Community engagement approaches to improve health: a cross-case study analysis of barriers and facilitators in UK practice

doi:10.21203/rs.3.rs-3416444/v1

Background

Interventions that engage communities have been shown to improve health and wellbeing in disadvantaged groups internationally, but there is little evidence on current community-led practice, particularly in relation to the process of community engagement. This paper presents a qualitative cross-case analysis of barriers & facilitators in six UK community engagement projects, using different models of community engagement.

Methods

The primary sampling criteria was the type of approach to community engagement, using a conceptual framework with four main groups: Strengthening communities; Volunteer and peer roles; Collaborations and partnerships; Connecting to community resources. Qualitative interview-based methods (semi-structured interviews and focus groups) explored community and professional perspectives in depth. Thematic analysis was used to analyse the data, building within-case studies before comparing findings and using an iterative process to build explanations in a cross-case analysis.

Results

Fifty-five people took part in the research. Prominent themes included barriers and facilitators to community engagement. Key themes related to successful community engagement were: trust within the community and between community members and service providers; respect for community members’ expertise; allowing sufficient time for relationships to establish and for outcomes to be seen; commitment of key people; and Flexibility.

Conclusions

This qualitative case study research found that in successful community engagement projects, community expertise is respected and valued, allowing community members to be fully involved and take ownership of the projects. Sufficient time should be allowed for this process. Flexibility and adaptation of project materials, protocols and role descriptions is important in overcoming barriers to community engagement.

Community engagement

health and wellbeing

cross-case analysis

health equity

health inequalities

public health

health promotion

qualitative research

Community engagement has been defined as the ‘direct or indirect process of involving communities in decision making and/or in the planning, design, governance and delivery of services, using methods of consultation, collaboration, and/or community control’ [1]. It is an ‘umbrella’ term, covering a wide range of community-centred approaches with differing populations, intentions and levels of engagement. Recent attempts to categorise these approaches have recognised that there is no ‘one size fits all’ best approach, and that the most effective projects may draw on a range of approaches to create a ‘bespoke’ design that responds to the needs and assets of the community in context [2, 3] .

Previous research has found that the more a community is supported to take control of activities to improve their lives, the more likely it is that their health will improve [4]. A systematic review of 319 studies of different types of community engagement for health inequalities concluded that community engagement interventions ”are effective in improving health behaviours, health consequences, participant self-efficacy and perceived social support for disadvantaged groups” [1].

Community engagement for health can involve varying degrees of participation and control, from giving views on a local health issue, jointly designing and/ or delivering services equally with public service providers, to communities completely controlling services [5]. A large systematic review found that peer-delivered interventions had the highest effect sizes, possibly because of their narrower focus, while “community empowerment models might be expected to have smaller effects over a broader range of health and social outcomes” [1]. Later research found that higher levels of community engagement (i.e., being involved in the design, delivery and evaluation of a project) may be associated with better health outcomes [6, 7].

There are many potential barriers to community engagement [8]. UK guidance [9], informed by a systematic mapping review [10], a systematic review of barriers and facilitators [11], and qualitative case studies [12], focused on what helps or hinders community engagement in the UK. The systematic review noted a lack of studies which attempt to evaluate how to overcome identified barriers to community engagement [11]. This paper reports the findings from the cross-case analysis of six case studies, with an emphasis on common factors that facilitated and overcame barriers to community engagement in practice in this heterogeneous sample.

Qualitative research was carried out at six case study sites, to address the following research questions:

What barriers and facilitators affect the delivery of effective community engagement activities – particularly to people from disadvantaged groups?

How can the barriers and challenges be overcome?

A multiple case study design was used, with the projects as the cases [13]. Qualitative methodology was used to gain in-depth understanding of community engagement processes within specific social contexts [14] and to retain flexibility to pursue lines of investigation [15, 16]. A holistic, multi-dimensional view of each community engagement project was first built through fieldwork and analysis, examining retrospectively the journey of each project from development, through to delivery and evaluation. The final stage was cross-case analysis to build explanations through rigorous qualitative techniques.

