Facilitators and barriers to engaging communities in health service research on dengue control in Indo-Pacific region: a systematic review

Abstract

Background

Dengue is a public health problem in the Indo-Pacific countries. There are concerns over the facilitators and barriers to community engagement in health service research aimed at dengue control. The objective of his study was to identify and synthesize facilitators and barriers to community engagement in health service research aimed at dengue control.

Methodology

The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) checklist was used to perform this review. Health-related databases including PubMed, Ovid, and Google Scholar were searched for relevant studies. A consolidated framework with five domains was developed after undertaking a six-phase reflective thematic assessment of the data.

Results

Thirteen studies were identified, spanning eight low-and middle-income countries of the Indo-Pacific region including Cambodia, India, Indonesia, Myanmar, Philippines, Sri Lanka, Thailand, and Vietnam. The studies in this review covered the period from 2002 to 2021. A broad range of study designs and objectives were revealed across these 13 studies. An array of communities such as the local government, project-related health staff, local health services staff, community leaders, local communities/residences/general public, heads of households, community health volunteers, school teachers, and schoolchildren participated in these dengue related studies. The five Consolidated Framework for Implementation Research (CFIR) domains of ‘intervention characteristics’, ‘inner setting’, ‘outer setting’,’ individual characteristics’, and ‘program implementations’ were used to identify and describe barriers and facilitators.

Conclusions

The findings indicate a range of barriers and facilitators to community engagement in dengue control in the selected LMIC in the Indo-Pacific countries. Future health services research on dengue control approaches should be carefully planned, methodologically constructed, aligned with community engagement principles, and involve considerable community participation at all stages of the research.

Background

Dengue fever/dengue haemorrhagic fever (DF/DHF) is one of the neglected tropical diseases. This infection is caused by one of the four closely related dengue virus (DEN) serotypes (DEN-1, DEN-2, DEN-3 and DEN-4). As such, there is extensive cross-reactivity in serological tests, but infection with one serotype does not provide cross-protective immunity against the others. Hence, individuals living in an endemic area can be infected with each of the four dengue serotypes during their lifetime [1]. Approximately half of the world’s population is at risk of dengue fever/dengue infection, with 5.2 million recorded cases in 2019 alone [2]. According to the WHO, dengue is endemic in 129 nations, with the Americas, South-East Asia (SEA), and Western Pacific areas being the most seriously affected. According to the reports, Asia accounts for almost 70% of the global disease burden [2, 4]. To date, there is no specific treatment for dengue/severe dengue [2]. The first dengue vaccine was licenced in 2015 but its performance depends on serostatus [5]. One of the five technical elements of the WHO Global strategy for Dengue Prevention and Control 2021–2030 is engaged and mobilized communities [2, 6].

Many health services, particularly in low-and-middle-income countries, operate with limited resources. Community engagement is often required and used to complement the government services, increasing access to resources such as human, transport, labour as well as drawing upon local knowledge and experiences to enhance the effectiveness of the health programmes [7]. Community engagement is increasingly promoted in health services research (HSR), but the concept itself, and how it is best implemented in practice engagement, is understudied and contested [8]. HSR is defined as “of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations” [9].

Community engagement in research stems from demands by community leaders, policymakers, and funders for meaningful community involvement to address health problems facing communities [10]. Numerous reviews have focused on community engagement in general health research [11,12,13], in which process or health outcomes were assessed.

Taken together, the purpose of the current study was to address the following question: What studies are available that identified facilitators and barriers to community engagement in HSR on dengue prevention and control? Hence, our objective was to identify and synthesize facilitators of and barriers to community engagement in HSR aimed at the prevention and control of dengue based on original research studies conducted in low-and middle-income countries (LMICs) of the Indo-Pacific region (table s1).

Methods

This systematic review adhered to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) (checklist s1). The current study was a part of larger study supported by TDR (the Special Programme for Research and Training in Tropical Diseases, cosponsored by UNICEF, UNDP, the World Bank and WHO) [Project ID AP21-00287]. A protocol is available from the authors on request.

