Community Engagement to Tackle Infectious Threats in Bangladesh, Uganda and Ukraine - A Research in Progress on a Social Science Mapping Process

Background: Successful epidemic preparedness and response require an understanding of social behaviour: social values, priorities and practices fundamentally shape human engagements with measures to prepare for and to prevent epidemics and antimicrobial resistance. Because of its capacity to document and evaluate health-seeking behaviors, local understandings of disease and explanations of transmission, and local reactions to public health interventions, social science, in particular anthropological research is well positioned to facilitate insight into these priorities and practices. Method: The SoNAR-Global project (A Social Science Network for Infectious Threats and Antimicrobial Resistance) undertook a mapping and assessment of existing Community Engagement (CE) models that target infectious threats and/or antimicrobial resistance (AMR) Bangladesh, Uganda and Ukraine, which are integrated in the project through partner universities. We compared our ndings with the UNICEF Communication for Development (C4D) Minimum Quality Standards for Community Engagement. Conclusions: On these grounds, we emphasize six critical elements for Community Engagement before and during epidemics. We argue that CE efforts must cooperate and dialogue with people in need and negotiate integrated, localized public health models that improve their lives before and during an epidemic. Results: We identied and recommend currently available social science tools for Community Engagement, which correspond to the six critical elements and can contribute to enhance preparedness and response activities to infectious threats.


Background
The SoNAR-Global project constitutes a Social Science Network for Infectious Threats and Antimicrobial Resistance [1] that connects social scientists from 15 partners across Europe, South East Asia as well as West and Central Africa in their research on epidemics and infectious diseases.
Recent Ebola virus disease (EVD) outbreaks in the Democratic Republic of Congo (DRC) and West Africa as well as the current COVID-19 pandemic illustrate how important it is to strive for a better understanding of community reactions to infectious disease outbreaks [2,3]. Preparedness and response activities must convene to people's demands and their cultural needs. Osborne et al. [4] point out the advantages of integrating social sciences into epidemiological research, as they " ll a gap left by traditional infectious disease science" and "provide not only appropriate methods for working with communities but also the theoretical and experiential knowledge that adds to a fruitful and empowering engagement process." One such social science approach is the concept of community engagement (CE), which will be discussed in this paper based on recently implemented community health projects in three partner countries of the SoNAR-Global project.
One pillar of the SoNAR-Global project constitutes the development of appropriate models for multi-layered, multi-sectored, dialogue-based engagement. To this end, a mapping and assessment exercise was initiated in 2019 to gather experiences with models of community engagement that target infectious threats and/or antimicrobial resistance (AMR) through active involvement of communities and community feedback. Here we present a de nition of critical elements for community engagement during epidemics and recommendations of currently available tools to enhance communities' preparedness and response activities.
Exploring existing engagement structures in three countries The mapping and assessment exercise was developed and coordinated by the Medical University of Vienna [1] which collected data in collaboration with SoNAR-Global partner organizations in three countries: BRAC University of Dhaka, Bangladesh, Makerere University of Kampala, Uganda and the Public Health Centre of the MOH of Ukraine, Kiev.
In the following phase, researchers from each partner country received detailed instructions to map existing engagement structures in their countries, assess local CE manuals and social science modelling, and consider existing structures to address the multi-layered dimensions of governance. The template for data collection was designed to cover a broad range of interventions, programs or projects on AMR or infectious diseases that involve communities and seek community feedback for program interventions [2]. The search included governmental and non-governmental health related communityengagement, -information, -consultation and -participation activities, including those of business enterprises and community-driven initiatives. Template questions collected information about the nature of the intervention, the leader of the initiative, the purpose of the project, which publics were engaged and how, levels of participation, project outcomes, and the ways that monitoring and evaluation were integrated into the project.
Regular online meetings with partners in Bangladesh, Uganda and Ukraine ensured a continuous feedback and re ection process, which allowed gathering and discussing information that was only available through local sources and speci c to the local context. Furthermore, compiling information on multiple CE projects targeting infectious threats illustrated the diversity of approaches applied. The mapping results from three countries were compared with UNICEF Communication for Development (C4D) Minimum Quality Standards for Community Engagement [5] to verify whether these projects were sustainable in establishing "an 'infrastructure' of participation and communication across social, political and cultural contexts" [5], and that systemisation, resources, and sound policies were considered to ensure quality and accountability. Furthermore, the UNICEF document stresses that CE needs to be speci c, localised, responsive, and bidirectional while emphasising that top-down approaches should be avoided. A concluding consultation meeting was held in June 2019, with experts from WHO, GloPID-R -Global Research Collaboration for Infectious Disease Preparedness, and SSHAP -Social Science in Humanitarian Action Platform framing additional recommendations on how to improve relevant engagement structures.
[1] Department of Social and Preventive Medicine, Unit for Medical Anthropology and Global Health [2] The template is available at: https://www.sonar-global.eu/wp-content/uploads/2019/12/Task-4.1_Template-Mapping_For-Homepage_031219_JC_EJ.pdf Methodology Rationale for the selection of partner countries Out of 15 SoNAR-Global partner countries we chose Bangladesh, Uganda and Ukraine because they faced multiple health challenges listed among the WHO-identi ed threats to global health [6]. These challenges could potentially result in epidemic outbreaks during the data collection period. Hence, those countries were most appropriate for mapping and evaluating CE elements that were part of ongoing preparedness and response activities. Our research would thus identify appropriate models for infectious disease preparedness and response in other countries, including for worldwide efforts to combat COVID-19.
In Bangladesh we identi ed antimicrobial resistance (AMR) as a major health issue resulting from a considerable expansion of the animal farming industry often using antibiotics without following sound environmental practices [7]. In humans, the misuse of antimicrobials is associated with a weak regulatory regime, economic interests of pharmaceutical industry, and the demand by patients to avoid doctor's fees [8]. As elsewhere, antibiotics serve as a substitute for lacking health infrastructure [9]. Our exercise in Uganda focussed on projects tackling regular outbreaks of viral haemorrhagic fevers (VHF) especially the Ebola virus disease (EVD), and AMR inside the country and in the neighbouring Democratic Republic of Congo. Ukraine was struggling with an unprecedented measles outbreak with more than 54,000 cases in 2018. Prevailing challenges are a lack of vaccination coverage for preventable diseases in general, as well as vaccine hesitancy among parents and health workers, fuelled amongst others by anti-vaccination campaigns in the media [10] -a public health issue with a previous history in this country [11].

