Participatory Approaches Involving Community and Healthcare Providers in Family Planning/Contraceptive Information and Service Provision: A Scoping Review

"Participation has been recognised as a precondition for sustainable development and for ensuring good-quality care and increased use of services..."

This scoping study examines the role of participation - the active involvement of affected populations in decision-making, implementation, management, and evaluation of policies, programmes, and services - in large-scale family planning/contraceptive (FP/C) programmes around the world. The researchers were motivated by the conviction that, as efforts to address unmet need for FP/C accelerate (about 225 million women and girls have an unmet need), voluntary use, informed choice, and quality must drive the commitment to human rights (HR) in the delivery of sexual and reproductive health (SRH) services. Although active involvement of affected populations has been recognised as one of the key principles in ensuring HR in the provision of FP/C and in improving quality of care, community and healthcare providers' unequal relationship can be a barrier to successful participation.

To synthesise and analyse relevant evidence, 5 online databases (PubMed/Medline, Cochrane Central Register for Controlled Trials, Global Index Medicus, Popline, and EBSCO) were searched up to April 30 2015, and a targeted Google search of websites of international, governmental, and non-governmental organisations (NGOs), as well as funding bodies and research groups active in FP/C, were conducted. A detailed analysis of 25 articles provided information on 28 specific programmes and identified 3 types of approaches for community and healthcare provider participation in FP/C programmes: (i) establishment of new groups - either health committees to link the health service providers and users or implementation teams to conduct specific activities to improve or extend available health services, (ii) identification of and collaboration with existing community structures to optimise use of health services, and (iii) operationalisation of tools to facilitate community and healthcare provider collaboration for quality improvement. For example, the community-oriented, provider efficient (COPE) framework is based on 10 key elements, which include on the one hand, clients' rights to information, access, choice, safe services, privacy and confidentiality, dignity opinion and comfort, and continuity of services, and on the other, staff members' need for good management, good supplies and infrastructure, information, and training. A participatory governance approach using community scorecards is another example. Here, community members and health care providers (HCPs) separately score indicators of coverage, quality, and equity of FP/C services. Both groups are then given an opportunity to discuss and identify solutions through interface meetings. Once an action plan has been identified, both agree on the roles, set timelines, and develop a monitoring and evaluation plan. Another project tested a social network package to raise awareness about FP/C and improve access to services, based on the recognition that women and men are members of formal and informal social networks who influence their reproductive health choices.

Analysis of studies on specific programmes and projects show that the rationales behind the interventions are varied and may be multiple. Most projects and programmes were initiated by researchers, NGOs, or the health service, whose clear objectives are to improve FP/C service provision or increase demand for services. Several programmes explicitly aimed to facilitate or maximise the involvement of community members or service users. In some examples, improving socio-economic conditions and increasing self-reliance or control over SRH are combined. There were also initiatives aiming to promote an enabling environment for participation, with a focus on improving community and provider relations and promoting capacity building, information, and education.

Integration of community and healthcare provider participation in FP/C provision were conducted through FP/C-only programmes, FP/C-focused programmes, and/or as part of a health service package. Early participatory programmes that introduced FP/C in settings where services were minimal or non-existent led to limited success. A programme evaluation showed that focus on FP/C provoked the mistrust of community members and, following a restructuring, an integrated service that included maternal and child health services was put in place. Integration with other health and/or developmental activities facilitated FP/C service and information delivery. Events focusing on children's health, where both men and women were more likely to attend, assisted in ensuring effective outreach. More recent FP/C-only services are showing promising results with improvement in quality of care (QoC), accountability, and governance.

The researchers found that no conclusions could be made on whether integrating participatory interventions in FP/C is more effective in integrated, FP/C-only, or FP focused services. Five of the 11 FP-only programmes did not report outcomes. Five out of 6 FP/C-focused examples were from the same secondary analysis. However, the evidence seems to suggest that integrated services may be better suited when using community and HCP participation to introduce FP/C service in a setting where it has been non-existent. Introducing participation through integrated services rather than FP/C-only may also be better suited when community structures are still weak or missing. "More recent attempts have yielded promising results in terms of quality improvement and governance in FP/C-only services. The difficulty in generating clear recommendations may be linked to the lack of quantitative and comparable data resulting from the lack of robust monitoring and evaluation mechanisms to measure empowerment outcomes and trace causal links between components of an intervention and the outcomes. This, in turn, may be closely linked to the lack of consensus on why participatory interventions are needed and implemented."

