Community Organising Frameworks, Models, and Processes to Improve Health: A Systematic Scoping Review

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Abstract

Community involvement engages, empowers, and mobilises people to achieve their shared goals by addressing structural inequalities in the social and built environment. Through this review, we summarised published information on models, frameworks, and/or processes of community organising used in the context of health initiatives or interventions and documented the outcomes following their use. A systematic scoping review was conducted in three databases with no restrictions on the date of publication, country, or written language. Out of 5044 studies, 38 met the inclusion criteria and were included in the review. The targeted health outcomes explored by the studies were diverse and included sub-domains such as the promotion of a healthy lifestyle, sexual and reproductive health, access to healthcare and equity, and substance abuse and chronic disease management. The outcomes of most initiatives or interventions were promising, with positive changes reported for the target populations. A wide variation was noted in the models, frameworks, or processes of community organising utilised in these studies. We concluded that variation implies that no single model, framework, or process seems to have predominance over others in implementing community organising as a vehicle of positive social change within the health domain. The review also highlighted the need for a more standardised approach to the implementation and evaluation of these initiatives. We recommend that it is essential to foster public and non-governmental sector partnerships to promote community-driven health promotion efforts for a more sustainable approach to these initiatives.

1. Introduction

Community involvement in research engages and mobilises people with an aim to achieve their shared goals by addressing structural inequalities in the social and built environment [1]. Communities that collectively take responsibility to influence and modify their social and built environment for the purposes of better health and wellbeing are increasingly recognised as effective vehicles for positive change [2]. Consequently, health promotion initiatives that genuinely engage communities are recognised as being more likely to succeed than those that do not engage communities [3,4,5].

Community organising primarily aims to bring people together to act on their common concerns; develop and expand their sense of community ownership; empower them; foster collaboration; and ultimately make the community powerful for the common good [6]. Community organising is an approach to community engagement that assumes communities can act on problems important to them collectively and make desired change. It also assumes the need for people to fully participate in managing organic change, thus supporting sustained positive change. Since these efforts to improve health are driven by community members rather than policymakers, health professionals or other stakeholders, the communities’ priorities take precedence [7,8].

Researchers from several disciplines, including health, have embraced community organising in their research and/or interventions, due to the increased likelihood of success when launched as community organising initiatives [4,5]. Many of those researchers have adopted one or more theoretical/research frameworks, models and community organising processes to structure, inform and/or guide their intervention(s). As a result, the current health literature on community organising comprises diverse initiatives that have adopted a wide range of frameworks, models, and/or processes of community organising. However, to our knowledge there is currently no published study that consolidates and summarises those initiatives and their frameworks, models, and processes in one place. Having this information consolidated will not only provide an opportunity to explore the variety of frameworks, models, and processes but also help identify how they were implemented, the gaps in their implementation, and the ways to strengthen their implementation in future health initiatives.

Therefore, this scoping review will answer the following questions:

What models, frameworks, and processes have been used in community organising initiatives that advance health?

2. Methods

This scoping review followed the Joanna Briggs Institute (JBI) scoping review guidelines [9] and has been reported in line with PRISMA-SCR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) reporting guidelines [10].

3. Search Strategy

Relevant studies were searched in three databases, SCOPUS, Sociological Abstracts, and Google Scholar. Free texts, MeSH terms, and controlled terms were used to construct the search with help from a university health librarian. Search strategies were modified according to each database platform’s command language. The synonyms to indicate “community organising”, “community”, and “framework/theory/model” were used as search terms. For Google Scholar, we screened the first ten pages of results. The reference lists of all studies selected from those ten pages were also reviewed to identify additional relevant studies.

Studies were eligible for the review if they met the following criteria:

A theory, model, or framework of community organising was specifically mentioned as being used to inform the work.

Peer-reviewed, grey literature, conference papers, and empirical or conceptual studies were considered for inclusion in the review. No limits were placed on the date of publication, study design, or the language of the studies.

