Multi-level rural community engagement in health

Aust. J. Rural Health (2009) 17, 39–44 Multi-level rural community engagement in health Sue Kilpatrick Department of Rural Health, University of Tasmania, Launceston, Tasmania, Australia Abstract Community participation in health is consistent with notions of democracy. A systems perspective of engagement can see consumers engaged to legitimise government agendas. Often community participation is via consultation instead of partnership or delegation. A community development approach to engagement can empower communities to take responsibility for their own health care. Understanding rural place facilitates alignment between health programs and community, assists in incorporating community resources into health care and provides information about health needs. Rural communities, health services and other community organisations need skills in working together to develop effective partnerships that transfer some power from health systems. Rural engagement with national/ state agendas is a challenge. Community engagement takes time and resources, but can be expected to lead to better health outcomes for rural residents. KEY WORDS: community engagement, community health development, community participation. Community engagement has again become prominent in health debates after some decades. In this paper, the international literature on community engagement in rural health is reviewed. The extent to which current practice in Australia aligns with the Alma Ata Declaration that put community engagement on the map 30 years ago is discussed. Analysis of this literature reveals two major discourses: the empowerment discourse and the systems discourse. By synthesising the salient points from these discourses, the paper argues that rural community engagement in health is appropriate contemporary practice, should be multifaceted and resourced at local, regional/district, state and national levels. What is community engagement? Community engagement is a multi-level concept, ranging from engagement in policy development, Correspondence: Associate Professor Sue Kilpatrick, Department of Rural Health, University of Tasmania, Locked Bag 1372, Launceston, Tasmania, 7250, Australia. Email: sue.kilpatrick@utas.edu.au Accepted for publication 6 November 2008. © 2009 The Author Journal Compilation © 2009 National Rural Health Alliance Inc. through partnerships with agencies and consumers to plan and deliver local services, to individual engagement with programs. This paper does not focus on the latter, but argues that paying attention to community engagement at higher levels will encourage engagement by rural and remote residents in their own health. The Alma Ata Declaration urges governments to develop the abilities of communities so that they can participate in planning and controlling health care.1,2 Community engagement and participation in health decisions are intertwined with notions of democracy, therefore socio-politically radical, especially for developing nations.3 An estimated 90% of health determinants are not health system-related, but social and economic.4 This legitimises demands for community development as a means of health improvement. Nevertheless, health policy continues to focus on individuals.5 A possible reason for this is that ‘community’ is not always a cohesive, easily identifiable group. Community as those who have social ties and/or share common perspectives is a practical definition for participation in health, particularly in a delineated geographical area, such as a rural site.6 The paper searched international literature databases for research on community engagement and community participation, and distilled aspects that could be regarded as good practice. It analysed current Australian policy documents for evidence of these elements in relation to rural health. Two discourses can be identified in the literature: systems and empowerment. The Alma-Ata Declaration contains seeds of both. The literature reveals that the systems discourse is a response by governments and health services to notions of democracy and civil society. Empowerment discourse is aligned to community development.3 Rural health services sit at their confluence because they represent the system in the community and rural community within the system. Systems discourse Collective community participation in health care decision-making is a democratic right7 that can be used to legitimise otherwise unpopular decisions.8,9 A review of community participation during the 1990s found that when it comes to community participation, many policy-makers are pragmatists who favour utilitarian models.3 A tendency towards an instrumental approach doi: 10.1111/j.1440-1584.2008.01035.x 40 S. KILPATRICK What is already known on this subject: • Community engagement is a multi-level concept, ranging from engagement in policy development, through partnerships with agencies and consumers to plan and deliver local services, to individual engagement with programs. • Community participation should be consistent with community values and attitudes, and take account of and draw on community resources. A health system–community partnership approach is good practice. • Community engagement takes time and resources, but can be expected to lead to better health outcomes for rural residents. means that consumers are engaged around the system’s agenda, rather than their own.10 Some Australian state governments, notably Victoria, have embraced community engagement in health policy, but have been criticised for making community an agent of government.11 There are issues of balance of professional and lay expertise: who represents community and whether it is safe, cost-effective and consistent with equitable outcomes to transfer power away from health experts.9 The recent federal government takeover of the Mersey Hospital in rural Tasmania and subsequent decisions not to proceed with previous promises of management by community board and reopening the intensive care unit highlight these issues.12 Empowerment discourse An empowered community takes responsibility for its own health.13 A community health development approach means supporting individuals and groups to participate in all issues that affect health, including education, water, housing and employment.3,10 It includes notions of personal development, consciousness-raising and social action,11,14 but disadvantaged groups even in developed