Aligning community engagement with traditional authority structures in global health research: a case study from northern Ghana

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

The role of stakeholder structure in fostering community ownership: A case study of community-based projects

Community health projects have played a crucial role in improving health issues. Listening to communities' voices and achieving community ownership are essential for conducting effective health projects. However, there are limited studies on the frameworks for collecting, aggregating, and operationalizing community preferences and values. In this study, we selected two cases of community field surveys from Japan and Cambodia to discuss who may represent a community and propose a practical approach to achieving community ownership. Both cases involved various stakeholders. From the insights of these two cases, we suggested the following three key components in the community project: the community representative, the communicator, and the institute outside the community. Notably, the community representative's role as the community's direct voice should be properly recognized and institutionalised to establish community ownership. We proposed the following key terms of the qualifications of community representatives: they should be able to represent voices from the community, should have extensive experience to decide the project direction and manage the project, and should be independent of outside actors. Our theoretical model of the structure of different stakeholder groups in community-based projects will be helpful to accelerate community capacity strengthening; moreover, it can help build the appropriate community institution and process, including multi-stakeholder groups to promote community ownership in health programs.

Understanding COVID-19 vaccination behaviors and intentions in Ghana: A Behavioral Insights (BI) study

INTRODUCTION

Vaccine uptake is influenced by a variety of factors. Behavioral Insights (BI) can be used to address vaccine hesitancy to understand the factors that influence the decision to take or refuse a vaccine.

METHODOLOGY

This two-part study consisted of a survey designed to identify the influence of various drivers of people's COVID-19 vaccination status and their intention to take the vaccine in Ghana, as well as an experiment to test which of several behaviorally informed message frames had the greatest effect on vaccine acceptance. Data was collected from a total of 1494 participants; 1089 respondents (73%) reported already being vaccinated and 405 respondents (27%) reported not being vaccinated yet. The mobile phone-based surveys were conducted between December 2021 and January 2022 using Random Digit Dialing (RDD) to recruit study participants. Data analysis included regression models, relative weights analyses, and ANOVAs.

RESULTS

The findings indicated that vaccine uptake in Ghana is influenced more by social factors (what others think) than by practical factors such as ease of vaccination. Respondents' perceptions of their family's and religious leaders' attitudes towards the vaccine were among the most influential drivers. Unexpectedly, healthcare providers' positive attitudes about the COVID-19 vaccine had a significant negative relationship with respondents' vaccination behavior. Vaccine intention was positively predicted by risk perception, ease of vaccination, and the degree to which respondents considered the vaccine effective. Perceptions of religious leaders' attitudes also significantly and positively predicted respondents' intention to get vaccinated. Although perceptions of religious leaders' views about the vaccine are an important driver of vaccine acceptance, results asking respondents to rank-order who influences them suggest that people may not be consciously aware-or do not want to admit-the degree to which they are affected by what religious leaders think. Message frames that included fear, altruism, social norms were all followed by positive responses toward the vaccine, as were messages with three distinct messengers: Ghana Health Services, a doctor, and religious leaders.

CONCLUSIONS

What drives COVID-19 vaccine intentions does not necessarily drive behaviors. The results of this study can be used to develop appropriate COVID-19 vaccine uptake strategies targeting the most important drivers of COVID-19 vaccine acceptance, using effective message frames.

Unsung heroes in Ghana's healthcare system: the case of community health volunteers and community health management committee

BACKGROUND

In Ghana, the community-based health planning and services (CHPS) policy highlights the significance of both community health management committees (CHMCs) and community health volunteers (CHVs) in the Ghanaian health system. However, research into their specific effects on health system improvement is scarce. Some research has focussed on the roles of the CHMCs/CHVs in implementing specific targeted health interventions but not on improving the overall health system. Therefore, this research aims to examine the role of the CHMCs and CHVs in improving the Ghanaian health system.

METHODS

The study was conducted in three districts in the Ashanti region of Ghana. A total of 35 participants, mainly health service users and health professionals, participated in the study. Data were collected using semi-structured individual in-depth interviews. Participants were selected according to their patient-public engagement or community health activity roles. Data were transcribed and analysed descriptively using NVIVO 12 Plus.

RESULTS

We found that the effectiveness of CHMCs and CHVs in health systems improvement depends largely on how members are selected. Additionally, working through CHMC and CHVs improves resource availability for community health services, and using them in frontline community health activities improves health outcomes.

CONCLUSIONS

Overall, we recommend that, for countries with limited healthcare resources such as Ghana, leveraging the significant role of the CHMCs and CHVs is key in complementing government's efforts to improve resource availability for healthcare services. Community health management committees and CHVs are key in providing basic support to communities with limited healthcare personnel. Thus, there is a need to strengthen their capacities to improve the overall health system.

Stakeholder engagement in the development of genetically modified mosquitoes for malaria control in West Africa: lessons learned from 10 years of Target Malaria's work in Mali

From 2012 to 2023, the Malaria Research and Training Center (MRTC), based out of the University of Sciences, Techniques and Technologies of Bamako (USTTB), was part of the Target Malaria research consortium working towards developing novel gene drive-based tools for controlling populations of malaria vector mosquitoes. As part of this work, Target Malaria Mali has undertaken a range of in-depth engagement activities with the communities where their research is conducted and with other stakeholders nationally. These activities were meant to ensure that the project's activities took place with the agreement of those communities, and that those communities were able to play a role in shaping the project's approach to ensure that its eventual outcomes were in line with their needs and concerns. This paper aims to conduct a critical assessment of those 10 years of stakeholder engagement in order to identify good practices which can inform future engagement work on gene drive research in West Africa. It sets out a range of approaches and practices that enabled the Target Malaria Mali team to engage a variety of stakeholders, to share information, collect feedback, and determine community agreement, in a manner that was inclusive, effective, and culturally appropriate. These can be useful tools for those working on gene drive research and other area-wide vector control methods in West African contexts to ensure that their research is aligned with the interests of the communities who are intended to be its ultimate beneficiaries, and to allow those communities to play a meaningful role in the research process.

Social innovation in health and community-driven engagement as a key strategy for addressing COVID-19 crisis challenges: insights and reflections from the multicultural society of Iran

Background

Social innovation is one of the strategies for appealing to people and encouraging social cooperation and engagement in interventions during crisis periods. In this regard, community engagement is an operative and innovative community health approach for achieving successful health outcomes. There is limited information about the role and operational impact of social innovation on community engagement during the challenges posed by the COVID-19 crisis. In this study, we aim to contribute to the understanding of innovative social strategies to attract social participation in crises such as the COVID-19 pandemic by highlighting the experience of social innovative strategies based on community-driven engagement in Iran.

Methods

This qualitative study was conducted in seven provinces of Iran-Mazandaran, Zanjan, Golestan, Lorestan, Tehran, Kurdistan, and Khuzestan-from 4 September 2021 to 1 March 2022. A sample of Iranians (15-71 years) was selected by purposeful and snowball sampling methods to participate in the study, and 187 semi-structured telephone interviews were conducted. Participants were recruited from three levels of the community: community leaders, healthcare providers, and laypeople. The data collection tool was an interview guide, which was designed based on a review of the literature. The data were analyzed using conventional content analysis. Exploratory analyses were performed to identify social innovative strategies based on community engagement used during the COVID-19 crisis in Iran. The interviews continued until data saturation was reached.