4. Study Selection

All identified studies were exported from the databases to the reference management software Zotero (version 5.0.96.3) and transferred to the review data management software, Covidence. Upon importing the studies to Covidence, duplicates were screened and removed. The screening was performed in two stages. First, study titles and abstracts were screened in duplicate by all authors (SK, JP, DC, HR, JH, JM, KB, LM, LB) and clearly irrelevant studies were excluded. Second, full-text versions of each of the studies were assessed in duplicate by authors (SK, JP, DC, HR, JH, JM, KB, LM, LB) and those not meeting the criteria were excluded. The reasons for exclusion of full review studies were documented (see Figure 1 ). Any discrepancies and conflicts were resolved by discussion between two authors (LB, DC). The remaining authors were also involved to meet consensus if further disagreements arose.

PRISMA flowchart detailing the article selection process for the scoping review.

5. Data Extraction

Data extraction from the included studies was conducted by all authors using the Covidence data extraction function. A purpose made template was developed and included details of first author’s name, year of publication, source of the article, title of the article, study design, and methods, geographic focus, sector, focus (context/behaviour/movement), and the community organising models, frameworks, and/or processes reported in the paper. Before data extraction commenced, all members of the research team involved in this step piloted the template, and amendments to the table were made according to their feedback.

For each paper, data were extracted independently by two researchers and the results were compared via Covidence. In case of disagreements, the consensus was met through discussion or consultation with a third reviewer.

6. Data Analysis

The data extracted from the included papers were narratively summarised and accompanied by descriptive tables.

7. Quality Appraisal

The mixed methods appraisal tool (MMAT), version 18, was used to critically appraise the articles [1]. This tool was specifically designed for systematic mixed studies reviews. The tool helps to examine the methodological quality of qualitative research, quantitative descriptive research, and mixed methods using relevant quality questions out of five key criteria. For each selected full-text papers, researchers (SK, DC, JM, JH, HR, LM, KB) reviewed quality and suitability, including appropriateness of study aim, adequacy of the methodological approach, representativeness of target population, data analysis, presentation of findings, and authors’ discussion and conclusion. Discrepancies were resolved through discussion.

8. Results

A total of 5044 studies were primarily identified in the search and 348 studies were automatically removed by Covidence as they were duplicates. The remaining 4696 studies were then screened by their titles and abstracts. After excluding 4546 non-relevant studies (unrelated to the review’s outcome and explanatory variables), 150 full text studies were reviewed. Of these, 38 met the inclusion criteria and were included in the review.

The main reasons for exclusion were: the study scope not falling under health domain (n = 72), not related to community organising (n = 27), no framework, model, theory discussed (n = 8), wrong study design (n = 3), wrong intervention (n = 1), and wrong outcomes (n = 1). Of the 38 studies selected for final analysis, 33 were conducted in the United States [2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34], two in the United Kingdom [35,36] and one each in Canada [37], Japan [38] and South Africa [39]. The target populations of 11 of these studies were children and youth [3,6,20,21,22,23,25,29,32,34,40] followed by six studies, each with general [16,26,27,31,35,39] and marginalised population groups [2,5,13,14,15,19]. Other target population groups were older adults [9,10,37,38,39], members of community organising teams themselves [11,36], parents or families [4,7], at-risk or vulnerable populations [28,33], gender minorities [17], and health care professionals/institutions [24]. The studies included in the review were conducted between 1978 and 2021, more than half of the studies 63% (n = 17) were conducted in the last ten years [2,3,4,5,7,10,13,14,18,19,20,21,24,25,27,28,29,30,32,33,34,36,38,40], 21% (n = 8) were conducted in the last 20 years [6,9,12,17,22,26,35,37], and 15% (n = 6) were conducted prior to that [11,15,16,23,31,39] (See Table 1 ).

Table 1

Sample characteristics, methods and outcomes of the reviewed studies on community organizing and health (n = 38).

* Intervention success defined as per the original study’s findings. + Not Available.

