Is scale-up of community mobilisation among sex workers really possible in complex urban environments? The case of Mumbai, India.

BACKGROUND: In the last decade, community mobilisation (CM) interventions targeting female sex workers (FSWs) have been scaled-up in India's national response to the HIV epidemic. This included the Bill and Melinda Gates Foundation's Avahan programme which adopted a business approach to plan and manage implementation at scale. With the focus of evaluation efforts on measuring effectiveness and health impacts there has been little analysis thus far of the interaction of the CM interventions with the sex work industry in complex urban environments. METHODS AND FINDINGS: Between March and July 2012 semi-structured, in-depth interviews and focus group discussions were conducted with 63 HIV intervention implementers, to explore challenges of HIV prevention among FSWs in Mumbai. A thematic analysis identified contextual factors that impact CM implementation. Large-scale interventions are not only impacted by, but were shown to shape the dynamic social context. Registration practices and programme monitoring were experienced as stigmatising, reflected in shifting client preferences towards women not disclosing as 'sex workers'. This combined with urban redevelopment and gentrification of traditional red light areas, forcing dispersal and more 'hidden' ways of solicitation, further challenging outreach and collectivisation. Participants reported that brothel owners and 'pimps' continued to restrict access to sex workers and the heterogeneous 'community' of FSWs remains fragmented with high levels of mobility. Stakeholder engagement was poor and mobilising around HIV prevention not compelling. Interventions largely failed to respond to community needs as strong target-orientation skewed activities towards those most easily measured and reported. CONCLUSION: Large-scale interventions have been impacted by and contributed to an increasingly complex sex work environment in Mumbai, challenging outreach and mobilisation efforts. Sex workers remain a vulnerable and disempowered group needing continued support and more comprehensive services

Considering risk contexts in explaining the paradoxical HIV increase among female sex workers in Mumbai and Thane, India.

BACKGROUND: The period 2006-2009 saw intensive scale-up of HIV prevention efforts and an increase in reported safer sex among brothel and street-based sex workers in Mumbai and Thane (Maharashtra, India). Yet during the same period, the prevalence of HIV increased in these groups. A better understanding of sex workers' risk environment is needed to explain this paradox. METHODS: In this qualitative study we conducted 36 individual interviews, 9 joint interviews, and 10 focus group discussions with people associated with HIV interventions between March and May 2012. RESULTS: Dramatic changes in Mumbai's urban landscape dominated participants' accounts, with dwindling sex worker numbers in traditional brothel areas attributed to urban restructuring. Gentrification and anti-trafficking efforts explained an escalation in police raids. This contributed to dispersal of sex work with the sex-trade management adapting by becoming more hidden and mobile, leading to increased vulnerability. Affordable mobile phone technology enabled independent sex workers to trade in more hidden ways and there was an increased dependence on lovers for support. The risk context has become ever more challenging, with animosity against sex work amplified since the scale up of targeted interventions. Focus on condom use with sex workers inadvertently contributed to the diversification of the sex trade as clients seek out women who are less visible. Sex workers and other marginalised women who sell sex all strictly prioritise anonymity. Power structures in the sex trade continue to pose insurmountable barriers to reaching young and new sex workers. Economic vulnerability shaped women's decisions to compromise on condom use. Surveys monitoring HIV prevalence among 'visible' street and brothel-bases sex workers are increasingly un-representative of all women selling sex and self-reported condom use is no longer a valid measure of risk reduction. CONCLUSIONS: Targeted harm reduction programmes with sex workers fail when implemented in complex urban environments that favour abolition. Increased stigmatisation and dispersal of risk can no longer be considered as unexpected. Reaching the increasing proportion of sex workers who intentionally avoid HIV prevention programmes has become the main challenge. Future evaluations need to incorporate building 'dark logic' models to predict potential harms

People-centred surveillance: a narrative review of community-based surveillance among crisis-affected populations.

