Actualising power sharing in community-led initiatives: Insights from community-based organisation leaders in Chicago, USA.

There is an increasing call for a governmental organisations such as local health departments and federal health and human service agencies to partner with community based organisations (CBOs) for health promotion. There is a large body of literature suggesting that CBOs need capacity building or empowerment to do this work, but less literature about the necessary culture shift at governmental organisations who fund public health work. This study aimed to examine the knowledge, attitudes, and beliefs of CBO leadership who do not want to partner with state funders, and understand which structures and practices demonstrate power-sharing in a community-led approach. We conducted six interviews with community-based organisation leaders and conducted a thematic analysis and a secondary, inductive discourse analysis of the transcripts to analyse why organisations chose not to apply for a government funded initiative and how they talked about power-sharing for community-led public health. Themes about the decision for CBOs to apply to the public health funding initiative: how it related to the CBO's scope of work, meeting the needs of the community, having the technical capacity, and cross-cutting themes of putting the community first and having a long-term positive impact. Organisations rejected the opportunity for this funding due to poor fit, even if they could fulfil the scope of work. A community-led approach was described as one that includes the government giving up control, creating spaces for meaningful participation and power-sharing, and systems demonstrating trust in CBOs. These findings reiterate that in order for public health to be community-led, there needs to be system-wide transformation and intentional investment that supports an infrastructure for community-led public health. State funders can learn from practices in trust-based philanthropy, such as flexible funding and reporting requirements. The results of this study can support the wider participation of CBOs in collaboration with state actors, maximising the transformative potential of collaboration, ultimately transforming power structures and advancing health equity.

Taking empowerment into account: the response of community-based organisations to the HIV care needs of men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France).

Empowerment is an ongoing process through which individuals and communities appropriate power and acquire the capability to function autonomously. Research on empowerment in men who have sex with men (MSM) is lacking in community-based contexts. We investigated the relationship between willingness to be empowered and HIV care needs in West African MSM accessing community-based organisations' (CBO) services. Fifty-three interviews were administered to HIV-negative MSM participating in the CohMSM study (Mali, Burkina Faso, Côte d'Ivoire, Togo). Five indicators of empowerment were identified from a discourse analysis: (i) motivation to access HIV services, (ii) willingness to improve HIV services, (iii) desire to be involved in new activities, (iv) desire to participate in such services, (v) willingness to collaborate in decision making. Based on these indicators, participants were classified into two profiles: high (19/53, 36%) and low (34/53, 64%) level of willingness to be empowered (HWE, LWE). Using a thematic analysis, HWE participants were focused on collective benefit (preventive follow-up, questions about MSM identity), while LWE participants were centred on individual benefit (medical care). CBOs should consider empowerment as a tool to advance collective health benefits for MSM. To improve empowerment in MSM, specific training on issues regarding sexual identity and stigma is needed for CBO providers.

Understanding the capacity of community-based groups to mobilise and engage in social action for health: Results from Avahan.

Community mobilisation improves outcomes from HIV to maternal and child health. Yet, little health research has explored why some community groups are better able to mobilise than others. We address this gap by considering the case of Avahan, the India AIDS Initiative, which sought to foster community mobilisation, including the creation of community-based groups serving men who have sex with men (MSM), female sex workers (FSWs), and injection drug users (IDUs). Using quantitative and qualitative data collected from 58 community-based groups from 2009-2012 across six Indian states, we analyse variation in groups' action on behalf of their members. Based on a mixed effects logistic regression, we find that older groups and those with bank accounts, crisis committees, or strategic relationships were most likely to take action on behalf of members by demanding rights or confronting gatekeepers and opinion leaders. Analysis of qualitative data reveals the types of action organisations took on behalf of members (mediation, removal of community members from harm, and advocacy), but also that sometimes organisations refused to take action, or community members declined their assistance. These findings indicate that organisations formalising, creating structures for social action, and building networks are important strategies to foster community mobilisation.

Finding the missing link: when community-based outreach in public space is key to engage migrants in health prevention programmes in Paris, France.

BACKGROUND: One of the classic challenges for prevention programmes is reaching the populations they serve. In France, a substantial number of African migrants living with HIV acquired their infection after migrating. The aim of this paper is to better understand the characteristics of the population reached by a community-based outreach approach. METHODS: We compared sociodemographic characteristics across three different groups in the Paris greater area: (1) the general African migrant population (Population census), (2) the African migrant population using either the regular healthcare system or the system for vulnerable populations (PARCOURS Survey) and (3) the African migrant population reached through a community-based mobile unit (Afrique Avenir). Comparisons were conducted according to sex, age, region of origin, duration of residence and occupational and legal statuses using χ2 tests. RESULTS: The migrants reached by the mobile unit were mostly men (69%), 52% of whom were younger than 35 years old. They more often lived in precarious situations than did the general sub-Saharan population (49% vs 35% were unemployed, respectively, p<0.001) and the ones accessing the regular healthcare system. Fewer of them lived in precarious situations than did migrants seeking healthcare consultations for vulnerable populations (42% in the mobile unit vs 54% in healthcare consultations were undocumented, p<0.028). CONCLUSION: Our study shows that the outreach approach can constitute a missing link in the prevention chain among sub-Saharan African migrants, reaching a group that differs from the general migrant population and from the migrant population in healthcare services-not only the newly arrived migrants who live in more precarious situations but also those who have been in France for several years and are still affected by social hardship.