The most common study design was a case report or case study (n = 9) [3,13,14,16,25,28,30,33,34] and qualitative design (n = 9) [5,11,15,19,21,24,26,36,37], followed by seven studies conducted as published project implementation and evaluation [4,9,10,17,18,29,39]. Four studies were prospective or longitudinal in design [6,23,27,32], including cohort studies, and another four had a quasi-experimental design [7,35,38,40]. Three studies were community randomised trials [20,22,31]. The remaining studies had adopted participatory research [12] and a community listening exercise [2].

In most studies, community organising was undertaken by either a charity, a not-for-profit organisation, or a non-government or civil society organisation [3,5,7,13,17,18,19,20,26,28,29,34,36,37]. University researchers were the second most common group of community organisers [9,10,15,16,25,27,31,32,38], followed by government agencies [2,4,21,24,40]. A diverse group of organisers including community groups or leaders, health professionals, service managers, or a combination of several communities and/or institutional actors were involved in some studies [6,14,23,33,35]. In the remaining studies, it was not clearly stated who the community organisers were [11,12,22,30,39] (See Table 1 ).

The length of time required to undertake the preparatory work at the start of the action phase was reported by 19 studies only. Most studies took 24 months or more to start the action phase [3,15,29,30,31,32,34,38], while five took more than 12 months but less than 24 months to do so [16,27,35,36,37]. Three studies took 6–12 months [13,18,24], while two took between 1 and 6 months [21,33]. Only one study was found to have initiated the action phase within less than a month following the listening and organising process to initiate its community action [19].

8.1. Frameworks, Models, and Processes Adopted

The review identified 22 different frameworks, models, or processes adopted by the studies (see Table 2 ). A framework usually represents a structure, overview, system, or plan composed of descriptive categories and does not provide an explanation, rather it groups the empirical phenomena into a set of categories. A model, on the other hand, is descriptive and typically involves a deliberate simplification of a phenomenon. Finally, a process is the analytical representation of the program activities. There were 10 studies that explicitly reported the use of a community organising framework [5,6,9,24,27,28,31,32,34,35]. All studies reported their use of community organising steps, and these varied between four and 10 steps. For instance: Cheadle et al. (2009) utilised community organising in the promotion of physical activity among older adults from southeast Seattle in the US. This study identified and involved champions in partner organisations for support and resources [9]. Rask et al. (2015) utilised the community organising technique to assess provider engagement and its impact in addressing the root cause of preventable readmissions by identifying participant-defined barriers [24]. Bezboruah (2013) examined the community organising technique to promote accessible and affordable health care to a marginalised neighbourhood in a large and diverse community [5].

Table 2

Core components of frameworks/model/process and details of selected studies (n = 38).

Similarly, Mckenzie et al. (2004) used community organising to create a community-wide cancer education/screening program [35]. The study selected local leaders based on their previous professions and contribution to the community in order to assess community needs, followed by the implementation and evaluation of the program [35]. Zanoni et al. (2011) employed community organising to address the epidemic of asthma and obesity among Latina/o children. They motivated their parents to create knowledge, take action, reflect on outcomes and have their voice heard in dominant-culture schools [34]. Santilli et al. (2016) were guided by community organising principles to mobilise community members and partners to develop and build community support for neighbourhood-driven intervention in chronic disease prevention [27]. A community organising approach to counter alcohol abuse through a community randomised trial was outlined by Wagenaar and colleagues [31]. Bosma et al. in 2005 also adopted a community organising model to prevent substance use and violence among young adolescents in school settings [6]. Wagoner et al. (2010) employed a practice-based community organising conceptual model using a grounded-theory approach [32].

Each of the above-mentioned studies conducted a needs assessment as a part of their community organising process. One-to-one networking with the community members and local organisations was the most followed approach for needs assessment. Some of these studies also hired community organisers to assist [9,27]. However, only two studies evaluated their achievements or goals at the end of the program [31,35], and only one had a sustainability strategy in place [24]. Community members were empowered to address the local issues of alcohol, tobacco and violence [6]. The logic behind emphasis on the community’s active role in the process was explained by Saxon et. al. [28], who stressed that participating in community organising tends to give community members more ownership over local issues and maintains power balance between the community members and community organisers.

