Evaluation of the WHO Community Engagement Research Initiative

"Relational community engagement intentionally readies health services to build the conditions that enable all communities, and particularly those marginalized..., to express their own health needs in ways that generate partnerships between service providers and communities that are able to respond to these health needs."

Too many communities are unreached, particularly during times of crisis. Early on in the COVID-19 pandemic, the World Health Organization (WHO) Regional Office for the Western Pacific recognised this gap, which spurred the creation of the Community Engagement Research Initiative to identify new ways of meaningfully engaging communities to improve trust and support equitable health service delivery. This report offers an independent evaluation of the Research Initiative, led by four country research teams (CRTs) in Cambodia, the Lao People's Democratic Republic, and Malaysia. It also provides recommendations for the WHO Regional Office and Member States in terms of committing to the principles and practices of transformative community engagement.

Starting from the conceptual foundation of systems theory and recognising that health systems function as complex adaptive systems, the Research Initiative adopted a relational lens to understand how and why community engagement works. WHO's defines community engagement as "a process of developing and maintaining relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive and sustainable health impact and outcomes." These relationships work together through a process that is founded on empowerment, health promotion, health equity, gender equality, human rights, and planetary health. This process, which spans the micro (individual), meso (group), and macro (systems) levels of human systems, is navigated through dimensions of:

• compatible values, vision, and purpose;
• interactions that are based on compassion, respect, and dignity;
• widespread, active, and inclusive participation;
• equitable, conjoint decision-making; and
• the equitable dynamic flow of power, control, and resources.

In close collaboration with the WHO project team, the Research Initiative was carried out in 5 phases:

1. Developing an overall conceptual approach;
2. Building understanding and assessing good practices across the capacity-building domains and using research and evidence to inform design and decision-making;
3. Supporting the CRTs to work with the WHO project team to create the most relevant and impactful approach;
4. Implementing the CRTs' projects, supported by the submission of monthly reports and periodic "deep dives" with the WHO project team; and
5. Completing the CRT projects, submitting initial drafts of final project reports, and participating in a final Community of Practice meeting.

All the CRTs chose to work with populations experiencing inequalities exacerbated by the ongoing pandemic - people living with HIV, or PLHIV (Cambodia CRT), and rural populations (Lao People's Democratic Republic CRT), and refugees and asylum seekers with mental health issues (Malaysia CRTs) - as well as patient managers, community health workers (CHWs), other healthcare workers, district officials, high-level stakeholders, patients, and local community members. Examples of activities included: a digital health intervention (DHI) to support communication and treatment adherence for PLHIV during the pandemic (Cambodia); participatory workshops (Lao People's Democratic Republic); and RELATE-ME, a series of relational activities hosted by CHWs to create an online support community, as well as individual activities to support mental well-being (Malaysia).

The methods and analytic processes used for the evaluation of the Research Initiative included in-depth scrutiny of written reports and reflective accounts, attendance at and observations of WHO project team meetings and group meetings with CRTs, and focus group discussions and interviews with members of the CRTs. Subsequent sections in this report set out the evidence generated by the research evaluation, including:

• Section 4 presents an overview of the baseline findings for the research. These comprise the health issue each research team sought to address, the outcomes their research sought to achieve, the community engagement undertaken, who was engaged and by what means, and the outcomes of the research.
• Section 5 presents a set of cross-cutting themes and patterns that emerged from the second-level, cross-case complexity analysis. This section also seeks to show how relational conditions can bring about change in the micro, meso, and macro levels of health systems - illustrated by case studies from the CRTs.
• Section 6 seeks to distil the findings from Sections 4 and 5 into a framework that describes the necessary processes for relational community engagement to effect systemic change in health systems. (See especially Table 3 - "Enabling conditions for relational engagement and the processes undertaken by each team" - pages 50-57.)
• Section 7 offers recommendations grounded in the research findings and specific to: WHO, commissioners and funders, and implementation and research teams.

Sample evaluation findings:

• The Cambodia team explored how community engagement could better support people living with HIV. Despite the circumstances of the pandemic, which interfered with treatment adherence, in the two months following the intervention, the percentage of patients not retained in HIV treatment care fell from 2.8% to 0.6% in the intervention group compared to 0.9% to 0.7% in the control group. The research team also reported enhanced relationships between healthcare workers and patients and improved communication resulting from less formal interactions.
• The Lao People's Democratic Republic team wanted to understand the enabling factors for the uptake of essential services such as family planning, antenatal care, delivery with skilled birth attendants, and vaccination delivery among rural populations. Following the community engagement intervention, one village health centre reported that antenatal care clinic attendance climbed to 80%, up from 41% in the corresponding period in the preceding year. Similarly, 34% of deliveries took place at local health centres after the intervention, compared to 12% during the same period in the previous year. Of note is the fact that the CRT was able to engage local governments in participating in their community engagement workshops, which also led to the signing of a memorandum of understanding between the Ministry of Health and the Ministry of Home Affairs.

The evaluation identified several key features that enabled the achievement of these and other outcomes. For instance:

• Strong, trusting relations should be in place among members of teams seeking to implement and research relational community engagement interventions. Commissioners of relational community engagement initiatives need to invest the time and resources required to build such relations.
• Commissioners need to be responsive to implementing teams, allowing them to identify the right time for action-based research work to be conducted. The timeliness of community engagement initiatives may be determined by a specific demand for interventions based on the lived realities of communities.
• Successful teams shared goals and collective values, which allowed them to develop cultures of experimentation, fostered by feelings of safety and trust, and without fear of failure. These teams were able to develop new ways of capturing process data to show how and why outcomes emerged and ways of intervening in health systems to allow for local adaptation.
• Relational community engagement requires practitioners and researchers to engage with people as persons and not as "problems"; this shift requires significant changes to how practitioners and researchers communicate but can foster a sense of empowerment.
• Engaging local authorities and health ministries can result in them taking ownership of the engagement processes and their outcomes, which can create conditions for transformative change within health systems as a whole.

In conclusion: "WHO can enable relational community engagement to become a core approach by which the social determinants of health become embedded across all technical health issue areas and within programming. In this way, relational community engagement can become an inherent way of working that supports WHO as an organization....This will, in turn, enable WHO to play a powerful role in convening and supporting the implementation of the principal values and core ethos of relational community engagement among its Member States....To achieve these aspirational ends, WHO decision-makers must begin by acknowledging and endorsing the transformative potential of relational community engagement..."