Participation through the lens of care: Situated accountabilities in the codesign of a digital health platform for HIV care

Participation of citizens and service users is increasingly commonplace in research, policy and technology development. Alongside this development, social scientists have become increasingly incorporated into large-scale research and innovation projects to facilitate participatory spaces. This requires reflection on the mechanisms, outcomes and, ultimately, the accountabilities of participation. In this paper, we propose the lens of care framework for approaching such reflections. We illustrate its value by using it to account for our role in establishing participatory spaces as part of a European Horizon 2020-funded research and innovation project, entitled EmERGE. We describe the codesign processes we developed and implemented with the aim of enabling heterogeneous voices, distinct experiences and multiple ideas to be articulated to inform the development and implementation of a digital platform for HIV care. We show how the lens of care framework enables us to trouble participation along prior theoretical distinctions between patients/citizens roles, invited/uninvited spaces and inclusive/scientistic voices and provides novel lines of inquiry to capture the relational and emergent processes of participation in digital health innovation. In the EmERGE project, spaces of participation were co-created within and by the community, whose members skilfully arranged the material, social and temporal set-up. Within these spaces we were able to articulate voices, deliberate knowledge and study the potentialities of technology so that initial technological inscriptions of empowerment through information-push were challenged and were, eventually, replaced by more interactive forms of clinician-patient engagement in digital HIV care. Through the lens of care, this paper aims to provide a reflective tool for researchers and practitioners who are involved in the design, implementation, and evaluation of participatory projects.

Public involvement in the Swedish health system: citizen dialogues with unclear outcomes

BACKGROUND

In systems with representative democracy, there is a growing consensus that citizens should have the possibility to participate in decisions that affect them, extending beyond just voting in national or local/regional elections. However, significant uncertainty remains regarding the role of public involvement in decision-making, not least in healthcare. In this article, we focus on citizen dialogues (CDs) in a health system that is politically governed and decentralised. The aim of the study was to evaluate the functioning of citizen dialogues in the Swedish health system in terms of representation, process, content, and outcomes.

METHODS

This study was conducted using a qualitative case design focusing on CDs at the regional level in Sweden. The regional level is politically elected and responsible for funding and provision of healthcare. The data consist of public documents describing and evaluating the CDs and interviews, which were analysed drawing on a modified version of the Abelson et al. analytical framework for evaluating public involvement in healthcare.

RESULTS

Some CDs were an attempt to counteract political inequality by inviting groups that are less represented, while others aimed to increase legitimacy by reducing the distance between policymakers and citizens. The results from the CDs-which were often held in the beginning of a potential policy process-were often stated to be used as input in decision-making, but how was not made clear. Generally, the CDs formed an opportunity for members of the public to express preferences (on a broad topic) rather than developing preferences, with a risk of suggestions being too unspecific to be useful in decision-making. The more disinterested public perspective, in comparison with patients, reinforced the risk of triviality. A need for better follow-up on the impact of the CDs on actual decision-making was mentioned as a necessary step for progress.

CONCLUSIONS

It is unclear how input from CDs is used in policymaking in the politically governed regions responsible for healthcare in Sweden. The analysis points to policy input from CDs being too general and a lack of documentation of how it is used. We need to know more about how much weight input from CDs carry in relation to other types of information that politicians use, and in relation to other types of patient and public involvement.

Determinant factors hinder urban structure plan implementation: The case of Nekemte Town, Ethiopia

Urban structure plan is widely used plan in the process of urbanization and rapid urban spatial expansion. However, rapidly growing urban centers of Ethiopia are facing challenges to implement their structure plan within the time horizon. Thus, this study aims to investigate the determinant factors that hinder structure plan implementation in Nekemte town. Questionnaire survey, interview, observation and land use survey were used to collect data. Descriptive data analysis and regression model were used to analyze the data. The main findings of the study show that all identified factors: lack of active participation, lack commitment, political instability and lack of sufficient budget significantly contribute for the failure of structure plan implementation at P-value of 0.05. The regression analysis further indicated that, lack of community participation; - 0.0499 coefficients is the most determining factors and followed by customary land tenure and lack of awareness -0.0489 and -0.0468 coefficients respectively. Hence, future structure plan implementation endeavors of Nekemte city must be underpinned by inculcating community participation and awareness of structure plan that is required to implement the plan to the expected level. Furthermore, use of modern technology like GIS and appropriate man power are also equally recommended to enhance structure plan implementation of Nekemte city.