8.1.1. Collective Impact Framework

Collective impact of some kind was employed as the model or framework of community organising, either on its own or as a part of multiple framework structure in at least four studies [18,22,23,26] (See Table 2 ). The Collective Impact Framework is a collaborative approach centred on the tenet that to create long-term change for complex social and health issues, organisations must coordinate their efforts around a common goal [41]. There are five core components of the Collective Impact Framework including a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and a backbone support organization [42].

In a study conducted by Poole and Colleagues in 1997, collective impact was set within the broader framework of the utility of action structures and was aimed to be a driver towards the attainment of national goals through a bottom-up approach in Oklahoma, US [23]. Salem et al. (2005) used the framework to increase the capacity of communities in Chicago, US to participate in public health decision making, promote new partnerships, make decision makers accessible to the communities, and to find a suitable role for the local public health department to support community-based health activities [26]. Hilgendorf et al. (2016) evaluated the lessons learned from a pilot obesity prevention approach by the Wisconsin Obesity Prevention Initiative for community action, which incorporated coalition as well as community organising efforts in two counties with the long-term goal of empowering community leaders to drive ongoing action [18]. Perry et al. (2000) represented the second phase of an early adolescent intervention against students’ alcohol use. This study promoted community action to increase community efficacy, integration and resilience to bring about positive changes in community norms [22].

These studies utilised a community-driven approach and actively involved, engaged or empowered community members, organisations and stakeholders in problem identification, development of solutions, planning and implementation of intervention(s). Community mobilisation activities were implemented and comprised the use of media campaigns and public events [22]. In addition, seeking support from community leaders in raising awareness of the problem and encouraging community members to take action were their key features. Building coalitions with the community members and sharing responsibilities with them to solve local problems were important power approaches used by Poole [23] and Salem et al. [26]. Furthermore, Salem argued that local needs are community owned and meeting them is not a sole responsibility of any organization.

8.1.2. Alinsky-Style Organising IAF Framework

Two studies adopted Alinksy-style organising as their framework of choice [17,29]. Subica et al. (2016) adopted the Alinsky-style community organising (also known as Industrial Areas Foundation (IAF style organising) framework to summarise the community organising initiatives of several grant recipients of projects targeting childhood obesity-causing structural inequities within 21 culturally/ethnically diverse communities through the creation of 72 environmental and policy solutions [29]. Prior to this in 2003, Hays et al. had employed the same model to build a strong, supportive young gay and bisexual men’s community through different outreach events and team performances where they could protect and support each other, promote having safer sex and help in HIV prevention efforts as a bigger goal through their Mpowerment project [17].

The Alinsky model begins with “community organising” and is based on a concept of separate public and private spheres [43]. In the Alinsky model, power and politics both occur in the public sphere, and Alinsky argued that poor communities could gain power through public sphere action, which involves taking public action such as protests and occupation to shift control from entities such as local government to the community [43]. The studies adopting IAF as their guiding framework [17,29] used a combination of community organising and other methods such as focus groups, interviews, and community meetings to engage community members in the research process. Feedback was gathered from community members on the acceptability and feasibility of their interventions. Outcomes focused on changes in both health behaviours and policy change. Aligned with the Alinsky approach, Hays et.al. [17] reported on shared power through the involvement of a core group who represent the various segments of the target community. This also signifies one way of maintaining the power balance between community organisers and community “organisee”.

