The Impact of Community Mobilisation on HIV Prevention in Middle and Low Income Countries: A Systematic Review and Critique

"While community mobilisation (CM) is increasingly advocated for HIV prevention, its impact on measurable outcomes has not been established.... One reason for the lack of systematic attention to CM is that it is used across categories of HIV intervention usually considered separately, namely, biomedical, behavioural and structural interventions."

This research "present[s] a systematic review of studies of the impacts of CM as a component of complex HIV prevention interventions." The study considers impact of CM across the three categories named above. While recognising the challenges of systematic appraisal of the literature due to varying terminology (community solidarity, social mobilisation, community participation, community engagement) and the debate on how to evaluate CM, the study also aims "to reflect on the methodological challenges of operationalizing, evaluating and reviewing CMI [CM interventions or CMI]." [Footnotes have been removed throughout by the editor.]

The role and conceptualisation of CM is described as: "A growing body of social research has underscored the role of CM in building HIV competent communities, ensuring interventions are relevant and accessible to local people, and enabling people to work collectively to create health-enabling environments. This work has also emphasised the significance of partnerships between communities and outside agencies as a key supportive condition for effective CM. Furthermore, the pertinence of Western conceptualisations of CM and its constituting elements needs to be validated in specific intervention contexts."

The researchers chose programmes that "seek to foster new capacities in a community by facilitating meaningful contact among community members, [including] enhancing supportive interpersonal relationships, building within- community support and solidarity (bonding social capital), and building bridges between communities and outside support partners (bridging social capital)", rather than those that simply reached out to recruit subjects or engage services. They then looked for: measurable HIV-related outcomes; a significant relationship between the implementation of a programme with a CM component and the outcomes; the programmatic conditions that resulted in successful programme outcomes; and the "methodological challenges of evaluating and synthesising evidence on CM."

Criteria for inclusion and data extraction and synthesis are described and charted on pages 5-15 of the document. Twenty studies were analysed. In concentrated HIV epidemics, community was conceptualised as: "groups most at risk"; in generalised epidemics, community was conceptualised as "youth" or "geographically-bound communities" of adults, often focusing on multiple groups within communities and wider community- or population-level studies.

The results are reported as differing by group in effectiveness. Sex worker interventions showed some decrease in sexually transmitted infections (STIs) when CM was combined with government policy changes - with more consistent and stronger results for behavioural and social outcomes than for biomedical ones. "Among youth and general communities, the evidence of the effects of CMI remains inconclusive."

"[T]wo more nuanced lessons" suggest that, first, CMI appeared to be more effective where there was a meaningful collective identity: "CMI often work through their situation of vulnerability to foster mobilisation that is cohesive and fuelled by a need not only to attain HIV-related goals, but also to increase their material and symbolic power and status in the community." More generalised community groups do not have "the extreme and conspicuous disadvantages, thus do not appear in need of tackling the social determinants of their problems."

Second, CMI seem more likely to generate favourable outcomes if accompanied by efforts for change at the structural level, such as a brothel policy of 100% condom use. Similarly, lack of structural change, such as low status of females and their financial reliance on males, can result in lack of measurable change and indicates a need to work not only with disempowered groups but also with other segments of communities to enable structural change.

The researchers conclude that "problems with operationalization, evaluation and review methodologies" create difficulties in evaluation. They identify and elaborate on "three flaws in the operationalization...: (i) understandings of CM remain under-developed, and often tokenistic; (ii) implementations of CMI are often characterised by inflexibility; and (iii) the evaluation of CMI tends to inadequately account for social impact." They state that there is: a need for an understanding of social change in the operationalisation of CMI; a need to work with communities "to address the socio-political context and to build supportive partnerships with more powerful groups, rather than with community groups in isolation"; and a need to make more local judgements on the suitability of CM, informed by a wider set of evidence than that provided by systematic reviews and outcome evaluations.