Participatory Systems Mapping for Municipal Prioritization and Planning

Rapidly growing cities face new and compounding health challenges, leading governments and donors to seek innovative ways to support healthier, more resilient urban growth. One such approach is the systems mapping process developed by Engaging Inquiry (EI) for the USAID-funded Building Healthy Cities project (BHC) in four cities in Asia. This paper provides details on the theory and methods of the process. While systems mapping is not new, the approach detailed in this paper has been uniquely adapted to the purpose of municipal planning. Strategic stakeholder engagement, including participatory workshops with a diverse group of stakeholders, is at the core of this approach and led to deeper insights, greater buy-in, and shared understanding of the city's unique opportunities and challenges. This innovative mapping process is a powerful tool for defining municipal priorities within growing cities across the globe, where the situation is rapidly evolving. It can be used to provide evidence-based information on where to invest to gain the biggest impact on specific goals. This paper is part of a collection in this issue providing a detailed accounting of BHC's systems mapping approach across four project cities.

Citizen participation and urban air pollution abatement: Evidence from environmental whistle-blowing platform policy in Sichuan China

This study employs the environmental whistle-blowing platform policy adopted at Leshan City, Sichuan Province, China in July 2017 as the quasi-natural experiment and applies Synthetic Control Method (SCM) and Difference-in-Difference (DID) to examine the causal effect between citizen participation, median supervision, and air pollution abatement by government. The results show: first, the launch of the environmental whistle-blowing platform decreases daily AQI at Leshan City by 19 units; second, days with excellent air quality increase by 2.6 days each month on average at Leshan City; third, the probability for a day with excellent or good air quality at Leshan City increases by approximately 16.6%. Moreover, when the sample is expanded from neighboring prefecture level cities of Leshan City to prefecture level cities in Sichuan Province or across China, the results remain robust. Based on the panel data from China Family Panel Studies (CFPS), we find the launch of the environmental whistle-blowing platform improves individual's approval of government at primary level significantly and increases their life satisfaction. This demonstrates citizen participation and media supervision generate substantial effects on air pollution abatement. This study serves as a reference for solutions to improvement of air quality and governance capability of the government.

Influence of selected aspects of local governance on the efficiency of waste collection and street cleaning services

Currently, in all developed countries there is great interest in improving democratic practices in local governments, as the administration closest to citizens. However, the possible influence of these actions on the management of public services and municipal finances have been side-lined, despite the great interest in evaluating the performance of local governments under budgetary constraints. Our research aims to fill this knowledge gap by studying the impact of key aspects of local governance (transparency and citizen participation), together with other environmental variables, on the efficiency of two municipal public services of both qualitative and quantitative importance: waste collection and street cleaning. The results show that the type of management, population density, the tourist activity of the municipality and the strength of local government are determinants that explain the efficiency of the public services examined in this research, while transparency and citizen participation have little impact.

The evaluation of citizen participation in policymaking: Insights from Portugal

While citizen participation in policymaking is on the rise worldwide, the scholarly debate centring around its evaluation has not developed to the same extent. The article discusses the methodology and findings of the evaluation of the project "Portugal Participa: Caminhos para a Inovação Societal" which started at the end of 2014, and was implemented in 2015 and 2016, in Portugal. As the project promoted actions at both national and local levels, the evaluation accounted for both layers with a major focus on the analysis of procedures and outputs to examine its success. Through the application of a multi-method approach - data collection and analysis, cost-effectiveness assessment, interviews, pre-post surveys, and counterfactual focus groups - involving a wide array of agents - political representatives, civil servants, NGOs, citizens, national academia, and the funding sponsor - findings have helped retrieve three main insights that aim to contribute to future research on the evaluation of citizen participation in policymaking, which should shed light on: the (re)connection of multiple agents; the role within the governance systems; and the pursuit of social inclusion.

