Interventions to increase participation of NGOs in preventive care: A scoping review.

Background and Aims: Nongovernmental organizations (NGOs) have enormous potential to effectively prevent and manage diseases; however, little research is available on interventions used to improve NGOs' participation in this area. A scoping review was conducted to identify options proposed or implemented to improve the participation of the NGOs in preventive care.
Methods: Pubmed, Web of Science, and ProQuest were extensively searched. Google Scholar was also searched to find potential studies related to the subject. Relevant keywords were used in the English language. The reference list of relevant studies was also scanned. Studies were screened with defined inclusion and exclusion criteria. Relevant data were then extracted. Two individuals independently screened and extracted studies. The interventions implemented or proposed to promote the participation of the NGOs in the implementation of preventive interventions were deductively identified and classified.
Results: Eighteen articles were included in our review. We identified 31 interventions and categorized them into 11 strategies, including (1) building strong collaboration among NGOs and with governments; (2) expanding networks and sustained relations among NGOs; (3) evaluating the NGOs' performance; (4) increasing intersectoral collaboration; (5) advocating for the role of NGOs; (6) supporting NGOs from the side of government; (7) empowering the abilities and capabilities of NGOs; (8) defining the precise roles and responsibilities of the parties; (9) strengthening the health system governance; (10) increasing the health literacy of the community; and (11) developing required regulations, rules, and policies. None of the interventions identified had evidence of its effectiveness.
Conclusion: The current evidence on effective interventions to strengthen NGOs' participation in implementing health care is scanty. It means there is an information gap in the effect of interventions to improve NGOs' participation in health.

INTRODUCTION

The term nongovernmental organizations (NGOs) can describe all nonprofit, voluntary, and independent of the government with different functions, levels of goals, structures, participation, and membership. They include civic groups or associations that provide social services, lobby groups, and advocates of policy change that affects the poor and marginalized. , NGOs are very diverse, have various interests, set different activity methods, have different amounts of resources, and perform different tasks. One specific area of NGOs' activity is health. NGOs in the health system support health by providing education and counseling, healthcare prevention, and health advocacy. They are essential in improving community health, reducing disparities, promoting equity, and strengthening the health system.

NGOs would have a high potential to participate in health by providing preventive care. There has been a dramatic increase in partnerships of NGOs in health and preventing diseases in many low‐ and middle‐income countries (LMICs) , during the last few decades. They have enormous potential to effectively prevent and manage diseases, particularly in vulnerable populations. , However, research focused on how to increase NGO partnerships is scant. Hence, the current review was conducted to identify the interventions offered or implemented to increase the NGOs' participation in preventive care. The finding of the present review allows health policymakers to summarize existing policies to increase NGOs' participation and select suitable ones for their national health plans.

LITERATURE SEARCH

Given the aims of this review, we used scoping review, which is mapping the existing literature on a topic. This approach helped us summarize the finding and identify research gaps. We employed the five‐stage methodological process of Arksey and O'Malley to strengthen review rigor, which includes defining the research question, identifying relevant literature, study selection, charting the data, and collating, summarizing, and reporting results. The PRISMA (Preferred Report Items for Systematic and Meta‐Analysis) flow diagram was used to select and screen the studies.

Defining the research question

With the need to define good questions in mind, the scoping review working group developed and refined the question to guide this review. Our review question was what are the initiatives/programs/interventions/options offered or implemented to promote the capacity/improve participation of the NGOs for the implementation of preventive care interventions? If possible, what are their effectiveness and implementation considerations?

Identifying the relevant studies

Our primary search enabled us to include all appropriate keywords. Then the search was conducted using the electronic databases PubMed, Web of Science, and Web ProQuest. There was no restriction on the publication date. The search strategy included terms related to each of the concepts of the non‐governmental organization, intervention, participation, and preventive care. Boolean operators (OR, AND, NOT) were used to connect the various terms properly. A sample of the search strategy is presented in Figure 1. The reference list of relevant studies was also scanned for cross‐referencing purposes.

