The meaning of community involvement in health : the perspective of primary health care communities

The goal of this study was to establish the understanding and appreciation of the essence of PHC principles in the two Primary Health Care (PHC) communities. The PHC communities in this study referred to the people who were involved in the operation of the phenomenon, that is health professionals working in the health care centers and the communities served by these health care centers. It was hoped that the study w ould enhance the understanding o f the im portance o f com m unity involvement in health (CIH) in health care delivery, for both community members and health professionals. A case study method was used to conduct the study. Two community health centers in the Ethekwini health district, in Kwa Zulu Natal, were studied. One health center was urban based, the other was rural based. A sample of 31 participants participated in the study. The sample comprised of 8 registered nurses, 2 enrolled nurses, 13 community members and 8 community health workers. Data was collected using individual interviews and focus groups, and was guided by the case study protocol. The findings of the study revealed that in both communities, participants had different, albeit complementary, understanding of the term ‘Community Involvement in Health’ (CIH). Essentially, for these participants, CIH meant collaboration, co-operation and involvement in decision-making.


Background to the problem
One o f the primary health care (PHC) principles that were identified at the Alma A ta conference held in 1978 was the principle o f community participation or community involvement in health (WHO, 1978: 2).Presently, very little is known as to the extent o f community involvement in health (CIH) in South Africa.Despite th e fa c t th a t th e g o v e rn m e n t has advocated community involvement as an im portant attribute in the delivery of health care.In developing the National H e a lth P la n , th e A fric a n N a tio n a l Congress (ANC) government based the plan on the A lm a-A ta principles o f c o m p re h e n siv e prim ary h ealth care (A N C , 1994: 20).The go v ern m en t's intention to provide primary health care to all the people was demonstrated in the National Health Service Delivery Plan.T his plan sta te d th a t an affo rd ab le, com prehensive health service should be developed, in which community members would have the power to decide on health issues (ANC, 1994: 21).In The W hite Paper f o r Transform ation o f the H ealth System in So u th A frica (Department of H ealth, 1997: 14) the objectives for restructuring the health system were set.One o f these objectives was to foster c o m m u n ity p a rtic ip a tio n acro ss the health sector by involving communities in various aspects o f the planning and provision of health services (Department of Health, 1997: 16).In this document the Governm ent indicates that com m unity participation in health prom otion and health service provision is an important com ponent in the improvement of health care (Van Rensburg, 2004:131).The findings of the survey of the national primary health facilities, conducted by Viljoen, Heunis, Janse van Rensburg, van Rensburg, Engelbrecht, Fourie, Steyn, and Matebesi (2000:82), showed that little progress had been made in facilitating community participation in PHC in South Africa in the two years since 1998.Viljoen et al. in this study further argue that even though KwaZulu Natal (KZN) was among the provinces where headway had been m ade, th e c h an g e w as d e sc rib e d as limited.
Owing to the geographic structure and conditions o f the com m unities in South A frica, and sp ecifically in the KZN province, effective CIH might not always be easy to achieve.The nature o f urban com m unities does not allow for the kind o f in te ra c tio n b e tw e e n c o m m u n ity members and health professionals, which is n eed ed fo r e ffe c tiv e C IH .U rban communities are not as closely knit as rural com m unities are.The community m embers in urban com munities tend to come together only in times of crisis and/ or need, rather than as a way of living.It would therefore seem that urban and rural communities present different challenges for CIH, with a particular understanding o f com m unity involvem ent having been developed in each setting.This study was aim ed at enhancing the understanding o f policy on CIH, and the importance of CIH in health care delivery, for both com munity members and health professionals.The m ore recent study conducted for the health systems trust (HST) by Gwele and Makhanya (2001:17-18) revealed that community involvement in health had taken many forms from mere establishm ent o f clinic com m ittees to intersectorial collaboration, focusing on more than health issues, by including community development as a whole.This range dem onstrated the significance of com m unity involvement in health care d e liv e ry an d in d ic a te d a n eed to d e te rm in e th e u n d e rs ta n d in g o f com m unity involvem ent by the PHC communities.

