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

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.


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 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.

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

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.

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

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.

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 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 quasiexperimental 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]. To build a strong, supportive young gay and bisexual men's community where young gay and bisexual men nurture and protect each other, particularly from HIV The Mpowerment Project mobilised youth to embrace their identities and support each other to take action on safer sex through different outreach events, and team performances such as "Gaywatch" bar outreach. Large events, such as dances, house parties, community forums, picnics, art shows were conducted as formal outreach. Smaller events such as weekly video parties, discussion groups and sports activities were also conducted. Beyond its preventive scope, the project creates a collective, community empowerment enabling the young men to organise together for taking on several other challenges they face. (a) To raise awareness about factors increasing an individual's risk of developing cancer and ways to reduce the risk (b) To provide screening opportunities for colorectal cancer to individuals who are at higher risk but are likely to be missed out of the screening A multiactivity intervention was created alongside two award-winning videos. 150 community volunteers were trained to deliver the education/screening program. 185 sessions reached more than 6000 individuals. The teachers of the intervention schools perceived the program to have been useful among their students. Cancer awareness was found to have been raised in the participants and more than 65% of the surveyed individuals said they would change at least one behaviour to reduce their cancer risk. To describe the development and implementation process of Project Northland intervention which is focused on delaying on-set and reducing adolescent alcohol use using community-wide, multiyear, multiple interventions

Yes
At the end of Phase one that spanned 7 years, there were significant reductions in alcohol use among intervention students-a 20% reduction in past-month drinking and a 30% reduction in past-week drinking. By the 10th year, even after 2 years without a substantive intervention program, there were no significant differences between the intervention and reference groups.
By the end of 11th grade, after 1 year of Phase two intervention activities, students in the intervention group drank less, but this was not statistically significant.
However, among baseline nonusers, the difference between groups in past-week alcohol use was marginally significant (p < 0.07) at the end of the 11th grade, suggesting some impact from the 11th-grade intervention among these students. To explore factors that facilitate and pose barriers to active youth involvement in a long-term, tobacco-related community change initiative.

Yes
The Teens Tackle Tobacco project exposed the young people's sense of (in)justice. CBPR helped the youth develop research skills needed to channel their outrage into an effective and multilevel campaign. The project helped change their view of themselves as community change makers. To understand the processes to facilitate change and improve health among underserved populations in three programs in Sri Lanka and Bangladesh

Yes
The study found that public health approaches can benefit from community organizing to develop local engagement and participation.
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].

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]. Community needs assessment methodology model Nine steps community based participatory approach was created: (1) Identify assessment teams and roles, communities of focus, (2) Review past assessment findings and set aims, Engage researchers and community partners through shared decision making. This community engagement approach offered an alternative to traditional research by challenging the notion of "researcher-as expert" and centring community expertise and lived experience. Use community dialogues in 1. round tables (community listening) 2. Refinement 3. Prioritisation. The community dialogue process used in this article is consistent with the principles of CBPR, and it helped the authors to ensure that the program was tailored to the specific needs of the community and that it was well-accepted by the community. However, more information about the recruitment process and measures to ensure participants' confidentiality and safety would have been beneficial.

Framework
Shared power through collaboration with community and researchers. Each minority group e.g., transgender only and youth-only Gives each group a chance to participate in an open space without being intimidated or silenced by older community members and/or professionals. Also considered geographic diversity 3 Berman 2018 [4] Implementation science framework (Proctor and colleagues) Healthy Lifestyles Initiative used five implementation strategies to support organizations in using the messaging materials and implementing policy, systems, and environmental activities: (1) educational training, (2) a structured action plan, (3) coalition support, (4) one-on-one support, and (5) materials dissemination and resource sharing.
Community organising conceptual framework The study adopted a community organising approach where semi structured interviews with executives of several non-profit organisations and community organisers were collected, also participated in events and meetings organised for community organising. Collected da Data collected from the interviews are analysed in a systematic manner that assisted in theory building Framework N/A Community organisation and community partnerships The program was combination of community organising and collaboration. Implemented with five components: Community partnership, parents education programs, major events, online events and a media campaign. For the community partnership, coalition between different partner groups and parents were created. Additionally, community influentials, leading professional, mayors were included in advisory committee. Parents met on regular basis to develop educational programs and events. Process Innovative program planning framework, community-based prevention marketing 9 steps approach: 9-step process: (1) mobilise the community; (2) develop a profile of community problems and assets; (3) select target behaviours, audiences, and when possible, interventions to tailor; (4) build community capacity to address the priority or target problem; (5) conduct formative research; (6) develop a marketing strategy; (7) develop or tailor program materials and tactics; (8) implement the new or tailored intervention; and (9) track and evaluate the program's impact

