Addressing diversity and complexity in the community engagement literature: The rationale for a realist review.

In this research note we reflect on our failed attempt to synthesize the community engagement literature through a standard systematic review and explain our rationale for now embarking on a realist synthesis of community engagement in global health research. We believe this paper will be helpful for many who grapple with the lack of clarity about community engagement's core elements and mechanisms.

The role of community engagement in the adoption of new agricultural biotechnologies by farmers: the case of the Africa harvest tissue-culture banana in Kenya.

BACKGROUND: The tissue culture banana (TCB) is a biotechnological agricultural innovation that has been adopted widely in commercial banana production. In 2003, Africa Harvest Biotech Foundation International (AH) initiated a TCB program that was explicitly developed for smallholder farmers in Kenya to help them adopt the TCB as a scalable agricultural business opportunity. At the heart of the challenge of encouraging more widespread adoption of the TCB is the question: what is the best way to introduce the TCB technology, and all its attendant practices and opportunities, to smallholder farmers. In essence, a challenge of community or stakeholder engagement (CE). RESULTS: In this paper, we report the results of a case study of the CE strategies employed by AH to introduce TCB agricultural practices to small-hold farmers in Kenya, and their impact on the uptake of the TCB, and on the nature of the relationship between AH and the relevant community of farmers and other stakeholders. We identified six specific features of CE in the AH TCB project that were critical to its effectiveness: (1) adopting an empirical, "evidence-based" approach; (2) building on existing social networks; (3) facilitating farmer-to-farmer engagement; (4) focusing engagement on farmer groups; (5) strengthening relationships of trust through collaborative experiential learning; and (6) helping farmers to "learn the marketing game". We discuss the implications of AH's "values-based" approach to engagement, and how these guiding values functioned as "design constraints" for the key features of their CE strategy. And we highlight the importance of attention to the human dimensions of complex partnerships as a key determinant of successful CE. CONCLUSION: Our findings suggest new ways of conceptualizing the relationship between CE and the design and delivery of new technologies for global health and global development.

Medical Council of India's amended qualifications for Indian medical teachers: Well intended, yet half-hearted.

The Medical Council of India (MCI) must be commended for its efforts to introduce definitive criteria for appointments and promotions for teachers in medical institutions. On June 8, 2017, the MCI issued a circular to amend the Minimum Qualifications for Teachers in Medical Institutions Regulations, 1998 (henceforth Regulations, 1998). The amendment clarifies the minimum qualifications required for various postgraduate teaching positions in medical colleges. It indicates MCI's sustained engagement with qualifications of teachers in medical colleges, with the aim of enhancing the quality of teaching and thereby the quality of medical professionals passing out. However, we believe that these efforts continue to be inadequate in addressing the varied issues that face medical education and the educators in India.

Considering risk contexts in explaining the paradoxical HIV increase among female sex workers in Mumbai and Thane, India.

BACKGROUND: The period 2006-2009 saw intensive scale-up of HIV prevention efforts and an increase in reported safer sex among brothel and street-based sex workers in Mumbai and Thane (Maharashtra, India). Yet during the same period, the prevalence of HIV increased in these groups. A better understanding of sex workers' risk environment is needed to explain this paradox. METHODS: In this qualitative study we conducted 36 individual interviews, 9 joint interviews, and 10 focus group discussions with people associated with HIV interventions between March and May 2012. RESULTS: Dramatic changes in Mumbai's urban landscape dominated participants' accounts, with dwindling sex worker numbers in traditional brothel areas attributed to urban restructuring. Gentrification and anti-trafficking efforts explained an escalation in police raids. This contributed to dispersal of sex work with the sex-trade management adapting by becoming more hidden and mobile, leading to increased vulnerability. Affordable mobile phone technology enabled independent sex workers to trade in more hidden ways and there was an increased dependence on lovers for support. The risk context has become ever more challenging, with animosity against sex work amplified since the scale up of targeted interventions. Focus on condom use with sex workers inadvertently contributed to the diversification of the sex trade as clients seek out women who are less visible. Sex workers and other marginalised women who sell sex all strictly prioritise anonymity. Power structures in the sex trade continue to pose insurmountable barriers to reaching young and new sex workers. Economic vulnerability shaped women's decisions to compromise on condom use. Surveys monitoring HIV prevalence among 'visible' street and brothel-bases sex workers are increasingly un-representative of all women selling sex and self-reported condom use is no longer a valid measure of risk reduction. CONCLUSIONS: Targeted harm reduction programmes with sex workers fail when implemented in complex urban environments that favour abolition. Increased stigmatisation and dispersal of risk can no longer be considered as unexpected. Reaching the increasing proportion of sex workers who intentionally avoid HIV prevention programmes has become the main challenge. Future evaluations need to incorporate building 'dark logic' models to predict potential harms.

