We screened a total of 11,218 references found in our electronic database searching, and examined a further 15 potentially relevant reports. We looked in detail at 220 evidence sources and included 44 of these representing 41 individual studies. Figure 1 outlines the process of evidence identification and selection.
This figure illustrates the flow of studies through the review
The included literature was dominated by UK research (see Fig. 2), with the greatest proportion of qualitative or case study design (see Table 1). We supplemented the European empirical literature (35 studies) with nine non-European papers containing theoretical models or frameworks (19–27). These models included the participation chain model (19), social innovation theory (20), a community capacity model (21), community capability model (22), decision process model (25), and the biographical approach (26).
This figure provides a summary of the countries from which the included literature originates
We identified eight other relevant reviews. The oldest of these was a rapid review of community engagement initiatives completed in 2011 (28). The next was a 2012 review of involvement strategies in environmental projects (29). Two 2016 reviews explored evidence on pathways from control to health inequalities,(10) and community capability (22). A review in 2017 explored evidence regarding public and stakeholder engagement in the built environment (30), and another in the same year focused on community engagement (11). The two most recent reviews were a review of the impact of joint decision-making on community well-being (31), and a review of opportunities to engage the public in local alcohol decision-making, which also included other local decision-making (32). While these reviews overlapped in some aspects with our review and provided valuable findings regarding potential pathways to outcomes, studies had often been included which described approaches more aligned to consultation than involvement. We therefore extracted only those findings answering our review questions.
Included studies categorised by study design
De Andrade 2016
Lewis 2018/Orton 2017/ Reynolds 2018
De Freitas 2015
Cross sectional (survey)
Iconic consulting 2014
Where appropriate, studies were appraised using checklists for each study design (see Additional File 1). The quality of the included quantitative literature was very limited, with very few studies collecting data at more than one time point, predominantly descriptive reporting, and little use of statistical analysis. Case studies also often focused on narrative reporting. There was greater quality in the qualitative studies, with these providing depth of insight into participant views and experiences. The review studies in general had been carried out using rigorous systematic methods.
Synthesis of results
Given the complexity of the findings, we developed a summary diagram (Fig. 3) to provide a structure for categorising and reporting the evidence, drawing on the models and theories we identified.
The synthesis outlines evidence within each of the four categories of the diagram in turn, moving from the outer to inner tiers. The first section of the synthesis outlines the differing forms and functions of initiatives described in the literature (outer tier). This is then followed by evidence of influencing factors, which were reported to either enable or constrain initiatives (including those relating to organisations, participatory processes and communities). The next section outlines evidence of the effects of approaches (including on relationships, individuals, communities, and the decision-making/participatory process itself). The final section (inner tier) relates to evidence of longer-term health and health inequalities impacts of approaches to increase public participation and influence.
Figure 3. Summary diagram of the evidence
This figure illustrates the structure of the reporting of evidence in four tiers from initiative form and function, influencing factors, intermediate outcomes, and longer term impacts.
Characteristics of approaches to increase public participation and influence
The literature outlined initiatives to increase public participation and influence in local decision-making and action in relation to eleven different local issue areas/decision-making topics: planning and the built environment (five studies), health inequalities and social exclusion (one study), environmental management (three studies), urban regeneration (three studies), alcohol licencing (three studies), citizen welfare (one study), community empowerment (two studies reported in four papers), service reconfiguration and community capability building (one study), health services (three studies), road safety (one study), and community involvement/participation generally (three studies).
Included sources labelled their approaches to public participation and influence in different ways: as “engagement activities” with young people (one study); neighbourhood planning (four studies); planning aid (one study); a social inclusion partnership (one study); a citizen sensor network (one study); participatory health impact/health needs assessment (three studies); asset-based approaches (three studies); financial investment (four studies reported in seven papers); alcohol licencing committee participation (two studies)’ and healthy cities networks (one study). Authors provided limited detail regarding exactly what activities formed part of the approach undertaken, and even less regarding how activities undertaken were intended to support public participation and influence, and with what effects on other wider determinants of health and health inequity. It was therefore often difficult to determine exactly what the intended function of people’s participation and influence was within decision-making processes and local actions.
