[The Involvement of the Public and Patients in Research in Primary Health Care in Portugal is the 17th Strategy]

N/a.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Community Participation in Primary Healthcare in the South Sudan Boma Health Initiative: A Document Analysis

BACKGROUND

Community participation is central to primary healthcare, yet there is little evidence of how this works in conflict settings. In 2016, South Sudan's Ministry of Health launched the Boma Health Initiative (BHI) to improve primary care services through community participation.

METHODS

We conducted a document analysis to examine how well the BHI policy addressed community participation in its policy formulation. We reviewed other policy documents and published literature to provide background context and supplementary data. We used a deductive thematic analysis that followed Rifkin and colleagues' community participation framework to assess the BHI policy.

RESULTS

The BHI planners included inputs from communities without details on how the needs assessment was conducted at the community level, what needs were considered, and from which community. The intended role of communities was to implement the policy under local leadership. There was no information on how the Initiative might strengthen or expand local women's leadership. Official documents did not contemplate local power relations or address gender imbalance. The policy approached households as consumers of health services.

CONCLUSION

Although the BHI advocated community participation to generate awareness, increase acceptability, access to services and ownership, the policy document did not include community participation during policy cycle.

Association between community environment and dependency among the elderly people from a service provision perspective

BACKGROUND

The incidence of dependency is high among the elderly people worldwide and increases with increasing life expectancy. The purpose of this study was to establish from the perspective of resource demand the association between community environmental resources and dependency among the elderly people.

METHODS

This study is a cross-sectional design based on community from 22 locations in China. A multistage sampling method was used to select the study objects. The questionnaires were used to collect the survey data by face-to-face interviews. A total of 950 individuals completed the survey, and 913 individuals were available for this analysis. Dependency and community environment were measured using the standard instruments. Logistic regression analysis was performed to identify the community environment factors associated with dependency. Cluster analysis was used and demonstrated that dependency was mainly associated with community primary preventive care service resources.

RESULTS

In the group aged under 70 years, the utilization of electronic health records and the need for health assessments, and rehabilitation equipment rentals were significantly associated with the levels of dependency scores: the OR was 2.81, 2.25 and 2.13 (P < 0.05), respectively. In the group aged 70 years and over, a short-term care home was strongly associated with levels of dependency: the OR was 4.01 (P = 0.002). The daycare and nursing service, transportation service, and regular lectures on health knowledge were associated with levels of dependency: the OR was 2.41, 1.86 and 1.93 (P < 0.05). In the group with low social support, an emergency call or monitoring system, transportation services, the need for health assessment, and regular lectures on health knowledge were significantly associated with levels of dependency: the OR was 2.42, 2.19, 1.89 and 1.98 (P < 0.05), respectively.

CONCLUSIONS

Community environment resources were significantly associated with dependency. These results suggest that the dependent on local environment resources may consider as the resource needs among elderly people.

Using photovoice to inform and support health systems to reach marginalised populations: experiences from six low- and middle-income countries

Photovoice methodology centralises the voices of marginalised populations within health systems using photography and critical dialogue to record, reflect and communicate community health issues. This paper presents findings from applying photovoice to explore and document the lived experiences of groups of marginalised populations in six low- and middle-income countries: Cambodia, Ghana, Nepal, Sierra Leone, Uganda and Zambia. The strengths of using photovoice included: creating safe spaces for communication; community solidarity and stakeholder engagement; community ownership of actions and advocacy; developing new soft skills and confidence; capturing hidden community challenges; and taking collective action. Suggestions for use in future photovoice studies include: providing space for the exploration of contextual factors before implementation; developing a capacity strengthening plan to ensure participants have the competencies required to effectively take part in research and dissemination; considering the use of non-visual methods alongside photovoice when needed; and having in place partnership structures between researchers and participants that facilitate power sharing, agency, empowerment and joint decision making. Lastly, we present recommendations that have the potential to strengthen the value and use of photovoice as more than a participatory method but also a vehicle for individual, relational and health systems improvements.

Patient-public engagement strategies for health system improvement in sub-Saharan Africa: a systematic scoping review

Background

Actively involving patients and communities in health decisions can improve both peoples’ health and the health system. One key strategy is Patient-Public Engagement (PPE). This scoping review aims to identify and describe PPE research in Sub-Saharan Africa; systematically map research to theories of PPE; and identify knowledge gaps to inform future research and PPE development.

Methods

The review followed guidelines for conducting and reporting scoping reviews. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 was conducted on Scopus, Medline (Ovid), CINAHL and Embase databases. Independent full text screening by three reviewers followed title and abstract screening. Using a thematic framework synthesis, eligible studies were mapped onto an engagement continuum and health system level matrix to assess the current focus of PPE in Sub-Saharan Africa.

