"Because of the importance of context-specific community participation in global health communication, closely examining what community engagement strategies and approaches are used in different contexts can help inform the design and implementation of future interventions."

Community participation and engagement has long been a cornerstone for public health communication interventions. Incorporating community voices in an intervention's planning and implementation can help ensure that an intervention's messages and materials resonate with potential audiences. Interventions with community participation at the centre can be described as falling into four quadrants characterised by two broad approaches (strengths and needs) and encompassing two broad strategies (consensus and conflict). This review explores needs-based and strengths-based approaches and consensus and conflict strategies in community-based global health communications programmes. The objective is to examine the current state of the field, outline lessons learned, and identify gaps in existing programming to help guide future interventions in different social and cultural contexts.

The framework driving this analysis translates well to global health communication because of a need to both meet community needs and to tailor interventions to unique, divergent social contexts that contribute to health inequities. The four quadrants of this framework describe approaches and strategies that are used to foster different levels of community engagement:

• Strengths-based approaches, which build on the community's existing strengths through community capacity, empowerment, critical consciousness, participation, relevance, and/or health equity;
• Needs-based approaches, which rely on the community's needs and/or if an intervention fulfills a desirable need;
• Consensus strategies, which draw on collaboration, cooperation, or participatory planning and emphasise building group identity and problem solving through community development, community building, and capacity building; or
• Conflict strategies, which question the status quo - primarily by focusing on advocacy strategies and efforts.

Based on their goals and objectives, global health communication interventions can combine these approaches and strategies at different times of programme development, implementation, and evaluation to achieve multiple outcomes.

For the review, PubMed and Web of Science were searched for articles published between 2010 and 2023. Studies were included if they described a community-based health communication intervention and an ongoing or completed implementation. Interventions were coded then categorised according to their level of community engagement and as single, hybrid, or complex, depending upon the number of approaches and strategies used. Single interventions used one approach and implemented one strategy (strengths or needs and consensus or conflict). Hybrid interventions used two approaches and implemented one strategy or used one approach and implemented two strategies. Complex interventions used all four elements.

The search yielded 678 results, and 42 were included in the final review and analysis. Two-thirds of the interventions were targeted at topics that required concerted community-level action - for example, zoonotic diseases or issues of maternal and child health. Thirty-four (81.0%) of the interventions used a needs-based approach, and 24 (57.1%) used a strengths-based approach. Consensus as a strategy was used in 38 (90.5%) of the manuscripts, and 9 (21.4%) implemented a conflict strategy.

The paper describes studies that are representative of each of the four intervention types. Within each section, examples of interventions are further sorted according to their level of community engagement, by World Health Organization (WHO) categorisation: community-oriented, community-based, community-managed, and community-owned.

Community-oriented was the most frequently used level of community engagement: A community-oriented level of engagement was implemented in 12 (66.7%) needs-based only interventions, 4 (50.0%) strengths-based only interventions, and 3 (18.8%) strengths- and needs-based interventions. A community-based level of engagement was used in 4 (22.2%) needs-based interventions, 3 (37.5%) strengths-based interventions, and was most commonly used in 5 (31.3%) needs- and strengths-based interventions. A community-managed level of engagement was implemented in 1 (5.6%) needs-based intervention and 7 (43.8%) strength and needs-based interventions. Community-owned was the least used among all levels, with only 1 intervention from each of all three approaches utilising this level of community engagement.

Only 4 (9.5%) of all interventions included in this review were complex, using both strengths- and needs-based approaches while implementing both consensus and conflict strategies. Each complex intervention included in this review also used a unique level of community engagement, creating an equal spread of 1 (25.0%) complex intervention per level of community engagement. Interventions that combined approaches and strategies were more likely to leverage a higher level of community engagement. For example, a complex (community-owned) intervention included in the review aimed to improve reproductive healthcare use among African-American women in the United States. Beyond only priority-setting, this intervention sought to build community capacity by strengthening existing networks and creating a sense of community ownership. Local community-based organisations were empowered to take a leading role in disseminating the intervention and promoting good health among community members.

Cross-analysing the descriptive statistics reported in the results revealed differences between regions historically defined as the global north and global south. Out of 15 interventions from the global north, 12 dealt with minority populations, whereas 20 of the interventions from the global south were designed for a general health population. It is possible to hypothesise that these results display different connotations of the word "community". In the global north, "community" refers to specific groups of individuals with a shared identity (e.g., homeless people, cancer patients, health workers), whereas interventions from low- and middle-income countries define the general population as a community. "This geographical difference in the application of community in global health communication is an important question to consider for future research."

The researchers note that only one-third of the interventions reference a conceptual model or theory of change; those that did tended to rely on individual-level behaviour change theories. They argue that, "While the need to keep individuals at the front and center of community efforts is often overlooked, this lack of cross-cutting theories or interpersonal or social theory constructs in intervention design and evaluation is noteworthy in its absence." Furthermore, "given that community-based interventions often focus on face to face or virtual interaction with others, the fact that only two interventions relied on social support and social networks models is surprising."

In this review, more than half of the included studies used one evaluation method, the most common of which was quantitative measurement of effects. It is surprising to the researchers that relatively few studies described using community-based participatory research (CBPR) at all stages. CBPR is a specific participatory research approach that empowers social change through cooperation, co-learning, and capacity building. These findings could reflect the reality that principles like CBPR are easier to talk about than they are to practice.

The results also indicate a lack of interventions that use conflict as a strategy to empower communities to act on their own behalf, even when at odds with existing power structures. One potential reason for the lack of interventions implementing conflict-based strategies could be the fact that much of the literature included in this review is grounded in the field of international development. The main focus of many of these interventions is to improve the lives of individuals through collaboration and consensus. An emphasis on conflict as a strategy is more likely to be evident in examining social movements. Thus, a possible recommendation for interventions that seek to engage community members by implementing conflict-based strategies is social action theory. Social movements such as #METOO that demand sexual responsibility provide an opportunity for health communication researchers interested in the social determinants of health to study conflict-based approaches to improved health and wellbeing.

In conclusion: "Almost all of the interventions in this review are community-oriented, indicating that global health communication has a long way to go in its quest for being truly community-owned....Recognizing that public health interventions should be centered around their benefactors, closely examining which approaches and strategies should be used and when, can lead health communication toward community ownership. Through this, public health can play an important role in achieving the aforementioned goals of 'global' health communication in an increasingly complex, interconnected world."