countries are unlikely to be able to participate equally or meaningfully,2,11,15 and those with power in the community are likely to influence the agenda at the expense of disadvantaged groups.2,7 Community development approaches to health do not always empower. A contributions approach that considers participation as voluntary contributions to a project, rather than decision-making, and an instrumental approach that defines health as a commodity and those who use it as consumers, are seen in Australia.10 Much of the empowerment and community health development literature comes from the third world. An What this paper adds: • A comprehensive review of the literature. • Identifies empowerment and systems discourses of community engagement. • Multi-level rural community engagement in health should produce a system that recognises and responds to community needs in a way that is consistent with both community and health system norms and values. It will develop capacity of community and health professionals and draw appropriately on community resources. empowerment approach has application to our indigenous communities, and mainstream Australian rural and remote communities, which make up most of the bottom quartile of locations in the Socio Economic Index for Australia.16 Engagement and health outcomes A systematic review of impacts of ‘patients’ in health care planning and development found changes in ways services are delivered, particularly improved access and information.8 Although there is evidence that involving patients in their own health decisions makes a difference, little evidence has been collected of improved satisfaction or health outcomes from involvement in planning and development of health. This should not be taken as absence of effect,8 but rather difficulty in measuring effect.13,17 More responsive services and incorporating needs from communities themselves are expected to lead to better health outcomes.9 Participation frameworks Community needs to be engaged in order to encourage participation according to the systems discourse. Further, government can choose the kind of participation it encourages or permits. There have been several attempts to classify community engagement or participation in health in terms of levels of power or control.17–19 For example, from Victorian health policy documents:20 Information: to support participation, convey facts, educate Consultation: to gauge reaction, invite feedback to influence policy or care Partnership: to involve in government, health service, organisational or treatment decision making © 2009 The Author Journal Compilation © 2009 National Rural Health Alliance Inc. MULTI-LEVEL RURAL COMMUNITY ENGAGEMENT IN HEALTH Delegation: to hand control within a specified framework; to ensure options are formulated at arm’s length from politics Control: to hand control of an issue to the electorate or a consumer Participation frameworks don’t suggest when and where a participation type is appropriate.17 Rural communities’ traditional support of health services through volunteering and fundraising gives a sense of ownership.10 This ‘engagement by donation’ is not participation according to these frameworks, although community resourcing assists in sustainable engagement.2 Community participation should be consistent with community values and attitudes.21 It should take account of and draw on community resources.22 According to both systems and empowerment discourses, good practice is a partnership approach with joint decision-making, and/or delegation of some decisions to ‘community’. Indicators of good practice in health services and communities working collaboratively distilled from literature and tested in two rural communities are: • Leadership by community and health service • Trust • External links and networks • Shared vision for community health • Use and valuing of community’s resources • Risk taking and moulding opportunities • Evaluation and reflective learning.22 Effective partnerships produce a sense of community ownership of the health service as a rural community hub, bringing together physical, human and social capital resources.23 The degree to which a partnership demonstrates each of the above indicators can be used to assess community-service partnership effectiveness, but doesn’t tell us how to go about the process of engagement. World Health Organization and Canada have toolkits for building community participation in health,2,24 and Australia has generic participation toolkits.25,26 From a systems discourse perspective, community health development must pay attention to the capacity of both health service and community, including infrastructure for engagement, such as support staff.27,28 Health service staff need to have community development skills29,30 and genuinely inclusive attitudes to consumer representation.31 A collaborative culture can be fostered through education of staff and community members in working together. The empowerment discourse holds that community health development should build social capital and capacity of community to participate in decisions.22 The process of engagement should recognise community diversity while building cohesion.32 Common expecta© 2009 The Author Journal Compilation © 2009 National Rural Health Alliance Inc. 41 tions and agreed goals should be established early.33 The community engagement process should be consistent with established community ways of working and level of community efficacy.2 It takes time to build relationships and trust.34 Rural communities can be conservative and suspicious of change, making the role of service providers living locally who are seen as imposing change uncomfortable.35 Health system employees who live locally can use the lens of a community member to analyse and lead actions to build and engage community capacity for health development. They can help align expectations of health service and community, so as to produce a system that is responsive to community needs in a way that is consistent with both community and health system norms and values. It can be expected that such a system will produce better health outcomes. However, health professionals might need support from the health system in order to acquire the skills and allocate the time necessary to build community capacity.23 Policy context An international review of health policy suggests five pillars of a modern health system: (i) local resource management that requires (ii) independent