World Cafés as a participatory approach to understanding research agendas in primary care with underserved communities: reflections, challenges and lessons learned.

BACKGROUND: Certain communities are underserved by research, resulting in lower inclusion rates, under researched health issues and a lack of attention to how different communities respond to health interventions. Minoritised ethnic groups are often underserved by research and services. They experience health inequalities and face significant barriers to accessing health services. It is recognised that new approaches are needed to reach underserved communities and make research more relevant. The purpose of this work was to utilise World Cafés, a participatory method, to explore research agendas with diverse communities. METHODS: Two World Cafés were conducted as research agenda setting activities with individuals from minoritised ethnic communities in Bristol, UK. World Café 1 explored Black and Asian women's perspectives about supporting mental health. World Café 2 with men from the Somali community, focused on prostate cancer. Community members co-developed the focus and questions of each World Café and were also instrumental in recruiting individuals to the sessions and facilitating discussions, including translation. Audio and written records were made of the discussions and from these key issues about each topic were identified, and a visual representation of the discussion was also generated. These were shared with participants to check for accuracy. RESULTS: Community members identified a range of issues that are important to them in relation to mental health and prostate cancer, including barriers to help seeking and accessing primary and secondary care, ideas for service improvements and a need for health information that is accessible and culturally relevant. CONCLUSIONS: World Cafés are a flexible method that can be successfully adapted for research agenda setting with individuals from minoritised ethnic communities. The role of community members in co-developing the focus of sessions, recruiting community members and co-facilitating sessions is crucial to this success. The discussions at both World Cafés provided a rich insight into the experiences of participants in relation to the topics mental health and prostate cancer and identified issues that are important to these communities that will be followed-up with communities, researchers and clinicians to co-develop research and service improvement strategies.

People from minoritised ethnic groupsgroups can have difficulty getting health care. They may also be left out of health research. There is a need to include a more diverse group of people in health research. World Cafés are an accessible way to listen to people by getting them to talk to each other about different questions and topics.We did this work to see if World Cafés are a helpful way to talk to people from minoritised ethnic groups about health. We wanted to learn what things are important to people around mental health and prostate cancer. We also wanted to see if designing and running the World Café with people from the same communities as people taking part in the World Cafés is a good way to do this. We worked together with people from racial and ethnic minorities to: Choose questions and topics, Ask people to take part Get people talking and write down what was said We learned that planning and running World Cafés with people from the same communities as the people taking part was very helpful. The people taking part in the World Cafés said that it can be difficult to get help and information about their health. They gave lots of reasons for this. They also had ideas to improve healthcare.Now that we have this information, we will work with the people who took part in and helped run the World Cafés, along with, doctors and researchers to take their ideas for improvements forwards.

An Analysis of Power Dynamics Affecting Handwashing Interventions in Sierra Leone: Findings From a Qualitative Participatory Study.

BACKGROUND: Handwashing is an effective and cost-efficient health behavior for preventing infectious diseases; however, its practice is shaped by multiple contextual factors and inequalities between different social groups in Sierra Leone. To address these inequalities, participatory approaches that allow a more equitable distribution of resources and the development of locally tailored interventions are increasingly used. However, social power dynamics have not been well integrated into the concept of participation, despite their known impact. OBJECTIVE: We sought to investigate the role of power dynamics in participatory approaches to handwashing in Sierra Leone. METHODS: From a socio-ecological perspective, this qualitative, formative interview study aimed to identify relevant actors and their power relationships before designing a participatory handwashing project in rural Sierra Leone. A field experiment with focus groups and a research diary compared the development of power dynamics in a participatory, community-driven approach with that in a nonparticipatory top-down approach. RESULTS: According to our formative study, in community-based projects, multiple groups and actors interact directly or indirectly with each other, located within a macro level (eg, political institutions), meso level (eg, community leaders and groups), and micro level (eg, families) of a socio-ecological model. Although distinct leadership structures were noticeable and affected intervention attendance and processes of change in nonparticipatory approaches, community-led activities and handwashing increased in the participatory approach, irrespective of the leadership structure. Despite their ambivalence, the strategic inclusion of different community leaders appeared essential to enhance the value of the project, mobilize creative action, and empower lower-ranking individuals to practice handwashing. A similar ambivalent role could be observed in relation to external researchers, especially if they come from a different cultural background than the research participants, for example, from a Western country in a non-Western project setting. Although external researchers can initiate a project or provide certain resources, distinct expectations regarding their roles and resources can impact participatory efforts and power relations. CONCLUSIONS: The results highlight the advantages of participatory approaches for health promotion. Power dynamics should be a core component of continuous reflection and analysis in participatory projects.

