Caroline Kabaria, Ivy Chumo and Blessing Mberu; African Population and Health Research Center (APHRC), Kenya.
Community radio is a short-range, not-for-profit radio station or channel that caters for the information needs of people living in a particular locality, in the languages and formats that are most adapted to the local context. The radio station serve as information diffusion strategies where different actors communicate developmental information in areas such as health and wellbeing. In Kenya, it is referred to as community or participatory broadcasting initiated and controlled by members of a community of interest, or geographical community, to express their concerns, needs and aspirations without outside interference or regulation of the Independent Broadcasting Authority. Despite the knowledge on role of radio stations by health and wellbeing actors, the role in dissemination and validation of research findings in informal settlements is still underexplored and underutilized.
ARISE explored using community radio stations for a wider reach in the validation and dissemination of research findings in Korogocho and Viwandani informal settlements, Nairobi, Kenya. Once researchers and co-researchers had completed mapping social and governance terrain activities – community profiling, social mapping, ground-truthing, and governance diaries – we planned to co-validate and co-disseminate the findings to the community and sought for advice on the subsequent work packages.
To start with, the radio presenter introduced us (researchers and co-researchers) as the guests for the session and encouraged the audience to listen and seek clarification after our presentations. We presented the main objective of ARISE project seeking to enhance accountability and improve the health and wellbeing of marginalized populations living and working in informal urban settlements in low- and middle-income countries. We also presented the project vision of aiming to catalyse a step change in approaches to improving accountability and promoting the wellbeing and health of marginalised people living and working in informal urban settlements. Further, we described the project activities involving data collection and participatory activities with communities and community actors in the attempt to develop interdisciplinary metrics that explore intersecting inequities. Lastly, we presented in-depth findings of mapping social and governance terrain including drivers of inequities, governance actors, marginalized and vulnerable groups, health and wellbeing priorities and social accountability mechanisms among others.
Dialogue and discussions followed our presentations, moderated by community radio host. The session was remarkably interesting, with citizens calling in to recognize us, seek further clarification, appreciating our work and airing out their thoughts, recommendations and concerns about our work in the community in general. It was a highly informative session for us since we learnt about different solutions from a broader range of audience. One thing was clear, in that the people’s voices needed much more amplification because they were feeling muffled by monopolistic and illegal service providers. The community audience also spoke passionately of the need for public participation to educate the community on social accountability mechanisms for improved health and wellbeing.
We accomplished our objective because the community audience were delighted to understand that the project phases and recommendation will catalyse a step change and empower slum residents to demand for services at three levels (macro-level, meso-level and micro-level). At the macro-level, empowerment will focus on the need for social accountability from institutions and policies affecting all citizens. At the meso-level, empowerment will focus on the need for social accountability in slum specific policies; policies such as those for migration and community engagement. Finally, micro-level empowerment will focus on the need for social accountability or interventions targeted at specific problems such as public health, upgrading environment, and health education. A step change on the three levels of social accountability when attained will promote equity in urban slums.
From our experiences, we conclude that there is need for greater participation of marginalized and vulnerable populations on accountability and equity dialogues for improved health and wellbeing. Promoting communication media such as community-based radio programmes on/for marginalized and vulnerable populations will facilitate access to important information and give a voice to the traditionally voiceless people living and working in informal settlements. In addition, radio stations can be an avenue to voice issues that affect equitable health and wellbeing from the domestic and marginalized life into the outside world.
Menstruation presents several challenges in the areas of physical and mental health, comfort, social ease, and productivity for many women. Women with socioeconomic capital, financial resources, employment benefits and security, agency, and autonomy are able to navigate menstruation using acute and longer-term strategies of safe and discreet menstrual hygiene management, exercise of appropriate social arrangements, prevention and screening of gynaecological ailments, promotion of general health, and utilisation of facilities for time off work if necessary. In contrast, women from socioeconomically disadvantaged communities face multiple hardships and have little or no recourse to solutions, taking menstruation from the normal physiological process that it should be to a recurring impediment to women’s physical, social, and economic health. On World Menstrual Hygiene Day 2022, we reflect on the impact that menstruation, and the social stigma around menstruation, have on the lives of women waste workers in India.