Study search

One investigator (NHH) searched studies in the health-related databases including PubMed, Ovid, Google Scholar, Cochrane Collaboration Library, Database of Abstract of Reviews of Effectiveness. The search was crossed checked by the second investigator (CN). The keywords with appropriate Boolean operators were used: “community engagement” “community participatory” “action research” “participatory research” “participatory action research” “community-based research” “dengue” “dengue fever " “dengue haemorrhagic’’ “dengue shock syndrome” “barriers” “enablers” “facilitators”. The search was extended to System for Information on Grey Literature including Social Science Research Network and Evidence for Policy Practice Information and Coordinating Community engagement (EPPI-Community engagement), Regional Bibliographic databases (e.g. Australian Education Index, AEI https://www.ace.org/my/library/Australian-education-index-aei). Search terms for Ovid are available in table s2. The search was limited to English language publications between 1990 and January 2023 in LMICs in the Indo-Pacific region (table s1).

Eligible criteria

Individual studies were selected, if they.

• 1. conducted in the LMICs of the Indo-Pacific regions, regardless of study designs.

• 2. described community-based interventions or program in the primary health care settings on dengue/ severe dengue in which communities were engaged. Communities are as defined in the primary studies.

• 3. targeted the health service need within the areas of dengue fever/severe dengue.

• 4. reported at least one barriers or facilitators to community engagement as contextual factors.

Barriers and facilitators in this review were based on the definition as described elsewhere [11] with necessary modification for the focus of this review. Barrier is a factor that hinder progress towards community engagement. Facilitator is a factor that promote community engagement. Put simply, barriers and facilitators are factors that make community engagement more difficult or easier to achieve [14]. Community was defined as a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings [15].

Studies were excluded, if they did not include participants from the specific LMIC in the Indo-Pacific region. Letters, case series, abstract/conferences proceedings without complete data, preclinical studies, experimental interventions with clinical outcomes or epidemiological studies that focus on the distribution of diseases were also excluded.

Data collection

Two investigators (NHH, CN) independently selected the included studies using pretested data collection sheets. The two investigators independently collected the textual data relevant to our review question and objective. Collected information included study country, setting, type of intervention, study objectives, funding source, description of the HSR (structure, process, outcome assessment), description of the community, and facilitators/barriers encountered.

Any disagreements in these steps were settled by discussion with the third review author (MAW or WST).

Data synthesis

Descriptive statistics for the important variables and reported as frequency/percentage (e.g., frequency of barriers) for categorical data, and mean (standard deviations, SD) for continuous data were undertaken. We planned to do meta-analysis if two or more studies provided numerical data of similar outcomes. However, due to a paucity of data in the selected studies, we were not able to undertake a meta-analysis.

Assessment of the methodological quality

The methodological quality of the included studies was evaluated using the “Risk Of Bias In Non-randomised Studies-of Interventions” (ROBINS-I) tool [16]. The ROBINS-I tool captured seven domains of bias (i.e., confounding, the selection of participants, measurement/classification of interventions/exposures, deviations from intended interventions/exposures, missing data, the measurement of the outcomes, and selection of the reported results). Two investigators (WST, CN) independently assessed the methodological quality, and any discrepancies were settled by discussion.

Identification of barriers and facilitators to community engagement in HSR

To synthesise results across studies, we adopted standardised terminology for terms such as leader, stakeholder and staff, adapted from the Cooper [17] with necessary modifications for the focus of the review, namely community engagement. In the current review, leaders are those in management or leadership positions or senior positions responsible for coordination of the community engagement activities for DHF control. Staff refers to all staff within an organisation across the different levels of hierarchy, and stakeholders refer to any individuals or partner organisations with a role in the intervention.

Synthesis of data involved the two steps such as thematic analysis and mapping of thematic synthesis into a determinant framework (i.e., Consolidated Framework for Implementation Research (CFIR)).

Thematic analysis

First, we undertook the six phases of reflexive thematic analysis (RTA): (1) familiarising oneself with data; (2) generating codes; (3) constructing (initial) themes; (4) reviewing potential themes; (5) defining and naming themes; (6) producing the report [13]. NHH started following familiarisation of the relevant data through screening, selection, and then multiple readings of the studies identified during the stage of study selection. The two investigators (CN, NHH) developed consensus on data coding practices in phase 2. NHH generated initial themes in phase 3, and initial themes were reviewed and developed during phase 4 by CN, and were consulted with MAW, who has extensive experiences in qualitative studies. Additionally, two other investigators, WST and HHA, gave feedback on the grouping and naming of themes in phase 5, and finally produced a report in phase 6. Following each phase of RTA reinforced the need for investigators to have deep immersion into the data as well continuous reflexive accounts [18].

Secondly, the report extracted from thematic analysis was mapped into the five domains of CFIR framework. Details of the CFIR framework are available elsewhere [19].