Purpose and objectives of the study
The purpose o f this study was to explore and d e s c rib e PH C c o m m u n itie s ' understanding and appreciation o f the essence of CIH as a principle o f PHC.The objectives were: 1.To describe urban and rural PHC com m unities' understanding of CIH.
2. To d e te rm in e s im ila ritie s and differences between the rural and urban communities' understanding and practice of CIH.

Definition of terms
Community: It is a group o f people who share some type of bond, who interact w ith each o th er, and w ho fu n c tio n collectively 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 interests, goals, or occupations (Clark, 1996:6).In addition to this definition the A N C 's definition o f the term community will be ad opted, th at is, "to rep rese n t those people living in the geographical area served by a com m unity health centre" (ANC, 1994:61).Swanepoel, 1999: 9).These two terms will be used interchangeably.

P r im a r y H e a lth
C are (P H C ) com m unities: In this study, this term refers to people who are involved in the operation of the phenomenon, that is, the health p ro fe ssio n a ls w orking in the health care centre and the com m unity served by the health centre.
H ealth professionals: T hese are the members of the health team, including the n u rse s (all c a te g o rie s ) w o rk in g in community health centres.refers to communities situated in the inner city, in which a large num ber o f people live and work in close proximity.The assum ption w ill be based on M ann 's (1983: 409) defin itio n th at in urban communities relationships are impersonal and superficial and segmental.Also, that the population is more heterogeneous owing to greater mobility o f 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 involvement (participation).Relevant research articles on com m unity participation in health problems and on measuring community participation were reviewed.In this article th e fo c u s w ill be on c o m m u n ity participation.

Participation in Health
C o m m u n ity p a r tic ip a tio n p lay s an important role in rendering effective PHC in the community.The community can participate in many ways and at every stage of PHC.According to the WHO (1 978: 5 1 ,) the c o m m u n ity can be in v o lv e d in th e a s s e s s m e n t o f the situation, the definition of problems and the setting of priorities, and can then help to plan PHC activities and co-operate fully when these activities are carried out.It is im portant that the com m unity is willing to participate.The health system will then be involved in explaining and providing information where necessary.

In Health
The term "community involvement" and/ o r "p a rtic ip a tio n in h e a lth " is an o u tg ro w th o f v a rio u s a tte m p ts at determining both the substance and the process of community involvement in the provision of health care.It first emerged or became popularised in health related lite ra tu re fo llo w in g the A lm a A lta conference in 1978.At this conference, the W H O id e n tifie d c o m m u n ity participation as one of the principles of PH C .T he o r g a n iz a tio n d e fin e d community participation as "the process by which the individual and the families assum e resp o n sib ility fo r th e ir own health and welfare and for that of the community, and develop the capacity to c o n trib u te to th e ir c o m m u n ity 's development" (WHO, 1978:50) Bichmann (1988:933), however, the WHO p re fe rs th e term 'c o m m u n ity involvem ent' to the term 'com m unity participation' because, according to the WHO, the term 'community involvement" implies active participation rather than passive engagem ent in health activities.
A similar view of community participation and/or involvem ent was conceived by Chimera-Dan (1996:13), who identified three forms of community involvement.It is therefore, apparent from the above statements that, in fact Rifkin does not really d iffere n tiate betw een the tw o concepts, at least, in so far as the nature o f the com m unities' participation and/or involvement in health is concerned.For Kahssay and Oakley (1999:5)

Specific targeting of project benefits:
B e n e fits a re ta rg e te d d ire c tly at previously excluded groups, for example, landless people, the poor and so on.The beneficiaries influence the direction and execution o f the developm ent project rather than merely receiving a share of the project benefits.3. Empowerment: Previously excluded g ro u p s are e m p o w e re d in o rd e r to in crease ac ce ss to and co n tro l over developm ent resources.This process includes the developm ent of skills and abilities to enable people to m anage existing developm ent delivery systems better and to have a say in whatever is done.
T he p re c e d in g d is c u s s io n o f the conceptualisation of the term 'community participation' by Chimera-Dan (1996), Kahssay and Oakley (1999) and the WHO stu d y g ro u p (1 9 8 5 ) sh o w s th at com m unity particip atio n , although it usually is externally introduced, can and does go beyond the level o f 'welfare activities', to ensure empowerment of the community.