Results

Based on our findings, we distilled innovative strategies into 6 main themes and 37 categories: (1) information giving/sharing, (2) consultation, (3) involvement/collaboration, (4) health education and prevention, (5) empowering, and (6) advocacy. The results revealed that the participants were very driven to engage in the management and control of the COVID-19 crisis, even though they faced significant challenges.

Conclusion

The spread of the COVID-19 pandemic required social- and community-based responses. These reactions increased the possibility of fair access to health services, especially for vulnerable groups and minorities. As with other epidemics, applying the experience of the comprehensive participation of communities played an important and active role in the prevention and control of COVID-19. In this regard, giving and sharing information, consultation, involvement/collaboration, health education/prevention, empowerment, and advocacy are the most important innovative strategies that might encourage the community to perform COVID-19 crisis management and control.

Learning from health system actor and caregiver experiences in Ghana and Nepal to strengthen growth monitoring and promotion

BACKGROUND

Globally, growth monitoring and promotion (GMP) of infants and young children is a fundamental component of routine preventive child health care; however, programs have experienced varying degrees of quality and success with enduring challenges. The objective of this study was to describe implementation of GMP (growth monitoring, growth promotion, data use, and implementation challenges) in two countries, Ghana and Nepal, to identify key actions to strengthen GMP programs.

METHODS

We conducted semi-structured key informant interviews with national and sub-national government officials (n = 24), health workers and volunteers (n = 40), and caregivers (n = 34). We conducted direct structured observations at health facilities (n = 10) and outreach clinics (n = 10) to complement information from interviews. We coded and analyzed interview notes for themes related to GMP implementation.

RESULTS

Health workers in Ghana (e.g., community health nurses) and Nepal (e.g., auxiliary nurse midwives) had the knowledge and skills to assess and analyze growth based on weight measurement. However, health workers in Ghana centered growth promotion on the growth trend (weight-for-age over time), whereas health workers in Nepal based growth promotion on measurement from one point in time to determine whether a child was underweight. Overlapping challenges included health worker time and workload. Both countries tracked growth-monitoring data systematically; however, there was variation in growth monitoring data use.

CONCLUSION

This study shows that GMP programs may not always focus on the growth trend for early detection of growth faltering and preventive actions. Several factors contribute to this deviation from the intended goal of GMP. To overcome them, countries need to invest in both service delivery (e.g., decision-making algorithm) and demand generation efforts (e.g., integrate with responsive care and early learning).

Understanding Factors Influencing Polio Vaccine Uptake in Ghana-Developing Meaningful Community Mobilization and Engagement Strategies in Collaboration with Religious Leaders

This qualitative study explores how religious leaders in Ghana view polio and polio vaccine-related knowledge and perceptions of the community members. It also examines the personal characteristics of those who are most likely to accept or reject the vaccine. On the basis of the findings, this study provides a set of evidence-based recommendations to support religious leaders' efforts to create polio vaccine demand in their communities. The study is based on focus group discussions conducted with religious leaders from various geographic locations across Ghana. The discussions were transcribed verbatim and analyzed thematically. Twenty religious leaders, including Christian, Muslim, and leaders of traditional African religions, participated in the study. The findings show that both religious leaders and community members lack knowledge and have multiple culturally and religiously influenced explanations for polio. In addition, the findings reveal that vaccine safety and efficacy are linked to emotional narratives, and receiving the polio vaccine is not a social norm in all communities. Educated mothers in urban settings were identified as those most receptive to the polio vaccine. To create polio vaccine demand, religious leaders need to combat misinformation and the negative perceptions about the vaccine. Recommendations include conveying high-quality information to community members, developing tactics to address culturally and religiously sensitive matters, using emotionally inspired personal accounts to enhance positive attitudes toward polio vaccines and act as catalysts for positive social norms towards the polio vaccine. Educated mothers from urban areas can be engaged as champions in vaccine demand creation.

Community engagement in research in sub-Saharan Africa: current practices, barriers, facilitators, ethical considerations and the role of gender - a systematic review

Introduction

meaningful community engagement is increasingly being considered the major determinant of successful research, innovation and intervention uptake. Even though there is available literature recommending community engagement in health research, there are still knowledge gaps in how communities might be best engaged in Sub-Saharan Africa. We, therefore, synthesized the existing literature on the current practices, barriers and facilitators, ethical considerations, and gender mainstreaming in the engagement of communities in research in sub-Saharan Africa.

Methods

this synthesis was developed following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). A combination of keywords and medical subject headings was used to search MEDLINE, EMBASE, Global Health Library through OVID SP, the Cochrane Library, PsychINFO, CINAHL, WHO Afro Library, WHO Global Index Medicus and the National Institute for Health Research, for all literature published between 1 January 2000 to 31 July 2021.

Results

thirty articles met our inclusion criteria. The key reported facilitators of effective community engagement in research included appropriate community entry and engagement of stakeholders. Barriers to effective community engagement in research included the availability of prohibitive cultural, historical and religious practices; geographical/spatial limitations, difficulties in planning and executing community engagement activities and communication barriers. Awareness creation and sensitization on the research through drama, social media, documentaries, and community durbars are some of the existing practices adopted in engaging communities in research. Gender mainstreaming was not considered appropriately in the engagement of communities in research, as only a few studies made provisions for gender considerations, and most of the time, interchanging gender for sex. Respect for autonomy, privacy and informed consent were the main ethical issues reported.

Conclusion

gender mainstreaming and ethical standards were reported as important, but not explored in depth. Gender as a social construct needs to be carefully integrated in the entire research cycle. Clear ethical concerns within a research project have to be co-discussed by the research team, community members and potential research participants.

Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana

Ghana is positioned to become the first country in sub-Saharan Africa to implement universal health coverage based on nationwide expansion of geographic access through the Community-based Health Planning and Services initiative. This achievement is the outcome of 3 decades of implementation research that health authorities have used for guiding the development of its primary health care program. This implementation research process has comprised Ghana's official endorsement of the 1978 Alma Ata Declaration, leading to the institutionalization of evidence relevant to the strategic design of primary health care and national health insurance policies and services. Rather than relying solely upon the dissemination of project results, Ghana has embraced a continuous and systemic process of knowledge capture, curation, and utilization of evidence in expanding geographic access by a massive expansion in the number of community health service points that has taken decades. A multisectoral approach has been pursued that has involved the creation of systematic partnerships that included all levels of the political system, local development officials, community groups and social networks, multiple university-based disciplines, external development partners, and donors. However, efforts to achieve high levels of financial access through the roll-out of the National Health Insurance Scheme have proceeded at a less consistent pace and been fraught with many challenges. As a result, financial access has been less comprehensive than geographical access despite sequential reforms having been made to both programs. The legacy of activities and current research on primary health care and national health insurance are reviewed together with unaddressed priorities that merit attention in the future. Factors that have facilitated or impeded progress with research utilization are reviewed and implications for health systems strengthening in Ghana and elsewhere in Africa and globally are discussed.

Community engagement in research in sub-Saharan Africa: approaches, barriers, facilitators, ethical considerations and the role of gender - a systematic review protocol

INTRODUCTION

Meaningful community engagement (CE) is increasingly being considered the major determinant of successful research, innovation and intervention uptake. Community leaders, policy makers and funders have expressed the need to engage communities in research. CE in research empowers the host community to participate in addressing its own health needs and health disparities while ensuring that researchers understand community priorities. Thus, appropriate CE opens a unique way to promote coproduction, coimplementation and coevaluation, which may strengthen both the sense of inclusion, ownership and the effectiveness of the research life-cycle. The aim of this review is to synthesise available evidence on how to engage communities in research in a gender-sensitive, ethical, culture-appropriate and sustainable way in sub-Saharan Africa (SSA). This protocol has been developed following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and follows the guidance provided by the Cochrane Handbook for Systematic Reviews.

