"Voice needs teeth to have bite"! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa

There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community "voice" and initiating dialogue with the authorities, giving the voice "teeth". Achieving "bite", however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative mindsets in organisational contexts aligning community voice with state capacity to respond.

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The copyright holder for this preprint this version posted July 9, 2022. 72 hours to consider and ask questions. Written consent was sought from all participants in which we assured 0 5 anonymity and that participants were free to leave the process at any time and for any reason. Participants were 0 6 provided with refreshments, transport costs and were reimbursed for time spent participating in workshops: The results are presented by emergent themes and, within this, by analytical constructs drawn from the 2 0 frameworks and theories adopted. These were: process forms and dynamics; actor interactions and interfaces; is illustrated with verbatim quotes from participants. This is followed by an account of transferrable learning. In Step 1, community stakeholders developed sophisticated, multi-level accounts of AOD abuse as an communities, and with children and adolescents placed at the centre of exposure to risk and lifelong . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 9, 2022. future is destroyed, which also destroys the future of the whole community [Community stakeholder, 4 0 Step Impacts in Step 1 were observed in terms of familiarity, ownership, and control, which built over the course of the 5 0 workshops. This was supported and enabled by prioritising prior relationships, co-designing the process, regular 5 1 dialogue, and engagement, and locating workshops in accessible areas and at reasonable times. New

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participants brought a needed perspective, but also challenges, reflecting aspects of wider social contexts.

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Some youth participants were initially sceptical about the potential for change and often disruptive during the 5 4 workshops.

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We have learned some of the things, but let's face the main issue -this process won't change anything, In response, we reinforced principles of respectful engagement and took time to manage expectations. We workshops with the authorities (Supporting Information 1). 6 6 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 9, 2022. The VA and PAR data and evidence were then used as the basis of dialogue between rural communities and the 7 6 authorities. Here, contextual, and organisational influences were again evident in the interactions and interfaces.

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The 'analysis' workshops were initially located in provincial DoH offices, which we quickly realised may have 7 8 restricted participation, especially among community representatives, owing to these being far away, highly 7 9 professional spaces. Nevertheless, key dynamics were observed. Government participants were responsive to 8 0 the process, verifying and remarking upon the consistency of their analysis with that of the communities'. (including visual) data combining 'hard' data on burden of disease, with evidence on lived experience (Fig. 4). . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 9, 2022. ; https://doi.org/10. 1101/2022 In terms of dynamics and interfaces, and while the action plan was only partially achieved, the process overall 8 9 was seen as valuable: engaging a diverse and otherwise disconnected set of stakeholders in 'safe spaces' 9 0 where difficult conversations could occur, and where shared awareness of local priorities could be built. Overall, 9 1 there was good participation, high levels of workshop attendance and engagement in follow-up discussions.

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Participants reported seeing the platform as able to foster learning opportunities and new ways of thinking: The workshops reconfirmed that community participation is key to planning and improving service delivery 9 5 [Government stakeholder, reflective workshop] 9 6 9 7 There have been a lot of service delivery protests in communities, but they did not accomplish much; elsewhere 67 ). The collective reflection was reported acknowledging all participants in a written report. Our initial theory of change was that a series of adaptive action-learning cycles could support development of 1 4 capacities and relationships to enable recognition and uptake in the health system 53 . Inclusivity was a key input.

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With a focus on marginalised voices, we initially worked with community stakeholders developing collective 1 6 capabilities to raise and frame local health concerns. Stakeholders from the authorities were then engaged to 1 7 build mutual understandings of the issues, appraise policy and systems responses, and identify how, where and 1 8 with whom collective local action could address the issues identified. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 9, 2022. ; https://doi.org/10.1101/2022.07.03.22277088 doi: medRxiv preprint 2 0 Throughout, inclusive representation and the criteria through which representatives were appointed were defined perspectives. This supported development of collective capabilities and voice, which provided a necessary 2 5 foundation for engaging with the authorities. Subsequent engagement with service providers at strategic and 2 6 operational levels (province, district, sub-district and local) introduced a range of power asymmetries related to 2 7 various forms of formal and informal status and privilege. We reconfigured and adapted processes and tools to 2 8 accommodate everyone regardless of status, embracing diversity and enabling mutuality. The Agincourt HDSS also brought additional 'hard' data to bear on the mortality burden related to community-3 1 nominated priorities. Such data are essential for public health planning, but their availability and quality are often 3 2 lacking, especially on community deaths. Credible, actionable information was a further input that supported 3 3 multisectoral engagement with the authorities. As stable public health observatories, HDSSs occupy strategically 3 4 important positions to broker data-driven decision-making between communities and authorities. Regular engagement was a critical mechanism that helped develop collaborative mindsets. Repeated 'safe 3 7 space' engagements first with community representatives, then with the authorities, helped build dialogue, The Local Action Plan was a crucial output that ratified shared understandings and commitments to work 4 7 together on common problems. While progress was mixed, and monitoring was identified as potentially punitive accountability and action. Collectively reflecting on and adapting the process was pivotal in supporting shared 5 0 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 9, 2022. ; https://doi.org/10.1101/2022.07.03.22277088 doi: medRxiv preprint ownership and control, and enabled uptake into formal service planning and management. The codesigned 5 1 adaptions will structure future cycles, further testing these inputs, mechanisms, and outputs, with deeper 5 2 reflection on contextual conditions and whether and how change can be achieved and sustained (Table 3).

