Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India?

BACKGROUND: Participatory health initiatives ideally support progressive social change and stronger collective agency for marginalized groups. However, this empowering potential is often limited by inequalities within communities and between communities and outside actors (i.e. government officials, policymakers). We examined how the participatory initiative of Village Health, Sanitation, and Nutrition Committees (VHSNCs) can enable and hinder the renegotiation of power in rural north India. METHODS: Over 18 months, we conducted 74 interviews and 18 focus groups with VHSNC members (including female community health workers and local government officials), non-VHSNC community members, NGO staff, and higherlevel functionaries. We observed 54 VHSNC-related events (such as trainings and meetings). Initial thematic network analysis supported further examination of power relations, gendered “social spaces,” and the “discourses of responsibility” that affected collective agency. RESULTS: VHSNCs supported some re-negotiation of intra-community inequalities, for example by enabling some women to speak in front of men and perform assertive public roles. However, the extent to which these new gender dynamics transformed relations beyond the VHSNC was limited. Furthermore, inequalities between the community and outside stakeholders were re-entrenched through a “discourse of responsibility”: The comparatively powerful outside stakeholders emphasized community responsibility for improving health without acknowledging or correcting barriers to effective VHSNC action. In response, some community members blamed peers for not taking up this responsibility, reinforcing a negative collective identity where participation was futile because no one would work for the greater good. Others resisted this discourse, arguing that the VHSNC alone was not responsible for taking action: Government must also intervene. This counter-narrative also positioned VHSNC participation as futile. CONCLUSIONS: Interventions to strengthen participation in health systems can engender social transformation. However they must consider how changing power relations can be sustained outside participatory spaces, and how discourse frames the rationale for community participation.ISIScopu

Unlocking community capability through promotion of self-help for health: experience from Chakaria, Bangladesh

Background People’s participation in health, enshrined in the 1978 Alma Ata declaration, seeks to tap into community capability for better health and empowerment. One mechanism to promote participation in health is through participatory action research (PAR) methods. Beginning in 1994, the Bangladeshi research organization ICDDR,B implemented a project “self-help for health,” to work with existing rural self-help organizations (SHOs). SHOs are organizations formed by villagers for their well-being through their own initiatives without external material help. This paper describes the project’s implementation, impact, and reflective learnings. Methods Following a self-help conceptual framework and PAR, the project focused on building the capacity of SHOs and their members through training on organizational issues, imparting health literacy, and supporting participatory planning and monitoring. Quarterly activity reports and process documentation were the main sources of qualitative data used for this paper, enabling documentation of changes in organizational issues, as well as the number and nature of initiatives taken by the SHOs in the intervention area. Health and demographic surveillance system (HDSS) data from intervention and comparison areas since 1999 allowed assessment of changes in health indicators over time. Results Villagers and members of the SHOs actively participated in the self-help activities. SHO functionality increased in the intervention area, in terms of improved organizational processes and planned health activities. These included most notably in convening more regular meetings, identifying community needs, developing and implementing action plans, and monitoring progress and impact. Between 1999 and 2015, while decreases in infant mortality and increases in utilization of at least one antenatal care visit occurred similarly in intervention and comparison areas, increases in immunization, skilled birth attendance, facility deliveries and sanitary latrines were substantially more in intervention than comparison areas. Conclusion Building community capability by working with pre-existing SHOs, encouraging them to place health on their agendas, strengthening their functioning and implementation of health activities led to sustained improvements in utilization of services for over 20 years. Key elements underpinning success include efforts to build and maintain trust, ensuring social inclusion in project activities, and balancing demands for material resources with flexibility to be responsive to community needs

Gene Regulation in Primates Evolves under Tissue-Specific Selection Pressures

Regulatory changes have long been hypothesized to play an important role in primate evolution. To identify adaptive regulatory changes in humans, we performed a genome-wide survey for genes in which regulation has likely evolved under natural selection. To do so, we used a multi-species microarray to measure gene expression levels in livers, kidneys, and hearts from six humans, chimpanzees, and rhesus macaques. This comparative gene expression data allowed us to identify a large number of genes, as well as specific pathways, whose inter-species expression profiles are consistent with the action of stabilizing or directional selection on gene regulation. Among the latter set, we found an enrichment of genes involved in metabolic pathways, consistent with the hypothesis that shifts in diet underlie many regulatory adaptations in humans. In addition, we found evidence for tissue-specific selection pressures, as well as lower rates of protein evolution for genes in which regulation evolves under natural selection. These observations are consistent with the notion that adaptive circumscribed changes in gene regulation have fewer deleterious pleiotropic effects compared with changes at the protein sequence level

