Realising radical potential: building community power in primary health care through Participatory Action Research

Background While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component. Methods Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks. Results Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district. Conclusions Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-023-01894-7.


WHAT IS THIS MANUAL?
This manual contains a set of tools that can be used by Community Health Workers (CHWs) who are working in their designated area as part of Ward Based Primary Healthcare Outreach Teams (WBPHCBOTs). The manual aims to assist CHWs to convene community stakeholder groups, to raise and/or respond to priority health concerns, to understand the nature of the concerns from different perspectives in the community and to start a discussion on and facilitate and monitor action that can be taken in communities and in the health systems and public services more widely.
WHO WILL BENEFIT?
The information in this manual has been developed to support CHWs to effectively conduct community mobilisation activities. The process is also intended to benefit people in communities. The tools can be used to support communities to convene to understand and address priority health issues collectively, and to support how the government makes decisions on health care in the local area.

HOW DOES IT WORK?
The manual contains a series of 5 participatory action research (PAR) tools to identify, understand and address priority health concerns in rural communities. The tools work through a stepwise sequence to: (1) identify the priority health concern; (2) collect data on the issue; (3) understand the causes and consequences of the issue; (4) map the main actors and impacts involved with the issue; (5) plan action with different stakeholders. 4 of the 5 tools are accompanied by a community-based workshop and the manual provides a discussion guide for each workshop.
The tools are underpinned by a four main principles (described in more detail on page 8): (1) 'homogenous group' -groups convene with shared conditions and concerns; (2) subjective perspectives' -to understand people's individual experiences; (3) 'collective validation' -only those issues that the group recognises are registered; (4) 'no delegation' -those dealing with the issue are the primary actors in the process. The content and messages are aligned with the National Department of Health policies and training curriculum for CHWs.

WHAT ARE WE AIMING FOR?
The process has been designed to promote local action on the social determinants of health, to support the development of mutual understanding and trust relationships between communities and CHWs, and to enable attention to the role of CHWs and WBPHCOTs in local health governance structures such as clinic committees and district health management teams.

CONTEXT
The social and cultural forces that shape people's everyday experiences and that directly and indirectly affect health and behaviour. These include historical, political, legal structures and processes (e.g. migration), organizations and institutions (e.g. schools, clinics, and community), and individual and personal factors (e.g. family, interpersonal relationships). Notably, these forces are formed in relation to and by each other and often influence people in ways of which they are not consciously aware.

STAKEHOLDER
The terms participants and stakeholders are used inter-changeably in this manual. These are people who are involved in the process, or who will become involved during the process.

SOCIAL DETERMINANTS OF HEALTH
The non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Examples include: Income and social protection (grants); Education; Unemployment and job insecurity; Food insecurity; Housing, basic amenities and the environment.

COMMUNITY MOBILISAITON
Community mobilisation can be defined as a process whereby local groups are assisted in clarifying and expressing their needs and objectives and in taking collective action to attempt to meet them. It emphasises the involvement of the people themselves in determining and meeting their own needs. It is closely linked with the concepts of participation and resilience.

COMMUNITY PARTICIPATION IN HEALTH
Meaningful participation requires that individuals are entitled to participate in the decisions that directly affect them, including in the design, implementation, and monitoring of health interventions. In practice, meaningful participation may take on a number of different forms, including informing people with balanced, objective information, consulting the community to gain feedback from the affected population, involving or working directly with communities, collaborating by partnering with affected communities in each aspect of decision making including the development of alternatives and identification of solutions, and empowering communities to retain ultimate control over the key decisions that affect their wellbeing. Also referred to as community engagement, community involvement and community empowerment.

EMPOWERMENT
To empower is to give power or to enable. As a process, empowerment develops capacities in individuals, groups and communities to make purposive choices and to transform those choices into desired actions and outcomes. As a transformational approach, it takes into account the felt needs of the actors and encourages collective involvement.

