Participation as process and outcome: Adapting community conversations to promote more meaningful participatory interventions for child health in Nigeria

Summary:

Given the renewed interest in the use of participatory approaches in research and health promotion in global health, we argue the need to revisit approaches to increase the ownership that target communities have, not only over outcomes, but also process, as this will ensure histories of tokenistic participation are not revisited on new generations of communities and local actors. Our work pilots an adaptation of community conversations to drive a co-design formative phase for the implementation of community based and community led interventions to tackle under-five pneumonia and other childhood infectious disease in Nigeria. As part of our formative research stage for a cluster randomised control trial of a community intervention in Kiyawa LGA, Jigawa State, we completed 36 community conversations involving participatory tools to generate debate and discussion around key social and relational processes that would influence the success of participatory groups and action around child health. The conversations gave communities the opportunity to explore and shape the pillars of the intervention allowing for a more robust exploration of the varied dimensions of complex community health systems (incl. service users, wider communities). Furthermore, we believe this process will increase the sustainability of the intervention as it ensures local relevance to community groups prior to roll out and evaluation. We argue that our proposed method should be a mandatory stage of intervention research in complex settings, and discuss practical and ethical implications of the approach.

Background/Objectives:

Participatory approaches are experiencing a resurgence in popularity. In global health, participatory learning and action (PLA) interventions have proved to be effective in improving health outcomes through shifting community norms, practices and decision making. However, participatory interventions are not without their challenges. Studies note that contextual issues and group dynamics can limit the success of such approaches. Formative research can address such challenges, however, this process is often extractive, and contradicts the theoretical models underpinning the very interventions it seeks to inform. Our objective was to pilot a new methodology to deepen community engagement in shaping participatory interventions for health.

Description of Intervention and/or Methods/Design:

We adapted the community conversations (CC) method to complete co-design processes, to engage communities in decisions about the components the interventions that will be delivered and scaled in our forthcoming cluster randomised control trial of community interventions( incl. PLA groups for men and women), in Kiyawa LGA, Jigawa, Nigeria. CC were held in 11 wards, adapting the UNDP model to focus on the first four steps of the methodology. Each session included participatory methods (body mapping, Venn diagrams, community asset mapping) to guide participants through discussion and debate on varied relational, structural and resource demands in the LGA. 36 conversations were conducted in 6 wards, refining the structure of the intervention in each site. In the final 5 wards, the intervention model developed by CC groups was debated in focus groups, to explore perspectives and agreement on the local value of the proposed intervention.

Results/Lessons Learned:

The CC process allows for a co-design approach to be extended to include a wider range of stakeholders in a local health system. In our groups we were able to access the intersections of gender and power dynamics (i.e. - perspectives of younger mothers vs. older mothers; husbands and men vs. male community elders/ traditional leaders). The use of participatory methodologies in CC's allowed us to promote debate and critical engagement that, in many ways, also prepares communities for the later interventions that will feature within the trial. This process also enables the intervention design to be directly aligned to local context, making the intervention more relevant to participants needs, and fostering buy-in from a larger range of stakeholders. This increases the likelihood that the intervention will reach the most vulnerable, and is anchored to existing community structures to enhance sustainability.

Discussion/Implications for the Field:

Our approach allowed us to pilot more a comprehensive and engaging methodology, and to involve large communities in a process of co-design. This has important implications for the wider use of participatory methods in global health, as well as highlighting the importance of thinking of participatory ideas as both process, and outcome in research and practice. We also note the ethical implications for this approach, which shifts our engagement from working 'on', into working 'with' communities in complex settings, through increasing their ownership over the entire process. Implications for the global health field as a whole are discussed.

Abstract submitted by:

Rochelle Burgess - University College London
Funmilayo Shittu - Save the Children
Ibrahim  Haruna - Save the Children
Paula Valentine - Save the Children