Toward the economic evaluation of participatory approaches in health promotion: lessons from four German physical activity promotion projects.

Health promotion increasingly employs participatory approaches, but the question arises whether the likely higher costs of participation also translate into greater benefits. This article takes a first step toward a full health economic evaluation by comprehensively reporting the costs of a specific participatory approach, Cooperative Planning, in a German research consortium to promote physical activity. We conducted a costing analysis of Cooperative Planning at 22 sites across six settings. Project teams used a custom template to record resource use. We calculated average costs per meeting, site and setting using the opportunity costs approach, and obtained feedback from participating researchers. A total of 144 planning meetings with an average of nine participants were conducted. Costs per meeting varied significantly across settings. Differences were mostly attributable to varying meeting duration, preparation time and numbers of participants. Across settings, human resources accounted for roughly 95% of the costs. Implementing researchers reported challenges regarding the logic and methods of the health economic analysis. A participatory approach to physical activity promotion may cause substantially varying costs in different settings despite similar cost structures. However, their value for money could turn out comparably favorable if (and only if) the expected benefits is indeed forthcoming. Despite some challenges implementing the costing exercise into the logistics of ongoing participatory projects, this analysis may pave the way toward a full health economic evaluation, and the template may be useful to future participatory health promotion projects.

Socioeconomic assessment of the relevance of a community-based goat breeding project in smallholding systems.

In the last decade, community-based animal breeding programs have gained attention for the genetic improvement of small ruminants in the tropics. Nevertheless, implementing such programs remains challenged by the issue of smallholders' participation. To shed light on this issue of participation, a goat genetic improvement project has been assessed for its socioeconomic relevance through participatory methods, taking account of goat multifunctionality. We quantified the gross margins per flock and per animal as indicators of viability. We assessed then the correspondence between the goat functions defined through a proportional piling tool with the relative share of these functions in the gross revenue. For that purpose, 160 smallholders were surveyed and 77 among them were monitored for one year. A cluster analysis of factors linked to the dynamic of goat farming identified three groups of farmers. The first group gathered farmers with the smallest goat flocks, who were goat oriented in the future. Their sustainable participation in goat breeding project was impeded by the excessive sales of goats. The second group involved farmers with the highest farm size, who planned to buy cattle to replace part of their goats. The third group included farmers who were members of the project with the largest goat flocks. This group emphasized the importance of goat for their future but showed weak abilities to manage large flocks. The gross margin per animal was the highest in the third group. The relative importance of goat functions as defined through participatory tools did not correspond to the relative share of these functions in the composition of the gross revenue from goats. Participatory tools and economic calculation then appear as complementary to understand farmers' priorities. Consolidating breeders' associations and supporting farmers to diversify their sources of income are two ways proposed here to ensure an enabling environment to goat husbandry and farmers' well-being.

Framework for Participatory Quantitative Health Impact Assessment in Low- and Middle-Income Countries.

