'Water is life': developing community participation for clean water in rural South Africa

Water Treatment Practices and Misperceived Social Norms among Women Living with Young Children in Rural Uganda

Access to water safe for consumption is critical for health and well-being, yet substantial structural barriers often necessitate household action to make water safer. Social norms about water treatment practices are understudied as a driver of personal water treatment practice. This study assesses reported and perceived water treatment practices among women in a rural, water insecure setting. We used cross-sectional data from a population-based study of women living with children under 5 years old across eight villages in southwest Uganda. Participants reported their typical household water treatment practices and what they perceived to be the common practices among most other women with young children in their own village. Modified multivariable Poisson regression models estimated the association between individual behavior and perceptions. Of 274 participants (78% response rate), 221 (81%) reported boiling water and 228 (83%) reported taking at least one action to make water safer. However, 135 (49%) misperceived most women with young children in their village not to boil their water, and 119 (43%) misperceived most to take no action. Participants who misperceived these norms were less likely to practice safe water treatment (e.g., for boiling water, adjusted relative risk = 0.80; 95% CI 0.69-0.92, P = 0.002), adjusting for other factors. Future research should assess whether making actual descriptive norms about local water treatment practices visible and salient (e.g., with messages such as "most women in this village boil their drinking water") corrects misperceived norms and increases safe water treatment practices by some and supports consistent safe practices by others.

Individual and Community-Contextual Level Factors Associated With Wellbeing Among Older Adults in Rural Zambia

Objective: This article aims to identify individual and community-contextual level factors associated with the wellbeing of older adults (50 years and older) in rural Zambia. Methods: Data from the nationally representative 2015 Living Conditions Monitoring Survey (LCMS) was used. Employing multilevel mixed effects, the individual and community-contextual factors on wellbeing were determined. Results: Overall, 31.7% of rural older adults perceived their wellbeing as good. Both individual and community-contextual level factors are associated with the wellbeing of older adults in rural communities. At the individual level, wellbeing was associated with higher education attainment. Community-contextual factors significantly associated with wellbeing included improved housing, access to piped tap water within the premises, own charcoal or income to purchase firewood. Conclusion: The findings foreground the imperative to analyse both individual and community-contextual level factors of wellbeing to generate and present evidence for investments in education across the life course and for the development of infrastructure towards increasing the wellbeing of rural older adults. Additionally, the results provide a basis for planning by devising policies and programmes for older people to thrive and for no one to be left behind regardless the setting.

Association between water insecurity and antiretroviral therapy adherence among pregnant and postpartum women in Greater Accra region of Ghana

BACKGROUND

Adherence to antiretroviral therapy (ART) can substantially reduce morbidity and mortality among women living with HIV (WLWH) and prevent vertical transmission of HIV. However, in sub-Saharan Africa (SSA), more than 50% of new mothers discontinue ART and HIV care after childbirth. The role of water insecurity (WI) in ART adherence is not well-explored. We examined the relationship between WI and ART adherence among pregnant and postpartum WLWH in Greater Accra region of Ghana.

METHODS

Using a cross-sectional survey, we recruited 176 pregnant and postpartum WLWH on ART across 11 health facilities. We examined the association between WI (measured using the Household Water Insecurity Experience Scale, and categorized as moderate and severe WI compard to low WI) and poor ART adherence (defined as scoring a below average observed CASE index score). Bivariate analysis was performed using chi-square test followed by multivariate logistic regression models. We included all variables with p-values less than 0.20 in the multivariate analysis.

RESULTS

Most (79.5%) of the pregnant and postpartum WLWH enrolled on ART, were urban residents. Over 2/3 were aged 30 years and older. Overall, 33.5% of respondents had poor ART adherence. Proportion of poor ART adherence was 19.4% among those with low WI, 44.4% in those with moderate WI, and 40.0% among those with high WI. Respondents with moderate household water insecurity had a greater odds of reporting poor ART adherence, as compared to those with low water insecurity (adjusted Odds ratio (aOR) = 2.76, 95%CI: 1.14-6.66, p = 0.024), even after adjusting for food insecurity. Similarly, respondents with high WI had a greater odds of reporting poor ART adherence, as compared to those with low water insecurity (aOR = 1.49, 95%CI: 0.50-4.48, p = 0.479), even after adjusting for food insecurity.