The challenges of menstruation for waste workers
Daily wage earners and ‘own account’ workers among waste workers have limited job security, with no option but to undertake their demanding waste picking and sorting activity every day. This involves walking long distances to work, with many forgoing public transport to save the fare. The work necessitates walking, carrying loads of collected waste, and repetitive bending and stretching. For those in difficult terrain, such as in hilly areas, everyday routes to work involve walking on uneven and steep paths, and narrow and steep stairways without railings, while carrying 10-30 kg of waste. Waste workers typically set out for work very early in the day and miss meals until they finish work late in the afternoon.
Women waste workers also have limited or no access to toilets, an amenity that is essential during menstruation. Those who have heavy bleeding prepare for these hard days by using two or three menstrual pads at once, or menstrual pads along with old cotton cloth, resigning themselves to unalleviated physical discomfort to overcome the lack of civic amenities.
Through it all, the overpowering embarrassment associated with mentioning, let alone discussing, menstruation impedes their menstrual hygiene management practices, including procuring or preparing menstrual absorbents, changing, washing, and drying used cloth, or wrapping and disposing of used pads. Over the long term, poverty and cultural norms that deprioritise women lead to suboptimal nutrition and unhealthy behaviours that place girls and women at higher risk for gynaecological disorders, and communicable and non-communicable diseases, while healthcare remains difficult to access.
Many women in the waste worker communities use old cotton cloth that they tear into rags and discard after a single use by open burning, shallow burying, or dumping with municipal garbage. Even these modes of post-use disposal are fraught with embarrassment and the need to wait for dark, and find a relatively deserted spot to discard used menstrual absorbents. Reusable menstrual hygiene products are not preferred, as there are no facilities to support their use, such as toilets, water supply, soap, and clotheslines to dry the washed cloth thoroughly and discreetly.
In areas where women in the waste worker communities have friendships and informal social relations centred around employment, and relatively better access to resources, the usage of commercially available disposable menstrual pads is common. But even these women lament the additional out-of-pocket expenditure for menstrual products, and hope for free or low-cost alternatives.
Menstruation and waste work: a two-fold challenge
Women in waste worker communities are also the ones who pick the discarded menstrual absorbents from municipal waste. When these are poorly disposed of, waste workers bear the brunt of it, often having to come into direct skin contact with used menstrual absorbents. Sometimes, street animals, while scavenging for food, tear apart waste bags containing used menstrual absorbents and lay them out in the open. For the waste workers, it is then not just a matter of shame, but also an increased risk of contracting infections that their occupation poses.
In addition, women from economically weak sections of society have always had to bear the double burden of responsibilities both inside and outside the home. This includes unrelieved sociocultural responsibilities in the family and community (such as care for children and the sick and infirm, as well as the duty to preserve modesty by not discussing or displaying menstrual hygiene products or practices), without the benefits of facilities for rest, recuperation, and recreation.
Menstruation leave: only for some
Affluent women with resources can claim menstrual leave or sick leave (in places where menstrual leave is not formally accepted). But such systems are not available for women in waste worker communities. They are apprehensive about seeking leave as missing work would mean that it would pile up for them to undertake on their return, or other workers would have to shoulder the burden of their work.
Improving menstrual hygiene management, and ending the stigma
Promoting safe and acceptable menstrual hygiene management for women in this complex context of sociocultural expectations and deprivation requires both adaptive and mitigating measures. This includes, for example:
safe, affordable disposable menstrual absorbents, as well as convenient facilities for disposal that have minimal adverse impact on the environment and on women’s health;
prompt and comprehensive provision of basic civic amenities, such as access to safe and affordable water and sanitation facilities;
community engagement to disrupt the silences, and eliminate the embarrassment and stigma associated with menstruation; and
accommodative workplace policies and legal safeguards that cater to the specific circumstances of women’s varied life experiences.
