The levels of Community Involvement in Health ( CIH ) : a case of rural and urban communities in KwaZulu-Natal

Kev words Community involvement in health, ladder of participation, Primary health care, and health programmes Abstract: Curationis 32(1): 4-13 The study aimed to describe the practice of community involvement in health pro­ grammes. The study therefore explored the nature and practice of community in­ volvement in health programmes in the two communities in KwaZulu Natal. The study was guided by the conceptual framework adapted from Amstein’s,( 1969) Lad­ der of Citizen Participation. This framework shows different levels and steps in com­ munity participation. A case study method was used to conduct the study. The two cases were one urban based and one rural based community health centers in the Ilembe health district, in Kwa Zulu Natal. A sample of 31 persons participated in the study. The sample comprised 8 registered nurses, 2 enrolled nurses 13 community members and 8 community health workers. Data was collected using structured indi­ vidual interviews and focus group interviews, and was guided by the case protocol. Community involvement in health largely depended on the type of community, with rural community members being in charge of their health projects and urban commu­ nity members helping each other as neighbours in times of need.


Background
Community involvement in health (CIH) plays an important role in rendering primary health care (PHC) services to the community.According to the World Heath Organization (WHO) (1978:51), community involvement can take many forms, including assessment of the situ ation, definition o f problems and set ting o f priorities.The community can then help to plan PHC activities and can co-operate fully when these activi ties have been carried out.This ap proach emphasizes that, in PHC col laborations, residents and health pro viders need to work in partnership as they each have their area and level of expertise.In this partnership, it is ar gued, health professionals and commu nity constituents will share responsi bilities, decision making and commit ment to interventions and outcomes to im prove the co m m u n ity 's health (Porsche, 2004:147) The basic characteristics o f the con cept of community participation are that • participation must be active, • people must have the right and responsibility to exercise power over decisions that affect their lives, and • there must be mechanisms avail able to allow the implementation of the decisions made by the community (Dennill, King & Swanepoel, 2002:82;Laverack, 2007:26).
Without these characteristics in the delivery o f health care, the health pro fessionals cannot claim the involve ment of the community in their imple mentation of health programmes.
It has been widely reported that com munities are seldom involved in the development o f health programmes beyond "being expected to bring their children for immunizations and pas sively to accept a thin offering o f serv ices" (Brown, Holtby, Zahnd & Abbott 2005:2; WHO, 1988:28).This means that although the importance of com munity involvement in health services is widely expounded, the actual in volvem ent is less apparent At this stage, com m unity involvem ent is viewed as the key to success in the delivery o f health care, yet there seems to be very little or no actual community involvement in the community context.Though in the Alma Ata conference community involvement in health was identified as one of the principles in PHC practice, thirty years post this conference there is still a missing link between the community and health care system, with community members be ing mere recipients of the health care and not involved in the decision mak ing and planning of health programmes (Bukenya 2008:1;Brown, Holtby, Zahnd & Abbott 2005:2).
In keeping in line with this concept of community involvement, the South African government introduced the following initiatives: 1.The government's National Health /lcf(ActNo.61 of2003) which is based on the belief that every individual has the right to achieve optimal health.Fur thermore, community participation is identified as an essential element that the national health system (NHS) must develop at a local level in order to be fully effective and not as an entity that can be prescribed and legislated into being (Republic of South Africa, 2004: 22).

In the white paper fo r Transforma tion o f the Health System in South
Africa (Department of Health, 1997) the objectives for restructuring the health system were set.One of these objec tives was to foster community partici pation across the health sector by in volving communities in various aspects of the planning and provision of health services (Department of health, 1997).
A review of relevant literature reveals that very few studies have been done on community participation in Kwa Zulu Natal (KZN).The findings of the national primary health facilities survey conducted by Viljoen, Heunis, Janse van R ensburg, van R ensburg, E ngelb recht, F ourie, S teyn, and Matebesi, (2000:82) showed that little progress had been made in facilitating community participation in PHC in South Africa since 1998.A study con ducted in KwaZulu Natal exploring community understanding of CIH re vealed that community members in both urban and rural communities have a common understanding of CIH being a collaborative effort between health professionals and community members (Mchunu & Gwele, 2005: 35).Even though KZN is among the provinces where headway had been made, the change in terms of the practice of com munity involvement in health has been described as very slight.