HOMOGENOUS GROUP Group with shared conditions, interests, and concerns
The tools in the guide should be used with homogenous groups, by this we mean groups with shared conditions, interests, and concerns, and groups whose voices are often excluded from the processes of service organisation and delivery. The groups that are convened by CHWs should aim to represent a particular view on a particular issue e.g. youth and adolescents and people who are experts in the field such as those delivering services to this group could be convened to discuss alcohol and drug abuse, while a more mixed group of community members (traditional leaders, family members, women of reproductive age) could be convened to discuss an issue such as lack of clean safe water in the community.

SUBJECTIVE PERSPECTIVES People's individual opinions and experiences are central
People's individual opinions and experiences are fundamental. Through the sequences of tools you will learn, people's individual experiences are drawn into the discussions, and using the tools they are systematised into collective forms of knowledge that represent the view of the community on the issue and on actions that might be feasible to address it. The process brings people's individual views, opinions and experiences together, and through respectful dialogue systematises these into collective forms of knowledge. A principle to ensure that the collective form of knowledge represents the view of the group is that only those issues that are recognised by the group as a whole are registered.

Those dealing with the issue are the primary actors generating information
Community mobilisation is about the active involvement of those most directly affected by the issue. Therefore, those dealing with the issue are the primary actors generating information on the issue, and discussing and assessing feasible actions that can be taken to address it.

RECRUITMENT PROCEURE
CHWs can recruit potential participants using a range of strategies such as door-to-door outreach, or community presentation and activities. During recruitment CHWs give a brief description of the process highlighting the aims and objectives of the process. It is very important to ask potential participants their contact details and address to follow with them later.
CHWs must recruit potential participants from their communities, possibly that have been involved in some activities in the community, are at home most of the time and are likely to be interested in the chosen topic above. Once you have chosen potential participants notify them about the time and venue of the workshop and check with them that they are able to get to the venue.
It is good practice, but not essential, to provide possible participants with written information on the process, the objectives and what is involved, with details of any risks and benefits from participating. It is also good practice to give possible participants enough time (usually around 72 hours) to read and absorb the information and the opportunity to ask questions before agreeing to be involved.

EXAMPLE INVITATION LETTER
An example invitation letter is included

FREQUENCY OF MEETINGS
The tools in this guide are intended to be applied in a sequence of weekly meetings. It is important to acknowledge that a series of at least 5 weekly meetings lasting from 2-3 hours is a significant undertaking for both CHWs, WBPHCOTs and community stakeholders. The series and sequence of meetings should be arranged jointly with participants (CHWs, WBPHCOTs and community stakeholders).

NUMBERS OF STAKEHOLDERS
A suitable number for a group discussion is around 12 to a maximum of 16 participants. Depending on the topics identified as of relevance to communities, participants for each topic will be agreed in meetings, and invited participants will be approached according to the topic to facilitate local ownership and relevance. However, it is possible to have the process and sequence described in this manual run independently in different villages, with villages coming together at the end of the process to share findings.

INFORMATION
Community stakeholders should be contacted individually by phone or in person and the proposed activites and intended outputs described. Those who express interest can be provided with an invitation letter if possible and given a minimum of 72 hours to think about whether they want to participate and ask questions by telephone or personally. For those agreeing to be involved, a convenient time/date will be arranged for the workshops. It is very important that participants agree to be part of the process, and that they understand what the process involves.

EXPECTATIONS
As community stakeholders are invited into a process of community mobilisation, it is important to be transparent and honest about activities, time commitments and to be realistic about change that will occur as a result of the process. There is a need to acknowledge (a) discouragement in communities, who may feel that existing health and engagement strategies have not been entirely effective, and (b) challenges and constraints in the system and services especially with regard to resourcing and top down norms/practices.

GROUND RULES
The facilitator should set out these ground rules to help ensure that the discussions are respectful, and through this work to build mutual understanding and trust relationships between all those involved.

PEOPLE MATTER
People are the foundation of the process. Develop an environment that conveys the idea that people are valued. Consider the physical spaces of meetings. Are they convenient for participants, do they offer space to have often difficult conversations? E.g. remove broken chairs or equipment.