METHODS AND ANALYSIS

A combination of key text words and medical subject headings such as 'Community Engagement' or 'Community Involvement' will be used to search 009 databases for all literature published between 1 January 2000 and 31 July 2021. Citations retrieved from database searches will be exported into EndNote X9 to remove duplicate citations and imported into Rayyan QCRI for screening. Two independent reviewers will conduct the screening and data extraction process. Disagreements between review authors will be resolved through discussions, consensus a third reviewer serving as a tiebreaker. The risk of bias will be assessed using the 10-item Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The three-staged process described by Thomas and Harden will be used for the thematic and narrative synthesis of findings.

ETHICS AND DISSEMINATION

This is a systematic review which uses already collected data thus ethical approval not required. Findings will be published in an open access peer-reviewed journal and presented in relevant conferences and workshops.

PROSPERO REGISTRATION NUMBER

This protocol has been submitted for registration in PROSPERO and has been published under registration number CRD42021282503 .

Clinical research on COVID-19: perceptions and barriers to participation in The Gambia

INTRODUCTION

The need to rapidly identify safe and efficacious drug therapies for COVID-19 has resulted in the implementation of multiple clinical trials investigating potential treatment options. These are being undertaken in an unprecedented research environment and at a higher speed than ever before. It is unclear how West African communities perceive such activities and how such perceptions influence participation in COVID-19 clinical trials. This qualitative study was conducted to assess the level of acceptability of a clinical trial on the prevention and treatment of COVID-19 in The Gambia and identify strategies to better engage communities in participating in such a trial.

METHODS

Data were collected using digitally recorded semistructured interviews (SSIs) and focus group discussions (FGDs) in Brikama and Kanifing local government areas. These are two of the most densely populated administrative subdivisions in The Gambia, where the clinical trial was to be implemented by the MRC Unit The Gambia. 26 men and 22 women aged between 19 and 70 years, with diverse socioeconomic profiles, participated in 8 FGDs (n=36) and 12 SSIs (n=12). Thematic analysis was used to analyse the data.

RESULTS

Fear of stigmatisation of patients with COVID-19 was a recurring theme in most FGDs and SSIs, with detrimental effects on willingness to accept COVID-19 testing and home visits to follow up patients with COVID-19 and their household contacts. Preserving the privacy of individuals enrolled in the study was key to potentially increase trial participation. Trust in the implementing institution and its acknowledged expertise were facilitators to accepting the administration of investigational products to sick individuals and their close contacts.

CONCLUSION

COVID-19 is a stigmatising disease. Developing a research-participant collaboration through an ongoing engagement with community members is crucial to a successful enrolment in COVID-19 clinical trials. Trust and acknowledged expertise of the implementing institution are key facilitators to foster such collaboration.

Supporting the Utilization of Community-Based Primary Health Care Implementation Research in Ghana

Ever since the 1990s, implementation research in Ghana has guided the development of policies and practices that are essential to establishing community-based primary health care. In response to evidence emerging from this research, the Community-based Health Planning and Services (CHPS) policy was promulgated in 1999 to scale-up results. However, during the first decade of CHPS operation, national monitoring showed that its pace of coverage expansion was unacceptably slow. In 2010, the Ghana Health Service launched a five-year plausibility trial of CHPS reform for testing ways to accelerate scale-up. This initiative, known as the Ghana Essential Health Intervention Program (GEHIP), included a knowledge management component for establishing congruence of knowledge generation and flow with the operational system that GEHIP evidence was intended to reform. Four Upper East Region districts served as trial areas while seven districts were comparison areas. Interventions tested means of developing the upward flow of information based on perspectives of district managers, sub-district supervisors, and community-level workers. GEHIP also endeavored to improve procedures for the downward flow and utilization of policy guidelines. Field exchanges were convened for providing national, regional, and district leaders with opportunities for participatory learning about GEHIP implementation innovations. This systems approach facilitated the process of augmenting the communication of evidence with practical field experience. Scientific rigor associated with the production of evidence was thereby integrated into management decision-making processes in ways that institutionalized learning at all levels. The GEHIP knowledge management system functioned as a prototype for guiding the planning of a national knowledge management strategy. A follow-up project transferred its mechanisms from the Upper East Regional Health Administration to the Policy Planning Monitoring and Evaluation Division of the Ghana Health Service in Accra.

Developing organizational learning for scaling-up community-based primary health care in Ghana

INTRODUCTION

Achieving effective community-based primary health care requires evidence for guiding strategic decisions that must be made. However, research processes often limit data collection to particular organizational levels or disseminate results to specific audiences. Decision-making that emerges can fail to account for the contrasting perspectives and needs of managers at each organizational level. The Ghana Health Service (GHS) addressed this problem with a multilevel and sequential research and action approach that has provided two decades of implementation learning for guiding community-based primary health care development.

METHOD

The GHS implementation research initiatives progressed from (i) a participatory pilot investigation to (ii) an experimental trial of strategies that emerged to (iii) replication research for testing scale-up, culminating in (iv) evidence-based scale-up of a national community-based primary health care program. A reform process subsequently repeated this sequence in a manner that involved stakeholders at the community, sub-district, district, and regional levels of the system. The conduct, interpretation, and dissemination of results that emerged comprised a strategy for achieving systems learning by conducting investigations in phases in conjunction with bottom-up knowledge capture, lateral exchanges for fostering peer learning at each system level, and top-down processes for communicating results as policy. Continuous accumulation of qualitative data on stakeholder reactions to operations at each organizational level was conducted in conjunction with quantitative monitoring of field operations.

RESULTS

Implementation policies were enhanced by results associated with each phase. A quasi-experiment for testing the reform process showed that scale-up of community-based primary health care was accelerated, leading to improvements in childhood survival and reduced fertility.

CONCLUSION

Challenges to system learning were overcome despite severe resource constraints. The integration of knowledge generation with ongoing management processes institutionalized learning for achieving evidence-driven program action.

The role of social cohesion in the implementation and coverage of a mass drug administration trial for malaria control in the Gambia: An in-depth comparison of two intervention villages

Mass drug administration (MDA), used increasingly in malaria eradication efforts, involves administering medication to an entire target population regardless of individual-level disease status. This strategy requires high levels of coverage and compliance. Previous studies have assessed individual and structural factors affecting MDA coverage, but there is a need to better understand the influence and expressions of community dynamics and social structures, such as social cohesion. We conducted a social science study concurrent to an MDA clinical trial for malaria control in The Gambia; ethnographic research was conducted prior to, throughout, and between MDA implementation July-November 2018, January-March 2019, and July-November 2019. We assessed how social cohesion, as expressed by the trial population, affects trial coverage through an in-depth ethnographic analysis of two trial villages, using observations, interviews, and focus group discussions with community members who took the trial medication and those who did not. We found that the villages had unique expressions of social cohesion. This was reflected through community participation in the trial implementation and may have affected coverage and compliance. The village with low coverage expressed a form of social cohesion where members followed advice to participate through a hierarchal system but did not actively participate in the MDA or its implementation. The village with high coverage expressed social cohesion as more participatory: individuals took the directive to participate but contextualized the trial implementation to their needs and wants. We analyze these different expressions of social cohesion and the important differences they make for the coverage and compliance levels reached in the two different villages.

