Thereisaneedformeaningfulresearch,especiallythroughaparticipatoryapproachtoexplorefactorsaffectingcommunityparticipationandachievingtruecommunityempowermentwithinthepublichealthcaredeliverysystem.ManyfindingsimplythatapplyingPLAmethodologiestothesensitiveandunderstudiedsubjectofgapidentificationandprioritizationmightyieldcontextualdataonneedassessment,mobilization,andgroupbuildingexperiences.Finally,participatorytechniquescanaidinthedesignofevaluationsaswellasthediscoveryofcausalpathwaysandpotentialmechanismsforprogramchange.
Atotaloffourtypesofparticipantswererecruitedbasedontheirdesignationandrepresentationinvariousaspectsofruralhealthcare.TheASHArepresentstheimplementationaspect,theGKSandPRImembersprojectthedecision-makingandresourceutilizationaspect,andfinally,theSHGmemberrepresentsthecommunityengagementaspect.Wehavemaintainedhomogeneitywithineachgroupasfarastheeducationallevelofparticipantsisconcerned,whichbalancesreflexivityinqualitativemethods.
ThePLAactivitywasspannedover2dayswiththefirstdaybeingusedfororientationofparticipantsregardingtheexercisesfollowedbythePLAsessionandpresentationonthesecondday.Atotalof10teamsfrom10villagesparticipatedinthePLAsessionwiththreeexercisesforeachteamseparately.TheoverallprocesshasbeensummarizedasFacilitationandDissemination.
AfterthecompletionofthePLAexercises,eachteampresentedandsummarizedkeyfindingsfromPLAsessionandinvitedfeedbackfromotherparticipants.Itwasaparticipant-drivendiscussionthatwasdocumentedbyourreportingteamforfurtheranalysis.
InthisPLAexercise,communitymembersacrossalmostallvillagesspokeabouttheimportanceofidentifyingtheenablerandbarrierstowarddifferentaspectsofhealththroughtheH-diagram.
Manyparticipantsidentifiedtheexistingsocialcoherenceintheirvillagesasoneofthesignificantenablersofcommunityparticipation.
AllthestakeholdersreportedthatschemessuchasUjjwalaYojana(freeLPGgasconnection),SwachhBharatMission(freetoilet),PublicDistributionSystem(PDS),andsoonhaveplayedasignificantroleinmaintainingthehealthintheircommunity.Inadditiontothis,theseschemeshavealsohelpedtobuildanenablingenvironmentforcommunityparticipationatthevillageleveleitherdirectlyorindirectly.Mostoftheparticipantsechoedthefactthatmaternalandchildhealthcarehaveimprovedsignificantlyintheirvillagesduetocommunityparticipationinpublichealthprogramsandenhancedawarenesswithinthefemalecommunity.
MostoftheparticipantsfeltthattheCOVID-19pandemichasmadevillagersmoreresponsibletowarddiseasepreventionwithintheircommunity.Manyofthemagreedthatthispandemichastaughtthevillagershowhealthisacollectiveresponsibilityofeveryonewithintheircommunity.ThelocalPRIsalsofeelmoreempoweredduetotheroleplayedbytheminmanagingthispandemicatthevillagelevelthroughcommunityparticipation.
Manyparticipantsemphasizedtheroleofmediaandtheinternetinimprovingcommunityparticipationintheirvillagesastheyhaveincreasedtheavailabilityofinformationaswellasthespeedofcommunication.
Someofthestakeholderswerelessvocalabouttheenablersofcommunityparticipationintheircommunityastheyweremoreconcernedaboutthebarriers.Ontheotherhand,theparticipantsalsoexpressedaneedforfurtherimprovementinsomeoftheenablingfactorsofcommunityparticipationhighlightedbythem.
Socialchallengessuchasilliteracy,migration,unemployment,andthelackofawarenessregardinghealthweredescribedasthemostimportantbarrierstowardestablishinghealthasasharedresponsibilityamongtheruralpopulation.
Almostalltheparticipantsidentifiedalcoholandothersubstanceabuseasasignificantchallengefromapublichealthperspectiveintheircommunity.Theyalsohighlightedthatalcoholabuseleadstoanincreasedincidenceofothersocialevilssuchasdomesticviolence,sexualabuse,andsoon.Problemssuchassubstanceabuseandlocalpoliticshaveerodedthesocialcohesionexistinginvillages.Thisinturnishamperingtheenvironmentforsocialmobilizationaswellassustainedcollaborationrequiredforcommunityparticipation.
Aspersomeparticipants,disruptioninservicedeliveryhasalsoaffectedtheenthusiasmtowardcommunityparticipationamongthevillagepopulation.Dissatisfactionamongthecommunityregardingthequalityofhealthcareaffectsthemotivationofvillagerstowardcommunityparticipation.Someoftheparticipantsalsohighlightedthatmanyfromtheruralpopulationaredependingonprivatehealthcareforhealthservicesmakingthemlessenthusiastictowardcommunityparticipation.
Amongotherbarriershighlightedbytheparticipants,thelackofleadershipqualityamongPRIsandfailureofgovernmentinsolvingsomeofthepre-existingproblemsrelatedtobasichealthneedsofvillageshaveaffectedtheinvolvementofvillagersincommunity-basedhealthevents.
Alltheparticipantgroupsmappedtheresourcesplayingasignificantroleinmaintaininghealthintheircommunitythrougharesourcemappingexercise.Onlythreeoutof10villageshadsubcenterintheirvillageandnoneofthevillageshadaprimaryhealthcenter.Althoughmostofthevillageshadprimaryhealthcenterswithinmanageabledistance,poorroadconnectivitywasoneoftheimportantissueshighlightedbytheteams.Fewvillageswerehavingcommunitycentersbutwereseldomutilizedforhealth-relatedevents.