Specific activities recommended to support participation and influence included: the use of three-dimensional graphics (33), use of virtual tools to help visualise a local area, social media, geographical information systems and decision support systems (30), newsletters and establishment of a communication plan (34). Paying attention to mechanisms for sharing information with the wider community was reported to be key (35), with clear feedback and demonstration of commitment required (36). Authors of one study cautioned that potentially a large number of meetings and public forums could be required to overcome barriers and mistrust (37). Studies highlighted that communities needed adequate knowledge and skills to enable involvement, for example mechanisms need to be put in place to support their contribution at meetings (31, 38, 39).
Theoretical papers provided more information about the intended functions of differing forms of activity to support people’s participation and influence in local decision-making and action. Activities such as “inviting people to participate’”, ‘”listening” and “responding” were highlighted as important, given that these are experienced as a vote of confidence in people’s personal competencies. They are seen to provide a sense of being able to make a difference; a signal that public views are valued and that participation has been influential (that people have made a difference). This in turn encourages further participation/involvement (19, 27). The use of facilitators was emphasised as a theoretically important activity given that they can act as bricoleurs (community builders) who help connect community participants to other local resources (20, 27). Citizens’ contextualised understanding of local problems can then be brought into decision-making processes alongside other stakeholder’s understandings of what may be feasible solutions (20).
Studies outlined how facilitators can also help create empowering spaces (protective niches) where community participants are “given permission” to consider issues and changes needed. In these spaces, trusting relationships between different stakeholders can grow, promoting knowledge exchange and collective learning within decision-making and limits professional dominance (19–21, 27). Activities supporting relationship-building between community organisations, civic groups and government stakeholders can provide opportunities for the public to advocate more effectively for policy changes of benefit locally (23).
Finally, theoretical papers highlighted the importance of activities such as training, technical assistance and community organisation/mobilising, which functioned by strengthening community capacity/collective capabilities to participate and exert an influence (e.g. via the development of civic skills, civic knowledge, social/political awareness) (21–23). Community-based activity with residents was also highlighted as important in supporting community capacity: developing resident’s knowledge (and ownership of that knowledge) for use in advocating for change and in decision-making (21).
Theoretical papers therefore highlighted that approaches should involve a set of activities functioning together to support public participation and influence (rather than just “one” intervention). Empirical papers similarly emphasised that differing forms of activity may be required to be influential within decision-making (39–41), and that activities will differ depending on context (42) and the breadth, depth and reach intended (34). While much of public involvement tends to be “top down” (30, 32, 43, 44), the literature emphasised the importance of moving towards a “bottom up” approach; starting from the communities’ agendas and not the organisations’ (39, 40). Authors cautioned of the need to ensure that aspirations of involvement do not turn into a cosmetic exercise (30)
Sources further highlighted that activities, and their intended function in enhancing public participation and influence may need to change over time (23), as aspirations grow or policies change (28), and enthusiasm may wane (46). Studies emphasised the need for continuity of public involvement, with particular consideration of sustainability, organisational commitment and the funding required (28, 39, 43, 47–49). One paper drawing on social innovation theory (20) argued for sustainability to be grounded in a shared vision and expectations across communities and other stakeholders.
Four studies noted that the timing of initiatives to increase participation is important, and that involvement should take place in early phases of decision-making (37, 38, 45, 50). The benefit of a holistic community approach was emphasised (48), with involvement of multiple agencies (46). The need for formal and organised involvement strategies was emphasised (41), together with having an organisation policy in place to drive change (47). There should be strengthening of people’s perception of the possibilities (51), and effective governance to support and drive through initiatives (34).
Factors influencing the characteristics of different approaches and outcomes
The literature identified diverse factors which affect the characteristics, and effects of approaches and actions. We categorised these as factors relating to: organisations; participatory processes; and communities.
Organisational factors described predominantly related to local government, as a key policy actor in local settings, but also extended to factors relating to other “governing authorities” (42) such as local health boards.
Studies emphasised how changes to the local government operating context could influence how much focus involvement was given internally (47). A study of alcohol licencing in the UK, for example, reported that re-elections and changes of individuals in key posts within alcohol licencing boards “completely changed the climate” (44). The increasing use of private companies to provide local services (such as refuse collection) was noted to provide additional challenges to public involvement, as local government distanced themselves from decisions made, and the established routes for public opportunities to influence became ineffective (52).