Framework
Capacity building activities such as the marketing skills and participatory research techniques for designing, tailoring, and implementing interventions that promote behaviour change were provided to the interested members. 9 Cheadle 2009 [9] Community organising model The SESPAN project was implemented on the basis of community organising approach where community organisers were hired to develop partnerships and network among community-based organisations, groups and institutions. These community organisations were focused on physical activity. Relationships between the key organisations were built through coalition and one-on-one networking. Semi structured interviews with community stakeholders, a variety of survey-based measures of older adults including pre/post survey were included.

Process
Partnered with many local organizations and sustain SESPAN activities after the 5-year research funding period ends. Social ecologic model Micro, meso and macro level input-combining individual-level programs with larger scale environmental and policy change follows the social ecologic model. The authors used a mixed-methods approach to evaluate the effectiveness of the community-organizing approach. They collected data on changes in physical activity, diet, and body weight through surveys, focus groups, and objective measures. They also collected data on the acceptability and feasibility of the interventions through focus groups and interviews with community members and organizations. Overall, the article describes a community-organizing approach that is grounded in CBPR principles and uses a variety of methods to engage community members in the planning and implementation of interventions to promote physical activity.  1) The greatest untapped resource for improving healthcare is the knowledge, wisdom, and energy of individuals, families, and communities who face challenging health issues in their everyday lives. (2) People must be engaged as coproducers of healthcare for themselves and their communities, not merely as patients or consumers of services. (3) Professionals can play a catalytic role in fostering citizen initiatives when they develop their public skills as citizen professionals in groups with flattened hierarchies. (4) If you begin with an established program, you will not end up with an initiative that is "owned and operated" by citizens, but a citizen initiative might create or adopt a program as one of its activities. (5) Local communities must retrieve their own historical, cultural, and religious traditions of health and healing and bring these into dialogue with contemporary medical systems. (6) Citizen health initiatives should have a bold vision (a BHAG. a big, hairy, audacious goal) while working pragmatically on focused, specific projects. Consist of five overarching strategies grounded in individual, organizational, and community empowerment processes and outcomes: (1) Developing a community base sympathetic to, and supportive of, public health change initiatives. (2) Building leader base, (3) Building ally base, supported by an aligned base of organizational allies with shared interests and values poised to work together toward community health equity, (4) Message reframing and (5) Activate and maintain ongoing community base participation in public health initiatives.

Framework
Empowering communities to directly redress health inequities 14 Fawcett 2018 [14] Playbook for implementing organisational change (A) Playbook for implementing organizational change for cultural competence: (1) initial orientation and commitment to engage, (2) assessment of the current organization or program, (3) dialogue on identified gaps and priority setting, (4) action planning: draft created by the smaller team and whole group review, (5) implementation and monitoring of progress, and (6) closing dialogue and celebration of achievements (B) playbook for improving quality through access to preventive health services and the Diabetes Prevention Program: (1) initial brief orientation session with potential partners, (2) review of recommendations and plan development, (3) pilot test of implementation protocol to identify prediabetic clients and referral protocols, (4) implementation and monitoring of progress, and (5) dialogue and celebration of achievements. (C) Playbook for improving access and linkage to care through insurance enrolment. The participatory process used five elements (1) initial orientation and dialogue about partnering, (2) review/commit to a level of partnership and related responsibilities, (3) development of an action plan, (4) implementation (typically, during the ACA enrolment period), and (5) monitoring and evaluation.

Process
The Coalition successfully engaged Latinos and other marginalised groups by partnering to enhance access and linkage to quality health services 15 Flick 1994 [15] Freire's theory of adult education Community mobilisation occurs through community participation and control. The professional serves as a resource and catalyst but program ideas and direction come from the community. Partnerships with the communities were made based on reciprocity, trust developed through continuous long-term involvement, social justice with its inherent assumption of equity, and a broad definition of health that includes well-being and a sense of community. Faculty was continuously involved to understand the interpersonal and political relationships among community residents and organisations and to identify when action was taken regarding an existing problem.

