Developing stakeholder participation to address lack of safe water as a community health concern in a rural province in South Africa

Hove, Jennifer; D’Ambruoso, Lucia; Twine, Rhian; Mabetha, Denny; Merwe, Maria van der; Mtungwa, Ishmael; Khoza, Sonto; Kahn, Kathleen; Witter, Sophie

doi:10.1080/16549716.2021.1973715

Cited by 10 publications

(5 citation statements)

References 50 publications

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“…Responding to the need for practical guidance on community participation programmes in rural LMIC settings, this work aimed to understand how multisectoral action to address a community-nominated priority could be developed and implemented at a local level. This work builds upon previous work on PAR process which we identified health priorities, documented and analyzed the issues, and published our findings elsewhere [37][38][39]. The objectives were to develop and implement local action plans, to understand how multiple stakeholders influenced the implementation process, and to identify facilitators and barriers to the implementation process in achieving positive outcomes at the local level.…”

Section: Lack Of Water In Bushbuckridgementioning

confidence: 91%

“…The VAPAR programme was designed to progress multi-sectoral engagement at different levels while prioritizing the needs of the communities to better understand their health problems and developing collective actions [37,38]. Lack of safe water was nominated as a priority health topic in one of the villages in Agincourt HDSS [37][38][39]. The VAPAR programme consists of a series of iterative five action learning cycles following a stepwise approach [43,44,51].…”

Section: Study Setting and Designmentioning

confidence: 99%

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Participatory action research to address lack of safe water, a community-nominated health priority in rural South Africa

Hove¹,

Mabetha²,

Merwe³

et al. 2023

PLoS ONE

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Background Despite international evidence supporting community participation in health for improved health outcomes and more responsive and equitable health systems there is little practical evidence on how to do this. This work sought to understand the process involved in collective implementation of a health-related local action plan developed by multiple stakeholders. Methods Communities, government departments and non-government stakeholders convened in three iterative phases of a participatory action research (PAR) learning cycle. Stakeholders were involved in problem identification, development, and implementation of a local action plan, reflection on action, and reiteration of the process. Participants engaged in reflective exercises, exploring how factors such as power and interest impacted success or failure. Results The local action plan was partially successful, with three out of seven action items achieved. High levels of both power and interest were key factors in the achievement of action items. For the achieved items, stakeholders reported that continuous interactions with one another created a shift in both power and interest through ownership of implementation processes. Participants who possessed significant power and influence were able to leverage resources and connections to overcome obstacles and barriers to progress the plan. Lack of financial support, shifting priorities and insufficient buy-in from stakeholders hindered implementation. Conclusion The process offered new ways of thinking and stakeholders were supported to generate local evidence for action and learning. The process also enabled exploration of how different stakeholders with different levels of power and interest coalesce to design, plan, and act on evidence. Creation of safe spaces was achievable, meanwhile changing stakeholders’ level of power and interest was possible but challenging. This study suggests that when researchers, service providers and communities are connected as legitimate participants in a learning platform with access to information and decision-making, a shift in power and interest may be feasible.

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Section: Lack Of Water In Bushbuckridgementioning

confidence: 91%

Section: Study Setting and Designmentioning

confidence: 99%

Participatory action research to address lack of safe water, a community-nominated health priority in rural South Africa

Hove¹,

Mabetha²,

Merwe³

et al. 2023

PLoS ONE

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“…The elements outlined above—pilot work [ 65 ], Cycle 1 community-based process [ 66 – 68 ], multisectoral engagement [ 69 ], VA [ 70 , 71 ], reflective/adaptive element [ 72 ], Cycle 2 redesign [ 73 , 74 ] and Cycle 3 CHW training [ 75 ]—are reported elsewhere.…”

Section: Methodsmentioning

confidence: 99%

Realising radical potential: building community power in primary health care through Participatory Action Research

Mabetha,

Ojewola,

van der Merwe

et al. 2023

Int J Equity Health

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Background While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component. Methods Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks. Results Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district. Conclusions Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

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“…There are two community health centres and seven PHC clinics [30]. The study was nested within the Verbal Autopsy with Participatory Action Research (VAPAR) programme, in which different partners organise evidence for action in a series of action-re ection cycles [31] [32]. The VAPAR approach is rooted in health policy and systems research (HPSR) and constructivist and participatory enquiry paradigms, based on assumptions that practical, experiential knowledge that is co-constructed, self-re ective, and embedded in complex, adaptive social and health systems can support and inform the organisation and delivery of equityoriented and people-centred public services.…”

Section: Study Settingmentioning

confidence: 99%

Expanding Community Health Worker decision space: impacts of a Participatory Action Research training intervention in a rural South African district

Abruquah

Witter

Mabetha

et al. 2023

Preprint

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BACKGROUND While recognised in policy and strategy, in practice, Community Health Workers (CHWs) in South Africa experience many challenges. Since the COVID-19 pandemic, CHW roles have expanded, shifting from communities to clinics. The objective was to assess a community-based training intervention to support functionality and local decision-making of CHWs in rural South Africa, aiding CHWs to undertake new, expanded roles during the COVID-19 pandemic. METHODS: CHWs from three rural villages were recruited and trained in rapid Participatory Action Research (PAR) methods via a series of workshops with community stakeholders. Training was designed to support CHWs to convene community groups, raise and/or respond to health concerns, understand concerns from different perspectives, and facilitate and monitor action in communities, health, and other public services. Narrative data from in-depth interviews with CHWs before and after the intervention were thematically analysed using the decision space framework to examine functionality in devolved decision-making. RESULTS: CHWs reported experiencing multiple, intersecting challenges: lack of financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organizational capacity, and fragile accountability mechanisms. CHWs had considerable commitment and resilience in the face of COVID-19 in terms of increased workloads, increased risk of infection and death, low job security and poor remuneration. The training intervention addressed some resourcing issues, increased management capacity, gave CHWs greater role clarity, improved community mobilisation skills and forged new community and facility-based relationships and alliances. Through regular spaces and processes for cooperative learning and collective action, the intervention supported CHWs to rework their agency in more empowered ways with communities, clinic staff and health managers, and among peers. The training thus served as an implementation support strategy for primary healthcare (PHC). CONCLUSION: The analysis revealed fundamental issues of recognition of CHWs as a permanent, central feature in PHC. The training intervention was positively impactful in widening decision space for CHWs, supporting functionality and agency for local decision-making. The intervention has been recommended for scale-up by the local health authority. Further support for and analysis of how to sustain expansion of CHW decision space is warranted.

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Developing stakeholder participation to address lack of safe water as a community health concern in a rural province in South Africa

Cited by 10 publications

References 50 publications

Participatory action research to address lack of safe water, a community-nominated health priority in rural South Africa

Participatory action research to address lack of safe water, a community-nominated health priority in rural South Africa

Realising radical potential: building community power in primary health care through Participatory Action Research

Expanding Community Health Worker decision space: impacts of a Participatory Action Research training intervention in a rural South African district

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