Abstract
Community knowledge can be a valuable resource for practitioners seeking to design and implement effective public health programmes. However, incorporating community knowledge into health programmes can be a challenging process, requiring careful planning and continuous engagement with community members, particularly for gender-specific issues. This systematic literature review is an attempt to synthesise the existing literature on this topic, with the aim of identifying notable instances of countries and interventions that have successfully translated community knowledge into public health programmes, keeping a gender focus. This review found relatively little evidence of translational interventions around gender and health that have been subsequently incorporated into national programmes, indicating that governments are yet to use community knowledge in a productive way. Broadly, three types of interventions were found: (a) interventions which were carried out by local organisations based on their knowledge of the community, who then used the results to lobby health ministries to institutionalise new policies or programmes; (b) interventions carried out by government health programmes that collaborated with local organisations to introduce elements of community-based participatory research into the intervention design and (c) interventions by government health programmes where community participation was incorporated by the inclusion of community health workers. While a gender lens was not incorporated into the intervention design in many studies, all the interventions in this review show that health outcomes, perception and beliefs can be impacted using community engagement and involvement.
Background
While a large volume of literature exists on mainstreaming interventions to address gender equality, there is relatively less evidence on the translational aspects of community-based (CB) knowledge and on the incorporation of a gender lens into national health programmes. Institutionalising community knowledge in public health programmes has become an increasingly important topic in the field of public health (World Health Organization, 2017). Community knowledge, defined as the knowledge and expertise held by members of a community, can be a valuable resource for practitioners seeking to design and implement effective public health programmes. However, incorporating community knowledge into public health programmes can be a challenging process, requiring careful planning, collaboration and sustainable and continuous engagement with community members.
Community participation has been a central theme in health-related discussions over the years, was confirmed in the Alma-Ata Declaration (Rifkin, 2009), and is in the World Health Organization (WHO) constitution. It reflects the principle of social justice, which holds that people have the right to be involved in decisions that affect their lives. However, incorporating community participation in government programmes might be less challenging than transferring knowledge and evidence that communities gather for such programmes. This is especially true of health interventions that need to adopt a gender-justice approach. While there may be instances of non-health interventions advocated by communities around gender that have been incorporated into programmes, we focus on the links between community knowledge on gender and health and the extent to which such knowledge has been institutionalised by policymakers and managers in their health programmes and interventions. We conduct a systematic literature review and attempt to synthesise the existing literature on this topic, with the aim of identifying notable instances of countries and interventions that have successfully translated community knowledge into public health programmes, keeping a gender focus. The findings of this review may be useful for practitioners, policymakers and researchers seeking to design and implement effective public health programmes that engage and empower communities.
Methodology
A systematic review of the existing literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify documents that reported on local and community knowledge on gender being institutionalised within programmes that were initiated, supported or funded by government agencies, at the national, state, regional or local level. The time period considered is 2000 to the present to account for the setting of the Millennium Development Goals (MDGs) in the year 2000, as several public health programmes were devised as a response to the MDGs. Community or local knowledge was defined as participation or insights gathered from the target population of a programme or intervention. Finally, to incorporate articles with a gender justice approach, a set of search terms was added to filter studies that mentioned their treatment of gender. All genders, cis and trans, were included and considered. The final set of search terms used is as follows:
(grassroots or local or community or indigenous) AND (knowledge or learning or insight or wisdom) AND (health) AND (national or global or program or programme or intervention or policy) AND (institutionalise or institutionalize or mainstream or incorporate) AND (gender or sex or women or men or trans or cis).
The search terms were run through the PubMed database to identify relevant articles. Additional documents were identified through the bibliographies of indexed articles, and further search studies were conducted in Google Scholar and websites of major international agencies, such as the WHO, World Bank and the United Nations Development Programme (UNDP), to discover grey literature. Springer, JSTOR and Elsevier databases were cross-checked for relevant documents. At the first stage, 1,379 results were returned using the above list of search terms. Of these, 119 were removed before screening after filtering the date range, 869 were excluded based on the titles, 3 were identified as duplicates and 322 were excluded after reviewing the abstracts. In total, 66 articles were read in full, of which 43 were found to be non-relevant, 3 were in languages other than English and 1 article could not be accessed. Finally, 19 articles were included in this review. The process of identification of studies has been laid out in a PRISMA diagram, which can be found in the Annexure, Figure A1. The entire screening and finalising process was carried out by a team of two researchers in February 2023.
