The Bio-Medical Evidence Linking Community Agency and Health
An Encouraging Evidence Base
Pritpal S Tamber
This report describes how community agency relates to health in the bio-medical literature. It emanates from some wider work on how agency (whether individual or communal) and belonging (especially in the context of systemic racism) relate to health.
To have agency is to be able to act or intervene to produce a particular effect. This is also known as having power, especially in political and social sciences. Within health, the terms most often used are control and/or empowerment.
I approached the work by speaking with nine key informants whom I identified with Tony Iton of The California Endowment from our understanding of the discipline and our networks. A number of the key informants told me that the evidence for community agency is weak because studying it is methodologically difficult.
Compounding this, numerous terms have been used for community agency. Sometimes these terms are synonyms, other times they only overlap somewhat.
Given the heterogenous nature of the evidence, I decided to focus on reviews.
One of the key informants was Margaret Whitehead, a well-respected researcher in public health and the determinants of health. In 2016, her team published a review of the theories of how control impacts health inequalities. I started with that, and then examined three subsequent reviews by Whitehead’s team and/or colleagues.
I also examined two reviews recommended by the key informants and two reviews that I found by searching PubMed. All in all, I examined and summarized eight reviews.
The titles of the review articles were (in the order in which they were examined):
- How could differences in ‘control over destiny’ lead to socioeconomic inequalities in health? A synthesis of theories and pathways in the living environment. (Whitehead, 2016)
- Group-based microfinance for collective empowerment: a systematic review of health impacts. (Orton, 2016)
- Scoping review of review-level evidence on co-production in local decision-making and its relationship to community wellbeing. (Pennington, 2017)
- A systematic review of evidence on the impacts of joint decision-making on community wellbeing. (Pennington, 2018)
- Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis. (O’Mara-Eves, 2013)
- What is the evidence on effectiveness of empowerment to improve health? (Wallerstein, 2006)
- Community participation in general health initiatives in high and upper-middle income countries: A systematic review exploring the nature of participation, use of theories, contextual drivers and power relations in community participation. (Chuah, 2018)
- Community participation in health services development, implementation, and evaluation: A systematic review of empowerment, health, community, and process outcomes. (Haldane, 2019)
As you can see, numerous terms were used for community agency – community control, collective empowerment, co-production, joint decision-making, community engagement, empowerment, and participation. Furthermore, not all of the articles included in these reviews involved interventions that sought to foster community agency. As a result, I had to examine the included articles to assess whether they mapped to the idea of fostering community agency.
To help me examine the articles, I needed to make sense of the terminology in the discipline. In truth, I did that on a review-by-review basis because each of the review articles had their own justification for the terms used. However, in the process of this work, I came across a number of frameworks and models that try to clarify terms and place them in some kind of sequence.
One such model is by Popay (2006) and includes a plausible theory of change (based on my wider understanding of the discipline) – see Figure A.
Figure A: Popay's conceptual model on pathways from community engagement to health improvement (Popay, 2006)*
The theory is that the type of outcomes possible depends on the depth of the engagement. At the lower end (informing and consultation) only service outcomes and health outcomes are possible, and both are only modest (as indicated by the width of the inverted triangles). As participation deepens, greater service and health outcomes become possible, both directly and as a consequence of intermediate social outcomes, such as greater social capital and enhanced community empowerment. Furthermore, these intermediate social outcomes become greater as community engagement deepens, which, in turn, impacts service and health outcomes.
Popay uses both ‘engagement’ and ‘participation’, two of the most common terms in the discipline, as overall terms. The idea is that engagement/participation can take any of the five forms listed on the left of the model. In the bio-medical literature, the terms ‘engagement’ and ‘participation’ are most commonly used to describe what Popay calls ‘informing’ and ‘consultation’, occasionally ‘coproduction’. Only rarely do those terms refer to ‘delegated power’ or ‘community control’, the two terms that map to community agency.
In my examination of the articles included in the reviews, I was looking for interventions that could be described as ‘delegated power’ or ‘community control’. However, through the rest of this summary I will continue to use ‘fostering community agency’ (or variations of it) for simplicity.
Within the reviews, there were 93 articles that described outcomes as a result of community agency, whether it was fostered by an intervention or pre-existing.