Figure 1

PRISMA flow chart of search, inclusion, and exclusion screening, and accepted studies of the review on interventions to increase participation of NGOs in preventive care. PRISMA, Preferred Report Items for Systematic and Meta‐Analysis.

Study selection

Two authors independently screened the abstract and full article given the eligibility criteria. Discrepancies in the authors' responses were resolved through discussion.

Inclusion and exclusion criteria

Full articles were eligible if they were: (i) published in the English language, (ii) conducted to November 11, 2020, (iii) published in peer‐reviewed journals, and (iv) included sufficient data to find interventions to increase the NGO's participation in providing preventive care. The studies were excluded if they were (i) not available as full‐text, (ii) not peer‐reviewed and published as abstract/conference proceedings, and (iii) lacking quantitative or qualitative details. Two authors independently screened and selected studies based on the inclusion and exclusion criteria.

Charting the data

The data extracted included: title, the surname of the first author, type of publication, year of publication, country area of the study, study design, the scope of the NGO activity, the name of intervention, evidence on intervention's effectiveness, and its implementing considerations. Two individuals independently extracted the data utilizing a structured data extraction form, and the disagreement between them regarding the data extraction process was resolved through discussion.

Collating and summarizing finding

The extracted data were repeatedly reread to increase the collated and summarized finding quality. The interventions offered or implemented to promote the NGOs' participation in preventive care were deductively identified and classified.

RESULTS

Screening results

An initial literature search resulted in 5655 articles. We excluded 43 articles because they were duplicate items. After scrutinizing the titles and abstracts, 5562 articles were excluded. The full text of 50 articles was screened, and regarding the inclusion and exclusion criteria, 17 articles were retained in the present scoping review. The process of study retrieval and selection is pictorially shown in Figure 1.

Characteristics of included studies

There has been a growing interest in this topic since 2010: 1 study was published before 2000, 5 studies were published from 2000 to 2010, and 11 were published after 2010. Fourteen articles were in LMICs. Twelve articles were original, and five were reviews or perspectives. The methodology of nine articles was qualitative, one was quantitative, and two were mixed methods. The area in which NGOs had participated was varied: three studies in HIV/AIDS, three studies in maternal and child health, one study in primary health care, one study in Ebola, and one study in medicine. The remaining studies related to health and the health system. None of the interventions identified had evidence of its effectiveness. The items identified and extracted as solutions for better NGOs' participation in preventive care are presented in Table 1.

Table 1

The interventions identified for improving NGOs' participation in implementing preventive care interventions

Title	First author	Country	Year	Area of activity	Evidence on implementation	Evidence of being effective
The potential of health sector non‐governmental organizations: policy options 11	Gilson L	LMIC	1994	NM		NM
Role of non‐governmental organizations in the prevention and care of HIV disease in women and children—It makes a difference 12	Solomon S	India	2000	HIV in women and children		NM
International NGOs and primary health care in Mozambique: the need for a new model of collaboration 13	Pfeiffer J	Mozambique	2003	Primary health care		NM
A methodological approach and framework for sustainability assessment in NGO‐implemented primary health care programs 14	Sarriot EG	Developing countries	2004	Child health		NM
Inter‐organizational collaboration (IoC) for health care between non‐governmental organizations (NGOs) in Pakistan 15	Gulzar L	Pakistan	2005	Health		NM
Strengthening community participation at health centers in rural Cambodia: role of local non‐governmental organizations (NGOs) 16	Ui S	Cambodia	2010	Health		NM
Core indicators evaluation of effectiveness of HIV‐AIDS preventive‐control programmes carried out by non‐governmental organizations 17	Berenguera A	Catalonia	2011	HIV‐AIDS		NM
NGOs and government partnership for health systems strengthening: a qualitative study presenting viewpoints of government, NGOs, and donors in Pakistan 18	Ejaz I	Pakistan	2011	Health system		NM
The role of non‐governmental organizations in the social and the health system 4	Piotrowicz M	Poland	2013	Social and health system		NM
The role of civil society organizations in the institutionalization of indigenous medicine in Bolivia 19	Babis D	Bolivia	2014	Medicine		NM
A qualitative study of community‐based health programs in Iran: an experience of participation in I.R. Iran 20	Eftekhari MB	Iran	2014	Health		NM
To what extent can evaluation frameworks help NGOs to address health inequalities caused by social exclusion? 21	Kara H	England	2015	Address health inequalities		NM
Public‐non‐governmental organization, partnerships for health: an exploratory, study with case studies from recent, Ghanaian experience 22	Hushie M	Ghana	2016	General		NM
Linkages between public and non‐government sectors in healthcare: A case study from Uttar Pradesh, India 23	Srivastava A	Uttar Pradesh, India	2016	Maternal and child health		NM
Chinese non‐governmental organizations involved in HIV/AIDS prevention and control: intra‐organizational social capital as a new analytical perspective 24	Wang D	China	2016	NM		NM
The effectiveness of international non‐governmental organizations' response operations during public health emergency: lessons learned from the 2014 Ebola outbreak in Sierra Leone 25	Shin YA	Sierra Leone	2018	Ebola outbreak		NM
Leveraging community engagement: the role of community‐based organizations in reducing new HIV infections among Black men who have sex with men 26	Burns PA	NM	2020	HIV infections		NM