Model
Empowered the community as a whole and increase its capacity to improve its own health.

JAGES Health Equity Assessment and Response Tool
The research team visualised and figured out community health needs by using a JAGES Health Equity Assessment and Response Tool and developed community diagnosis forms. Municipality health sector staff members were supported to utilise the community assessment data tool (JAGES-HEART) and promote intersectoral collaboration, aiming to develop health-promoting social activities in the community.

Framework
Researchers empowered local health sector staff members 17 Hatch 1978 [16] Rothman's locality development model Community diagnosis was carried out to identify community needs and methods for utilising resources available inside and outside of the community to meet these needs. Field team members and students continue their responsibilities as requested by the committee and became involved in publicity and media reporting for the program. Each committee member functioned as a group leader assuring the completion of his task at the designated time and shared equal responsibilities. Team members continued attending meetings and talking with more community people and recognised and supported the outstanding work of committee members.

Model N/A 18 Hays 2003 [17]
Alinsky-style organising (also known as IAF style organising) Hiring coordinators, 2. community assessment 3. community organising through core groups, goal development, Action 4. Linking with another organisation 5. Tailoring project to community. The Mpowerment Project is a community-based intervention that uses a combination of community organising, peer education, and social marketing to empower young gay and bisexual men to take control of their health and reduce their risk of HIV infection. The authors used a CBPR approach and a variety of methods to engage and evaluate the young gay and bisexual men in the project.  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 organisation supports broad participation of residents in the democratic process, especially through congregation-based community organizing 22 Kang 2015 [19] Community-based participatory research (CBPR) An alternative paradigm of knowledge production in which groups who are adversely affected by a social problem undertake collective study to understand and address it. The author implemented CBPR by closely involving the community members in the research process, prioritizing community ownership, and addressing potential biases by inviting multiple perspectives and using techniques such as member-checking and negative peer analysis throughout the data analysis process.

Framework
Shared power through collaboration with the community and researchers-uses an intergenerational approach 23 Livingston 2018 [20] Communities Mobilizing for Change on Alcohol (CMCA) An iterative process with six stages of community organising was adopted to implement the intervention CMCA, (a) assessment of community interests through face-to-face, one-on-one or two-on-one meetings with hundreds of community residents; (b) building a base of support through one-on-ones and establishment of a community action team; (c) expanding the base of support through one-or two-on-one meetings, presence and presentations at community events, and media advocacy; (d) development of a plan of action; (e) implementation of actions; and (f) maintenance of effort and institutionalisation of change. Mckenzie and Smeltzer used a model with 10 steps to bring behaviour change in the targeted population. Those steps were: 1. Recognizing the concern, 2. Gaining entry into the community, 3. Organizing the people, 4. Assessing the community, 5. Determining the priorities and setting the goals, 6. Arriving at a solution and selecting an intervention, 7. Implementing the plan, 8. Evaluating the outcomes of the plan of action, 9. Maintaining the outcomes in the community, 10 Community organisers were hired to work with community groups. Interviews with key stakeholders were conducted to prioritise major areas upon which to focus their community capacity-building efforts. Education and data to community members and policy makers were provided to understand the potential health implications of the proposed projects.

Model
Authors has discussed about capacity building among community members. 26 Perry 2000 [22] Collective Impact; Community Action Behavioural model to change community efficacy and norms through market and policy levers. Use community organising process. Community listening, community action teams, Action plans, execution of action plan in community