Sample selection

Purposive sampling was used to select six community engagement projects as case study sites. The primary sampling criteria was the type of approach, using the ‘Family of Community-Centred approaches’ [2, 17] as a conceptual framework. This comprises four main groups

Strengthening communities - approaches build on community capacities to take action together on health and the social determinants of health;
Volunteer and peer roles - approaches enhance individuals’ capabilities to provide advice, information and support or organise activities around health and wellbeing in their or other communities;
Collaborations and partnerships - approaches involve communities and local services working together at any stage of planning cycle, from identifying needs through to implementation and evaluation (includes co-production);
Connecting to community resources - approaches connect people to community resources, practical help, group activities and volunteering opportunities to meet health needs and increase social participation.

Secondary sampling criteria, used to gain maximum variation in the sample [16], were:

Population group;
Definition of community: geographical, cultural, common interest or other definition;
Geographical location (spread in England particularly between North and South);
Type of activity.

Based on the findings of a previous systematic review [1] and conceptual paper [18], we anticipated evidence gaps on empowerment approaches and unexpected effects. We aimed to include at least one community-led initiative for which there was no substantial evaluation report.

An online Register of Interest, established as part of the mapping review [10] identified relevant English projects willing to be a case study. Projects were mapped against the sampling criteria and an initial ‘long list’ of potential projects drawn up. The final six sites were selected at a meeting where each was judged in terms of fit with the criteria and the need to ensure a broad sample.

In collaboration with the project leads, a sample of participants was identified within each case to encompass different roles and responsibilities. This included public health commissioners, project managers, practitioners, project staff, representatives from partner organisations and community stakeholders.

Data collection

Qualitative semi-structured interview-based methods were used to explore community and professional perspectives in depth [19]. Focus groups were used where community participants usually met as groups [20, 21].

The choice of methods was underpinned by wishing to retain where possible a naturalistic approach to data collection [22], fitting with the way each project operated and also supporting the preferences of participants on how the interview was conducted. In most cases individual interviews were conducted with stakeholders, but in some instances two participants chose to be interviewed together in a dyad [23]. This was usually where people routinely worked or volunteered together.

The main topics explored in interviews were:

Project activities, purpose, and background;
Community involvement in design, delivery and evaluation of project; nature and extent of involvement; barriers and facilitators;
Community members’ impact on decisions;
Whether community members feel accepted and included in the project;
Benefits to community members, wider community and wider impact of project;
Unanticipated effects and drawbacks;
Connections with other projects in the community.

Analysis

Thematic analysis was chosen to analyse the qualitative data [15]. The approach was broadly inductive to ensure all relevant themes were mapped, but informed by the overarching research objectives.

Within-case analysis

Explanations were built within-case through the production of individual case study reports for each of the case study projects [13]. These reports organised and displayed the data as a thematically ordered display with quotations, written up in a standardised report format to allow for later cross-case analysis [24]. Case study reports also included narrative summaries of project context, history and networks drawn from interviews and project documentation where available. Each case study report (with all personal identifying details removed) was checked for authenticity by the project leads or other appropriate stakeholder for that project.

Cross-case analysis

Cross-case analysis involved comparing findings and using an iterative process to build explanations [13]. A matrix was produced as a visually ordered display representing the whole data set and summarising the themes across each case study [24]. The matrix was used alongside the case study reports to produce a narrative synthesis across the main themes, drawing out emerging cross-cutting themes as required. The lead researcher synthesised the findings of the case study reports using an iterative process, returning to the data as necessary to build explanations. All researchers involved in the data collection were also involved in checking the final narrative account.

Table 2 presents details of the six selected case study projects. Fifty-five people (28 community stakeholders and 27 professional stakeholders) took part in five focus groups and 26 interviews across the six sites (see Table 1).

Table 1

Case study participants
Case study	N of interviews	N of focus groups (n participants)	N professional stakeholders	N community stakeholders	Total N participants
Leeds GATE	3*	1 (3)	4	3	7
Life is Precious	5*	2 (10)	6	10	16
Wandsworth Church-based family therapy	6	1 (10)	6	10	16
Friends of Everton Park	2	1 (3)	3	2	5
Youth.com	5	0	4	1	5
Connecting Communities	5*	0	4	3	6**
TOTAL	26	5	27	29	55

*One interview was conducted as a dyad (with two participants) **One of the interviewees was both a professional stakeholder and a resident.