Unlocking Community Capabilities Across Health Systems in Low- and Middle-Income Countries: Lessons Learned from Research and Reflective Practice

The right and responsibility of communities to participate in health service delivery was enshrined in the 1978 Alma Ata declaration and continues to feature centrally in health systems debates today. Communities are a vital part of people-centred health systems and their engagement is critical to realizing the diverse health targets prioritised by the Sustainable Development Goals and the commitments made to Universal Health Coverage. Community members' intimate knowledge of local needs and adaptive capacities are essential in constructively harnessing global transformations related to epidemiological and demographic transitions, urbanization, migration, technological innovation and climate change. Effective community partnerships and governance processes that underpin community capability also strengthen local resilience, enabling communities to better manage shocks, sustain gains, and advocate for their needs through linkages to authorities and services. This is particularly important given how power relations mark broader contexts of resource scarcity and concentration, struggles related to social liberties and other types of ongoing conflicts.IS

A cluster randomised controlled trial of the community effectiveness of two interventions in rural Malawi to improve health care and to reduce maternal, newborn and infant mortality

<p>Abstract</p> <p>Background</p> <p>The UN Millennium Development Goals call for substantial reductions in maternal and child mortality, to be achieved through reductions in morbidity and mortality during pregnancy, delivery, postpartum and early childhood. The MaiMwana Project aims to test community-based interventions that tackle maternal and child health problems through increasing awareness and local action.</p> <p>Methods/Design</p> <p>This study uses a two-by-two factorial cluster-randomised controlled trial design to test the impact of two interventions. The impact of a community mobilisation intervention run through women's groups, on home care, health care-seeking behaviours and maternal and infant mortality, will be tested. The impact of a volunteer-led infant feeding and care support intervention, on rates of exclusive breastfeeding, uptake of HIV-prevention services and infant mortality, will also be tested. The women's group intervention will employ local female facilitators to guide women's groups through a four-phase cycle of problem identification and prioritisation, strategy identification, implementation and evaluation. Meetings will be held monthly at village level. The infant feeding intervention will select local volunteers to provide advice and support for breastfeeding, birth preparedness, newborn care and immunisation. They will visit pregnant and new mothers in their homes five times during and after pregnancy.</p> <p>The unit of intervention allocation will be clusters of rural villages of 2500-4000 population. 48 clusters have been defined and randomly allocated to either women's groups only, infant feeding support only, both interventions, or no intervention. Study villages are surrounded by 'buffer areas' of non-study villages to reduce contamination between intervention and control areas. Outcome indicators will be measured through a demographic surveillance system. Primary outcomes will be maternal, infant, neonatal and perinatal mortality for the women's group intervention, and exclusive breastfeeding rates and infant mortality for the infant feeding intervention.</p> <p>Structured interviews will be conducted with mothers one-month and six-months after birth to collect detailed quantitative data on care practices and health-care-seeking. Further qualitative, quantitative and economic data will be collected for process and economic evaluations.</p> <p>Trial registration</p> <p>ISRCTN06477126</p

The architecture and effect of participation: a systematic review of community participation for communicable disease control and elimination. Implications for malaria elimination

Community engagement and participation has played a critical role in successful disease control and elimination campaigns in many countries. Despite this, its benefits for malaria control and elimination are yet to be fully realized. This may be due to a limited understanding of the influences on participation in developing countries as well as inadequate investment in infrastructure and resources to support sustainable community participation. This paper reports the findings of an atypical systematic review of 60 years of literature in order to arrive at a more comprehensive awareness of the constructs of participation for communicable disease control and elimination and provide guidance for the current malaria elimination campaign.Evidence derived from quantitative research was considered both independently and collectively with qualitative research papers and case reports. All papers included in the review were systematically coded using a pre-determined qualitative coding matrix that identified influences on community participation at the individual, household, community and government/civil society levels. Colour coding was also carried out to reflect the key primary health care period in which community participation programmes originated. These processes allowed exhaustive content analysis and synthesis of data in an attempt to realize conceptual development beyond that able to be achieved by individual empirical studies or case reports.Of the 60 papers meeting the selection criteria, only four studies attempted to determine the effect of community participation on disease transmission. Due to inherent differences in their design, interventions and outcome measures, results could not be compared. However, these studies showed statistically significant reductions in disease incidence or prevalence using various forms of community participation. The use of locally selected volunteers provided with adequate training, supervision and resources are common and important elements of the success of the interventions in these studies. In addition, qualitative synthesis of all 60 papers elucidates the complex architecture of community participation for communicable disease control and elimination which is presented herein.The current global malaria elimination campaign calls for a health systems strengthening approach to provide an enabling environment for programmes in developing countries. In order to realize the benefits of this approach it is vital to provide adequate investment in the 'people' component of health systems and understand the multi-level factors that influence their participation. The challenges of strengthening this component of health systems are discussed, as is the importance of ensuring that current global malaria elimination efforts do not derail renewed momentum towards the comprehensive primary health care approach. It is recommended that the application of the results of this systematic review be considered for other diseases of poverty in order to harmonize efforts at building 'competent communities' for communicable disease control and optimising health system effectiveness

Task shifting: the answer to the human resources crisis in Africa?

