CSIRO PUBLISHING

Australian Journal of Primary Health, 2015, 21, 2–8

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http://dx.doi.org/10.1071/PY12164

Impact of community participation in primary health care:

what is the evidence?

Jessamy Bath A,B,C and John Wakerman A,B

A
Centre of Research Excellence in Rural and Remote Primary Health Care, PO Box 666, Bendigo,
Vic. 3552, Australia.
B
Centre for Remote Health, a joint centre of Flinders University and Charles Darwin University,
Alice Springs, PO Box 4066, Alice Springs, NT 0871, Australia.
C
Corresponding author. Email: jess.bath@gmail.com

Abstract. Community participation is a foundational principle of primary health care, with widely reputed benefits
including improved health outcomes, equity, service access, relevance, acceptability, quality and responsiveness. Despite
considerable rhetoric surrounding community participation, evidence of the tangible impact of community participation is
unclear. A comprehensive literature review was conducted to locate and evaluate evidence of the impact of community
participation in primary health care on health outcomes. The findings reveal a small but substantial body of evidence that
community participation is associated with improved health outcomes. There is a limited body of evidence that community
participation is associated with intermediate outcomes such as service access, utilisation, quality and responsiveness that
ultimately contribute to health outcomes. Policy makers should strengthen policy and funding support for participatory
mechanisms in primary health care, an important component of which is ongoing support for Aboriginal Community
Controlled Health Services as exemplars of community participation in Australia. Primary health-care organisations and
service providers are encouraged to consider participatory mechanisms where participation is an engaged and developmental
process and people are actively involved in determining priorities and implementing solutions.

Received 21 December 2012, accepted 13 September 2013, published online 1 November 2013

Introduction
The right of people to participate in the planning and
implementation of their health care was articulated in the
declaration of Alma-Ata over 30 years ago (World Health
Organization 1978). Since that time, community participation as a
concept has permeated much of the primary health care (PHC)
literature. The assumed benefits of community participation are
diverse and include improved health outcomes, access, equity,
relevance, acceptability, service quality and responsiveness
(Rifkin 1990; World Health Organization 2002; Jolley et al.
2008; Draper et al. 2010). Given the rhetoric surrounding
community participation, what evidence is there of tangible
impact and how is this of use to policy makers, PHC organisations
and service providers?
In the current climate of health-care reform in Australia, with a
renewed focus on PHC, and population-based planning that
takes into account local needs, participation as a strategy is of
critical policy interest. But for what level of participation should
services be opting for and what are some of the likely outcomes?
This article reviews evidence of the impact of community
participation in PHC and considers possible implications.
Methods
A comprehensive literature review was conducted to locate and
evaluate evidence of the impact of community participation in
PHC on health outcomes. For the purposes of the review,
community participation is defined as the range of activities
whereby individuals and organisations are actively involved
in health-service planning, decision-making, programme
implementation or evaluation. PHC is defined as:
Socially appropriate, universally accessible, scientifically
sound first level care provided by a suitably trained
workforce supported by integrated referral systems and in
a way that gives priority to those most in need, maximises
community and individual self-reliance and participation
and involves collaboration with other sectors. It includes
the following: health promotion, illness prevention, care of
the sick, advocacy, and community development.
(Australian Primary Health Care Research Institute 2010)
A range of public health and health system-related databases
were interrogated as well as relevant websites, which are
presented in Table 1. Search terms included community
participation, consumer participation, health, impact, outcome
and evidence and were used in a variety of combinations. While
no date limits were set, searching was limited to English. The
database search returned 617 records, which were screened by
reading titles and abstracts. An additional 89 records were
identified through other sources such as websites and reference
lists of relevant papers. Overall, 175 papers were assessed for

Journal compilation Ó La Trobe University 2015 www.publish.csiro.au/journals/py

Impact of community participation in primary health care Australian Journal of Primary Health 3

