Power imbalances and equity in the day-to-day functioning of a north plus multi-south higher education institutions partnership: a case study.

BACKGROUND: Partnerships between Higher Education Institutions (HEIs) in the global north and south have commonly been used as a vehicle to drive global health research and initiatives. Among these initiatives, include health system strengthening, research capacity building, and human resource training in developing countries. However, the partnership functioning of many global north-south partnerships still carry legacies of colonialism through unrecognized behavior patterns, attitudes, and belief systems in how they function. Even with research literature calling for a shift from equality to equity in the functioning of these partnerships, many still struggle with issues of complex and unspoken power dynamics. To understand the successes and challenges of north-south partnerships, this paper explored partnership development and functioning of a northern and multi-southern HEIs partnership focused on nutrition education and research. METHODS: A qualitative research approach was used; data were collected through in-depth interviews (IDIs) with questions developed from the Bergen Model of Collective Functioning (BMCF). Thirteen IDIs were conducted with partners from all institutions including stakeholders. FINDINGS: The partnership was built on the foundation of experiences and lessons of a previous partnership. Partners used these experiences and lessons to devise strategies to improve partnership inputs, communication, leadership, roles and structures, and maintenance and communication tasks. However, these strategies had an impact on partnership functioning giving rise to issues of inequitable power dynamics. The northern partner had two roles: one as an equal partner and another as distributor of project funds; this caused a conflict in roles for this partner. The partners distinguished themselves according to partner resources - two partners were named implementing partners and two named supportive partners. Roles and partner resources were the greatest contributors to power imbalances and caused delays in project activities. CONCLUSION: Using the BMCF to examine partnership dynamics illuminated that power imbalances caused a hierarchical stance in the partnership with northern partners having overall control and power of decision-making in the partnership. This could impact the effectiveness and sustainability of project in the southern institutions going forward.

Wellbeing as a policy framework for health promotion and sustainable development.

For years Gross Domestic Product (GDP) has served as a key indicator of human progress and "successful" societies. Unfortunately, GDP has failed to robustly capture the human experience or predict resilience through crises; and obscures the presence of inequity -- a key determinant of suffering. It is clear the global community needs a new organizing principle: one that envisions and measures progress by focusing on the conditions that support health, resilience, and overall wellbeing. This paper examines key health promotion concepts and approaches, juxtaposed with philosophical underpinnings of the concept of wellbeing, alternative measurement strategies, and examples of wellbeing policy initiatives. In doing so, the paper highlights the relevance of wellbeing policy frameworks to health promotion, the utility of health promotion strategies for implementing wellbeing policy frameworks, and controversies and pitfalls that require consideration. The paper concludes by outlining how health promotion is uniquely poised to contribute to wellbeing policy frameworks that promote the sources of human and planetary thriving through sustainable development, and that promoting a wellbeing agenda can strengthen efforts to promote health by addressing social determinants and ensuring universal access to resources that support coping with emerging challenges and strengthen resilience.

A health promotion approach to emergency management: effective community engagement strategies from five cases.

Community engagement is crucial for controlling disease outbreak and mitigating natural and industrial disasters. The COVID-19 pandemic has reconfirmed the need to elevate community engagement to build equity, trust and sustained action in future health promotion preparedness strategies. Using the health promotion strategy of strengthening community action enhances the opportunity for better outcomes. There is, therefore, a need to improve our understanding of community engagement practices during crises, scale-up good community engagement initiatives, and improve and sustain people-centered approaches to emergency responses. This paper presents five case studies from the United States, Singapore, Sierra Leone, Kenya and South Africa that demonstrate the potential strengths that can be nurtured to build resilience in local communities to help mitigate the impact of disasters and emergencies. The case studies highlight the importance of co-developing relevant education and communication strategies, amplifying the role of community leaders, empowering community members to achieve shared goals, assessing and adapting to changing contexts, pre-planning and readiness for future emergencies and acknowledgement of historic context.