ARISE endeavours to promote safe and sustainable menstrual hygiene management
The ARISE team at The George Institute is embarking on a menstrual hygiene management intervention among women in waste worker communities in three action sites. The intervention, planned to be conducted over four months, will involve:
group and individual discussions to understand menstrual practices and norms;
distribution of sustainable menstrual hygiene management kits (including menstrual cups, reusable cloth pads, and period underwear, as well as amenities for post-use treatment); and
the filling in of a menstrual health log complemented with discussions to understand women’s experiences of using the kits over the duration of the project.
This work will provide us with findings on current practices, barriers and enablers of safe, healthy, and sustainable menstrual hygiene management, and acceptability and ease of use of various menstrual hygiene products. We anticipate that these findings will inform the development of future programmes by local governments, workers’ collectives, and NGOs in these sites as well as in other communities, particularly those facing socioeconomic disadvantages.
Menstruation presents several challenges in the areas of physical and mental health, comfort, social ease, and productivity for many women. Women with socioeconomic capital, financial resources, employment benefits and security, agency, and autonomy are able to navigate menstruation using acute and longer-term strategies of safe and discreet menstrual hygiene management, exercise of appropriate social arrangements, prevention and screening of gynaecological ailments, promotion of general health, and utilisation of facilities for time off work if necessary. In contrast, women from socioeconomically disadvantaged communities face multiple hardships and have little or no recourse to solutions, taking menstruation from the normal physiological process that it should be to a recurring impediment to women’s physical, social, and economic health. On World Menstrual Hygiene Day 2022, we reflect on the impact that menstruation, and the social stigma around menstruation, have on the lives of women waste workers in India.
The challenges of menstruation for waste workers
Daily wage earners and ‘own account’ workers among waste workers have limited job security, with no option but to undertake their demanding waste picking and sorting activity every day. This involves walking long distances to work, with many forgoing public transport to save the fare. The work necessitates walking, carrying loads of collected waste, and repetitive bending and stretching. For those in difficult terrain, such as in hilly areas, everyday routes to work involve walking on uneven and steep paths, and narrow and steep stairways without railings, while carrying 10-30 kg of waste. Waste workers typically set out for work very early in the day and miss meals until they finish work late in the afternoon.
Women waste workers also have limited or no access to toilets, an amenity that is essential during menstruation. Those who have heavy bleeding prepare for these hard days by using two or three menstrual pads at once, or menstrual pads along with old cotton cloth, resigning themselves to unalleviated physical discomfort to overcome the lack of civic amenities.
Through it all, the overpowering embarrassment associated with mentioning, let alone discussing, menstruation impedes their menstrual hygiene management practices, including procuring or preparing menstrual absorbents, changing, washing, and drying used cloth, or wrapping and disposing of used pads. Over the long term, poverty and cultural norms that deprioritise women lead to suboptimal nutrition and unhealthy behaviours that place girls and women at higher risk for gynaecological disorders, and communicable and non-communicable diseases, while healthcare remains difficult to access.
Many women in the waste worker communities use old cotton cloth that they tear into rags and discard after a single use by open burning, shallow burying, or dumping with municipal garbage. Even these modes of post-use disposal are fraught with embarrassment and the need to wait for dark, and find a relatively deserted spot to discard used menstrual absorbents. Reusable menstrual hygiene products are not preferred, as there are no facilities to support their use, such as toilets, water supply, soap, and clotheslines to dry the washed cloth thoroughly and discreetly.
In areas where women in the waste worker communities have friendships and informal social relations centred around employment, and relatively better access to resources, the usage of commercially available disposable menstrual pads is common. But even these women lament the additional out-of-pocket expenditure for menstrual products, and hope for free or low-cost alternatives.
Menstruation and waste work: a two-fold challenge
Women in waste worker communities are also the ones who pick the discarded menstrual absorbents from municipal waste. When these are poorly disposed of, waste workers bear the brunt of it, often having to come into direct skin contact with used menstrual absorbents. Sometimes, street animals, while scavenging for food, tear apart waste bags containing used menstrual absorbents and lay them out in the open. For the waste workers, it is then not just a matter of shame, but also an increased risk of contracting infections that their occupation poses.
In addition, women from economically weak sections of society have always had to bear the double burden of responsibilities both inside and outside the home. This includes unrelieved sociocultural responsibilities in the family and community (such as care for children and the sick and infirm, as well as the duty to preserve modesty by not discussing or displaying menstrual hygiene products or practices), without the benefits of facilities for rest, recuperation, and recreation.