Challenges / Limitations
The literature provides a great variety of de nitions of what community and community engagement is. What is meant by community can differ depending on the project's objective and needs to be speci ed in each case. The scope of this term ranges from geographic contexts to shared interests and common social and political networks. Likewise, the term engagement oscillates between "a dynamic multidimensional relational concept featuring psychological and behavioural attributes of connection, interaction, participation, and involvement, designed to achieve or elicit an outcome at individual, organization, or social level" [12] and a "two-way dialogue between crisis-affected communities, humanitarian organizations, and [...] within and between communities (enabling) affected people to meet their different needs, address their vulnerabilities and build on their pre-existing capacities" [13].
The lack of common and uniform de nitions of these terms among the projects under investigation was addressed in the data collection template underlining the necessity to scrutinize use and meaning of these concepts in each project of the exercise. As a reference for a common ground we suggest the de nitions lined out in the UNICEF Minimum Quality Standards for Community Engagement [5], which allow for framing communities as wider networks that "may have direct local inputs into the transfer of health, educational, social, informational, economic, cultural and political resources" and often include "unequal distributions of authority, access, and power over decision-making and resources" [5]. The same authors de ne CE as "a foundational action for working with traditional, community, civil society, government, and opinion groups and leaders; [...] CE empowers social groups and social networks, builds upon local strengths and capacities, and improves local participation, ownership, adaptation and communication. Through CE principles and strategies, all stakeholders gain access to processes for assessing, analysing, planning, leading, implementing, monitoring and evaluating actions, programmes and policies that will promote survival, development, protection and participation" [5].

Discussion Of The Mapping Process
Out of total 42 projects mapped, we identi ed and analysed 11 projects complying with CE standards: 4 in Bangladesh, 4 in Uganda and 3 in Ukraine (see table 1). Here we evaluate in greater detail one key example demonstrating both positive effects of cooperation and dialogue with affected populations to develop integrated, localized public health models and show its limitations and lessons learned. We highlight six critical elements for CE that are crucial for inclusive community health projects and link existing social science tools to each of the critical elements of CE to enhance community preparedness and response activities to infectious threats (see table 2).

