What influences community engagement and healthcare system strengthening interventions for cholera control in lower- and middle-income countries? A scoping review

Cholera is endemic in many lower- and middle-income countries (LMICs) due to persistent environmental reservoirs, poor sanitation, hygiene, and water services, compounded by humanitarian disasters. Community engagement and health system strengthening are two proposed pillars of the WHO Global Taskforce on Cholera Control (GTFCC) Roadmap 2030 to eradicate cholera in endemic countries. Health system strengthening interventions has shown positive impacts on health outcomes; and community engagement appears to facilitate lowered water-borne disease transmission rates in outbreak situations. However, specific barriers and facilitators for both concepts, and any interfacing factors are unclear. Therefore the objective was to identify and describe the facilitators and barriers concerning community engagement and healthcare system strengthening for cholera control as well as any factors acting at the interface of both interventions in LMICs.

The Arksey and O’Malley framework for scoping reviews was employed and three electronic databases (PubMed, CINAHL and Web of Science) were searched using database specific combinations of search terms representative of cholera, community, and healthcare system components. Documents in English, within the period 1990 to 2021, in LMICs and focusing on explicitly reasoned facilitators or barriers of health system strengthening, community engagement or the interface between were included. Data charting was completed using narrative descriptive analysis, followed by thematic analysis. Reporting was done in line with PRISMA-ScR guidelines.

Forty-four documents met the study predefined inclusion criteria and were included for the review. Documents covered a wide range of countries, with Haiti most often mentioned. Half of included documents related to Sub-Saharan African countries, 68% (30/44) to cholera endemic settings and 20.5% (9/44) to conflict or civil unrest settings. Thematic analysis identified three themes of facilitators and barriers for health systems strengthening: cooperation between stakeholders; capacity for task fulfilment; governance, supervision, and feedback; and insecurity. Two themes described Community engagement facilitators and barriers: trust building and social cohesion. Strong governance and capacity adaptation facilitated health system strengthening while community representatives and civic structures enabled community participation and empowerment. Stigma, communication strategies targeting personal characteristics, poor leadership, interfering socio-political factors and conflict acted as barriers to both concepts as well as the interface between.

Findings from this study suggest that insecurity, community representatives and poor governance with interfering socio-political factors influence community health system interactions and trust building and may impair intervention impact.

Cholera is an ongoing global health problem, especially in poor communities or refugee camps lacking water and sanitation services. To eradicate cholera the WHO Global Taskforce on Cholera Control (GTFCC) Cholera roadmap proposes health system strengthening and community engagement interventions. But it is not known how best to achieve these. To explore this gap a scoping review of facilitators and barriers to the two concepts was completed. This included searching electronic databases for relevant documents and analysing them. 44 documents were included with most concerning Sub-Saharan African countries and countries that have cholera as a long term problem, and some documents mentioned Insecurity and conflict. results showed that conflict, interfering social and political factors and poor leadership affected both health system and community engagement interventions. Health system strengthening was influenced by cooperation, capacity adaptation, supervision and feedback. Community engagement was improved through community representatives and organisations.

Awareness of facilitators and barriers to community engagement and what affects community-health system interactions can help to contextualise these to ensure the greatest chance of sustained community ownership of cholera interventions. Mitigating against barriers of health system strengthening interventions can help build resilient health systems.