NON-THREATENING
Offer genuine appreciation of people's views and roles in the community. Acknowledge the value of diverse views, cultures and identities, and encourage consideration of how diverse views can be respected as well as the power of collective action.

NO BLAME
Make sure that people's concerns and frustrations are heard. Acknowledging that there are difficult relationships within communities and between communities and the authorities, but that with time, patience, and respectful dialogue, common aims can be developed through which relationships and trust can grow.

RELAXED ENVIRONMENT
Offer encouragement for people to share experiences and explore solutions.

RESPECT
It is important that there is time and space for listening with respect and interest, and without interruption. Everyone will have a chance to talk and give input. Participants can be asked, for example, to raise their hands before talking to help the facilitator ensure there is balanced input from participants.

INFORMATION
Working in a way that respects the experiences of community members. Bringing different sources of data, including statistical and visual to the process.

DEMANDS ON FACILITATORS
The demands on facilitators, and for resilience on the part of convenors to be part of the conversation on building relationships is critical and key element of relationship-building. This is a demanding process and the requirements and impacts of that need to be part of the conversation.

ACTIVE LISTENING
Active listening is a basic skill for facilitating group discussions. Active listening helps people feel that they are being understood as well as heard, and encourages people to share their experiences, thoughts, and feelings more openly. It shows participants that their ideas are valuable and important when it comes to solving problems. Active listening involves: • Pay attention: Use body language to show interest and understanding. In many cultures, this will include nodding your head and turning your body to face the person who is speaking.
• Show that you're listening: Showing interest and understanding to reflect what others are saying. It may include looking directly at the person speaking. In some communities, such direct eye contact may not be appropriate until the speaker and the listener have established some trust Listening not only to what is said, but also to how it is said, by paying attention to the speaker's body language.
• Ask clarifying questions: Asking the speaker questions to show that you want to understand. 'Can you explain how you can this this conclusion?" "Where did you hear that?: Summing up the discussion to check that what was said was understood. Ask for feedback. •

IDENTIYING HEALTH CONCERNS
Tool 1: RANKING AND VOTING

INTRODUCTION
The meeting should be 2-3 hours. There needs to be an attendance register, the register is very important for final report writing. This is a community mobilisation process to build community knowledge and action around the social and structural determinants of health. The process is also to build trust and find solutions in with health and local authorities.

GROUND RULES
Our environment is non-threatening, no-blame and democratic. Everyone here is an official member and a partner in the process. Read/discuss the 4 principles (page 8). Together we are a team. Here, we will begin to organise experiences, identify shared needs and desired outcomes.

OUTLINE PROCESS AND ACTIVITIES
• We would like to meet once per week every second week for 4 weeks in meetings of 2-3 hours • People can leave at any time and for any reason • We will ask about people's experiences and opinions on the topic nominated • From this we will develop collective understandings and actions to address the issues identified • We will take the outputs of the process, with community representatives, to engage with stakeholders in the district health system to analyse, plan and act on the information that we generate.

Tool 1: RANKING AND VOTING
To identify priority health topics of relevance to the community. A list of health priorities is developed during the discussion, after which participants vote for the topics of highest relevance using adhesive stickers, beans or sticks. The voting progresses through at least two rounds with discussion and agreement at the end.

METHOD:
ranking and scoring/multi-dot system TIME: 30 mins MATERIAL: pen and flip chart paper, counters (stones, seeds, markers) OVERVIEW This tool will enable CHWs to identify priority health topics of relevance to the community. A list of health priorities is developed during the discussion, after which participants vote for the topics of highest relevance using beans, counters or adhesive stickers. The voting progresses through two (or more if necessary) rounds with discussion and agreement at the end. PROCEDURE 1. Ask participants to list health/social needs/concerns in their community. They can do this on the flip chart, this can be at the front of the group or on the ground.
2. When the list has been developed, give each participant 3 stones, beans or any other marker available. Ask them to distribute or place their counters against three health concerns they think are most important and need the greatest attention. Ask participants to discuss and interrogate the scoring. Prompts • What were the differences between the participants' priorities?
• How can you explain these differences?
• What do they tell us about the different needs of men and women, youth and adults? • How does this impact on health programmes? • Do these findings reflect the views of everyone in the community?
If not, how can you ensure that other community members' views are taken into account?
3. Ask if anyone wants to change their vote at this stage and allow them to do so.
4. Count the total counters for each item listed and write the totals on the flip chart paper. The group now has a list of three top priority health concerns which are the three with the most counters. Record these three on a new flip chart.
5. Ask participants to justify why they thought these three health concerns deserve most attention. Prompt • We now have a list of concerns in the community, which one is the biggest priority among those listed?
6. Have a second round of voting on the three prioritised concerns so that one health concern is identified.
7. Conclude the priority topic and record.

