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BACKGROUND: Poverty-related diseases (PRD) remain amongst the leading causes of death in children under-5 years in sub-Saharan Africa (SSA). Clinical practice guidelines (CPGs) based on the best available evidence are key to strengthening health systems and helping to enhance equitable health access for children under five. However, the CPG development process is complex and resource-intensive, with substantial scope for improving the process in SSA, which is the goal of the Global Evidence, Local Adaptation (GELA) project. The impact of research on PRD will be maximized through enhancing researchers and decision makers' capacity to use global research to develop locally relevant CPGs in the field of newborn and child health. The project will be implemented in three SSA countries, Malawi, South Africa and Nigeria, over a 3-year period. This research protocol is for the monitoring and evaluation work package of the project. The aim of this work package is to monitor the various GELA project activities and evaluate the influence these may have on evidence-informed decision-making and guideline adaptation capacities and processes. The specific project activities we will monitor include (1) our ongoing engagement with local stakeholders, (2) their capacity needs and development, (3) their understanding and use of evidence from reviews of qualitative research and, (4) their overall views and experiences of the project. METHODS: We will use a longitudinal, mixed-methods study design, informed by an overarching project Theory of Change. A series of interconnected qualitative and quantitative data collections methods will be used, including knowledge translation tracking sheets and case studies, capacity assessment online surveys, user testing and in-depth interviews, and non-participant observations of project activities. Participants will comprise of project staff, members of the CPG panels and steering committees in Malawi, South Africa and Nigeria, as well as other local stakeholders in these three African countries. DISCUSSION: Ongoing monitoring and evaluation will help ensure the relationship between researchers and stakeholders is supported from the project start. This can facilitate achievement of common goals and enable researchers in South Africa, Malawi and Nigeria to make adjustments to project activities to maximize stakeholder engagement and research utilization. Ethical approval has been provided by South African Medical Research Council Human Research Ethics Committee (EC015-7/2022); The College of Medicine Research and Ethics Committee, Malawi (P.07/22/3687); National Health Research Ethics Committee of Nigeria (01/01/2007).
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Salud Infantil , Guías de Práctica Clínica como Asunto , Humanos , Recién Nacido , Lactante , Malaui , Preescolar , Sudáfrica , Nigeria , Medicina Basada en la Evidencia , Pobreza , Toma de Decisiones , Creación de Capacidad , Participación de los Interesados , Salud del Lactante , Práctica Clínica Basada en la Evidencia , Proyectos de Investigación , Evaluación de Programas y Proyectos de Salud , Servicios de Salud del Niño/normas , Servicios de Salud del Niño/organización & administraciónRESUMEN
BACKGROUND: Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient 'decision space' to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa. METHODS: This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system. RESULTS: Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity. CONCLUSIONS: By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability.
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Toma de Decisiones , Salud Pública , Sudáfrica , Humanos , Atención a la Salud , Sector PúblicoRESUMEN
BACKGROUND: Sub-Saharan Africa is the region with the highest under-five mortality rate globally. Child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step in this process was to identify national priorities for newborn and child health guideline development, and this paper describes our approach. METHODS: We followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. We established national Steering Groups (SG), comprising 10-13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with SGs where final priority topics were agreed. RESULTS: Based on survey results, nine, 10 and 11 topics were identified in SA, Malawi, and Nigeria respectively, which informed consensus meetings. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In SA, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants. CONCLUSIONS: Through dynamic and iterative stakeholder engagement, we identified three priority topics for guideline development on newborn and child health in SA, Malawi and Nigeria. Topics were specific to contexts, with no overlap, which highlights the importance of contextualised priority setting as well as of the relationships with key decisionmakers who help define the priorities.