8.1.3. Community-Based Participatory Research Framework

Three studies adopted community-based participatory research framework (CBPR) in their community organising effort [3,19,25]. The proponents of community-based participatory research (CBPR) claim that it benefits community participants, health care practitioners, and researchers alike [44]. They argue that CBPR creates bridges between scientists and communities through the use of shared knowledge and valuable experience [45,46]. Therefore, CBPR is a collaborative approach that emphasises the active involvement of community members in all facets of the research process [19]. All studies embracing CBPR [3,19,25] prioritised community ownership, active involvement of community members, and addressing potential biases in different ways. Following the CBPR framework, community ownership and active involvement were achieved through implementing community dialogue, community problem-solving, participatory action research and social justice approaches. Kang [19] and Bauermeister [3] highlighted the shared power achieved through collaboration with community and researchers while considering the geographical diversity. Similarly, Ross et al. [25] described the power of youth’s research and participation/action on health behaviour change to inspire key decision makers for developing new policies and ordinances.

8.1.4. Socio-Ecological Framework

Two studies that adopted the socio-ecological framework also used a community-based approach [10,33]. One of these two studies aimed to understand the structural issues that affected the creation of a community action and advocacy board (CAAB) and to identify strategies for overcoming those issues [33], while the other aimed to promote physical activity in older adults [10]. Community engagement and empowerment were central to both studies. Power was emphasised in both studies. For example: Weeks [33] recognised that members of the community were grassroots “experts” and “leaders” in key areas of HIV/STIs prevention, women’s health and empowerment, and community health needs. Cheadle [10] discussed the involvement of community in coalitions, thereby promoting the bottom-up approach.

A range of additional frameworks were applied as a part of community organising in the remaining studies. Coalition between different community partners, formative research, action planning and mobilizing the community members to solve the local needs by utilizing community resources, implementation and dissemination are major focus areas of these additional models or frameworks, including Rothman’s development model [16], innovative program planning frameworks [8], implementation science frameworks [4], community partnership frameworks [7], community need assessment methodology model [2], and communities mobilizing for change model [20]. Green care theory was one of the standalone theories that did not fit under one broad theme and it was used to describe connectedness to the natural environment by a collaborative approach [36].

The Mckenzie and Smeltzer community organisation model [37], Cottrell’s Community Competency framework [11], and the eight steps process [39] were three models that were bound by the commonality of using the eight step process. In this process, the initial steps were focused on community contacts and one-to-one relationships with individuals and groups to identify barriers and assets in the community. The intermediate steps facilitated the open meeting to identify the community needs and their solutions. The final steps, on the other hand, were focused on maintaining and sustaining the program.

Citizen health care model [12], Freire’s theory of adult education [15], and Community capacity framework [21] were other models with the common aim of emphasising the knowledge, wisdom, and energy of an individual to promote their full participation in healthcare as a coproducer rather than just a patient or consumer. They believed that professionals can serve as catalysts in fostering such citizen initiatives with program ideas and directions through the creation of community partnerships and coalitions. Therefore, they emphasised power between professionals and consumers by enhancing individual capacity to command/demand more control over their health.

Similarly, Tawtaw used a conceptual framework that combines organizing theory and horizontal participatory approaches for the community health improvement plan life cycle [30]. Fawcett et al. used three playbooks for implementing an organizational change model, where initial briefing were carried out with partners who then reviewed the recommendations and developed an action plan for implementation [14]. Haseda and colleagues [38] visualised and figured out community health needs by using a JAGES Health Equity Assessment and Response Tool and developed community diagnosis forms [38]. Furthermore, Haseda [38] and Fawcett [14] both discussed empowering the local health sector and engaging them through coalition.