WORKSHOP REPORT a) GROUP RECORD
The person who has been recording the most important discussions fills in this record. Facilitator takes digital images of the flip charts with ranking/scoring/multi-dot system. The recorder records queries, comments or areas of debate raised in the discussion below. The scriber reads this record at the end of the session and one of the other participants verifies.
Session recorded by: Verified by*:

ORGANISING EXPERIENCES
Tool 2: PROBLEM TREE

INTRODUCTION
The workshop should be 2-3 hours. Facilitators take digital images of discussion and participants. There needs to be an attendance register, the register is very important for final report writing.

GROUND RULES
Our environment is non-threatening, no-blame and democratic. Everyone here is an official member and a partner in the process. Read/discuss PAR Principles from Handout (page 8). Together we are a team. Here, we will begin to organise experiences, identify shared needs and desired outcomes.

WORKSHOP OBJECTIVES
• To develop an understanding of the causes and impact of concern • To identify needs and desired outcomes for [health concern] • To identify skills acquired during the workshop • Produce a short summary report of the workshop

OUTLINE PROCESS AND ACTIVITIES
Our focus is on developing knowledge on priorities. Revisit priority concern identified. Participants invited to draw on their knowledge/experience of the priority health concern. Record discussion (see prompts) and confirm record with group in Group Record.

ORGANISING INTO COLLECTIVE KNOWLEDGE
• Follow process in Tool 2 • Record discussion and confirm record with group

SUMMARY AND REFLECTIONS
• Now we have finished the discussion, Mr/s [NAME] will summarise our discussion to the group. • Is this an accurate summary? Did we miss anything?
• What about the activities? Should any changes be made? What works? What doesn't? • Who benefits from this process? How? Who controls the process? How? • Invite feedback on the process. What do people think about participation?

Method:
Problem tree (organising causes) Time: 45mins Materials: Copy of the 'problem tree'/ask participants to draw OBJECTIVE Understand the major causes and consequences of health concern(s). Develop shared understandings of the health concern(s).

PROCEDURE
This activity helps participants to explore the root causes of an identified health concern. The problem tree offers a structured way of getting to the various levels of a problem.

FOCUS ON PRIORITY HEALTH CONCERN
Facilitator invites input and makes list of issues related to [CONCERN] and records them on a flipchart.

Prompts
• What is known about [concern] and its causes?
• What are the experiences of people in this group?
• What are signs/symptoms and interventions • How do services respond?
• Is there a shared definition? How has this concern had an impact in this group? In the community? • Who is affected? Does [concern] affect different groups in different ways? How?
The list is interrogated and discussed, people cross check and correct each other; [Facilitator takes care to maximise the diversity and richness of information, and to check, verify, amend and added to the collective account and ensure that the participants own it]; [Facilitator encourages inputs from all participants to organise the list].

ANALYSE PROBLEM
Using a picture of a tree, participants analyse the causes of the identified problem. The pods are the problems; The branches that hold them are the immediate individual or biological causes; The large branches are the environmental causes; The trunks or roots are the underlying structural causes; The ground is the political systems and values that are the context for the structural causes. Facilitator records each point on the tree once the group has decided where it goes on the tree.

LOOK AT THE CAUSES AND DISCUSS
During this discussion, the position of the points on the tree might change, and the facilitator can make these changes on the problem tree diagram.