Rationale for the importance of community involvement in health
As the key concept in primary health care, community involvement is said to be within the level of community resi dents' participation in health decision making.It is argued that the residents need to participate in decisions about the health of the community in order to promote development and self-reli ance.Com m unity participation in health programmes generates a sense that health and decision-making is community-owned, and the personal expe riences of citizens become integral to the formulation of policy (Wright, Parry & Mathers J, 2005:58).There is an em phasis that in PHC, community mem bers and health providers need to work in partnership as they each have their area and level of expertise.This, it is argued, is needed to actively engage community members as active partici pants in solving complex community problems (Porche, 2004:147) Bhuyan (2004: 2) and Stanhope and Lancaster (2004: 350) are in agreement with Porche's argument that commu nity involvement is a critical element of PHC and health development.But, there is a further argument that the peo ple's involvement should not just be in the support and functioning o f health services but more importantly, in the definition of health priorities and the allocation o f scarce health resources at the district level.Nkasa and Chapman (2006: 512) have advocated that involv ing community members in planning pro ject a c tiv ities w ill ensure sustainability of community projects.For these authors, a community project will be sustained if those involved in it come to feel ownership of it.
The achievement o f an appropriate health care delivery system requires involvement o f people at grass root as part o f the process so that they can effectively utilize the service (Dolamo, 2009:5).Literature has shown that com munities invest in their community re sources in a number o f diverse ways to achieve com m unity developm ent.However, previous research studies have revealed that while community involvement in health services is widely expounded, the actual involvement in health programmes is still surrounded by a host of challenges including lack of leadership, lack o f credibility and the fact that many people still need to be convinced of the dividends of their in volvement (Padarath et al., 2006:101).

Problem statement
In spite of all the initiatives by the South African government to improve health care delivery at primary health care level, some problems persist, including the lack of optimal community involve ment.Several questions remain unan swered, particularly questions aiming to explore the nature and practice of community involvement in health pro grammes.

The purpose and objectives of the study
The study aimed to describe the prac tice of community involvement in health related community programmes, using a ladder of participation as a framework.The objectives of the study were there fore to Describe the levels of CIH in rural and urban communities.

•
Determine similarities and dif ferences between the rural and urban practice o f CIH.

Conceptual framework
The study was guided by the model adapted from the Ladder of Citizen Par ticipation (Amstein, 1969) (Figure 1) This framework was chosen because it showed all the different levels and steps in community participation.In this study, the ladder's steps represented In this Ladder of citizen participation levels of community participation are explained as follows: Participation 10

Community in charge
The community decides what to do.The health professionals are involved only if the community asks for help.

9
The community leads/the health professionals help The community takes the lead in deciding, with help from the health professionals.

Joint decision
The health professionals and the community decide together on a basis of equality.

Consultation
The health professionals con sult the community and con sider their opinion carefully, then the health professionals decide, taking all opinions into account.

Invitation
The health professionals invite the community's ideas but make the decision themselves on their own terms.

Pre-participation 5 Tokenism
The health professionals decide what to do.Afterwards the com munity is allowed to decide some minor aspects.

Decoration
The health professionals decide what to do, the community takes part by singing, dancing or per forming ceremonial functions.

Manipulation
The health professionals decide what to do and ask the commu nity members if they agree (the community must agree).

Non-participation 2
The health professionals rule kindly The health professionals make all decisions, the community is told nothing except what they must do and they are given rea sons and explanations. 1 The health professionals rule The health professionals make all decisions; the community is told nothing except what they must do.

No consideration for the community
The community is not given any help or consideration at all, they are ignored.

Definition of terms
Community: It is a group of people who share some type of bond, who interact with each other, and who function col lectively regarding common concerns.
The bond may take many forms, in that it can be shared ethnicity or culture or living in a specific geographic location or it can take the form of similar inter ests, goals, or occupations (Clark, 2003).In addition to this definition the ANC's definition of the term commu nity will be adopted, that is, "to repre sent those people living in the geo graphical area served by a community health centre" (ANC, 1994:61).