As shown in this review, implementation of community participation may not fall clearly within either one of the main typologies identified, which are participation as a means of improving health service delivery and participation as an empowerment process, wherein community members take more control of their own health. These two very different aims impact the way programmes are designed and what role community members take on.

Although not one of the outcomes pre-defined for the review, the majority of the programmes reported on outcomes related to the participatory mechanism itself and client-provider relations. The reported impact on community and healthcare provider participation was mixed. An analysis of 7 case studies found that, overall, the degree of community involvement in designing the projects had been limited. Healthcare providers working closely with the community had the greatest influence in the decisions made. In these examples, the health committees provided support and helped legitimise the action plans. In other examples, improvement in community and healthcare provider relations remained limited. Community members reported that they felt treated paternalistically by staff, and professionals were frustrated by the recommendations made by committee members that lacked focus or specific strategies for implementation.

Nine of the programmes resulted in positive outcomes on the participation between community and healthcare providers itself. In these cases, the interventions were successful in identifying needs of the community - e.g., knowledge gaps to be addressed, use of both male and female community health workers to reach a wider range of users and potential users, and engaging key influencers who play a significant role in women's reproductive health choices such as their husbands or their mothers-in-law. They were also effective in implementing solutions identified by them or jointly with healthcare providers and with their participation - e.g., suggesting Family Planning Days to improve outreach to youth, determining the acceptable limits of FP-community health workers (CHW), participatory action planning and management of services to improve quality of services, and rural and regional radio programming as a means of educating wider public on maternal health and FP.

Increasing the link between health providers and the community that they serve led to greater awareness from both sides about the issues, barriers, and needs, leading to the identification of appropriate actions and solutions. Interventions helped bridge the gap between providers and their clients in the Better Life for Youth and Bamako initiative examples. The Pont d'Or project led, not only to the identification of barriers, but also to finding and implementing solutions. These practical outcomes were accomplished through COPE, which the researchers describe as "an important relationship building exercise. COPE was also reported to be successful in promoting new levels of understanding of QoC".

One study showed initial promise in involving women. The SOS Mulher women's group was formed very quickly following the start of the Santa Barbara project, but it was short-lived due to the difference in socio-economic status among the women in the group and the users of the service, as well as external factors. Youth participation was addressed in 3 studies. One example saw young people participating in committees for FP and development activities, which resulted in the community recognising them for their active involvement and the benefits they brought. An effective youth-adult collaboration could be seen in Quality Improvement Teams, where youth members and HCP worked together in a Youth-Defined Quality process that involved collaborating on problem identification, information, education, and communication (IEC), and training activities and programme evaluation. Foundation for Research in Health Systems (FRHS) reported engaging youth representatives within village-level health committees to ensure inclusion of youth needs in their assessment activity.

According to the researchers, although a number of studies reported increase in FP/C knowledge and uptake, the lack of robust monitoring and evaluation mechanisms and quantitative and comparable data resulted in difficulties in generating clear recommendations. For example, increase in FP/C knowledge, utilisation, and uptake was reported in 11 of the programmes; however, for the majority, a clear causal relationship between the outcome and participatory component could not be identified, and only 4 reported quantitative data. In fact, out of the 28 programmes, 11 did not have any information on monitoring and evaluation. For this reason, the researchers urge: "It is imperative that programmes are systematically designed, evaluated and reported." Specifically, they suggest that evaluation of participatory interventions should include indicators for measuring the impact on community and healthcare provider relations. Indicators should be, at least partially, identified by the service users and providers. Key intermediate outcomes need to be identified to ensure that the causality between intervention activities and health outcomes can be established. "A better understanding of the relationship between outcomes and participation involving community and HCP is needed to help ensure that individuals' sexual and reproductive health and rights remain in the fore as efforts to address unmet need for FP/C accelerate."