Community engagement and involvement in managing the COVID-19 pandemic among urban poor in low-and middle-income countries: a systematic scoping review and stakeholders mapping

ABSTRACT Background Community engagement and involvement (CEI) was crucial for the COVID-19 pandemic response, particularly among the urban poor in low-and middle-income countries (LMICs). However, no evidence synthesis explores how CEI can benefit public health emergencies. Objective We conducted a systematic scoping review of the CEI with an emphasis on stakeholder identification, accountability mapping, the support system, and the engagement process among urban poor populations in LMICs during the COVID-19 pandemic. Methods We searched eleven databases, including PubMed, Embase, Web of Science, and CINAHL, following the PRISMA-2020 guidelines to find articles published between November 2019 and August 2021. PROSPERO registration No: CRD42021283599. We performed the quality assessment using a mixed-method appraisal tool. We synthesized the findings using thematic framework analysis. Results We identified 6490 records. After the title and abstract screening, 133 studies were selected for full-text review, and finally, we included 30 articles. Many stakeholders were involved in COVID-19 support, particularly for health care, livelihoods, and WASH infrastructure, and their accountability mapping by adopting an interest – influence matrix. This review emphasizes the significance of meaningful CEI in designing and implementing public health efforts for pandemic management among urban slum populations. The interest – influence matrix findings revealed that specific community volunteers, community-based organizations, and civil society organizations had high interest but less influence, indicating that it is necessary to recognize and engage them. Conclusion Motivation is crucial for those with high influence but less interest, such as corporate responsibility/conscience and private food supply agencies, for the health system’s preparedness plan among urban populations.


Background
Community engagement and involvement (CEI) are critical to achieving the Sustainable Development Goals (SDGs). CEI addresses the issues of the specific community including behavioral, cultural, and social factors, health system determinants, health prerequisites, and upstream health driving forces [1,2]. The World Health Organization (WHO) defines community engagement as establishing relationships that allow stakeholders to collaborate to address health-related issues and promote wellbeing to achieve good health impact and outcomes [3]. The WHO's 13th General Programme of Work (2019-2023) aims to improve the health and wellbeing of the community by strengthening CEI [4]. Moreover, CEI refers to the involvement and participation of individuals, groups, and structures within the social boundary in decision-making, planning, design, governance, and service delivery [5]. The four pillars of CEI approaches are communityoriented, community-based, community managed, and community-owned [1]; all of which are crucial for the improved health status of the vulnerable population.
In 2015, 54% of the world's population resided in urban regions is gradually increasing [6]. According to the United Nations, more than 90% of expected urban population growth would occur in low-and middle-income countries (LMICs) [7]. Hence, the CEI is crucial to understand and successfully implement various community programs such as health, livelihood, water, sanitation, and hygiene [8].
The COVID-19 pandemic has claimed countless lives and infected individuals and has had diverse effects on communities worldwide [8]. COVID-19 is more likely to infect displaced and underprivileged populations like the urban poor, where the community support system would play a vital role for disease prevention and livelihood support [5]. The public health incidents demonstrate the significance of context-appropriate CEI approaches, including community participation, for outbreak containment [5]. Recent global data have shown the importance of community health workers (CHWs) and community involvement during the COVID-19 pandemic. In the case of LMICs, however, to our knowledge, no evidence synthesis explores how CEI can benefit human public health emergencies, such as pandemics among the urban poor. Therefore, we conducted a systematic scoping review of the CEI with an emphasis on stakeholder identification, accountability mapping, the support system, and the engagement process among urban poor populations in LMICs during the COVID-19 pandemic.