Outbreaks of disease in settings affected by crises grow rapidly due to late detection and weakened public health systems. Where surveillance is underfunctioning, community-based surveillance can contribute to rapid outbreak detection and response, a core capacity of the International Health Regulations. We reviewed articles describing the potential for community-based surveillance to detect diseases of epidemic potential, outbreaks, and mortality among populations affected by crises. Surveillance objectives have included the early warning of outbreaks, active case finding during outbreaks, case finding for eradication programmes, and mortality surveillance. Community-based surveillance can provide sensitive and timely detection, identify valid signals for diseases with salient symptoms, and provide continuity in remote areas during cycles of insecurity. Effectiveness appears to be mediated by operational requirements for continuous supervision of large community networks, verification of a large number of signals, and integration of community-based surveillance within the routine investigation and response infrastructure. Similar to all community health systems, community-based surveillance requires simple design, reliable supervision, and early and routine monitoring and evaluation to ensure data validity. Research priorities include the evaluation of syndromic case definitions, electronic data collection for community members, sentinel site designs, and statistical techniques to counterbalance false positive signals

Red Cross volunteers’ experience with a mobile community event- based surveillance (CEBS) system in Sierra Leone during-and after the Ebola outbreak- A qualitative study

Purpose: The objective of this study was to explore the volunteers’ experiences with and perspectives on the community event-based surveillance system in Sierra Leone. Methods and materials: 62 volunteers from 14 different chiefdoms participated in in-depth interviews and focus group discussions, which were audio recorded and transcribed. A comprehensive and systematic thematic analysis was conducted, which identified key benefits and challenges. Results: The volunteers believe CEBS positively impacts their communities. CEBS increases knowledge and behavior change, contributing to the prevention of Ebola and other diseases and decreasing overall mortality. Volunteers are motivated to participate by an aspiration of helping their community, although many volunteers also participated in the hope of receiving monetary incentives. Communities were initially reluctant to participate in surveillance due to fear of Ebola, but acceptance increased with improved community engagement. Reporting by phone call and SMS was perceived as a quick and simple way of reporting, although challenges with access to mobile network, sim registration and cost for charging were identified. Many of the volunteers could not repeat or explain the different case definitions and explained reporting on symptoms solely or other health events, suggesting that the volunteers did not have a clear understanding of case definitions or purpose of CEBS. Conclusion: SMS reporting directly from the community is perceived as a timely, easy and reliable way of sharing important information, but the usefulness of the system relies not only on the structure of the system itself, but also on external factors, such as the relationship between the community members and the volunteers, and the logistical structure

Participants profile

<p>Abbreviations used: ORW = outreach worker; PC = program coordinator; PE = peer educator; NGO = non-governmental organisation; CBO = community based organization; NACO = National Aids Control Organisation; MDACS = Mumbai District Aids Control Society.</p><p>.</p

Factors identified to impact on participation and implementation of community mobilisation interventions (CMIs) and interviews in which they featured.

<p>The findings demonstrate how the identified factors influence both participation and implementation of the CM interventions and reveals close interactions between the interventions and the sex industry.</p><p>Factors identified to impact on participation and implementation of community mobilisation interventions (CMIs) and interviews in which they featured.</p

Community-based surveillance programme evaluation using the platform Nyss implemented by the Somali Red Crescent Society—a mixed methods approach

Abstract Background Somali Red Crescent Society (SRCS), supported by Norwegian Red Cross, has implemented community-based surveillance (CBS) in Somaliland. This methodology aims to reduce the high risk of epidemics by strengthening early warning and response from and at community level, particularly where there is a weak public health surveillance system. CBS is implemented through SRCS community volunteers, who report signals from the community via SMS to the software platform Nyss. This paper presents key findings from the CBS programme evaluation. Methods A retrospective observational mixed-methods approach to evaluate the CBS programme was conducted, using routine CBS data from 2021 for Awdal and Togdheer regions and qualitative interviews with stakeholders’ representatives. Results The usefulness of the CBS programme in preventing, detecting, and responding to disease outbreaks was acknowledged by the stakeholders’ representatives. 83% of the signals in Awdal region matched a Community Case Definition (CCD) and were escalated to the Ministry of Health and Development (MoHD)). For Togdheer region, 97% were escalated. Verification of signals by supervisors and escalation to the authorities was done timely.Alert outcome and response action was not well recorded, therefore there is limited evidence on sensitivity. The programme was shown to be simple and can be flexibly adjusted for new diseases and changing CCDs.Stakeholders appreciated being engaged, the good collaboration, their participation throughout the implementation and expressed high acceptance of the programme. Conclusion CBS can support early warning and response for a variety of public health risks. Improved documentation for alert outcomes could help to better evaluate the sensitivity of CBS. A participatory approach is vital to achieve successful community volunteer engagement. Software tools, such as the Nyss platform, can be useful to support effective and efficient CBS implementation

Additional file 1 of Community-based surveillance programme evaluation using the platform Nyss implemented by the Somali Red Crescent Society—a mixed methods approach

Supplementary Material