Community involvement and/or par ticipation:
This refers to a shift in em phasis from external agencies supply ing health services, to the people of a community becoming active partici pants in their own health care.Commu nity members become partners in health care by generating their own ideas, as sessing their needs, involvement in decision-making process, planning, implementing, and even evaluating the care they receive.(Dennill et al. 2002 :9).These two terms will be used inter changeably.
PHC communities: For this study, it means the people who are involved in the operation of the phenomenon, that is, the health professionals working in the health care centre and the commu nity served by the health centre.
Health professionals: the members of the health team, including the nurses (all categories) working in community health centres.
Rural community: Geographically, this term refers to areas that are remote and isolated.Rural communities are not homogeneous, but the following char acteristics for rural communities will be assum ed, nam ely, (a) sparse populations, (b) low family income, (c) unemployment, (d) poor schools, and (e) inadequate to non existent health care systems (Deloughery, 1991).
Urban community: In this study it will refer to communities situated in the in ner city, in which a large number of peo ple live and work in close proximity.The assumption will be based on Mann's (1983) definition that in urban commu nities relationships are impersonal and superficial and segmental.Also, that the population is more heterogeneous due to greater mobility of the people.

Literature survey
In the literature review, the following key concepts were explored: (a) the community, (b) primary health care (PHC), and (c) community involve ment (participation).Relevant research articles on community participation in health problem s and on measuring com m unity participation were re viewed.
The WHO defines PHC, as: "Essential care based on practical, scientifically sound and socially ac ceptable m ethods and technology made universally accessible to indi viduals and fam ilies through their fu ll participation and at a cost that the community and the country can afford to maintain at every stage o f their de velopment in the spirit o f se lf reliance and se lf determination " (WHO, 1978, p. 16).
According to the WHO (1978), primary health care policies need to be trans ferred into practical programmes.It is further asserted that there is a need for a specific strategy for formulation and implementation of these primary health care programmes.The national strat egy plan will include, among other things: • Support from relevant compo nent from other sectors, such as education, transport, agricul ture, and sectors dealing with environment.

•
Commitment of the government to develop and launch the strat egy and to maintain momentum.

•
In order to devise and imple ment the strategy, the commu nities in need o f such care should be identified, in order to decide on their grouping for the purpose of support and their re ferral.

•
For communities to be involved in their health development they need to have easy access to the right kind of information con cerning their health situation and how they themselves can improve it.This information can be in the form of magazines, newspapers, radio, television, films, plays, posters, commu nity notice boards and any other means available, including the health professionals, so as to increase the accessibility o f the services.The assumption is that the more accessible the serv ices are, the more interested people will be to participate in health programmes.
Elaborating on these basic strategies, Dennill et al. ( 2002) asserted that Com munity participation and involvement refers to a shift in the emphasis from external agencies supplying the health services, to the people o f a community becoming active participants in their own health care.
They become partners in health care by generating their own ideas, assess ing their needs, making decisions, planning, im plem enting, and even evaluating the care they receive.This process encourages and allows the community to take responsibility for their own situation, thus empowering them.It also encourages self-reliance and self-determination (Dennill et al., 2002:9).
According to Reid (2000) there is no one right way define community in volvement and as community partici pation will look different in every com munity.Yet, according to this author, there are some common elements to sound participation that will be found in all communities.Some authors there fore provide traditional definition of community involvement in health, in terms o f partnerships, achieving the goals and objectives o f health pro grammes, and community taking re sponsibility for their own health (WHO, 2006, Rifkin 1990, Bhuyan 2004).
Pragmatic definitions o f community in volvement in heath view this concept as in terms of decision making and em powerment such that it is an empower ment tool through which the communi ties take responsibility to solve their own health and development problems (Morgan, 2001, Abelson, 2001).

Research methodology Research design:
A qualitative research approach using the case study design was chosen for this study.A multiple case study de sign was used.The practice o f commu nity participation in rural and urban com m unities was explored and an analysis o f the type of community par ticipation was done based on the con ceptual framework.The case study pro tocol was used to guide the researcher to keep her focused on the purpose of the study.
The case study design focuses on ho listic descriptions and explanation, an swering the questions such as "how" and "what" (Yin, 2003:7).Within the context o f this study this involved the assessm ent o f how the community members were involved in the devel opment of health programmes, includ ing identification o f needs, and plan ning and decision-making in the imple mentation o f these programmes.The study looked at the practice o f commu nity participation in both urban and rural communities in the Ilembe health district, province of KZN.