Search strategy and selection criteria
A thorough search was conducted on eleven scholarly online repositories (PubMed/MEDLINE, Embase, Web of Science, CINAHL (EBSCO), ProQuest, Cochrane, Epistemonikos, WHO Global Index Medicus, MedRxiv and BioRxiv, 3ie Impact Evaluation Repository, and Google scholar). Primarily, we created a broad search using the terms: slums, COVID-19, LMICs (based on World Bank classification) [9], and community engagement and involvement. The inclusions and exclusions criteria were provided in Table 1.
We reported this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guideline [10] and the protocol is registered on PROSPERO (CRD42021283599).
All curated studies were then imported into EndNote X8 software to identify and remove duplicate records. Title and abstract screening of included articles were done by three reviewers independently using Rayyan software. We selected all primary (qualitative quantitative and mixed-method articles) peer-reviewed articles. Commentaries, editorials, perspectives, reviews, and any non-COVID-19 studies related to community engagement and involvement (CEI), non-LMICs, and settings other than slums were excluded. The full-text screening was done by two reviewers (MRS and SN) independently to ensure compliance with the study's objectives. We excluded articles that did not include CEI data during the full-text review.

Data extraction and synthesis
We extracted quantitative data in Microsoft Excel using a standardized template. The data included the study type, the country, the types of urban poor, the data collection method, type of stakeholder, and type of support provided. Two reviewers separately extracted data, then cross-checked and compiled it by a third reviewer.
We synthesized qualitative findings using a thematic framework analysis approach. The authors thoroughly reviewed the selected studies, and finally, developed a framework for data coding interestinfluence matrix. We coded the data and extracted the key findings using MAXQDA Analytics Pro 2022. We used an interest-influence matrix for stakeholders mapping and engagement in community services among the urban poor during the COVID-19 pandemic. Influence represents a stakeholder's power to resist, and interest indicates stakeholders' likely concerns. Prioritizing stakeholders requires determining their interests and influence. Low-interest, lowinfluence stakeholders are unimportant to the program, but monitoring them may be necessary for the future. High-interest, low-influence stakeholders are more involved. Despite their interest, they have little power to change things; this group's engagement strategy is proactive communication. Low-interest, high-influence stakeholders aren't interested; however, this group is influential. Keep this group satisfied by holding regular meetings. The high-interest high-influence group has much interest and influence; this group's strategy for managing stakeholders is active collaboration [11].

Quality assessment
Quality assessment of included studies was done by two reviewers using the mixed-method-appraisal (MMAT) tool [12] and disagreement was settled by a discussion with a third reviewer.

Results
We identified 6490 records. After removing 1482 duplicates, 5008 articles were selected for the title and abstract screening. Based on inclusion criteria, we excluded 4875 studies. We reviewed the full texts of 133 studies. Finally, 30 articles included -nine quantitative, thirteen qualitative, and eight mixedmethod studies. The steps involved in study selection are depicted in the PRISMA flow diagram (Figure 1). The characteristic of the included studies is provided in Table 2.
We did not find any studies that reported on low interest and low influence stakeholders for community participation among urban poor populations during the pandemic. 'The majority of participants said they were given soap or hand sanitizer, followed by meals. When asked what their single greatest unmet need was, the top two responses were food (94% in April, 86% in May) and cash (45% in April, 48% in May). The government, non-governmental organizations, good Samaritans/corporate sponsorship, and religious institutions all donated items' [23].
'Members of non-governmental organizations came to see us on a regular basis and brought us dry food and water bottles, as well as transporting a few patients to hospitals' [38].

Support domains and community engagement approaches
The studies identified health, livelihoods, water, sanitation, and hygiene (WASH) as significant support domains. Twelve studies (40%) described the CEI in healthcare services, such as preventative and curative services. Ten studies described CEI as a means of sustaining livelihoods during pandemics. Approximately four studies featured CEI support for health and livelihood, and one study each described health and WASH and livelihood and WASH.