Abbreviations: LMIC, low‐ and middle‐income countries; NGOs, nongovernmental organizations; NM, not mentioned in evidence.

Interventions identified through review for improving NGOs' participation in preventive care: About 31 interventions categorized into 11 strategies were recognized, as shown in Table 2. The implementation considerations are also listed in Table 3.

Table 2

Summary of strategies and interventions identified for improving NGOs' participation in preventive care

Strategy	Intervention
Building strong collaboration among NGOs and with governments (6 studies)	Establishment of transparent and accountable structures and mechanisms for coordination and collaboration among NGOs and with governments 4 , 11 , 14 ; investment in a longer‐term relationship and skills transfer projects 14 ; focus on concrete objectives 21 ; developing new relations by adopting and implementing evidence‐based health interventions 23 ; stronger linkage for sustained and efficient collaboration, with joint planning, implementation, and evaluation. 24
Expanding networks and sustained relations among NGOs (4 studies)	Encouraging networking among NGOs to share their experiences 12 , 18 ; relying on mechanisms to increase the willingness to cooperate, a need for expertise and funds, and adaptive efficiency 16 ; sharing of accurate and timely information among stakeholders to ensure more effective program outcomes. 23
Evaluating the NGOs' performance (6 studies)	Implementing a mechanism to assess the quality, effectiveness, and sustainability of NGO's activity 11 , 15 , 19 , 22 ; considering financial and nonfinancial incentives, especially tangible rewards, for example, learning skills or capacity building 21 ; establishment and strengthening of effective monitoring and evaluation. 23
Increasing intersectoral collaboration (4 studies)	Build a robust collaboration between the government agencies, nongovernmental organizations, and the private sector 12 , 21 , 25 ; using decentralized structures and existing country systems to promote local ownership and sustainability of programs. 23
Advocating for the role of NGOs (4 studies)	Overcome the reluctance of health policymakers and researchers to admit the abuses and failures of the current model of NGO's partnership 14 ; recognizing and supporting the role of local NGOs 17 , 20 ; ensure political support. 21
Supporting NGOs from the side of the government (3 studies)	Determining technical assistance priorities by Ministries of Health and focusing on a coordinated plan for capacity building 14 ; distribution of prophylactic material 18 ; commitment to mobilize resources and support for effective working. 23
Empowering the abilities and capabilities of NGOs (3 studies)	Attention to the selection, support, and contributions of boundary; spanners 16 ; capacity‐building activities (e.g., workshops, training courses) of NGOs to increase their knowledge and skill 18 ; implementing innovative and culturally appropriate prevention interventions. 26
Defining the clear roles and responsibilities of the parties (2 studies)	Defining the areas and sectors where the government needs support from the NGOs 4 ; defining clear roles and responsibilities of the parties; nature and timeline of deliverables 4 ; defining a clear plan of scaling up and sustainability 4 ; formalizing expectations for collaborative relationships and respective project roles and responsibilities. 23
Strengthening the health system governance (1 study)	Strengthening and developing Ministry of Health capacities for effective coordination and regulation. 11
Increasing the health literacy of the community (1 study)	Editing and preparation of informative material for the prevention 18 ; distribution of informative materials on the street, in saunas, pubs, flats, clubs, schools, and high schools. 18
Developing required regulations, rules, and policies (1 study)	Prepare policy tools to allow NGOs to enter the field on time. 26