Setting
The setting was community health cen tres and their surrounding communi ties in different types of communities.
The sub-districts within Ilembe district (formerly Region F) were chosen as suitable sites for this study because the district ranges between extreme ur ban and extreme rural communities.One clinic was chosen from each sub-dis trict.

Case study protocol
According to Yin (2003: 67) a case study protocol is essential if one is doing a multiple case study.This case study protocol contained the instru ment as well as procedures and gen eral rules to be followed in using the protocol (Yin, 2003:67).
The case protocol contained the fol lowing information:

Case Description
In this study the case was a health cen tre (clinics) in the chosen health sub districts with all the community mem bers utilising the clinic, health pro grammes and community health work ers as its embedded units of analysis.The context o f the case was the cho sen urban (case A) and rural (case B) com m unities within the Ethekwini health district

Case selection
Cases were purposively selected to ensure that the chosen cases were typi cal of the population required (Gerring, 2007:147).One case was selected from each sub district to represent the rural community and the second case was selected to represent the urban com munity.Case A was an urban commu nity while case B was a rural commu nity.

Sample selection
Theoretical sampling was used to se lect study participants.The initial group o f participants were nurses and com munity members in different PHC com munities.The researcher kept on in cluding another group of participants other than the nurses and the commu nity members as the need arose.In theo retical sampling, the researcher can do 'ongoing inclusion of groups' and 'se lection o f comparison groups' which can be done when the researcher needs to turn to certain groups or sub-groups for the next data collection (Glaser & Strauss, 1967:49, Polit & Beck, 2004: 307).
A total of 31 participants representing both cases, participated in this study.In case A(urban community): All in all 17, participants were interviewed.These consisted o f five registered nurses, six community members who live in the areas surrounding the town ' and six community health workers.Of the five interviewed registered nurses, three were in charge o f the specific health programmes.These programmes were HIV/ AIDS, training of health per sonnel and CHWs coordination.In case B (rural community), a total number of 14 participants were inter viewed.The health professionals inter viewed consisted o f three registered nurses, one of whom was the person in charge of the clinic and two enrolled nurses.From the community side, in terviewed were two izinduna, and five active community members.The com munity health workers included one community health workers' coordina tor, who is in charge o f the CHWs who are attached to the clinic, and one of the four volunteer community health workers who are not attached to the clinic.
In case A, where active community members were not clearly identified, the researcher used convenience sampling to include community members.Peo ple who happened to be at the clinic at that time were identified as possible participants (Bums & Grove, 2001:374;Polit, Beck & Hunglcr, 2001:237).The researcher visited the clinic over the period o f one week and explained the proposed research to the clients who were waiting in the waiting area.The interested community members volun teered to participate, but could only be included if they were residents of this community and not just visiting.In case B, community members were sampled using snowball sampling.This seemed to be the most appropriate method as the researcher was looking for people with specific traits (Polit & Beck, 2004: 306), namely people who have been utilizing the same clinic for a number of years.The criterion for se lecting active community members was through identification o f these indi viduals by a variety o f sources.These included the nursing staff, community health workers (such as the AIDS co ordinators, the community health work ers' trainers and facilitators).The re searcher also included those commu nity members identified by community leaders and other informants (such as Indunas and other respected commu nity members).

Data collection methods
The strategies used for data collection included face-to-face interviews in the form o f focus group interviews and in dividual interviews.The research ques tions were used in both the individual interviews and focus groups and the researcher had to probe to obtain more information.
Purposively selected focus group in terviews were conducted where the in formants were found as a group or for informants who were working together.This was to ensure that the groups were homogenous, and hence facilitate open discussion (Bums & Grove, 2001:452).One focus group was conducted in each community.In case A focus group was conducted with the community health workers whereas in case B the focus group was on community mem bers.This was determined by the avail ability o f participants.

Data analysis
Data collection and analysis were done simultaneously.The analysis o f data was commenced by using a template, in this case the template being a case protocol.Template analytic techniques more open-ended and includes genera tion o f themes, patterns and interrela tionships in an interpretive rather than a statistical process (Crabtree & Miller, 1992: 19).A case protocol together with the research question guided the analy sis of data.
The researcher identified themes and pattern s and did in terp re tatio n a l manual data analysis.Data was then segmented to meaningful units.The segments were coded and sorted into categories.Relationships among cat egories were then established.As de scribed by Miles and Huberman, (1994: 90) within case and cross case analy sis was done to compare the findings in different settings.Information was put in different arrays, a matrix o f cat egories was developed and evidence placed within such categories (Miles & Huberman: 1994in Yin: 2003: 111).These were presented in tables.