Menstruation leave: only for some
Affluent women with resources can claim menstrual leave or sick leave (in places where menstrual leave is not formally accepted). But such systems are not available for women in waste worker communities. They are apprehensive about seeking leave as missing work would mean that it would pile up for them to undertake on their return, or other workers would have to shoulder the burden of their work.
Improving menstrual hygiene management, and ending the stigma
Promoting safe and acceptable menstrual hygiene management for women in this complex context of sociocultural expectations and deprivation requires both adaptive and mitigating measures. This includes, for example:
safe, affordable disposable menstrual absorbents, as well as convenient facilities for disposal that have minimal adverse impact on the environment and on women’s health;
prompt and comprehensive provision of basic civic amenities, such as access to safe and affordable water and sanitation facilities;
community engagement to disrupt the silences, and eliminate the embarrassment and stigma associated with menstruation; and
accommodative workplace policies and legal safeguards that cater to the specific circumstances of women’s varied life experiences.
ARISE endeavours to promote safe and sustainable menstrual hygiene management
The ARISE team at The George Institute is embarking on a menstrual hygiene management intervention among women in waste worker communities in three action sites. The intervention, planned to be conducted over four months, will involve:
group and individual discussions to understand menstrual practices and norms;
distribution of sustainable menstrual hygiene management kits (including menstrual cups, reusable cloth pads, and period underwear, as well as amenities for post-use treatment); and
the filling in of a menstrual health log complemented with discussions to understand women’s experiences of using the kits over the duration of the project.
This work will provide us with findings on current practices, barriers and enablers of safe, healthy, and sustainable menstrual hygiene management, and acceptability and ease of use of various menstrual hygiene products. We anticipate that these findings will inform the development of future programmes by local governments, workers’ collectives, and NGOs in these sites as well as in other communities, particularly those facing socioeconomic disadvantages.
On 31 March 2022, SPARC’s ARISE virtual session at the 2nd Gobeshona Global Conference took place. Vinodkumar Rao from SPARC chaired the 90 minute session titled “Urban Marginality and Resilience Expectations – learning from ARISE”. Presenters included Shrutika Murthy and Inayat Kakkar from TGI, Wafa Alam from BRAC – JPGSPH and Aditya Pradhyumna from APU.
The session aimed to explore the less-discussed aspects of urban resilience, which has had a lot of attention recently. Urban resilience requires actions from duty bearers and policy makers in investing into building resilience among communities, particularly the poor, who disproportionately bear the brunt of catastrophic and slowly induced climate related and other urban vulnerabilities.
But what does our experience in engagement with poor urban communities tell us about their vulnerabilities, organically developed resilience strategy, and their expectations from others, particularly those that are accountable for their well-being in general? Do we need to look at urban resilience with a new lens and challenge some of the problematic viewpoints that have potential to reduce the role of governance and accountability and replace them with self-resilience?
Indian waste workers bearing the brunt of climate change
Shrutika Murthy and Inayat Kakkar presented on the living and working conditions of waste workers in Shimla, Guntur and Vijaywada. Shimla is a city situated in the hilly northern India while Guntur and Vijaywada are situated in the southern part of India. The waste workers live precarious lives – they reside on informal living conditions, have poor and fragmented access to public health care forcing them to seek expensive and unaffordable private health care, and they face intersectional discrimination on the basis of caste and gender. There is little recognition of their contribution, and, in many cases, poor access to documentation that establishes their rights as citizens.
Waste workers often work in extreme weather, such as extreme heat in summers in the south and extreme cold in winters in the north, resulting in heightened exposure to climatic vulnerabilities. They are also constantly exposed to harmful wastes due to the nature of their occupation.
Many live on precarious and untenable lands and are therefore under constant threat of being displaced due to extreme climatic events, beyond facing evictions from state institutions. Gradual informalisation of even those who did have formal employment arrangements with the state institutions – such as the Municipal Corporation in Shimla for example – only worsens the precarity of their occupation.