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While suggestive of impact, the results should be interpreted with caution in terms of the relative strengths and 5 5 limitations of the process. Firstly, while designed to be jointly owned, researchers controlled several aspects: overall design, resources, monitoring implementation of the action plan, and preparing outputs such as 5 7 manuscripts and other briefing materials. Nevertheless, and while the action plan was only partly achieved, the 5 8 process was clearly acceptable, and of practical value and benefit to participants. Reflecting on instrumental and 5 9 intrinsic value in accountability processes, Joshi highlights the importance of how, and by whom, success is In terms of the researchers' positionality, the team was primarily South African, based at Agincourt HDSS or 6 6 Mpumalanga Department of Health and in the UK affiliated to Agincourt. We are a long-standing collaboration 6 7 with a shared commitment to distributed and evidence-informed decision-making in rural PHC. Within the team, 6 8 we considered practices, such as who controls funding, collects and analyses data, who publishes, and whose sub-national priorities, and support accountability of researchers to local contexts. In future iterations, more explicit recognition that design choices overall are underpinned by ideological and what extent change occurs should be driven in future cycles by the collective. As described above, limitations of 7 9 social accountability relate to sustaining collective action among multiple stakeholders to achieve and 8 0 understand change in long-term processes 74 . A learning approach that is emergent, built in and for local 8 1 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 9, 2022. ; https://doi.org/10.1101/2022.07.03.22277088 doi: medRxiv preprint contexts, inclusive of collective articulation of theories of change, attention to power and sustained action will 8 2 support relevant and sustainable processes enabling mutual accountability. Framed in terms of social accountability, the process thus made gains raising community voice and initiating abuse was observed by 2016 and the absence of an implementation strategy was acknowledged in the nevertheless, it also underscores the necessity of real-time local data and action, community involvement, and  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
Hutain J, Perry HB, Koffi AK, et al. Engaging communities in collecting and using results from verbal autopsies  Action item Outcome Implementation mechanisms Community stakeholders (leads) 1. Identify AOD abuse hotspots to focus action and aid departments planning interventions Achieved A home-based carer (CHW category) working outside the study area was nominated to lead this action as a community stakeholder representative. The researchers found it hard to engage with her during the monitoring period, however, and through the home-based care organisation connected with a home-based carer working within the study area who was a community stakeholder. Together with other community stakeholder representatives, they validated a list of AOD abuse hot spots (shebeens, taverns) obtained from a study in the Agincourt HDSS, and added hotspots that were not on the list. While community leaders were not convened due to lack of resources and other commitments, the action was completed by other means, with verification of the hotspots by community stakeholders. 2. Strengthen collaboration between traditional leaders and police service to regulate taverns Some progress Follow-up visits highlighted various and variable connections between traditional leaders and law enforcement. The action is happening in the sub-district in which the Agincourt HDSS is based, but not in the study area. The Local Drugs Action Committee (LDAC) (a body consisting of government, SAPS, and NGO partners) works with traditional leaders encouraging community members (especially men) to attend LDAC information sessions. To further understand the connection between traditional leaders and law enforcement, we linked to Community Policing Forums (CPFs) in the study area to find out how they work with police and report cases of AOD abuse. Through this, we established that CPFs in the study area do not know about LDAC. We also engaged with MER (Mpumalanga Economic Regulator previously liquor board) that works with traditional healers, SAPS and municipalities when issuing licences. Traditional leaders endorse the application while SAPS checks for criminal records on all applicants. Department of Health (leads): district, sub-district and community levels 3. Encourage nurses to adopt schools (primary and secondary)

No progress
Stakeholders leading the process reported multiple and competing priorities during implementation follow up, which precluded action. In response, the researchers met with DBE in March 2018 to find out more about school health services, which revealed a gap between services mandated and delivered, as well as providing insights into where NGOs such as SANCA are working with the authorities to deliver health promotion in schools. DBE advised that while DoH policy supports nurses in schools, in practice, nurses only provide services when required. Otherwise, SANCA provides health promotion in schools, albeit variously, and in partnership with DoH, SAPS and DSD. Other departments and agencies (leads): district, sub-district and community levels and NGOs 4. Align Department of Justice (DoJ) and SAPS on application of substance abuse legislation in liquor outlets Some progress This is a long-term outcome. The policy is under review at national level. However, we engaged with MER, whose main duties are compliance and licensing, to understand the process of licensing and issues of compliance. MER runs programmes with SAPS, DBE, HSRC (Human Science Research Council), municipality and traditional leaders. MER also work with SANCA and other organisations on public awareness in schools and communities. MER have inspectors in the sub-district on compliance and responsible trading. The researchers established a relationship with MER and they are willing to attend our workshops when invited in the next action-learning cycle.