Baum’s (2008) typology of participation, which is presented in

What is known about the topic? Table 2.
* Community participation is a foundational principle of
primary health care, with widely reputed benefits
including improved health outcomes, equity, access, Findings
quality and responsiveness. Despite rhetoric, evidence There is small but significant body of evidence that community
of impact is unclear. participation is associated with improved health outcomes
(Raymond and Patrick 1988; Chandler and Lalonde 1998;
What does this paper add? O’Rourke et al. 1998; Sare and Kirby 1999; Rowley et al. 2000,
*This paper locates and evaluates evidence of the impact 2008; Hancock et al. 2001; Warchivker and Hayter 2001; Brady
of community participation in primary health care on et al. 2003; Espino et al. 2004; Goodrow et al. 2004; Manandhar
health outcomes and considers possible implications for et al. 2004; Fitzpatrick and Ako 2007; Nikniaz and Alizadeh
policy makers and service providers. 2007; Bhutta et al. 2008; Draper et al. 2010; Lavoie et al. 2010;
Kibria et al. 2011; Oba et al. 2011).
Interestingly, much of the evidence relating to community
eligibility along the lines of community participation, PHC and participation and health outcomes is from studies that document
evidence of impact. The final synthesis included 33 papers. community-based participatory health interventions (O’Rourke
The literature was categorised in terms of study design using et al. 1998; Rowley et al. 2000; Warchivker and Hayter 2001;
the Oxford Centre for Evidence-Based Medicine (2009) levels Espino et al. 2004; Goodrow et al. 2004; Manandhar et al. 2004;
of evidence. In this hierarchical model of assessment, studies Fitzpatrick and Ako 2007; Nikniaz and Alizadeh 2007; Bhutta
are ranked from 1 to 5 with 1 being the highest level of et al. 2008; Draper et al. 2010; Kibria et al. 2011; Oba et al.
evidence. The literature was also categorised according to 2011). These are public health interventions that involve the
community for the purpose of achieving the aims of the
intervention. While participatory mechanisms are central to these
Table 1. Literature sources searched health interventions, it is difficult to disentangle community
participation from the broader intervention process in order to
Databases searched Websites searched quantify its contribution to health outcomes.
APAIS-Health (Informit) Australian Policy Online There is a limited body of evidence that community
ATSIhealth (Informit) Communication Initiative Network participation is associated with a range of intermediate outcomes
CINAHL HealthInfoNet such as access (Uddin et al. 2001; Wilson et al. 2001; O’Meara
Embase Health Issues Centre and Houge 2003; Tyrrell et al. 2003; Mutton 2004), utilisation
Health and Society Health Systems Evidence – McMaster (Kibria et al. 2011), quality (Uddin et al. 2001) and
(Informit) University responsiveness (Wilson et al. 2001; Mutton 2004) that ultimately
Medline Cochrane Institute of Medicine Reports contribute to improved health outcomes.
RURAL (Informit) Lowitja Institute
Baum’s (2008) typology of participation was used as a
NHS Economic Evaluation Database
World Health Organization
conceptual framework to guide the substantive analysis. Where
sufficient detail permitted, the literature was categorised

Table 2. The continuum of participation

Consultation Participation as a means Substantive participation Structural participation

Form Asking for people’s Using participation to achieve People are actively involved in Participation as an engaged
opinions and a defined end determining priorities and and developmental
reactions to policy implementation but process in which
plans initiative externally community control
controlled predominates
Examples of mechanism *
Community meeting *
Community meeting *
Community meeting *
Elected board of
of participation governance
*
Focus group *
Focus group *
Focus group *
Health transfer agreement
*
Patient satisfaction *
Interview *
Survey
survey
*
Face-to-face or *
Local advisory committee *
Steering committee
telephone interview
*
Brainstorming session with *
Local health planning team
stakeholders
*
Participatory action group *
Community reference group
*
Women’s group *
Stakeholder committee
*
Community education group *
Joint planning
*
Collaborative relationships
4 Australian Journal of Primary Health J. Bath and J. Wakerman