Research methodology
T he u n d e rs ta n d in g o f c o m m u n ity p a rtic ip a tio n in ru ra l and u rban comm unities was explored and analysed based on the different community types.The case study protocol was used to guide the research er and to keep her focused on the purpose o f the study.

Research Design
A qualitative research approach using the case study design was chosen for this study.A m ultiple case study design was used where cases were selected from both rural and urban communities.M ultiple case stu d ie s w ere used b ecau se the findings arising from two different cases are considered more powerful that those from a single case, which can enhance the generalizab ility o f findings (Yin, 2 0 0 3 :5 3 ).P u rp o siv e sa m p lin g w as u sed as a method of sampling the two communities.This method was selected because the researcher needed to obtain views from individuals with different com m unity backgrounds (Bums & Grove, 2001:376).

Case Description
In this study the case was a community h ealth c e n tre (c lin ic ) in the ch o sen com m unities w ith all the com m unity m em bers u tilisin g the clin ic, health programs and community health workers as its embedded units of analysis.The context of the case was the chosen urban (case A) and rural (case B) communities within the Ethekwini health district.

Case Selection
Purposive sampling was used to select cases.T he rese arch er id entified tw o particular types o f cases for in-depth investigation (Neuman, 1997:206).These ca se s w ere se le c te d p u rp o siv e ly to ensure that the chosen cases were typical o f the p o p ulation required (Seam an, 1987:244).O ne case was selected to represent the rural community and the second case was selected to represent the urban community.A sampling frame, which had the names of all the areas classified under this health district, was used to select the cases.From the sampling frame, the researcher id e n tifie d one ru ra l and one u rban com m unity.Each case w as carefully selected to e n su re th a t it p re d ic te d contrasting results (Yin, 2003:47).

Sampling of Participants
The m ost ap p ro p riate case sam pling strategy for qualitative research is non probability sam pling, one exam ple of which is theoretical sampling.In case B, com m unity m em bers were sampled using snowball sampling.This seem ed to be the m ost a p p ro p ria te method as the researcher was looking for people with specific traits (Polit and Hungler, 1999:281), namely people who had been utilizing the same clinic for a period of over 5 years.The criterion for selecting active community members was th ro u g h id e n tif ic a tio n o f th e se in d iv id u als by a variety o f sources.T h ese in c lu d e d th e n u rsin g sta ff, community health workers (such as the AID S co -o rd in ato rs, the com m unity health w orkers' trainers and facilitators).The re se a rc h er also in clu d ed those co m m u n ity m em b e rs id e n tifie d by community leaders and other informants (such as izinduna and other respected community members).

Ethical considerations
Perm ission to conduct the study was requested from the department of health in KZN.Authorities from the different in stitu tio n s c o n c e rn e d , nam ely, the various community health centres, were also approached for consent to conduct a study.Community leaders were also a p p ro a c h e d fo r th e ir c o n s e n t.A ll p artic ip an ts w ere asked for e ith e r a written or verbal informed consent and w ere g iv e n a c h o ic e to re fu s e to participate.They were informed that they were free to discontinue at any time of the study.C o n fid en tiality w as to be maintained at all times.The researcher ask ed fo r p e rm issio n to re c o rd all interviews, including the focus groups.P a rtic ip a n ts w ere a s s u re d th a t no physical risks w ere involved in this study.

Data collection
Data collection in this study was guided by the 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 following: • A short description o f each case, in terms o f its demography, services offered and present activities.

• A n in terv iew sch ed u le w ith one research question to be asked, the main research question being " What is your u n d e r s ta n d in g o f c o m m u n ity involvem ent in health?"
This research question was used in both the in d iv id u al in terv iew s and focu s groups and the researcher had to probe to obtain more information.The strategies used for data collection included face-to-face interviews in the form o f focus group in terv iew s and individual interview s.The interview s allowed the respondents to comment on widely defined issues and to feel free to e x p a n d on th e ir e x p e rie n c e s , as is c h a r a c te r is tic o f s e m i-s tru c tu re d interviews.Purposively selected focus group interviews were conducted where the informants were found as a group or fo r in fo rm a n ts w ho w ere w o rk in g together.This was to ensure that the groups were homogeneous, to facilitate open discussion (Burns & Grove, 2001: 452).One focus group was conducted in each com munity.In case A the focus group was conducted with the CHW s, whereas in case B, the focus group was on community members.This difference was determ ined by the availability of participants.