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Cuidados Posteriores , Salud Infantil , Embarazo , Lactante , Femenino , Niño , Humanos , Recién Nacido , Preescolar , Nigeria , Malaui , Sudáfrica , Recien Nacido Prematuro , Alta del Paciente , Prioridades en SaludRESUMEN
BACKGROUND: Low and middle-income countries remain disproportionately affected by high rates of child mortality. Clinical practice guidelines are essential clinical tools supporting implementation of effective, safe, and cost-effective healthcare. High-quality evidence-based guidelines play a key role in improving clinical management to impact child mortality. We aimed to identify and assess the quality of guidelines for newborn and child health published in South Africa, Nigeria and Malawi in the last 5 years (2017-2022). METHODS: We searched relevant websites (June-July 2022), for publicly available national and subnational de novo or adapted guidelines, addressing newborn and child health in the three countries. Pairs of reviewers independently extracted information from eligible guidelines (scope, topic, target population and users, responsible developers, stakeholder consultation process, adaptation description, assessment of evidence certainty). We appraised guideline quality using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. RESULTS: We identified 40-guidelines from the three countries. Of these, 8/40 reported being adopted from a parent guideline. More guidelines (n = 19) provided guidance on communicable diseases than on non-communicable diseases (n = 8). Guidelines were most often developed by national health ministries (n = 30) and professional societies (n = 14). Eighteen guidelines reported on stakeholder consultation; with Nigeria (10/11) and Malawi (3/6) faring better than South Africa (5/23) in reporting this activity. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used in 1/7 guidelines that reported assessing certainty of evidence. Overall guidelines scored well on two AGREE II domains: scope and purpose median (IQR) score 68% (IQR 47-83), and clarity of presentation 81% (67-94). Domains critical for ensuring credible guidance scored below 20%: rigour of development 11% (4-32) and editorial independence 6% (0-27). CONCLUSION: National ministries and professional societies drive guideline activities in Malawi, Nigeria and South Arica. However, the methods and reporting do not adhere to global standards. We found low AGREE II scores for rigour of guideline development and editorial independence and limited use of GRADE or adaptation methods. This undermines the credibility of available guidelines to support evidence-informed care. Our findings highlight the importance of ongoing efforts to strengthen partnerships, capacity, and support for guideline development.
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Salud Infantil , Niño , Humanos , Recién Nacido , Malaui , Nigeria , Sudáfrica , Guías de Práctica Clínica como AsuntoRESUMEN
BACKGROUND: While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. METHODS: CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. RESULTS: CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. CONCLUSIONS: Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.
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Agentes Comunitarios de Salud , Investigación Participativa Basada en la Comunidad , Investigación sobre Servicios de Salud , Humanos , COVID-19/epidemiología , SudáfricaRESUMEN
[This corrects the article DOI: 10.1371/journal.pgph.0000323.].
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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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Investigación Participativa Basada en la Comunidad , Prioridades en Salud , Humanos , Sudáfrica , Investigación sobre Servicios de Salud , Salud PúblicaRESUMEN
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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COVID-19 , Humanos , Investigación sobre Servicios de Salud , Participación de la Comunidad , Atención Primaria de Salud , Sudáfrica , Agentes Comunitarios de SaludRESUMEN
BACKGROUND: Community knowledge is a critical input for relevant health programmes and strategies. How community perceptions of risk reflect the burden of mortality is poorly understood. OBJECTIVE: To determine the burden of mortality reflecting community-nominated health risk factors in rural South Africa, where a complex health transition is underway. METHODS: Three discussion groups (total 48 participants) representing a cross-section of the community nominated health priorities through a Participatory Action Research process. A secondary analysis of Verbal Autopsy (VA) data was performed for deaths in the same community from 1993 to 2015 (n = 14,430). Using population attributable fractions (PAFs) extracted from Global Burden of Disease data for South Africa, deaths were categorised as 'attributable at least in part' to community-nominated risk factors if the PAF of the risk factor to the cause of death was >0. We also calculated 'reducible mortality fractions' (RMFs), defined as the proportions of each and all community-nominated risk factor(s) relative to all possible risk factors for deaths in the population . RESULTS: Three risk factors were nominated as the most important health concerns locally: alcohol abuse, drug abuse, and lack of safe water. Of all causes of deaths 1993-2015, over 77% (n = 11,143) were attributable at least in part to at least one community-nominated risk factor. Causes of attributable deaths, at least in part, to alcohol abuse were most common (52.6%, n = 7,591), followed by drug abuse (29.3%, n = 4,223), and lack of safe water (11.4%, n = 1,652). In terms of the RMF, alcohol use contributed the largest percentage of all possible risk factors leading to death (13.6%), then lack of safe water (7.0%), and drug abuse (1.3%) . CONCLUSION: A substantial proportion of deaths are linked to community-nominated risk factors. Community knowledge is a critical input to understand local health risks.