Table 2

Case study sites
Project	Approach to Community Engagement	Population	Type of Activity	Brief description
Leeds- Gypsy and Traveller Exchange (GATE)	Strengthening communities	Gypsies and Travellers	Community health needs assessment	Leeds Gypsy and Traveller Exchange (GATE) is a registered company, a charity and a community members association which is led by, and representative of, Gypsies and Irish Travellers [25]. The overall aim of Leeds GATE is to improve the quality of life for Gypsy and Irish Travelling people living in or resorting to Leeds.
Dudley- ‘Life is Precious’	Volunteer & peer roles	Local Black and Minority Ethnic (BME) people	Community health champions; art workshops; focus on cancer	‘Life is Precious’ is a cancer health improvement project commissioned by Dudley Public Health Community Health Improvement Team [26]. The project used a creative arts approach to engage local people from minority ethnic communities in a dialogue around cancer.
Wandsworth- Church-based Family Therapy	Connecting to community resources; partnerships/ coalitions	Local people; BME; faith; mental health	Co-production model, empower pastors to disseminate key messages around relationship building and mental health to the local community	The ‘Church based family therapy in Wandsworth’ project, is a partnership between Wandsworth NHS clinical commissioning group, South West London Mental Health NHS Trust, Wandsworth Community Empowerment Network (WCEN) and the Pastors Network for Family Care [27]. The aim of the project is to increase uptake of early intervention and decrease use of acute mental health services among the BME community and to embed therapeutic skills inside communities.
Liverpool- Friends of Everton Park (Natural Choices)	Strengthening communities; volunteer and peer roles	Local community in a deprived area	Regeneration; capacity building; volunteers; health and wellbeing; natural environment/ green space	The Friends of Everton Park are an open voluntary organisation of partners and communities who were established in 2010, to work together to make the Park a common treasury for all. The Friends run an annual programme of events where the local residents engage into music, sports, arts and leisure events. In 2012 the Natural Choices Programme was delivered, funded by Liverpool Primary Care Trust (PCT) and ran in partnership with The Mersey Forest. The aim of the programme was “to promote health and wellbeing in Liverpool residents by utilising natural environments and the talents and interests of communities” [10]. A total of 38 community projects were funded by the Natural Choices Programme, including the development of the Faith plot by Friends of Everton Park.
London-Youth.com	Strengthening communities; partnership/ coalitions; peer roles	Young people	Developing partnerships and community projects; health promotion; changing attitudes	Youth.com (originally called Youth.comUnity) was created by the Well London Alliance to be led by Central YMCA (CYMCA) [10]. Two Youth.com Programme coordinators, each in 10 of the target sites, aimed to recruit two Young Ambassadors in each site, provide them with some expenses, project money, training, and support, and network them together and with other external youth organisations. The Young Ambassadors would then set about engaging with other young people from the target areas and signpost them into the various activities as well as using the small project funds to create their own activities.
Margate- Connecting Communities (C2)	Strengthening communities; partnership/ coalitions	Local people in deprived areas	Supports delivery of a 2-year intervention designed to improve the health and wellbeing of deprived communities by setting up a 'People and Services' Partnership, led by local residents supported by a multi-agency team of service providers.	Connecting Communities (C2) is a framework for transformative change in disadvantaged communities, based on evidence of what works from experience and reflective practice. It is a seven-step process that engages both service providers and residents. It was implemented in two Kent neighbourhoods – Cliftonville West in Margate and Newington in Ramsgate from 2012.

Cross-case analysis:

Thematic categories across the six case studies related to:

Context and background;
Barriers and facilitators to community engagement;
Training;
Benefits for community stakeholders;
Impacts on the wider community;
Unanticipated issues;
Sustainability and growth.

Prominent themes were barriers and facilitators to community engagement, and within these categories were a number of themes that were consistent across several of the case studies. Facilitators to community engagement was a stronger theme than barriers, with many of the facilitators originating in response to perceived barriers.

[Table 1 presented here]

Context and background

The need for the projects was identified by community stakeholders in three of the projects and by professional stakeholders in the other three. The release of relevant policy or funding streams, or a significant negative event in the community seemed to be catalysts for the initiation of projects.

All six case studies were underpinned by elements of different theoretical approaches, including community health champions [28, 29], co-production [30–32], community development, diffusion of innovation theory [33], popular opinion leaders [34]. What they had in common was that they were either community-led from the outset or professional stakeholders actively encouraged and supported community members to take ownership of project design and delivery.

Barriers and facilitators to community engagement were categorised as contextual or process related [11].