Data analysis
Data collection and analysis was done simultaneously.The analysis of data was begun by using a template, in this case a ca se p ro to c o l.T e m p la te a n a ly tic techniques are m ore open-ended and include generation o f themes, patterns and interrelationships in an interpretive rather than a statistical process (Crabtree & M iller, 1992: 19).A case protocol, to g e th er w ith the research q u estio n , guided the analysis o f data.The researcher identified them es and patterns and did interpretational manual data analysis.Data was then segmented to meaningful units.The segments were c o d e d an d so rte d in to c a te g o rie s .R elationships am ong categories were then established.As described by Miles and Huberman, (1994:90) within case and cross case analysis was done to compare th e fin d in g s in d iffe re n t s e ttin g s .Information was put in different arrays, a matrix o f categories was developed and evidence placed within such categories (Miles & Huberman, 1994, in Yin, 2003: 111).These results were presented in tables.

Trustworthiness
To ensure richness and depth of data as well as to enhance credibility of this study, tr ia n g u la tio n w as im p le m e n te d by utilizing multiple sources of data (Polit & Hungler, 1999:428).For data triangulation m u ltip le sou rces o f data w ere used.These sources included using two cases, an d h a v in g h e a lth p ro fe s s io n a ls , com m unity m em bers and com m unity health workers as study participants.For method triangulation, different m ethods o f data collection were used and these included focus group interview s and individual interviews.Peer examination was achieved by discussing the findings with a colleague who is an experienced and credible researcher.Focus groups were also conducted for data verification and member checks.

Understanding of CIH by the community members
Perusal o f Table 2 reveals

(Urban community) "It is a b o u t h elp in g each other, the clinic h elp in g us an d us helping the clinic. It m eans having committees that s ta n d f o r h e a lth m a tte r s in the com m unity". (Urban community)
For the rural community, however, CIH meant more than mutual assistance.It was seen as a more a collaborative partnership w ith specific focus on that health professionals have a good starting point in involving the community in health matters because the community knew exactly w hat they wanted in order to involve them selves in health matters and hence im prove their health status.
In the urban community, the community members w ho participated in the study had a very limited understanding o f CIH.T his w as not surprising because the participants were people who only visited the clinic occasionally, when there was a need.Their only understanding o f CIH was that it m eant mutual assistance and participating in health committees.This   (Rosenthal, 1998, cited in Swider, 2002: 12).This means that if people are com pliant in taking their treatment, then the CHW s saw them as b e in g c o o p e ra tiv e w ith th e h e a lth programmes.

Conclusions and recommendations
The researchers set out to explore the meaning of CIH for PHC communities in rural and urban health centres.It is essential, however, that the health professionals and the com m unity they serve talk to each other, and ensure that they have a com m on understanding of C IH an d th a t d iffe re n c e s in understanding are clarified.It is only then that implementation of CIH in its essence is possible.Meetings or workshops could be held where this issue of community involvement can be discussed in depth and each com m unity can com e to an u n d e rs ta n d in g as to how th e y w ill approach his issue.Their understanding need not necessarily be the same as in other com m unities but should be in line with PHC principles.

