‘Whose failure counts?’ A critical reflection on definitions of failure for community health volunteers providing HIV self-testing in a community-based HIV/TB intervention study in urban Malawi

Abstract

The category of community health worker applied within the context of health intervention trials has been promoted as a cost-effective approach to meeting study objectives across large populations, relying on the promotion of the concept of ‘com-munity belonging’ to encourage altruistic volunteerism from community members to promote health. This community-based category of individuals is recruited to facilitate externally driven priorities defined by large research teams, outside of the target research environment. An externally defined intervention is then ‘brought to’ the community through locally recruited community volunteers who form a bridge between the researchers and participants. The specific role of these workers is context-driven and responsive to the needs of the intervention. This paper is based on the findings from an annual evaluation of community health worker performance employed as community counsellors to deliver semi-supervised HIV self-testing (HIVST) at community level of a large HIV/TB intervention trial conducted in urban Blantyre, Malawi. A performance evaluation was conducted to appraise individual service delivery and assess achievements in meeting pre-defined targets for uptake of HIVST with the aim of improving overall uptake of HIVST. Through an empirical ‘evaluation of the evaluation’ this paper critically reflects on the position of the community volunteer through the analytical lens of ‘failure’, exploring the tensions in communication and interpretation of intervention delivery between researchers and community volunteers and the differing perspectives on defining failure. It is concluded that community interventions should be developed in collaboration with the population and that information guiding success should be clearly defined.

Ethical Gifts?: An Analysis of Soap‐for‐data Transactions in Malawian Survey Research Worlds

“…; Sambakunsi et al. ). Finding the informed consent script too lengthy, he summarizes it instead of reading it verbatim, for example.…”

“…; Sambakunsi et al. ). Yet, naming soap “ethical” does not preclude critical engagements with the ensuing production of value and knowledge from information collected.…”

“…His comments echo the emphasis on moral responsibility beyond formal ethical practice endorsed by fieldworkers and other intermediaries across contexts (Kingori ; Sambakunsi et al. ). Further, they illustrate how a gift can be ethical when evaluated from a perspective within a research world, but unethical when evaluated in light of historical memory and experience—activated by soap‐for‐information transactions—in a particular time and place.…”

“…In this composite sketch of a typical research encounter in the field, Ndema, a high school-educated fieldworker in his 20s who lives in Mary's district, embodies the mannerisms and practices he has been taught in pre-fieldwork training sessions: He is respectful, dressed professionally, gracious, and careful in his interaction with Mary. Yet, as a bridge between his community and foreign researchers, he modifies standards and guidelines for administering surveys to adapt to unfolding conditions in the field (Kingori 2013;Madiega et al 2013;Reynolds et al 2013;Sambakunsi et al 2015). Finding the informed consent script too lengthy, he summarizes it instead of reading it verbatim, for example.…”

“…The justification for research in impoverished settings relies on a presumption that it will improve the collective good or bring abstract future benefits to participants, but participants may expect their individual or collective lives in the present to be transformed (Reynolds et al 2013, 122;Titmuss 1997Titmuss [1970, 281). While anthropologists document how research transactions of blood, information, and benefits activate multiple gift economies that come into friction, soap, even as it is assigned competing meanings, works because its transaction is legitimated as ethical by both participants and researchers embedded in the worlds created by human subjects research guidelines (Lairumbi et al 2012;Sambakunsi et al 2015). Yet, naming soap "ethical" does not preclude critical engagements with the ensuing production of value and knowledge from information collected.…”