In any health intervention, it is essential to ask how we can mobilize communities to be engaged in bettering their health behaviors and access to healthcare. Through the evaluation of past successes and failures, we can learn how to effectively motivate, involve, and empower communities to improve their health.
In Asia, communities suffering from the HIV epidemic are generally socially marginalized and even criminalized. High-risk populations include individuals who frequently engage in dangerous behaviors, such as injecting-drug users, sex workers, transgenders, or men who have sexual relations with other men. Because these cohorts are often socially isolated, it is challenging for them to access healthcare through mainstream services. The mission of “community friendly” clinics was developed to provide outreaches where the patients feel comfortable obtaining health services. A spectrum of resource suppliers would assist in running these clinics, including personnel such as “private practitioners, community organizations, NGOs and even government bodies.”(1) However, community engagement and uptake of intervention services is extremely complex. Social and political frameworks marginalize these target populations, and the open acknowledgement or discussion of these pivotal issues is often avoided by politicians.
Social mobilization evidence has shown us that in order to succeed in attaining sustained behavioral changes, services must be driven by the people instead of driven by targets. For example, in Thailand and Cambodia, HIV prevention campaigns have followed this model successfully. The acute pervasiveness of HIV was overturned by involving brothel owners and other authorities instead of only sex workers themselves. Shortly after this success story occurred, multiple agencies in Asia offered financial backing for STI testing sites and condom distribution without carefully noting the factors that influence use and acceptance, therefore making this approach significantly less effective. Another surge of programs arose from the Sonagachi project that demonstrated successful community mobilization, organization, and general approval of the intervention methods from locals. This ultimately led to increased rates of condom utilization and decreased rates of HIV infection among the target population.(2)
Two different methods of HIV prevention have developed in the past decades: one of which is driven by the community, and the other of which is primarily led through broader structural changes. Across the many services offered by NGOs and other organizations, methods that focus more on community approval have started to be adopted, including the “friendly clinics” that function at favorable times and provide necessary information in addition to patient care.(3)
A new mission to enhance community-driven approaches has been initiated by AVAHAN, a program whose financial backing from the Bill and Melinda Gates Foundation has enabled it to become the largest HIV-prevention initiative for just one country. AVAHAN offers aid and assistance to certain HIV prevention programs in the six Indian states with greatest HIV rates. These programs target the populations most susceptible to HIV infections, such as sex workers and their partners, or injection drug users. By shifting to a “by the community” framework instead of a “for the community” one, AVAHAN has been able to improve the uptake of condoms and achieve overall decreases in STIs.(4)
There is a demonstrated need for community organizations to be actively engaged in movements in order for them to work. While outside organizations can serve as helpful motivation and support, local programs must remain the primary sources of health services, outreach groups, condom and needle dissemination, HIV testing and counseling. Involving community members in the planning of prevention strategies is also an effective method of fending off hurtful stigma and prejudice that often come with being HIV-positive in many places.(5)
The Polio Eradication Initiative stands out as one of the most determined global health endeavors currently, and social mobilization is a key element to accomplishing this. The application of social mobilization in this area has concentrated on vaccination promotion to increase uptake of vaccine services during National Immunization Days, especially in countries that suffer from crumbling health infrastructures and poor immunization rates. During National Immunization Days, social mobilization has primarily relied on the efforts of local health employees and community volunteers to provide the oral polio vaccine, media promotions to inform the community about the numerous advantages of getting vaccinated, documentation of unimmunized youth per household, and follow-up observations of cases. These interventions have involved a multitude of local organizations, including those that are educational, religious, and business-affiliated. Worldwide, approximately ten million people have contributed to the polio immunization social mobilization effort.(6)
Community involvement in polio eradication has also assisted other local health initiatives. For instance, local systems and infrastructure established by the polio intervention have also been used to support other health programs, such as “measles immunization, deworming campaigns, avian influenza control, and community surveillance." Examining the essential features of the polio eradication initiative can assist in determining the remaining obstacles to polio eradication, and will allow for further exploration about the complexity of social mobilization. In May 2010, Obregon and Waisbord conducted an analysis of the current literature on communication and global health, data on social mobilization experiences from polio eradication efforts in Africa and Asia, and some hands-on fieldwork in areas where the polio eradication initiative continues today.(7)
Three main conclusions were drawn from this study that have tremendous implications for the future of social mobilization in health programs globally. First, the knowledge gained from polio eradication efforts demonstrated how social mobilization should not be viewed nonchalantly as a top-down educational tactic. This rings true particularly strongly in under-resourced, underserved populations. Social dynamics are ever-unpredictable, and factors that determine whether a group will accept or reject initiatives are highly circumstantial. A “cookie-cutter approach” to social mobilization is a sentence for failure, as methods must be adjusted to accommodate specific cultural beliefs, health requirements of the area, general population attitudes towards health services, local power structures, and persuasive authorities. (8)
A second important conclusion is that “centralized strategies” will not lead to social mobilization. Planning and implementation must occur through bottom-up approaches, using local empowerment and heavily involving community health workers. Frequently, social mobilization for polio vaccinations was not decentralized, especially in communities with extremely poor health conditions and few services being offered. When communities are not allowed to make their own decisions about core issues such as methods, personnel, and finances, the gap between the government and the community grows exponentially wider. When social mobilization is instigated as a top-down policy, communities feel exploited and therefore resent the initiatives instead of embracing them.(9)
