Manifestations and Strategies to Deal with Politics Science Adulteration in Community Engagement Healthcare Research

Politics and its Manifestation in Community Engagement Research

Politics is traditionally associated with institutions of government and ruling in a politically organized community [11, 12]. The variables associated with politics in the modern literature include power, government authority, and competing interests to allocate resources and values. In his preface to democratic theory, Robert Dahl, defines politics as who gets what, where, when, and how [13] It also relates to the use of authoritative means to define, articulate, and protect public interests [14]. Politics, also relates to governing, exercise of power, and making collective choices for citizens, which involves those who acquire power and authority in politically organized communities [12].

Apart from the actual exercise of power, politics has been associated with the efforts, initiatives, and strategies used to acquire power. Power acquisition is a means towards the end, which is to hold a public authority -a position that allows individuals to decide for others [15]. As observed by Thomas Callaghy in the context of developing countries, politics at this stage may not necessarily be ethical since it involves struggle by interested political groups and individuals to establish domination and control [16]. Therefore, it the politics of power acquisition can hardly be free of conducts such as manipulation of information, misinformation, and misrepresentation of government institutions and their stance on important and sensitive public affairs such as healthcare.

In research, politics can take many different forms and shapes. On the first extreme, it may involve active and open use of political power, authority, and platforms to shape the understanding of the problem and required solutions within the study communities. On the other extreme, it may take form of inert and covert lobbying and manipulation that in the long run affects the breadth and depth of engagement with the study communities and their key institutions [17]. Through financing, political actors can control the agenda of research and dictate what findings should be put to the public [18]. There are also instances where political institutions and political actors tend to capture and control research dissemination outlets. For instance, Jeffrey Henig provides examples where government institutions attract researchers to present their preliminary findings through conferences that are organized for the purposes of furthering policy positions. Such findings are used as evidence to shape legitimize the preferences of political authorities rather than being disseminated through scientific platforms such as peer reviewed journal [19]. All these will necessarily affect objectivity and adherence scientific principles that govern research to ensure that research generates reliable and valid evidence.

Politics as who gets what, where, when and how involves an interplay of conducts including both ethical and unethical. Given the potential effects of politics on community engagement research and research outcomes, the view that good science should rarely entertain politics is decisively promoted by public policy research experts [20]. This is because if it is left uncontrolled, the effect of politics on community engagement research may be damaging. The most damaging effect happen when political actors, for political interests successfully influence, manipulate, or divert a well-planned research project in the way that it fails to meet the requirements for scientifically credible research [5, 9]. This kind of alteration is what is termed as science adulteration, which is the next subsection explains.

Science Adulteration in Community Engagement Research

We employ the concept science adulteration in the same way as it is used by Bansal S, et al. [21] in their study on food adulteration risks and Azad T, et al. [22] in their study on milk adulteration detection techniques. Adulteration here denotes a situation where a food contains a substance that is considered to be dangerous, contaminated, or deleterious and thus renders it unsafe or injurious to health [23, 24]. In this case, we employed the concept science adulteration to refer to any invasive impositions in the research process that are likely to alter the intentions and outcomes of the research and thus make it procedurally anomalous or generate and disseminate information that is substantially wrong.

Any kind of research can be adulterated in different ways including an invasive imposition of private nonscientific methods, researchers’ bias, replacement of intended objectives by private goals, and intentional manipulation of the findings to legitimize private interests and agenda. The agent of science adulteration can, therefore, be a scientist himself or a third-party. Specifically, science adulteration can involve replacement of rationally planned and approved research methods with what is thought to fit the personal needs of a researcher or a third-party during data collection, analysis, or dissemination [25]. For instance, if the approved protocol required that participants’ selection should involve randomization, but the researcher decides to take whoever is in place in order to complete the data collection in a short time, that is adulteration.

In the case of our community engagement research, there were several forms of science adulteration initiated by both members of the research team and politicians at the grassroots. On the side of the study team included two research assistants and eight volunteers who had been recruited from the same communities. Therefore, they were part and parcel of the local politics. During the invitation for community dialogues for instance, the volunteers who were responsible for inviting community groups tended to excluded households they thought were from the radical political opposition parties. Similarly, family and blood relationship and social ties such as friendship, religious identities, tribal and ethnical belonging had a significant interplay with the local-native politics.

There were two salient science adulteration attempts that manifested in the course of our engagement activities. The first one involved two politicians who claimed to have invited the CBM4Tanzania study team to go to the district and save the communities out of rampant corruption. Both claimed that the CBM4 Tanzania project could not have been there if it was not the friendship they had with the Principal Investigator and the leadership of the University of Dar es Salaam where the PI was coming from. This was indeed not true. The PI himself had never met or talked the two politicians before. The second experience was the attempt by grassroots leaders to silence the community members not to provide information during both the baseline survey and community dialogue meetings.