Ever since the 2006 World Health Report advocated increased community participation and the systematic delegation of tasks to less-specialized cadres, there has been a great deal of debate about the expediency, efficacy and modalities of task shifting

Malaria vector control practices in an irrigated rice agro-ecosystem in central Kenya and implications for malaria control

<p>Abstract</p> <p>Background</p> <p>Malaria transmission in most agricultural ecosystems is complex and hence the need for developing a holistic malaria control strategy with adequate consideration of socio-economic factors driving transmission at community level. A cross-sectional household survey was conducted in an irrigated ecosystem with the aim of investigating vector control practices applied and factors affecting their application both at household and community level.</p> <p>Methods</p> <p>Four villages representing the socio-economic, demographic and geographical diversity within the study area were purposefully selected. A total of 400 households were randomly sampled from the four study villages. Both semi-structured questionnaires and focus group discussions were used to gather both qualitative and quantitative data.</p> <p>Results</p> <p>The results showed that malaria was perceived to be a major public health problem in the area and the role of the vector <it>Anopheles </it>mosquitoes in malaria transmission was generally recognized. More than 80% of respondents were aware of the major breeding sites of the vector. Reported personal protection methods applied to prevent mosquito bites included; use of treated bed nets (57%), untreated bed nets (35%), insecticide coils (21%), traditional methods such as burning of cow dung (8%), insecticide sprays (6%), and use of skin repellents (2%). However, 39% of respondents could not apply some of the known vector control methods due to unaffordability (50.5%), side effects (19.9%), perceived lack of effectiveness (16%), and lack of time to apply (2.6%). Lack of time was the main reason (56.3%) reported for non-application of environmental management practices, such as draining of stagnant water (77%) and clearing of vegetations along water canals (67%).</p> <p>Conclusion</p> <p>The study provides relevant information necessary for the management, prevention and control of malaria in irrigated agro-ecosystems, where vectors of malaria are abundant and disease transmission is stable.</p

How is Perceived Community Cohesion and Membership in Community Groups Associated with Children’s Dietary Adequacy in Disadvantaged Communities? A Case of the Indian Sundarbans

Background: Membership in community groups and a sense of community cohesion may facilitate collective action in mobilizing resources towards better health outcomes. This paper explores the relationship of these factors, along with individual level socio-economic variables, to dietary adequacy among children below 6 years of age, a proximate determinant of child malnutrition. Methods: We conducted a cross-sectional survey in Patharpratima block of the Sundarbans in West Bengal, India, using a two-stage, 30 cluster random sampling design. In 1200 sampled households, we used a structured questionnaire to interview mothers of children below 6 years of age on their child’s nutritional intake. We also interviewed household heads to assess perceived community cohesion using a nine item scale, membership in any community self-help organization, and other socio-economic determinants. We used a logistic regression model to assess their association with a minimum acceptable diet among children between 6 months to 6 years. Results: Only 9.33 % children between 6 and 71 months of age received a minimum acceptable diet. With each increase in the perceived community cohesion score (scale 0-9), a child is 1.31 times more likely to have minimum acceptable diet (95 % CI 1.14, 1.50). The odds of minimum acceptable diet were also higher among children whose mothers had primary education (2.09, 95 % CI 1.03, 2.94) as compared to illiterate mothers and in households with surplus food resources (2.72, 95 % CI 1.32, 5.58) as compared to those without surplus or deficit. In contrast, registering at an Anganwadi (government early child development) centre (odds ratio 1.34 95 % CI 0.69, 2.60) and community membership (odds ratio 0.93, 95 % CI 0.59, 1.46) were not associated with minimum acceptable diet. Conclusion: The results are consistent with what is known about the importance of maternal education and access to food resources in ensuring that children have a minimum acceptable diet. Perceived community cohesion seems to play a positive role in children’s diets. Further research needs to clarify which community characteristics and services are the most relevant, how they can better support children’s diets, and how interventions can strengthen these community characteristics and services