Results
Among the large volume of literature on community participation in health interventions, studies were streamlined based on the following: (a) community knowledge or insights from community participation were institutionalised into public health programmes and (b) the gender justice approach was followed. Interventions that did not account for gender-specific factors addressing gender inequities, or were run by non-government organisations or were not mainstreamed into public health responses, were excluded.
Many of the included interventions were related to human immunodeficiency virus (HIV) prevention and screenings for breast- and cervical cancer, and several were targeted at minority and underserved communities. A large number of studies involved the community health workers (CHWs) in health programmes. CHWs are frontline healthcare workers who serve as a bridge between healthcare providers and the communities they serve (Love et al., 1997), and they are trusted members of their communities who receive specialised training to provide basic health services and education, often in underserved or marginalised communities. CHWs have been incorporated into public health programmes in innovative ways in many countries, particularly in low- and middle-income countries. Some of the studies included in this review described interventions by local NGOs, where community knowledge was brought out during the intervention and then incorporated in the public health policy. While some of the other studies described interventions that were part of national health programmes, where the importance of community participation had already been highlighted, and collaborations with local organisations were included as part of the intervention design.
HIV Prevention Interventions
Five of the included studies were focused on HIV prevention interventions.
Warren and Philpott (2003) discussed the inclusion of female condoms into national health programmes in Brazil, Ghana, Zimbabwe and South Africa. They discussed strategies for condom adoption in each country, providing details on cultural contexts and the approaches followed. In each country, local organisations worked with the ministries to develop marketing and dissemination strategies based on community research. For instance, in South Africa, qualitative and quantitative data were collected from women to find use patterns, and women reported that they used female condoms out of fear that male condoms might break and that some men might poke holes, fail to put it on or remove it prior to penetration. In addition, the ability to remain in control gave the women a greater sense of security. In Zimbabwe, an acceptability study conducted by the Women and AIDS Support Network (WASN) found a high demand for female condoms among women. Moreover, men were more accepting of the female condoms from a family planning—rather than disease prevention—perspective, which yielded a negotiating tool for women. In Brazil, public sector distribution and social marketing for female condoms were done simultaneously, allowing the product to be more widely available. While promotion of female condoms was typically aimed at women, in many countries, men still maintained the dominant role in sexual decision-making, especially for contraception and prevention of sexually transmitted infection (STI)/HIV. The approaches devised by community-based organisations (CBOs)/NGOs in collaboration with the health ministries and adopted by these health programmes illustrated the importance of including men in the promotion of the product.
Gilley (2006) described another HIV prevention intervention, which was a part of the national health programme, targeted at Native American (NA) communities in the western USA. Using data collected from ethnographic research with HIV prevention workers, persons living with HIV/AIDS and others from the community, the researchers found that NA people have some of the lowest rates of condom use—only 41% of NA youths who were sexually active reported using a condom in their last sexual encounter. The reasons given were substance abuse, beliefs about lack of susceptibility to HIV and lack of preference for condom use. People were reluctant to accept condoms from family members and outreach workers or to pick them up from a booth at public events. Thus, the snag bag was devised—a brown paper bag containing condoms, lubricant, Native-focused STD or HIV/AIDS literature and local healthcare and HIV testing contact information. Sometimes the bags also included female condoms and information on local services for sexual and gender minority groups. The bags were distributed at powwows, clinics, tribal headquarters and social events for NA people. The article points out that the snag bag helps bridge the gap between the individual and community by integrating condoms into the specific cultural values of the communities. While focused mainly on men, the inclusion of male and female condoms indicates that gender and sexuality were kept in mind while creating the snag bags.