Re-envisioning health promotion: Thinking and acting salutogenically towards equity for historically resilient communities.

This paper explores how the salutogenic theory can enable us to re-envision health promotion work with marginalized communities, towards an approach that acknowledges and honours their resilience. We use the three core concepts in Antonovsky's salutogenic model of health - sense of coherence, generalized resistance resources and specific resistance resources - to explore the theory's relevance to health equity, thus presenting new opportunities for how we might radically re-evaluate current health promotion approaches. We conclude that a more equitable health promotion requires increased participation of marginalized communities in shaping their futures and suggest a new model for historically grounded salutogenic health promotion.

Dismantling historical power inequality through authentic health research collaboration: Southern partners' aspirations.

Several health research organisations whose work focuses on international collaboration outline guidelines that support ethical practice in health research partnerships including building consensus around good collaborative research practice. This paper explores researcher's perspectives, experiences, and reflections on the elements of successful health research partnerships between Northern and Southern countries/institutions. The study adopted a qualitative research approach using in-depth interviews to explore what an authentic partnership is as experienced and aspired by stakeholders in health research partnerships in Zambia. Interviews were conducted with stakeholders implementing various health research activities in the country. Our findings revealed that Southern partners aspired for equal status and participation, transparency, and accountability, interdependency, and reciprocity, commitment to shared goals, open dialogue and sustainability in partnerships. While to some extent these aspirations overlap with the categories covered throughout the different partnership guidelines, some key aspects go beyond what is included in existing recommendations such as status and recognition which are salient in the broader guidelines. An important aspect in dismantling power structures that causes inequality in partnerships is through generating knowledge and innovation using local resources in the South to address local needs which can be subsequently re-used to address challenges at the global level.

Black Lives Matter in health promotion: moving from unspoken to outspoken.

Racism is a public health crisis. Black communities (including Africans, the African diaspora and people of African descent) experience worse health outcomes as demonstrated by almost any measure of health and wellbeing-e.g. life expectancy; disease prevalence; maternal mortality rates. While health promotion has its foundation in promoting equity and social justice, it is clear that however well-intended, we are not affecting meaningful change for Black communities quickly enough. Through this article, we outline the intersection of social determinants of health and anti-Black racism. We describe how in the first 8 months of 2020 Black communities around the globe have been disproportionately affected by COVID-19, while also having to respond to new instances of police brutality. We assert that the time has come for health promotion to stop neutralizing the specific needs of Black communities into unspoken 'good intentions'. Instead, we offer some concrete ways for the field to become outspoken, intentional and honest in acknowledging what it will take to radically shift how we promote health and wellbeing for Black people.

Contemporary issues in north-south health research partnerships: perspectives of health research stakeholders in Zambia.

BACKGROUND: The late 1990s and early 2000s have seen a growth in north-south health research partnerships resulting from scientific developments such as those in genetic studies and development of statistical techniques and technological requirements for the analysis of large datasets. Despite these efforts, there is inadequate information representing the voice of African researchers as stakeholders experiencing partnership arrangements, particularly in Zambia. Furthermore, very little attention has been paid to capturing the practice of guidelines within partnerships. In this paper, we present achievements and highlight challenges faced by southern partners in north-south health research partnerships. METHODS: A qualitative inquiry was employed using in-depth interviews developed using the Bergen Model of Collaborative Functioning with 20 key informants in Lusaka district in Zambia purposively sampled from a wide range of health research partnerships. RESULTS: Partnerships produce benefits for southern partners, including evidence generation to influence policy, improved service delivery, infrastructure development and designing interventions to improve the healthcare of populations in greatest need. Most importantly, through partnerships, there is availability of financial resources to accomplish partnership goals. For success to be achieved, there must be effective communication and leadership, values and accountability that go into the process of partnership functioning. Trust interacts with different elements that create partnerships where there is co-ownership of study rewards. Challenging aspects of the interaction are largely due to funding mechanisms where 90% of the funding for health research is from northern partners. This funding mechanism results in power imbalances that lead to publication challenges, dictation of research agenda and ownership of samples and data leading to a general lack of motivation to collaborate. CONCLUSION: Mistrust has implications on joint working such that partners find it difficult to work together and produce results greater than their individual efforts. Property rights and resource sharing must be resolved early in the partnership and each partner's contributions recognised. These findings highlight areas that partnerships need to focus on to make the most of guidelines on research partnership with developing countries.