Orton (2016) and Pennington (2018) were explicitly about empowerment and so all of the studies included in them are part of the 93 (although for Orton , the results of one article were not described well and so were not included and another was omitted by mistake). In Chuah (2018), the authors classify the studies according to the level of community participation and all of the ones classified as ‘delegated power’ or ‘control’ were included. In Haldane (2019), the authors are clear about which of the studies had empowerment outcomes and these were the ones included.
For two of the reviews, the process was less straightforward.
Despite the size of the work, O’Mara-Eves (2013) only included four studies that could reasonably align with the idea of community agency. I also decided against including the results of the meta-analysis within the review because most of the included studies were about communities being consulted rather than expressing their agency. All in all, only the four articles were included in the 93.
For Wallerstein (2006), only a handful of studies looked at community agency. These were the ones that were included in the 93.
Two of the reviews did not contribute articles to the 93. The first was Whitehead’s review of the theories connecting control and health inequalities (Whitehead, 2016) – precisely because it was about theories. And one of the reviews was a scoping review (Pennington, 2017) that then informed a subsequent systematic review (Pennington, 2018), the latter being mentioned above. The systematic review supersedes the scoping review.
Some of the reviews assessed the quality of the articles included. Others did not. Of those that did, a three-tier classification system was used. I decided to stick with a three-tier system and found ways to assess the quality of the articles in the reviews that did not do it.
Twelve articles were classified as high-quality, 45 as medium-quality, and 36 as low-quality.
The Evidence from High-Quality Research
The evidence from the 12 articles classified as high-quality shows that interventions that involve community agency most frequently impact the personal development of those participating. This includes their emotional, social, organizational, communication and financial skills, which has an overall impact on their confidence.
Individuals also reported feeling empowered, with some people saying that the work made them feel as though they were making a difference while others expressed a greater willingness to challenge their negative circumstances. Participation in such interventions also has a positive impact on their perceptions of their area, including their sense of pride and their sense of belonging.
Fostering community agency also has a positive impact on the social fabric between people, whether it’s called social cohesion or social connectivity.
That said, an interesting picture emerges when it comes to trust. While some studies reported an increase in trust in local agencies, one reported a decrease and another reported that some community members were suspicious that their concerns were being trumped by the concerns of better-resourced community members.
Some studies reported positive impacts on the local environment, including greater access to green space. One study showed the community members were more likely to access services as a result of the intervention and there were also positive impacts on mental health, social isolation, partner violence, and the general sense of safety.
The picture is not unequivocally positive, however. One study reported increased physical and psychological strain amongst community members as a result of the engagement/participation process, especially amongst disabled people. Another described tensions and disagreements amongst community participants. And another reported frustration and dissatisfaction with the engagement/participation process, as well as its outcomes.
The Evidence from Medium-Quality Research
The evidence from the 45 articles classified as medium-quality shows that fostering community agency most frequently enhances the empowerment of individuals, with one study saying it occurred through skills-based training.
Fostering community agency also has a positive impact on the social fabric between people, whether it’s called a sense of community or increased social connectivity, with one study making the point that this also worked across generations.
Four studies showed that community agency is increased with one being explicit that it occurred through an increase in the number of community activists, although another study found no impact on levels of community mobilization.
Other changes observed amongst individuals were that they gained new ideas and knowledge, developed skills/expertise, including leadership, increased their ability to progress towards goals, and increased in confidence, aspirations, happiness, enthusiasm, and, amongst children, improved school attendance and behavior.
Turning to health care services, efforts involving community agency have led to improved facilities, improved efficiency, and a more equitable distribution of services.
As in the high-quality studies, there are also negatives. Participants expressed dissatisfaction with the process and frustration with their perceived lack of influence and/or the rate of change. There is also significant tension, both within and across community groups, and for professionals who seek to focus on a community’s priorities while also seeking to focus on the needs of excluded or disadvantaged groups.
The idea of new relationships also featured through the articles. One reported that community health workers valued agency-fostering approaches as they gave them access to populations that they previously had little contact with. One described how partnerships and connections developed within and outside of communities, while two others suggested that civil society associations were strengthened, participation in local government was enhanced, and institutional barriers were reduced. Another study found increased trust, respect and reciprocity between communities and agencies.
Four studies, however, highlighted the structural challenges that communities face. One illustrated that improvements to confidence, self-esteem and social networks were offset by the structural challenges involved in devolving power. Another described how communities felt restricted by ‘the system’. Two studies in sex workers illustrated how mobilization and empowerment are inhibited by their subordinated and exploited social positions.