Results

Initially 1948 articles were identified, but 18 from 10 Sub-Saharan African countries were eligible for the final synthesis. Five PPE strategies implemented were: 1) traditional leadership support, 2) community advisory boards, 3) community education and sensitisation, 4) community health volunteers/workers, and 5) embedding PPE within existing community structures. PPE initiatives were located at either the ‘involvement’ or ‘consultation’ stages of the engagement continuum, rather than higher-level engagement. Most PPE studies were at the ‘service design’ level of the health system or were focused on engagement in health research. No identified studies reported investigating PPE at the ‘individual treatment’ or ‘macro policy/strategic’ level.

Conclusion

This review has successfully identified and evaluated key PPE strategies and their focus on improving health systems in Sub-Saharan Africa. PPE in Sub-Saharan Africa was characterised by tokenism rather than participation. PPE implementation activities are currently concentrated at the ‘service design’ or health research levels. Investigation of PPE at all the health system levels is required, including prioritising patient/community preferences for health system improvement.

Framework for Patient and Informal Caregiver Participation in Research (PAICPAIR): Part 1

The term user involvement is frequently applied in research. Frameworks for patient and informal caregiver participation as coresearchers in studies concerning patients with life-threatening illness are however sparse. The PhD project Dying With Dignity—Dignity-Preserving Care for Older Women Living at Home With Incurable Cancer has implemented a thorough cooperation with patients and informal caregivers from the early stages of the research process. A framework for Patient and Informal Caregiver Participation In Research (PAICPAIR) is suggested—creating a stronger foundation for democracy, equality, and research quality by also promoting active participation among vulnerable people experiencing incurable, life-threatening illness, as coresearchers.

Patient-public engagement interventions for health system improvement in Sub-Saharan Africa: A systematic scoping review protocol

BACKGROUND

Research has found health system improvement cannot be achieved without continuously engaging patients, their families and all stakeholders in the design, management and delivery of health care services. Following the Alma Ata declaration on Primary Health Care in 1978, the focus of health system improvement has tended to shift from physician or hospital-centric approaches to a more democratic vision of engaging the public and/or patients in the commissioning, planning, organisation, operation and control of the health care system. Thus, patient-public engagement (PPE) has become an important tool in health system improvement particularly for countries with poor health outcomes including countries in sub-Saharan Africa which carries an estimated 24% of the global burden of diseases in both human and financial costs. The aim of this scoping review is to describe and systematically map PPE research in sub-Saharan Africa, and then to synthesise this research in relation to key theories of PPE, identify the key drivers and barriers of PPE and to identify the knowledge gaps that may usefully be addressed by future research.

METHODS

This scoping review will follow Arksey and O'Malley's best guidelines for conducting scoping reviews and also follow the standard guidelines for reporting using the Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews checklist. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 will be conducted on four databases: Scopus, CINAHL, Medline (Ovid) and Embase. The initial screening of titles and abstracts will be undertaken independently by two reviewers, followed by full text screening involving three independent reviewers. A thematic framework synthesis will be employed in the analysis of data to identify the various PPE interventions, and outcomes mapped to a framework of engagement continuum to understand its overall effect on health system improvement in sub-Saharan Africa.

DISCUSSION

To our knowledge, this scoping review will be the first to systematically investigate PPE interventions implemented across sub-Saharan Africa, map the outcomes of identified interventions to a framework of engagement continuum and to understand its overall effect on health system improvement. Findings of this review will be published in an open-access peer review journal and disseminated at scientific conferences.

A review of reviews on principles, strategies, outcomes and impacts of research partnerships approaches: a first step in synthesising the research partnership literature

Background

Conducting research in partnership with stakeholders (e.g. policy-makers, practitioners, organisations, patients) is a promising and popular approach to improving the implementation of research findings in policy and practice. This study aimed to identify the principles, strategies, outcomes and impacts reported in different types of reviews of research partnerships in order to obtain a better understanding of the scope of the research partnership literature.

Methods

This review of reviews is part of a Coordinated Multicenter Team approach to synthesise the research partnership literature with five conceptually linked literature reviews. The main research question was ‘What principles, strategies, outcomes and impacts are reported in different types of research partnership approaches?’. We included articles describing a literature review of research partnerships using a systematic search strategy. We used an adapted version of the Revised Assessment of Multiple Systematic Reviews tool to assess quality. Nine electronic databases were searched from inception to April 2018. Principles, strategies, outcomes and impacts were extracted from the included reviews and analysed using direct content analysis.

Results

We included 86 reviews using terms describing several research partnership approaches (e.g. community-based participatory research, participatory research, integrated knowledge translation). After the analyses, we synthesised 17 overarching principles and 11 overarching strategies and grouped them into one of the following subcategories: relationship between partners; co-production of knowledge; meaningful stakeholder engagement; capacity-building, support and resources; communication process; and ethical issues related to the collaborative research activities. Similarly, we synthesised 20 overarching outcomes and impacts on researchers, stakeholders, the community or society, and the research process.