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Salud Pública , Población Rural , Autopsia , Causas de Muerte , Humanos , Factores de Riesgo , Sudáfrica/epidemiologíaRESUMEN
BACKGROUND: In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services. OBJECTIVE: This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs). METHODS: Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically. RESULTS: There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders. CONCLUSION: Power and authority in decision-making, resources and accountability are key for effective community participation of marginalized people. Practical guidance is urgently required on how mandated participatory governance structures can be sustained and linked to wider governance systems to improve service delivery.
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Participación de la Comunidad , Recursos Hídricos , Humanos , Atención Primaria de Salud , Responsabilidad Social , SudáfricaRESUMEN
There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community 'voice' and initiating dialogue with the authorities, giving the voice 'teeth'. Achieving 'bite', however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative.
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Medicines have been re-purposed as therapeutics for COVID-19 and it is with great interest that we read the publication entitled, "Effects of Vitamin D Supplementation on COVID-19 Related Outcomes: A Systematic Review and Meta-Analysis" [...].
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COVID-19 , Humanos , Vitamina D/uso terapéutico , Suplementos Dietéticos , NutrientesRESUMEN
BACKGROUND: Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water. OBJECTIVE: This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa. METHOD: We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process. RESULTS: Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the functioning of other sectors and learning by doing were achieved. CONCLUSION: Our process reflected willingness and commitment among stakeholders to work together collectively addressing local water challenges. Location in an established public health observatory helped to create neutral, mediated spaces for participation.
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Salud Pública , Población Rural , Participación de la Comunidad , Humanos , Sudáfrica , Participación de los Interesados , AguaRESUMEN
BACKGROUND: Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme-a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa-for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance. METHODS: Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017-19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts. RESULTS: Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR stakeholders participating in routine health planning and review activities and frontline health officials being involved in the VAPAR process. Findings were collated into a revised theory of change. CONCLUSIONS: The VAPAR learning platform was regarded as a feasible, acceptable and relevant approach to facilitate cooperative learning and community participation in health systems. The evaluation provides support for a collaborative learning platform within routine health system processes and contributes to the limited evaluative evidence base on embedded health systems research.
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Prácticas Interdisciplinarias , Niño , Atención a la Salud , Investigación sobre Servicios de Salud , Humanos , Atención Primaria de Salud , SudáfricaRESUMEN
Background: Alcohol and other drug (AOD) abuse is a major public health challenge disproportionately affecting marginalised communities. Involving communities in the development of responses can contribute to acceptable solutions.Objectives: To: (1) document forms, processes, and contexts of engaging communities to nominate health concerns and generate new knowledge for action; (2) further build participation in the local health system by reflecting on and adapting the process.Methods: PAR was progressed with 48 community stakeholders across three rural villages in the MRC/Wits Agincourt Health and Socio Demographic Surveillance System (HDSS) in Mpumalanga, South Africa. A series of workshops explored community-nominated topics, systematised lived experience into shared accounts and considered actions to address problems identified. Photovoice was also used to generate visual evidence. Narrative and visual data were thematically analysed, situated within practice frameworks, and learning and adaption elicited.Results: AOD abuse was identified as a topic of high priority. It was understood as an entrenched social problem with destructive effects. Biopsychosocial impacts were mapped and related to unemployment, poverty, stress, peer pressure, criminal activity, corruption, and a proliferating number of taverns. Integrated action agendas were developed focussed on demand, supply, and harm reduction underpinned by shared responsibility among community, state, and non-state actors. Community stakeholders appreciated systematising and sharing knowledge, taking active roles, developing new skills in planning and public speaking, and progressing shared accountability processes. Expectations required sensitive management, however.Conclusion: There is significant willingness and capacity among community stakeholders to work in partnership with authorities to address priority health concerns. As a process, participation can help to raise and frame issues, which may help to better inform action and encourage shared responsibility. Broader understandings of participation require reference to, and ultimately transfer of power towards, those most directly affected, developing community voice as continuous processes within social and political environments.
