Understanding participation dilemmas in community mobilisation: can collective action theory help?

How Social Media Algorithms Shape Offline Civic Participation: A Framework of Social-Psychological Processes

Even though social media platforms have created opportunities for more efficient and convenient civic participation, they are unlikely to bring about social change if the online actions do not propagate to offline civic participation. This article begins by reviewing the meta-analytic evidence on the relation between social media use and offline civic participation. Following this discussion, we present a theoretical framework that incorporates the attitudinal, motivational, and relational processes that may mediate the effect of social media use on offline civic participation. The framework highlights how social media algorithms may shape attitudes on important societal issues, promote generalized action goals among habitual users, and build social capital. We further discuss factors that may strengthen or undermine each of these processes, suggest ways to design and implement algorithms that may promote offline civic participation, and propose questions for future research.

Halting and re-issuing of the Zambia community health strategy (2017-2021): a retrospective analysis of the policy process and implications for community health systems

BACKGROUND

Over the years, low-and middle-income countries have adopted several policy initiatives to strengthen community health systems as means to attain Universal Health Coverage (UHC). In this regard, Zambia passed a Community Health Strategy in 2017 that was later halted in 2019. This paper explores the processes that led to the halting and re-issuing of this strategy with the view of drawing lessons to inform the development of such strategies in Zambia and other similar settings.

METHODS

We employed a qualitative case study comprising 20 semi-structured interviews with key stakeholders who had participated in either the development, halting, or re-issuing of the two strategies, respectively. These stakeholders represented the Ministry of Health, cooperating partners and other non-government organizations. Inductive thematic analysis approach was used for analysis.

RESULTS

The major reasons for halting and re-issuing the community health strategy included the need to realign it with the national development framework such as the 7th National Development Plan, lack of policy ownership, political influence, and the need to streamline the coordination of community health interventions. The policy process inadequately addressed the key tenets of community health systems such as complexity, adaptation, resilience and engagement of community actors resulting in shortcomings in the policy content. Furthermore, the short implementation period, lack of dedicated staff, and inadequate engagement of stakeholders from other sectors threatened the sustainability of the re-issued strategy.

CONCLUSION

This study underscores the complexity of community health systems and highlights the challenges these complexities pose to health policymaking efforts. Countries that embark on health policymaking for community health systems must reflect on issues such as persistent fragmentation, which threaten the policy development process. It is crucial to ensure that these complexities are considered within similar policy engagement processes.

Evaluating barriers to reaching women with public health information in remote communities in Mali

Telecommunications offers an alternative or supplement to community-based interventions as a means of extending healthcare services and improving health outcomes in remote settings but can fail to reach target communities and achieve the desired impact if barriers to access are not overcome. We conducted seven focus group discussions and 26 interviews with community health workers, community leaders, and female members of the public who declared that they had or had not previously accessed free audio health messages provided via a mobile platform in two rural communities of Mali, Koulikoro and Bougouni. A content analysis showed that participants accessed and trusted health information from a range of sources, including radio, telephone and television, as well as town criers, local relays and community health centres. Barriers to access faced by women included economic factors, lack of network or electricity, and social factors such as illiteracy, cultural restrictions and being unaware of mobile communication. Through analysis and interpretation of the participants' responses, we have made recommendations for future campaigns for the dissemination of health-related information for women in remote settings.

Community health worker perspectives on advocacy: design-based research to develop a digital advocacy training course

Introduction

While community health workers (CHWs) are well-positioned as health advocates, they frequently lack support and feel undervalued. Advocacy training may prepare CHWs to support communities better.

Methods

This study uses a design-based research approach to (1) explore how participation in curriculum-development workshops for a digital advocacy course influenced CHWs' (n = 25) perceptions of advocacy and (2) describe how CHW involvement shaped course development. Data were collected via five discussion groups and seven surveys over six months.

Results

Initially, the CHWs perceived themselves as community-advocates but not as self-advocates. They increasingly reflected on the merits of advocating for better working conditions and aspired to greater involvement in decision-making. CHWs reflected positively on their advisory role in shaping the course to improve content acceptability and validity.