BACKGROUND: Conducting health impact assessments (HIAs) is a growing practice in various organizations and countries, yet scholarly interest in HIAs has primarily focused on the synergies between exposure and health outcomes. This limits our understanding of what factors influence HIAs and the uptake of their outcomes. This paper presents a framework for conducting participatory quantitative HIA (PQHIA) in low- and middle-income countries (LMICs), including integrating the outcomes back into society after an HIA is conducted. The study responds to the question: what are the different components of a participatory quantitative model that can influence HIA implementation in LMICs? METHODS: To build the framework, we used a case study from a PQHIA fieldwork model developed in Port Louis (Mauritius). To explore thinking on the participatory components of the framework, we extract and analyze data from ethnographic material including fieldnotes, interviews, focus group discussions and feedback exercises with 14 stakeholders from the same case study. We confirm the validity of the ethnographic data using five quality criteria: credibility, transferability, dependability, confirmability, and authenticity. We build the PQHIA framework connecting the main HIA steps with factors influencing HIAs. RESULTS: The final framework depicts the five standard HIA stages and summarizes participatory activities and outcomes. It also reflects key factors influencing PQHIA practice and uptake of HIA outcomes: costs for participation, HIA knowledge and interest of stakeholders, social responsibility of policymakers, existing policies, data availability, citizen participation, multi-level stakeholder engagement and multisectoral coordination. The framework suggests that factors necessary to complete a participatory HIA are the same needed to re-integrate HIA results back into the society. There are three different areas that can act as facilitators to PQHIAs: good governance, evidence-based policy making, and access to resources. CONCLUSIONS: The framework has several implications for research and practice. It underlines the importance of applying participatory approaches critically while providing a blueprint for methods to engage local stakeholders. Participatory approaches in quantitative HIAs are complex and demand a nuanced understanding of the context. Therefore, the political and cultural contexts in which HIA is conducted will define how the framework is applied. Finally, the framework underlines that participation in HIA does not need to be expensive or time consuming for the assessor or the participant. Yet, participatory quantitative models need to be contextually developed and integrated if they are to provide health benefits and be beneficial for the participants. This integration can be facilitated by investing in opportunities that fuel good governance and evidence-based policy making.

Utilizing an integrated assessment scheme for sustainable waste management in low and middle-income countries: Case studies from Bosnia-Herzegovina and Mozambique.

Solid waste management assessment methods that simultaneously analyze the economic, social and environmental dimensions are limited. Tools are rarely applied in developing countries because of several constraints encountered during their implementation (e.g. lack of data availability and difficulties concerning data interpretation), consequently hampering the development of sustainable solid waste management practices. In addition, the incorporation of stakeholders in most decision-making tools and processes, as well as the availability of credible data in developing countries is often limited. To address these issues, this paper presents one of the first large scale studies, utilizing a tool, named Integrated Assessment Scheme (IAS). Use of IAS provides a holistic, integrated approach evaluating the economic, environmental and social dimensions in order to support the decision making process and to facilitate more sustainable waste management in low and middle-income countries. The use of IAS in the two case studies from Bosnia-Herzegovina and Mozambique suggests its suitability to communities in similar contexts. However, its limitations are also discussed.

Re-thinking health literacy: using a capabilities approach perspective towards realising social justice goals.

Health literacy has gained popularity as a useful concept to promote and protect health. Even though health literacy research has been prolific it has also been fragmented, facing challenges in achieving its empowerment and social justice-related aims. Crucial limitations make the application of its principles to the health of vulnerable and underrepresented groups problematic, even though these groups are disproportionately affected by ill health. Efforts to refine and make the concept more relevant have tended to expand health literacy models and situate health literacy 'in context' to reflect environmental and social factors shaping health literacy. Context-related factors however, have not been consistently embedded in operationalisation and measurement efforts.This paper argues for health literacy to be re-conceptualised through a capabilities approach lens. It proposes that the capabilities approach can uniquely address the conceptual and methodological criticisms applied to health literacy, whilst encompassing its critical conceptual understandings of health. The advantage of this approach over and above other developments in health literacy theory and practice is its focus on both people's opportunities or freedoms to achieve desired health-related aims, and their ability to do so. It enables shifting the focus away from health literacy as individual skills and competencies and towards the enabling or inhibiting factors shaping health literacy. A participatory approach is seen as essential for realising this conceptual shift.

Planning for change: Transformation labs for an alternative food system in Cape Town, South Africa.