Contextual barriers included:

Stigma and negative attitudes within and outside the community. Some of these concerns centred around “sensitive” health issues, such as mental health or certain types of cancer, which led to reluctance to discuss these issues, and difficulties in dealing with them, such as not attending cervical screening appointments. Other concerns were unhelpful attitudes of professional staff towards marginalised communities:

“… in these communities, [there is] a lot of misunderstanding of what is mental health and mental illness; a lot of fear, a lot of stigma about mental illness. So when you had people who were coming from that mind-set, there was actually quite a number of steps and quite a lot of engagement and quite a lot of learning that was about paradigm shifting that needed to happen before you could even get engagement.” (Professional Stakeholder)

A history of poor relations between service providers and community members, making residents cynical and often unwilling to engage because they find it difficult to believe anything will change:

“To start with – residents have been consulted to death, you know, and, "Do you know what? We would like another bin," and they'd get a bench (laughs) because that's what the service providers have said that you [need]…Yeah. So they just think, well, what's the point of saying anything? It's like, you know, you're not going to listen to me anyway.” (Community Stakeholder)

Lack of respect for or belief in community stakeholders’ ability to take ownership of projects. For example, in the Youth.com project, it was reported that perceived attitudes towards young people were that it was great to have them involved as participants but that they were not capable of influencing decisions in a useful way.

Perceived role conflicts for community or professional stakeholders when taking on additional roles. Specifically, for the Wandsworth Church-based family therapy project, this related to concerns among some community Pastors regarding engagement, due to historical “problematic” associations between faith and mental health structures:

“There needs to be some level of interest in the faith groups for wanting to do this. Historically, faith and mental health is a problematic, and not very easy, association. So [people with mental health problems], clinicians, practitioners in mental health services were often very, very suspicious of faith leaders, and faith leaders were suspicious of the mental health structures.” (Professional Stakeholder)

Funding, including a lack of funding and complicated application processes. Lack of funding led to limited opportunities for training, limited resources for project delivery and lack of childcare facilities and other necessary resources to support engagement of community stakeholders. Short-term funding led to a need to gain further funding, which some community groups felt ill-prepared for in comparison to more established groups competing for the same funding:

“And also sometimes the governance of community organisations is not always as robust. And so if you're going for a bid and, you know, […] bids for it, they will fill in the form perfectly, they have an audit committee, they'll have a Director of Finance, they'll have a whole system behind them which kind of makes sure they're able to kind of fill the requirements of a funding organisation, whilst community groups don't have that, which puts them at a massive disadvantage…” (Professional Stakeholder)

Lack of awareness of the purpose, models used and long-term nature of community engagement by wider public health and health services, presenting a barrier to commissioning, especially of projects which focus on capacity building and long-term outcomes, but lack immediate health impacts.

Cultural barriers (e.g. religion, gender, language), if not handled correctly. For example, professional stakeholders in one project mentioned that running workshops during religious meeting times had resulted in poor attendance in previous projects. One of the projects needed to put on separate groups for men and women, and took steps to overcome language barriers by using a translating service to provide interpreters.

Process barriers included:

Training – community members were sometimes put off taking part due to the time needed to complete the training, and concerns about their own ability to engage with a particular learning style.

Bureaucracy - the time and skills/ experience needed to complete paperwork (such as funding applications and evaluations) was another perceived barrier. Projects tried to avoid formal Disclosure & Barring Service (DBS) checks and paperwork where possible. Staff in one project proposed to overcome these barriers by designing an informal training package, to encourage community members to share their skills, knowledge and experience.

Lack of support and commitment from key people. For example, one project reported barriers due to a lack of support and direction from a professionally-led steering group:

“So we were fighting a bit of a battle already you know and we didn’t have key partners consistently on board with us […] disgusted – that nobody turned up at the steering meeting you know.” (Community Stakeholder)

Lack of time to attend meetings, promote initiatives and enable positive change. Lack of time for training and delivery of new projects alongside existing projects was overcome in one project through ongoing consultation that resulted in the flexible and adaptable delivery of the project. Time is also needed to develop relationships and trust, and to measure meaningful outcomes.

Community stakeholders not feeling involved or represented. This was overcome by on-going consultation and ensuring each individual group was represented.