CONCLUSION

Water insecurity is prevalent among pregnant and postpartum WLWH and is a significant risk factor for poor ART adherence. Governments and other stakeholders working in HIV care provision should prioritize water security programming for WLWH along the HIV care continuum.

Building resilience to hazards in the water, sanitation, and hygiene (WASH) systems: a global review

Building the resilience of communities is essential in achieving Sustainable Development Goals (SDG). Scientific research is crucial in identifying gaps in the development of WASH systems and the management of WASH-related hazards . The main purpose of this paper was to analyze the global research evolution on resilience and Water, Sanitation, and Hygiene (WASH) between the period 2003 and 2021. Bibliometric analysis was done through the analysis of research articles from the Web of Science and Scopus using R Package software A total of 110 articles were generated from the Web of Science and Scopus databases. The study revealed that there was very little research on WASH from 2003 to 2010 and a steady increase from 2011 to 2018 and a sharp increase from 2019 to 2020 with a slight drop in 2021. This paper, therefore, recommends more focused scientific research on WASH issues in Africa and Southern Africa in particular.

Modelling the historical distribution of schistosomiasis-transmitting snails in South Africa using ecological niche models

Schistosomiasis is a vector-borne disease transmitted by freshwater snails and is prevalent in rural areas with poor sanitation and no access to tap water. Three snail species are known to transmit schistosomiasis in South Africa (SA), namely Biomphalaria pfeifferi, Bulinus globosus and Bulinus africanus. In 2003, a predicted prevalence of 70% was reported in tropical climates in SA. Temperature and rainfall variability can alter schistosomiasis-transmitting snails' development by increasing or decreasing their abundance and geographical distribution. This study aimed to map the historical distribution of schistosomiasis from 1950 to 2006 in SA. The snail sampling data were obtained from the historical National Snail Freshwater Collection (NFSC). Bioclimatic variables were extracted using ERA 5 reanalysis data provided by the Copernicus Climate Change Service. In this study, we used 19 bioclimatic and four soil variables. The temporal aggregation was the mean climatological period pre-calculated over the 40-year reference period with a spatial resolution of 0.5° x 0.5°. Multicollinearity was reduced by calculating the Variance Inflation Factor Core (VIF), and highly correlated variables (> 0.85) were excluded. To obtain an "ensemble" and avoid the integration of weak models, we averaged predictions using the True Skill Statistical (TSS) method. Results showed that the ensemble model achieved the highest Area Under the Curve (AUC) scores (0.99). For B. africanus, precipitation-related variables contributed to determining the suitability for schistosomiasis. Temperature and precipitation-related variables influenced the distribution of B. globosus in all three models. Biomphalaria pfeifferi showed that Temperature Seasonality (bio4) contributed the most (47%) in all three models. According to the models, suitable areas for transmitting schistosomiasis were in the eastern regions of South Africa. Temperature and rainfall can impact the transmission and distribution of schistosomiasis in SA. The results will enable us to develop future projections for Schistosoma in SA based on climate scenarios.

Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district

BACKGROUND

While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs.

METHODS

CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making.

RESULTS

CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC.

CONCLUSIONS

Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.

Realising radical potential: building community power in primary health care through Participatory Action Research

BACKGROUND

While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.

METHODS

Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.

RESULTS

Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.