Turning to health and well-being outcomes, agency-fostering interventions are associated with:
- Prevention: Greater likelihood to use contraceptives; increased rates of immunizations in children; improvements in cardiovascular risk factors
- Health Behaviors: Pursuing healthier lifestyles, more frequently obtaining information from health professionals, more satisfaction with access to health information, and greater health literacy regardless of socioeconomic status
- Morbidity: Less stunting amongst children; higher weight-for-height z-scores of children; reductions in emotional stress; fewer sexually transmitted infections amongst sex workers; the greater use of condoms (be sex workers) at last paid sex
- Mortality: Lower infant mortality
- Health Care Facilities: A better use of investment when it comes to constructing auxiliary health care units, including reducing the delivery times of said units; increased use of health care; fostering knowledge and confidence about how to access health care
- Well-Being: A lower likelihood of women being beaten by their husbands; increased perceived value of health; increased self-esteem and family well-being
- Policy Influence: Creating healthy public policies that have, in turn, led to improved health; increased perceived control over policies
- Environment: Mediating levels of violence in a community; better water quality; the successful implementation of speed humps; better health and safety conditions for hotel workers; better pollution practices in the hog industry; improved physical environment
As ever, the picture is not unequivocally positive. Agency-fostering interventions are also associated with: no influence over self-assessed health or exposure to health risks; no impact on the use of contraceptives; no influence over body mass index; and no influence over the nutritional status of women and children.
The Evidence from Low-Quality Research
Much of the evidence from the low-quality research echoed what’s above so I have only included the articles that reported something different. That is not to say, however, that the articles in this segment are entirely without merit or that their conclusions should be dismissed. Conducting research into community-based strategies is difficult to do well so even ‘low-quality’ articles should be considered.
Amongst the 36 articles classified as low-quality, fear seemed to feature. One study described how community participants feared reprisals from other residents, another described how residents were concerned about how public agencies might react, and another talked about distrust building between communities and public agencies.
There were also more negative outcomes than in the higher-quality research: no impact on violence towards women; an increase in violence towards better educated women; an increase in stress for non-members of microfinance schemes in households that received loans; no association with women’s general health; no association with maternal depression; no association with women’s access to cancer screening; no association with rates of child illness; and concerns about potential gentrification and associated tax rises.
Reading Across the Evidence
Fostering community agency seems to impact six broad, inter-related areas:
- The skills of community members
- The confidence of community members
- The sense of empowerment among community members
- The social fabric between community members
- The sense of collective power among community members
- The level of trust within a community
Items 4 and 5 map to Popay’s model on the pathways from community engagement to health improvement. Item 4 (social fabric) could be considered an alternative term for social capital. Item five (collective power) is an alternative term for community empowerment.
It’s interesting, however, that Popay’s model is silent on the changes seen in individuals – their skills, confidence, sense of empowerment – and the recurring topic of trust (although trust is said to underpin social capital, which is mentioned in Popay’s model). The evidence suggests an updated version of the model should include these things.
Relating the Evidence to the Theories
As noted above, one of the reviews (Whitehead, 2016) was a summary of the theories connecting control and health. They were depicted as pathways. The evidence supports a number of the pathways.
At the Community Level
At the community level (Figure B), the upper branch is about protective factors and the lower branch is about risk factors. Much of the evidence supports the upper/protective branch.
Figure B: Synthesis of the theoretical pathways from low control to inequalities in health at the community level (Whitehead, 2016)**
- Given that ‘social protective factors’ encompasses things like social cohesion, community capacity, ontological security and sense of coherence, it’s clear that the evidence is supportive – as we have seen, there is ample evidence that interventions that seek to foster community agency have a positive impact on the skills of individuals (ie community capacity) and on social cohesion.
- There is also evidence of community empowerment, albeit on the basis of whether people feel
- There is evidence of increased trust, although there is some evidence that trust within communities and in local agencies can be diminished, especially if the engagement/participation process is frustrating or the progress slow. There was nothing specific on reciprocity.
- There were a few studies that reported deflections of threats to the local environment and many studies described its maintenance and enhancement.
- There was some evidence for the improvement of services and facilities, to some extent the opposite of them being hollowed out.
- Turning briefly to the lower/risk factors branch, there is evidence that interventions can improve safety (or the sense of safety)
- And reduce individual and collective sense of powerlessness (or increase individual and collective power).