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.

Community engagement and feedback of results in the H3Africa AWI-Gen project: Experiences from the Navrongo Demographic and Health Surveillance site in Northern Ghana

Community and Public engagement (CE) have gained traction as an ethical best practice for the conduct of genomics research, particularly in the context of Africa. In the past 10 years, there has been growing scholarship on the value and practice of engaging key stakeholders including communities involved in genomics research. However, not much has been documented on how research teams, particularly in international collaborative research projects, are navigating the complex process of engagement including the return of key research findings. This paper is part of a series of papers describing the CE processes used in the AWI-Gen study sites. We describe the key processes of engagement, challenges encountered and the major lessons learned. We pay particular attention to the experiences in returning research results to participants and communities within the Demographic and Health Surveillance site in northern Ghana.

"Drones are a great idea! What is an AED?" novel insights from a qualitative study on public perception of using drones to deliver automatic external defibrillators

Background

The quickest way to ensure survival in an out-of-hospital cardiac arrest (OHCA) is for a bystander to provide immediate cardiopulmonary resuscitation (CPR) and apply an automated external defibrillator (AED). The urgency of OHCA treatment has led to the proposal of alternative avenues for better access to AEDs, particularly in rural settings. More recently, using unmanned aerial vehicles (or drones) to deliver AEDs to rural OHCA sites has proven promising in improving survival rates.

Objective

A pilot drone AED delivery program is currently being piloted in the community of Caledon, Ontario. The purpose of this study was to develop an understanding of public perception and acceptance of the use of drones for this purpose and to identify tailored community engagement strategies to ensure successful uptake.

Methods

In-depth qualitative descriptive study using interviews and focus group data collection and inductive thematic analysis. Purposive sampling was used to recruit 67 community members (40 interviews; 2 focus groups of 15) at existing community events in the project area. Interview guides were used to ensure consistency across data collection events. Detailed field notes were recorded when audio-recording was not possible.

Results

The central message seen throughout the data was quickly identified as the potential impact of low levels of CPR and AED literacy in the community over anything else including concerns about the drone. The impact of the community's existing relationship with the EMS; the need for bystander CPR & AED promotion prior to the program launch; and the value the community places on transparency and accountability related to the research and the drones were also key findings. In general, the drone concept was found to be acceptable but concerns about providing CPR and using the AED was what created anxieties in the lay public that we underestimated.

Conclusion

Drone-delivered AEDs may be feasible and effective but successful uptake in smaller communities will require a deep understanding of a community's cardiac arrest literacy levels, information needs and readiness for innovation. This work will inform a robust community engagement plan that will be scalable to other locations considering a drone AED program.

Structural coercion in the context of community engagement in global health research conducted in a low resource setting in Africa

BACKGROUND

While community engagement is increasingly promoted in global health research to improve ethical research practice, it can sometimes coerce participation and thereby compromise ethical research. This paper seeks to discuss some of the ethical issues arising from community engagement in a low resource setting.

METHODS

A qualitative study design focusing on the engagement activities of three biomedical research projects as ethnographic case studies was used to gain in-depth understanding of community engagement as experienced by multiple stakeholders in Malawi. Data was collected through participant observation, 43 In-depth interviews and 17 focus group discussions with community leaders, research staff, community members and research participants. Thematic analysis was used to analyse and interpret the findings.

RESULTS

The results showed that structural coercion arose due to an interplay of factors pertaining to social-economic context, study design and power relations among research stakeholders. The involvement of community leaders, government stakeholders, and power inequalities among research stakeholders affected some participants' ability to make autonomous decisions about research participation. These results have been presented under the themes of perception of research as development, research participants' motivation to access individual benefits, the power of vernacular translations to influence research participation, and coercive power of leaders.

CONCLUSION

The study identified ethical issues in community engagement practices pertaining to structural coercion. We conclude that community engagement alone did not address underlying structural inequalities to ensure adequate protection of communities. These results raise important questions on how to balance between engaging communities to improve research participation and ensure that informed consent is voluntarily given.

Community engagement in Genomics research; Challenges and lessons learnt in the AWI-Gen study at Dikgale Health and Demographic Surveillance System (HDSS) Site, South Africa

As health research often requires consent from participants and permission from community gate keepers, community engagement is considered an integral process of health research. Community engagement is also important in building trust between the research team and participants, gathering information on the needs and expectations of the community with respect to the project and present the community with an opportunity to gain more information on the goals of the research. Although there are published guidelines on how to conduct community engagement activities, the concept itself and the way in which it is put into practice is highly contextual. In this paper we reflect on the community engagement strategy used in the AWI-Gen Phase 1 study at the Dikgale Health and Demographic Surveillance System (Dikgale HDSS) site, the challenges encountered throughout the research process and the lessons learnt. Lastly, we highlight possible improvements to the CE strategic framework for AWI-Gen Phase 2 in Dikgale HDSS that may enhance the participation of the community.

Ethical challenges in community engagement practices in research during the COVID-19 pandemic in Africa

Community engagement (CE) has been highlighted as a key process in the prevention and transmission control of coronavirus disease 2019 (COVID-19). However, the nature of the virus and national response strategies such as social distancing have challenged traditional methods of community engagement. In this paper, we discuss the role of community engagement in research during COVID-19. We first set out the case for community engagement that emerges from international guidance for research during public health emergencies. We then describe the challenges that are emerging with community engagement in health research generally, and on COVID-19 related research specifically in Africa in the context of the COVID-19 pandemic. We further describe the strengths and weaknesses of the current engagement and communication platforms, and suggest ways to overcome some of these challenges. We provide an ethical argument for researchers and research institutions to respond directly to addressing the COVID-19 pandemic by responding to emergency health care needs of the community; and provide some challenges and critiques of such an approach. Finally, we support the call for concerted efforts in responding to the global pandemic, requiring flexibility in funding.

The roles of stakeholder experience and organizational learning in declining mass drug administration coverage for lymphatic filariasis in Port-au-Prince, Haiti: A case study

The World Health Organization (WHO) defines an effective round of mass drug administration (MDA) for lymphatic filariasis (LF) as one that reaches at least 65% of the target population. In its first round of MDA in 2011–2012, the National Program to Eliminate LF in Haiti achieved a 79% epidemiological coverage in urban Port-au-Prince. In 2013, coverage dropped below the WHO threshold and has declined year-over-year to a low of 41% in 2017. We conducted a retrospective qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. Our findings suggest that the main contributors to the decline in MDA coverage appear to be the absence of effective documentation of practices, reporting, analysis, and program quality improvement—i.e., learning mechanisms—within the program’s MDA design and implementation strategy. In addition to their contribution to the program’s failure to meet its coverage targets, these deficits have resulted in a high cost for the MDA campaign in both lost momentum and depleted morale. Through a proposed operating logic model, we explore how the pathway from program inputs to outcomes is influenced by a wide array of mediating factors, which shape potential participants’ experience of MDA and, in turn, influence their reasoning and decisions to take, or not take, the pills. Our model suggests that the decisions and behavior of individuals are a reflection of their overall experience of the program itself, mediated through a host of contextual factors, and not simply the expression of a fixed choice or preference. This holistic approach offers a novel and potentially valuable framing for the planning and evaluation of MDA strategies for LF and other diseases, and may be applicable in a variety of global health programs.