Citizen participation dilemmas in water governance: An empirical case of Kumasi, Ghana

Citizen participation in decision-making on water-related initiatives offers a valuable pathway to move towards a more equitable and sustainable water delivery, now and into the future. However, given the acknowledged impacts of active citizen participation in the water governance process, there is an increase institutional search for ideal approaches to enhance local inputs in water decisions. To enhance institutional knowledge on this quest, this paper adopts a qualitative exploratory method using 48 interviews and 2 focus group discussions (6 participants in each group) to present an empirical case of Kumasi in Ghana. Findings from the study show that citizens are willing to participate in decision-making on water-related process through radio programs; public meetings; surveys or polls and telephone. It was also realised that Ghana Water Company focuses more on the technical aspect of water delivery than the social aspect which borders on appropriate engagement strategies that involve customers in the decision-making process. The results imply a significant difference regarding feasibility and outcomes for each currently deployed participatory mechanism. The study recommends a change in current institutional and governance arrangements to influence citizen participation strategies at all levels of water service delivery and governance.

Improvement of regional environmental quality: Government environmental governance and public participation

The improvement of regional environmental quality (REQ) not only requires local governments to adopt environmental investment, legislation and law enforcement, but also requires the coordination of government environmental governance and public participation. This study analyses the impact mechanism of government environmental governance, public participation and their coordinated effect on the improvement of REQ, which is a comprehensive indicator measured by the emission of waste gas, waste water and waste solids. After empirical analyses using sample data from 30 provinces in China, the results show that, REQ has been increasingly deteriorating; the effects of government's environmental investment, legislation and law enforcement on REQ improvement are significantly positive, and public participation also helps to stimulate REQ. There also exists a coordinated effect between government environmental governance and public participation. Compared with citizen participation, environmental non-government organisations' participation has a more significant positive effect on REQ improvement. Finally, the influence of government environmental governance and public participation on REQ has significant spatial heterogeneity. The conclusions above can provide inspiration for Chinese government to improve the environmental governance system, which is good for the improvement of REQ.

[Participation in research: interest and opinions on participatory research among participants of a senior university]

BACKGROUND

In gerontological research, older people are often used as test subjects. Participatory research means the active and equal involvement of those affected by the research question, i.e., the subjects and the academic researchers. But what is the interest in participatory research among older people who participate in an educational institution of the third age? In order to answer this question, participants of a senior university were interviewed.

MATERIAL AND METHODS

The survey was conducted as a standardized postal survey combined with an optional online survey of participants from the Senior University of Zurich (Switzerland). The sample consisted of 811 persons aged between 56 and 96 years.

RESULTS

Of the respondents 24% had already participated in a participatory research project and of these, older people and people with a high level of education were more likely to be involved, as were people who are more likely to be extraverted and who regularly volunteer. Of all respondents, 62% were interested in participatory research projects. In a multivariate perspective, interest depended on age, education, volunteering and experience with such research projects.

CONCLUSION

The interest in participatory participation among Senior University members was high. This interest was more pronounced among people who already had experience with such projects. Further studies should evaluate the interest in research participation on the basis of implemented participatory projects and define optimal framework conditions.

Study protocol: evaluation of a community health promotion program in a socioeconomically deprived city district in the Netherlands using mixed methods and guided by action research

BACKGROUND

Voorstad on the Move (VoM) is a community health promotion program implemented in a socioeconomically deprived city district in the Netherlands. Based on exploration of the health situation, concurrent views on health promotion, and insights from literature, VoM is grounded in a social-ecological perspective and puts three action principles center core: citizens' participation, intersectoral collaboration, and a health supportive environment. VoM aims to improve the health of inhabitants, mostly low socioeconomic status (SES) families, and to realize changes in the social and physical environment. This current research, as part of the wider VoM project, aims to study the impacts and action principles of VoM. The main research questions concern the inhabitants' perceptions on health and health supportive environments, the perceived benefits of citizen participation in terms of health literacy and empowerment, and the factors and mechanisms that contribute to citizen participation and intersectoral collaboration.

METHODS

The study has a mixed methods design, including process evaluation and monitoring, and combines qualitative and quantitative data. Research activities include literature study, in-depth interviews, focus group discussions, concept and capacity mapping, document analysis, and health survey data. A prominent strategy is action research, which aims to involve all stakeholders, capturing the different perspectives of citizens and professionals, and engaging low SES groups. The principle of triangulation is continuously applied to optimize the reliability of this study, using multiple methods and multiple sources. Internal validity is enhanced by triangulation of methods and resources. Other verification techniques will also be used, such as expert consultation.

