Navigating the swampy lowland: a framework for evaluating the effect of community mobilisation in female sex workers in Avahan, the India AIDS Initiative

Abstract

BackgroundFew models of how community mobilisation works have been elaborated in the scientific literature, and evaluation of the impact of these programmes on HIV and other health outcomes is extremely limited. Avahan, the India AIDS Initiative, has been implementing community mobilisation as part of its prevention programming with groups of high-risk individuals across six states since 2005.PurposeTo articulate a programme theory and evaluation framework for evaluation of Avahan's approach to community mobilisation among female sex workers in four southern states in India.MethodsThe authors use a goal-based evaluation approach to describe the programme goals and an underlying programme theory that specifies how the programme is expected to work. Using multilevel structural equation modelling with propensity score matching, the evaluation will compare what is observed in the data with the predicted relationships specified by the model.ResultsThe Avahan model of community mobilisation posits that meaningful participation in high-risk group intervention, structural intervention and organisational development activities leads to identification, collectivisation and ownership, which in turn leads to improved programme outcomes. Strong community groups and an enabling environment reinforce social norm and behaviour change outcomes and lead to sustained impact.DiscussionSpecifying an explicit programme theory can aid in the evaluation of complex interventions, especially when the evaluation design is observational. In addition to articulating Avahan's community mobilisation approach in a model that can be tested, we recommend some specific measures and methods that could be used to improve evaluation efforts in the future.

Design of a Community Ownership and Preparedness Index: using data to inform the capacity development of community-based groups

“…First, a multiple-scenario analysis was carried out using the adopted design before the actual collection of the data, by inserting all possible types of potential answers into the cells. This analysis was helpful in checking the consistency and validity of possible responses to the questions, and whether the overall analysis aligned with the community mobilisation model for change 31 39. Second, a pilot test of the survey was conducted with four CBGs in the states of Andhra Pradesh, Maharashtra and Manipur, and when the data were scored using the COPI design, the results were found to be consistent with the current status of those CBGs as perceived by programme implementers.…”

“…Based on these discussions, a core design team, including high-risk community members and experts, identified three broad categories of stakeholders whom CBGs need to engage to address issues of vulnerability: (1) the project (HIV prevention intervention), including the implementing NGOs and programme components such as clinics and drop-in centres; (2) the state, that is, governmental bodies and authorities; and (3) wider society, for example, neighbourhood residents, religious leaders, politicians and gatekeepers (gatekeepers might include owners of sex establishments, clients of sex workers, drug dealers, intimate partners and law enforcement authorities). Table 1 uses the stages of the Avahan community mobilisation logic model to illustrate the expected trajectory of CBGs in relation to these stakeholders 31. Over the 10-year period of the Avahan Initiative, CBGs were expected to move towards the more advanced outcomes of Stage 3, where they would take ownership of elements of the intervention, develop procedures and spaces to claim their entitlements from the state, and assert their identity and rights as citizens within wider society.…”

“…The Avahan community mobilisation logic model posits that participation and change by high-risk communities lead to stronger HIV prevention outcomes and the long-term goal of a sustained HIV response through CBGs 31. One major objective of Avahan's second phase (2009–2013) was transition to a model in which the government—and, to a limited extent, CBGs—would manage targeted interventions37 and CBGs would transform their own role by taking action to address their vulnerabilities and building strong organisations that would be sustainable beyond the lifetime of the Avahan programme 32.…”

Community mobilisation programme for female sex workers in coastal Andhra Pradesh, India: processes and their effects

“…Details of the overall Avahan strategy for the development and evaluation of the community mobilisation programme are discussed in the paper by Galavotti et al 14 in this volume. The implementation strategy that Swagati adopted is presented in detail in this paper.…”

Learning about scale, measurement and community mobilisation: reflections on the implementation of the Avahan HIV/AIDS initiative in India

“…The logic model for community mobilisation in Avahan was not detailed enough to inform these tools, and this, coupled with the challenge of designing routine quantitative indicators to inform qualitative processes, meant that both efforts were modified extensively over the subsequent 2 years until they were eventually integrated into new monitoring tools in Phase 2 of Avahan. The new form of these tools can be seen in the community ownership and preparedness index (COPI) and behavioural tracking surveys complementing the revised logic model 45 52…”