In order to eliminate lymphatic filariasis from a region, the World Health Organization recommends a strategy of preventative drugs delivered annually to the population. At least 65% of the population must participate for four to six consecutive years for this approach to be effective. In urban Port-au-Prince, Haiti, the number of people taking the drugs has been declining progressively below the 65% benchmark since 2012. We used a qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. We found that the lymphatic filariasis elimination program lacks the necessary design and program infrastructure to ensure reliable learning about problems faced by pill distribution teams on the ground, and the improvisations they introduced to address these challenges. The inability to incorporate these lessons into program improvements and refinements resulted in under-performance and contributed to the decline in coverage. Furthermore, the way that people experience the program is strongly influenced by a host of contextual factors, which shape potential participants’ experience of the program and, in turn, influence their reasoning and decisions to take, or not take, the pills.

Integrating tuberculosis research with public health infrastructure: Lessons on community engagement from Orizaba, Mexico

Background: The Orizaba Health Region, in Veracruz, Mexico, has hosted the research programme of the Consorcio Mexicano contra la Tuberculosis since 1995. Methods: The objective of this retrospective case study conducted in 2009 was to describe and explain the evolution and outcomes of the stakeholder and community engagement activities of the Consorcio. Recorded interviews and focus groups were coded to identify major themes related to the success of stakeholder and community engagement activities. Results: The Consorcio successfully managed to embed its research program into the local public health infrastructure. This integration was possible because the core research team tailored its engagement strategy to the local context, while focusing on a large spectrum of stakeholders with various positions of authority and responsibility. The overall engagement strategy can be described as a three-pronged endeavor: building a “coalition” with local authorities, nurturing “camaraderie” with community health workers, and striving to be “present” in the lives of community members and participants. Conclusions: The Consorcio’s efforts teach valuable lessons on how to approach stakeholder and community engagement in tuberculosis (TB) research, particularly in developing countries. Furthermore, the health outcomes reveal stakeholder and community engagement as a potentially under-tapped tool to promote disease control.

A realist review of community engagement with health research

Introduction: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. Methods and analysis: Community engagement in practice is often a complex set of interventions. We will conduct a realist review - a theory driven approach to evidence synthesis - to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. Ethics and dissemination: A formal ethics review is not required for this literature review.  Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. PROSPERO registration number: CRD42019125687.

A realist review of community engagement with health research

Introduction: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. Methods and analysis: Community engagement in practice is often a complex set of interventions. We will conduct a realist review - a theory driven approach to evidence synthesis - to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. Ethics and dissemination: A formal ethics review is not required for this literature review.  Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. PROSPERO registration number: CRD42019125687.

Evolution of a programme to engage school students with health research and science in Kenya

Facilitating mutually-beneficial educational activities between researchers and school students is an increasingly popular way for research institutes to engage with communities who host health research, but these activities have rarely been formally examined as a community or public engagement approach in health research. The KEMRI-Wellcome Trust Research Programme (KWTRP) in Kilifi, Kenya, through a Participatory Action Research (PAR) approach involving students, teachers, researchers and education stakeholders, has incorporated 'school engagement' as a key component into their community engagement (CE) strategy. School engagement activities at KWTRP aim at strengthening the ethical practice of the institution in two ways: through promoting an interest in science and research among school students as a form of benefit-sharing; and through creating forums for dialogue aimed at promoting mutual understanding between researchers and school students. In this article, we provide a background of CE in Kilifi and describe the diverse ways in which health researchers have engaged with communities and schools in different parts of the world. We then describe the way in which the KWTRP school engagement programme (SEP) was developed and scaled-up. We conclude with a discussion about the challenges, benefits and lessons learnt from the SEP implementation and scale-up in Kilifi, which can inform the establishment of SEPs in other settings.

Current challenges and proposed solutions to the effective implementation of the RTS, S/AS01 Malaria Vaccine Program in sub-Saharan Africa: A systematic review

BACKGROUND

The Malaria Vaccine Implementation Program, coordinated by the World Health Organization, intended to initiate the roll-out of the RTS, S/AS01 malaria vaccine in 3 sub-Saharan African countries in 2018. With sub-optimal implementation, the effectiveness of this vaccine in routine clinical use could be significantly lower than its measured efficacy in randomized trials. This study had as objectives to systematically review and summarize published studies addressing the challenges faced during the implementation phase of malaria vaccination programs and randomized trials conducted in sub-Saharan Africa. The review also sought to report proposed solutions to the challenges identified.

METHOD

This was a systematic review of studies published between 1947 and 2017. Medline, Embase and the Cochrane library databases were searched. Of the 365 studies retrieved, 8 eligible studies reported on challenges of implementing a malaria vaccine in sub-Saharan Africa and possible solutions to these challenges. Data were abstracted from the eligible studies and a qualitative synthesis was done.

RESULTS

The 8 studies included in the review had a total of 6189 participants and used a variety of methodologies (3 qualitative, 1 quantitative, 3 mixed method studies and 1 clinical trial review). There was an overall positive acceptance towards the new malaria vaccine (n = 6/8 studies), with a mean acceptance rate of 86.1% (95% CI: 62.0-110.2, n = 2). The main challenges to vaccine receptivity were: inadequate community engagement due to lack of information about the vaccine (n = 6), fear of the vaccine's side effects (n = 5), inefficient delivery of vaccination services to children (n = 4), and sub-optimal quality of the health services (n = 3). Main themes identified from the proposed solutions consisted of the following: using dynamic communication models and trusted sources for delivering vaccine-related health information to the communities (n = 6), community engagement at both national and district level (n = 6), implementing the new vaccine services alongside the existing health services already delivered (n = 6).

CONCLUSION/RECOMMENDATIONS

Effective implementation of the malaria vaccine program requires careful consideration of the socio-cultural context of each community. The RTS, S/AS01 malaria vaccine acceptance and uptake may be significantly enhanced if caregivers' perceptions about vaccines and their importance are adequately fine-tuned. In order to achieve these, community participation and the provision of adequate information in an acceptable form via reliable communication channels seem to be imperative.

Fear and rumours regarding placental biopsies in a malaria-in-pregnancy trial in Benin

Background

A multi-country, community-based trial on scheduled screening and treatment for malaria in pregnancy was conducted in Benin, The Gambia and Burkina Faso. Despite standardized procedures and outcomes, the study became subject to rumours and accusations of placenta being sold for mystical and financial gain by trial staff, leading to drop-out rates of 30% and the consequent halting of placental biopsy sampling in Benin. This paper explores the role of socio-cultural beliefs related to placenta and identified additional factors contributing these rumours.

Methods

A qualitative comparative emergent-theory design was used to assess social factors related to trial implementation and uptake in the three countries. Data from participant observation, informal conversations, group discussions and interviews were triangulated and analysed with NVivo Qualitative Analysis software.

Results

Despite similar sociocultural beliefs about the sacred nature of the placenta in all three study countries, these beliefs did not affect participation rates in Burkina Faso and The Gambia and placenta-related rumours only emerged in Benin. Therefore, the presence of beliefs is not a sufficient condition to have generated placenta-selling fears. The rumours in Benin reflected the confluence of placenta-related beliefs and factors related to the implementation of the trial (including a catalysing adverse event and miscommunication during the informed consent procedure). Furthermore, distinct socio-political factors contributed to the emergence of rumours, including the historical distrust in governmental organizations and the tense relationship between some of the actors involved in the trial.