Table 3. Evidence of impact of community participation by type of clinics, thereby improving service access and responsiveness.
participation and level of evidence While substantive participation may be externally initiated,
Type of Study Oxford Centre for people involved in these projects have been found to take
participation Evidence-Based Medicine increasing ownership with time.
level of evidence With respect to structural participation, much of the literature
documenting this type of participatory mechanism comes from
Consultation Nilsen et al. (2006) 1
the Aboriginal community-controlled sector. Outcome data in
Means Bhutta et al. (2008) 1
Kibria et al. (2011) 4
the Indigenous context need to be interpreted in terms of the
Manandhar et al. (2004) 1 complex and changing social milieu of an Indigenous population
Oba et al. (2011) 4 subjected to and resisting colonisation. There is a limited body
O’Rourke et al. (1998) 3 of evidence that structural participation is associated with
Warchivker and Hayter (2001) 4 improved health outcomes (Chandler and Lalonde 1998; Rowley
Substantive Draper et al. (2010) 4 et al. 2000, 2008; Lavoie et al. 2010). A Canadian study by
Hancock et al. (2001) 1 Chandler and Lalonde (1998) found that First Nation
Mutton (2004) 5 communities that had some measure of control over the provision
Nikniaz and Alizadeh (2007) 4 of health-care services had lower rates of youth suicide than
Sare and Kirby (1999) 5
communities that did not. In an innovative study of First Nations’
Tyrrell et al. (2003) 4
Uddin et al. (2001) 4
health services in Manitoba, Lavoie et al. (2010) demonstrated
Wilson et al. (2001) 5 that the longer a community health service has been under
Structural Chandler and Lalonde (1998) 3 community control, the lower the rate of hospitalisation for
Lavoie et al. (2010) 3 Ambulatory Care Sensitive Conditions (ACSCs). The Indian
Rowley et al. (2000) 2 Health Transfer Policy in Canada provides a framework for First
Rowley et al. (2008) 2 Nations and Inuit communities to enter into a transfer process
with Health Canada. Over the transfer period, health services
are supported to assume the management and administration of
according to the type of participation and the level of evidence, health resources based on local needs and priorities.
and is presented in Table 3. In the Australian context, there is evidence that structural
The search uncovered very little evidence of the impact of participation is associated with improved health outcomes
consultation as a participatory process in PHC. Nilsen et al. (Rowley et al. 2000, 2008). The Looma Healthy Lifestyle project
(2006) identified two trials in which consumer involvement in is an example of structural participation in which a community-
the development of patient information material resulted in driven diabetes, obesity and cardiovascular disease prevention
more relevant and understandable material; and one trial programme are associated with sustainable improvements in
comparing face-to-face and telephone discussion with consumers health behaviours and selected health outcomes (Rowley et al.
that found that face-to-face consultation was more likely to 2000). In a more recent study, Rowley et al. (2008) found lower
engage consumers and may result in different community health than expected morbidity and mortality for an Aboriginal
priorities. population living on the Utopia homelands, serviced by the
There is evidence relating to participation as a means to community-controlled Urapuntja Health Service. The nature of
achieve a defined end such as a reduction in neonatal mortality the PHC service, as well as a range of social factors and the
(Manandhar et al. 2004; Bhutta et al. 2008), a reduction in decentralised mode of outstation living are cited as contributing
perinatal mortality and child growth (O’Rourke et al. 1998; to positive health outcomes (Rowley et al. 2008).
Warchivker and Hayter 2001), and an increased utilisation of Brady et al. (2003) provided an account of structural
antenatal and perinatal care and diabetes mellitus prevention participation in an Aboriginal community in South Australia
(Oba et al. 2011; Kibria et al. 2011). Espino et al. (2004) where the Yalata community fought to control the availability
presented several case studies in which community participation of alcohol. The authors cite a significant decline in deaths from
had been used in tropical disease control programmes in all causes, particularly among 15–29-year-olds, following the
resource-poor settings. Participation as a means has been used implementation of alcohol restrictions. Another example of
as a strategy to engage community members in externally structural participation is the Gippsland community action
devised projects to ensure uptake and success. In this way, campaign to prevent the closure of the Gippsland helicopter
participation as a means is not dissimilar to community ambulance service (O’Meara and Houge 2003).
mobilisation. There are several highly informative, broad overviews of
At the substantive level of participation, community members evidence of community participation, on which this study builds
are actively involved in determining priorities and implementing (Crawford et al. 2002; Rosato et al. 2008; Perry et al. 2009; Rifkin
solutions. There is a limited body of evidence that substantive 2009; Preston et al. 2010). Crawford et al. (2002) presented a
participation is associated with improved health outcomes systematic review of patient involvement in the planning and
(Sare and Kirby 1999; Hancock et al. 2001; Nikniaz and Alizadeh development of health care. The authors concluded that patient
2007; Draper et al. 2010), service quality (Uddin et al. 2001), involvement has contributed to changes in services but the