Prather et al. (2006) described a women-focused HIV prevention intervention and presented a qualitative analysis of the Sisters Informing Sisters About Topics on AIDS (SISTA) intervention under the Centers for Disease Control and Prevention (CDC). The CDC worked with CBOs, health departments, providers and other agencies on a set of group- and community-level HIV interventions. The SISTA intervention aimed to address the lack of culturally relevant HIV prevention programmes targeting African American (AA) women, who represented 67% of the AIDS cases among women while comprising only 13% of the US female population. The high infection rates were attributed mainly to having unsafe heterosexual sex with an infected male partner or sharing contaminated needles. A series of group-level cultural and gender-relevant activities, which incorporated cultural materials and triggers that made it challenging for women to negotiate safer sex, was planned. The integration of Afrocentric components into the national diffusion of SISTA proved to be successful.
In India, the Research and Intervention in Sexual Health: Theory to Action (RISHTA) project, which focused on the reduction of HIV/STI transmission risk and gender-based inequities among married women in low-income communities, proved successful due to the inclusion of inputs from men despite being a women-centric programme (Kostick et al., 2011). The authors contend that cultural contexts are key, as many commonly used strategies to reduce HIV-risk among women (e.g., abstinence, fidelity and condom use) are ineffective because they fail to address how cultural practices and institutions contribute to gender-discriminatory practices affecting women’s sexual risk and disempowerment. As part of the intervention, participants were given individual and group couples’ counselling on topics related to risky sexual behaviours. Interviews were conducted with men and women from the community to understand their perspective on gender and cultural norms to help devise a questionnaire, which was administered to more community members. The responses helped understand the views of groups and individuals, and an examination of individual scores within subgroups allowed the researchers to identify individuals who were more likely to be supportive of gender equity messages that RISHTA partners disseminated in the community.
Purcell et al. (2014) described the incorporation of couple-based approaches into HIV prevention interventions for gay and bisexual men. This narrative study synthesised data from the literature to show that men are more likely to engage in unprotected sex with their primary male partners than with casual partners, but the shift from ‘casual’ to ‘primary’ is not always clearly defined. Thus, HIV prevention strategies must account better for the contexts in which relationships occur to be successful. The study analysed couple-based approaches of HIV prevention for gay/bisexual men in CDC programmes and described CDC’s HIV/AIDS Prevention Research Synthesis Project, which identified evidence-based interventions from local organisations to reduce sexual and injection risk behaviours, to be included in CDC’s Compendium of HIV Prevention Interventions. The article describes the Couples HIV Testing and Counselling (CHTC) intervention, which occurs when two persons in a sexual relationship receive HIV testing together, and the test results are delivered to the couple together, and counselling messages are based on the results of both partners (concordant HIV-negative, concordant HIV-positive or discordant HIV status). Health providers also use the opportunity to explore the couple’s agreements about sex outside the relationship. The study also describes recent biomedical strategies based on antiretroviral medication use, which have also been incorporated for use by couples.
Interventions on Cancer Screening and Reproductive Health
Another set of studies discusses interventions to promote screenings for breast and cervical cancer and completely focuses on women.
Fowler et al. (2005) presented the evaluation of an intervention under the National Breast and Cervical Cancer Early Detection Programme (NBCCEDP) to promote mammography screenings among AA women in Ohio, USA. Ten-year tracking data from NBCCEDP showed that AA women completed significantly fewer mammography screenings, as compared to non-Hispanic, Caucasian women (17% vs. 60%), due to reasons such as bad previous experiences with health workers, lack of culturally sensitive educational materials and cultural beliefs about ignoring the need for screenings. The NBCCEDP offered free mammography screening and follow-up breast health services for women without jobs or health insurance and collaborated with the Community Health Advisor (CHA) programme to support the breast health intervention. The CHAs were trained in individually interacting with the AA women in the intervention and creating culturally sensitive posters and brochures for education and information. Both mammography screenings and knowledge among community members were increased due to this intervention.