CONCLUSIONS

Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

Review of Community-Managed Water Supply—Factors Affecting Its Long-Term Sustainability

Although water is considered a human right, rural communities in many countries face challenges related to the lack of a safe water supply. In rural areas, where there is no access to public or private water supply, populations have no other choice than to rely on other unsafe sources of water. Community-managed water supply (CMWS) has emerged as an alternative to address the lack of access to safe water. Nonetheless, this alternative has several critical characteristics that harm the sustainability of water supplies. Studies on sustainability and the long-term impact of the CMWS were explored through a review of recent literature using Scopus and Web of Science databases, which analyzed 86 papers reporting on research into the sustainability and efficiency of water supply systems managed and operated by local communities, as well as the long-term critical factors that can interfere with the functionality of these systems. Based on the critical factors most cited in the literature, we proposed a framework of strategies that interrelate and integrate the critical factors into levels of responsibility. The most critical factors are related to the community level, such as inadequate capacity and ineffective systems. This demonstrates the relevance of local characteristics in the implementation of water management systems. The most cited sustainability strategies refer to the local level as the one requiring action to promote effective community involvement and post-construction support. The framework helps to conceptualize what we called an enabling environment for decision-making, and thus, the achievement of the long-term sustainability of water supply.

Exploring linkages between drought and HIV treatment adherence in Africa: a systematic review

Climate change is directly and indirectly linked to human health, including through access to treatment and care. Our systematic review presents a systems understanding of the nexus between drought and antiretroviral therapy (ART) adherence in HIV-positive individuals in the African setting. Narrative synthesis of 111 studies retrieved from Web of Science, PubMed/MEDLINE, and PsycINFO suggests that livelihoods and economic conditions, comorbidities and ART regimens, human mobility, and psychobehavioural dispositions and support systems interact in complex ways in the drought-ART adherence nexus in Africa. Economic and livelihood-related challenges appear to impose the strongest impact on human interactions, actions, and systems that culminate in non-adherence. Indeed, the complex pathways identified by our systems approach emphasise the need for more integrated research approaches to understanding this phenomenon and developing interventions.

Lessons from community participation in primary health care and water resource governance in South Africa: a narrative review

BACKGROUND

In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services.

OBJECTIVE

This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs).

METHODS

Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically.

RESULTS

There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders.

CONCLUSION

Power and authority in decision-making, resources and accountability are key for effective community participation of marginalized people. Practical guidance is urgently required on how mandated participatory governance structures can be sustained and linked to wider governance systems to improve service delivery.

Collective reflections on the first cycle of a collaborative learning platform to strengthen rural primary healthcare in Mpumalanga, South Africa

BACKGROUND

Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme-a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa-for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance.

METHODS

Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017-19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts.

RESULTS

Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR stakeholders participating in routine health planning and review activities and frontline health officials being involved in the VAPAR process. Findings were collated into a revised theory of change.

CONCLUSIONS

The VAPAR learning platform was regarded as a feasible, acceptable and relevant approach to facilitate cooperative learning and community participation in health systems. The evaluation provides support for a collaborative learning platform within routine health system processes and contributes to the limited evaluative evidence base on embedded health systems research.

A Qualitative Analysis of Factors Influencing Household Water Treatment Practices Among Consumers of Self-Supplied Water in Rural Ethiopia

Background

The health of a community depends greatly on the availability of sufficient and clean water. Rural households relying on self-supplied drinking water must take full responsibility for the treatment of their drinking water. Globally, not many inquiries appear to have been carried out to satisfactorily inform us regarding how and why improvements in behavior related to water treatment occur in some selected individuals and not in others. Related investigations in Ethiopia are even fewer.

Methods

In the rural Aleta Wondo district of Ethiopia, a total of fifteen focus group discussions were conducted with community members. Similarly, ten key informant interviews were conducted with officers responsible for organizing water and hygiene programs. To gather data for this study, two qualitative data collection methods, viz., key informant interviews and focus group discussions, were used. Open code software 4.03 was used for thematic analysis.

Results

Factors influencing household water treatment practices were categorized into individual-level factors (eg cognitive factors, emotional factors), household-level factors (household means and decision-making balance), community-level factors (the value that is given for water quality and Public resources) and, environment and context-related factors (access to products and reliance on external sources).