regulation and (iii) governance that brings together professions and public to legitimise decision-making, (iv) corporate alliances and (v) government in a stewardship role.36 Increased stakeholder participation and partnerships between public and private, health and community sectors, and training organisations require skills in joint planning and decision-making. A drift back from community participation via partnership and accountability towards consultation, as in the UK, is a danger30 In Australia, the federal Labor government is consulting with high-level rural representative groups,37 and moving health and community service sectors closer together, consistent with international policy trends. All eight state and territory health plans or similar documents include processes for restructuring health that explicitly or implicitly include ‘rationalising’ rural and remote services. All make multiple mention of partnerships, except for South Australia, which talks of working together.20,38–44 Partnerships focus on government partnering with organisations, consistent with international trends towards complex stakeholder partnerships.45 Consumers are mentioned as partners in all plans except Tasmania and New South Wales, which mention consultation. Genuine community partnerships require governments to provide resources while relinquishing control.11 Partnership requires particular skills, such as communication and relationship building;46 they are an opportunity for capacity building and empowerment 42 through health development. Victoria’s ‘Doing it with us, not for us’ appears positioned highest on participation frameworks; consumers are ‘meaningfully involved in decision making’ within a multi-level participation framework. Support for participation is provided to consumers and health services.20 Rural community engagement Rural contexts vary greatly from urban contexts and each other. Rural communities of place comprise diverse groups, some marginalised, such as youth and indigenous. The issue of community representation is fraught – can a few individuals represent this diversity?9,13 Local knowledge and understanding of context are critical in designing and implementing services for health outcomes,3,9 but local and larger concerns are often in conflict, especially with respect to place.47 Rural health is delivered in the context of national and state policies. Resources from various external ‘silos’ arrive in rural communities, usually with strings attached. Locals are best placed to see waste and efficiencies. Rural residents are not obvious in positions of influence at regional, state or national levels. Rationalisation of services means that rural residents have come to understand that government no longer hands out services, but rather sets the structural frame within which they must volunteer or source resources to supplement services, while simultaneously being removed from positions of power and influence by consolidation of services in distant centres.48 More positively, there are reports of engaging rural consumers and health providers around particular health issues leading to improved patient outcomes, for example, GP – hospital integration49 or asthma management.50 In a rare reported case of community-initiated engagement, a Division of General Practice initiated consultation for a new ambulance paramedic model that resulted in a new inter-government funding agreement. Paramedic time was allocated to train volunteers. Community members led the process, which built social capital, consistent with good community development practice.51 Community health needs analyses where external agents, such as researchers work with professionals and others in communities, are effective in engaging rural communities in Australia,52 as elsewhere.53,54 They determine needs from inside and external perspectives, identify community resources and gain ownership of plans. Case studies of Australian rural communities find that understanding a rural place is a prerequisite for effective health development. Understanding: (i) facilitates alignment between health programs and community expectations, customs, values and norms; (ii) assists in identifying and incorporating relevant community S. KILPATRICK assets, including social capital, skills and local organisational contexts; and (iii) provides information about health needs and priorities.10,23,31 In two Tasmanian rural communities facility managers comfortable and skilled in working with community and health bureaucracy engendered trusting relationships and altered expectations of both. Outcomes were a jointly organised ambulance service and a well-being centre that met locally identified needs and drew on community and government resources.23 Community engagement processes can become ‘governmentalised’32 when rural health professionals, who set local engagement agendas, tend to adopt an instrumental approach to engagement, wanting consumers to engage around their own agenda without considering the nature of the community, yet the evidence from the literature presented here suggests that rural health consumers are more likely to engage in a system that matches their needs and values.10 Further, it is reasonable to expect that better health outcomes will flow from a system that matches health needs. Most partners engaged by rural health services are heavily reliant on government funds: Medicare providers, not for profits with government contracts, or local, state or federal government agencies. Biomedical training can impede participatory approaches; partners might be attracted to pragmatic, utilitarian rather than empowerment approaches to engagement.3 Conclusion Rural community engagement should be multifaceted, occurring at multiple levels of the participation framework. It takes time and requires regional/district as well as local and state/national health service commitment.3,15 Planning together is crucial at all levels.36 Community engagement is a mark of a democratic society, and should be resourced as part of enhancing capacity of communities and agencies. Multi-level, meaningful rural community engagement in health should produce a system that recognises and responds to community needs in a way that is consistent with both community and health system norms and values. It will develop capacity of community and health professionals and draw appropriately on community resources. 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