The waste workers’ living conditions demonstrate our argument – in the absence of state action, this marginalised community, while disproportionately bearing the effects of climate change, may seem resilient, but is this the case?
Image by Darsheet Vora, Intern at SPARC
The informal systems built by informal settlement residents in Dhaka
Wafa Alam’s presentation reiterated Bangladesh’s position among the top climatically vulnerable countries. Large numbers of people live and work informally, and they will bear the brunt of climatic events more than others. Most settlements are built on empty Government and private land in low lying areas prone to flooding.
In some cases, people flee lands due to climatic events, only to resettle in another slightly less vulnerable area. For example, Kolyanpur Pora Basti – an informal settlement in Dhaka -is situated in a low-lying area that frequently floods. Residents are migrants from Bhola – a southern district – where gradual coastal erosion made the land unliveable. In the absence of adequate Government support, and over time, residents built systems themselves (although informal) to meet their needs. Residents pooled money and got water connections, particularly to tide them over in times of flooding when access to clean water and sanitation is normally severely affected.
During COVID, communities developed self-protection mechanisms, such as crowd control at public toilets and other amenities and setting up wash stations. Residents even complained about mismanagement of relief support and distribution, as they were not involved, pointing to a lost opportunity to use their networks for more efficient distribution of scarce relief resources.
This example of communities from Kolyanpur Pora Bastimay make them seem resilient, and they clearly are. However, while this should be appreciated, should these efforts not be supported by the state to make it more robust?
Public health systems investment is essential
Aditya Pradhyumna’s presentation highlighted the need to invest in health equity and to strengthen public health systems in India. Summing up the experience shared by the other speakers, he highlighted the increased health vulnerability faced by the urban and rural poor due to their living and working conditions and exclusion from public services.
There is now adequately established knowledge that climate change affects health and as such their individual vulnerabilities are not divorced from each other. We are seeing increasing prevalence of non-communicable diseases such as diabetes, increased wasting and stunting across India, worsening air quality due to pollution, and excessive heat, all of which is exacerbating the existing vulnerabilities of the poor. With the already weak existing public health system, it has no capacity to absorb heightened challenges due to climate change. Existing discrimination on the basis of caste, gender, and religion in the public health systems make them practically inaccessible to the most marginalised.
Aditya’s presentation points to deep gaps in the ability of public health systems to be resilient, and highlights that drastic improvements are required to build them.
SPAs: Addressing the needs of the local context
Vinodkumar presented on the Mukuru Special Planning Area (SPA) as a community led resilience building example on behalf of Smruti Jukur. The brief presentation largely spoke of how a SPA development of a large informal settlement such as Mukuru in Nairobi allows building development plans based on what works locally. While urban development norms and regulations have specific standards to be followed, they most often turn development of a dense urban informal settlement into something completely untenable. Therefore, the Mukuru SPA developed alternative norms that addressed the needs of the local context, while adhering to the key principles of urban planning. This is an example of collaborative community-led resilience building with investment from state institutions.
Adaptations are possible and important pathways to countering climate induced urban problems, however, the most marginalized must be a central part of its discourse.
Urban vulnerabilities to climate change are manifold and intersectional
In much of the discussions around effects of climate change in the contexts of urban vulnerable populations, the focus is on the impact to livelihoods. For example, waste pickers’ issues with climate and environment are manifold. However, very often their particular vulnerabilities are seen only from the lens of their occupations and less so on their basic needs for healthy living – such as housing and access to basic services – and even less so on seeking ways to pull them out of precarious livelihoods with daily exposure to harm.
The recent COVID pandemic showed us that urban vulnerabilities can immediately become visible and intensify in situations of pan-geographic catastrophes. However, many existing fault-lines often remain less visible due to their micro-occurrence in separate geographies. For example, those living and working informally face different challenges across cities, but their issues are not central to urban planning, and need large-scale disruptions, like the COVID pandemic, for them to become visible. Very often, with little or no intervention by state institutions, such unequal systems inch back to ‘normal’ and may be considered as a show of resilience, but the fault lines remain waiting for a catastrophe to lay them bare again. In thinking of building resilience, it is important that we understand the health disparities and the challenges in accessing health care systems in urban areas.