Prompts:
• Which causes can communities act on with the resources they have? How? • Which ones need to be acted on by others within their own district or area?
• Who do communities need to influence to make these actions happen?
• Which ones need to be acted on by governments or other national institutions? • Who do communities need to influence for these actions?

RECORD
Record on the session record sheet (see overleaf). Facilitator takes digital images of the diagrams. Facilitator records queries, comments or areas of debate raised in the discussion Adapted from: Cavestro, 2003;EQUINET, 2006 Tool 2: PROBLEM TREE

This is a tool to understand and 'unpack' nominated topics from different perspectives. Through facilitated discussions using a tree diagram visible to all, participants identify cause-and-effect relationships at various levels from root (tree roots) to intermediary causes (trunk and branches) and consequences and other effects (tree pods), building subjective perspectives into shared accounts through consensus.
The person who has been recording the most important discussions fills in this record Facilitator takes digital images of the flip charts with ranking/scoring/multi-dot system. The recorder records queries, comments or areas of debate raised in the discussion below. The scriber reads this record at the end of the session and one of the other participants verifies.

Session recorded by:
Verified by*:

WORKSHOP REPORT b) GROUP REFLECTIONS
The CHW asks another participant in the group to ask these questions and record the group answers Session recorded by: Verified by*: Photovoice is a method that helps those who are often the subject of photographs to become photographers and tell their own story. Photovoice believes nobody should be denied the right to speak out and be heard.

BASICS OF PHOTGRAPHY
Photography is "drawing with light". Stakeholders can be introduced to: (a) composition/framing: ask participants to make a rectangle with thumbs and forefingers of both hands. Held to the eye, this forms a viewfinder which can be moved in/out by moving arms forwards/backwards; (b) Foreground and background -what is the relationship between them? (c)The main subject or focal point -where should it be placed in the frame? (d) Cropping within the frame -do you want to include all of the main subject? (e) The basic shapes in the picture / Creating space between objects. Proximity or distance from the main subject

USING YOUR PHONE TO TAKE AND SEND PROFESSIONAL PICTURES
Open discussion about who has access to email, WhatsApp and discuss how to send pictures with verbal permission from people in them from the phone to other devices.

EXERCISES
Stakeholders asked to go in pairs to take 3 pictures and return to the group in 15 mins to present and discuss. The pictures can be of landscapes, people/portraits, emotions, movement etc. Return to the group to discuss the pictures taken. Take notes about the images and write a few words about the photograph, what it is of, why they took it, and what it is intended to communicate.

SOME GROUND RULES
Participants need explain to subjects why they are taking photographs and what the intended use of these photos might be; ALWAYS ASK PERMISSION BEFORE TAKING SOMEONE'S PHOTOGRAPH; They should acquire verbal consent wherever possible; Everyone is entitled to privacy and to be made aware of what they are being associated with.

VISUAL EVIDENCE
Community stakeholder presenting and discussing visual evidence (image reproduced with permission) "By presenting and discussing visual evidence that is collected throughout the process, community stakeholders build skills in public speaking and analysis, group work and relationship building"

EXAMPLES OF VISUAL EVIDENCE
Examples of visual evidence on alcohol and drug abuse, with captions developed by community stakeholders Source: Mabetha, 2018 Alcohol and drugs -the stress relievers Men dancing and singing after drinking alcohol and smoking. Alcohol and drugs were described as stress relievers for people living in hardship. According to participants, alcohol makes them forget their problems and helps them through to the next day.
Photographer: Delight Zitha / VAPAR learning platform Youth drinking and driving A young man at the wheel of a car at night with an alcoholic drink in one hand and a cell phone in the other. Villagers considered such practices as contributing to the high levels of death and disability owing to road traffic accidents in the village Photographer: Cornright Zitha / VAPAR learning platform Alcohol abuse in older people An elderly woman lies down after drinking a number of bottles of beer. The photo was taken in the early hours of the day to show how widely alcohol use and abuse is accepted in the community: it is normal for anyone to drink alcohol at any time of day Photographer: Ennie Khoza / VAPAR learning platform

INTRODUCTION
The meeting should be 2-3 hours. Facilitators take digital images of discussion and participants. If participants have one photo they want to share with others, then this should be shared across devices. Today we want to build our understanding of the impact of the health concern.
GROUND RULES Our environment is non-threatening, no-blame and democratic. Everyone here is an official member and a partner in the process. Read/discuss PAR Principles from Handout (page 8). Together we are a team. Here, we will begin to organise experiences, identify shared needs and desired outcomes.