Several studies identified the influence of organisational culture on support provided to, or the approach taken towards public participation and influence. Organisational culture could determine perceptions and organisational values regarding whether and how to involve the public (including cynicism about participation) and whether there was leadership on participation (32, 38–40, 48, 53). Views held could be different at different levels within organisations, with high-level support needed for cultural transformations and changes in mind-sets, if public participation with scope for influence is to become the norm (38). Training for staff in involvement approaches was recommended, together with support to enable them to work in new ways (39). Several studies noted where a lack of skills and/or knowledge in community engagement had adversely effected an organisation’s ability to involve the public successfully (32, 38–40, 48).
Papers outlining theories and frameworks also drew attention to organisational factors either fostering, sustaining or undermining approaches to public participation and influence, and outcomes (19). Personal, professional, and organisational attitudes shaped the willingness to listen during public participation, with those who appreciate the value of public participation and knowledge most prepared to engage and/or consider new ways of working (19, 24, 27, 40). Studies described “asymmetries of power” between “expertise” and public insights and understanding (24). Whether the public were acknowledged organisationally as legitimate participants could shape an organisation’s capacity to value the potential richness and complexity of involvement (26). One paper highlighted that for those organisations with governing authority, their approach to involvement could depend on their understanding of the type of problem (42).
The key role of power inequalities as an influencing factor during processes of participation was emphasised (44, 52, 54, 55). Two studies noted dilemmas regarding how far initiatives instigated by local government to increase involvement should give communities decision-making powers when there is disparity between what local government perceive to be acceptable and sustainable, and resident expectations of what could be achieved (46, 56). Other authors pointed to often differing national priorities and funding streams which constrain choices available to local decision-making (45, 55). Councillors in one study for example highlighted how despite their best intentions, power at a local level could be limited by top down decision-making systems (40).
The literature highlighted that time was a key factor, in order to allow sufficient input from communities and to build relationships (32, 37–40, 45, 48, 52, 54), and also to develop shared trust (21). Authors highlighted that there can be potential for mismatches between community expectations of change, and time scales required to achieve it (30, 32, 37, 38, 43, 45, 57).
A sizeable volume of studies highlighted challenges in involving a wide cross-section of any community in involvement initiatives (34, 35, 41, 45–47, 56–58). Authors noted the often small number of individuals participating, and that increased involvement/influence often did not extend beyond “the few”, with a particular need to empower those who are typically excluded. Studies described community apathy, disenfranchisement, reluctance to engage, lack of awareness of opportunities, communities being bombarded by researchers, and participation of only those who were highly motivated (30, 38, 39, 43, 44). An evaluation of an initiative to increase public involvement in local planning for example noted that the small number of individuals who drove activities were typically male homeowners aged over 59, with prior experience of the planning system (57).
Concepts of community capacity and resilience (social and environmental capital existing in individuals and a community) were highlighted as important in influencing a communities’ ability to be involved (21, 41). Participation might be most effective when community capacity is at a “tipping point”, or state of readiness, which could be harnessed by additional resource or stimulus (11, 47).
The conceptual framework developed by Brunton et al. (11) refers to multiple factors which can influence whether or not community members participate including: personal gain (wealth/health/skills), community benefits ideas about altruism/responsible citizenship. The authors emphasised that needs, issues and motivations of communities should provide a foundation to structure how initiatives to encourage community involvement develop. One study (19) recommended a “mobilising” approach via direct invitations and approaches to participate, in order to enhance the involvement and influence of marginalised groups, migrants, and people from ethnic minority backgrounds.
The literature emphasised that the concept of “communities” is often unclear and fluid, creating challenges to increasing community involvement. Authors described how some residents may not identify with a geographical area, that changes in the demographic of the local area can adversely influence the cohesiveness of a community, and how there can be shifting concepts of community boundaries (34, 40, 45, 46, 57, 59, 60). Cultural variance was noted as important to recognise, with language and literacy affecting whether and how some members of a community participate (39). Authors outlined the potential for sub-community tensions to shape participatory processes, with differing perceptions of amenities, territorial pockets, and perceptions of improvement not being equal across all areas (34, 35, 39, 41, 44, 47, 55).
Papers drawing on theoretical models echoed the need to fully consider varying definitions of community (11), raising questions about how “the public” is defined (42), and cautioning that any quest to involve “the ordinary citizen” is challenging (26).
Two studies emphasised the importance of community hubs and other social spaces as facilitators of participation. In one (47) authors reported that meeting places and community facilities were critical to an initiative to develop and maintain resident engagement and influence in local issues. The other (20) similarly noted the role of an empowering space in involvement.