Conclusions

This review of reviews is the first that presents overarching principles, strategies, outcomes and impacts of research partnerships. This review is unique in scope as we synthesised literature across multiple research areas, involving different stakeholder groups. Our findings can be used as a first step to guide the initiation and maintenance of research partnerships and to create a classification system of the key domains of research partnerships, which may improve reporting consistency in the research partnership literature.

Trial registration

This study is registered via Open Science Framework: 10.17605/OSF.IO/GVR7Y.

Partnerships, Processes, and Outcomes: A Health Equity-Focused Scoping Meta-Review of Community-Engaged Scholarship

In recent decades, there has been remarkable growth in scholarship examining the usefulness of community-engaged research (CEnR) and community-based participatory research (CBPR) for eliminating health inequities.This article seeks to synthesize the extant literature of systematic reviews, scoping reviews, and other related reviews regarding the context, processes, and research designs and interventions underlying CEnR that optimize its effectiveness. Through a scoping review, we have utilized an empirically derived framework of CBPR to map this literature and identify key findings and priorities for future research. Our study found 100 reviews of CEnR that largely support the CBPR conceptual framework.

Community participation in health research: an ethnography from rural Swaziland

Community participation in all aspects of health research is widely advocated. However, there is a lack of specificity in reporting what community members actually do, and reported participation is typically limited to discrete research activities. Greater specificity in reporting has potential to clarify how community participation might occur and how it might influence empowerment and research rigour. We conducted an ethnographic study of participatory health research (PHR) in a socio-economically marginalized rural Swazi community. Data about 10 community co-researchers' participation in research workshops and field work were collected through participant observation over 14 months and analysed using directed content analysis, informed by the Comprehensive Community Participation in Research Framework (CCPRF). The analysis demonstrated that facilitating extensive community participation in PHR is feasible and identified 10 new research process activities in which community members might participate, for inclusion in an expanded CCPRF. We provide examples of how community members might participate in 57/59 expanded CCPRF activities and show that participatory, dialogue-based activities can be effective tools for facilitating research participation in ways that empower individual co-researchers and enhance research rigour. However, our results highlight limitations of community participation related to utilizing research results to inform actions, and empowering communities to control their environments and improve their health.

Key populations and power: people-centred social innovation in Asian HIV services

Key populations increasingly lead the design, implementation, and evaluation of HIV services, which provides an opportunity to make them more people-centred. Despite many challenges, a strong argument that these populations must have a greater role in HIV service planning, development, and delivery worldwide exists. This Viewpoint focuses on Asia, where key populations have advocated for legal reform, engaged vulnerable groups to decrease stigma, co-created innovative HIV services, and developed new key population-led health services. Further research on key populations and their roles in HIV implementation and sustainable scale-up is needed in Asia and beyond.

Process and Outcomes of a Recursive, Dialogic Member Checking Approach: A Project Ethnography

There is limited empirical evidence about member checking, a long-standing qualitative research technique for establishing validity. I conducted directed content analysis of ethnographic data detailing the process and outcomes of a "dialogic" member checking approach I implemented in rural Swaziland. It involved 10 participants, checking results about their participation and empowerment as co-researchers in participatory health research. The process involved participants in four recurring stages: thinking independently, hearing findings, appraising findings, and negotiating final representations. It increased the transferability and accuracy ("transactional" validity) of the results by adding richly descriptive data and establishing the extent of participant agreement with my findings. It had emancipatory outcomes ("transformational" validity) including developing critical understandings, influencing the research trajectory to "give voice" to participants, and establishing more equitable researcher-researched relationships. Further development, implementation, and appraisal of recursive, dialogic approaches can advance member checking as a technique for enhancing "holistic" validity in qualitative health research.

Community-based care of children affected by AIDS in Swaziland: a gender-aware analysis

BACKGROUND

Care of children affected by AIDS in Swaziland is predominately provided by families, with support from 'community-based responses'. This approach is consistent with United Nations International Children's Fund's (UNICEF) framework for the protection, care and support of children affected by AIDS. However, the framework relies heavily on voluntary caregiving which is highly gendered. It pays limited attention to caregivers' well-being or sustainable community development which enables more effective caregiving. As a result, the framework is incompatible with the social justice principles of primary health care, and the sustainable development goals (SDGs).AimOur aim was to examine the effects and gender dimensions of providing voluntary, community-based, care-related labour for children affected by AIDS.