8.2. Targeted Health Behaviour or Topics Used by Community Organising Initiatives

Non-specific health promotion, health education, or lifestyle modification were the primary objectives of community organising in most studies [2,10,11,16,19,23,26,27,36,39]. This was followed by substance use (alcohol, tobacco, illicit drugs) and violence and associated behaviours [6,20,22,25,31,32]. Chronic disease management was the focus of four studies [13,21,29,35] including a cancer education/screening program in the UK, childhood obesity among low SES communities in the UK, asthma in Detroit, Michigan and obesity in the US. Health care access was the focus of another four studies [14,15,24,38], with one study focusing specifically on culturally appropriate healthcare access [14]. The other areas of specific focus were sexual/reproductive health [3,7,17,33], healthy eating [15,37], cancer prevention [35], gender discrimination [28], local environment factors [21], physical activity [9], social activities of older adults [38], assessment of community partnership [30], and coordination of health services [24]. However, it should be noted that many of these studies had overlapping focus areas especially relating to health promotion/healthy eating/healthy lifestyles. The outcomes of most initiatives were promising, with positive changes reported (at least in the short term) in health outcomes for the target populations in most studies (32/38) (see Table 1 ).

Quality Appraisal

Out of 38 included articles, 32 were assessed using MMAT criteria (see Table 3 ). Six articles were excluded from MMAT assessment following the first two screening questions. The methodological quality of the studies was mixed. The quality of the qualitative articles was high, with 13 out of 16 studies meeting the five MMAT criteria. The mixed methods study was also of high quality and met all five criteria. Only two quantitative articles (2/14) met all possible appraisal criteria. Low non-response bias risk and blinded outcome assessors to the intervention were the most frequent unmet criteria for quantitative studies.

Table 3

Mixed Methods Appraisal Tool (Version 2018) for critically appraising quantitative (n = 14), qualitative (n = 16), and mixed methods (n = 2) study reviews.

Index Abbreviations: Y = Yes, N = No, U = Unclear, MMAT = Mixed Methods Appraisal Tool. A. Mixed Methods Appraisal Tool (MMAT) screening questions for all studies—QS1: Are the research questions clear?, QS2: Do the collected data allow to address the research questions? B. Mixed Methods Appraisal Tool (MMAT) for qualitative studies—Q1.1: Is the qualitative approach appropriate to answer the research questions?, Q1.2: Are the qualitative data collection methods adequate to address the research question? Q1.3: Are the findings adequately derived from the data?, Q1.4: Is the interpretation of results sufficiently substantiated by data?, Q1.5: Is there coherence between qualitative data sources, collection, analysis and interpretation? C. Mixed Methods Appraisal Tool (MMAT) for quantitative Randomised Controlled Trail—2.1. Is randomization appropriately performed? 2.2. Are the groups comparable at baseline? 2.3. Are there complete outcome data? 2.4. Are outcome assessors blinded to the intervention provided? 2.5 Did the participants adhere to the assigned intervention? D. Mixed Methods Appraisal Tool (MMAT) for quantitative non-Randomised—3.1. Are the participants representative of the target population? 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? 3.3. Are there complete outcome data? 3.4. Are the confounders accounted for in the design and analysis? 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? E. Mixed Methods Appraisal Tool (MMAT) for quantitative descriptive studies—Q4.1: Is the sampling strategy relevant to address the research question?, Q4.2: Is the sample representative of the target population?, Q4.3: Are the measurements appropriate?, Q4.4: Is the risk of nonresponse bias low?, Q4.5: Is the statistical analysis appropriate to answer the research question? F. Mixed Methods Appraisal Tool (MMAT) for mixed-method studies—Q5.1: Is there an adequate rationale for using a mixed methods design to address the research question?, Q5.2: Are the different components of the study effectively integrated to answer the research question?, Q5.3: Are the outputs of the integration of qualitative and quantitative components adequately interpreted?, Q5.4: Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?, Q5.5: Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?

9. Discussion

This review synthesised the literature on community organising initiatives that pursued advancements in health. The review aimed to identify the targeted health behaviour or topics that community organising initiatives have addressed as well as models, frameworks, and processes that have been used by those initiatives. Overall, the review found that community organising has been regularly utilised over several decades as a guiding mechanism for community-based health initiatives. Positive changes were reported in health outcomes for the target populations in most of these initiatives.