Process
The members of the teams were a small percentage of the entire intervention cohort, and so this direct empowerment opportunity was not experienced by most of the cohort.
The purpose of these interviews was to identify each community's social, economic, and power structures; determine both the community's and the interviewee's interest in reducing high school students' access to alcohol; determine how the problem was perceived in the community; and build a broad base of support for future actions. 27 Poole 1997 [23] Collective Impact; Other: Community Health Planning Committee Community organising-not collective impact-Process: Action structures, Community Problem-Solving Process, Process To ensure that solving local problems is a shared responsibility, all Metro Commission projects are community partnerships. This reflects the organization's philosophy that local needs are community owned, and that meeting them is a shared responsibility, not the responsibility of any one sector or service entity. 28 Rask 2015 [24] Community organising process The community organising process consists of five phases: community assessment, coalition building, strategic planning, action, and sustainability. Community-based participatory research PYD and SJYD are used in the context of CBPR to ensure that the youth are actively involved in the initiative, that their needs and perspectives are taken into account, and that the initiative promotes social justice and addresses health disparities among marginalised youth. By using PYD and SJYD in CBPR, the initiative is able to create a sense of ownership, investment, and empowerment among the youth while also addressing the social and economic determinants of health and reducing health disparities among marginalised youth. The article concludes that PYD and SJYD can be an effective approach for engaging marginalised youth in long-term tobacco control initiatives. Worked closely with community residents and community-based organisations to develop trust partnerships and to gain deep knowledge of history, norms and leadership. Before the survey, community organisers were hired, letters were emailed, conducted one-on-one meetings with community members and based on a well-established relationship with the local press, a press conference was held. Community youth volunteers were trained for data collection and survey methods and analysed data were disseminated to the community.  Alinsky-style organising (also known as IAF style organising) Community organizing-based health promotion consists of grassroots movements (interventions) that raise individuals' collective capacity to control their social and built environments by advocating for public policies that balance decision-making power and resource distribution toward health equity Community grants, the article describes a community organizing approach that is grounded in CBPR principles and uses a variety of methods to engage community members in the identification, prioritization, and addressing of health issues.

Framework N/A
The study used a mixed-methods approach to evaluate the effectiveness of the approach and gather feedback from community members on acceptability.
Framework N/A 34 Tataw 2020 [30] Conceptual framework that combines organizing theory and horizontal participatory approaches The program used the integrated framework of explanatory, change and organising theories for the community health improvement plan life cycle in three stages: health problems clarification; organising; issue prioritisation, and program activities Framework N/A 35 Wagenaar 1999 [31] Community organizing approach Intervention community followed an organizing process that included seven stages, 1. Assessing the community, 2. Creating a core leadership group, 3. Developing a plan of action, 4. Building a mass base of support, 5. Implementing the action plan, 6. Maintaining the organization and institutionalizing change, 7. Evaluating changes Framework Used power mapping for the data collection, became familiar with the demographics of their communities, the power relationships within the community. 36 Wagoner 2010 [32] Community organising conceptual model A full-time community organiser was hired who was familiar with substance abuse prevention, knowledge of environmental approaches to health behaviour change, and had experience in community organising. In-depth interviews of an average 60 min were conducted among community organising members. All interviews were audio-recorded and non-verbal reactions were recorded by a note taker. Data were analysed and presented.

Model
Assessed both the problem of alcohol use and the power dynamics of their campus Community engagement approach using various theories. Community action advisory board (CAAB), CAAB mobilisation and capacity building. It used a multiple case study design, which allowed the authors to gain a more in-depth understanding of the issues related to creating CAABs in different contexts. The use of both interviews and document review also allowed the authors to triangulate data and strengthen the reliability of the findings.

Framework
Authors approached the CAAB training recognizing that members were grassroots "experts" and "leaders" in key areas of HIV/STIs prevention, women's health and empowerment and community health needs. 38 Zanoni 2011 [34] Community organising with a focus on power Little Village Environmental Justice Organization (LVEJO) hired an organiser (parents with children in community school) to communicate and lead the discussion on youth obesity and overweight with community participants through outreach activities. Parents received the training for the semi structured interview, documenting and reporting. Based on the results action plan was developed

Process
One of the parents/teachers internalised the risk of obesity in her daughter after looking at the program module and developed many activities for her students to prevent obesity. Parents are the main persons who will observe and change their children's habits Similarly, Mckenzie et al. (2004) used community organising to create a communitywide 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.

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.

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 obesitycausing 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".

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.

Socio-Ecological Framework
Two studies that adopted the socio-ecological framework also used a communitybased 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. 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.

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.

First Author (Year)
Question

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 communityfocused 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.

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.

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.

Conclusions
This review showed that community organising is a promising approach to communitybased 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.