Discussion

Training efforts to engage CHWs in advocacy must overcome systemic barriers and norms internalized by CHWs that deter them from reaching their full potential as advocates.

Perspectives of acute, post-acute, physician and community support providers on community collaborative efforts to improve transitions of care

BACKGROUND

Transitional care (TC) involves multiple organizations as patients transition from hospitals. Collaboration to reduce readmissions has been encouraged by government initiatives. As part of Project ACHIEVE, a comparative TC study, we sought provider perspectives on TC improvement efforts.

METHODS

We aimed to identify perceived problems that drove improvement efforts, influences on interventions implemented, facilitators or barriers to desired outcomes, and sustainability. Investigators interviewed 63 representatives from collaborative improvement efforts across 13 states in 2015. Directed content analysis was performed, with inductive coding as insights emerged. Data was also analyzed for differences in participant perceptions, such as the organization represented, geographic characteristics, and source of funding for interventions.

RESULTS

Participants in semi-structured interviews included physicians, nurses, care navigators, and administrators from hospitals, nursing facilities, community-based organizations, and medical practices. Participants reported that changing reimbursement practices and readmissions penalties drove TC efforts, and common problems they sought to address included insufficient inter-provider communication, medication management, and challenges related to chronic condition management. Solutions implemented were often adapted according to community and setting characteristics and population factors. Findings also suggest differences in the types of interventions implemented according to funding sources, which also impacted the ability to sustain these interventions.

CONCLUSIONS

Cross-site collaboration, communication, and partnership among stakeholders is essential to effective transitional care. Collaboration led to shared understanding among stakeholders of health care and support services available in the community. Coalition-based work also facilitated trust among partners which led to expansion and sustainment of TC efforts. Unmet social needs of patients are a barrier.

IMPLICATIONS

Opportunities exist for increased and improved collaboration among clinical providers with community-based and social services organizations. Increased involvement of primary care providers in such collaborations would improve communication with both the patient and involved providers. Communities with external funding were more likely to implement evidence-based interventions, while those relying on institutional support addressed identified problems with more targeted interventions.

Mechanisms for community prevention of violence against women in low- and middle-income countries: A realist approach to a comparative analysis of qualitative data

Growing evidence suggests that community-based interventions in low- and middle-income countries (LMICs) can effectively address harmful social norms that promote or sustain gender inequality and drive violence against women (VAW). However, understanding what actions communities are already taking to address harmful social norms and prevent VAW is an essential first step for intervention development. Towards this goal, drawing on collective action theory, we conducted a realist analysis of secondary qualitative data collected with communities in India, Afghanistan, Peru and Rwanda. We coded interview and focus-group data from 232 participants to identify the contexts, mechanisms and outcomes (CMO) relevant for community action. We synthesized CMO configurations from each dataset into a conceptual framework composed of three middle-range theories of mechanisms driving community action to prevent VAW in LMICs. Our results highlight the importance of dedicated spaces for discussing VAW, VAW leaders as positive role models, and community perceptions of VAW as a problem worthy of intervention. In Rwanda and Peru, there was strong evidence to support the operation of these mechanisms. Contextual factors, including national and local policy and programmes targeting VAW, activated mechanisms that led to community action. In India and Afghanistan, evidence for the presence of these mechanisms was weaker, with social norms about women's position and violence being a private family matter preventing communities from addressing violence. Despite contextual differences, our data demonstrated communities in all four settings were somewhere along a pathway of change towards VAW prevention. This supports the need to build future prevention interventions on pre-existing mechanisms that trigger community action, rather than implementing existing interventions without local adaptation. Our conceptual framework serves as a tool for assessing these mechanisms of community action as part of intervention development research, centring community knowledge and fostering local ownership for more relevant and sustainable VAW prevention interventions.

