Contributions to the literature
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Research has shown that community engagement approaches to health can be effective. Those that have impacted on health outcomes are often time intensive, small-scale and require high levels of financial and human resources.
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We explore a process of developing an embedded approach to community engagement, which was co-produced by researchers, policy makers, programme managers, practitioners and communities.
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This study is a contribution to the literature on intervention development, which shows how linking an intervention into existing health system and community structures and ensuring it is appropriate for cultural context optimises its potential to be scalable and sustainable.
Background
Methods
Study setting
Qualitative study methods
Survey methods
Structured approach to developing intervention processes and tools
Interactions among the study team
Co-production of intervention with key stakeholders
Development of intervention materials and pre-testing
Results
Key findings from umbrella review: context, mechanisms of impact, sustainability and scalability
Implementation strategy: culturally sensitive mechanisms through which to embed the CDA into existing health system and community infrastructure of rural Bangladesh
Administrative and social organisation
- given the size and expected sense of community cohesion, the village was selected as the appropriate unit of community dialogue implementation. However, explicit care was taken to ensure that each para was included;
- volunteer facilitators were selected by village and conducted Community Dialogues in their respective villages;
- the CSG was selected as the appropriate mechanism through which to embed the CDA into the formal health structure, given its link with CCs and overlap with villages. This was achieved by identifying CSG members to act as supervisors for volunteer facilitators.
Community meetings
- Community Dialogues were held separately for men and women;
- Volunteer facilitators were encouraged to liaise with local leaders to organise Community Dialogue sessions and mobilise participants.
Health education
- the CSG and its members were identified as a suitable mechanism for embedding the intervention into the existing health system and community infrastructure. This was achieved through providing supervision to volunteers as CSG members are often familiar with health issues and health education;
- it was recognised that communities were used to visual tools and printed materials to support health education; but there was also a critical need to emphasise the difference between uni-directional, specialist-led health education and Community Dialogues as a participatory, community-owned space for exploring health issues and taking action.
Facilitators
- the suggested characteristics were incorporated into the selection criteria provided to communities during sensitisation;
- male/female volunteers facilitated Community Dialogues with participants of the same sex;
- there were 2–3 pairs of volunteers per village, depending on the number of households; volunteers were unpaid, but some non-monetary incentives were provided.
Developing key issues to explore through community dialogue: antibiotics and antibiotic resistance
1) Knowledge and awareness of antibiotics | • Different diseases have different causes. • Many diseases are either caused by bacteria or viruses. • Different types of medicines work for the diseases caused by bacteria and viruses. • If you take the wrong type of medicine, they will not cure the disease. • Antibiotics are medicines used to prevent and treat bacterial infections. • Antibiotics do not treat infectious disease caused by viruses. Common cold and sore throats are often caused by viruses and therefore antibiotics do not work against these diseases. • The antibiotics provided in regular health facilities pass through various quality controls and are very effective to treat the diseases caused by bacteria. |
2) Knowledge and awareness of antibiotic resistance | • Many people use antibiotics often, even though they cannot prevent and treat all infections. • If used inappropriately, antibiotics may stop being useful for fighting infections in the future. This is called antibiotic resistance. • This is very dangerous as people may be sick more often or even die from infections that we have previously been able to control. • You can prevent infections and avoid taking antibiotics by regularly washing your hands, handling food in a clean manner, washing hands after contact with sick people and covering your mouth when you cough. • Do not throw left-over or expired antibiotics in the open environment as they may harm the good bacteria. |
3) Accessing antibiotics | • Sometimes the symptoms of diseases caused by bacteria and viruses can be similar. • Only a qualified health care provider can diagnose what causes your disease and which medicines you need to cure it. • If you are severely ill, always go to a community clinic or another qualified provider for diagnosis and treatment. • Only use antibiotics when advised by a qualified provider to ensure you get correct treatment for your disease. • Do not take any antibiotics by yourself and only buy them from a pharmacy if advised by a qualified provider. • You can help ensure that antibiotics remain effective by only taking antibiotics when advised by a qualified provider. • Sometimes diseases may be mild – if you only feel mildly ill, you may not need any medication at all. |
4) Appropriate use of antibiotics | • Always follow the advice of Community Healthcare Providers or other qualified providers about how antibiotics should be taken. • It is important to use antibiotics at the right time for the right duration. This will ensure they remain effective in the future. • Always complete a full course of antibiotics as advised by a qualified provider, even if you feel better. Sometimes people start feeling better before the infection is completely cured, but it’s important to get rid of the bacteria altogether. • By taking a full course of antibiotics as advised by a qualified provider, you help to ensure that lifesaving antibiotics will continue to stay effective for us, our families and everyone in the community. • Never save antibiotics for later or share them with others, as this poses risks for you and others. |