Limitations of the study
• The com m unity m em bers in both co m m u n ities co u ld not d iffe re n tiate b etw e e n the C H W s and the h e a lth professionals.In their responses, some of the co m m u n ity m em bers kept on referring to the CHW s when they meant the health professionals and vice versa.
• The other limitation was that in Case A, the community members from the sub urban residential areas were not utilizing the clinic as expected.The majority of clients attending the clinic were from areas outside town.The people who were utilizing the clinic were only in town for employm ent but did not live in town.
• Owing to the sampling method used the sample size was too small and not fully representative of the comm unities in both cases, therefore the study cannot be generalised.
• With such a small sample size, it was d iffic u lt to a c h ie v e in fo rm a tio n re d u n d a n c y , w h ic h is o n e o f th e d is a d v a n ta g e s o f u sin g p u rp o s iv e sampling (Bums & Grove, 2001:376) • In case B, some community meetings had to be c a n c e lled b ecau se o f bad weather and transport problems for the participants.
C o m m u n ity in v o lv e m e n t a n d /o r participation: This refers to a shift in e m p h a s is fro m e x te rn a l a g e n c ie s supplying health services, to the people o f a c o m m u n ity b e c o m in g a c tiv e participants in their own health care.This m eans that the com m unity m em bers b eco m e p a rtn e rs in h e a lth ca re by generating their own ideas; assessing their needs, by involvement in decision m ak in g p ro c e s s e s , p la n n in g , implementing, and even evaluating the care they re c e iv e (D en n ill, K ing & Rural community: Geographically, this term refers to areas that are remote and isolated.R ural co m m unities are not h o m o g e n e o u s, b u t the fo llo w in g characteristics for rural communities will be a ssu m e d , n am ely , (a) sp a rse population, (b) low family income, (c) unemployment, (d) poor schools, and (e) inadequate or inaccessible health care systems (Deloughery, 1998:359).Urban community: In this study, this term 31 Curationis May 2005 These were (a) a program instrument (b) p a rtn e rs h ip , and (c) c o m m u n ity empowerment.These forms of community involvement were described as follows: 1.A p r o g r a m in str u m e n t: T he co m m u n ity is used to a d v a n c e the objectives of the program, and to improve e ffic ie n c y , e ffe c tiv e n e s s an d c o st recovery of the project.2. Partnership: This is formed with the local authority, arriving at a compromise between the community and the health a u th o ritie s to o rg a n ise se lf-h e lp programs, respect for the individual and w illingness by the authorities to co operate.3. Community empowerment: This refers to a means of prompting self-reliance and self-determination at both individual and community level.K a h ssa y and O a k le y (1 9 9 9 : 8) d if f e r e n tia te b etw ee n the c o n c e p ts 'c o m m u n ity p a r tic ip a tio n ' and 'community involvem ent' in health.For these authors, community involvement differs from community participation in that the former is not just a mechanism to lend support to externally led health d ev elo p m en t program s. C om m unity involvement is described as "a strategy, w h ic h s y s te m a tic a lly p ro m o te s com m unity participation ancj supports and strengthens it in order to provide b e tte r h e a lth fo r the m a jo rity o f people"( Kahssay & Oakley, 1999: 8).T hey arg u e th at C IH w orks as an u m b re lla th a t in v o lv e s c o m m u n ity participation.In other words, community participation is part of CIH.For instance, they assert that CIH " increases the p o ssib ility that health program s and p ro je c ts w ill be a p p ro p ria te and successful in m eeting the health needs defined by local people as opposed to th o se d e fin e d by h e a lth services'^Kahssay & Oakley, 1999:9).Woelk (1992:420) cites Rifkin's definition o f community participation, which does not differ in essence from what Kahssay an d O a k le y see as co m m u n ity involvem ent in health.Rifkin defines com m unity participation as "a social process whereby a specific group with sh a re d n e e d s, liv in g in a d e fin e d geographic area, pursues mechanisms to meet those needs" (Woelk, 1992: 420).Rifkin (1990) further defined community involvement in health as: "a process by which a partnership is e sta b lish ed betw een the g o vernm ent and local communities in the planning, implementation and utilization o f health a c tiv itie s in o r d e r to b e n e fit fr o m increased local self-reliance and social c o n tr o l o v e r in fr a s tr u c tu r e a n d technology o f P H C " (cited in Kahssay & Oakley, 1999:10).