Sustainable development goals for health promotion: a critical frame analysis.

The Sustainable Development Goals (SDGs) lay the foundations for supporting global health and international development work for the next 15 years. Thirty years ago, the Ottawa Charter defined health promotion and outlined key principles for global action on health, including the importance of advocating, enabling and mediating for health equity. Advocacy underscores a human right to health and suggests political action to support its attainment. Enabling speaks to health promotion's focus on the empowerment of people and communities to take control over their health and aspirations. Mediation draws attention to the critical intersectoral partnerships required to address health and social inequities. Underpinned by this approach, the aim of this paper is to consider how key health promotion principles, namely, rights, empowerment and partnership feature (and are framed) within the SDGs and to consider how these framings may shape future directions for health promotion. To that end, a critical frame analysis of the Transforming Our World document was conducted. The analysis interrogated varying uses and meanings of partnerships, empowerment and rights (and their connections) within the SDGs. The analysis here presents three framings from the SDGs: (1) a moral code for global action on (in)equity; (2) a future orientation to address global issues yet devoid of history; and (3) a reductionist framing of health as the absence of disease. These framings raise important questions about the underpinning values of the SDGs and pathways to health equity - offering both challenges and opportunities for defining the nature and scope of health promotion.

What makes intersectoral partnerships for health promotion work? A review of the international literature.

A Health in All Policies approach requires creating and sustaining intersectoral partnerships for promoting population health. This scoping review of the international literature on partnership functioning provides a narrative synthesis of findings related to processes that support and inhibit health promotion partnership functioning. Searching a range of databases, the review includes 26 studies employing quantitative (n = 8), qualitative (n = 10) and mixed method (n = 8) designs examining partnership processes published from January 2007 to June 2015. Using the Bergen Model of Collaborative Functioning as a theoretical framework for analyzing the findings, nine core elements were identified that constitute positive partnership processes that can inform best practices: (i) develop a shared mission aligned to the partners' individual or institutional goals; (ii) include a broad range of participation from diverse partners and a balance of human and financial resources; (iii) incorporate leadership that inspires trust, confidence and inclusiveness; (iv) monitor how communication is perceived by partners and adjust accordingly; (v) balance formal and informal roles/structures depending upon mission; (vi) build trust between partners from the beginning and for the duration of the partnership; (vii) ensure balance between maintenance and production activities; (viii) consider the impact of political, economic, cultural, social and organizational contexts; and (ix) evaluate partnerships for continuous improvement. Future research is needed to examine the relationship between these processes and how they impact the longer-term outcomes of intersectoral partnerships.

An Ecological Understanding of Caregiver Experiences in Palliative Care.

Palliative care is specialized health care to improve quality of life for patients with serious illness and their families through prevention and relief of suffering. A Palliative Care Institute was held in western Washington to capture community voices about diverse needs, strengths, and opportunities for improvement of palliative care. Researchers employed qualitative methods to obtain thematic data, provide real-time analysis, and engage in a multivoting technique to reflect stakeholder interest in individual themes and prioritize larger group interests. Bronfenbrenner's ecological systems framework was used to explore caregiver experiences. Within the microsystem, caregivers reported difficulties in interactions with medical providers as a key challenge. Within the mesosysytem, interactions between patients and medical providers and the impact on caregivers were explored. Within the exosystem, caregivers reported lack of control over the schedules of personal care staff. Macrosystem influences included impact of local culture on the development of palliative care services. Chronosystem influences include de-medicalization of childbirth and its impact on perceptions of palliative care. Implications include the need for social workers to be proactive in fostering trust and effective communication between care providers and caregivers, and the demand for health care provider training in communication with patients and families.

