Who Speaks for the Community? Residents' Perceptions of Effective Community Representation in Local Health Decision Making

Purpose: Community participation in local health decision-making has been heralded as an essential strategy to improve the design and delivery of health services (Church, et al., 2002; Morgan, 2001). While much literature has sought to understand this participatory approach (Jewkes and Murcott, 1998; Zakus and Lysack, 1998), considerably fewer studies have engaged the essential first-order question: How would we know who the appropriate community representatives are? When community representatives are not elected, but are chosen or self-selected, it is crucial to learn from community members themselves what characteristics a ‘good' representative should possess. This is especially important when addressing the needs of vulnerable populations in low-income communities who are less involved in community health decisions (Boyce, 2001). Drawing from theoretical frameworks on representation, we explore the degree to which characteristics such as technical expertise, community knowledge, and participant empowerment are important to residents from low-income communities. The following main research question is addressed: Which characteristics and qualities do residents believe a community health representative should possess?

Method: This exploratory study used qualitative methods in order to understand the meaning that underrepresented community members placed on the concept of representation. In-depth, open-ended interviews were conducted with 14 residents (10 African-Americans and 4 Hispanics) from five low-income communities on the Southside of Chicago. A theoretical sampling strategy was used with residents varying by race, age, education, employment, and years of residence on the Southside. Interviews lasted approximately two hours, were digitally recorded and professionally transcribed. Each transcript was coded by multiple researchers and thematically analyzed along conceptual domains in order to detect patterns across interviews.

Results: Though residents had a difficult time conceptualizing “representation”, they were able to prioritize a set of key characteristics. Residents felt that representatives should be instrumentally driven; that is, "getting something done" was the most important characteristic of effective representation. "Getting something done," however, was a multidimensional concept that encompassed obtaining resources, providing services or sharing information. Residents also believed that technical expertise was important for effective representation, but they defined expertise on health issues quite broadly. In contrast, while affinity characteristics (e.g. same race, lived in community for a long time) were mentioned, they did not emerge as important to effective representation.

Implications: This study addresses a fundamental yet often neglected question in promoting and sustaining community participation in health: who should be involved in representing a community's health interests? Findings from this study provide new information that may help ensure the most important community health needs are heard in participatory decision making processes. This study also yields information especially relevant for low-income, vulnerable populations frequently left out of community level health decisions. Finally, this study can help governmental and non-governmental organizations interested in engaging community-level actors in local health decisions. Specifically, findings should be used to inform the development of new outreach and recruitment strategies so that community participation in health becomes an inclusive process that expands rather than constrains the pool of community based representatives.