Is scale-up of community mobilisation among sex workers really possible in complex urban environments? The case of Mumbai, India.

BACKGROUND: In the last decade, community mobilisation (CM) interventions targeting female sex workers (FSWs) have been scaled-up in India's national response to the HIV epidemic. This included the Bill and Melinda Gates Foundation's Avahan programme which adopted a business approach to plan and manage implementation at scale. With the focus of evaluation efforts on measuring effectiveness and health impacts there has been little analysis thus far of the interaction of the CM interventions with the sex work industry in complex urban environments. METHODS AND FINDINGS: Between March and July 2012 semi-structured, in-depth interviews and focus group discussions were conducted with 63 HIV intervention implementers, to explore challenges of HIV prevention among FSWs in Mumbai. A thematic analysis identified contextual factors that impact CM implementation. Large-scale interventions are not only impacted by, but were shown to shape the dynamic social context. Registration practices and programme monitoring were experienced as stigmatising, reflected in shifting client preferences towards women not disclosing as 'sex workers'. This combined with urban redevelopment and gentrification of traditional red light areas, forcing dispersal and more 'hidden' ways of solicitation, further challenging outreach and collectivisation. Participants reported that brothel owners and 'pimps' continued to restrict access to sex workers and the heterogeneous 'community' of FSWs remains fragmented with high levels of mobility. Stakeholder engagement was poor and mobilising around HIV prevention not compelling. Interventions largely failed to respond to community needs as strong target-orientation skewed activities towards those most easily measured and reported. CONCLUSION: Large-scale interventions have been impacted by and contributed to an increasingly complex sex work environment in Mumbai, challenging outreach and mobilisation efforts. Sex workers remain a vulnerable and disempowered group needing continued support and more comprehensive services.

SEARCH's HBNC trial: towards a broader debate on the ethics of social intervention research.

The SEARCH home-based neonatal care (HBNC) trial generated a heated debate amongst health activists, researchers and demographers in India upon its publication in the Lancet in 1999. More than a decade after the Lancet article, a new debate has been sparked, this time on the ethics of the study. Against this backdrop, we identify three key questions which require in-depth discussion. First, was the choice of the study design (cluster nonrandomised control trial), appropriate given the circumstances relating both to the study site and the locale? Second, was it ethical not to offer any intervention to the control units given that a known treatment existed? Third, do contemporary research ethics guidelines satisfactorily address all the ethical issues related to the study design? This paper examines the first question. We draw three main conclusions from this critical appraisal of the HBNC trial. First, the study design of the trial is motivated by the paradigm of evidence-based programmes and policy formulation. Second, generally speaking, the HBNC study design passes the internal and external validity tests but raises important ethical questions. Third, these questions transcend the HBNC trial to apply to many other social and health interventions studies; as such, the HBNC trial should be studied as a paradigmatic case.

Aligning community engagement with traditional authority structures in global health research: a case study from northern Ghana.