Results

Search outcome

Figure 1 presents the study selection process. Of the 385 records identified, 79 duplicates were removed, and 274 titles and abstracts were screened. Of these, 34 studies that were deemed relevant were assessed in full-text and a final of 13 studies [20,21,22,23,24,25,26,27,28,29,30,31,32] met the inclusion criteria. The reasons for exclusion of 21 studies are provided in Table s3.

Fig. 1

Study selection process

Characteristics of the included studies

Table 1 provides the characteristics of the included studies. They were conducted across eight countries in the Indo-Pacific region (i.e., Cambodia, India, Indonesia, Myanmar, Philippines, Sri Lanka, Thailand, Vietnam). Of these eight countries, the majority are lower-middle income countries (6/8, 75%) such as Cambodia, India, Myanmar, Philippines, Sri Lanka, and Vietnam. Of 13 studies identified, the most frequent studies were conducted in Thailand [26, 29, 31] or Vietnam [24, 25, 30]. Three studies (3/13, 23%) were published in 2012 [23, 30, 32], while the earliest and latest studies in this review appeared in 2002 [24] and 2021 [31].

Table 1 Characteristics of the studies identified for this review

Several research designs such as three cross-sectional surveys [25, 28, 29], community-based interventions [23, 24, 32], or community-participatory (action) research [26, 27, 31], three qualitative designs [21, 22, 31], and one prospective experimental study [20] were implemented. A broad range of objectives emerged across these 13 studies in eight countries (Table 1). However, none addressed barriers/facilitators as the primary aim of the study, instead addressing these as part of the findings, or limitations.

Types of participating communities

A broad range of communities participated in these dengue-related studies, including local government, project-related health staff [23, 26], local health services staff including auxiliary nurse midwives (ANWS), accredited social health activists (ASHAs) [28], community leaders [22, 26], local communities/residences/general public and head of households [24, 27, 30], community health volunteers [22,23,24], school teachers and school children [22, 24], faith leaders [22], and multi-stakeholder partner groups [32]. Their participation was predominantly described as being participants involved in focus group discussions (FGDs) and/or in-depth interviews (IDIs).

Methodological quality

In terms of methodological quality, the studies were assessed to be at either moderate or high risk of bias in domain-based assessment; none of these studies were rated to be at low risk of bias. Overall, the quality of the studies was at moderate risk of bias with all 13 studies mainly due to the concerns over confounding bias and bias related to deviations from intended intervention (Fig. 2).

Fig. 2

Quality assessment of the studies

Barriers and facilitators

The organizing and grouping of the barriers and facilitators were identified using the five CFIR domains, namely intervention characteristics, inner setting, outset setting, individual characteristics and “programme implementation” (Table 2). In many instances, the opposite side of a problem, challenge, tension, or barrier was framed as a facilitating factor or ‘enabling factor’. For instance, having a variety of stakeholders involved allowed for the facilitation of a broad range of perspectives on the research topic. On the other hand, having low involvement of stakeholders involved in the pre-implementation requirements was viewed as an impediment.

Table 2 Summary of findings under CFIR Constructs

The following are outlines of the five CFIR domains, which were attributed to the barriers/facilitators mentioned in the studies selected for the current review. The respective constructs are presented in Table 2.

Intervention characteristics

The health issues that were the focus of the intervention to be accepted, adapted, tailored, refined, or reinvented to meet local needs was reported as barriers to community engagement in four studies (4/13, 31%) [27, 29, 30, 32]. For instance, the actual vertical nature of the health programme was a barrier to engagement, whereas having a more integrated service facilitated engagement [27, 32]. A low budget that was inadequate to undertake the duties required [30] or the perception that dengue control was solely a government responsibility [29] were identified as barriers.

Three studies (3/13, 23%) reported enabling factors [29, 30, 32]. The availability of the required materials from the local manufacturers [32], quality of materials [29], having an adequate budget, and having communities’ supporting any additional local costs [30] were identified as facilitating factors for community engagement in interventions. Moreover, the involvement of trained specific groups of ‘eco-health volunteers’, who were then engaged in regular dialogue with local community leaders and coordinators for mobilizing dengue vector control activities in their communities [32] was a facilitator.

Inner setting

Seven studies (7/13, 53%) identified challenges such as a lack of enthusiasm of the participating stakeholders, insufficient knowledge about the intervention, lack of incentives, inadequate networking and communications, concern about the extra workload, a shortage of human resources, and cultural barriers [22,23,24, 27, 29, 31, 32].