Bangladesh
In Bangladesh, the project "Community Dialogue to address antibiotic resistance" explored the potential of the Community Dialogue Approach (CDA) that strongly relied on social and behaviour change theories to improve antibiotics use on a community level [14]. It built on a qualitative study of perceptions and misconceptions relating to antibiotics, as well as on a household knowledge, attitudes and practices (KAP) survey to develop its key messages. Community volunteers trained in appropriate antibiotics use performed 200 community meetings providing community members with an overview of antibiotics and AMR facts and risks. As with other CE initiatives identi ed in Bangladesh [15], this project sought to understand the local context through the involvement of community members. While other interventions were initiated by external researchers who invited local stakeholders to participate, this project was based on community volunteers to facilitate community meetings and transfer knowledge, thus avoiding a top-down approach. The study also highlighted the need to reinforce key messages in regular feedback meetings with the volunteers and to advocate for the application of evaluation techniques.

Uganda
In Uganda, the "Emergency Plan of Action for EVD preparedness" involved intensi ed CE through risk communication and sensitization. Community-based surveillance and community feedback mechanisms (including a rumour-tracking system) were established. Community-based volunteers trained in risk communication, social mobilization and EVD psychological rst aid carried out interpersonal communication and hygiene promotion at household and community level. Almost 700,000 individuals were reached with critical messages on EVD prevention [16]. Although communities were included in all preparedness-and response pillars, these CE interventions in Uganda provided limited possibilities for a two-way dialogue with communities, instead relying primarily on top-down communication. Moreover, monitoring, evaluation and learning components, as de ned in the Minimum Quality Standards for CE [5], played a subordinate role in all projects mapped in Uganda, which might be due to the emergency context of these EVD projects.

Ukraine
In Ukraine, the most promising project to address growing vaccination hesitancy and the resulting measles outbreak through a CE approach was identi ed in "Public consultations on health policy formation and implementation", which became legally binding for new legislation since 2010 [17]. Such communication and information procedures can be initiated either by community request or by government and public institutions. The consultations can occur via face-to-face meetings, electronically, or as social research. They are considered transparent and sustainable by the stakeholders as they are statutorily funded by the state. Hence, drafts of public health-related bills need to be published on a government webpage. Consequently, communities have a chance to comment on improvements of these documents and regulations according to their needs. If experts endorse their proposals, the drafts will be modi ed. Public consultations facilitate national decision-making, collaboration and community participation on multiple levels. Nevertheless, because experts' approval of public suggestions is required, public opinion is not always adopted or implemented, and systematic, formative evaluation processes are yet to be established.

Conclusions
The mapping process revealed three different, quite distinct models of CE that were applied to tackle infectious threats and AMR in Bangladesh, Uganda and Ukraine. How communities were engaged varied in the three countries, each demonstrating strengths and weaknesses. Weaknesses emerged in limited two-way communication models and the lack of evaluation and transparency concepts. Further research of the SoNAR-Global project will focus on the development of approaches to address these aspects.
The mapping and analysis of CE projects as well as the mutual re ection with our contributors and the consultation with experts resulted in the formulation of six critical elements for CE: 1. Knowledge from social science, in particularly anthropology, should inform the engagement process to grasp the complexity of communities and their actual health requirements. Social scientists should facilitate insights such as: What does 'community' mean in a given context? How do social groups interact within a community and the health system? How do power relations and cultural aspects within a given context in uence the engagement process and the interaction of stakeholders?
2. Any CE project should draw on local infrastructures and re ect the heterogeneity of a community. Relevant stakeholders should be de ned and involved across sectors and multiple levels.
3. Engagement structures should incorporate a systems perspective to understand relationships between stakeholders and the ow of communication and collaboration between them.
4. CE projects should cultivate a horizontal dialogue to facilitate inter-sectoral communication and collaboration. Deviation from this approach for a more top-down or bottom-up communication -if considered necessary -should be aligned with local socio-economic and political circumstances.
5. Communities need to be empowered to cooperate with other communities and stakeholders, to nd strategies against infectious threats according to their possibilities and needs.
. There should be a plan for evaluation and monitoring of the CE structures and processes. Goals and objectives must be clearly identi ed and comprehensible. Ideally, CE is a continuous process that is measured as it unfolds and that is adjustable to process-dependent needs and developments.

Recommendations
Above all, we advocate for the consideration of the named critical elements for CE in the planning, implementation and monitoring of CE projects that pursue inclusive epidemic preparedness and response activities. Following our analysis of speci c CE models in our three partner countries, we emphasize the establishment of more dialogic and horizontal forms of communication and a systematic integration of evaluation procedures in CE activities. We also recommend the use of already available social science tools for CE that -if modi ed accordingly -can enhance preparedness and response activities to infectious threats, both in our three partner countries and elsewhere. The recommended tools are assigned to the above critical elements for CE in the following