Despite the recognition of its importance, guidance on community engagement practices for researchers remains underdeveloped, and there is little empirical evidence of what makes community engagement effective in biomedical research. We chose to study the Navrongo Health Research Centre in northern Ghana because of its well-established community engagement practices and because of the opportunity it afforded to examine community engagement in a traditional African setting. Our findings suggest that specific preexisting features of the community have greatly facilitated community engagement and that using traditional community engagement mechanisms limits the social disruption associated with research conducted by outsiders. Finally, even in seemingly ideal, small, and homogeneous communities, cultural issues exist, such as gender inequities, that may not be effectively addressed by traditional practices alone.

The origins of a research community in the Majengo Observational Cohort Study, Nairobi, Kenya.

BACKGROUND: Since the 1980s the Majengo Observational Cohort Study (MOCS) has examined sexually transmitted infections, in particular HIV/AIDS, in a cohort of sex workers in Majengo, an impoverished urban village in Nairobi, Kenya. The MOCS investigators have faced criticism since the women have remained in the sex trade for the duration of their participation in the study, prompting concerns about exploitation. Yet despite these concerns, the cohort has survived for almost 30 years. METHODS: In this retrospective qualitative case study, we examine the community engagement practices of the MOCS and explore the factors that account for its durability. RESULTS: Women in sex work in Kenya were a highly stigmatized and disfranchised community. As a result, there was no natural 'community' of sex workers either in Nairobi or in the Majengo village. The Majengo clinic aimed to reduce the barriers to health care the women experienced at the STC clinic by bringing the services closer to them and by providing a non-discriminatory environment. The women acknowledged the fact they had hoped their participation in the MOCS would have helped them find a path out of the sex trade. But our findings also add another dimension to this debate, since every cohort member we interviewed expressed her gratitude for the deep impact the MOCS has had on her life, much of it beyond the improved health status made possible by access to quality healthcare services. Participation in the MOCS has improved and enriched their lives. The CE activities have played a central role in creating a community that did not exist independently of the MOCS. CONCLUSIONS: Our case study identified 3 distinct phases of community engagement in the MOCS: (1) reaching out: mobilization, dialogue and education; (2) foundations of trust through relationships of care; and (3) leveraging existing social capital to form a cohort community. The findings demonstrate the importance of some of the less obvious benefits of participation in research, namely the evolving experience of community and the accompanying gains in personal security and solidarity that have kept the women in the cohort, some for 20 years or more.

'Relief of oppression': an organizing principle for researchers' obligations to participants in observational studies in the developing world.

BACKGROUND: A central question in the debate about exploitation in international research is whether investigators and sponsors from high-income countries (HIC) have obligations to address background conditions of injustice in the communities in which they conduct their research, beyond the healthcare and other research-related needs of participants, to aspects of their basic life circumstances. DISCUSSION: In this paper, we describe the Majengo sexually transmitted disease (STD) Cohort study, a long-term prospective, observational cohort of sex workers in Nairobi, Kenya. Despite important scientific contributions and a wide range of benefits to the women of the cohort, most of the women have remained in the sex trade during their long-standing participation in the cohort, prompting allegations of exploitation. The Majengo STD cohort case extends the debate about justice in international research ethics beyond clinical trials into long-term observational research. We sketch the basic features of a new approach to understanding and operationalizing obligations of observational researchers, which we call 'relief of oppression'. 'Relief of oppression' is an organizing principle, analogous to the principle of harm reduction that is now widely applied in public health practice. Relief of oppression aims to help observational researchers working in conditions of injustice and deprivation to clarify their ethical obligations to participants. It aims to bridge the gap between a narrow, transaction-oriented account of avoiding exploitation and a broad account emphasizing obligations of reparation for historic injustices. We propose that relief of oppression might focus researchers' consideration of benefits on those that have some relevance to background conditions of injustice, and so elevate the priority of these benefits, in relation to others that might be considered and negotiated with participants, according to the degree to which the participating communities are constrained in their realization of fundamental freedoms. SUMMARY: The over-arching aim of relief of oppression is that, within the range of benefits negotiated over time with the local communities and organizations, an increasing proportion reflects a shared interest in improving participants' fundamental freedoms. We describe how harm reduction serves as a useful analogy for how we envision relief of oppression functioning in international research.