ThemostimportantresourceforcommunityparticipationinvillageswastheASHAsandAWWsasagreedbymostofthestakeholders,especiallythePRImembersandSHGmembers.
MostoftheASHAsandAWWswerestayinginthesamelocalityandwerewellengagedwiththecommunityassignedtothem.Incaseofanycommunity-basedactivity,ANMandASHAtaketheleadroleincommunitymobilization.AWW,membersfromPRIsandSHGs,supporttheminreachingtovillagersandcreatingpositiveopinionsregardingtheeventwithinthesociety.Fewparticipantsreportedthatnow-a-daysschoolteachersaregettinginvolvedinhealth-relatedeventssuchastheMeasles-Rubellacampaign,massdrugadministration,andsooninvillages.However,primarily,theyareinvolvedinteachingandprovidingnutritiousfoodtoschoolchildrenthroughamid-daymealprogram.
Aspertheparticipants,mostofthevillagerswerehavingfarminganddailylaborasanoccupation.Buttheyweredependentonthepublicdistributionsystem(PDS).forsubsidizedmonthlyfoodsupplythroughrationcards.Ontheotherhand,itwasvoicedbysomemembersthatfoodsecurityisnoreplacementfornutritionsecurityandkitchengardensaretryingtofillthisgaptosomeextent.Someotherresourcessuchasdrinkingwatersupplyandproperdrainageweremappedbytheteammembersbutduringdiscussion,andtheyexpressedtheirdissatisfactionduetopooraccessibilityandmaintenance.Theyalsoagreedupontheneedforvillagerstotaketheresponsibilityformaintainingacleanandhygienicvillageenvironment.
Mostofthestakeholderswereputtingtheresponsibilityongovernmentadministrationforequippingthevillageswithsufficientresourcesneededforahealthycommunity.Manyparticipantsagreedthatcommunitymobilizationneedssustainedeffortsandnotjustresourcesasithasasignificantroleinprimaryhealthcare,especiallyinresource-limitedsettings.
Mostoftheparticipantswereabletoidentifytheresourcesandtheirutilitiesalreadyavailableintheirvillagesinimprovingcommunityparticipation.TheyconsideredlocallevelinstitutionssuchasAWC,subcenter,schools,andpanchayatofficeastheessentialresourcespromotingcommunityparticipationintheirvillages.However,theywerelackinginorientationtowardastructuredapproachforcommunityparticipationinsolvinglocalproblemsandutilizingavailableresources.
Underlong-termplans,somevillagesproposedcollaboratingwithlocalNGOsinimplementingtheirannualactionplansfortheircommunity.Crowdfundingwasalsodiscussedasanoptiontoimplementlow-costsolutionsthroughproperplanningandtransparency.GKSmembersfromsometeamssuggestedimprovingthecoverageofbeneficialhealth-relatedschemessuchasBijuSwasthyaKalyanYojana(Bijuhealthinsurancescheme).andothersocialbenefitschemestogetmorecommunitysupport.ThemajorityoftheteamsalsopointedoutthattheywouldpromotephysicalactivityandadoptionofahealthylifestylethroughcommunityparticipationasapartoftheiractionplantotackleNCDsintheircommunity.Allthevillages,especiallythoseteamswithSHGmembersstressedworkingtowardimprovingmenstrualhealthintheircommunitybystrengtheningadolescenthealthservicesintheircommunity.
Althoughalltheteammemberswereverymuchexcitedinpreparinganactionplanfortheirvillages,manyoftheinterventionstheyidentifiedneededinfrastructuralchanges(e.g.,buildingroads,hospitals,etc.).Allofthemagreedtohighlighttheseneedsinfrontoftheadministrationmoresensiblyandcoherently.
Mostoftheparticipantsagreedthatthereisalreadyanexistingsystemforcommunityparticipationineveryvillage.Manyparticipantsstressedtheneedforregularvillagemeetingswithhealthasaprioritytopictomaintainasenseofurgencyamongthegeneralpopulation.MostoftheteamsalsoechoedthefactthatthePLAtechniquecanbeverymuchusefulinplanningforhealthcareinterventionsatthevillagelevel.
Therawdatasupportingtheconclusionsofthisarticlewillbemadeavailablebytheauthorswithoutunduereservationuponreasonablerequest.
ThestudiesinvolvinghumanparticipantswerereviewedandapprovedbyInstitutionalEthicalCommittee,AllIndiaInstituteofMedicalSciences,Bhubaeswar.Thepatients/participantsprovidedtheirwritteninformedconsenttoparticipateinthisstudy.Writteninformedconsentwasobtainedfromtheindividual(s)forthepublicationofanypotentiallyidentifiableimagesordataincludedinthisarticle.
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Theauthorsdeclarethattheresearchwasconductedintheabsenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasapotentialconflictofinterest.
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Keywords:communityparticipation,participatorylearningandaction,ruralhealth,healthsystem,communityengagement
Citation:MishraA,SinghAK,ParidaSP,PradhanSKandNairJ(2022)UnderstandingCommunityParticipationinRuralHealthCare:AParticipatoryLearningandActionApproach.Front.PublicHealth10:860792.doi:10.3389/fpubh.2022.860792
Received:23January2022;Accepted:27April2022;Published:06June2022.
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Disclaimer:Allclaimsexpressedinthisarticlearesolelythoseoftheauthorsanddonotnecessarilyrepresentthoseoftheiraffiliatedorganizations,orthoseofthepublisher,theeditorsandthereviewers.Anyproductthatmaybeevaluatedinthisarticleorclaimthatmaybemadebyitsmanufacturerisnotguaranteedorendorsedbythepublisher.