Conclusion

Transdisciplinary social science research designs should accompany the implementation of the trial. The integration of multiple stakeholders’ knowledge and involvement is required to define and solve upcoming barriers.

What motivates Ebola survivors to donate plasma during an emergency clinical trial? The case of Ebola-Tx in Guinea

INTRODUCTION

During the 2014 Ebola Virus Disease (EVD) epidemic, the Ebola-Tx trial evaluated the use of convalescent plasma (CP) in Guinea. The effectiveness of plasmapheresis trials depends on the recruitment of plasma donors. This paper describes what motivated or deterred EVD survivors to donate CP, providing insights for future plasmapheresis trials and epidemic preparedness.

METHODS

This qualitative study, part of Ebola-Tx, researched and addressed emergent trial difficulties through interviewing, participant observation and focus group discussions. Sampling was theoretical and retroductive analysis was done in NVivo 10.

RESULTS

Willingness or hesitance to participate in plasma donation depended on factors at the interface of pre-existing social dynamics; the impact of the disease and the consequent emergency response including the trial set-up. For volunteers, motivation to donate was mainly related to the feeling of social responsibility inspired by having survived EVD and to positive perceptions of plasmapheresis technology despite still unknown trial outcomes. Conversely, confidentiality concerns when volunteering due to stigmatization of survivors and perceived decrease in vital strength and in antibodies when donating, leading to fears of loss in protection against EVD, were main deterrents. The dynamic (dis)trust in Ebola Response Actors and in other survivors further determined willingness to participate and lead to the emergence/decline of rumours related to blood stealing and treatment effectiveness. Historic inter-ethnic relations in the health care setting further defined volunteering along socio-economic and ethnic lines. Finally, lack of follow-up and of dedicated care further impacted on motivation to volunteer.

CONCLUSIONS

Ebola-Tx was the first trial to solicit and evaluate blood-product donation as an experimental treatment on a large scale in Sub-Saharan Africa. An effective donation system requires directly engaging with emergent social barriers and providing an effective ethical response, including improved and transparent communication, effective follow-up after donation, assuring confidentiality and determining ethical incentives.

Challenges of developing a district child welfare plan in South Africa: lessons from a community-engaged HIV/AIDS research project

The Amajuba Child Health and Wellbeing Research Project measured the impact of orphaning due to HIV/AIDS on South African households between 2004 and 2007. Community engagement was a central component of the project and extended through 2010. We describe researcher engagement with the community to recruit participants, build local buy-in, stimulate interest in study findings, and promote integration of government social welfare services for families and children affected by HIV/AIDS. This narrative documents the experience of researchers, drawing also on project reports, public documents, and published articles, with the objective of documenting lessons learned in this collaboration between researchers from two universities and a community in South Africa during a period that spanned seven years. This experience is then analyzed within the context of an applied research, community-engagement framework.

Public engagement in Malawi through a health-talk radio programme ' Umoyo nkukambirana': A mixed-methods evaluation

Radio is an effective source of health information in many resource poor countries. In Malawi, 53% of households own radios however few radio programmes in Malawi focus on health issues in the context of medical research. An interactive health-talk radio programme ' Umoyo nkukambirana' was introduced by Malawi-Liverpool-Wellcome Trust Clinical Research Programme on a national radio station. The aim was to increase awareness of health and medical research, and improve engagement between researchers, healthcare workers and the public. The content and presentation were developed through participatory community consultations. Focus Group Discussions were conducted with established Radio Listening Clubs whilst quantitative data was collected using toll free FrontlineSMS to explore national response. A total of 277 to 695 SMS (Median: 477) were received per theme. The majority of SMS were received from men (64%) and mainly from rural areas (54%). The programme improved knowledge of medical research, health and dispelled misconceptions. This study suggests that the radio may be an effective means of increasing the exposure of men to health information in resource poor settings.

Male involvement in maternal health: perspectives of opinion leaders

Background

Twenty years after acknowledging the importance of joint responsibilities and male participation in maternal health programs, most health care systems in low income countries continue to face challenges in involving men. We explored the reasons for men’s resistance to the adoption of a more proactive role in pregnancy care and their enduring influence in the decision making process during emergencies.

Methods

Ten focus group discussions were held with opinion leaders (chiefs, elders, assemblymen, leaders of women groups) and 16 in-depth interviews were conducted with healthcare workers (District Directors of Health, Medical Assistants in-charge of health centres, and district Public Health Nurses and Midwives). The interviews and discussions were audio recorded, transcribed into English and imported into NVivo 10 for content analysis.

Results

As heads of the family, men control resources, consult soothsayers to determine the health seeking or treatment for pregnant women, and serve as the final authority on where and when pregnant women should seek medical care. Beyond that, they have no expectation of any further role during antenatal care and therefore find it unnecessary to attend clinics with their partners. There were conflicting views about whether men needed to provide any extra support to their pregnant partners within the home. Health workers generally agreed that men provided little or no support to their partners. Although health workers had facilitated the formation of father support groups, there was little evidence of any impact on antenatal support.

Conclusions

In patriarchal settings, the role of men can be complex and social and cultural traditions may conflict with public health recommendations. Initiatives to promote male involvement should focus on young men and use chiefs and opinion leaders as advocates to re-orient men towards more proactive involvement in ensuring the health of their partners.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1641-9) contains supplementary material, which is available to authorized users.

Experiences of community members and researchers on community engagement in an Ecohealth project in South Africa and Zimbabwe

Background

Community engagement (CE) models have provided much needed guidance for researchers to conceptualise and design engagement strategies for research projects. Most of the published strategies, however, still show very limited contribution of the community to the engagement process. One way of achieving this is to document experiences of community members in the CE processes during project implementation. The aim of our study was to explore the experiences of two research naïve communities, regarding a CE strategy collaboratively developed by researchers and study communities in a multicountry study.

Methods

The study was carried out in two research naïve communities; Gwanda, Zimbabwe and uMkhanyakude, South Africa. The multicentre study was a community based participatory ecohealth multicentre study. A qualitative case study approach was used to explore the CE strategy. Data was collected through Focus Group Discussions, Key Informant Interviews and Direct Observations. Data presented in this paper was collected at three stages of the community engagement process; soon after community entry, soon after sensitisation and during study implementation. Data was analysed through thematic analysis.

Results

The communities generally had positive experiences of the CE process. They felt that the continuous solicitation of their advice and preferences enabled them to significantly contribute to shaping the engagement process. Communities also perceived the CE process as having been flexible, and that the researchers had presented an open forum for sharing responsibilities in all decision making processes of the engagement process.

Conclusions

This study has demonstrated that research naïve communities can significantly contribute to research processes if they are adequately engaged. The study also showed that if researchers put in maximum effort to demystify the research process, communities become empowered and participate as partners in research.

Implementing Community Engagement for Combination Prevention: Lessons Learnt From the First Year of the HPTN 071 (PopART) Community-Randomized Study

Key to the success of a HIV combination prevention strategy, including galvanizing the current push to roll out universal test and treat (UTT), is the involvement and buy-in of the populations that the strategy aims to reach. Drawing on the experiences of engaging with 21 communities in Zambia and South Africa in the design and implementation of a community-randomized study of combination HIV prevention including UTT, this paper reflects on the commitment to, approaches for and benefits of involving communities. Key lessons learnt include that all communities require continuous community engagement (CE) and engagement needs to be adapted to diverse local contexts. Intrinsic goals of CE, such as building trusting relationships between study stakeholders, are necessary precursors to instrumental goals which strengthen the research quality. Engaging the community for combination prevention requires that CE successfully bridges science and real life, paying attention to influences in the wider social landscape.