Trusworthiness
To ensure richness and depth o f data as well as to enhance credibility o f this study, triangulation was implemented by utilizing multiple sources o f data (Polit, Beck & Hungler, 2001:313).For data triangulation multiple sources of data were used.This included using two cases, and having health profes sionals, community members and com munity health workers as study partici pants.For method triangulation, differ ent methods o f data collection were used and these included focus group interviews and individual interviews.Peer examination was achieved by dis cussing the findings with a colleague who is an experienced and credible re searcher.Focus groups were also con ducted for data verification and mem ber checks.

Ethical considerations
Permission to conduct the study was requested from the departm ent o f health in KZN.Authorities from the dif ferent institutions concerned, namely, the various community health centres, were also approached for consent to conduct a study.Community leaders were also approached for their consent.All participants were asked for either a written or verbal informed consent or a choice to refuse to participate.They were informed that they were free to discontinue at any time o f the study.To maintain confidentiality during in terviews the researcher explained to the participants that whatever information was discussed during the interview should be kept in confidence.Further more, participants were asked not to give their real names, but to use pseudo names during the discussion.The re searcher asked for permission to record all interview s including the focus groups.Participants were assured that no physical risks were involved in this study.

Results
Each case is presented individually using the case protocol, the research objectives and the conceptual frame work.The levels o f community in volvement in health were derived from the participants' description o f the practice of CIH.

Levels of CIH
In this community participants identi fied two types o f community involve ment in health namely (a) participation and (b) non-participation.The community members and health professionals had differing views on the levels at which the members were involved in health.Some community members verbalized that they sometimes met on their own to help each other should there be somebody who was ill in the commu nity.The following quotes support this statement: What we are doing is to meet and dis cuss i f the person is sick.We advise him what to do or where to go i f he has this problem.
We ju st help each other as neighbours and friends.Say i f a person is sick we ju st plan and say let s go and see him.
The health professional were in agree ment with this as they felt that there was a very high level o f community participation since the com m unity members identified some of their needs and acted upon them with some help from the health professionals.Accord ing to these health professionals wellestablished community structures had also been put in place by the commu nity, with little help from health profes sionals.Through these structures, the commu nity could communicate with the clinic.From the interviews, the following quotes demonstrating this observation were identified: My experience in CIH was the building o f one o f the clinics in which the community was involved rightfrom the beginning.This clinic was built be cause the community identified the need...The community has already chosen the community health workers; they have established the health committees and the clinic's involvement will only be in training the community health workers and supervision as and when needed.Some participants in all categories disa greed that there was participation as they felt that they were still at non-participation level.The community mem bers verbalized that although the staff was very friendly to them; they (health professionals) never went out to them, as the community and they are there fore never involved in decision-mak ing.This was indicated in the follow ing passages: I 've never been involved in any decision-making or changes being made at the clinic.
As long as I can remember, nothing is happening in this community.The only time I visit the clinic is when I am sick.The sisters treat us very well but they don't go out to our community to dis cuss any health problems with us.Some health professionals were in agreement with this non-participation, and they felt that the decisions came from the higher authorities, such as pre planned programmes on the health cal endar.According to these health pro fessionals, the clinic did not involve the community, as they should, in ren dering health care services.These health professionals however felt that they did not have a stable community that they could involve in the health programmes.The following passages support these statements: Sometimes the directors o f clinic serv ices and the community services work together with the local councils to make decisions.These decisions are then communicated to the community.

I d o n ' t see any community involvement
in health programmes taking place in our clinic.In this clinic we deal mostly with people who visit the clinic be cause they work here in town, so I would be telling a lie i f I say we ever go out to them fo r community devel opment purposes.
The CHWs however described the level o f community involvement as at participation level.These participants felt that the community was driving most o f the community projects, and that they identified their own needs, and the health professionals assisted them to some extent.The CHWs take responsibility to liase between the clinic and the community.We teach each other and the commu nity about the existing health pro grammes.
Through community meetings we dis cuss any community problems.We talk to the community members and they identify the need for a project.