, however, the tw o c o n c e p ts a re d is tin c t and separate.These authors see community participation as a process that ensures the lo cal p e o p le 's c o -o p e ra tio n or collaboration w ith externally induced development program s and projects and th e re fo re , fa c ilita tin g the e ffe c tiv e implementation o f such activities.K ahssay and O ak ley (1 9 9 9 :5 ) view community participation as: 1. C o lla b o r a tio n : H ere, p e o p le v o lu n ta rily , o r as a re su lt o f som e incentive, agree to collaborate with an e x te rn a lly d e te rm in e d d e v e lo p m en t project often by contributing their labour and other resources in return for some other expected benefits.
T h e se tw o c a s e s a lso represented tw o contrasting situations, and th is w as d e e m e d g o o d fo r comparison o f findings.Population The population consisted o f community health centres, health professionals in th e se c e n tre s , and th e su rro u n d in g communities, in the different community settings in the Ethekwini health district.Sampling T he s e ttin g w as c o m m u n ity h e a lth c e n tre s in tw o d iff e r e n t ty p e s o f com m unities, nam ely rural and urban com m unities.Two com m unity health centres within Ethekwini health district w ere chosen as suitable sites for this stu d y b e c a u s e th e d is tr ic t ra n g e s between extreme urban and extreme rural communities.This district, according to the classification by the KZN department o f h ealth , c o n sists o f areas such as Pinetown, Durban, Chatsworth, U m lazi,, In a n d a an d iN d w e d w e (h ttp :// w w w .kzn.gov.za,accessed on 04/02/ 2005).(At the tim e when this study was conducted these areas were classified under Ilembe health district).Two cases (PHC com m unities) were selected for p a rtic ip a tio n in th e stu d y .T h e se c o m p ris e d o n e c a se fro m ru ra l community and one case from an urban community.
Theoretical sam pling was used in the selection of study participants.The initial group of participants were nurses and community m e m b e rs in th e tw o se le c te d PH C c o m m u n itie s. S in ce th is m ethod o f sampling was used, the researcher kept on including other groups of participants, other than the nurses and the community m em bers as the need arose.This was done, because in theoretical sampling, the researcher can do what Glaser and Strauss (1967: 49) refer to as 'ongoing inclusion o f groups' and 'selection of comparison groups', which can be done when the researcher needs to turn to certain groups or sub-groups for the next d a ta c o lle c tio n .In th is stu d y the researcher added the community health workers (CHW s), as participants, as they were also involved in health matters in the community.A total o f 31 participants, representing both cases, participated in this study.C ase A (urban community): All in all 17 participants w ere interview ed.These in c lu d e d 5 re g is te re d n u rse s, 6 community members who lived in the areas surrounding the clinic and 6 CHWs.O f the 5 registered nurses interviewed, 3 33 Curationis May 2005 were in charge o f the specific health programmes.These program m es were HIV/ AIDS, training of health personnel and th e c o o rd in a tio n o f C H W s programme.C ase B (rural community): A total o f 14 participants were interviewed.The health professionals interviewed consisted o f 3 registered nurses, one o f whom was the person in charge o f the clinic and 2 enrolled nurses.From the community, 2 izinduna were interviewed and 5 active c o m m u n ity m e m b e rs.T he C H W s included one community health workers' coordinator, w ho is in charge o f the CHWs who are attached to the clinic, and one of the 4 volunteer CHW s who are not attached to the clinic.In case A, w here active com m unity members were not clearly identified, the researcher used convenience sampling to include community members.People who happened to be at the clinic at that tim e w ere id e n tifie d as p o ssib le participants (Burns & Grove, 2001:374; P o lit and H u n g ler, 1999 :281).The researcher visited the clinic over the period of one week and explained the proposed research to the clients who were waiting in the waiting area.The in te re s te d c o m m u n ity m e m b ers volunteered to participate, but could only be included if they were residents of this community and not just visiting.
that the term CIH meant various things to the rural and to the urban communities.From the data a n a ly sis it e m e rg e d th at the u rban comm unity understood CIH as mutual assistance and organized participation.Mutual assistance referred specifically to community members assisting each other in times of need and assisting the health c e n tre w h en th e n eed a ro se .T he fo llo w in g e x c e rp ts fro m the u rban in te rv ie w e e s d e m o n s tra te th e se observations: "It m e a n s w o rk in g to g e th e r as a com m unity, helping peo ple like those who have problems, i f they are hungry or i f they nee d fo o d it means giving them fo o d " .
