Facilitators and Barriers to Engaging Communities in Health Service Research on Dengue Control in Indo-Pacific Region: A Systematic Review

"Community engagement is increasingly promoted in health services research (HSR), but the concept itself, and how it is best implemented in practice engagement, is understudied and contested..."

Community engagement in health services research (HSR) stems from demands by community leaders, policymakers, and funders for meaningful community involvement to address health problems facing communities. The objective of this systematic review was to identify and synthesise facilitators of and barriers to community engagement in HSR aimed at the prevention and control of dengue based on original research studies conducted in low-and middle-income countries (LMICs) of the Indo-Pacific region. This region includes Asia, which accounts for almost 70% of the global dengue fever/dengue haemorrhagic fever (DF/DHF) disease burden.

The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) checklist was used to perform this review. Health-related databases including PubMed, Ovid, and Google Scholar were searched for relevant studies. Thirteen studies were identified, spanning eight low- and middle-income countries (LMICs) of the Indo-Pacific region, including Cambodia, India, Indonesia, Myanmar, Philippines, Sri Lanka, Thailand, and Vietnam. The studies in this review covered the period from 2002 to 2021.

A broad range of study designs and objectives were revealed across these 13 studies. A broad range of communities participated in the HSR, including local government, project-related health staff, local health services staff (including auxiliary nurse midwives (ANWS) and accredited social health activists - ASHAs), community leaders, local communities/residences/general public and heads of households, community health volunteers, school teachers and school children, faith leaders, and multi-stakeholder partner groups. Their participation was predominantly described as being participants involved in focus group discussions (FGDs) and/or in-depth interviews (IDIs).

The five Consolidated Framework for Implementation Research (CFIR) domains - intervention characteristics, inner setting, outer setting, individual characteristics, and programme implementations - were used to identify and describe barriers and facilitators. In many instances, the opposite side of a problem, challenge, tension, or barrier was framed as a facilitating factor or "enabling factor". For instance, having a variety of stakeholders involved allowed for the facilitation of a broad range of perspectives on the research topic. On the other hand, having low involvement of stakeholders involved in the pre-implementation requirements was viewed as an impediment.

The level of effectiveness of partner communication and the extent of stakeholder participation were the two distinct CFIR constructs noted as facilitators, and in the converse, obstacles that were most commonly described in this systematic review. Similar to a published systematic review of polio vaccination programmes, the studies current review described three major obstacles: a lack of enthusiasm by stakeholders, a lack of incentives for community participation (especially for volunteers), and insufficient staff in the government programmes delivering the intervention. Therefore, considering creative ways that motivate and encourage staff to visit rural areas and vulnerable groups may be the core for effective implementation.

In addition, this review identifies networking and communication as essential elements for community engagement. For example, the involvement of trained groups of "eco-health volunteers" who were then engaged in regular dialogue with local community leaders and coordinators for mobilising dengue vector control activities in their communities was a facilitator. A published study cited here suggests that this kind of communication (via networking or local gatherings) would support the development of a new and deeper understanding of the issues by the stakeholders, supporting them to reflect on actions undertaken and information obtained and then to inform them about further action. To facilitate communication, language and cultural obstacles were identified as needing to be addressed, such as by using a translator in all communications prior to implementation in order to facilitate partnership building and sustaining. A well-functioning partnership can support synergy among the members of the partnership and affect outcomes.

When considering ways to address the identified barriers as observed in the analysis, the researchers point to the need to leverage the scarce time and resources of trained community members and health practitioners by involving them in interpreting and making sense of the data. Research projects involving communities, such as dengue control in our study, require academic members to become part of the community and community members to become a part of the research team. Among the factors that motivate people to participate in health (and HSR) are wanting to play an active role in bettering their own lives, fulfilling social or religious obligations, feeling a need for a sense of community, and wanting cash or in-kind rewards.

In conclusion: "Future health service research on dengue control approaches should be carefully planned, methodologically constructed, created in accordance with community engagement principles, and involve considerable community participation at all stages of the research."