There is now a lot of civil society interest in addressing climatic vulnerabilities faced by the poor. And there are spaces where it is possible to bring the lives of the poor to the centre stage of planning. Urban planning, for example, now acknowledges informality and development plans can use this knowledge more meaningfully. The Special Planning Area (SPA) methodology is an example.
Making resilience-building central to urban planning
What spaces for adaptation and building resilience exist? Perhaps we have romanticised the living and working of the poor as acts of ‘resilience’ and as ‘contribution to a sustainable environment’. But are they largely just a reflection of choices available to them? We ask for access to slum housing that uses sustainable materials, but do we really ask if tenure security, safe housing and access to basic services precludes housing material choice? Should this not be a basic and blanket policy measure to be able to seek use of sustainable materials? Changing environment due to climate change requires new ‘sustainable’ ways of living and working, but are enough choices made available for the urban poor population living and working in informality to be able to practice them?
Much of this is now a part of mainstream ‘resilience building strategy’ discussions, but are we still far away from recognising this problem as central to urban planning and policy making? Policies must recognise the specific urban inequities that exacerbate problems for the poor more than they do for the general urban population, as well as mitigation strategies that themselves may further vulnerabilities of those already living and working on the margins of precarity.
While it may seem easier to tackle issues separately, the challenges are interconnected and the vulnerabilities intersect. In the context of climate change, if the socio-economic issues due to weak governance and their intersection with deep impact to human settlements is not acknowledged adequately, building resilience will remain a distant dream in countries of the global south.
Adaptations are possible and are important pathways to countering climate-induced urban problems, however, the most marginalized must be a central part of its discourse.
Image credit: Images by Darsheet Vora, Intern at SPARC
By Inviolata Njeri, Neele Wilten-Georgi and Lynda Keeru
If you are looking to know whether and how your research project has been impactful, look no further. Ripple effect mapping derives its name from the concept of throwing a stone in a pool of water that gives rise to concentric waves emanating from the point at which it impacts. The ripples spread far and wide.
Community Based Participatory Research (CBPR) is complex and involves multiple levels of stakeholders. Regular evaluation processes often overlook the nuances of CBPR, including the unintended but significant impacts of engaging communities in health research and action for social change along the journey and miss out on capturing community perspectives of intended and unintended outcomes.
The Ripple Effect Mapping Tool provides a space for research partners to reflect on their achievements and refocus on their aims while also supporting reflexivity processes on positionality, inclusion and equity. As such, grounds the research within the lived realities of communities. The tool also supports communities and researchers to engage in critical learning. It promotes a shared critical consciousness as a collective group while supporting researchers to communicate the concept of academic research and the aims of the research programme to communities in a visual and participatory way.
Research conducted by ARISE represents the stone in the form of an intervention that seeks responsiveness and accountability for equity for people living and working in urban informal settlements. Ripple effect mapping training, was conducted with co-researchers from Kenya and Sierra Leone. The co-researchers from Sierra Leone and SDI-Kenya visited Viwandani slums where they met co-researchers working with LVCT Health in Viwandani. The meeting that took place in mid-March 2022, was organized in a community hall where most community meetings and activities happen.
In order to maximize documentation of the richness, profundity, span, complexity of the ripple effect in the community programmes working with ARISE, the process started with an explanation of the ripple effect mapping. During the workshop, through a role play, two co-researchers from SDI-Kenya, modelled how the ripple effect mapping is conducted. In the role play, one of the co-researchers told a story (story teller), the other one (listener) listened to their story. This was followed by drawing a map using prompts to receive more details about the story and the role of the story teller in their story. All co-researchers were then given chance to seek clarification and give suggestions on how ripple effect mapping can be improved including what other questions could be used as prompts to guide the process better.
The ripple effect training involved pairing co-researchers in small groups of three each representing Sierra Leonne, SDI-K and LVCT Health. Five small groups were formed for practice purposes. Each of the three took turns to narrate, and listen while capturing the story on a flip chart. In turns, one of the pairs narrated his experience of the ARISE study activities while the other two listened. They then wrote their understanding of the process and effects of the study activities on a flip chart while asking questions to seek clarification and more details on the same. The narration detailed what the activity was, the people involved in the activity and their role, benefits that emanated from the study activities and the negative effects of the study activities if any.
