Community engagement approaches to addressing individual and population health can be effective (1–13). A recent review identified influences on the effectiveness of community engagement approaches for communicable disease control. These included the application of key principles during the development of community engagement interventions, with shared leadership and tailoring being influential in determining the effectiveness of engagement on proximal and health outcomes (14). However, a critique of community engagement is that approaches that have impacted on health outcomes are often time intensive, small-scale and require high levels of financial and human resources. They can be difficult to sustain and scale-up in low resource settings. Given the reach of health services into communities in low income countries, the health system provides a valuable and potentially sustainable entry point that would allow for scale-up of community engagement interventions. A challenge is to ascertain the balance between the inputs that are available within routine health service delivery contexts and the inputs that are required to ensure that community engagement is meaningful and effective.
Interest in implementation research (15), getting research into policy and practice (16), and embedded development and research (17) has tended to focus on health service delivery within facility settings. There has been less focus on how to embed interventions that aim to engage community stakeholders within the existing health system and community infrastructure. We understand an embedded approach to refer to two interrelated concepts: 1) that researchers, policy makers, programme managers, practitioners and communities co-produce the intervention and that, through this process of co-production and the subsequent experience of implementation, capacity is developed for researchers as well as within the health system and within communities; and 2) that the intervention is designed to be linked into existing health system and community structures, is designed to be appropriate for the cultural context within which it will be implemented, and therefore has the potential to be implemented at scale. Taking this approach increases local ownership, as well as the likelihood that the intervention will be sustainable.
This study explores the process of developing an embedded approach to community engagement taking the global challenge of antibiotic resistance as an example. We understand community engagement to mean a participatory process through which equitable partnerships are developed with community stakeholders, who are enabled to identify, develop and implement community-led sustainable solutions using existing or available resources to issues that are of concern to them and to the wider global community. Antibiotic resistance poses a significant threat to health and the World Health Organisation warns that “without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill” (18). In Bangladesh, resistance has been detected in most tested pathogens and many first-line drugs have been found to be ineffective (19). Social mobilisation is one of a plethora of strategies recommended to address antibiotic resistance in Bangladesh (20).
The intervention described here brought together two existing initiatives, one focusing on provider behaviour, the other on user behaviour. First, the Revitalization of Community Health Care Initiative in Bangladesh, which aims to improve access, utilisation and equity of healthcare, was established by the Ministry of Health and Family Welfare in order to enable community clinics (CCs) in rural areas to deliver an essential service package to the approximately 6000 people in their catchment areas. Around 14,000 CCs have been built across the country and each has a community group (CG) and three community support groups (CSG) that form part of the management structure of the community clinics, deliver targeted health education, and provide links between the CCs and communities. A key part of this package involved training community health care providers (CHCPs), situated in CCs, to prescribe antibiotics correctly. An evaluation showed that 89% (95%CI 87–91) of consultations resulted in the correct prescription of antibiotics (21).
Second, we identified the Community Dialogue Approach (CDA) as having the potential to address antibiotic consumer behaviour through community engagement. The approach involves training community volunteers on a health issue and group facilitation techniques. Equipped with a set of visual tools, the volunteers host regular Community Dialogue sessions in their communities to explore the health issue, identify solutions and plan for taking action. This approach has been used in a range of contexts, including integrated community case management (iCCM) of malaria, pneumonia and diarrhoea in Uganda, Zambia and Mozambique, and prevention and control of neglected tropical diseases in Mozambique. A description of the approach has been published in an implementation guide (22). Community Dialogue has been shown to be effective in filling health information gaps and helping communities make collective decisions for improved health practices (23), and a study evaluating the use of Community Dialogues to improve prevention and control of schistosomiasis indicates that the approach is feasible in resource-poor settings, well-received by the population and improves knowledge at population level (24).
The CDA was adapted from the Integrated Model of Communication for Social Change (25). The model assumes that a stimulus is required to trigger dialogue among community members about issues that are of concern for the community. Dialogue is understood as a dynamic, iterative process that results in collective decision making to resolve those issues. It is theorised that this process results in social change through increasing individual and collective self-efficacy, strengthening community ownership and shaping social norms. In the CDA, the stimulus is both external (provision of training and tools) and internal (selection of volunteers, volunteers mobilise participants to attend community dialogue sessions) to the community. While volunteers are given the flexibility to tailor each community dialogue session to the specific needs and requirements of the community, the sessions are designed to be highly participatory, giving all participants the opportunity to share experiences and voice concerns. Each Community Dialogue session concludes with participants committing to a course of action. Participants are also encouraged to spread information through word of mouth, set a positive example among family, friends and neighbours and to hold each other to account for applying decisions reached during Community Dialogue sessions [see Fig. 1].
The aim of this study was to adapt the CDA in order to address antibiotic resistance in Bangladesh. The hypothesis is that potential for impact, sustainability, scalability and value for money will be enhanced if the intervention is co-produced by key stakeholders and is designed to be appropriate for the health system, community and cultural context. Specific objectives were:
- To conduct formative research to inform the content of and the processes for delivering Community Dialogues to address antibiotic resistance in Bangladesh;
- To adapt the CDA to ensure that the content of and processes for delivering the intervention are appropriate for the setting, with particular emphasis on embedding the approach within the existing health system and community infrastructure.