Abbreviation: NGOs, nongovernmental organizations.

Table 3

The implementation considerations identified through review for improving NGOs' participation in preventive care

Implementing considerations	Reference
Policy options should consider the strengths and weaknesses of NGOs	[11]
NGOs should be considered and participate as partners in government programs.	[12, 17]
It is essential to rely on a participatory, action‐planning process, engaging a “local system” of stakeholders in developing health plans.	[14, 20]
Strong and dedicated partners and supportive policy environments are critical for better intersectional collaboration,	[20]
Each collaboration between the government and NGOs demands different partnerships.	[22]
Safe space fosters an environment of trust and support where participants may be comfortable sharing stories and experiences around sensitive issues.	[26]

Abbreviation: NGOs, nongovernmental organizations.

Establishment of transparent and accountable structures and mechanisms for coordination and collaboration among NGOs and with governments , , ;

investment in a longer‐term relationship and skills transfer projects ;

focus on concrete objectives ;

developing new relations by adopting and implementing evidence‐based health interventions ;

stronger linkage for sustained and efficient collaboration, with joint planning, implementation, and evaluation.

Encouraging networking among NGOs to share their experiences , ;

relying on mechanisms to increase the willingness to cooperate, a need for expertise and funds, and adaptive efficiency ;

sharing of accurate and timely information among stakeholders to ensure more effective program outcomes.

Implementing a mechanism to assess the quality, effectiveness, and sustainability of NGO's activity , , , ;

considering financial and nonfinancial incentives, especially tangible rewards, for example, learning skills or capacity building ;

establishment and strengthening of effective monitoring and evaluation.

Build a robust collaboration between the government agencies, nongovernmental organizations, and the private sector , , ;

using decentralized structures and existing country systems to promote local ownership and sustainability of programs.

Overcome the reluctance of health policymakers and researchers to admit the abuses and failures of the current model of NGO's partnership ;

recognizing and supporting the role of local NGOs , ;

ensure political support.

Determining technical assistance priorities by Ministries of Health and focusing on a coordinated plan for capacity building ;

distribution of prophylactic material ;

commitment to mobilize resources and support for effective working.

spanners ;

capacity‐building activities (e.g., workshops, training courses) of NGOs to increase their knowledge and skill ;

implementing innovative and culturally appropriate prevention interventions.

Defining the areas and sectors where the government needs support from the NGOs ;

defining clear roles and responsibilities of the parties; nature and timeline of deliverables ;

defining a clear plan of scaling up and sustainability ;

formalizing expectations for collaborative relationships and respective project roles and responsibilities.

Strengthening and developing Ministry of Health capacities for effective coordination and regulation.

Editing and preparation of informative material for the prevention ;

distribution of informative materials on the street, in saunas, pubs, flats, clubs, schools, and high schools.

Prepare policy tools to allow NGOs to enter the field on time.

DISCUSSION

This review article aimed to identify strategies to increase the participation of NGOs in improving preventive care. Most of the interventions identified in the studies focus on creating a constructive and sustainable interaction between NGOs and government. NGOs and governments have unique capabilities and capacities to provide universal health coverage. Governments usually play their role by setting the priorities and policies and providing the resources needed to implement policies and programs. NGOs have also been a significant player in providing care and support services due to their access to the community and understanding and responsiveness to their needs. With a constructive and sustained interaction between NGOs and government, both sides can be more effective in education, providing healthcare services, social mobilization network, nutrition, medicine, financing, and policy‐making.