For instance, the extra workload was discussed as a barrier because the extra number of people participating created a larger population to serve by an already stretched number of staff [27, 29]. Another study described the issue of inadequate availability of human resources and vehicles for ward-based waste collections [32]. Limited stakeholder participation [31], and poor attendance at the project inception [23] were described as barrier to engagement in the project. Another study highlighted that cultural barrier such as using serial blood samples from an apparently healthy population were the culturally based resistance to the collection of blood [24].

Numerous factors that promoted community engagement were identified in nine studies, including the use of existing community networks and active communications between the researchers and the communities, the commitments of local leaders, the involvement of trained volunteers, faith leaders, and local schools to the intervention, and the availability of funding [21,22,23,24,25,26,27, 32]. For instance, ‘bench conferences in village setting as a means of actively communicating with the community [23], high-level stakeholder meetings [22], receiving pocket money as incentives [21, 24, 25], the commitments of the head of local authority such as mayor (Risma) [21], and the involvement of monks could transfer knowledge on dengue during ceremonial occasions [22] were enabling to community engagements.

Outer setting

Four studies (4/13, 31%) addressed various challenge such as the lack of local government commitments, volunteer attritions, frequent changes of local leaders, and heir accountability n under this domain [23, 27, 30, 32]. For instance, there were delays in launching he intervention due to political elections [27], a lack of local government leadership [23], frequent changes of the chairperson, and a lack of accountability of the ward’s People’s Committee [30], and attrition of volunteers and inadequate system for volunteers’ replacement [32] were also barriers to community engagements.

Within the outer setting, having sustained support and commitments and offering incentives for reporting were facilitating factors addressed in two studies [27, 32].

Individualised characteristics

An array of challenges including a lack of interest or enthusiasm within the target community, or lack of suitable skills/qualifications amongst the health staff providing the intervention, dependency of individuals, and community members having a sense of fear of the health providers/volunteers of engaging with communities were barriers to community engagement in four studies [23, 27, 28, 30]. For instance, when the community perceived hat dengue control was the city health officers’ responsibility [23] they were less engaged. The lack of suitable skills or experience included the language barrier [27], and the need for health workers’ knowledge and skills in persuasion and motivation, while working with the community [30] were described as barriers. A sense of fear of the ANWS and ASHAs in engaging communities was also reported [28].

On the positive side, the unique role of ward (community) leaders and their commitments, strong coordination with other stakeholders, and effective communication in local language proficiency seemed to be facilitating factors described in two studies [27, 32].

Processes of implementation

Six studies (6/13, 46%) reported numerous challenges such as lack of rules/regulations supporting engagement processes, lack of champions, difficulties arising due to frequent substitution of stakeholder’s representatives leading to lack of continuity and commitment, low involvement by the communities in pre-implementation activities as barriers to community engagement [20,21,22,23, 30, 31]. For instance, it was difficult to identify a suitable champion for strategies in dengue control due to low attendance numbers in the provided training [23]. The involvement of multiple stakeholders created a challenge in ensuring the sustainability of engagement in the intervention without the input of the research team [21]. Also, a lack of implementing rules and/or regulations [23], and difficulties encountered in encouraging the community to change [21] were barriers to community engagement in implementation.

Four studies (4/13, 31%) described the key facilitators under the domain of ‘process implementation’ [22, 27, 31, 32]. For instance, engaging stakeholders in pre-implementation activities or discussions during the process made empowered them to be self-reflective, which in turn assisted in conflict resolution and a better understanding of the objectives of the work and more competency in team work [31, 32] or codesign of intervention [22]. Also, recruiting and identifying the champions as the ambassadors of teamwork [27] was of paramount importance to operate in the community’s capacity.

Discussion

This review included 13 studies that fulfilled the criteria for inclusion, most of which came from lower-middle income nations in the Indo-Pacific region and contextualized a number of barriers and facilitators to implementing community engagement in HSR aimed at dengue control. Key findings were identified under the five CFIR domains, namely intervention characteristics, inner setting, outset setting, individual characteristics, and programme implementation. To our knowledge, this is the first review that has addressed barriers and facilitators to community engagement in HSR aimed at dengue control that used the CFIR domain in reporting. Studies included in this review were from the high burden Asian countries, as reported by WHO [2], reflecting a certain degree of geographic representativeness.

A published systematic review of the use of the CFIR domains reported that a comprehensive understanding of barriers and facilitators might serve as a means to improve the implementation of the intervention. However, there was a lack of international synthesis on this aspect [33]. The current review attempts to fill such gap in community engagement in HSR aimed at dengue control in the selected countries.