There has been a call for more participatory processes to feed into urban planning for more resilient food systems. This paper describes a process of knowledge co-production for transforming towards an alternative food system in Cape Town, South Africa. A 'transformative space' was created though a T-Lab process involving change-agents advocating for an alternative food system, and was designed to discuss challenges in the local food system from a range of perspectives, in order to co-develop potentially transformative innovations that could feed into government planning. In this paper, we describe and reflect on the T-lab in order to consider whether its design was able to meet its objective: to initiate an experimental phase of coalition-building by diverse actors that could feed into the provincial government's strategic focus on food and nutrition security. Our findings indicate that T-labs have the potential to be important mechanisms for initiating and sustaining transformative change. They can be complementary to urban planning processes seeking to transform complex social-ecological systems onto more sustainable development pathways. However, as with all experimental co-production processes, there is significant learning and refinement that is necessary to ensure the process can reach its full potential. A key challenge we encountered was how to foster diversity and difference in opinions in the context of significant historical legacies of inequality, whilst simultaneously acting for 'the common good' and seeking ways to scale impact across different contexts. The paper concludes with deliberations on the nature of planning and navigating towards systemic transformative change.

"Our voices matter": a before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya.

BACKGROUND: Community-participatory approaches are important for effective maternal and child health interventions. A community-participatory intervention (the Dialogue Model) was implemented in Kwale County, Kenya to enhance uptake of select maternal and child health services among women of reproductive age. METHODS: Community volunteers were trained to facilitate Dialogue Model sessions in community units associated with intervention health facilities in Matuga, Kwale. Selection of intervention facilities was purposive based on those that had an active community unit in existence. For each facility, uptake of family planning, antenatal care and facility-based delivery as reported in the District Health Information System (DHIS)-2 was compared pre- (October 2012 - September 2013) versus post- (January - December 2016) intervention implementation using a paired sample t-test. RESULTS: Between October 2013 and December 2015, a total of 570 Dialogue Model sessions were held in 12 community units associated with 10 intervention facilities. The median [interquartile range (IQR)] number of sessions per month per facility was 2 (1-3). Overall, these facilities reported 15, 2 and 74% increase in uptake of family planning, antenatal care and facility-based deliveries, respectively. This was statistically significant for family planning pre- (Mean (M) = 1014; Standard deviation (SD) = 381) versus post- (M = 1163; SD = 400); t (18) = - 0.603, P = 0.04) as well as facility-based deliveries pre- (M = 185; SD = 216) versus post- (M = 323; SD = 384); t (18) = - 0.698, P = 0.03). CONCLUSIONS: A structured, community-participatory intervention enhanced uptake of family planning services and facility-based deliveries in a rural Kenyan setting. This approach is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes.

Toilet training: what can the cookstove sector learn from improved sanitation promotion?

Within the domain of public health, commonalities exist between the sanitation and cookstove sectors. Despite these commonalities and the grounds established for cross-learning between both sectors, however, there has not been much evidence of knowledge exchange across them to date. Our paper frames this as a missed opportunity for the cookstove sector, given the capacity for user-centred innovation and multi-scale approaches demonstrated in the sanitation sector. The paper highlights points of convergence and divergence in the approaches used in both sectors, with particular focus on behaviour change approaches that go beyond the level of the individual. The analysis highlights the importance of the enabling environment, community-focused approaches and locally specific contextual factors in promoting behavioural change in the sanitation sector. Our paper makes a case for the application of such approaches to cookstove interventions, especially in light of their ability to drive sustained change by matching demand-side motivations with supply-side opportunities. Abbreviation: DALY: Disability-adjusted life year; CHC: Community Health Club; CLTS: Community-Led Total Sanitation; HAP: Household air pollution; BM-WASH: Integrated Behavioural Model for Water, Sanitation and Hygiene; ICS: Improved cookstove; LPG: Liquefied petroleum gas; NBA: Nirmal Bharat Abhiyan; NGO: Non:governmental organisation; OD: Open defecation; ODF: Open defecation free; HAST: Participatory Hygiene and Sanitation Transformation; RANAS: Risks, Attitudes, Norms, Abilities and Self-regulation RCT: Randomised controlled trial; (Sani) FOAM: Focus, Opportunity, Ability and Motivation; SBM: Swachh Bharat Mission; TSC: Total Sanitation Campaign; WASH: Water, Sanitation and Hygiene.