Two more articles present qualitative analyses of breast cancer interventions under the CDC’s Racial and Ethnic Approaches to Community Health (REACH, 2010) initiative; one based on an NA tribe in New Mexico (English et al., 2008) and the other based on Laotian and Cambodian immigrant communities in California (Ngoc Nguyen et al., 2008).
English et al. (2008) stated that breast cancer is the second-highest cause of cancer mortality among NA women; their 5-year survival rates are significantly poorer when compared to other races and ethnicities, and they are more likely to be diagnosed and treated at advanced stages of disease. The article describes a CB participatory approach followed by the intervention partners—the Ramah Band of Navajo Indians, local health boards, universities, community organisations and federal agencies. The intervention assembled focus groups to ascertain the knowledge, attitudes and beliefs of women in the community and to identify structural promoters and barriers to breast cancer screening exams. The exercise identified several individual-, community- and system-level factors affecting mammography rates among community women, including inadequate transportation, lack of financial support, healthcare system disorganisation, lack of awareness, fear, fatalism, stigma, isolation, language and provider barriers. Using the created framework, the study committee prioritised the most easily changeable aspects to design the intervention. Additionally, female community health representatives (CHRs) were engaged to serve as the primary outreach workers to promote participation in the project.
Ngoc Nguyen et al. (2008) posited that the use of community health navigators (CHNs) is effective in increasing access to breast- and cervical-cancer screenings and health services because they have the necessary knowledge and understanding of the language, cultural values and structural needs and resources of diverse communities to bridge the gap between the community and health system. This article describes the Promoting Access to Health (PATH) intervention for women, which was a community collaboration of seven CBOs and two universities, focused on decreasing disparities in breast and cervical cancer among immigrant communities in California. In this intervention, interviews were conducted with CHNs in both Cambodian and Laotian communities to understand the differences in insights and resulting methods of community engagement. For instance, in the Cambodian community, outreach regarding health programmes was preferred via media; in the Laotian community, door-to-door individual meetings were preferred. The CHNs also helped to create tailored educational and promotional materials for breast cancer screening. For instance, a poster of a rural Cambodian village with breast- and cervical cancer health messages was created for the Cambodian community and a flip chart featuring Lao women dressed in ethnic clothing, along with brochures on breast examinations, mammograms and cervical education for the Laotian community. Both communities acknowledged the importance of men as household heads and co-decision-makers, and thus, brochures were created for men as well.
A study examining the role of traditional birth attendance in health systems presents a case study from Timor-Leste (Sarmento, 2014). In general, the activities performed by all cadres of CHWs mainly depend on the local context, and traditional birth attendants (TBAs) have played an important role in providing maternity care to the community. A cadre of voluntary CHWs called family health promoters or promotor saude familia (PSFs) was created to follow up with families throughout the mother’s pregnancy to monitor progress and has been well received by mothers. The PSF referral intervention resulted in an increase in antenatal care (ANC) from skilled health staff (prevalence increased from 41% in 2006 to 86% 2010), and the maternal mortality ratio also improved from 660 per 100,000 live births in 2003 to 557 in 2010.
Gallegos et al. (2017) assessed the formal integration of traditional beliefs, knowledge and practices into pregnancy- and childbirth-related public healthcare in Ecuador, with a qualitative examination of the role of TBAs during childbirth and pregnancy. TBAs did not receive salaries from the government, and their inclusion in deliveries was at the discretion of public health professionals. A healthy level of coexistence was achieved through the provision of separate but simultaneous services during pregnancy and childbirth. TBAs were mostly accepted by the public health professionals, though there were instances of institutionalised intolerance as they were, on occasion, barred from entering public health facilities and delivery rooms.