At the Individual Level
At the individual level (Figure C), the upper branch is about ‘actual’ levels of control and the lower branch is about perceived levels.
Figure C: Synthesis of the theoretical pathways from low control to inequalities in health at the individual level (Whitehead, 2016)**
- Starting with the upper/actual branch, the evidence suggests that as the skills of community members are enhanced, they develop greater resources to help them cope with the excessive demands of their lives.
- There is also some evidence that people become willing to challenge their negative circumstances (ie they have greater power to influence critical decisions).
- With regards to the lower/perceived branch, it is possible to see that as individuals and communities begin to feel empowered, they increasingly believe they have control and greater self-efficacy.
- Were this belief proven to be true, one can also envisage a reduction in socialized fatalism.
- And a reduction in all of the other pathways linking low control beliefs to poor health.
Linking Individual and Community
An analysis of how individual agency begets community agency, and vice versa, was beyond the scope of this report but traces of it are there to see in this summary of the evidence.
My reading of it is that it comes down to skills – also known as ‘capacity’ in some of the research and a type of ‘resource’ in Figure C. Interventions that foster practical skills in individuals have the potential to build their confidence, and hence encourage them to understand and step into their power. This, combined with greater skills in communication and collective working, can then underpin community power.
Community power – especially when successful in bringing about changes that communities want – has the potential to not only give communities confidence but also give individuals confidence, which, in turn, can encourage them to acquire new skills and hence build their confidence. And so, the cycle has the potential to be reinforcing.
Context & Characteristics
Four of the reviews described the context and characteristics of successful community agency strategies.
The context for successful community agency strategies includes:
- strong social relationships
- community skills and assets
- ontological security
- the absence of exclusion
- and a political environment sympathetic to equity.
It’s striking how similar this list is to what Whitehead describes in Figure B as social protective factors (social cohesion, community capacity, ontological security and sense of coherence).
The characteristics of successful community agency strategies includes:
- clear and transparent operations
- being authentic about sharing power
- including communities from the start
- proactively seeking to overcome barriers to participation
- creating content tailored to people’s levels of education and cultural values
- being led by local opinion leaders with a strong commitment to equitable participation
- having skilled facilitation
- and having a clear understanding of local geography and its possible impact on the work.
It’s striking how doing all of the above would go some way to avoid the frustration recorded in a number of the articles.
My overall conclusion is that despite significant problems in the evidence base – the confusion in terminology, the lack of articles on interventions that are truly about community agency, and the general difficulty in doing the research – there is an encouraging uniformity to the findings in the 93 articles examined for this report. That, combined with the theoretical pathways presented by Popay (2006) and Whitehead (2016), suggests that there is theoretical and empirical justification for employing strategies that foster community agency as a way to improve health.
Possible Weaknesses in this Work
There are (at least) three weaknesses in this work that are important to acknowledge.
The first is that I relied on the authors of the reviews to faithfully represent the findings of the articles they included. Related to that, when I needed to look at the articles included in the reviews, I stuck to the titles and abstracts so I also relied on the authors of those articles to faithfully represent their work in their titles and abstracts.
The second is in how I assessed the quality of the articles. In some of the reviews there was not enough information to do this in a robust manner so, although what I did felt justifiable, it didn’t always feel scientific.
And the third is that this report may have benefitted from a deeper analysis of the frameworks and models that have been proposed for community agency and health. While I suspect what I have covered represents the best of what there is, there is a chance that I have missed something important.
I would like to express my sincere gratitude to Brad Caftel of the Insight Center for overseeing the funding and the myriad other administrative and legal details involved in completing this report. I also wish to thank The California Endowment for funding this work.
* This image was taken from O’Mara-Eves (2013), which was published under the terms that its content could be freely reproduced for the purposes of private research and study, and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. The original publication of the image (Popay, 2006) is no longer available but its author has provided written consent to its use (correspondence on file).
** These images were taken from the article, which was published under an open access license (CC BY-NC-ND 4.0) that allows copy and redistribution for non-commercial purposes as long as the original source is identified (more information here).
About This Report
This report illustrates the link between community agency (power) and health, as reported in the health literature. Its findings are based on 93 primary research articles that were found in eight review articles, most of which were recommended by key informants. The work was funded by The California Endowment and done in collaboration with the Insight Center for Community Economic Development.
Project this report was part of: Agency, Belonging and Health