Structural and Community Change Outcomes of the Connect‐to‐Protect Coalitions: Trials and Triumphs Securing Adolescent Access to HIV Prevention, Testing, and Medical Care

Abstract

Connect to Protect (C2P), a 10-year community mobilization effort, pursued the dual aims of creating communities competent to address youth’s HIV-related risks and removing structural barriers to youth health. We used Community Coalition Action Theory (CCAT) to examine the perceived contributions and accomplishments of 14 C2P coalitions. We interviewed 318 key informants, including youth and community leaders, to identify the features of coalitions’ context and operation that facilitated and undermined their ability to achieve structural change and build communities’ capability to manage their local adolescent HIV epidemic effectively. We coded the interviews using an a priori coding scheme informed by CCAT and scholarship on AIDS-competent communities. We found community mobilization efforts like C2P can contribute to addressing the structural factors that promote HIV-risk among youth and to community development. We describe how coalition leadership, collaborative synergy, capacity building, and local community context influences coalitions’ ability to successfully implement HIV-related structural change, demonstrating empirical support for many of CCAT’s propositions. We discuss implications for how community-mobilization efforts might succeed in laying the foundation for an AIDS-competent community.

Village community mobilization is associated with reducedHIVincidence in young South African women participating in theHPTN068 study cohort

“…We also found a strong protective association between higher village leadership scores and reduced HIV incidence. Investigations of what is needed for successful health promotion have proposed that skilled, accountable, flexible and inclusive leadership and leadership networks (including coalition building) are essential in fostering structural change and strong health programming in the United States and abroad , with poor or authoritarian leaders negatively impacting HIV community capacity . This study is, however, among the first to associate a quantitative measure of community‐rated quality of leadership (including items on community leaders’ capacity, diversity, responsiveness, accountability, accessibility, and support of collective decision‐making) with reduced HIV infections.…”

Methods to measure effects of social accountability interventions in reproductive, maternal, newborn, child, and adolescent health programs: systematic review and critique

“…There were various attempts to capture the impact of the intervention on decision-making and policy change. For example, “process tracing” was used, “to assess whether and how scorecard process contributed to changes in policies or changes in attitudes or practices among key stakeholders” [ 23 p. 374], and “outcome mapping” (defined as, “emphasis on capturing changes in the behavior, relationships, activities, or actions of the people, groups, and organizations with whom an entity such as a coalition works”) [ 27 , p. 6] was used to assess effects of the intervention on systems and staff.…”

“…The term “social accountability” may imply an adversarial relationship where certain individuals are acting in bad faith. One of the studies in our review used different terminology—“collaborative synergy”—referring to the work of coalitions in the Connect2Protect intervention [ 27 ]. We speculate that lack of agreed, common terminology may hinder learning from other areas of research—the phrase “social accountability” is not commonly used in the patient and public involvement (PPI) literature, possibly because of the greater emphasis in high income settings on co-production and sustainability compared with more of a “policing” emphasis in the literature reporting on LMIC settings.…”

“…Others explicitly aimed to examine how the interventions could affect specific outcomes. This was the case for studies of an HIV/AIDS programme for military families [22]; effects of community-based monitoring on service delivery [13]; effectiveness of engaging various stakeholders to improve maternal and newborn health services [23]; acceptability and effectiveness of a telephone hotline to monitor demands for informal payments [24]; effectiveness of CARE's community score cards in improving reproductive health outcomes [25]; assess effects of quality management intervention on the uptake of services [26]; examine structural change in the Connect 2 Protect partnership [27]; improve "intercultural maternal health care" [28]; and whether and how scale up of HIV services influenced accountability and hence service quality [29]. Some studies were unclear in the write up what the original aims were, but appeared to try to document both implementation and effectiveness, for example the papers reporting on scorecards used in Evidence4Action (E4A) [30,31].…”

Studying social accountability in the context of health system strengthening: innovations and considerations for future work

“…empowering service providers, mutual responsibility, increased confidence of service users) using psychometric measures and structured observations, which have been tested and are now moving into multi-country validation [2, 14, 20]. Others have been using approaches such as the Bellwether approach, outcome mapping and process tracing to assess changes in duty-bearers’ actions as a consequence of such interventions [3, 27, 28]. These innovations can be learnt from and built upon.…”