Contextual facilitators included:

Strongly established community or network, and trust within that community enabled new initiatives to engage with the community more easily. For example, the role of the Wandsworth Church-based family therapy project in bringing individuals and organisations together was felt to be key. Trust in key individuals was felt to be important, which in one project meant consistency in staffing:

“What has made it work I think has been the mediation of [organisation]. I don't think it would have worked without a third between the Trust – even though we were a very small department, but I think [NAME] has done a really fantastic job of negotiating across the CCG, the Trust, […], and that’s a very skilled piece of negotiation.” (Professional stakeholder)

Enthusiasm of community and professional stakeholders for the projects and communities involved was particularly useful for getting people involved initially:

“I think what makes it work well is the enthusiasm of the [community stakeholders] – that's working well – and that enthusiasm is probably driven by increasing demands and the need for supply.” (Community Stakeholder)

Professional stakeholders having a positive attitude towards community stakeholders’ knowledge and abilities to devise solutions themselves, if with some support:

“…by engaging with the young people, we were able to target and deliver projects that young people really wanted on the estate, you know. So it was very much an empowering process that was very bottom up and not a top down process. And you're able to keep people and engage people in such a programme because their voice and working alongside a professional, they're doing a co-production where they are on an equal setting with the professionals. So it was very, very, very different and had a very positive impact.” (Professional Stakeholder)

Process facilitators included:

Commitment and involvement from key and respected people and organisations, by providing expertise, support, endorsement or by actively recruiting community or professional stakeholders to join the project.

Having or recruiting the right people for the right roles:

“The specialist health midwife helped us […]; she was really great […] having a key member within the health you know, on board, wholly on board who isn’t dictating the agenda or manipulating what’s happening, like to fit in with their own work...” (Community Stakeholder)

Spending a long time building a project, allowing relationships and links to existing networks to establish:

“And to get to where we are now has taken about seven/eight/nine years anyway. So I think all of that kind of work needs to be, I suppose, understood and recognised because it's the groundwork to relationships. The trust is a big thing.” (Professional Stakeholder)

A sense of ownership of the projects by the community. Projects which successfully engaged the target communities were those in which the community had ownership and led decisions regarding the design, delivery and evaluation of the project, and its future direction. The Wandsworth church-based therapy project mentioned the related need for service providers to be receptive to change and to the need for resident-led action:

“Yes, and I think they feel an ownership in terms of how it goes forward. They don’t feel that something’s going to be done to them.” (Professional Stakeholder)

Cultural adaptation of training and resources, including culturally appropriate and accessible training and resources (e.g., running same sex groups where appropriate), identifying target audience and languages for interpretation, and generally being sensitive to religious and cultural beliefs and needs. Projects involved on-going conversations about acceptable images & messages that could be fed back to communities:

“Quite a lot of them got the faith and their religious aspect, it was ensuring that we’re not running the workshops that are going to clash with those dates as well and ensuring that they are able to pick their children up on time.” (Professional Stakeholder)

Flexibility (e.g. of project protocol, roles and timing), holding meetings and activities at convenient times for community members:

“Definitely we scheduled meetings at times which were convenient to them, in locations which were convenient to them. That was really important. If they were out of time, we'd help with expenses, travel expenses. That was really important.” (Professional Stakeholder)

Good communication in terms of inviting people to take part, ensuring that meetings and activities are advertised and promoted to all the right people, and giving feedback on decisions being taken forward and other outcomes. Communication styles needed to be adapted to audience. Face to face meetings and personal invitations seemed to be effective in most projects, but:

“I think another important thing was being able to communicate on a range of platforms, especially the social media platforms. So, Facebook was used an awful lot, as well as WhatsApp. So it was being able to communicate and knowing how to engage with the young people.” (Professional Stakeholder)

Working in partnership with other local organisations:

“Locally, there were […] local partners who came to the table who were enthused and very supportive of the young people and were able to add capacity by giving them further funding for a talent show on their estate that the young people led on. For example, a representative from the local schools in the area, I believe, gave the young people £250 towards the talent show. We also had NHS Greenwich Public Health who supported the young people with their event, and the local police were very much involved in the events that the young people delivered. Charlton Athletic also was another organisation that was very supportive […].” (Professional Stakeholder)

Familiarity and trust. Using venues and trusted professionals that people were familiar with encouraged engagement by ensuring that community members felt safe. Where trust was not there initially, mechanisms were put in place to build trust between community members and service providers:

“What is really important is, it took part, the [name of group] one for example, took part in their community centre, so it was making them quite relaxed, so making a safe environment in the first place.” (Professional stakeholder)

Respect from professionals for community expertise and related concepts of working together and of valuing community members were very strong themes. Engaging the community from the start in design and delivery of the project (and ideally of the evaluation), allowing them to lead and take ownership, and continuing those conversations about what is most acceptable and useful seems to be key.