Consumer Perceptions of the Use of Nondegradable Plastic Packaging and Environmental Pollution: A Review of Theories and Empirical Literature

Studying people’s perceptions of their attitudes and behaviour toward the use and inappropriate disposal of plastics is necessary because it helps explain the meaning of sustainable environmental behaviour in the context of African countries. Formulating appropriate behavioural change interventions may lead to a shift in people’s behaviour in terms of plastic consumption if they become aware of the environmental risk of plastics. Using a qualitative review of literature, relevant materials for this paper were identified using a search strategy that involved keywords and databases. Previous empirical studies employed several theoretical frameworks. However, inconsistences in the use and definition of variables, make comparing the results of these studies difficult. Although the literature is growing, more empirical evidence is still needed to understand the drivers of people’s perceptions toward unsustainable environmental behaviour in the context of African countries and to formulate appropriate behavioural change interventions. A review of the literature determined four broad drivers of people’s perceptions toward unsustainable environmental behaviour. These include policy or institutional variables, product and market attributes, community variables, and individual characteristics. Additionally, we offer a consolidated conceptual framework for analysing consumer perception in relation to the use of nondegradable plastics and environmental pollution and identify the drivers of people’s perceptions. Policy implications for developing countries as well as future research directions are flagged.

Self-reliance or social accountability? The raison d'être of community health committees in Nigeria

Social justice requires that communities demand social accountability. We conducted this study to inform ongoing efforts to facilitate social accountability through community health committees in Nigeria. We theorised that committees may see themselves in two ways - as outwardly-facing ('social accountability') and/or as inwardly-facing ('self-reliance'). We analysed the minutes of their meetings, alongside interviews and group discussions with committee members, community members, health workers, and health managers in four states across Nigeria. The committees' raison d'être reflects a bias for self-reliance in three ways. First, seen as a platform for the community to co-finance health services, members tend to be the local elite who can make financial contributions. Second, in a one-sided relationship, they function more to achieve the goals of governments (e.g. to improve the uptake of services), than of the community (e.g. rights-based demands for government support). Third, their activities in the community reflect greater concern to ensure that their community makes the most of what the government has already provided (e.g. helping to drive the uptake of existing services) than asking for more. Optimising the committees for social accountability may require support by actors who do not have conflicts of interests in ensuring that they have the necessary information and strategies to demand social accountability.

Social and Psychological Readiness to Take Collective Action Against Violence Against Women: A Mixed Methods Study of Informal Settlements in Mumbai, India

Past failures to mobilize communities in collective action against violence against women (VAW) have been ascribed to contextual challenges, but researchers have not systematically mapped community capacity for collective action against VAW. We conducted a mixed methods study in Mumbai, India using quantitative data from a household survey (n = 2,642) and qualitative data from 264 community meetings. We found attitudes supporting gender inequality and violence coexisted with significant enthusiasm and support for collective action against VAW. These findings open up avenues for policymakers to treat communities as less vulnerable and more capable of changing situations and problems that affect them.

Classroom, club or collective? Three types of community-based group intervention and why they matter for health

Interventions involving groups of laywomen, men and adolescents to promote health are increasingly popular, but past research has rarely distinguished between different types of intervention with groups. We introduce a simple typology that distinguishes three ideal types: classrooms, clubs and collectives. Classrooms treat groups as a platform for reaching a population with didactic behaviour change strategies. Clubs seek to build, strengthen and leverage relationships between group members to promote health. Collectives engage whole communities in assuming ownership over a health problem and taking action to address it. We argue that this distinction goes a long way towards explaining differences in achievable health outcomes using interventions with groups. First, classrooms and clubs are appropriate when policymakers primarily care about improving the health of group members, but collectives are better placed to achieve population-level impact. Second, classroom interventions implicitly assume bottleneck behaviours preventing a health outcome from being achieved can be reliably identified by experts, whereas collectives make use of local knowledge, skill and creativity to tackle complexity. Third, classroom interventions assume individual participants can address health issues largely on their own, while clubs and collectives are required to engender collective action in support of health. We invite public health researchers and policymakers to use our framework to align their own and communities’ ambitions with appropriate group-based interventions to test and implement for their context. We caution that our typology is meant to apply to groups of laypeople rather than professionalised groups such as whole civil society organisations.