A key message derived from the current analysis is that there are challenges in conducting effective community engagement across all stages of the HSR process. There are concerns about where the priorities should lie. According to a published systematic review that addressed the benefits of community-based research, the partnership between researchers and communities fostered a process of co-learning and empowerment and made it easier for them to share knowledge, skills, capacity, and power with each other [35]. However, as mentioned in this review, the opportunity for co-learning was limited by the stakeholders’ lack of suitable participants. Some but not all studies included in this review addressed the challenges and opportunities linked to the five CFIR domains and underlined the value and implications of partnership synergy across various stakeholders.

The level of effectiveness of partner communication and the extent of stakeholder participation were the two distinct CFIR constructs noted as facilitators, and in the converse, obstacles that were most commonly described in this systematic review. Similar to a published systematic review of polio vaccination programs [37], the current review encountered three major obstacles: a lack of enthusiasm by stakeholders, a lack of incentives for community participation especially for volunteers, and insufficient staff in the government programs delivering the intervention. Therefore, as indicated earlier [14, 37], considering creative ways that motivate and encourage staff to visit rural areas and vulnerable groups may be the core for effective implementation. Additionally, this review identifies networking and communication as essential elements for community engagement. A published study suggested [37] that this kind of communication (via networking or local gatherings) would support the development of a new and deeper understanding of the issues by the stakeholders, supporting them to reflect on actions undertaken and information obtained and then to inform them about further action. To facilitate communication, language and cultural obstacles were identified as needing to be addressed, reflecting the necessity to focus on these, for example, by using a translator in all communications prior to implementation, in order to facilitate building and sustaining the desired partnerships.

Building capacity to improve health involves the development of sustainable skills, resources, and organizational structures in the affected and vulnerable communities [12]. A study on the assessment of community engagement in Partnered Mental Health Services Projects [36] reported that community engagement in research and partnership size impact both partnership functioning and outcomes. A well-functioning partnership will support synergy among the members of the partnership and affect outcomes.

Public Health implications

The findings identify studies that addressed a variety of barriers and facilitators to community engagement in dengue control of the LMICs in Indo-Pacific region. When considering ways to address the identified barriers as observed in our analysis, it was more valuable to focus on the use of scarce time and resources of the trained community members and health practitioners to involve them in interpreting and making sense of the data, as highlighted by Israel and associates [34, 35].

Research projects involving communities, such as dengue control in our study, require academic members to become part of the community and community members to become a part of the research team. This would have created a distinctive working and learning environment before, during, and after the research [11]. However, a published study has highlighted that while partnered research projects (a term used interchangeably with community engagement) have the potential to address pressing community health issues, there is little empirical evidence about the impact of the degree of community engagement in research on outcomes of the projects [36]. The studies identified for the present review did not explicitly discuss outcomes from community engagement, thus not addressing this gap.

Among the factors that motivate people to participate in health (and HSR) are wanting to play an active role in bettering their own lives, fulfilling social or religious obligations, feeling a need for a sense of community, and wanting cash or in-kind rewards [12]. Although not all factors were explicitly identified in the studies included in the review, some did report how the lack of cash incentives was a barrier.

Study limitations

We acknowledge some limitations. First, the search did not include studies that were published in languages other than English. Useful evidence in published or grey literature written in languages other than English could be overlooked because of information bias. Second, no information on gender-based community engagement was provided in the studies that we included in this review. As a consequence, there is a shortage of gender equity evidence in this review. Thirdly, due to a multi-context approach in data synthesis, the findings might be too general, overlook specific contexts, and blur the critical differences between the included studies.

Nevertheless, the current review has some advantages. This systematic review addressed the systematic collection of community input and experiences in dengue research. Studies of the eight endemic countries where dengue is a high burden were identified. The findings highlighted that community-based research recognizes social structures and social processes that support or develop community members’ capacity to collaborate to improve health [37]. By utilizing a CFIR determinant framework, the findings contribute to the limited body of knowledge from an implementation perspective. The factors identified in the present review may assist researchers, policymakers, volunteers, and community members in developing better plans and designs for community engagement in health service research on dengue control programs.

Conclusions

The findings indicate a range of barriers and facilitators to community engagement in dengue control in the selected LMIC of the Indo-Pacific countries. Future health service research on dengue control approaches should be carefully planned, methodologically constructed, created in accordance with community engagement principles, and involve considerable community participation at all stages of the research.