and access (Tyrrell et al. 2003). Wilson et al. (2001) and effects on accessibility and acceptability of services or impact
Mutton (2004) documented intermediate outcomes such as the on the satisfaction, health, or quality of life of patients has not
establishment of a transport service or men’s and women’s been examined. Perry et al. (2009) and Rosato et al. (2008)
Impact of community participation in primary health care
provided an overview of the effect of community participation
on maternal and child health. Both studies cited evidence of
effectiveness relating to several specific interventions. Preston
et al. (2010) synthesised evidence of the effectiveness of
community participation in terms of health outcomes. While
the analysis revealed some evidence of improved health
outcomes, very little is of a high level. Rifkin (2009) reviewed
the lessons learned by policy makers, planners and programme
managers in attempting to implement community participation.
Along with outlining why community participation is so difficult
to implement, Rifkin (2009) claimed there is evidence that
community participation has made significant contributions to
health improvements. While these overviews are highly relevant
and suggest an association between community participation
and health outcomes, they do not provide sufficient detail of
specific participatory processes to be included in Table 3.
Three papers reported community participation to have little
impact and are also not included in Table 3 (Zakus 1998; Murthy
and Klugman 2004; Chilaka 2005). Instances where community
participation was not found to have an association with outcomes
also offer some valuable insights. First, in circumstances where
essential service requirements are not met, community
participation had little impact (Chilaka 2005). Essential service
requirements include factors such as adequate funding,
infrastructure and workforce supply (Wakerman et al. 2008).
Second, power imbalance between health professionals or
government officials and public participants can destabilise the
participatory process, as evidenced by Zakus (1998) and Murthy
and Klugman (2004). Murthy and Klugman (2004) found
hierarchies of power between health professionals, and the
public tended to play out in community forums with marginalised
groups being poorly represented. Zakus (1998), on the other
hand, found that community members participating in a
participatory programme devised by the Ministry of Health
attained little strategic power or control of their work and
activities. ‘They were expected to give freely of their time
within structures determined by the Ministry, while being given
very little power base of their own and very few opportunities to
develop it’ (Zakus 1998, p. 491). These dynamics of power can
result in a kind of ‘pseudo participation’, which is frustrating for
community participants and has little demonstrated benefit at a
community level.
Implications
Community participation is a complex social process and it is
not altogether surprising that there are relatively few studies that
rigorously measure and document its impact. There are also
limitations associated with evidence of hierarchical models of
assessment, such as the framework used in this study. However,
there is an absence of a widely used and accepted alternative.
We acknowledge the importance of appropriateness of research
design, context, process of implementation, and size of effect
that should also be considered when assessing any complex
non-clincial intervention (Rychetnik et al. 2002; Petticrew and
Roberts 2003).
Community participation is likely to have a moderating or
mediating effect on the relationship between health-service inputs
such as adequate funding, infrastructure and workforce supply
Australian Journal of Primary Health 5
and outputs such as health outcomes, service access, quality and
responsiveness (see Wakerman and Humphreys 2011). For this
reason, quantifying the unique contribution of community
participation to health-service outputs is methodologically
challenging.
While the available evidence is limited, it contains valuable
insights for policy makers, PHC organisations and service
providers. As community participation has been shown to have
some association with improved health outcomes, service
access, utilisation, quality and responsiveness, policy makers
should strengthen policy and funding support for participatory
mechanisms in PHC. An important component of this is ongoing
support for ACCHSs as exemplars of community participation
in Australia that provide a model of participation for other
health services looking to entrench participatory mechanisms.
Since the early seventies in Australia, ACCHSs have been
providing accessible, effective, appropriate, needs-based health
care with a strong focus on prevention and social justice.
ACCHSs have a formal mechanism for community participation
by way of community representation on boards of governance.
The existence of a community board of governance in and of
itself may not necessarily equate to structural participation and
does not protect a health service from encountering serious
problems. Furthermore, structural participation in ACCHs may
not necessarily equate to improved health outcomes for
Indigenous peoples because of social, economic and political
inequalities that contribute to poor health outcomes at a
population level. Despite challenges, this model of participation
has generally been successful in the Australian context,
contributing to empowerment and improved access for
Aboriginal people as well as sustainable health services
(Eckermann et al. 2010).
In terms of the level of participation to which PHC
organisations and service providers should be aspiring toward,
while participatory mechanisms are most entrenched in structural
participation, not all communities and health services are in a