Healthcare support
For healthcare support, urban slum stakeholders organize isolation or quarantine centers, facilitate the screening and diagnosis of COVID-19, and help Many studies showed that it proved challenging to maintain home isolation, quarantine, and physical distance guidelines for COVID-19 prevention among urban slum dwellers due to insufficient housing and WASH infrastructure and high population density. By transforming Anganwadi centers into COVID-19 care facilities, city officials constructed institutional quarantine for migrants [16]. About half of the slums used community places such as schools and meeting rooms to isolate themselves; nonetheless, some larger houses adopted a new furniture layout but entirely sacrificed lighting and ventilation for COVID management [26]. In Mumbai, local officials took the initiative to set up quarantine facilities in nearby schools, sports complexes, marriage palaces, and community halls to provide critical care in collaboration with private hospitals and nongovernmental organizations [14].
In many countries, the city officials, medical professionals from government hospitals, community health workers, and community volunteers were engaged in surveillance, contact tracing, and hygiene and preventative awareness initiatives related to COVID-19 [16,18,31]. Community action groups in Malvani assisted municipal employees in addressing the difficulty of tracking and detecting positive COVID-19 cases in densely inhabited slums. To help restrict the spread of infection, government officials tattooed the palms of affected people with the help of local community volunteers [22,30]. Community action groups assisted local NGOs in developing COVID-19 awareness, control, and prevention messaging in local languages that were simple to grasp, contextualized, and acceptable to the communities [30]. The community health workers raised community awareness about positive cases and guidelines. They also advised slum dwellers to avoid congested routes or places [14,21]. Community health professionals began raising community awareness in Thailand and Kenya, but the primary challenges were convincing people to collaborate and probable violence from some community members [32].
The health facility focal points and community health workers enabled referrals for people with flulike symptoms and positive cases, either home care or admission to healthcare facilities [18,21]. Patients were referred to government hospitals, community clinics, and mobile clinics, and medicine was given to them [21]. Many non-governmental organizations (NGOs) in Bangladesh offer emergency care [24]. Community health professionals in Kenya, Nigeria, and Pakistan provided screening services through fixed/mobile primary healthcare clinics [24]. Community health workers in India recognized cases and followed up on symptomatic patients, in addition to other routine health programs such as Urban Health and Nutrition Day and Routine Immunization Day [16].

Livelihood support
Economic difficulties during COVID-19 contributed to the food insecurity [19,26] and poor quality of life [28]. About sixty percent of households chose to cut back on food, while sixty-five percent skipped meals. Approximately 5% sold home items to finance foodrelated expenses. Many relied on minimal aid from non-governmental organizations [19,26]. Furthermore, closing public schools that provided free lunches, loss of income, and rising food prices were obstacles for joint families [27]. They believed they would die of hunger rather than the virus, so they borrowed money from relatives or neighbors to purchase milk and bread for their children rather than masks, gloves, and expensive sanitizer [27]. Few urban women established modest businesses, such as tiffin booths, relying on government subsidies to support their families [16,19].
The homeless and street dwellers hoarded the food donated by local NGOs and handed it to them [38,42]. Numerous family members borrowed money to meet their fundamental wants [19,26,28]. Many urban poor relied on money to endure the lockout [26,27].

WASH support
The lockdown regulations have stressed the strained mobile toilets (often known as 'duped chemical toilets') [39]. The number of portable toilets has been increased to fifty to serve a larger population. People use nearby bushes as toilets [39]. The slum community was promptly supplied with piped water, making it easier to wash hands frequently and maintain a clean home. Using sanitizers and masks provided by the government [28,43], urban residents could engage in cleanliness activities. At various times, 91% of slum residents utilized soap and water for hygiene routines supported by NGOs [36,39]. During the same activities, those who did not use soap opted to wash their hands with running water [16]. Due to the paucity of toilets, baths, and water sources, only 10% could afford to construct improvised toilets by borrowing from family and friends without NGO or government assistance/loans/subsidies [26].
Many urban poor populations could not buy gloves, masks, and disinfectants and had limited access to water, making it impossible for them to maintain COVID preventative measures [26]. Others utilized homemade masks or received free masks and soaps from non-governmental organizations due to the lack of affordability [26]. Nonetheless, 95% of residents stopped using the masks and soaps after NGOs ceased providing them [26]. Most relied on government and nongovernment organizations for sanitizers and masks to overcome this condition [28,43]. They also chose an alcohol-based hand-washing liquid [26].