The other interventions identified in this review are the prerequisites for creating this constructive and sustainable interaction. These interventions emphasize the government's adequate support for NGOs. , , Government, particularly the Ministry of Health, can set instructions or guidelines for coordination and cooperation with NGOs, supporting and monitoring common programs' implementation. It will also be helpful to evaluate the performance capacity of NGOs in different situations by government and prepare and regulate quality monitoring processes and tools. , , , , Another part of the interventions refers to NGOs' empowerment and capacity building, which needs to be implemented in a planned and purposeful way. , , NGOs can play their roles in society through efficient resource management, sustainable mobilization of resources, and no excessive dependence on external resources. Also, they can be more accountable for resource use through transparent management systems. Therefore, it is recommended that they prepare themselves to interact with the government and the other healthcare partners and accept the need for some adjustment in their activities, some regulation, and coordination.

Constructive interaction between government and NGOs can create an atmosphere of trust and turn both parties into partners in developing and implementing health programs. This process facilitates the effective role of government and NGOs and can improve community participation in health planning. One of the most important plans of NGOs is to create links between the main local health actors to mobilize local resources and promote community participation. In addition to the health workforce and community representatives, other actors are involved, such as local council representatives, school principals and teachers, and religious leaders. Actors out of the health sector often think that health concerns are only the responsibility of the Ministry of Health. Their expectations of the health committees and the awareness of their and others' responsibilities in health are varied and still far from what they should be. The NGOs can join the planning sessions and provide training to brief local authorities, support their concerns, and take more responsibility for health. These activities can provide a supportive environment that helps the community to participate more in health.

In our review, there was no evidence of the identified interventions' effectiveness in strengthening NGOs' participation in implementing preventive care. However, the influential role of NGOs in preventive care cannot be ignored. Given the importance of preventive care in maintaining and promoting health, especially in the current situation where the burden of emerging contagious and chronic diseases is one of the challenges of health systems, and the capacity of NGOs to participate in more effective prevention services (such as controlling risk factors, identifying at‐risk groups, changing behavior and lifestyle, etc.), it is evitable to strengthen the position of the NGOs to participate in the implementation of preventive care. The lack of evidence of the effectiveness of interventions to strengthen the participation of the NGOs in the implementation of preventive care indicates an information gap that requires further studies using more accurate methods to measure the effectiveness of these interventions. Further studies are needed to identify the context and effective mechanisms for implementing these interventions.

CONCLUSION

The main strategies to increase participation of NGOs in preventive care relate to building strong collaboration among NGOs and with governments, evaluating the NGOs' performance, and expanding networks and sustained relations among NGOs. Additionally, relying on a participatory approach is the primary consideration in developing, implementing, and evaluating programs in the area where NGOs can participate. It is worth noting that none of the interventions identified had evidence of their effectiveness. It shows that the current evidence on effective interventions to strengthen NGOs' participation in implementing health care is scanty. It means there is an information gap in the effect of interventions to improve NGOs' participation in health.

AUTHOR CONTRIBUTIONS

Haniye Sadat Sajadi: Conceptualization; investigation; project administration; writing original draft; review and editing. Laleh Ghadirian: Conceptualization; methodology; formal analysis; review and editing. Fatemeh Rajabi: Conceptualization; formal analysis; funding acquisition; review and editing. Azadeh Sayarifard: Conceptualization; methodology; formal analysis; validation; writing review and editing. Narges Rostamigooran: Conceptualization; methodology; review and editing. Reza Majdzadeh: Conceptualization; supervision, review and editing. All authors have read and approved the final version of the manuscript. Azadeh Sayarifard had full access to all the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

This study was approved by the Ethics Committee of Tehran University of Medical Sciences and Health Services (IR.TUMS.VCR.REC.1396.3166).

TRANSPARENCY STATEMENT

Azadeh Sayarifard affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.