The small groups reported back to the whole group. Some preferred narrating their own stories, while others narrated their peer’s story. One research assistant from Sierra Leone shared that he understood his story and was in a much better position to narrate it. All participants asked questions and commented on the different stories presented by the co-researchers. The feedback was related to engaging the community, who would draw the map, the level the story should focus on (community or individual impacts), and how many people would participate in a group. Everyone had their own opinion here so the important point is to have conversations around adapting the process to the participant’s needs and wants
The ripple effect mapping stood out as an easy way to conduct monitoring and evaluation with co-researchers who may not understand the technical aspects of monitoring and evaluation including the language used. The co-researchers enjoyed telling their stories and learning about each other’s experiences. Some of the co-researchers noted that they had never really thought about what they have been doing comprehensively, but the ripple effect mapping helped them reflect on their work and its impact on the community. All the co-researchers noted that they would like to use the ripple effect mapping to reflect on their work and use it to report their work.
The ripple effect maps developed looked different even for the same activity. This underscores the need to develop guidance to help standardize reporting using ripple effect mapping. Co-researchers need continuous mentorship on ripple effect mapping for them to effectively use it as a reporting tool. Colour coding for processes, activity and effects could also help to make the ripple effect maps clearer. Researchers have found this process particularly helpful for understanding expected and unexpected programme outcomes, as well as for inspiring and energizing programme participants, motivating them to continue their work and generate new initiatives
Image credit: Photo by AMISOM Public Information is licensed under Public Domain CC0 1.0
Mental health awareness week falls annually in May. Lynda Keeru and Inviolata Njeri kick off ARISE conversations on mental health with this blog about our work in Kenya
Despite of the continual gains and advances in mental health awareness, research and treatment, there is still a lot to be done and covered. To this end, mental health week is an effort to promote a more efficient and proactive approach to addressing mental health issues and creating more visibility.
ARISE are aware that mental health influences people’s quality of life just as much as physical health. On account of this, it needs to be prioritized and this is best done through joint community efforts. Communities are essential for mental health management as they provide support, belonging and purpose among many other functionalities.
Inviolate Njeri, a senior research and learning officer at LVCT Health, reflected on her interaction with community members, “Working in Korogocho and Viwandani slums in Nairobi in the course of implementing the ARISE project, has opened my eyes to people’s daily experiences that one can only learn by interacting with people living and working in these areas.”
Mental health issues can remain concealed in vulnerable communities only to manifest themselves through alcohol use, violence, unsafe sexual practices and crime that include robbery with violence. Our work using the photovoice method identified mental ill health as a key community challenge.
Unsurprisingly, the vulnerable, who include, child headed households, older people and persons living with disability bear the greatest brunt of mental ill health. Both sub-County and community-level groups conducted root cause analyses using the fishbone technique and developed a change plan to address mental health in the informal settlements.
“Child headed households had the concern of how their peers viewed them, this led them to avoid some type of friends who would make them feel out of place. Older persons regretted their past and felt sorry for themselves having to take care of their adult children who were irresponsible or grandchildren; occasioned by death of their parents. Persons with disability felt stigmatized through exclusion from public and social facilities due to how they have been designed or equipped,“ shared Inviolata.
Communities have created Work Improvement Teams to act on mental ill health and, with support from the counties and sub counties, they have trained at least sixty Community Health Volunteers (CHVs) on mental health issues. This included how to record mental health data and how to conduct referrals for further care. On account of this, there are now referrals for mental health issues to primary health facilities in both informal settlements. In addition to this, as part of the change management plans, a Mental Health Clinical Officer was posted in Ruaraka sub-County to address mental health referrals.
“As I listened to the discussions among community members, I realized abject poverty was indeed the bedrock for most mental health problems faced by residents of Korogocho and Viwandani. This is manifested in high stress levels experienced by the people and families. The high stress experienced, over time results into depression and eventually, a hopeless attitude in life,” explained Inviolata.