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Disseminate information on AOD abuse activities Some progress DSD had in their annual plan to host the 'Blitz' event however it was not done due to lack of funds. At the time of reporting, the DSD are awaiting the subsequent annual budget and seek to highlight the need for role clarification and dissemination of information on provisions for social support identified through the process in department planning in the subsequent period.
6. Mobilise resources for communitybased rehabilitation Some progress There were no applications for treatment centres received by DSD at province level by the time of reporting. However, the district level is assisting and supporting willing organisations to apply, none of whom are in the study area. A potential role for the researchers was discussed during implementation follow up to mediate and support the applicants to keep pace/motivation through a mid-term process.
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The copyright holder for this preprint this version posted July 9, 2022. ;https://doi.org/10.1101https://doi.org/10. /2022   • Inclusivity is fundamental, representation should be continually negotiated, focussed on those most marginalised, excluded and hard to reach; • Communities generating information on their own situations confers collective efficacy, action and generates credible, actionable information; • Initiating new linkages with and insights into the functioning of other sectors and departments for improved understanding of public services as well as of the roles and responsibilities of different stakeholders; Information • Community knowledge is a rich and vivid source of sophisticated information; • Information that is coproduced with citizens and service providers confers legitimacy; • Clear, accessible information that is useful and actionable by stakeholders is more easily integrated into routines; • Connecting to the health observatories brings additional data to bear on community-nominated priorities; Mechanisms Processes, dynamics and interfaces • Regular community engagement builds strategic, analytical and publicspeaking skills and confidence; • Regular engagement between communities and authorities, fosters awareness, mutual understanding and trust; • 'Safe spaces' outside institutional processes to connect with and understand other agencies and communities are valuable; • Spaces close to implementation contexts support inclusivity, managed expectations, reinforced principles, and a process owned and controlled by those involved; • Processes framed as shared endeavours can deepen engagement, ownership and understanding; . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 9, 2022. ; https://doi.org/10.1101/2022.07.03.22277088 doi: medRxiv preprint • Processes need time to build and maintain constructive, cooperative relationships and trust between sectors; • Monitoring is effectively done by those closest to the issue; • Recognition of roles of mediators is important -facilitators between communities and authorities with two-way communication "bridging cultural and power gaps"; • Incentives and renumeration require careful consideration as positive reinforcement to sustain the practice; Outputs/ outcomes Legitimate process, ownership, uptake and collective action • Identify range of intermediate and ultimate outcomes and timeframes with sensitivity to challenges in operational levels; • Continually and collectively test and revise assumptions about theories of change to build relationships and trust; • Document and emphasise improved engagement and mutual understanding, capacity in deliberative processes; • Develop collective action towards shared priorities, joint reflection and adaption of process; • Coordinate with government reforms, processes and priorities. Uptake of process into routine planning and management processes important to support state response; • Sandwich strategies' building citizen voice and support state responsiveness can help build mutual respect, understanding, and ultimately mutual empowerment. Analysis should focus on different ways that 'voice' and 'teeth' combine, interact and situate in particular contexts; Contexts Meso/micro context (structure) • Identify capacity built on local relationships for innovation, efficiency and responsiveness to improve the quality of service delivery; • Build on existing processes to avoid imposing administrative burdens in already constrained operational environments; • Sustainability key consideration: iterative, dynamic and responsive/sensitive to realities on the ground to support strategic, empowerment-focussed approaches to emerge and have legitimacy; • Past experience of interaction with the state, trust, cultures of expectations from the state need to be recognised; Macro context (structure) • Focussing only on local, front-line service providers, should be supplemented with attention to higher levels; • Attention to macro-level social and political contexts can help to identify how impacts are both supported and undermined; • Forward-looking, preventative approaches may be challenging to advance in contexts of limited accountability; • Universal Health Coverage and Primary Health Care are important supporting reforms; however realities of implementation reflect deep tensions that require dedicated analysis; • Design as longer political process of citizen engagement with the state; • Consider how to improve incentives to sustainably engage higher-level leadership for policy design and implementation.