The 'experimental public' in longitudinal health research: views of local leaders and service providers in rural South Africa

BACKGROUND

The concept of 'experimental public' has been recently applied to publics involved in clinical trials. This term could also be applied to publics involved in longitudinal research such as health and demographic surveillance systems. The ethics of practice and public engagement with these experimental publics are of key importance and include issues of informed consent, confidentiality, collection of body tissue samples and fair local benefit.

METHODS

Individual (n = 11) and focus group (n = 5) qualitative semi-structured interviews were conducted with 56 local leaders and service providers regarding their views about research activities in a longitudinal health research study site run by the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in rural South Africa. Deductive and inductive thematic analysis was undertaken using NVivo software to identify the emergent themes.

RESULTS

There was an understanding of the usefulness of collecting demographic data, but reasons for gathering other contextual data such as on food security, as well as the reasons for collection of blood was less clear. While appreciation was expressed for feedback of individual results such as blood pressure levels during home-based data collection, there were requests for more results from biomarkers, and for these to be given at home, rather than at the clinic. There were reports of indirect refusals, and offers by leaders to assist in reducing refusal rates. There were concerns about confidentiality, especially in the publication of results. Some leaders would have liked to receive more individual level data for planning of services, although they understood this would breach confidentiality. Service providers were concerned about the withdrawal of some services post intervention trials.

CONCLUSIONS

This experimental public has, over time, developed a nuanced understanding of the reasons for research and the procedures undertaken. Discussions concerning fair benefit ranged from requests for more individual clinically-relevant results for participants, to understanding how research results could assist in planning of public health services at local and national levels. The concerns illustrate the complexity of the ethics of practice which has implications for policy, practice and governance for those working in longitudinal health research sites globally.

Developing the science and methods of community engagement for genomic research and biobanking in Africa

Historically, community engagement (CE) in research has been implemented in the fields of public health, education and agricultural development. In recent years, international discussions on the ethical and practical goals of CE have been extended to human genomic research and biobanking, particularly in the African context. While there is some consensus on the goals and value of CE generally, questions remain about the effectiveness of CE practices and how to evaluate this. Under the auspices of the Human Heredity and Health in Africa Initiative (H3Africa), the H3Africa CE working group organized a workshop in Stellenbosch, South Africa in March 2016 to explore the extent to which communities should be involved in genomic research and biobanking and to examine various methods of evaluating the effectiveness of CE. In this paper, we present the key themes that emerged from the workshop and make a case for the development of a rigorous application, evaluation and learning around approaches for CE that promote a more systematic process of engaging relevant communities. We highlight the key ways in which CE should be embedded into genomic research and biobanking projects.

Gendered negotiations for research participation in community-based studies: implications for health research policy and practice

There is a growing literature documenting the complex realities of consent processes in the field, and the negotiations and ethical dilemmas involved. Much has also been written about how gender and power shape household decision-making processes. However, these bodies of literature have rarely been brought together to inform research theory and practice in low-income settings. In this paper, qualitative research (observation, focus group discussions and interviews) were used alongside large clinical community-based studies conducted on the Kenyan Coast to explore how gender and power relations within households and communities and between fieldworkers and communities shape consent processes and interactions. This exploration is embedded in relevant literature and the implications for community-based health research policy and practice are considered. Across diverse forms of households, we observed significant consultation on whether or not to participate in research. Although men are typically described as household decision-makers, in practice, decision-making processes are often far more nuanced, with many women using their agency to control, sometimes subtly, the decisions made. Where decisions are made without adequately consulting women, many find strategies to exercise their choice, in ways that safeguard important relationships within households in the longer term. We also found that the gender of field staff who typically conduct research activities in the field, including consent processes, can influence household dynamics and decision-making processes with important implications for the science and ethics of research. It is essential that frontline field staff and their supervisors are aware of the complex and gendered realities of consent processes at household level, and their implications, and that they develop appropriate context-informed approaches that support ethical practice.

The role of community engagement in the adoption of new agricultural biotechnologies by farmers: the case of the Africa harvest tissue-culture banana in Kenya

Background

The tissue culture banana (TCB) is a biotechnological agricultural innovation that has been adopted widely in commercial banana production. In 2003, Africa Harvest Biotech Foundation International (AH) initiated a TCB program that was explicitly developed for smallholder farmers in Kenya to help them adopt the TCB as a scalable agricultural business opportunity. At the heart of the challenge of encouraging more widespread adoption of the TCB is the question: what is the best way to introduce the TCB technology, and all its attendant practices and opportunities, to smallholder farmers. In essence, a challenge of community or stakeholder engagement (CE).

Results

In this paper, we report the results of a case study of the CE strategies employed by AH to introduce TCB agricultural practices to small-hold farmers in Kenya, and their impact on the uptake of the TCB, and on the nature of the relationship between AH and the relevant community of farmers and other stakeholders. We identified six specific features of CE in the AH TCB project that were critical to its effectiveness: (1) adopting an empirical, “evidence-based” approach; (2) building on existing social networks; (3) facilitating farmer-to-farmer engagement; (4) focusing engagement on farmer groups; (5) strengthening relationships of trust through collaborative experiential learning; and (6) helping farmers to “learn the marketing game”. We discuss the implications of AH’s “values-based” approach to engagement, and how these guiding values functioned as “design constraints” for the key features of their CE strategy. And we highlight the importance of attention to the human dimensions of complex partnerships as a key determinant of successful CE.

Conclusion

Our findings suggest new ways of conceptualizing the relationship between CE and the design and delivery of new technologies for global health and global development.

Initiating community engagement in an ecohealth research project in Southern Africa

Background

Community Engagement (CE) in health research ensures that research is consistent with the socio-cultural, political and economic contexts where the research is conducted. The greatest challenges for researchers are the practical aspects of CE in multicentre health research. This study describes the CE in an ecohealth community-based research project focusing on two vulnerable and research naive rural communities.

Methods

A qualitative, longitudinal multiple case study approach was used. Data was collected through Participatory Rural Appraisals, Focus Group Discussions, In-depth Interviews, and observations.

Results

The two sites had different cultural values, research literacy levels, and political and administrative structures. The engagement process included

introductions to the administrative and political leaders of the area;

establishing a community advisory mechanism;

community empowerment and

initiating sustainable post-study activities.

In both sites the study employed community liaison officers to facilitate the community entry and obtaining letters of permission. Both sites opted to form Community Advisory Boards as their main advisory mechanism together with direct advice from community leaders. Empowerment was achieved through the education of ordinary community members at biannual meetings, employment of community research assistants and utilising citizen science. Through the research assistants and the citizen science group, the study has managed to initiate activities that the community will continue to utilise after the study ends. General strategies developed are similar in principle, but implementation and emphasis of various aspects differed in the two communities.

Conclusions

We conclude that it is critical that community engagement be consistent with community values and attitudes, and considers community resources and capacity. A CE strategy fully involving the community is constrained by community research literacy levels, time and resources, but creates a conducive research environment.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0231-9) contains supplementary material, which is available to authorized users.