DISCUSSION

The design of the study, with a strong focus on action research, facilitates the involvement of all stakeholders and contributes to the development of capacities, learning, and empowerment, and thus contributes to health. The VoM program is innovative because it adopts an open approach in which activities evolve from citizens' needs, with a focus on action elements. This study will unravel the mechanisms of the action elements at community level, thereby helping to find ways to reduce health inequities. The findings will further elucidate what works and why it works for low SES groups.

[Public participation in research from the perspective of primary health care researchers]

OBJECTIVE

Explore the strengths, weaknesses, opportunities and threats (SWOT) for development of public involvement in research by Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol) according to primary health care researchers in Catalonia (Spain).

METHODS

Cross-sectional study carried out in 2017 with 36 primary health care research teams accredited by IDIAPJGol and its management staff. An open questionnaire (paper and online) was designed and piloted to develop a SWOT technique, and 65 answers were obtained (14 in paper and 51 online). A thematic content analysis was carried out.

RESULTS

Most informants consider public involvement in research a useful, innovative, viable and essential strategy, but it requires a change of mentality and a move away from the hierarchical paradigm. It can be difficult to execute and can complicate studies. They are concerned about which citizens should be involve, how to select them, possible conflicts of interest and training needs. The main proposals for its implementation are to disseminate previous strategies, encourage motivation and synergies among citizens, researchers and institutions, and to clarify the roles of the actors involved. IDIAPJGol should develop recommendations for the public involvement in research, encourage their inclusion, have a mentor and advise the research teams.

CONCLUSIONS

Despite the challenges, developing public involvement in research in primary health care is essential and feasible, what it is more should be based on a participatory strategy with all actors. The citizens can participate in any kind of design and phase of the research, adapting each project, being the primary health care a privileged area to develop the public involvement in research.

Conflicting perceptions on participation between citizens and members of local government

There is a growing consensus among citizens and members of local government that citizen participation is desirable for local government. However in practice, there are differing perceptions between them regarding the level and extent of citizen participation. As citizen participation is a multi faceted concept, its meaning is construed differently by both the members of local government and the citizen groups. This paper attempts to describe the conflicts that arise from participation. The paper is based on the study of the process of citizen participation in local government carried out in Torbat-Heydarieh city, Iran. A qualitative research method is seen as the most suitable approach of collecting and analyzing the data. The method employed for data collection in this research is in-depth interviews. In-depth interviews were conducted to gauge the existence of conflicts regarding participation. The findings reveal four areas that give rise to conflicts. This study also attempts to highlight two different views regarding citizen participation; the people-centered view and authority-centered view.

[Building local citizen participation among older adults : A participatory project]

AIM

Dutch municipalities are looking for ways to promote citizen participation, among which older adults. This paper discusses older adults' experiences regarding favoring and inhibiting factors for lasting and independent citizen participation around the themes of housing, wellbeing and health care.

METHODS

The participatory research project lasted from April 2014 to March 2016. The organizational structure consisted of a working group, a group of 21 participants (aged 65+) and the research team. Interviews and focus-group discussions were used.

RESULTS

The project did not result in lasting and independent citizen participation of older adults, as was intended beforehand. When we examined the experiences of the participants, we found that their participation was favored and inhibited by the factors Can do, Like to, Enabled to, Asked to, and Responded to.

CONCLUSIONS

In order for citizen participation to be successful, all five identified factors should be met by the stakeholders involved. To achieve this we recommend to fine-tune the mutual expectations of the stakeholders, using the CLEAR model. The empirically grounded knowledge, generated throughout the project, strengthens the existing evidence-base about participation of older adults and helps to shape local participation programs.

Assessing How Participators Combine Acts in Their "Political Tool Kits": A Person-Centered Measurement Approach for Analyzing Citizen Participation

Scholars have recognized that a recent increase in the ways citizens participate beyond the electoral arena may be a promising avenue of renewal for citizen participation. In this article we test the theory that different kinds of citizenship norms motivate some citizens to specialize in electoral-oriented activities (e.g. voting), while others specialize in non-institutionalized activities (e.g. protest). The latent class analysis of data from the U.S. Citizen, Involvement and Democracy Survey (2005) in the current study assesses how actors combine a variety of acts in their "political tool kits" of participation, and facilitates a comparison to prior findings that analyze single political behaviors. Results indicate a participatory type that specializes in non-institutionalized acts, but the group's high probability of voting does not align with the expectations in the literature. An electoral-oriented specialist type is not identified; instead, the findings show that a majority of the population is best characterized as disengaged, while a small group of all-around activists embrace all possible opportunities for political action. The actor-centered theoretical and measurement approach in this study identifies caveats to the theory that changing citizenship norms are leading to civic and political renewal. We discuss the implications of these findings for measuring different aspects of democratic (dis)engagement and participatory (in)equality.