Qualitative Analysis of a Teacher's Reflections on Medical Students Using Public Narratives to Promote Health

A qualitative, inductive content analysis was done to explore a teacher's reflections on the experiences of a team of medical students using public narratives to promote health within a Colombian university. Data were collected from the teacher's written reflective journal and an academic report, the latter, submitted by the medical students. 'Being mobilized' emerged as an overarching category. The experiences were described in three interrelated categories: team involvement, barriers and countering these barriers. In terms of team involvement, students were motivated, committed, connected with people and frustrated. On the other hand, barriers such as doubts and discomfort remarked, and finally these barriers were countered through training, practice and teamwork. As conclusion, the public narrative framework has changed the way medical students think about how to mobilize people for health promotion in a university. Narrative approaches are gaining strength as sources of motivation to support the adoption of healthy behaviors.

Modelling collective action to change social norms around domestic violence: social dilemmas and the role of altruism

Interventions promoting collective action have been used to prevent domestic violence in a range of settings, but their mechanisms of operation remain unclear. We formalise and combine feminist theoretical approaches to domestic violence into a game-theoretic model of women's collective action to change gendered social norms and outcomes. We show that social norms create a social dilemma in which it is individually rational for women to abstain from action to prevent domestic violence among neighbours, but all women suffer negative consequences if none take action. Promoting altruism among women can overcome the social dilemma. Discouraging women from tolerating domestic violence, imposing additional external punishment on men for perpetrating violence, or lowering costs to women of taking action against violence may not work or even backfire. We invite researchers on community mobilisation to use our framework to frame their understandings of collective action to prevent domestic violence.

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.919; root mean square error of approximation, 0.036; weighted root mean square residual, 1.949). Comparison of multi-group models across gender, education, caste, and marital status showed little evidence against measurement invariance. Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts.

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.920; root mean square error of approximation, 0.035; weighted root mean square residual, 1.952). Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts.

Process evaluation of a community mobilization intervention for preventing men's partner violence use in peri-urban South Africa

Intimate partner violence (IPV) is experienced by one-third of women globally, yet few programs attempt to shift men's IPV perpetration. Community mobilization is a potential strategy for reducing men's IPV perpetration, but this has rarely been examined globally. We conducted a mixed-methods process evaluation alongside a trial testing community mobilization in peri-urban South Africa. We used in-depth interviews (n=114), participant observation (160 h), and monitoring and evaluation data to assess program delivery. Qualitative data (verbatim transcripts and observation notes) were managed in Dedoose using thematic coding and quantitative data were descriptively analyzed using Stata13. We learned that outreach elements of community mobilization were implemented with high fidelity, but that critical reflection and local advocacy were difficult to achieve. The context of a peri-urban settlement (characterized by poor infrastructure, migrancy, low education, social marginalization, and high levels of violence) severely limited intervention delivery, as did lack of institutional support for staff and activist volunteers. That community mobilization was poorly implemented may explain null trial findings; in the larger trial, the intervention failed to measurably reduce men's IPV perpetration. Designing community mobilization for resource-constrained settings may require additional financial, infrastructural, organizational, or political support to effectively engage community members and reduce IPV.

Promoting women's and children's health through community groups in low-income and middle-income countries: a mixed-methods systematic review of mechanisms, enablers and barriers

INTRODUCTION

Community mobilisation through group activities has been used to improve women's and children's health in a range of low-income and middle-income contexts, but the mechanisms through which it works deserve greater consideration. We did a mixed-methods systematic review of mechanisms, enablers and barriers to the promotion of women's and children's health in community mobilisation interventions.

METHODS

We searched for theoretical and empirical peer-reviewed articles between January 2000 and November 2018. First, we extracted and collated proposed mechanisms, enablers and barriers into categories. Second, we extracted and synthesised evidence for them using narrative synthesis. We assessed risk of bias with adapted Downs and Black and Critical Appraisal Skills Programme checklists. We assigned confidence grades to each proposed mechanism, enabler and barrier.