METHODS

We conducted multiple-methods research involving an ethnography and participatory health research, in a rural Swazi community. We analysed data related to community-based responses using an abductive, mixed-methods technique, informed by the capabilities approach to human development and a gender analysis framework.FindingsTwo community-based responses, 'neighbourhood care points' (facilities that provide children meals) and the 'lihlombe lekukhalela' (child protector) program were being implemented. The unpaid women workers at neighbourhood care points reported working in challenging conditions (eg, lacking labour-saving technologies), insufficient and diminishing material support (eg, no food), and receiving limited support from the broader community. Child protectors indicated their effectiveness was limited by lack of social power, relative to the perpetrators of child abuse. The results indicate that support for community-based responses will be enhanced by acknowledging and addressing the highly gendered nature of care-related labour and social power, and that increasing access to material resources including food, caregiver stipends and labour-saving technologies, is essential. These strategies will simultaneously contribute to the social and economic development of communities central to primary health care, and achieving the poverty, hunger, gender and work-related SDGs.

Health Capability Deprivations in a Rural Swazi Community: Understanding Complexity With Theoretically Informed, Qualitatively Driven, Mixed-Method Design, Participatory Action Research

Comprehensive theories of health justice can supplement rights-based approaches like primary health care, by conceptualizing key terms, and systematizing knowledge about structural factors that influence health. Our aim was to use "health capability" as a theoretical lens for understanding how primary health care approaches might address structural factors impeding health in a rural Swazi community. We conducted abductive, interpretive, analysis of a mixed-method (QUAL+quan) data set about "health capability deprivations," generated through participatory action research. Four themes are discussed: illness and disease, unhealthy daily living environments, inability to move freely, and gendered expectations and norms. The analysis demonstrates that there were complex interrelationships between health capability deprivations, material and ideological deprivation prevented community members from aspiring to or securing their right to health, health capability theory can augment primary health care approaches and vice versa, and qualitatively driven, mixed-method research can generate unique insights about structural factors that influence health.

Ethical Research Practice or Undue Influence? Symbolic Power in Community- and Individual-Level Informed Consent Processes in Community-Based Participatory Research in Swaziland

In community-based participatory research (CBPR), community-level consent is assumed to enhance ethical rigor, when obtained prior to individual informed consent. However, community leaders' permission to conduct research may influence individuals' agency to decline participation. This article presents findings of a Bourdieusian analysis of ethnographic data documenting CBPR in rural Swaziland. The findings reveal that the "symbolic power" of leaders who provide community-level consent constrains individual agency and reproduces existing relations of power, if individual informed consent is simply a procedure. However, when informed consent is a process that introduces notions of autonomy and rights, it can disrupt power relations. Implications for ethical CBPR practice, and ethnography's value for developing theory from real-world research ethics practice, are discussed.

Gendered childcare norms - evidence from rural Swaziland to inform innovative structural HIV prevention approaches for young women

Addressing discriminatory gender norms is a prerequisite for preventing HIV in women, including young women. However, the gendered expectation that women will perform unpaid childcare-related labour is rarely conceptualised as influencing their HIV risk. Our aim was to learn from members of a rural Swazi community about how gendered childcare norms. We performed sequential, interpretive analysis of focus group discussion and demographic survey data, generated through participatory action research. The results showed that gendered childcare norms were firmly entrenched and intertwined with discriminatory norms regarding sexual behaviour. Participants perceived that caring for children constrained young women's educational opportunities and providing for children's material needs increased their economic requirements. Some young women were perceived to engage in "transactional sex" and depend financially on men, including "sugar daddies", to provide basic necessities like food for the children they cared for. Our results suggested that men were no longer fulfilling their traditional role of caring for children's material needs, despite women's traditional role of caring for their physical and emotional needs remaining firmly entrenched. The results indicate that innovative approaches to prevent HIV in young women should incorporate structural approaches that aim to transform gendered norms, economically empower women and implement policies guaranteeing women equal rights.

'I was thinking we would be spoon-fed': Community co-researchers' perceptions of individual empowerment in participatory health research in Swaziland

Empowerment is an influential concept in global public health. Current theoretical models, which were developed in resource-rich countries, conceptualise individual-level empowerment as a process (or outcome) of developing positive self-perceptions, critical thinking expertise and new behaviours. They neglect the social and structural aspects that were central to early conceptualisations of empowerment, and may be culturally biased. My aim was to elucidate lay-people in Swaziland's perspectives about individual-level empowerment. Twenty-one focus group discussions with lay-community 'co-researchers' were collected longitudinally over 14 months of a participatory health research process. Findings generated using interpretive analysis of epiphanies highlighted the salience of socio-historic context, in limiting the co-researchers' expectations and experiences, and shaping their perceptions, of empowerment. The findings demonstrate that the co-researchers perceived: working independently and collaboratively; developing new perceptions of others, and technical (health and research) expertise; using expertise to take action; and accessing material resources were important aspects of empowerment. They indicate that individual-level empowerment models utilised in global public health might be enhanced by incorporating social and structural dimensions. These dimensions are needed to capture the relations and interactions which mediate socially excluded people's agency to access the social and material resources needed to secure their right to health.