WORKSHOP OBJECTIVES
• To identify services for addressing needs for [health concern] • Understand impacts and identify gaps/weaknesses to be addressed or strengths to be reinforced • To share any photograph that participants wish to illustrate • To identify skills acquired during the workshop • Produce a short summary report of the workshop OUTLINE PROCES AND ACTIVITIES Facilitator displays the problem tree. We have developed a collective account of [health concern]. Today we will build our understanding of [concern]. ADDRESSING THE ISSUES DISCUSSED • Follow Tool 4: Venn diagram SHARING PHOTOS Participants to share one photo with participants and discuss.

SUMMARY AND REFLECTIONS
• Now we have finished the discussion, Mr/s [NAME] will summarise our discussion to the group. • Is this an accurate summary? Did we miss anything?
• What does this mean for who and how [health concern] is experienced?
• What does this mean for health planning, services and health workers?

This is a tool to understand impacts and actors involved. Collective account developed with Venn diagram made from cardboard circles of different sizes and colours to indicate relationships and interactions between various actors and institutions, identifying internal and external organisations active in the topic and how they related to one another in terms of contact and collaboration. Identify services (health and other) for addressing needs for [health concern
]. Identify how services perform in relation to desired outcomes, access, uptake 31 Method: Venn diagram (Stakeholder mapping) Time: 45mins Materials: large piece of paper, small coloured pieces of paper, scissors Background: Venn Diagram shows institutions, organisations, groups and important individuals in the village, as well as the villagers' view of their importance in the community. Additionally, the Diagram explains who participates in these groups in terms of gender and wealth. The Diagram also indicates contact and cooperation between those organisations and groups.

OBJECTIVES
• To identify organisations/groups/persons active in the community around [health concern] • To identify who participates in local organisations/institutions • To find out how different groups relate to each other in terms of contact, cooperation, flow of information and provision of services PROCEDURE 1. Working in groups, participants list the main health-related institutions operating in their community. Prompts: • Ask participants which organisations/ institutions/groups are found in the village and which other ones from elsewhere are working with them. • Make sure that they also think of the small not formal groups like e.g. neighbourhood committees.
2. Write the names of these institutions and people on the flip chart.
3. Provide participants with paper circles of different sizes to represent each institution/person, the larger circle, the more important the institution/person.
3. Ask the participants to compare the sizes of the circles and to adjust them so that the sizes of the circles represent the importance of the institution, organisation or group. Participants should write the organisation name of the size of paper the group decides best represents the organisation. Prompts: • What kind of ways of assisting each other for [health concern] exist among people?
• Which local groups are organised?
• Are there political groups?
• Who makes important decisions in the village?
• Are there local people working/ concerned with politics, livestock etc? Who are they and how do they contribute?
4. Ask participants to place the circles on a bigger piece of paper showing their relationships and linkages -the overlaps indicate cooperation between or among institutions and separate circles show no links or that the roles or activities of the institutions are different. Participants can adjust the size or arrangements of the circles as they consider appropriate.
5. While participants are developing their diagram, explore with them why they are making certain choices. Prompts: • Why is this institution so far away from the others?
• These 2 institutions are overlapping -what type of activities do they share? Document what they say 6. At the end, exhibit the diagram and do all or some of the following • Identify patterns in the way institutions relate to each other • Look at whether certain kinds of people, for example, women, the poor or orphans, are excluded from participation in certain institutions. Suggest reasons why they are not represented and how they cope.
Record on the session record sheet (see overleaf). Facilitator takes digital images of the diagrams. Facilitator records queries, comments or areas of debate raised in the discussion, or asks another CHW to help with taking these notes and images.

