Hubris, Humility and Humanity: Expanding Evidence Approaches for Improving and Sustaining Community Health Programmes

"Ensuring that evidence translates into action will require humility in understanding the heterogeneity of evidence needs, the dynamic nature of community contexts and the brokering of relationships that are key to...build[ing] layers of evidence, critical thinking and collaborative learning to effect change."

Evidence supports working with communities as a key foundation for improved reproductive, maternal, newborn, and child health (RMNCH). Prior evidence initiatives largely emphasise the technical content of what must be done and focus on discerning the effects of discrete interventions, yet - as this paper seeks to make clear - few practitioners and community members implement singular interventions in isolation. Multiple, at times competing, health needs arise at the community level through various health actions, and interventions involve disparate actors, embedded in sometimes-contested power relationships. In this context, a range of supportive systems are required to broker community partnerships that embrace this complexity and uncertainty. Considering these needs, the authors outline strategies both for enriching appreciation of implementation realities in which community programmes take place and for strengthening the research foundation to address these realities.

Following an introduction, the first section of the paper examines understanding community implementation realities, stressing the need for humility here in order to open up the need for a broader range and better fit between research questions, designs, and types of evidence. Themes covered include:

• Communities as social systems versus passive beneficiaries - Attention to how different subgroups within communities may stand to gain or lose differentially due to an intervention is critical, and Box 1 in the paper shares examples of how social hierarchies influence community health programmes. For instance, community health workers (CHWs) may provide fewer services to community members outside of their kinship ties, and female CHWs may face significant gender norms constraining their performance. Stressing the importance of contextual determinants does not mean that communities are helpless victims of contextual factors, and Box 2 features examples to demonstrate this, such as successful advocacy by community volunteers in Chattisgarh, India, which led to improvements in facility care. What this means is that research initiatives need to invest time into continuous dialogue and learning mechanisms with communities over the course of the project. Such efforts to ensure transparency, trust, and legitimacy among community members and between communities and external actors are essential but often-neglected characteristics of community-level initiatives.
• Interventions as social processes dynamically evolving with social context - Provided in Figure 1 (and above) is a framework for understanding the complexity and context embeddedness of community interventions by differentiating (a) intervention characteristics, (b) delivery strategies, (c) community contexts, and (d) the dynamic health systems within which implementation occurs. The authors use this framework to contrast the complexity and contextual considerations involved in 2 examples of community RMNCH interventions: zinc for the management of acute diarrhoea in children and participatory action women's groups (see Table 1). The takeaway is that "Community RMNCH is inherently about how diverse actors interpret, respond, and adapt to the social changes sparked by interventions. The need, then, is to better understand the fluidity of interventions, which entails "continuous assessment of how diverse stakeholders view and dynamically respond to interventions, along with holistic theories or pathways of effect....This has implications for facilitating implementation, and for the varied evaluation needs that arise."
• Evidence: heterogeneity versus hierarchy of needs and uses - From the perspective outlined here, evidence that supports implementation needs to focus on how to learn from error and foster local problem solving and critical thinking based on analytical generalisation, rather than trying to find universal solutions that are adapted to local contexts later. Critical factors supporting scale-up include understanding and modifying the nature of the intervention - with the engagement of multiple stakeholders - supported by data and dialogue that address context-specific needs and further innovation. Research prioritisation exercises for integrated community case management for sick children (iCCM) have shown that research questions deemed important by national and regional actors were different from those based in the headquarters of global health agencies. So, "When considering issues of implementation, scale and sustainability, rather than constrain learning to a hierarchy of evidence, we need to match the varied needs arising from the diverse types of learning and engagement of key stakeholders whose capacity is being built to support and sustain further innovation and implementation over time..."

The paper goes on to examine strategies for strengthening the robustness of implementation research by building common ground through improving the use of conceptual frameworks, addressing uncertainty, and fostering collaboration. As detailed in the next sections, common elements for ensuring robustness of research include:

• Better mapping and building of conceptual frameworks to interpret evidence and embrace complexity and context rather than controlling or adjusting for it - For example, mapping out the complex pathways in which community scorecards effect change in communities and local health facilities may help clarify reasonable expectations and timeframes. In doing so, frameworks can help to focus the purpose of evaluations and clarify their limitations in terms of what can be changed and measured.
• Use of multiple data points to understand phenomena and search for plausible alternative explanations - Part of this may involve research communities, including journals and research donors, coming to value and encourage the publication of negative findings and unintended consequences, along with the reflections of what could have been done differently. Confidence in research findings can arise by fostering long-term engagement and relationship building with a diversity of stakeholders - in part through exploration of alternative framings of the problems examined.
• Collaboration as the basis for evidence use and generation - "Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change." As noted here, "The kinds of relations needed are not simply political or personal, but also entail different actors bringing a spirit of collaboration and mutual learning, and building communities of knowledge....This entails supporting local capacity-building and creation of local forums, which routinely review evidence and implementation experiences at different levels of the health system. While learning communities and forms of embedded research encompass experts, policy makers or providers, experiences related to community participation illustrate key principles underlying such engagement." However, despite its potential, several factors, which are outlined here, make community engagement challenging in research and evaluation. One way of dealing with these challenges might include identifying mechanisms that facilitate engagement collaboratively so that they address the power relations and barriers that inhibit participation of marginalised groups. Community needs, expectations, and rights need to be clarified, communicated, and negotiated to sustain trust.

The authors conclude by reiterating that - far from succumbing to the hubris of relying on one form or hierarchy of evidence to sustain community programmes at scale - those implementing and sustaining community programmes at scale must embrace humanity in all its complexity, and researchers assessing these programmes should:

• Use conceptual frameworks that consider the complexity and context embeddedness of interventions.
• Explore contradictory or negative evidence and respect each research tradition for its own ways of ensuring confidence in research findings.
• Collaborate with and align expectations among a broader range of stakeholders in evidence gathering, interpretation, and use.