This book seeks to ‘explore the “roots” and “branches” of community involvement in health’ and ‘is concerned with helping to support good practice in relation to community involvement’. The authors claim that this book is of interest to a range of different people, including health professionals, service providers and academics. I suspect that the book will be of use to those actively involved in community projects and, given the authors practical expertise, may well ‘support good practice’. However, the book leaves many fundamental questions unanswered and lacks the rigour required by an academic audience.
Part I of this book seeks to provide the background and context to community involvement in health. The authors provide a good introduction to the issues but there are a great many problems with this section. Firstly, many key concepts, such as ‘empowerment’, ‘rights’ and ‘duties’ are not clearly defined. Most frustrating of all, the concept of community itself is not defined and, as a result, I was left wondering what the difference is between community involvement and public involvement.
Secondly, there are no clear set of objectives by which to judge the success or otherwise of community involvement initiatives. In addition to the extent to which they enhance overall population health, it would seem that such programmes are to be judged according to a wider set of criteria which take account of ‘process‐related’ benefits such as public participation. But nowhere are these objectives, and the possible trade‐offs between them, ever made explicit.
Thirdly, the alternative ways in which these objectives can be met are not discussed. It is simply taken for granted that community involvement (particularly through a ‘bottom‐up’ approach) is a good thing. But little justification is given for this assumption and many potential problems (such as rent‐seeking behaviour by groups or organisations) are not discussed at all. All of this (the lack of clear definitions of concepts, the failure to specify objectives and the reluctance to set out the costs and benefits of alternative approaches) is likely to be very frustrating to an academic reader.
Part II of the book seeks to move from theory into practice. Some of the concepts are more clearly defined in Chapter 5. However, since people ‘may or may not acknowledge membership of a particular community’, the source of the definition of a community remains an unresolved question. The overall objectives of community involvement are a little clearer by the end of this section but the relative weights given to the different objectives and the trade‐offs between them are still very unclear. And the discussion of the potential for ‘hijack’ by particular interest groups is still glaring by its absence. Indeed, in general there is very little discussion of incentives to be found within the book.
Part II of the book raises many more issues which are not discussed. Firstly, there is the crucial issue of the circumstances under which it might be legitimate to over‐ride community preferences (in the interests of greater health improvement, say). Secondly, there is the extent to which process‐related benefits from community involvement (such as increased access to resources) bring about improved health outcomes. The authors appear to take for granted that improved processes bring about better outcomes. Thirdly, there are important questions relating to the boundaries between health and non‐health benefits and which agencies are responsible for those benefits. Of course, it would be impossible to fully resolve any of these issues but a discussion based around them is certainly required.
On a more positive note, I would recommend that all health economists involved in economic evaluations read chapter 10 on ‘a participatory approach to evaluation’. This chapter identifies a number of key questions, which an evaluation needs to address and focuses on a much wider range of issues than those addressed through the exclusively outcome oriented perspective of an economic evaluation. This chapter makes clear that knowledge of the processes by which decisions are made is as important to effecting change as is information regarding the outcomes of those decisions.
Part III of the book is concerned with taking community involvement forward. It is this section that seems to be of most use to the practitioner. It sets out how to bring about greater community involvement in a clear and concise way. The use of case studies appears to be particularly useful. My main criticism of this section is its failure to give explicit recognition to considerations about the relative cost‐effectiveness of different types and levels of community involvement.
In their conclusion, the authors claim to have described ‘practical checklists for action that have been developed and can be used by those active in the field’. I would argue that they have achieved this aim. It is a shame that some of the more fundamental questions relating to community involvement, of which only a few have been outlined here, were not also addressed by this book.
Paul Dolan,
University of Sheffield