Discussion
This study systematically reviews community engagement and involvement (CEI) in managing the COVID-19 pandemic among the urban poor in LMICs. It defines the many stakeholders involved in COVID-19 support, particularly for health care, livelihoods, and WASH infrastructure, as well as their accountability mapping by adopting an interestinfluence matrix [high interest (+), strong influence (+), low interest (-), and low influence (-)]. Typically, community engagement entails spending time with communities to establish trust and guarantee that community representation structures are inclusive and responsible. The CEI entailed the participation of public and private stakeholders, from the local to the international level, primarily the local community volunteers, to support the community during any humanitarian disaster. The evidence suggests that motivation is an important determinant of effective CEI.
Past pandemic responses to Ebola outbreaks have highlighted the significance of community engagement for the successful long-term management of infectious disease epidemics [44,45]. Experience from the 2014-2015 Ebola outbreak and other epidemics has highlighted the crucial role of community leaders as conduits for effective communication and meaningful community engagement in infection identification and control efforts [46]. The value of understanding local customs, beliefs, knowledge, and practices and the necessity of including meaningful community engagement with proven disease control techniques in disease prevention and control initiatives.
Community engagement for health is the process of establishing relationships that allow members of a community and organizations to collaborate to address health-related issues and promote well-being to produce good health impacts and outcomes [1]. The community is not a passive player in community engagement for health; instead, it plays an active role in addressing and resolving health challenges [2][3][4]. The COVID-19 pandemic has significantly influenced the health, lives, and livelihoods of individuals and communities worldwide, especially the most vulnerable population [47]. Even in nations where the pandemic has been successfully managed, communities that are underprivileged, marginalized, and alienated from most of the population remain at a higher risk due to their low income, poor living conditions, or lack of access to health care [46]. Community participation helps to maximize the effectiveness of COVID-19 readiness, response, and recovery activities at the community level to prevent and contain transmission [4]. Community engagement can also help the health sector prepare for and respond to the needs and problems of various communities in contextually appropriate ways, as well as address health and gender disparities during and after the pandemic. As a result, community governance institutions should be strengthened to leverage existing processes and create capacity among national and local stakeholders.
Community engagement is critical during an emergency and crucial for ensuring culturally relevant responses [5,48]. Populations at risk may not have enough access to government and social services, especially during health crises. They are frequently excluded from the national, subnational, and local response and relief programs. Additionally, these vulnerable populations may have had harmful interactions with health and other authorities, resulting in a lack of trust in institutions. In addition, many disadvantaged groups are not captured by existing institutional frameworks [1,4]. This review highlighted the importance of active engagement of community health professionals in surveillance and data gathering to enhance the community-based participatory techniques [1,4,5,48]. The expertise of recognized community organizations is required in order to support vulnerable populations, maintain the delivery of major services, provide critical resources to engage and empower them. Regional and municipal administrations must undertake infection prevention measures and provide essential public services. As COVID-19 grows, more families, especially urban poor, have trouble meeting basic health needs. During COVID-19, the government considers expanding community-level case-management services and innovative methods to provide social support for vulnerable populations. Reduce barriers for slum and homeless isolation in community centres and schools.
Community engagement facilitates the formation of social dynamics based on power and control that perpetuate the marginalization of groups. The legitimacy of the actors involved in mobilization and decision-making must be acknowledged by the rest of the community [48]. It is of the utmost importance to comprehend and support the inventiveness of community partners and key stakeholders as they devise means to engage with their people during the pandemic. In addition to leadership, buy-in for many community activities, maintaining a balance between power and the representation of many viewpoints is also essential [1,4,5,48].
The most significant reason for identifying and comprehending stakeholders is that it allows for their active participation in community services.
