies that focused on the development of educational materials, authors indicated that when the target population was involved in the development process, the end result or product was strengthened.^8,12–14,16 As discussed in each of these studies, community engagement enabled researchers and program staff to first assess the baseline knowledge level of community members about a given family planning topic, and existing perceptions and attitudes toward the use of family planning resources, and then to tailor language and images based on this understanding. Moreover, numerous changes to preliminary drafts of the educational or motivational materials were required to ultimately create products that used acceptable vocabulary, appropriate images/pictures, and ensured that other cultural sensitivity issues were addressed.

Studies of Program Development and Evaluation

All six studies that described community engagement for purposes of program development or evaluation identified benefits to engagement. In one study, market research within the community (using a phone-based survey) prior to the opening of a family planning center proved to be a useful mechanism for targeting the promotion of its new services.¹¹ The study identified individuals within the community that were in need of the service and most likely to use it, and the best channels for advertising the new service to these individuals. In another study that involved the development of a campaign to promote condom use, community mobilization efforts served as a foundation for the entire project.⁸ Initial formative research with the community to be served was used to better understand the issues surrounding condom use and access to condoms for teenagers, and to identify teens’ preferences in the style and tone of advertising that would be employed. This research further established what the best media venues would be for delivering messages to the populations they wanted to serve. By involving teens in the process, the researchers were able to address pertinent problems and challenges facing teens, and to address these issues in the approach that was designed. In addition, involving the broader community (local community members and leaders) allowed the researchers and program staff to determine the threshold for acceptability of the campaign messages, which were then toned to the needs and values of the community members. The authors further reported that this process fostered a sense of goodwill toward the project by involving them in the development process and listening to their concerns.

Other articles indicated that community engagement also could enhance community awareness, understanding, and acceptance of service changes. For instance, in one study,¹⁸ the use of multiple community participation efforts (survey, focus groups, and community forums) facilitated the addition of contraceptive services within a school-based health center. The planning group in this study recognized the potential controversy that could result from making contraceptive services available, and therefore set out to involve the community and the School Board in discussions of the benefits and approaches that would be acceptable to the community. In the program evaluation studies, engagement of clients in the process of evaluating services helped evaluators to learn about issues that deter service utilization and satisfaction among community members, and practical ways to address them.^9,15

Finally, two studies described the value of their particular modes of engagement. One study from the UK found that the use of clients as interviewers of other clients in their service evaluation study was feasible and yielded information they may not have obtained otherwise, though doing so required additional recruitment and training.¹⁰ Assessing the utility of the Photovoice method was a primary objective of another study, which described an intensive process that provided access to the perspectives of a marginalized population (in that case, new Latino immigrants) and used the photo results to stimulate greater sensitization among key service providers about that population.¹⁷ The authors of the study describing market research for a new health center¹¹ also noted that their phone survey was feasible, having been conducted on a small budget and with some donated technical assistance.

Facilitators and Barriers to Implementing and Participating in Community Engagement

Collectively, these studies noted some barriers and facilitators to community engagement (Appendix C). For the staff implementing community engagement, facilitators included obtaining extensive background information to bring to community engagement events (e.g., data on sexual activity reported by students at a school whose health center was being discussed¹⁸) and obtaining pro bono technical assistance from a local university.¹¹ Barriers to conducting engagement activities included substantial staff time, participant time, and other resources (e.g., compensation, child care) required.^8,13,14,17

Discussion

We identified 11 studies related to community engagement in family planning materials and program development in the U.S. The studies varied in their purpose and in the methods and reported outcomes of engagement. The evidence regarding outcomes was qualitative or descriptive, and none addressed impact on medium- or long-term outcomes. However, all indicated benefits to engagement, from better educational or promotional materials to new insights into the perspectives of the client population. All efforts were geared toward the ultimate goal of better meeting the needs of the communities served.

A targeted search was run in PubMed for the period from January 1, 2011, through December 31, 2014, to search for newly published studies in the area. Four additional studies have been published since this systematic review was completed. Two^20,21 relate to engagement done to help develop new educational materials or an online contraceptive decision aid, and two^22,23 relate to engagement conducted in the course of implementing new service components within existing family planning or sexual health services (Appendix C, bottom panel). Two additional methods of obtaining client feedback were described that were not mentioned in the studies described above: use of mystery shoppers to document details of service users’ experiences²² and use of adaptive conjoint analysis, which is a structured method of assessing user preferences that is drawn from the marketing field.²¹ Like those described above, these additional studies were largely descriptive and qualitative in nature, and they outlined various ways that the process of engaging community members or services users identified ways to improve their product or services to better meet their needs.