Engaging with the community leaders or prominent figures can be another way to engage the masses and change their beliefs about health outcomes. In the study of Ma et al. (2018), the authors engaged with clans and their leaders in four villages to determine the barriers and facilitators to ANC use in rural areas with high HIV prevalence. It highlights the importance of local clans in China as a means of influencing the public healthcare system’s use, particularly for ANC in rural areas. Clan leaders were trained to give educational messages on ANC to male clan members and encouraged to actively promote ANC use. The local health system was also involved in this: village nurses were trained to provide education on ANC to women and to help them with pregnancy testing. Both the local health infrastructure and clan leaders played important roles in the committee and intervention. The authors observe an increase from 21% to 64% in the use of ANC services by post-partum women, as well as improved knowledge on ANC. Hence, involving influential members of a community seemed to have helped improve the health system usage. The female ANC outcomes and the involvement of the clan leaders and community engagement are both important components of this study.
Priority Setting and Other Interventions
Communities can be involved in health programmes without a particular disease intervention, as depicted in a priority setting intervention from Tanzania (Kamuzora et al., 2013). The Tanzanian government organised the REsponse to ACcountable priority setting for Trust in health systems (REACT) intervention to establish the setting of health priorities. The intervention involved several stakeholders, the Council Health Management Team and Service Board, local government officials, NGOs, CBOs and faith-based organisations (FBOs), and health workers from both public- and faith-based health facilities. Data were collected via analysis of documents and interviews with key officials, health workers and representatives of all targeted marginalised population groups: women, youth, elderly, disabled and people living with HIV/AIDS. While the exercise was challenging, some key insights were raised by community representatives, such as the poor quality of services in the health facilities, poor language skills of the health workers, general cleanliness in the health facilities and the ineffectiveness of the drugs dispensed by the facilities. Respondents reported several improvements in priority setting and service delivery within the health system, due to the involvement of the community representatives. One of the target groups was women, indicating that gender was taken into consideration when designing the intervention.
Another intervention was a health promotion intervention from a community of Cape Verdean immigrants in the USA, which was part of the national health programme (De Jesus, 2009). Health promoters are health workers from within the community who work with health-based CBOs and take an active role to raise awareness of health issues and provide knowledge and limited service delivery to the community. A qualitative analysis was conducted to explore the ways Cape Verdean health promoters described their health promotion practices to local women. It was found that the quality of their relationships with community women differed significantly from those with ‘mainstream’ health workers, as they were able to mutually engage with each other more than ‘traditional’ health professionals are able to. The importance of purposefully sharing information about their lives and experiences as a way of building mutual relationships with the community women was found to be important. The findings indicate that strengthening community supports (e.g., community health promoters, social networks and CB coalitions) is vital to supporting individuals’ health, and health promoters are critically important to the goal of providing culturally responsive health promotion strategies to marginalised women.
Another significant study that depicted how research evidence on mental health was incorporated into policy comes from Vietnam (Harpham & Tuan, 2006). Until 2004 in Vietnam, mental healthcare was limited until a local NGO—Research and Training Centre for Community Development—presented its findings on mental illness to a meeting of the National Assembly’s Parliamentary Commission for Social Affairs. They found a higher than expected prevalence of depression, anxiety and suicide ideation among young mothers and children. A study found that 33% of women attending general health clinics in Ho Chi Minh City were depressed, and 19% explicitly acknowledged tendencies toward suicidal ideation. Another survey found a 20% prevalence of depression or anxiety among mothers of 1-year-olds (in both rural and urban areas) and 20% prevalence of mental health issues among children. The NGO lobbied for policy changes along with their own outreach efforts, and the government agreed to screen pregnant women and children for mental illness in order to implement early detection and treatment policies. Education about mental health was also decided to be incorporated into early childhood development programmes and a CB intervention programme to treat people with mental illness was planned.
A CB participatory research project involving women at risk for diabetes and hypertension in a US state was included in the review (Harvey et al., 2009). The Healthy Connection project was built on an existing CB participatory research initiative—the East Side Village Health Worker Partnership—which focused on improving the health and well-being of women and children by addressing the social determinants of health. Initiated in 1995, the federal programme collaborated with representatives from local CBOs, healthcare and state agencies, academic institutions and community members. Village Health Workers included in the intervention were suggested the use of House Parties—defined as small, informal gatherings of community residents—to provide screening and to promote cardiovascular health and type 2 diabetes prevention among women. A participatory process was used to recruit AA and Latina community residents for positions as CHWs, who helped develop and circulate recruitment flyers widely through churches, neighbourhood city halls, community organisations, etc. Results of the study suggest that the CHWs were effective in reaching women at high risk of hypertension and type 2 diabetes for screening and dissemination of health information.
