Understanding Communication in Community Engagement for Maternal and Newborn Health Programmes in Low- and Middle-Income Countries: A Realist Review

"Better insight and an understanding of what and how CE communications work, for whom and why will inform meaningful recommendations for policy and practice."

Community engagement (CE) has become an increasingly important component of global health interventions and research due to its role in addressing systemic challenges and integrating care systems. CE includes clearly presenting the purpose and goals of research to a community as well as providing information overall, which requires communication. CE communication should go beyond top-down information provision and may include communication for development (C4D), which emphasises the community’s participation and ownership in communication delivery. The purpose of this realist review is to understand how, why, to what extent, and for whom communication in CE contributes to outcomes in maternal and newborn health (MNH) programming in low- and middle-income countries (LMICs), which have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths.

A realist review methodology was chosen because it is a theory-driven form of synthesis appropriate for explaining the complexity of programmes implemented in complex and layered systems. Informed by published systematic reviews, this search strategy was last run across seven databases on October 1 2021 for records published since 1975. Data were extracted as context–mechanism–outcome configurations (CMOCs) and synthesised into patterns or tendencies to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents.

The 11 included documents were academic peer-reviewed literature that described communication in CE for MNH across Bangladesh, Burkina Faso, Cote d'Ivoire, the Democratic Republic of the Congo, Ghana, India, Malawi, Nepal, Nigeria, and Uganda. The CE communication and activities described in these programmes ranged from public gatherings and dramas to recurring women's groups and community committees. Outcomes of CE communication spanned a range that included encouraging community's involvement, fostering participation and/or ownership in a programme (or lack thereof), improving acceptance of a programme or specific messaging, increasing knowledge or awareness, increasing care-seeking or use of health services, developing appropriate programmes or messaging, and enabling the sharing of feedback from the community.

The 45 CMOCs informed five programme theories (PTs) explaining that communication in CE for an MNH programme works when:

1. Communities are actively involved throughout the programme (co-creation): This PT is supported by 16 CMOCs extracted from 9 documents, with supporting evidence from 8 additional documents. It holds that, when communities are actively involved throughout the identification, design, and implementation of communication messaging and strategies for an MNH CE programme, the communication is more relevant, acceptable, and trusted. Community members play an active role in co-creating the communication messaging by informing what information should be communicated (e.g., community's priorities and needs) and how (e.g., communication methods and avenues), identifying challenges or misunderstandings, holding programme implementers accountable, and raising overall awareness of the programme through tailored messaging. This engagement increases their ownership over the MNH programme, enabling longer-term sustainability.
2. The messaging and programme are acceptable: Nine CMOCs extracted from 8 documents and further supported by 8 documents provide evidence for this PT, which describes the importance of messaging (the information, content, or material that is being verbalised, written, shared, or discussed) that is adapted and tailored to the community context. When MNH implementers acknowledge and consider local practices/norms and power structures in the communication messaging/processes, and the communication approaches and programme goals are tailored appropriately to the community's needs, norms, and expectations, then the MNH programme and the messaging and MNH programme are likely to be acceptable to and shared further by the community. This PT is applicable throughout the stages of the C4D framework, from the initial identification of messaging and priorities to the design and actual implementation of how communication is shared.
3. Communication sources are trusted: This PT is supported by the 23 CMOCs extracted from 10 documents, with further evidence supporting these CMOCs found in 6 additional documents. When messaging is aligned with community members' values and experiences and is delivered through familiar or agreed upon communication avenues/structures by respected and influential messengers, and the programme is also perceived to have positively contribute to the community, then the communication sources for the CE programme are trusted. Building this trust may start as early as the initial identification stage and continues to be important throughout the roll-out and implementation of the communication.
4. The community has a reciprocal relationship with the programme: This PT is supported by 14 CMOCs that were extracted from 6 documents and were further supported by 3 additional documents. It emphasises that communication and dialogue are a two-way street rather than a one-sided or top-down experience. When the actors involved in an MNH programme (including local leaders, stakeholders, implementers, and health providers) develop a positive relationship with community members and directly act on feedback from the community to inform the programme and messaging, community members feel heard and valued as equals in a reciprocal relationship with the MNH programme.
5. The community sees value in the programme: Eight CMOCs from 6 documents and supported by an additional 3 documents provide evidence for this PT. When a community experiences/perceives value or benefits from an MNH programme through the messaging shared, knowledge gained, or services provided, then they are inclined to continue to support/participate in the programme and disseminate messaging further. This engagement enables the longer-term sustainability or continued functioning of the programme, beyond an "intervention period".

The findings of this review demonstrate the layered and complex nature of CE communications through the interconnected nature of the PTs. For example, co-creating with communities early described by PT1 influences the acceptability of messaging (PT2) as well as the trust in communications (PT3) and the overall relationship with the programme (PT4).

The PTs mirror previous experiences from the field and substantive theories in the literature, which the researchers explore in the paper's discussion section. To cite only one example, first proposed by Freire (1974), critical consciousness refers to when a community (often a marginalised group) becomes aware of and takes action against systems that perpetuate poor maternal health, in this case. This critical consciousness could be both an outcome of a community's early and systemic involvement in messaging development and a mechanism that propagates the sustainability of the programme.

While the PTs presented were developed from examples of programming within the field of MNH, they may have wider applications. This might be because the PTs describe the processes or how communication in CE is functioning, which is perhaps less influenced by what health area specifically the activities aim to address. This process also highlighted that the PTs may span across the stages of the C4D framework, from the initial identification of messaging and priorities to the design and actual implementation of how communication is shared. This consideration reflects the emphasis on centring the community in CE communication.

In terms of practice, the refined theories align with existing guidance on communication in CE. For example, it is known that CE should not be tokenistic and must meaningfully engage populations and communities. Findings from this review describe how and why communication works to support meaningful engagement. The insights can be used to design more appropriate CE communication strategies for different MNH programmes.

While these PTs present what may enable effective CE communication for MNH programming, the wider fields of C4D and social behaviour change communication have described a number of challenges that may also be applicable to MNH. Some of these challenges have been addressed by prioritising budget allocations to communication, pre-testing messages, and using a range and number of communication channels where possible. Relatedly, the timing of CE should not be overlooked and is emphasised throughout the PTs: Incorporating and involving the community from the inception of a programme is vital, with this review highlighting the importance of their continuous and meaningful input in influencing the acceptability, trustworthiness, and perceived value of the programme.

"As a next step, these theories will be further tested and refined through a realist evaluation case study. Future primary research that tests these theories across settings (including both geographical settings but also within different health and social programmes) and over time can provide a more in-depth understanding of generative causation, which can be used to support the design and implementation of future CE communications across contexts."

Click here to read the protocol for this paper.