Lastly, strategies that focus only on information distribution and communication are not adequate to truly mobilize and engage a community. It is imperative to involve influential community members, including “local voluntary associations, the media, religious and political leaders, and informal networks,” as these people hold the power to change attitudes towards immunization and raise awareness about key issues. These individuals also can assist in reporting useful information to health organizations, can explain the most pressing needs of the population, are fully versed in the politics of the area, and can help contribute to the overall goals of an initiative.(10)
An ongoing debate exists as to whether sanitation conditions and uptake of other health services can be better improved by providing monetary subsidizations, or by using emotional motivators. Those who support the funding theory argue that poor individuals are most limited by their lack of income and need financial assistance more than anything else. The other side of the argument consists of “shaming proponents,” who are strongly convinced that permanent changes in behavior require inherent motivation, and that people are more likely to use and value what they have paid for. In rural Orissa, India, shaming techniques and subsidy techniques were used together in low-income households. The intervention was driven by community needs and led by local people, but was applied by state governments. The campaign engaged a multitude of community members, offered economic compensation to meet the program mission, and encouraged populations to define their own objectives to accomplish. There was widespread hope in Orissa that the Total Sanitation Campaign would be able to improve the uptake of household latrines and therefore reduce rates of open defecation.(11)
Sanitation and health data about twenty treated and twenty control villages in the coastal district of Bhadrak, Orissa was collected both prior to and following the community-led sanitation endeavor. The overall findings were that while latrine ownership did not improve within the control villages, it rose in treatment villages in households that were both below the poverty line and those that were above the poverty line. Overall, the rigorous campaign efforts had a significant influence on routine latrine use and acceptance. This successful social mobilization can be described in terms of the four social marketing P’s: the “product” being sold was not only health, but also the attitudes and feelings about privacy and dignity associated with household latrines; the “placement” refers to the campaign effects that came from local motivators’ door-to-door promotions; “promotion” is embodied by the social pressure and peer monitoring of the community and overall inertia of the intervention; and “price” includes the subsides that were combined with shaming techniques in order to succeed. While subsidies are not always required to ignite action, they are extremely helpful when used along with social pressure approaches such as “shaming” in the Indian culture.(12)
Kiberia is a slum in Nairobi, Kenya, currently ranked as the second largest slum in Africa and one of the biggest worldwide. Locations such as this one serve as a deadly infectious zone for dangerous water borne illnesses that impact the whole population of the area, in addition to the half million residents suffering from HIV/AIDS. The number of public facilities available is extremely low, causing waste to be frequently disposed of in inappropriate ways. Open sewers and free flowing human excrement can be found abundantly throughout the city. Despite the blatant evidence that immediate change is required, sanitation issues are considered taboo and therefore open discussions about the problem seldom occur. The repercussions of these complications even carry over to the public school systems. The Ministry of Education Science and Technology has dubbed Kenya as “dangerous” because over one hundred students are using a single latrine. Additionally, because girls and boys use the same bathroom, girls often will be absent from school for at least one week during their period.(13)
A Kiberia native, David Kuria, established himself as a community leader in the sanitation sector. Because he was so familiar with the area, Kuria distinguished himself from foreign aid workers who had attempted to improve sanitation in the past. He knew exactly what would work and what would not work in his community, and he decided to develop his enterprise from the mantra “think beyond the toilet.” IkoToilet started as a vision where affordable sanitary toilet facilities would bring the community together and allow them to feel honored and satisfied. Emily Haggstrom, blogger for ISOCA Magazine, describes Kuria’s mission:
“It would be a community venture where leaders could generate community support around the sanitation issue. He invited the local community to become involved and share their ideas too. It was from these workshops that new designs and ideas came about. Once members of the community realized the toilets would be neighbor run, the IkoToilet idea generated community ownership and something community members could take pride in.”(14)
Just as Kuria had imagined, the toilets became a place of congregation and a venue associated with deep pride. When Kuria was designated as an Ashoka Fellow in 2007, the IkoToilet venture was able to grow and expand. The idea was to generate a scheme that would allow the toilets to be sustainable, useful, and profitable for locals. Kuria accomplished this impeccably, ultimately establishing IkoToilets as the hub of the community by featuring “business advertising, meeting rooms, fresh water, shoe shines, newsstands, telephones, showers with hot water, clean toilets, and employment opportunities for slum dwellers.”(15) As Kuria effectively demonstrated, social mobilization must develop from a community-driven model, and the widespread needs and desires of locals should be seriously considered and ultimately included in the project.
(1) Sarkar, S. “Community engagement in HIV prevention in Asia: going from ‘for the community’ to ‘by the community’ – must we wait for more evidence?” Sexually Transmitted Infections, vol. 86, no. 1, (February 2010). Accessed 9 August 2010.
(4) Sarkar, S. “Community engagement in HIV prevention in Asia: going from ‘for the community’ to ‘by the community’ – must we wait for more evidence?” Sexually Transmitted Infections, vol. 86, no. 1, (February 2010). Accessed 9 August 2010.
(6) Obregon, R. & Waisbord, S., “The Complexity of Social Mobilization in Health Communication: Top-Down and Bottom-Up Experiences in Polio Eradication.” Journal of health Communication, Vol. 15, No. 1, pp. 25 – 47, (07 May 2010). Accessed on 8 July 2010.
(11) Pattanayak et. al., “Shame or subsidy revisited: social mobilization for sanitation in Orissa, India.” Bull World Health Organ, vol. 87, no. 8, pp. 580-587, (Aug 2009). Accessed on 10 Aug 2010.
(13) Haggstrom, E. “Slums Find Dignity In Sanitation,” ICOSA Magazine, (2010). Accessed on 11 Aug 2010.