Faith-based Interventions
Another path by which community knowledge has been mainstreamed into public health programmes is through intervention by FBOs, since they are often in close touch with the communities they serve. Four articles in this review are on faith-based interventions, and they also have a gender component.
Flórez et al. (2020) conducted a review of 43 studies where the church has been used as a means to improve knowledge and health outcomes. Several studies showed a significant impact of church-based interventions on obesity, albeit with limitations. The sample size in these studies varied significantly, especially for women. In all but one of the reviewed articles, more than half of the sample consisted of females.
Derose et al. (2019) undertook a study that did not focus on a specific health outcome, but instead examined the governance structure, identified a health priority for partnership, characteristics of congregations and lessons learned. With this objective, they found that partnering with church congregations is a feasible strategy for addressing and reducing health disparities. It also brings forth the difference in participation rates among women in the AA and Latino communities, while also pointing out that a large proportion of the sample was female. Local government officials and the executive director of the network of community health centres in the area were included as members of the steering committee, which provided network support and helped to leverage assets.
Husbands et al. (2021) used a church-based intervention (Black PRAISE) to promote awareness and stigma reduction associated with HIV. It uses booklets, videos and sermons by pastors to educate congregants and understand their perspectives on HIV and also conducts interviews to gather individual perceptions regarding HIV. In-line with the sample distribution found in previous studies, 75% of the congregants were female, though the sample size is small (18 participants consisting of 6 pastors and 12 congregants). This article suggests that a CB approach is effective for both awareness and stigma reduction on HIV. It is worth mentioning that many of the individuals interviewed recommended partnerships with local organisations, while also involving organisations at the grassroots and political levels to mobilise capacity building for HIV-related issues. Robillard et al. (2020) similarly stated that community engagement, by incorporating a story-writing component, is an effective means to promote HIV prevention. However, this study employs a small sample of women, bringing into question both its internal and external validity. They used a community engagement approach wherein they organised a community advisory board that included members of the local health department.
Discussion and Conclusion
Overall, this review identified three types of interventions in the health sector where community knowledge has been mainstreamed into government health programmes. Interventions where local NGOs, CBOs, development agencies or FBOs carried out interventions based on their knowledge of the community and then used the results to lobby health ministries to institutionalise new policies or programmes Interventions carried out by government health programmes that have acknowledged the role of community participation and collaborated with local NGOs and CBOs to introduce elements of CB participatory research into the intervention design Interventions by government health programmes where community participation has been incorporated into the intervention with the inclusion of CHWs.
While these interventions were often not explicit about a gender-justice framework, they had elements of a gender-sensitive approach. Some of the reviewed interventions also incorporated more than one of the above approaches.
An example of the first type of intervention is the Vietnamese NGO Research and Training Centre for Community Development, which gathered findings on the prevalence of mental health in Vietnam and presented the findings to a Parliamentary Commission for Social Affairs. They framed mental illness as a poverty-related issue and pushed for the development of guidelines for a national mental health programme (Harpham & Tuan, 2006). While this intervention did not start with a gender angle, the data gathered pointed to young mothers’ needs for mental illness interventions. Harpham and Tuan (2006) noted that the intervention was successful because the NGO was able to establish its own credibility through prior effective interventions, present solid data to policymakers, link the agenda of mental health to poverty and time the meeting to coincide with a new planning cycle in parliament. All these factors play an important role in successfully lobbying for change.
