Transitions: Community Participation
Volume 14, No. 3, April 2002

This Transitions is also available in [PDF] format.

By Nicole Cheetham, MHS, Deputy Director, International Division, Advocates for Youth

A community's members are a rich source of knowledge about their community and of energy and commitment to that community. When public health professionals envision a program to address health issues in a particular community, tapping into the community's expertise and enthusiasm is frequently an essential issue. Genuine participation by community members, including youth, is the key. Community members control the project at the same time that professional partners build the community's capacity to make informed decisions and to take collective action.

Experience has demonstrated that people can devise their own … alternatives if they are allowed to make their own decisions.¹

Community participation is a proven approach to addressing health care issues and has been long utilized in HIV prevention in the United States and in development internationally, in projects varying from sanitation to child survival, clean water, and health infrastructure. However, the quality of participation varies from project to project. Moreover, in spite of the failure of many health programs designed without the participation of target communities, some professionals continue to question the value of community members' participating in program design, implementation, and evaluation. This article looks at the critical importance of community participation in addressing the reproductive and sexual health of adolescents.

Why Use Community Participation Approaches in Adolescent Reproductive & Sexual Health Programming?

Youth do not live in a vacuum, independent of influences around them. Rather, social, cultural, and economic factors strongly influence young people's ability to access reproductive and sexual health information and services. To improve young people's sexual and reproductive health, therefore, programs must address youth and their environment. In order to address youth adequately and appropriately, programs should be designed and implemented with the meaningful involvement of youth.⁺ To address youth's environment, planners must acknowledge that community and families significantly influence youth.

Programs that ignore the influence of community and family in the lives of young people are, in fact, creating a nearly impossible situation—asking young people to change their world on their own. It is unfair to ask youth to change their beliefs and behaviors without also providing community support for these changes. Especially when reproductive and sexual health issues are controversial and/or taboo, it is critical to bring other community members into the process so that they, too, can support healthy change.

If implemented properly, community participation can be effective for a number of reasons.

• Communities have different needs, problems, beliefs, practices, assets, and resources related to sexual health. Getting the community involved in program design and implementation helps ensure that strategies are appropriate for and acceptable to the community and its youth.
• Community participation promotes shared responsibility by service providers, community members, and youth themselves for the sexual health of adolescents in the community.
• When communities "own" adolescent sexual health programs, they often mobilize resources that may not otherwise be available. They can work together to advocate for better programs, services, and policies for youth.
• Community support can change structures and norms that pose barriers to sexual health information and services for youth and can increase awareness regarding youth's right to information and treatment.
• Community participation can increase the accountability of sexual health programs and service providers.
• Participation can empower youth within the community.

What Is Community?

"Community" is important within a public health context. Research demonstrates that:

• Prevention and intervention take place at the community level.
• Community context is an important determinant of health outcomes.

However, the lack of a commonly accepted definition of community results in different collaborators forming contradictory or incompatible assumptions about community. This often undermines their ability to evaluate the contribution of the community in achieving public health outcomes.

In December 2001, the American Journal of Public Health published the results of research to define community within a public health context.² Researchers identified core dimensions of "community," as defined by people from diverse groups. Five core elements emerged: locus, sharing, action, ties, and diversity. A common definition of community emerged:

A group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings.²

What Is Community Participation?

Although this may appear to be a simple question, there is no single definition of participation by communities but, rather, a potpourri of definitions varying mostly by the degree of participation. The continuum on the next page provides a helpful framework for understanding community participation. In this continuum, "participation" ranges from negligible or "co-opted"—in which community members serve as token representatives with no part in making decisions—to "collective action"—in which local people initiate action, set the agenda, and work towards a commonly defined goal.

Youth from Burkina Faso offer a practical definition of community participation. In an example of collective action (see chart below), these youth work with organizations in their communities to improve adolescent reproductive and sexual health.*

Community Participation³

Community participation occurs when a community organizes itself and takes responsibility for managing its problems. Taking responsibility includes identifying the problems, developing actions, putting them into place, and following through.⁴

Who Benefits from a Community Participation Approach?