Training, although mentioned as a potential barrier, could also be a facilitating factor, particularly if it was seen as a means of supporting community members during the project, recognising their value by gaining qualifications and increasing their personal assets, and encouraging them to achieve their own goals. The time taken to attend the training sessions and complete assignments in one project was felt to be a barrier to community engagement, which community members needed support from peers and professional stakeholders to overcome. Flexibility was felt to be important in terms of content (acknowledging the skills that community members bring; adaptation to cultural needs), delivery, time and place.

Having sufficient funding and support to apply for funding:

“If there wasn't any support, then obviously I think it would have been quite chaotic. I don't think the project would have been quite as successful. You know, it wouldn't probably have happened if that was the case […]. It gave me backup in the sense that if I had an issue […] I could easily phone or send an email, and my questions would have been answered straightaway.” (Community Stakeholder)

Providing feedback quickly and responding quickly to things that can be done quickly (‘quick wins’) – for professional stakeholders and service providers to show they have listened to community members and build trust:

“It got positive because people, for the first time, felt they’d been listened to, and the results, you’ve got your top ten or you’ve got your ten top themes there. And everyone was like yeah, right I said that.” (Community Stakeholder)

Strong (but flexible) evidential methodology for community engagement was mentioned as a facilitator in one project.

A further cross-cutting theme related to strategies to overcome perceived barriers, as a result of professional stakeholders applying learning from previous projects. Table 3 sets out these barriers and strategies to overcome them.

Table 3

Overcoming barriers
Barrier	Response
Stigma & negative attitudes within and about the community	Commitment & involvement from key people
Training taking too much time & being off-putting in nature	Adapting training, providing support and reframing as recognition of value and increasing personal assets
Community members do not feel involved or represented	Professional stakeholders respect & value community expertise & contributions; allow to lead
Too much paperwork, too little time	Flexibility in timings of meetings, content of projects, definitions of roles

Case studies examine social phenomena within real-life contexts and are an appropriate design where there are many variables of interest and where there is an interaction between a phenomenon and the context in which it occurs [13]. In this study, multiple aspects of interest were examined including practitioner and community perspectives; support systems and delivery processes; community engagement approaches and practices; outcomes, effects and sustainability. The choice of design therefore fitted with an ‘ecological systems’ approach to evaluation that shifts focus from viewing the impact of interventions on communities to examining the dynamic relationship between an intervention and community systems [35, 36].

Although community engagement interventions have been shown to improve health and reduce health inequalities [37, 38], as demonstrated in the recent Covid-19 pandemic, less is known about how to engage with communities successfully [18], or about what works, for whom and in what circumstances. This research aimed to investigate the processes of community engagement in existing UK projects as part of evidence commissioned to inform the community engagement guidance update [9] .

The most prominent themes to emerge in this cross-case analysis related to barriers and facilitators to community engagement. An earlier systematic review [4] found more evidence on barriers than facilitators, while in 2015 the situation was reversed, with a large number of facilitators identified [11]. This is likely due to advances in the field of community engagement in terms of policy, practice and research, with a greater emphasis being placed on how community engagement works. The later review noted a lack of studies which attempt to evaluate how to overcome identified barriers to community engagement [11]. This gap is addressed to some extent in this paper, as most included case studies involved professional stakeholders applying their own learning from previous projects where barriers to successful community engagement had been noted.

Due to time constraints, we were in some cases unable to give the planned two weeks during the recruitment process between first mention of the project to community members and contact from the research team. We did not meet our own target in all cases of five interviews and one focus group, usually due to time constraints but sometimes due to the small size of the project teams.

We were unable to include any rural case studies, despite this being one of our secondary sampling criteria. This may have been due to lack of time or resources in the rural case study that was initially selected. This means that we cannot be sure whether the process of community engagement is substantially different in rural initiatives.

All the included case studies were able to offer positive examples of community engagement; none were unsuccessful so we were unable to compare features of successful and unsuccessful community engagement initiatives. However, professional stakeholders did volunteer information about barriers to community engagement that had limited the success of previous initiatives. They had used the learning from these negative experiences to improve the chances of successful community engagement in their current initiatives.

We were not able to speak to any community members that did not wish to engage with the projects, so we do not know what might have encouraged or prevented their engagement.