position to have a community board of governance. Where
structural participation is not practical, lower levels of
participation are a reasonable objective for PHC organisations
and service providers. Participation as a means as well as
substantive participation may still offer benefits in terms of
health outcomes, service access, utilisation, quality and
responsiveness (O’Rourke et al. 1998; Sare and Kirby
1999; Hancock et al. 2001; Uddin et al. 2001; Warchivker
and Hayter 2001; Wilson et al. 2001; Tyrrell et al. 2003;
Manandhar et al. 2004; Mutton 2004; Nikniaz and Alizadeh
2007; Bhutta et al. 2008; Draper et al. 2010; Kibria et al. 2011;
Oba et al. 2011).
While there is evidence of the impact of participation as
a means (O’Rourke et al. 1998; Warchivker and Hayter 2001;
Manandhar et al. 2004; Bhutta et al. 2008; Kibria et al. 2011;
Oba et al. 2011), it is largely driven from outside the community.
The nature of this participatory mechanism does raise questions
about its sustainability. It is likely that this sort of participation
will not continue beyond the life of the project unless it is
somehow firmly entrenched in the operations of the local
health service. The involvement of local health services in
these studies of participation as a means is not clear from the
literature.
6 Australian Journal of Primary Health
PHC organisations may wish to consider Citizens’ Juries as
a mechanism for substantive participation in health decision-
making (Coote and Lenaghan 1997). A Citizens’ Jury is a group
of randomly selected community representatives who are brought
together to discuss and reflect on questions of interest against a
backdrop of resource restraints. The Jury is provided with
detailed information by experts and given an opportunity to ask
questions. Citizens’ Juries provide a mechanism for community
members to participate in decision-making relating to the way
health services are structured, resourced and delivered, and
have been used at varying levels in the health system to ascertain
community values. Based on an analysis of two Citizens’ Juries
in the UK, Pickard (1998) points to limitations of the model
in terms of the accountability, authority, legitimacy and
representativeness of the jury.
Service providers looking to establish a substantive
participatory mechanism in their service may wish to consider
a Critical Friends Group, a mechanism for substantive
participation in general practice (Greco et al. 2006). Critical
Friends Groups are essentially patient advisory groups made up
of practice staff and patient participants who meet on an ongoing
basis. Practitioners select participants with whom they feel
comfortable and who they believe will make a constructive
contribution to group discussions. Meetings are an opportunity
for patients and practitioners to share information and work
together to address quality improvement issues. In this way, the
process is a combination of patient participation and quality
improvement. This model for participation, implemented in
Devon, UK, has broader applicability for general practice in
Australia and elsewhere. The accountability, authority and
representativeness of Critical Friends Groups as a participatory
mechanism have not been evaluated in the context of PHC.
There is an opportunity to entrench participatory mechanisms
in Medicare Locals. These PHC organisations are designed to
meet local health needs and fill service gaps; community
participation is likely to support these objectives. The Northern
Territory Medicare Local, for example, has entrenched a
participatory mechanism through a Community Health
Advisory Committee. There is a risk, however, that power
differentials between health professionals, government officials
and community participants will destabilise the participatory
process (Zakus 1998; Murthy and Klugman 2004).
Conclusions
This review has uncovered a small but significant body of
evidence that community participation is associated with
improved health outcomes. Much of this literature documents
community-based participatory health interventions. There is
also a limited body of evidence that community participation is
associated with intermediate outcomes such as service access,
utilisation, quality and responsiveness that ultimately contribute
to health outcomes.
Structural participation in the Aboriginal community-
controlled sector has been shown to have an association with
improved health outcomes in some instances. Policy makers
should strengthen policy and funding support for participatory
mechanisms in PHC. Substantive participation is a viable
option for PHC organisations and service providers looking to
J. Bath and J. Wakerman
entrench participatory mechanisms. Citizens’ Juries and Critical
Friends Groups are two potential mechanisms to enable
participation in PHC services and mainstream general practice.
Quantifying the impact of community participation is
methodologically challenging and a future research challenge is
the development of a pragmatic mechanism for assessing and
monitoring community participation in PHC.
Conflicts of interest
None declared.
Acknowledgements
The authors are members of the Centre of Excellence for Rural and Remote
Primary Health Care. The research reported in this paper is a project of the
Australian Primary Health Care Research Institute (APHCRI), which is
supported by a grant from the Australian Government, Department of Health
and Ageing. The information and opinions contained in it do not necessarily
reflect the views or policy of APHCRI or the Australian Government,
Department of Health and Ageing. The Centre for Remote Health is funded
by the Department of Health and Ageing. We are grateful to John Humphreys
and Nicholas Biddle for their helpful comments on earlier drafts of the
manuscript.
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