Despite the use of community organizing frameworks over several decades, there is still no single gold standard framework adopted. A wide variety of models, frameworks, or processes of community organising were applied in the included studies. The variation implies that no one specific model, framework or process seems to have predominance over others in implementing community organising as a vehicle of positive social change within the health domain. Some frameworks that were common between studies that reported positive outcomes were the community organising model [6,10,32], socio ecological model [9], Rothman’s locality development model [16], and community-based participatory research model [19,25]. Despite such a wide variation, some themes were prevalent across the reviewed studies, including (1) the creation of partnerships and coalitions, (2) community integration and resilience, (3) joint problem-solving, (4) bottom-up approach, (5) community ownership, (6) community empowerment and (7) capacity building. Therefore, regardless of which framework is used, health interventions or initiatives are likely to deliver positive outcomes if they are delivered in a coordinated manner by incorporating these core components. As a result, future research should focus on supporting these key components to be a more common part of community activities.

Most studies (33/38) included in the review were conducted in the United States. This strong adoption of community organising could be because community organising as a vehicle for change began earlier in the United States than in other countries, potentially in Philadelphia with the wages strike in 1786 [47]. Additionally, the dominant political ideology in the United States (e.g., desire for small governments and lower taxes etc.) along with a largely inequitable, predominantly user-funded healthcare system could be seen as further drivers for more community organising activity since it allows people to organise, unionise, and consolidate their power [48,49]. Countries such as Australia and the United Kingdom, which can be considered comparable to the United States in many aspects such as language, culture, democratic election of government, etc., have also had a long history of labour unions, but these countries are more distinct from the United States due to their publicly funded healthcare systems (Medicare and National Health Services respectively). The health systems in these countries are known to be more equitable [50,51], thereby limiting the need for citizens and communities in these countries to organise for access to healthcare. Despite these factors, there are gaps which could be filled by more community-focused and community driven health initiatives or interventions. However, this review suggested that community organising as a vehicle of health initiatives or interventions has yet to pick up traction in countries outside of the United States. Therefore, it highlights the opportunity for the concept to be expanded in public health initiatives outside of the United States, learning from the experiences of the studies implemented there.

Most studies targeted a broad, general population, while some focused on specific population groups. Despite the heterogeneity in the selection of target population groups, there was consistency among most studies in terms of positive change reported in their targeted health outcomes. Such consistency in positive outcomes despite the variation among target population groups reinforces the argument that community organising has the potential to be an important vehicle for positive change [2,3,12,17,19]. This notion is important, particularly for the marginalised and disadvantaged communities who are more likely to be overlooked by existing mainstream health initiatives or interventions that are perhaps designed using a one-size-fits all approach [52]. Community organising provides an opportunity to listen to community voices and concerns, engage them deeply, work together with them to address those concerns, and create solutions to the community problems together with them, instead of adopting top-down approaches [52]. Authors have also referred to this bottom-up approach as a means of power-sharing with the communities to help them solve their own problems [53]. Power sharing has been recommended as an essential driving force and strategy behind other grassroots community initiatives [54,55]. However, when examining power issues, there are likely to be evaluation challenges. For example, how to measure shared power, Kang [27] and Bauermeister [3], or Ross et al. [25], power of youth’s research and participation/action on health behaviour. While there a range of frameworks identified in this review, they are applied to different contexts. Future research could examine the suitability of different frameworks for different community contexts, taking into consideration their unique issues and starting points.