"Ways and channels for voice regarding perceptions of maternal health care services within the communities of the Makamba and Kayanza provinces in the Republic of Burundi: an exploratory study".

BACKGROUND: Increased availability of maternal health services alone does not lead to better outcomes for maternal health.The services need to be utilized first.One way to increase service utilization is to plan responsive health care services by taking into account the community's views or expressed needs. Burundi has a high maternal mortality ratio, and despite improvements in health infrastructure, skilled staff and the abolition of user fees for pregnant women,utilization of maternal health services remains low. Possible reasons for this include a lack of responsive healthcare services. An exploratory study was conducted in 2013 in two provinces of Burundi (Makamba and Kayanza), with the aim to collect the experiences of women and men with the maternal health services,their views regarding those services, channels used to express these experiences, and the providers' reaction. METHODS: Semi-structured interviews were used to collect data from men and women and key informants, including community health workers, health committee members, health providers, local authorities, religious leaders and managers of non-governmental organizations. Data analysis was facilitated by MAXQDA 11 software. RESULTS: Negative experiences with maternal health services were reported and included poor staff behavior towards women and a lack of medicine. Health committees and suggestion boxes were introduced by the government to channel the community's views. However, they are not used by the community members, who prefer to use community health workers as intermediaries. Fear of expressing oneself linked to the post-war context of Burundi, social and gender norms, and religious norms limit the expression of community members' views, especially those of women. The limited appreciation of community health workers by the providers further hampers communication and acceptance of the community's views by health providers. CONCLUSION: In Burundi, the community voice to express views on maternal health services is encountering obstacles and needs to be strengthened,especially the women's voice. Community mobilization in the form of a mass immunization campaign day organized by women fora, and community empowerment using participatory approaches could contribute towards community voice strengthening.

Using a quality improvement approach to improve maternal and neonatal care in North Kivu, Democratic Republic of Congo.

Providing quality health care services in humanitarian settings is challenging due to population displacement, lack of qualified staff and supervisory oversight, and disruption of supply chains. This study explored whether a participatory quality improvement (QI) intervention could be used in a protracted conflict setting to improve facility-based maternal and newborn care. A longitudinal quasi-experimental design was used to examine delivery of maternal and newborn care components at 12 health facilities in eastern Democratic Republic of Congo. Study facilities were split into two groups, with both groups receiving an initial "standard" intervention of clinical training. The "enhanced" intervention group then applied a QI methodology, which involved QI teams in each facility, supported by coaches, testing small changes to improve care. This paper presents findings on two of the study outcomes: delivery of active management of the third stage of labour (AMTSL) and essential newborn care (ENC). We measured AMTSL and ENC through exit interviews with post-partum women and matched partographs at baseline and endline over a 9-month period. Using generalised equation estimation models, the enhanced intervention group showed a greater rate of change than the control group for AMTSL (aOR 3.47, 95% CI: 1.17-10.23) and ENC (OR: 49.62, 95% CI: 2.79-888.28), and achieved 100% ENC completion at endline. This is one of the first studies where this QI methodology has been used in a protracted conflict setting. A method where health staff take ownership of improving care is of even greater value in a humanitarian context where external resources and support are scarce.

"Freedom to go where I want": improving access to sexual and reproductive health for women with disabilities in the Philippines.