RESULTS

78 articles met the inclusion criteria, of which 39 described interventions based on a participatory group education model, 19 described community-led structural interventions to promote sexual health in marginalised populations and 20 concerned other types of intervention or multiple interventions at once. We did not have high confidence in any mechanism, enabler or barrier. Two out of 15 proposed mechanisms and 10 out of 12 proposed enablers and barriers reached medium confidence. A few studies provided direct evidence relating proposed mechanisms, enablers or barriers to health behaviours or health outcomes. Only two studies presented mediation or interaction analysis for a proposed mechanism, enabler or barrier.

CONCLUSION

We uncovered multiple proposed mechanisms, enablers and barriers to health promotion through community groups, but much work remains to provide a robust evidence base for proposed mechanisms, enablers and barriers.

PROSPERO REGISTRATION NUMBER

CRD42018093695.

A theory of change for community interventions to prevent domestic violence against women and girls in Mumbai, India

Background: We describe the development of a theory of change for community mobilisation activities to prevent violence against women and girls. These activities are part of a broader program in urban India that works toward primary, secondary, and tertiary prevention of violence and includes crisis response and counselling and medical, police, and legal assistance. Methods: The theory of change was developed in five phases, via expert workshops, use of primary data, recurrent team meetings, adjustment at further meetings and workshops, and a review of published theories. Results: The theory summarises inputs for primary and secondary prevention, consequent changes (positive and negative), and outcomes. It is fully adapted to the program context, was designed through an extended consultative process, emphasises secondary prevention as a pathway to primary prevention, and integrates community activism with referral and counselling interventions. Conclusions: The theory specifies testable causal pathways to impact and will be evaluated in a controlled trial.

A theory of change for community interventions to prevent domestic violence against women and girls in Mumbai, India

Background: We describe the development of a theory of change for community mobilisation activities to prevent violence against women and girls. These activities are part of a broader program in urban India that works toward primary, secondary, and tertiary prevention of violence and includes crisis response and counselling and medical, police, and legal assistance. Methods: The theory of change was developed in five phases, via expert workshops, use of primary data, recurrent team meetings, adjustment at further meetings and workshops, and a review of published theories. Results: The theory summarises inputs for primary and secondary prevention, consequent changes (positive and negative), and outcomes. It is fully adapted to the program context, was designed through an extended consultative process, emphasises secondary prevention as a pathway to primary prevention, and integrates community activism with referral and counselling interventions. Conclusions: The theory specifies testable causal pathways to impact and will be evaluated in a controlled trial.

'There is no point giving cash to women who don't spend it the way they are told to spend it' - Exploring women's agency over cash in a combined participatory women's groups and cash transfer programme to improve low birthweight in rural Nepal

Cash transfer programmes form an integral part of nutrition, health, and social protection policies worldwide, but the mechanisms through which they achieve their health and nutritional impacts are incompletely understood. We present results from a process evaluation of a combined participatory women's groups and cash transfer programme to improve low birth weight in rural Nepal. We explored the ways in which context, implementation, and mechanism of the intervention affected beneficiary women's agency over cash transfers. Informed by a grounded theory framework, we conducted and analysed semi-structured interviews with 22 beneficiary women, 15 of their mothers-in-law, 3 of their elder sisters-in-law and 20 husbands, as well as a focus group discussion with 7 supervisors of the women's group intervention. Our study reveals how women's group facilitators, their supervisors and community members developed a shared dynamic around persuading and compelling recipients of unconditional cash transfers into spending them according to criteria developed by the group. We found these dynamics effectively constituted 'soft conditions' on beneficiary spending which restricted women's ability to make decisions over their cash transfers, but also increased their likelihood of spending them on their own pregnancy. Our findings demonstrate the importance of understanding how programmes are implemented and responded to in order to understand their implications for beneficiary agency and empowerment.