Levels of CHI in case B: rural community
From the com m unity m em bers, it emerged that all three levels of partici pation existed in this community as participants felt there was a) participa tion, others identified the levels as (b) pre -participation while others believed that (c) non-participation existed in this community.
The community members felt that there was participation taking place but this involved only the community members and that the health professionals were not providing any form of support as far as these projects were concerned."We are nursing sick people at home; terminally ill people are at home with out any support from the clinic.The clinic sta ff does not give us support such as gloves or to tell us how to give treatm ent to these sick p eo p le at home "."We do have women' s clubs such as handw ork, gardening and candle making.Some o f these projects were initiated by CHWs ".
For the some community members there was some participation; however these participants felt that it was only at pre participation level.These participants verbalized that they were only called during implementation o f programmes when they were asked to come and give speeches and to dance.This was view ed as "deco ratio n " whereby health professionals decide what to do, the community takes part by singing, dancing or performing cer emonial functions.M aybe i t ' s during im plem entation when they go to dance at the clinic.People sometimes go to play sketches and sing at the clinic.
We are never involved in planning but we get informed i f they want us to par ticipate such as saying a poem, deliv ering a speech, and so on.
The health professional were in agree ment with this community view on pre participation level as they felt that some times, depending on the type o f deci sion, the clinic staff made decisions, in which the community members would be involved during implementation, af ter being informed by clinic staff.Ac cording to these health professionals, the community is only involved during im plem entation o f the health pro grammes.They do attend the clinic functions and they participate by bringing their chil- The other community members how ever agreed with some health profes sionals that there was no community participation at all.For these commu nity members there were no projects that were in place and that involved the clinic and the community.The health professionals also made it evident that the decisions are made at the main clinic (sometimes based on clinic statistics) and they have to in form the community about these deci sions which have to be implemented.
The CHWs in this community were di vided into CHWs linked to the clinic and the volunteer CHWs.For CHWs linked to the clinic the feeling was that there was community involvement in health.They felt that the community was involved in decision making in all the health related matters.The involve ment of the community was said to be from the planning to evaluation o f the project.The following was quoted: "We involve them at the beginning because they have to decide on the date.Before we do anything in our planning we have to let them know.So, i t ' s from the beginning to the end.Even the program is compiled with them; we cannot do it alone because we are working with the community.We do not ju st come and tell them here is the programme ".
The volunteer CHWs however had a different view as they felt that there was no community involvement in health programmes.The following lines were quoted: "No, they do not encourage us to get involved.We would love to go and participate but they do not invite us, by the time we hear about an event at the clinic i t ' s long past.This makes us feel bad because we are supposed to work with them; we are supposed to be there.We, the community have never been involved in the planning o f these health events".
The results are summarized in table 1.

Discussion and conclusion
The rural community members felt that they were in charge o f their health projects where they were working with out the health professionals.This find ing o f the community being in charge o f the projects is at the highest level in the ladder o f participation, and there fore demonstrated a very high level of community participation in health pro grammes.The com m unity projects which the community members were referring to included such projects as sewing, poultry farming and candle making only, which therefore excluded other health programmes such as im munisations, breastfeeding and health education.
The health professionals also felt that the community was involved in health programmes since they were involved during implementation o f such health programmes as breastfeeding and im munizations.What also emerged from the rural community was that the two groups o f CHWs were functioning in dependency from each other, and there was therefore no integration in their service provision.
The findings in the urban community differed from that o f the rural commu nity in that community members in the urban community helped each other as neighbours in times of need without the help o f the health workers.In the rural community the community was in charge by working on their own in their community projects.In the urban com munity, on the contrary, there were no community projects on which the com munity members were working.
This lack of interest in participation in health programmes by the urban com munity members confirms that the com munity cannot be defined in terms of its geographical boundaries and its shared interests.This is the case be cause the people in this community are in the same geographical boundary but they do not share the same interest with the other community residents in the same geographical boundaries as far as health needs are concerned.The urban community members did not identify the need to involve themselves in the clinic health programmes.
Probing was done during the interview process Questions that were asked: "How have you participated in health projects in the past two years?", "In your view, what health activities involve commu nity members in this com m unity?"