One of the participants explained, “When a father or mother has nothing to offer the children looking up to them, the hopelessness often results in an uncontrolled anger, which then translates into violence and the break of families. Parents who resort to alcoholism and abandon their children, are the starting point of households headed by children. Child headed households are subjected to very heavy burdens of care despite their limited capacities. They shoulder care for their incapacitated parents and/or younger siblings which exposes them to high levels of stress and anxiety.”
Due to the poverty that faces many in these informal settlements like Korogocho, people spend long hours in search of their livelihood. Consequently, the communal spirit is eroded and people have not time to identify and spot the struggles of fellow community members. This means that individuals carry their own problems the best way they know how; including adoption of unhealthy coping mechanisms.
“Now that there is a community health center and a community health unit with CHVs drawn from the area, there is need to vigorously continue the process of building their capacity. This is a critical pillar in addressing mental health challenges among the residents given that they are in touch with the people. The health facility within Korogocho ought to strengthen its capacity to handle referred mental health services by investing in the capacity of its health care providers and health infrastructure. Mental health awareness need to be brought to the fore through different for a such as local radios and theatre plays and groups,” said Inviolata as she signed off.
Image credit: Photo by nantonov is licensed by iStock.
Principle 11:
Value academic rigour in research partnerships
Involving community researchers and the broader community in the development and validation of priorities, study tools, data collection processes, data analysis, interpretation and action planning is important to the quality of the CBPR process. Consistently engaging the community in monitoring the progress of community activities and gaining their reflexive accounts of the actions ensures rigour within the research process.
Capacities (competencies and conditions)
●Awareness of trustworthiness criteria that draw on critical epistemologies
●Ability to assess and develop contextualised code of research ethics including safeguarding
●Capacity to undertake validation exercises with stakeholders and the wider community to ensure the study is relevant, accepted and supported
●Ongoing learning, quality assessment and safeguarding assessment
●Capacity to contextualise research materials that value local ways of knowing and knowledge production
●Knowledge on how to engage in and apply reflexivity, considering positionality with regard to research findings, to strengthen rigour and trustworthiness
●Ability to triangulate different sources of information to determine research priorities, approach and actions
●Rigorous research findings which draw on trustworthiness criteria
●Generalisable research processes that can enhance CBPR techniques
●Community based research that is robust and adds value to communities, policies and practices
●Community members learn research skills, gain access to resources, and find ways to legitimate their knowledge, which have previously been limited by a history of exclusionary research practices
●After the research partnership has undertaken a process of prioritisation, and before conceptualising the research, validate the priorities and incorporate additional context to increase trustworthiness in the process
●Design research analysis and interpretation procedures that involve community researchers and associated stakeholders
●Have an outsider to help increase the rigour and real and perceived validity of the research
●Conduct data interpretation sessions to discuss interpretations, add context to information collected, and facilitate a better understanding of project documentation
●Triangulate data sources and add participant checking
●Undertake co-analysis activities with co-researchers and stakeholders
●Increase the reliability of the study by developing and using a case study protocol and a chain of evidence
●Design survey and interview questions that are culturally aligned enhancing the fit of the research with the implementing context
●Identify relational and situated ethical and safeguarding concepts and approaches that best fit the specific context and the process-oriented nature of CBPR (25)
●Constructive negotiation with gatekeeping bodies such as funders and research ethics committees to increase understanding of appropriate approaches
●Engage co-researchers and community members during the research tool preparation to cover all the essential aspects of the research including safeguarding risks
Utilise quality criteria to evaluate the CBPR process – see Springett, Atkey (26) and Sandoval, Lucero (27
●Documentation on the translation and adaptation of the materials and quality assurance processes through minutes and notes on discussions and engagement within the team and with stakeholders
●Documentation of research validation processes
●Documentation of discussion during triangulation of findings
●Case studies/stories/blogs that show reflexivity processes
●Peer reviewed publications
●Audio or notes from community validation processes
●NVivo or other screenshots showing quality checking processes
●Development and use of a case study protocol and the development of a database and a chain of evidence to improve reliability of the study
*Please note that some statements are adaptations or direct quotes from the papers listed in the reference section