The reviewed studies did not document long-term outcomes or health impacts. While most studies reviewed reported positive change in the health outcomes, we noted that these measures were typically collected over relatively short and focused project durations. Many studies did not discuss the long-term sustainability of positive impacts, particularly after the funding had been exhausted. Only 18/38 articles in the review mentioned prolonged action or sustainability of community organising efforts beyond their research period. Some of the major strategies employed to sustain the community organising actions beyond the funded period in these studies were: empowering the community leaders and educating community members to engage and maintain the community action; continuing ongoing meetings with stakeholders; and ensuring trust between them and the community organisers. Some articles also discussed influencing public policy change/government support as a strategy to sustain community organising initiatives beyond the life duration of a particular focused project [5,22,31]. Utilising “partnership brokers” such as local governments and non-governmental organisations has also been suggested in initiatives beyond the health sector [56] to ensure the sustainability of community-institution partnership through the establishment of a systems-based approach. Studies included in this review in terms of outcome selection can be categorised into four groups: (1). to identify issues (1/38); (2). description of program implementations (6/38); (3). evaluation of program implementations with lessons learnt and influencing factors (19/38); and (4). effect directly on health outcomes (12/38). However, among the 12 studies directly reporting on health outcomes, five discussed quantitative/statistical conclusions. These four categories show the outcomes with increasing correlation to the ultimate objective: to improve health. Quality of implementation and effect on community capacity is an intermediate outcome to the final health outcome. The inclusion of more direct health measurements would improve the ability to evaluate the impact of these initiatives. Future studies should aim to measure long-term impact from their initiative, not just the measurement of outcomes during the funded period.

10. Strengths and Limitations of the Review

This review brought together evidence on the use of community organising in the health domain and the adoption of several frameworks of community organising. However, the review did not systematically assess whether the studies adhered to the framework guidelines in a step-by-step manner. Therefore, the review should not be viewed as an assessment of their level of adherence to these frameworks. This could also be considered this review’s strength as it identified that there is not any standardisation/guideline for reporting such adherence. Another limitation of the study lies in the heterogeneity of topics and community groups, meaning that a rigorous meta-analysis was not possible. Nonetheless, the heterogeneity (of target population groups and frameworks) can also be considered a strength as it is suggestive that the approach can be used in many contexts and is therefore worthy of further consideration. Most studies included in the review also showed that the initiatives successfully improved the targeted health outcomes in the short term, which indicates the positive role of community organising in solving community problems with their active involvement. It needs to be acknowledged that it might also be reflective of selective publishing, where relatively less successful initiatives are not published and of a lack of follow-up studies to check whether these successes sustain over time in the absence of an active implementation team of community organisers/organisations. The assessment of publication bias and sustainability assessment was beyond the scope of this review.

11. Implications for Research

No guidelines exist to inform the development or reporting of tools to implement and evaluate community initiatives or interventions in a consistent way to enable comparison and conclusions to be drawn. Therefore, future studies could emphasise developing such implementation and evaluation guidelines to support the implementation and assessment of implementation fidelity and allow for comparability across initiatives. Furthermore, assessing the sustainability of community organising initiatives beyond the short-term project duration will also be helpful, since a lack of funding and active engagement from community organisers might mean that programs are discontinued, and any community benefits gained could cease or even regress.

12. Conclusions

This review showed that community organising is a promising approach to community-based health initiatives. Health initiatives with successful outcomes in recent decades include the widespread shift to a bottom-up approach towards including community members in organising efforts to address their identified needs through active participation in their community. There is opportunity for a more standardised approach of implementation and evaluation of these initiatives, including objective measures of success and long-term sustainability. Future research should explore whether long-term sustainability can be achieved by encouraging a more proactive public sector role or by fostering a public- and non-governmental sector partnership to promote community-driven health promotion efforts. Regardless of the approach, ensuring community trust and empowering local leaders should remain the cornerstone of all these initiatives.

Acknowledgments

We thank the health librarian staff at Griffith University for assisting throughout the data search and with access to electronic databases.

Funding Statement

This research received no external funding.

Author Contributions

S.K. conducted the preliminary database search, analysed, and interpreted data and took a lead role in writing the manuscript. J.P. conceptualised the study and J.P. and L.B. oversaw and supervised the study and contributed to manuscript development. S.K., L.B., D.C., H.R., J.H., J.M., K.B., L.M. and J.P. contributed to data screening and extraction. S.K., L.B., D.C., H.R., J.H., J.M., K.B., L.M. and J.P. critically reviewed and provided constructive feedback. All authors have read and agreed to the published version of the manuscript.