In common with many other public health interventions, the pathway from involvement initiatives to social determinant effects is complex, multi-faceted and distal, and may be direct or indirect (10). We identified several frameworks which offered varying typologies of outcomes (10, 21, 23, 31, 32, 42, 46, 58). We endeavoured to synthesise these models in our reporting, which distinguishes four main types of effects: effects on relationships (civic sector alliances); effects on the decision-making process and actions; effects on relationships and assets within communities; and effects on individuals.
Effects on relationships (civic sector alliances)
Four empirical papers concluded that increased involvement in decision-making leads to the formation of new relationships between local government and residents. Involvement can lead to the development of new personal contacts and partnerships, and a shared sense of responsibility (30, 36, 53, 60). The outcome of increased trust was central in these improved relationships (21, 23, 31, 36, 37, 46). Other empirical studies noted outcomes of increased joint commitment (41), and development of a shared vision (59).
Effects on decision-making and action
A key effect to consider is whether approaches to increase public participation and influence actually have an effect on actions and local decision-making choices that affect peoples’ lives and where they live. Here, the evidence was mixed. Eight papers from seven studies (32, 36–38, 46, 50, 54, 56, 58) suggested approaches to increase involvement enable greater public influence on decisions. For example one (38) reported that community participation in plans for a major housing development appeared to have resulted in revised plans integrating the preferred options of the community. Another (32) concluded that community priorities had been incorporated into alcohol licensing plans. An Italian study suggested that a participatory health impact assessment had led to community empowerment, which in turn was associated with more equitable decision-making about local health needs and priorities (37). Another paper (23) claimed there was evidence of participatory budgeting approaches influencing decision-making on spending priorities (the allocation/distribution of public funds), particularly choices about capital projects and/or physical infrastructure improvements (e.g. green space, transportation, streets, recreation, renovating schools). Other papers suggested that approaches to support participation and influence could go as far as to reshape policy choices in ways that deflect threats to local environments; reducing the unequal distribution of environmental stressors/risks that affect health and health inequalities (10, 21).
We looked for evidence of the process whereby these impacts might come about. Seven empirical studies reported that public participation and influence had the intermediate effect of providing additional/alternative knowledge during the decision-making process, which could potentially then affect the decisions made (32, 33, 37, 40, 50, 52, 56). One study (40) highlighted that public involvement enabled two types of knowledge to be brought to the planning processes– local expertise, and specialist knowledge (although the authors noted that this knowledge could be viewed by planners as being “unreliable”). Another study of planning decisions argued that approaches to increase involvement (partnership in planning) had led to community consensus about what was needed and therefore more effective planning (37). Papers reporting theories and frameworks echoed the potential for approaches which aimed to increase participation and influence, to lead to the inclusion of different forms of knowledge within the decision-making process (19, 42). This knowledge could raise local government awareness of community needs that were “forgotten/invisible” under “business as usual” (23). Public involvement therefore could resolve knowledge “deficits” and/or lead to innovative ideas and co-designed solutions (20).
While reports of influence (perceived or actual) on local decision-making and actions, and increased knowledge brought to the decision-making process suggest positive effects of approaches to increase involvement, literature also reported uncertainty regarding effects, or evidence of little effect. A description of an initiative to increase public participation in waste management decision-making in Wales (52) for example outlined how planning systems precluded public participation. Short time limits on responses can similarly adversely affect the ability of community groups to mobilise (61). Lack of transparency in decision-making processes makes it often difficult to tell whether or how public participation and influence has shaped the decisions made (33). One paper highlighted that there is a need to clearly distinguish involvement from consultation if the effects are to be discerned (32).
Effects on relationships and assets within communities
Increased knowledge in terms of a positive outcome for communities (rather than the decision-making process) was emphasised in six included empirical studies. One (56) reported that participation workshops led to improved health literacy and health system literacy for community participants. A road safety initiative for young people increased knowledge of community issues amongst participants (33). Similarly, a study of community-led planning reported that participants had better awareness of local issues and needs (36). A study from The Netherlands likened additional community knowledge to gaining “information-power” (54).
Papers emphasised other community outcomes arising from processes of participation, including: improved social relationships and forms of mutual support, and networks of connections (11); group confidence and sense of entitlement to participate (19); identity, community-minded behaviour, social capital, connectivity and cohesion, resources for change, sense of community, intergenerational connectivity (47); and the development of civic skills, knowledge and social and political awareness (23). These intermediate outcomes in turn were described as increasing collective efficacy and power to take action of benefit to people in a particular area (11), and/or to advocate for change (21). New communities of interest can be formed, as a shared vision for an area is developed (59).