Recent review articles about community engagement within health programs more generally complement the family planning literature described here. Three studies^24–26 described in a Cochrane review²⁷ assessed the impact of community engagement on health outcomes focused on short-term outcomes, such as increased knowledge about a pending clinical procedure or clinical study they would be participating in. In each of these studies, individuals were randomized to either read materials or documents that were created with or without community input. The two studies^24,25 that focused on patient educational materials found positive effects of community engagement on short-term outcomes; however, the other study²⁶ that assessed the effect of community input on the comprehension of consent forms found no differences in comprehension. That review found generally that there was limited evidence of a positive impact on patient knowledge and little evidence of a positive impact on medium-term outcomes.²⁷

In a systematic review of studies on community engagement in the UK health system, Evans and colleagues²⁸ also identified largely qualitative studies, which either described the complexities involved in community engagement or claimed success with community engagement without providing rigorous or objective evidence of that success. Both that and the Cochrane review²⁷ pointed to a lack of rigorous research on community engagement, in contrast to the amount of attention that it is given. A recent report from the UK National Institute for Health Research conducted a review of community engagement to reduce inequalities in public health more generally, using a much broader scope than that used here or in the other two reviews.²⁹ That report found that community engagement can be effective for various process and health-related outcomes of disadvantaged engagees. They also found limited evidence of effectiveness for community-level outcomes, and little information on costs. They emphasize the wide variation in approaches, definitions, and metrics used across this literature and offer a new conceptual framework for community engagement to help guide further work.

Overall, compared against standard criteria for evidence, the strength of this body of evidence for community engagement in family planning for program development purposes was low, reduced by the qualitative study designs and resulting high risk for bias. None provided data to help answer KQ1 or KQ2, and most of the possible outcomes of KQ3 (short-term outcomes) were not addressed. Rather, authors focused on the process of community engagement and described the value, providing examples of ways that materials or service were, or could be, improved as a result of engaging community members or clients.

Additional, more rigorous research could benefit this field. However, this topic may merit a different approach to evaluation; traditional evaluation approaches may be unrealistic or inappropriate for many community engagement interventions. Some of the outcomes are, in some ways, more intangible or difficult to measure well, including, for example, how appropriate materials or programs are for certain communities or community members, how supportive communities are for family planning programs, or how much program staff understand the communities served. Researchers are identifying ways to better document and assess the various outcomes of community engagement, providing alternative frameworks for evaluation that may better suit this topic than traditional approaches.^30–32 Future studies of engagement, and future systematic reviews, should draw on these frameworks.

Moreover, community engagement could be viewed more as a value, or a fundamental principle of good practice, particularly for those who work with low-income or other marginalized populations that historically may not have had a voice in the services provided to them. Rather than trying to build a traditional body of evidence that shows whether community engagement affects key outcomes, perhaps it is more appropriate to gather more studies documenting various approaches, with limited resources and within particular program contexts, to help guide practitioners already committed to the principle.

Limitations

This review is subject to numerous limitations. First, although our search strategy cast a wide net, it is likely that some studies were missed. The fact that many of our 11 family planning–related studies came to light during supplementary searching is one indication of this possibility. Publication bias in favor of more positive or successful community engagement efforts is likely. The description provided here is not exhaustive of community engagement efforts among family planning providers. There are other examples of ways that community engagement has been used in family planning program contexts, garnered additional benefits or other effects, and faced barriers and facilitators to implementation that were not described in the studies included in this systematic review.

Conclusions

The results of this review were presented to an Expert Panel in May 2011 and considered as part of Expert Workgroup meetings in September 2011 and June 2012, all convened as part of the development of “Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs.”³³ Across meetings, experts voiced support for community engagement as important to meeting the needs of communities served and did not feel that the limited scientific evidence base for engagement should be used to caution against doing it. During the last expert meeting, three of five experts agreed with the recommendation that family planning programs should tap into the perspectives and experiences of clients and community members in respectful and meaningful ways, to identify how to improve services and better meet their needs. They agreed that the benefits in terms of services that are better tailored to communities’ needs, and increased knowledge and support from the community for services, outweighed the potential costs of conducting community engagement activities. One expert felt that, though valuable, community engagement of this kind should not be recommended as a core component of quality family planning services, given the mixed evidence and the often severe resource constraints that many family planning programs face. “Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs” ultimately focused on clinical services and did not include any recommendations related to community engagement.³³ However, these recommendations were submitted to the Office of Population Affairs for integration into Title X program operations.

Appendix. Supplementary data

Supplementary data associated with this article can be found at http://dx.doi.org/10.1016/j.amepre.2015.03.029.