INTRODUCTION
The meeting should be 2-3 hours. We have developed a problem tree and a Venn diagram from previous workshops, today we will develop a change pathway and action plan from this group to address the issues identified.

GROUND RULES
Our environment is non-threatening, no-blame and democratic. Everyone here is an official member and a partner in the process. Read/discuss PAR Principles from Handout (page 8). Together we are a team. Here, we will begin to organise experiences, identify shared needs and desired outcomes.

WORKSHOP OBJECTIVES
• To develop a and action pathway from this group to address the issues identified • To share any photographs that participants wish to illustrate • To identify skills acquired during the workshop • Produce a short summary report of the workshop OUTLINE PROCESS AND ACTIVITIES Facilitator displays problem tree and Venn diagram from the previous meetings. Facilitator revisits the main features, needs and desired outcomes around [concern] from the problem tree. Facilitator revisits the main actors, institutions and services (health and other) from the Venn diagram. From these activities we will now consider actions to address the issues identified. • Which ones need to be acted on by others within their own district or area?

PRIORITISING ACTIONS
• Who do communities need to influence to make these actions happen?
• Which ones need to be acted on by governments or other national institutions? • Who do communities need to influence for these actions?
• When can these actions take place?
• How can we monitor them? • How will we know then they have been achieved?
• What is the role of DoH? What is the voice of this community? 2. When the lists have been developed, give each participant 3 stones, beans or any other marker available. Ask them to distribute or place their counters against three actions they think are most important and need the greatest attention. Ask participants to discuss and interrogate the scoring. Have a second round of voting: Count the total counters for each item listed and write the totals on the flip chart paper. The group now has a list of top priority health actions. Record these on a new flip chart.

NEXT STEPS
Some of the main challenges reported by CHWs in their role is lack of trust between them and the communities and lack of resources. Although CHWs serve a critical purpose in communities, they are often only known as providing HIV related services and awareness of other services is low.

DEVELOPING TRUST RELATIONSHIPS IN COMMUNITIES
Regular, respectful engagement and meaningful communication is essential to build mutual understanding as a foundation for trust relationships between CHWs and communities. Many people in rural communities are not aware of spaces such as the community feedback meetings, leadership meetings and other spaces where various stakeholders meet to engage on issues affecting local people. There are several ways to raise community voice and support the use of evidence generated through rapid participatory methods.

CONNECTING TO RESEARCHERS
VAPAR is embedded in the MRC/Wits-Agincourt Unit's Health and sociodemographic surveillance system, which brings additional data to bear on the effects of the community-nominated priorities. VAPAR researchers support spaces and processes enabling engagement, exchange and the aligning of external research to national and sub-national priorities and needs to facilitate the accountability of researchers to local contexts, and the uptake of research output and the meaningful translation of research into policy and practice.

MULTISECTORAL STAKEHOLDERS
Developing multisectoral engagement and action supporting community responses addressing social determinants can be achieved by engaging stakeholders in the process set out in this manual. Stakeholders can be invited to join from provincial and district DoH including PHC, MCHWYN, and NCD programmes. As can representatives from the Department of Cooperative Governance and Traditional Affairs (COGTA), Department for Social Development (DSD), Department of Basic Education (DBE) and Department of Culture, Sport and Recreation (DCSR). Key local stakeholders include clinic committee, ward committee, Local Municipality, sub district.

CONNECTING TO THE HEALTH SYSTEM
Supporting routine PHC planning and review with evidence on communitynominated public health priorities, associated burdens of disease, the lived experience of that burden, and on how and with whom action could progress to address the issues identified is fundamental to the process. Prior to e.g. clinic committee meetings, sub-district PHC review meetings, or district health management team (DHMT) meetings, community groups supported by CHWs can plan for engagement, including convening smaller sub units planning and review teams, and negotiating access to programmes (e.g., maternal, child, women's and youth health), and convene sub-sets of management groups to support with priority setting, review and feedback as appropriate. www.vapar.org