The key stakeholders, according to this review, are usually government officials and policymakers such as legislators, mayors, city/town councilors, and local NGOs. However, this review portrayed that during an emergency or in the case of any community development initiative, the media and community leaders are the major motivators and liaising groups among community members, in this case, the urban poor population, and government agencies. Community stakeholders such as neighborhoods, community development groups, development organizations, and NGOs frequently serve as immediate service providers for emergency preparedness and key motivators for community awareness on adherence to emergency guidelines . Hence, facilitating highly engaged stakeholder participation in discussions is critical [16,21,24,[31][32][33]. Taking these actions before and during participant involvement will result in better stakeholder engagement and outcomes. Stakeholders often participate based on their interest in the community development program and ability to contribute; however, their involvement will also be determined by the extent to which the program outcomes will influence those being consulted [31][32][33][34]. Therefore, there is a urge for identification of motivational factors to ensure active and sustainable CEI during any emergency.
The first step toward a successful implementation of a CEI programme is to conduct an analysis of the various stakeholders. It is preferable that individuals, as well as private or public organizations and individuals or groups, who are involved in community development and service could be considered stakeholders [49]. According to an interest -influence matrix, the influence, and interests of diverse stakeholders are crucial for delivering effective services. Moreover, the motivation is key to continued stakeholder engagement with CEI. Ninety percent of the COVID-19 pandemic cases have been recorded in urban areas. Cities are bearing the brunt of the problem, with many suffering from overburdened health systems, insufficient water and sanitation facilities, and other difficulties [50]. The individuals living in slums have challenges in terms of livelihood, WASH, housing, and health care. Because of their living conditions -overcrowding, substandard housing, and shared toilets and water points -slums and informal settlements are not prepared to deal with the pandemic. Therefore, in order to combat the pandemic for the urban poor frequently encourage better CEI. This review showed that city officials, community health workers, police, the public health system, local and international NGOs, and the mass media all played critical roles in the prevention and rehabilitation of the urban poor population during pandemic; they were the highly influential and interested stakeholders [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]. Therefore, it is recommended to closely manage, engage, and motivate the above stakeholders for the purpose of the CEI sustainability for health system preparedness among urban poor. The local government also urged the CSR group and the private food agency to actively participate in CEI during the pandemic [13,23]. Even though this group is powerful or has a great deal of influence, they have little interest; consequently, for any future emergency preparedness plan, it will be required to maintain their satisfaction by holding regular meetings through orientation and awareness. On the other hand, although community volunteers, community-based organizations, and civil society platforms have a strong desire to serve the community, they have received little assistance or permission from the government [14][15][16]18,21,[23][24][25][26]29,30,[33][34][35][36][37][38][39][40][41][42]. Consequently, we may keep these parties in the loop, informing, engaging, and equipping them appropriately for involvement. We must adequately monitor the less influential and less invested parties [51].
This systematic review is one of its kind to entail the role of CEI for the urban poor using influence -interest matrix during a pandemic. It advocates strengthening of CEI to avert any crisis among the urban poor during pandemic or any other public health emergencies. This review is methodologically rigorous; however, very limited studies define the clear role definition of each stakeholder. Moreover, the findings from this review are limited to the urban poor residing in LMICs only, as the studies on urban poor from higher-income countries were not considered.

Conclusion
This review emphasizes the significance of meaningful participation and engagement of diverse stakeholders in designing and implementing public health efforts for pandemic management among urban slum populations. The interest -influence matrix findings revealed that specific community volunteers, community-based organizations, and civil society organizations had high interest but less influence, indicating that it is necessary to recognize, engage, and empower them. Similarly, motivation is crucial for those with high influence but less interest, such as corporate social responsibility and private food supply agencies, for the health system's preparedness plan among urban populations.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding information
This systematic review was funded by the UNICEF/UNDP/ World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland (Grant No: 2021/ 1086892-1/P20-00116).

Authors contributions
KCS developed the protocol. MRS, SD and SN completed the search, screened the articles for inclusion, and extracted the data. MRS, SN, and KCS extracted the data and synthesized the findings, interpreted the results, and drafted the manuscript. MRS and SN completed the risk of bias assessments. SP and MOB interpreted the results. All authors critically revised the manuscript. All authors approved the final version.

Data availability statement
Data will be made available on request.