(a) sharing o f in fo rm a tio n (b ) o rg a n iz a tio n a l participation, which is the formation of su p p o rt s tru c tu re s su c h as h e a lth c o m m itte e s (c) c o -o p e ra tio n by community members (d) involvement of the community in decision making about health programmes rendered at the clinic (e) c o m m u n ic a tio n b etw e e n h e alth p r o f e s s io n a ls an d the c o m m u n ity members and (f) contribution of skills in health care provision.In their own words: "It means being inform ed about health program m es being run in the clinic.It also m eans that people should have a say in how they should be treated in the clin ic ".(Rural community) "Community involvem ent in health does not exist in this place but we are also pa rt o f the problem since we do not have proper channels o f communication such as health c o m m ittee s w here we can re p o r t h e a lth p r o b le m s ". (R u ra l community) "M y u n d e r s ta n d in g o f c o m m u n ity involvement in health is that it refers to c o m m u n ity 's in v o lv e m e n t in h ea lth com m ittees".(Rural community) B oth urban and ru ral c o m m u n itie s' understanding o f CIH tallied very well with the characteristics o f com m unity participation as identified by different authors in the field of CIH (Dennill, King & S w anepoel, 1999: 85; K ahssay & O akley, 1999: 7; R ifk in , M u lle r & Bichm ann, 1988: 932).Furtherm ore, according to the W HO (1985:31), access to information as well as the right of the people to exercise pow er over decisions th a t a ffe c t th e ir liv e s are key c h a ra c te r is tic s o f C IH .T he b ro a d u n d e rsta n d in g o f C IH by the ru ral community m em bers m ight have been stre n g th e n e d by th e fa c t th at th ese c o m m u n ity m e m b e rs had b een prev io u sly in v o lv ed in developm ent committees and health committees that existed in the com m unity before the new m unicipality dem arcations were put in place.This understanding o f CIH means com m uni cate its needs to the health p ro fe ss io n a ls .T he h e a lth pro fessio n als should c o m municate with the community by giving them advice.Contributive participation: both the community and the health professionals should c o n trib u te in h e a lth c a re provision.Cooperation: community members to cooperate with the service providers by attending clinic functions and utilizing the service.Knowledge of community needs: the community needs to report their health needs to the health professionals Community Health Workers Cooperation: the community has to a c c e p t th e h e a lth program m es to show th eir involvement.Collaboration: the community and the health professionals have to work hand in hand during health care provision.Cooperation: community members cooperating with service providers during service provision, such as "choosing what you eat when you have diabetes and hypertension and the importance o f taking medications".Collaboration: between the community and the clinic.The community assisting clinic staff should they need assistance, "we work together" .
limited understanding o f CIH could have b een lin k e d to the fact th a t th ese community m em bers had never had any exposure to com m unity developm ent pro g ram m es, u n lik e the co m m u n ity members in the rural community.They came to the clinic only for treatment and therefore could not have been aware of the then existing health committees.This in turn might be attributed to the nature of relationships in urban communities.A c c o rd in g to M a n n 's (1 9 8 3 : 4 0 9 ), relationships in urban communities tend to be im p e rs o n a l, s u p e rfic ia l and segmented.T he c o n c e p tu a lis a tio n o f C IH as collaboration by the rural community and as m u tu al a s s is ta n c e by the urb an community should be seen as a positive finding; after all, the W HO (1985: 32) study group em phasized the necessity fo r c o lla b o ra tio n w ith c o m m u n ity representatives and where possible with community members.
It was expected that the two communities (rural an d u rb a n ) w o u ld d iffe r in th e ir understanding of CIH, if only because of the contexts in w hich CIH has to be operationalised.This expectation was supported by the findings o f this study.Not only did the understanding of CIH differ between these two communities, but also between different participants within communities.When differences in understanding exist, it unlikely that the p a rtie s in v o lv e d w o u ld be w o rk in g toward a com m on goal.C om m onalities in understanding did, however, also exist.In both settings, for th e c o m m u n ity m e m b e rs w ho participated in this study, CIH means w orking with the health professionals w hether by merely assisting each other or through collaboration between health p ro fe s s io n a ls and th e c o m m u n ity .According to the rural community and the urban health pro fessio n als, such collaboration is more than cooperation w ith eac h o th e r b u t m u st in c lu d e in v o lv e m e n t in d e c is io n -m a k in g , planning and implem entation of health programmes.B ased on th e s e re s u lts , it can be c o n c lu d e d th a t, a lth o u g h th e re are differences in u n d erstanding o f CIH b e tw e e n an d w ith in g ro u p s, som e commonalities exist between the rural and the urban com m unities' understanding and to a c e r ta in e x te n t w ith in communities.