An example of the second category of interventions where women were one of the five target groups is the REACT project in Tanzania, where the government collaborated with a series of organisations and community members to set health priorities in the area (Kamuzora et al., 2013). Following the intervention, an evaluation survey was conducted, and respondents reported that there had been improvements in priority setting and service delivery, which the majority attributed to the involvement of community representatives. The study also suggested that although the national environment at the time had been favourable for policy changes, it was not until community representatives were involved in priority setting that positive outcomes were seen. This example highlights the critical role that is played by community representatives in making their problems heard.
An example of the third category is the intervention with health promoters in Cape Verdean immigrant communities in the USA (De Jesus, 2009). The health promoters interviewed in the study reported that developing mutually engaging relationships with community women with whom they worked was key in promoting women’s health. There has been a lot of evidence that reported that health promoters and other cadres of CHWs are critical for addressing the gaps in health systems (Afzal et al., 2021), and CHWs have been adapted into health programmes in several countries.
All the interventions in this review have shown that health outcomes, perception and beliefs can be impacted using community engagement and involvement. However, the review did not find many studies where gender was considered from the start of the intervention design. The RISHTA programme from India, which built an intervention focused on the reduction of HIV/STI transmission risk within existing cultural and gender norms, is one example of an intervention where the gendered context was addressed and embedded within the intervention right at the outset (Kostick et al., 2011). For others, gendered health outcomes were an important outcome, if not the primary goal.
Involving influential individuals can be key in certain instances, such as the study in China where clan leaders were trained to give educational messages on ANC (Ma et al., 2018). Faith-based interventions, which involve the government, are important because they can potentially include all members of a single faith, irrespective of gender and other socioeconomic factors. However, if participation is voluntary, unless a specific gender concern is incorporated in the programme, there is a chance of non-participation by the key affected groups. Furthermore, some studies show that the lack of ethnic diversity in a sample may limit the relevance of the outcomes. Hence, the external validity of such interventions, which involve community members, may be in question as the context can become an important determinant of the outcome.
The behavioural impact of an intervention may be different depending on the environmental, cultural or religious context. Such interventions can surely change perceptions and beliefs, as is evident from the HIV intervention among AA women in the USA, which devised a culturally specific intervention based on storytelling (Robillard et al., 2020). The study reported that interventions, such as this, have resulted in increased knowledge and greater intentions around protective behaviour, decreased sexual risk behaviour and stigma reduction among HIV-positive women, especially in AA audiences. Whether this behavioural change can improve health outcomes or change perceptions and beliefs on public health use may depend on various aspects, as mentioned above. One criticism is that it is not clear in a lot of the included studies whether and how evaluation of the interventions was done, and if feedback from the planning and priority-setting meetings was shared with the concerned communities.
Knowledge, perceptions and beliefs are important aspects with reference to small or under-represented communities. These beliefs may hinder the uptake of modern health system technology. The resulting low uptake by such communities may be addressed by involving local traditional methods. Involving influential local leaders may improve uptake by changes in perceptions; however, institutional inclusion of traditional forms of medication can improve the rate of uptake, as in the health programme from Ecuador, where traditional beliefs, knowledge and practices are formally integrated into the Ecuadorian health system through TBAs (Gallegos et al., 2017). The study reports that an accompanying TBA can be helpful in improving the rate of public healthcare system usage.
In conclusion, while the evidence is not exhaustive, it does enable us to tentatively conclude that government involvement with organisations that work with communities makes a difference to health service utilisation and health outcomes across the board, especially if the lessons are incorporated into interventions, programmes and policies. The inclusion of traditional knowledge, perceptions and beliefs is important for interventions to be effective, especially for communities with little to no exposure to public health systems.
However, the review also indicates that this translational stakeholder–policymaker relationship is a generally under-researched area, and definitely in the context of gender and health. Furthermore, most of the gender focus has been on women, and there are very few studies that have included specifically other genders—especially men—in discussions and evidence gathering on translating community knowledge for policymakers. The most inclusive set of interventions to date that have used the translational potential of community knowledge and evidence for policy action remains interventions around HIV/AIDS. This also indicates that in areas of health that are not obviously or apparently gender-focused, one might find a dearth of interventions that have been able to translate community evidence and knowledge into institutionalised government action and policy formulation.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
