Building cooperative learning to address alcohol and other drug abuse in Mpumalanga, South Africa: a participatory action research process

Figures & data

Figure 1. Problem tree developed by community stakeholders illustrating the non-linear, self-reciprocating relationships between causes and effects of AOD abuse

Table 1. Composition of discussion groups

Participants*	Original	New	Total
(a) Three village-based discussion groups (including group nominating water)
Religious leader	1		1
Traditional healer	3		3
Community official	5		5
Community health workers	3		3
Family member**	7	4	11
Woman of reproductive age	5	4	9
Youth		16	16
TOTAL	24	24	48
(b) Two village-based discussion groups (group nominating AOD abuse)
Religious leader	1		1
Traditional healer	2		2
Community official	3		3
Community health workers	2		2
Family member**	4		4
Woman of reproductive age	4		4
Youth		16	16
TOTAL	16	16	32

*All participants were 18 years or older. Acknowledging that participants have multiple roles at home and in the community, a primary role was agreed with participants for the purposes of recruitment. **Close relatives: parents, siblings, in-laws, nieces, nephews, cousins.

Table 2. Schedule of workshops and PAR tools and techniques

Community-based group (priority health topic)	Focus topic (tools and techniques)
	Week 1	Week 2	Week 3	Week 4	Week 5	Week 6	Week 7	Week 8
A (AOD)	Workshop 1: Topic selection (ranking and voting)	Workshop 4: Causes/ Impacts (problem tree)	Workshop 7: Impacts/Actors (Venn diagram)	Workshop 10: Action (action pathways)	Workshop 13: Causes/ Impacts (problem tree)	Workshop 14: Impacts/Actors (Venn diagram)	Workshop 15: Action (action pathways)	Workshop 16: Reflection and next steps (facilitated discussion)
B (AOD)	Workshop 2: Topic selection (ranking and voting)	Workshop 5: Causes/ Impacts (problem tree)	Workshop 8: Impacts/Actors (Venn diagram)	Workshop 11: Action (action pathways)
C (Water)*	Workshop 3: Topic selection (ranking and voting)	Workshop 6: Causes/ Impacts (problem tree)	Workshop 9: Impacts/Actors (Venn diagram)	Workshop 12: Action (action pathways)
Ranking and voting	To identify priority health topics of relevance to the community. A list of health priorities was developed during the discussion, after which participants voted for the topics of highest relevance using adhesive stickers. The voting progressed through two rounds with discussion and agreement at the end.
Problem tree	To understand and ‘unpack’ nominated topics from different perspectives. Through facilitated discussions using a tree diagram visible to all, participants identified 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.
Venn diagrams	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.
Action pathways	To articulate overall goal(s) to address the issues identified and visualise and depict stepwise actions and actors to achieve these. The action pathway was collectively developed to represent moving towards a desired goal via a series of interconnected steps and events.
Photovoice	To visually convey lived experience. Participants given basic training in photography, research ethics and digital cameras to take photographs illustrating the topic or condition as it existed in the physical environments. Photographs presented and discussed in meetings, and captions developed to describe what images conveyed.
Facilitated discussion	On reflections and next steps: to reflect on experiences, outputs and how the process should be carried forward to engage government and non-government organisations. Participants discussed differences and similarities between the workshop outputs, cross-verified each other’s outputs and reflected on the process and future development

* Results presented elsewhere. Source [69].

Figure 2. Venn diagram prepared by community stakeholders showing the range of actors addressing AOD abuse, and their levels of importance and connection to the community

Figure 3. Action agenda prepared by community stakeholders to address AOD abuse in communities indicating overall goals, actions, actors, timelines, and progress monitoring

Table 3. International learning on building social participation in health systems, process reflections, and future adaptions. Adapted from [40]

International learning	Process reflections	Adaptations
1. Participation is both a means for health improvement and an end in itself based on values and rights	Broader understanding of forms, processes and contexts requires explicit reference to, and ultimately transfer of power towards, disadvantaged groups, and a focus on change processes developing community voice as a continuous process, situated within social and political environments	Framing in terms of social justice and citizenship may help to communicate key features of the process and what it seeks to achieve
2. Community experience is a key entry point, and community activism and leadership are key drivers of participatory practice	Mobilisation activities related to participation and deliberation were possible to progress, and there was some evidence of individual acts of information sharing in the wider community	Enabling community experience and leadership, with less researcher control and more shared ownership should be incorporated into collective design decisions
3. Participatory processes and social power in health are more likely to thrive when services go into community settings	All activities were conducted in accessible community spaces in which there were generally supportive attitudes. Community settings appear supportive and enabling of PAR	While institutional and political support is important, claimed spaces in which issues can be autonomously raised and framed are important to cultivate and maintain
4. They are supported by and elicit more holistic models of health	Self-nominated priority topics, and facilitated participatory problematization clearly elicited holistic models of health	For acting on the evidence generated, a wider set of stakeholders should be engaged, beyond department of heath
5. Informal and formal spaces and processes both play key roles. The synergies and links between them enrich both	Formal (e.g. clinic committees) and informal (e.g. VAPAR) structures exist for community participation in this setting	Interaction between claimed and invited participatory spaces will be sought and progressed
6. Institutional and individual facilitators play a critical role	Sensitive facilitation was key to convey process, co-design, and power dimensions that enabled rich action-oriented interpretations of community nominated. Management of expectations important	Lift up and make explicit the key contribution of facilitation. Explore skills exchange for effective and respectful facilitation
7. Sharing Information and participatory processes to gather, analyse, discuss and use community evidence in planning are necessary (but not sufficient) for meaningful social participation	The wider VAPAR process is geared towards cooperative action cooperation with health authorities in the province, district, sub-district and locally	A wider set of stakeholders beyond department of health, should be engaged to share, interpret, act on, and learn from community evidence
8. Accessible processes for co-determination that link decisions to shared plans, actions and resources to act are central to meaningful participation		Careful consideration and appraisal of implications of proposed actions in cooperation with health systems stakeholders, and other government and non-governmental stakeholders, are necessary as process progresses
9. Deepening of participation takes a consistency of presence, time and capacities	The wider VAPAR programme supports this consistency	Attention to specifics of engagement over time, and beyond defined periods of engagement, is required with a focus on making implicit issues of presence, time and capacities explicit. Careful attention to issues of marginalisation and representation are required
10. Learning from action (and evaluation) needs to track diverse forms of progress to build strategic review	Wider VAPAR programme enables the tracking of progress	Diverse forms of progress (and failure) require careful monitoring as the action elements progress

Mabetha D ‘It destroys families and communities’: alcohol and drug abuse in rural South Africa. In: 5th Global Symposium on Health Systems Research [Internet]; 2018 [cited 2020 Jan 30]. Available from: https://tinyurl.com/wrab76p

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Loewenson R, Beznec P, Coelho V, et al. Building social power and participation in local health systems: learning from practice. In: Harare: TARSC; 2017 [cited 2020 Jan 30]. Available from: https://tinyurl.com/vc5mte5

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Data availability

Data available on reasonable request to the corresponding author.