Four studies drew such associations between participation and control and empowerment. One (40) theorised that community participation in planning provided opportunities to be actively involved and influence, which then led to increased control and empowerment, with the outcome of individuals and communities becoming more resilient. Similarly, authors of a study evaluating a community action model suggested that a “strengthened community” could be associated with increased capacity to influence decision-making (50).
A note of caution however, is provided by one study which found that following an intervention (a large funded programme) there were increases in the intermediate outcome of “feeling part of the community”, but there did not appear to be statistically significant change in community outcomes (46, 58). Two papers reported potential adverse outcomes, with increased involvement leading to conflicts within communities, and differing points of view regarding priorities for funding (45, 59). Another described how one project had failed to even start, due to disputes within the community (41).
Effects on individuals
Empirical studies reported benefits for individuals in terms of well-being, self-confidence, self-esteem, and physical, emotional and mental health (28, 31, 33). Also, increased individual efficacy (32) and individual empowerment (28, 31, 37). One study (28) noted benefits in particular for individuals from “at risk” population groups, with increased social integration potentially having a protective effect on individual health and quality of life. Theoretical papers echoed the beneficial effects of participation for individuals in terms of: increased sense of ability to make a difference, strengthened resources, motivation, confidence, perceived success and psychological empowerment (19, 23, 27).
However, the literature also highlighted potentially adverse effects for individuals. Authors described: exhaustion, frustration, stress, and fatigue from taking part (28, 31, 45), and how engagement can become dispiriting and disempowering, resulting in scepticism, limited expectations of participation and a reluctance to engage further (11, 28, 32, 36, 52).
Health and health inequalities impacts
We scrutinised the literature for evidence of any impact on individual or community health, health inequalities or health determinants. A systematic review of the effects of joint decision-making suggested a potential association between increased control and a reduction in inequalities (31). Another review hypothesised a potential association between community empowerment and personal psychological health and well-being, which then leads to a cumulative health improvement at the population level (28). A study of community participation in health impact assessments drew a potential association between improved evidence-informed decision-making and population health improvement (52). Authors of one paper hypothesised that the development of civic skills, knowledge and social and political awareness via participation could potentially be linked to improved mental health outcomes in the longer term (23).
An empirical evaluation of a large funded programme (46, 58) however, found no relationship between participation/perceived influence in decision-making, and impacts on health. A paper reporting multiple qualitative case studies on involvement in planning decision-making (57) found some limited evidence of a narrowing of the gap between more and less deprived households on some outcomes, but also potential to widen inequalities. Exclusion of marginalised groups may potentially reinforce inequalities (32, 38, 61), and a lack of representativeness which may then lead to a lack of validity of decisions made (34, 56, 62).
A particular focus of this review was the actual or potential impact of constrained resources on approaches to increase public participation and influence, given the challenging economic context for local governments, communities and their organisational partners.
Included studies drew attention to the often insufficient costing of participation within tight budgets (30, 32, 38, 39). A qualitative study of an asset-based approach for example outlined how limited engagement was the result of practicalities, budget and funding cuts, and lack of resources (39).
Papers reported how the requirement for efficiency in local government tends to be framed as inconsistent with public participation and influence, with “costs” sometimes used as a justification for local government not attempting approaches to increase the involvement of members of the public in local decision-making (38, 52, 57). Studies highlighted that public participation was not high up the budgetary agenda (30, 32, 39), and there was competition for resources between different projects (45). Time and resource are also required from communities themselves, and participants in one study viewed the costs of participation as “barely justifiable in regard to what was achieved” (40).
Financial sustainability needs to be central if ideas, knowledge and solutions developed through participatory approaches are to thrive; with the prevailing macro-level (policy) regime a key influence on this (20). Sustainability of funding is key if trust with communities is to be developed and organisations are to avoid “leaving communities when the money ran out” (39). Papers drew attention to how low investment in public services, declining neighbourhood assets and/or limits to people’s personal resources (e.g. money, power, information) can undermine individual or community capacity to participate (10, 21).
Space for participation, including community hubs and other social spaces within communities are important, with weak economic conditions perpetuating limited investment by developers in community assets and facilities (47).