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Alcoholismo/prevención & control , Investigación Participativa Basada en la Comunidad/organización & administración , Promoción de la Salud/organización & administración , Salud Pública/educación , Población Rural/estadística & datos numéricos , Trastornos Relacionados con Sustancias/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sudáfrica/epidemiologíaRESUMEN
INTRODUCTION: There is a growing recognition of the importance of developing learning health systems which can engage all stakeholders in cycles of evidence generation, reflection, action and learning from action to deal with adaptive problems. There is however limited evaluative evidence of approaches to developing or strengthening such systems, particularly in low-income and middle-income settings. In this protocol, we aim to contribute to developing and sharing knowledge on models of building collaborative learning platforms through our evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme. METHODS AND ANALYSIS: The evaluation takes a participatory approach, focussed on joint learning on whether and how VAPAR contributes to its aims, and what can be learnt for this and similar settings. A realist-informed theory of change was developed by the research team as part of a broader collaboration with other stakeholders. The evaluation will draw on a wide variety of perspectives and data, including programme data and secondary data. This will be supplemented by in-depth interviews and workshops at the end of each cycle to probe the different domains, understand changes to the positions of different actors within the local health system and feedback into improved learning and action in the next cycle. Quantitative data such as verbal autopsy will be analysed for significant trends in health indicators for different population groups. However, the bulk of the data will be qualitative and will be analysed thematically. ETHICS AND DISSEMINATION: Ethics in participatory approaches include a careful focus on the power relationships within the group, such that all groups are given voice and influence, in addition to the usual considerations of informed participation. Within the programme, we will focus on reflexivity, relationship building, two-way learning and learning from failure to reduce power imbalances and mitigate against a blame culture. Local engagement and change will be prioritised in dissemination.
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Autopsia/métodos , Programas de Gobierno , Investigación sobre Servicios de Salud , Aprendizaje , Humanos , SudáfricaRESUMEN
BACKGROUND: South Africa is a semiarid country where 5 million people, mainly in rural areas, lack access to water. Despite legislative and policy commitments to the right to water, cooperative governance and public participation, many authorities lack the means to engage with and respond to community needs. The objectives were to develop local knowledge on health priorities in a rural province as part of a programme developing community evidence for policy and planning. METHODS: We engaged 24 participants across three villages in the Agincourt Health and Socio-Demographic Surveillance System and codesigned the study. This paper reports on lack of clean, safe water, which was nominated in one village (n=8 participants) and in which women of reproductive age were nominated as a group whose voices are excluded from attention to the issue. On this basis, additional participants were recruited (n=8). We then held a series of consensus-building workshops to develop accounts of the problem and actions to address it using Photovoice to document lived realities. Thematic analysis of narrative and visual data was performed. RESULTS: Repeated and prolonged periods when piped water is unavailable were reported, as was unreliable infrastructure, inadequate service delivery, empty reservoirs and poor supply exacerbated by droughts. Interconnected social, behavioural and health impacts were documented combined with lack of understanding, cooperation and trust between communities and authorities. There was unanimity among participants for taps in houses as an overarching goal and strategies to build an evidence base for planning and advocacy were developed. CONCLUSION: In this setting, there is willingness among community stakeholders to improve water security and there are existing community assemblies to support this. Health and Socio-Demographic Surveillance Systems provide important opportunities to routinely connect communities to resource management and service delivery. Developing learning platforms with government and non-government organisations may offer a means to enable more effective public participation in decentralised water governance.