Women with disabilities experience a range of violations of their sexual and reproductive rights. The Philippines ratified the United Nations Convention on the Rights of Persons with Disabilities and have laws in place to promote the rights to sexual and reproductive health and protection from violence. However, limited resourcing, and opposition to such laws undermine access to these rights for all women. Inadequate disability inclusion within policy and programming, and limited disability awareness of services, further impedes women with disabilities from attaining these rights. The W-DARE project (Women with Disability taking Action on REproductive and sexual health) was a three-year participatory action research program designed to (1) understand the sexual and reproductive health experiences and needs of women with disabilities; and (2) improve access to quality sexual and reproductive health, including violence response services, for women with disabilities in the Philippines. In response to the highlighted need for more information about sexual and reproductive health and greater access to services, the W-DARE team developed and implemented a pilot intervention focused on peer-facilitated Participatory Action Groups (PAGs) for women with disabilities. This paper focuses on the qualitative findings from the evaluation of this PAG intervention.

Social life cycle assessment and participatory approaches: A methodological proposal applied to citrus farming in Southern Italy.

UNLABELLED: Recently, Social Life Cycle Assessment (S-LCA) has been developed under the methodological framework of Life Cycle Thinking (LCT) to evaluate the social impacts that emerge during the overall life cycle of a product or service. There is not yet a standardized methodology for S-LCA as there is for environmental LCA (eLCA), due to the nature of social impacts that do not depend only on the processes themselves, but also on the behavior and context of actors (manufactures, consumers, local community members, etc.). One of the most critical steps in the application of S-LCA concerns the choice of criteria for selecting affected actors, impact categories, subcategories, and the taxonomic relation among them. Moreover, the importance (in terms of weight) of these impacts may be felt differently by affected actors, confirming the importance of the context within which impacts arise. In this sense, the integration of participatory tools can be useful in making the S-LCA more locally relevant. The aim of the present study is twofold. First, we will outline a methodology that combines S-LCA with two research tools. The first is the focus group, adopted from qualitative research. The second is the Analytic Hierarchy Process (AHP), adopted from operational research, which belongs to the framework of Multicriteria Decision Analysis (MCDA). These have been used to make the S-LCA more locally relevant and to legitimate the criteria used. Second, we will test this methodology by applying it to a specific field, i.e., 3 production areas and 3 different crop systems of citrus growing in the Calabria region in Southern Italy. Citrus growing is one of the most important agricultural sectors at regional level, and it is also well known for issues of social concern, particularly in relation to immigrant workers. The results show a number of differences between cases and could offer useful insights to both local decision makers, such as agricultural entrepreneurs, and to those public decision makers that design and implement territorial planning strategies. Results have allowed the authors to rank the social performance of each case and to reflect on the most critical steps in conducting an S-LCA. KEY FINDINGS: The integration of qualitative techniques and a multicriteria in sLCA allows catching local specificities by involving local experts and stakeholders Results highlighted that impact categories mostly contributed to performance differences Public deciders can be supported in deciding which farming practices should be encouraged, which social domains must be paid more attention, and where social problems mostly occur The methodological application allowed the authors also to foresee the feasibility of the integration of LCA and LCC results as inputs in sLCA to conduct a Life Cycle Sustainability Assessment (LCSA).

Stakeholder engagement in scenario development process - bioenergy production and biodiversity conservation in eastern Finland.

In this study participatory approaches were used to develop alternative forest resource management scenarios with particular respect to the effects on increased use of forest bioenergy and its effect on biodiversity in Eastern Finland. As technical planning tools, we utilized a forest management planning system (MELA) and the Tool for Sustainability Impact Assessment (ToSIA) to visualize the impacts of the scenarios. We organized a stakeholder workshop where group discussions were used as a participatory method to get the stakeholder preferences and insights concerning forest resource use in the year 2030. Feedback from the workshop was then complemented with a questionnaire. Based on the results of the workshop and a questionnaire we developed three alternative forest resource scenarios: (1) bioenergy 2030 - in which energy production is more centralized and efficient; (2) biodiversity 2030 - in which harvesting methods are more nature friendly and protected forests make up 10% of the total forest area; and (3) mixed bioenergy + biodiversity 2030 scenario - in which wood production, recreation and nature protection are assigned to the most suitable areas. The study showed that stakeholder engagement combined with the MELA and ToSIA tools can be a useful approach in scenario development.