[Local and citizen participation and representation strategies in Healthcare Administration]

The public as a whole are the rightful owners and beneficiaries of the public healthcare system in our country. As such, they collaborate in its maintenance and upkeep through payment of taxes. The government is accountable to the public as to how the ever-scarce resources are allocated. When it comes to the area of healthcare, this represents an added factor of complexity and specificity which makes the issue a particularly sensitive one. In the field of healthcare, both the General Health Law and the Law of Catalan Healthcare Code define the actors responsible for the public representation of its citizens. Nevertheless, their inclusion does not necessarily guarantee the perception of participation by its citizens or that of a greater democratic quality. The model must be understood as the intermediary link between a legally regulated framework and the actual debate, which in a globalized world with such an immense volume of information available to citizens and with the current online social networking sites, occurs at the heart of society in general, even though government has no such incorporation channel. The system will need to be developed as new technologies enable this, towards a more direct and more global models for participation. Participation is a flexible concept which, as far as possible, needs to adapt to the different problems as well as the different regions. Legislative regulation must therefore provide the mechanisms and stable frameworks for participation. In turn however, it must also establish dynamic systems capable of adapting to and incorporating the varying demands and methods of participation coming from the public in response to disparate processes.

Health provider responsiveness to social accountability initiatives in low- and middle-income countries: a realist review

Social accountability in the health sector has been promoted as a strategy to improve the quality and performance of health providers in low- and middle-income countries. Whether improvements occur, however, depends on the willingness and ability of health providers to respond to societal pressure for better care. This article uses a realist approach to review cases of collective citizen action and advocacy with the aim to identify key mechanisms of provider responsiveness. Purposeful searches for cases were combined with a systematic search in four databases. To be included in the review, the initiatives needed to describe at least one outcome at the level of frontline service provision. Some 37 social accountability initiatives in 15 countries met these criteria. Using a realist approach, retroductive analysis and triangulation of methods and sources were performed to construct Context-Mechanism-Outcome configurations that explain potential pathways to provider responsiveness. The findings suggest that health provider receptivity to citizens' demands for better health care is mediated by health providers' perceptions of the legitimacy of citizen groups and by the extent to which citizen groups provide personal and professional support to health providers. Some citizen groups activated political or formal bureaucratic accountability channels but the effect on provider responsiveness of such strategies was more mixed. Favourable contexts for health provider responsiveness comprise socio-political contexts in which providers self-identify as activists, health system contexts in which health providers depend on citizens' expertise and capacities, and health system contexts where providers have the self-perceived ability to change the system in which they operate. Rather than providing recipes for successful social accountability initiatives, the synthesis proposes a programme theory that can support reflections on the theories of change underpinning social accountability initiatives and interventions to improve the quality of primary health care in different settings.

Citizen participation and discontent in three Southern European health systems

Participation has featured in political agendas in recent decades and the domain of healthcare has not been indifferent to its appeal. Although emerging later than in other European regions, the involvement of civil society in healthcare decision-making procedures has proved one of the biggest challenges facing Southern European health systems. The health systems of the countries considered in this analysis - Italy, Portugal and Spain - underwent reforms that brought citizen participation to the forefront of the health system. Through national laws or health plans, each of these countries has recognised the need to promote participation in order to 'give a voice' to citizens in the health sector. Accordingly, a range of significant activities have been implemented in the region, although they have been developed unequally within national territories, at different paces and involving the mobilisation of different actors. This article focuses on the most relevant experiences of citizen participation designed and implemented in the three selected countries, describing their key features and potential, as well as the main critical issues and contradictions that have emerged over time. Particular emphasis is given to the impact of the current financial crisis on Southern European national health systems, especially in terms of participatory methods, the way in which citizen participation is progressing and civil society's reaction to these important changes.