Grassroots volunteers in context: rewarding and adverse experiences of local women working on HIV and AIDS in Kilimanjaro, Tanzania.

Many nongovernmental organizations in Africa rely on grassroots volunteers to provide critical health services. Considering context and the interplay of individual, organizational, and societal influences on the experience of volunteers, this paper addresses three questions: What do grassroots volunteers contribute? What organizational processes promote volunteer engagement? What are the positive and negative consequences of volunteering? Eighteen members and staff of the Tanzanian HIV and AIDS NGO, KIWAKKUKI, were selected from 6000+ women volunteers to be interviewed. The interviews were recorded, transcribed, and analyzed for themes. Within KIWAKKUKI, volunteers contributed time and local knowledge, leading to an indigenous educational approach building on local norms and customs. Volunteers' engagement was motivated by the desire to support family members, reverse stigma, and work/socialize with other women. Benefits to volunteers included skills acquisition and community recognition; yet some volunteers also reported negative experiences including burnout, conferred stigma, and domestic violence. Positive organizational processes built on cultural practices such as collective decision-making and singing. The findings point to important considerations about context, including the synergistic effect training can have on local traditions of caring, complications of gender inequity, and how community health planning processes may need to be modified in extremely poor settings. This research also suggests good utility of the research framework (the Bergen Model of Collaborative Functioning) that was used to analyze volunteer engagement for service delivery in sub-Saharan contexts.

Evaluation of a community-academic partnership: lessons from Latinos in a network for cancer control.

Established in 2002, Latinos in a Network for Cancer Control is a community-academic network supported by the Centers for Disease Control and Prevention and the National Cancer Institute. The network includes >130 individuals from 65 community and academic organizations committed to reducing cancer-related health disparities. Using an empirically derived systems model--the Bergen Model of Collaborative Functioning--as the analytic frame, we interviewed 19 partners to identify challenges and successful processes. Findings indicated that sustained partner interaction created "meaningful relationships" that were routinely called on for collaboration. The leadership was regarded positively on vision, charisma, and capacity. Limitations included overreliance on a single leader. Suggestions supported more delegation of decision making, consistent communication, and more equitable resource distribution. The study highlighted new insights into dynamics of collaboration: Greater inclusiveness of inputs (partners, finances, mission) and loosely defined roles and structure produced strong connections but less network-wide productivity (output). Still, this profile enabled the creation of more tightly defined and highly productive subgroups, with clear goals and roles but less inclusive of inputs than the larger network. Important network outputs included practice-based research publications, cancer control intervention materials, and training to enhance the use of evidence-based interventions, as well as continued and diversified funding.

Mapping synergy and antagony in North-South partnerships for health: a case study of the Tanzanian women's NGO KIWAKKUKI.

North-South partnerships for health aim to link resources, expertise and local knowledge to create synergy. The literature on such partnerships presents an optimistic view of the promise of partnership on one hand, contrasted by pessimistic depictions of practice on the other. Case studies are called for to provide a more intricate understanding of partnership functioning, especially viewed from the Southern perspective. This case study examined the experience of the Tanzanian women's NGO, KIWAKKUKI, based on its long history of partnerships with Northern organizations, all addressing HIV/AIDS in the Kilimanjaro region. KIWAKKUKI has provided education and other services since its inception in 1990 and has grown to include a grassroots network of >6000 local members. Using the Bergen Model of Collaborative Functioning, the experience of KIWAKKUKI's partnership successes and failures was mapped. The findings demonstrate that even in effective partnerships, both positive and negative processes are evident. It was also observed that KIWAKKUKI's partnership breakdowns were not strictly negative, as they provided lessons which the organization took into account when entering subsequent partnerships. The study highlights the importance of acknowledging and reporting on both positive and negative processes to maximize learning in North-South partnerships.