Residents' perceptions of effective community representation in local health decision-making

Community participation in local health decision-making has been envisioned as a key strategy to improve the design and delivery of health services in the USA. While much literature has sought to understand this participatory approach, considerably fewer studies have engaged the essential first-order question: How would we know who the appropriate community representatives are? An important first analytic step is to learn from community members themselves what characteristics they feel a 'good' representative should possess. Two primary research questions are addressed: 1) To what degree can low-income adults identify and articulate what they believe constitutes an effective community health representative and 2) What do low-income adults believe are the specific characteristics an effective community health representative should possess? In-depth, open-ended interviews were conducted with 14 African-American and Latino residents of four low-income communities on the Southside of Chicago, USA. A theoretical sampling strategy was used with residents varying by age, education, employment, and years of residence on the Southside. We found that respondents had difficulty articulating what a community health representative might do or generating the names of potential representatives, but were able to express clear preferences for what would constitute good representation when given meaningful choices. Three primary characteristics were identified: 1) outcomes 2) expertise, and 3) active communication. These characteristics did not operate in isolation but together communicated the trust and commitment that respondents found fundamental to representation. In exploring this essential yet often neglected question, we sought to build an empirical foundation to more fully examine the precursors to effective community health representation. These data provide important clues as to how to build an inclusive process that expands rather than constrains the pool of community-based representatives.