Community participation has many direct beneficiaries when carried out with a high degree of community input and responsibility. Everyone benefits when participating in the activities. For example, adults and youth might participate in village committees to improve services. Everyone might watch a play or video and learn from presentations about local programs. Youth benefit from improved knowledge about contraception and HIV/AIDS or from increased skill in negotiating condom use, and other community members benefit, too. A truly participatory program involves and benefits the entire community, including youth, young children, parents, teachers and schools, community leaders, health care providers, local government officials, and agency administrators. Programs also benefit because trends in many nations towards decentralization and democratization also require increased decision making at the community level.

What Key Characteristics and Skills Facilitate a Community Participation Approach?

Above all, those promoting community participation need to be able to facilitate a process, rather than to direct it. Facilitators need to have genuine confidence in a community's members and in their knowledge and resources. A facilitator should be willing to seek out local expertise and build on it while bolstering knowledge and skills as needed. Key characteristics and skills important to facilitating community participation include:

• Commitment to community-derived solutions to community-based problems
• Political, cultural, and gender sensitivity
• Ability to apply learning and behavior change principles and theories
• Ability to assess, support, and build capacities in the community
• Confidence in the community's expertise
• Technical knowledge of the health or other issue(s) the project will address
• Ability to communicate well, especially by actively listening
• Ability to facilitate group meetings
• Programmatic and managerial strengths
• Organizational development expertise
• Ability to advocate for and defend community-based solutions and approaches.^5,6

What Key Challenges Face Community Participation Programs?

Community participation also poses important challenges. Two are highlighted here.

Evaluating Participation

One challenge for program planners is how to evaluate community participation. In particular, what should be evaluated—health outcomes, participation levels, improved capacities, or some combination of these—and how will they be evaluated? While measuring health outcomes—such as birth rates or sexual health knowledge, attitudes, and behaviors in a particular age group—may be fairly straight forward, it will be important for community participation programs also to identify and measure indicators of participation. One of the goals is to achieve participation. Whether planners want to measure changes in community self-efficacy or changes in local capacity to identify and solve problems, it is important to define these objectives clearly and to develop appropriate tools for measuring progress toward the objectives. Qualitative tools (or some combination of qualitative and quantitative) may be most appropriate to assess the subjective quality of "participation," but indicators of participation and ways of assessing it should be defined by the community, and community members should decide and carry out the evaluation.

Scaling Up Participatory Models

Increasingly, funding sources express interest in programs that have potential for "scaling up." Community participation programs present some obstacles to "scaling up" due to their deliberately and intensely local nature. As a program develops and matures, program planners may face the challenge of "scaling down" the intensity of community participation in order to "scale up" the project without compromising its participatory nature and results.

Conclusion

Community participation is a vitally important strategy in efforts to work with youth to improve their sexual and reproductive health. Community participation is a strategy that respects the rights and ability of youth and other community members to design and implement programs within their community. Community participation opens the way for community members—including youth—to act responsibly. Whether a participatory approach is the primary strategy or a complementary one, it will greatly enrich and strengthen programs and help achieve more sustainable, appropriate, and effective programs in the field.

References:

1. Bhatnagar B et al. Participatory Development and the World Bank. [World Bank Discussion Paper] Washington, DC: The World Bank, 1992.
2. MacQueen KM et al. What is community? An evidence-based definition for participatory public health. Am J Pub Health 2001;91:1929-1938.
3. Cornwall A. Training handout. [s.l.], 1995.
4. Advocates for Youth. Unpublished data from the Burkina Project. Washington, DC: 2001.
5. National Institutes of Health. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Institutes of Health, National Cancer Institute, [1995?].
6. Howard-Grabman L, Snetro G. How to Mobilize Communities for Health and Social Change. Baltimore, MD: Johns Hopkins University Center for Communication Programs, forthcoming.

+ For more information on forming effective youth-adult partnerships, see Transitions, volume 14, no. 1, October 2001

* The project is described briefly on page 7 and stories of participants follow on pages 8 and 9.

Next Chapter: Community Participation to Promote Adolescent Reproductive and Sexual Health in Burkina Faso: A Template for Program Development
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Transitions (ISSN 1097-1254) © 2002, is a quarterly publication of Advocates for Youth—Helping young people make safe and responsible decisions about sex. For permission to reprint, contact Transitions' editor at 202.419.3420.

Editor: Sue Alford