Trust me, I'm a researcher!: The role of trust in biomedical research

In biomedical research lack of trust is seen as a great threat that can severely jeopardise the whole biomedical research enterprise. Practices, such as informed consent, and also the administrative and regulatory oversight of research in the form of research ethics committees and Institutional Review Boards, are established to ensure the protection of future research subjects and, at the same time, restore public trust in biomedical research. Empirical research also testifies to the role of trust as one of the decisive factors in research participation and lack of trust as a barrier for consenting to research. However, what is often missing is a clear definition of trust. This paper seeks to address this gap. It starts with a conceptual analysis of the term trust. It compares trust with two other related terms, those of reliance and trustworthiness, and offers a defence of Baier's attribute of 'good will' a basic characteristic of trust. It, then, proceeds to consider trust in the context of biomedical research by examining two questions: First, is trust necessary in biomedical research?; and second, do increases in regulatory oversight of biomedical research also increase trust in the field? This paper argues that regulatory oversight is important for increasing reliance in biomedical research, but it does not improve trust, which remains important for biomedical research. It finishes by pointing at professional integrity as a way of promoting trust and trustworthiness in this field.

Assessing the Impact of Community Engagement Interventions on Health Worker Motivation and Experiences with Clients in Primary Health Facilities in Ghana: A Randomized Cluster Trial

Background

Health worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps.

Purpose

To evaluate the effect of SCE interventions on health worker motivation and experiences with clients.

Methods

The study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation.

Results

Intrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff.

Conclusion

Community-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter.

Addressing the continuum of maternal and newborn care in Ghana: implications for policy and practice

Although the past decade has brought global reductions in maternal, infant and child mortality, many low-resource settings have failed to make significant gains relative to their high-income counterparts. In Ghana, nearly 50% of under-five mortality in 2014 could be attributed to deaths during the first 28 days after birth. This article analyses the data across a mixed-methods study of the factors impacting maternal and neonatal care in northern Ghana. The stillbirth and neonatal death study (SANDS) was conducted in 2010 and included both quantitative (N = 20 497) and qualitative data collection (N = 253) to explore the issues associated with the continuum of reproductive health care. Findings were compared against an adaptation of the WHO/UNICEF framework for integrated maternal and newborn care and used to generate concrete recommendations for clinicians, policymakers and programmers across the continuum of care, from pregnancy through delivery and postnatal care. SANDS elucidated epidemiological trends: 40% of neonatal deaths occurred on the first day after birth, and the leading causes of early neonatal mortality were birth asphyxia/injury, infection and complications of prematurity. Qualitative data reflect findings along two axes-community to facility-based care, and pre-pregnancy through the postnatal period. Resulting recommendations include the need to improving clinicians' understanding of and sensitization to local traditional practices, the need for policies to better address quality of care and coordination of training efforts, and the need for comprehensive, integrated programmes that ensure continuity of care from pre-pregnancy through the post-partum period. SANDS illustrates complex medical-social-cultural knowledge, attitudes and practices that span the reproductive period in rural northern Ghana. Data illustrate that not only are the first few days of life critical in infant survival but also there are significant social and cultural barriers to ensuring that mothers and their newborns are cared for in a timely, evidence-based manner.

Public/community engagement in health research with men who have sex with men in sub-Saharan Africa: challenges and opportunities

Background

Community engagement, incorporating elements of the broader concepts of public and stakeholder engagement, is increasingly promoted globally, including for health research conducted in developing countries. In sub-Saharan Africa, community engagement needs and challenges are arguably intensified for studies involving gay, bisexual and other men who have sex with men, where male same-sex sexual interactions are often highly stigmatised and even illegal. This paper contextualises, describes and interprets the discussions and outcomes of an international meeting held at the Kenya Medical Research Institute-Wellcome Trust in Kilifi, Kenya, in November 2013, to critically examine the experiences with community engagement for studies involving men who have sex with men.

Discussion

We discuss the ethically charged nature of the language used for men who have sex with men, and of working with ‘representatives’ of these communities, as well as the complementarity and tensions between a broadly public health approach to community engagement, and a more rights based approach. We highlight the importance of researchers carefully considering which communities to engage with, and the goals, activities, and indicators of success and potential challenges for each. We suggest that, given the unintended harms that can emerge from community engagement (including through labelling, breaches in confidentiality, increased visibility and stigma, and threats to safety), representatives of same-sex populations should be consulted from the earliest possible stage, and that engagement activities should be continuously revised in response to unfolding realities. Engagement should also include less vocal and visible men who have sex with men, and members of other communities with influence on the research, and on research participants and their families and friends. Broader ethics support, advice and research into studies involving men who have sex with men is needed to ensure that ethical challenges – including but not limited to those related to community engagement – are identified and addressed.

Summary

Underlying challenges and dilemmas linked to stigma and discrimination of men who have sex with men in Africa raise special responsibilities for researchers. Community engagement is an important way of identifying responses to these challenges and responsibilities but itself presents important ethical challenges.

PREventing Maternal And Neonatal Deaths (PREMAND): a study protocol for examining social and cultural factors contributing to infant and maternal deaths and near-misses in rural northern Ghana

Plain English Summary

The Preventing Maternal And Neonatal Deaths (PREMAND) project works to understand the social and cultural factors that may contribute to the deaths and near-misses (people who almost die but end up surviving) of mothers and babies in four districts in Northern Ghana. Examples of these factors include such thing as treating a sick baby at home with traditional medicine instead of going to a hospital or health center, or pregnant women needing permission from several people before they can go to a hospital to deliver. These social and cultural factors will be placed on a map to understand where patterns and clusters of deaths and near-misses are present in these four communities. The final phase of the project will include support and small grants for community members and local leaders to use these maps and this information to create their own solutions that address the specific needs of each community.

Abstract

Background

While Ghana is a leader in some health indicators among West African nations, it still struggles with high maternal and neonatal morbidity and mortality rates, especially in the northern areas. The clinical causes of mortality and morbidity are relatively well understood in Ghana, but little is known about the impact of social and cultural factors on maternal and neonatal outcomes. Less still is understood about how such factors may vary by geographic location, and how such variability may inform locally-tailored solutions.

Methods/Design

Preventing Maternal And Neonatal Deaths (PREMAND) is a three-year, three-phase project that takes place in four districts in the Upper East, Upper West, and Northern Regions of Ghana. PREMAND will prospectively identify all maternal and neonatal deaths and ‘near-misses’, or those mothers and babies who survive a life threatening complication, in the project districts. Each event will be followed by either a social autopsy (in the case of deaths) or a sociocultural audit (in the case of near-misses). Geospatial technology will be used to visualize the variability in outcomes as well as the social, cultural, and clinical predictors of those outcomes. Data from PREMAND will be used to generate maps for local leaders, community members and Government of Ghana to identify priority areas for intervention. PREMAND is an effort of the Navrongo Health Research Centre and the University of Michigan Medical School.

Discussion

PREMAND uses an innovative, multifaceted approach to better understand and address neonatal and maternal morbidity and mortality in northern Ghana. It will provide unprecedented access to information on the social and cultural factors that contribute to deaths and near-misses in the project regions, and will allow such causal factors to be situated geographically. PREMAND will create the opportunity for local, regional, and national stakeholders to see how these events cluster, and place them relative to traditional healer compounds, health facilities, and other important geographic markers. Finally, PREMAND will enable local communities to generate their own solutions to maternal and neonatal morbidity and mortality, an effort that has great potential for long-term impact.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-016-0142-z) contains supplementary material, which is available to authorized users.