Conclusion

Household water treatment practice has a range of multilevel influences. Beyond the model of providing ongoing safe water education by health extension workers, potential initiatives could be improved by community mobilization activities that include community leaders, women’s groups, etc., in promoting water treatment at community engagements. Also, the results of the present study indicate that it could be beneficial to provide health extension staff with additional training to improve their ability to encourage community members across, a wide range of user types or levels of readiness, to treat their water.

Developing stakeholder participation to address lack of safe water as a community health concern in a rural province in South Africa

BACKGROUND

Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water.

OBJECTIVE

This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa.

METHOD

We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process.

RESULTS

Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the functioning of other sectors and learning by doing were achieved.

CONCLUSION

Our process reflected willingness and commitment among stakeholders to work together collectively addressing local water challenges. Location in an established public health observatory helped to create neutral, mediated spaces for participation.

Building cooperative learning to address alcohol and other drug abuse in Mpumalanga, South Africa: a participatory action research process

Background: Alcohol and other drug (AOD) abuse is a major public health challenge disproportionately affecting marginalised communities. Involving communities in the development of responses can contribute to acceptable solutions.

Objectives: To: (1) document forms, processes, and contexts of engaging communities to nominate health concerns and generate new knowledge for action; (2) further build participation in the local health system by reflecting on and adapting the process.

Methods: PAR was progressed with 48 community stakeholders across three rural villages in the MRC/Wits Agincourt Health and Socio Demographic Surveillance System (HDSS) in Mpumalanga, South Africa. A series of workshops explored community-nominated topics, systematised lived experience into shared accounts and considered actions to address problems identified. Photovoice was also used to generate visual evidence. Narrative and visual data were thematically analysed, situated within practice frameworks, and learning and adaption elicited.

Results: AOD abuse was identified as a topic of high priority. It was understood as an entrenched social problem with destructive effects. Biopsychosocial impacts were mapped and related to unemployment, poverty, stress, peer pressure, criminal activity, corruption, and a proliferating number of taverns. Integrated action agendas were developed focussed on demand, supply, and harm reduction underpinned by shared responsibility among community, state, and non-state actors. Community stakeholders appreciated systematising and sharing knowledge, taking active roles, developing new skills in planning and public speaking, and progressing shared accountability processes. Expectations required sensitive management, however.

Conclusion: There is significant willingness and capacity among community stakeholders to work in partnership with authorities to address priority health concerns. As a process, participation can help to raise and frame issues, which may help to better inform action and encourage shared responsibility. Broader understandings of participation require reference to, and ultimately transfer of power towards, those most directly affected, developing community voice as continuous processes within social and political environments.

Verbal Autopsy with Participatory Action Research (VAPAR) programme in Mpumalanga, South Africa: protocol for evaluation

INTRODUCTION

There is a growing recognition of the importance of developing learning health systems which can engage all stakeholders in cycles of evidence generation, reflection, action and learning from action to deal with adaptive problems. There is however limited evaluative evidence of approaches to developing or strengthening such systems, particularly in low-income and middle-income settings. In this protocol, we aim to contribute to developing and sharing knowledge on models of building collaborative learning platforms through our evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme.

METHODS AND ANALYSIS

The evaluation takes a participatory approach, focussed on joint learning on whether and how VAPAR contributes to its aims, and what can be learnt for this and similar settings. A realist-informed theory of change was developed by the research team as part of a broader collaboration with other stakeholders. The evaluation will draw on a wide variety of perspectives and data, including programme data and secondary data. This will be supplemented by in-depth interviews and workshops at the end of each cycle to probe the different domains, understand changes to the positions of different actors within the local health system and feedback into improved learning and action in the next cycle. Quantitative data such as verbal autopsy will be analysed for significant trends in health indicators for different population groups. However, the bulk of the data will be qualitative and will be analysed thematically.

ETHICS AND DISSEMINATION

Ethics in participatory approaches include a careful focus on the power relationships within the group, such that all groups are given voice and influence, in addition to the usual considerations of informed participation. Within the programme, we will focus on reflexivity, relationship building, two-way learning and learning from failure to reduce power imbalances and mitigate against a blame culture. Local engagement and change will be prioritised in dissemination.