Discussion
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WHY The CDA was adapted from the Integrated Model of Communication for Social Change. The model assumes that a stimulus is required to trigger dialogue among community members about issues that are of concern for the community. Dialogue is understood as a dynamic, iterative process that results in collective decision making to resolve those issues. This process results in social change through increasing individual and collective self-efficacy, strengthening community ownership and shaping social norms. In the CDA, the stimulus is both external (provision of training and tools) and internal (selection of volunteers, volunteers mobilise participants to attend community dialogue sessions) to the community. While volunteers are given the flexibility to tailor each community dialogue session to the specific needs and requirements of the community, the sessions are designed to be highly participatory, giving all participants the opportunity to share experiences and voice concerns. Each Community Dialogue session concludes with participants committing to a course of action. Participants are also encouraged to spread information through word of mouth, set a positive example among family, friends and neighbours and to hold each other to account for applying decisions reached during Community Dialogue sessions. | |
WHAT Materials A range of non-visual tools to support sensitisation, training, community dialogue sessions, supervision, monitoring and evaluation were developed by the study team: | |
Intervention materials | Purpose |
Sensitisation | |
Sensitisation sheet (villages) | Introduces the study and outlines selection criteria and proposed selection process for the role of community dialogue facilitator |
Sensitisation sheet (supervisors) | Summarises the role of supervisors and expected commitment |
Candidate contact details recording form | Used to record contact details of candidates for the role of community dialogue facilitators |
Training | |
Training-of-trainers manual | Describes content and format of a three-day training of trainers |
Training manual | Describes content and format of a two-day training for all community dialogue facilitators and supervisors |
Community dialogues | |
Community dialogue flipchart | • Visually illustrates the intervention’s key messages, with messages printed on the back of each page • Intended to be used by community dialogue facilitators to stimulate discussion among the community |
Community dialogue discussion guide | Lists questions community dialogue facilitators could explore with communities during each of the phases of the community dialogues |
Antibiotic resistance leaflet | • Uses a selection of drawings and messages from the flipchart • Intended to be handed out to community dialogue participants to share with friends, neighbours and family |
Community dialogue facilitators’ guide | The guide summarises the format and purpose of community dialogue and explains community dialogue facilitators’ roles and responsibilities. |
Monitoring and evaluation | |
Community dialogue report template | • Captures basic information about each community dialogue conducted • To be completed by the community dialogue facilitator |
Decision log | Used by community dialogue facilitators to record any decisions made by the community during the community dialogues |
Supervision | |
Supervision checklist and report template | Takes supervisors through issues to be discussed with community dialogue facilitators during monthly supervision exchanges |
Monthly community dialogue plan template | Helps supervisors and community dialogue facilitators to plan community dialogues for the coming month |
Procedures A set of procedures around sensitisation, training, community dialogue sessions, supervision, monitoring and evaluation were implemented: | |
Procedures | Purpose |
Sensitisation | The research team invited key stakeholders (including, for example, CHCPs and Union Parishad Chairs) from each community to a sensitisation meeting. The study was introduced and they were requested to introduce the study within their communities and to facilitate the selection of community dialogue facilitators (based on criteria derived from the formative research) and supervisor from the CSGs and CGs. |
Training | Members of the research team delivered a three-day training of trainers session in Dhaka; after which the trainers delivered two-day trainings for the community dialogue facilitators and supervisors. |
Community dialogues | Community dialogue facilitators delivered community dialogues over a period of 6 months. Male facilitators delivered dialogues with male participants, and female facilitators with female participants. |
Monitoring and evaluation | Community dialogue facilitators completed a brief report after each community dialogue, and a decision log of any decisions taken by the community. |
Supervision | Supervisors held review meetings with community dialogues facilitators every month, using a check list and report template to guide the process. The supervision meetings also included planning for the next month’s activities. |
An implementation guide can be found here: | |
WHO PROVIDED Community dialogue facilitators were selected from within the community, using the following criteria (which were developed through the formative research): • Candidates should be adults • Candidates should be literate • Candidates should be passionate about improving health at village level • Candidates should be of good standing within their community • Candidates should be comfortable talking and leading discussions with community members Supervisors were selected from within the existing CSGs and CGs. | |
HOW Community dialogue facilitators delivered community dialogues to groups over a period of 6 months. Male facilitators delivered dialogues with male participants, and female facilitators with female participants. | |
WHERE Community dialogue facilitators were advised to identify an appropriate public space, such as a school building, in which to deliver the community dialogue. | |
WHEN AND HOW MUCH Community dialogue facilitators were advised to identify a time of day that was suitable for participants to deliver the dialogue. They were advised to ensure that each area within their community was reached at least once per month. |