The case study research did not set out to evaluate the success of the included projects in terms of achieving their health- or wellbeing-related objectives, but rather to explore the process of community engagement, and whether that had been perceived to be successful. Therefore, we cannot offer any further insight into which elements of community engagement might be associated with improvements in health or wellbeing, other than to note that all six projects had success in engaging with the community and also in achieving some health- and wellbeing-related objectives.

These case studies in community engagement practice in the UK identified a range of barriers and facilitators to community engagement, and ways in which barriers may be overcome. Key facilitators of successful community engagement were: trust within the community and between community members and service providers; respect for community members’ expertise; allowing sufficient time for relationships to establish and for outcomes to be seen; commitment of key people; and flexibility.

Community engagement initiatives need to work with established communities or networks and trusted key people. If communities are fragmented or trust does not exist between community members and service providers, measures must be put in place to establish that trust, and sufficient time allowed for that process to work. Community members’ expertise should be respected and valued, allowing their views to be heard and acted upon, and for them to be involved in decisions made about design, delivery and evaluation, and to take ownership of the initiatives. This can involve a lengthy process if community members are to be fully involved, so sufficient time and resources should be allowed for this. Flexibility and adaptation of project materials, protocols and role descriptions is important in overcoming barriers to community engagement.

This work did not aim to evaluate the effectiveness of the included case study initiatives in improving the communities’ health and wellbeing. Further research on whether, how and for whom successful community engagement is linked to improved health and wellbeing would be useful. Such research would ideally use participatory methods and be community-led in order to be as inclusive of community members as possible. Consideration should be given to novel methods of data collection such as arts and photography, and to reducing the burden on community members in terms of time and effort.

BME: Black and Minority Ethnic

C2: Connecting Communities

CCG: Clinical Commissioning Group

DBS: Disclosure & Barring Service

GATE: Gypsy and Traveller Exchange

NHS: National Health Service

NICE: National Institute for Health and Care Excellence

PCT: Primary Care Trust

PHAC: Public Health Advisory Committee

UK: United Kingdom

WCEN: Wandsworth Community Empowerment Network

Ethics approval and consent to participate: Ethical approval was obtained from Leeds Beckett University’s Research Ethics Committee. Informed consent was obtained from all study participants, who were provided with information about the study and had chance to ask questions before signing a consent form.

Consent for publication: Not applicable.

Availability of data and materials: The qualitative datasets generated by this study are not publically available, as to share full interview transcripts would compromise the anonymity of the research participants. However, detailed within-case analyses for each of the six case studies are publically available in the full report (Bagnall et al., 2016b) at https://www.nice.org.uk/guidance/ng44/documents/evidence-review-6 or https://eprints.leedsbeckett.ac.uk/id/eprint/2344/ or from the corresponding author on reasonable request.

Competing interests: Professor Jane South was a member of the NICE Public Health Advisory Committee (PHAC) developing the community engagement guideline and was seconded to Public Health England to develop the family of community centred approaches during development of the guideline. There were no other conflicts of interest in the writing of this report.

Funding: This paper is based on work commissioned and funded by the National Institute for Health and Care Excellence (NICE). The views expressed are not necessarily those of NICE.

Authors’ contributions:

AMB was the principal investigator and led the overall project for NICE, designed the study, was involved in recruitment, selection and data analysis, wrote the final report and manuscript. JS was involved in the overall study, and a major contributor to study design and analysis. KK was involved in the overall study, contributed to study design, and led on recruitment, selection, data collection and analysis, and collected data at 3 sites. JT was involved in the overall study, contributed to study design, recruitment and selection, collected data at 3 sites, and carried out data analysis with KK and KS. KS was involved in the overall study, contributed to recruitment and selection, collected data at 3 sites and carried out data analysis with KK and JT. AH was involved in the overall study, led the linked systematic review, was a major contributor to study design, and was involved in recruitment, selection and data analysis. All authors read and approved the final manuscript.

Acknowledgements: With thanks to all the participants in the six included case studies.

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Competing interest reported. Professor Jane South was a member of the NICE Public Health Advisory Committee (PHAC) developing the community engagement guideline and was seconded to Public Health England to develop the family of community centred approaches during development of the guideline. There were no other conflicts of interest in the writing of this report.

Community engagement approaches to improve health: a cross-case study analysis of barriers and facilitators in UK practice

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Results

Cross-case analysis:

Context and background

Contextual barriers included:

Working in partnership with other local organisations:

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1