The first instance occurred in one of the villages where the research assistants left the village office for administering the questionnaire. As soon as they left the office, the village chairperson sent two young men to go around the village insisting to the villagers that there were visitors collecting data and thus the villagers should not let down their leaders once asked about the state of health services in the village. Noting that, the study team had to remind the research assistants that proper introduction of themselves and the aim of the study would make the respondents open up and present the real experiences they had regarding health services in the villages. A slightly different experience was that of village leaders implanting their people to attend the community dialogues and note the names of those who were saying bad things about the leaders and health workers. Having noted that, the study team had to insist at the beginning of the meetings that the purpose of the study was not to identify who was the cause of healthcare problems in the villages. It was rather to understand the existing problems and work with the communities to devise better ways to solve such problems. Strategies to Deal with Politics in Engagement Research As pointed out in the proceeding text, politics are unavoidable since they are part of the day-to-day undertaking of the communities. Decision-making, resource allocation, planning and prioritization, and distribution of goods and services in communities involve power, competition, and collision of interests. That is politics in practice. Therefore, doing away with politics in the context of community engagement or any other activities that involve different community-level actors is quite impractical. Instead, it is feasible to devise strategies and tactics that would remedy engagement research and associated activities from adulteration by politics. The next four subsections provide a thematic synthesis of the strategies we used to deal with politics in our research project insisting on the ways in which each of the strategies contributed to the success of the research project.

Creating Cognitively Aware Communities

The first step into community engagement is the creation of cognitively aware communities. By cognitively aware communities, we mean developing the capacities and capabilities of the communities to recognize the existence of a sensitive healthcare challenge that has a potential of affecting the wellbeing of the community [26]. For instance, spending a couple of days sensitizing and mobilizing the communities to understand that the problem of stockout was associated with inefficient management and oversight of the available healthcare resources and service delivery in the communities was the best entry point in our project. The same understanding had a far-reaching effect on the understanding of the communities that they had the right to participate in planning and priority setting, and to get demand information on financial allocations and expenditures within the Community Health Fund (CHF), a community-level voluntary prepayment insurance scheme. It also increased the confidence to question when there are unaccountable practices, and to summon health workers to village assembly meetings to explain when healthcare services fail to satisfy community needs or meet expected standards [27].

Noting the need for cognitive awareness as a prerequisite for controlling science adulteration by politics, orientation to the project and its essence incorporated strong messages to show that the CBM4Tanzania was a scientific research project. The aim in this case was to recorrect the preconceptions that had been built by some grassroots politicians during political rallies that CBM4Tanzania was an initiative of the government to improve primary health services in the district. With this politicization, there had been widespread beliefs among ordinary community members that the CBM4Tanzania team was sent by the government to collect information on the misuse of financial resources following request by grassroots and party leaders. To counter this, the team had to explain and make communities aware that the engagement was building on previous studies by the PI [28, 29, 30] to understand better the nature of the problems such as medicine stockout that the team had known they existed and collaborate with communities to learn how such problems could be approached and addressed.

The initial stages of engagement that involved community-wide mobilization and sensitization, therefore, served as a strong tool for not only educating the communities and empowering them to play and oversight role but also detaching the CBM4Tanzania research project and its associated activities from politics. Combined with the use of locally recruited volunteers, research assistants, and Community Advisory Committee (CAC); this strategy contributed significantly to the development of community ownership of the project. It also encouraged ordinary community members to engage in active and open discussions about sensitive topics that were traditionally regarded to the matters to see and not to say such as mistreatment of patients by nurses and health workers’ absenteeism. We also observed that the increase in use of the Mobile Suggestion Box as a legitimate service monitoring and feedback tool was associated with the efforts invested in making communities aware of the need and right to participate in monitoring financial resources and service delivery as well as the importance of voicing out the communities’ healthcare concerns.

Preparing and Orienting Stakeholders to Guidelines

Implementation guidelines are required for not only ensuring that planned activities are adhered to but also for making key stakeholders aware of the essence and objectives of the engagement. The guidelines need to be simple to be understood by lay and non-expert participants [31] and clear to eliminate the possibility of having cases of information fratricide in the project. Information fratricide, in its simple terms, means a situation where an actor communicates out some information or message thinking that such communication is beneficial. However, the same information becomes a killer that adversaries may use to build an unforgivably negative case against the actor that has communicated that information [32]. In some cases, information fratricide can take a form of sending out an information that is ambiguous or having a potential of being misunderstood by the intended receiver and thus leading to a negative reaction by the information recipient.

Guidelines in community engagement research tend to answer some basic questions about the engagement questions. These questions include who should be engaged, what should be the engagement message and why, and how should engagement be conducted and evaluated? The guidelines have to define clearly the problem on the ground and encourage reflective practices through which the community-level stakeholders work with the research team to redefine and refine the problem, set-up a proper structure for managing the engagement activities, and documentation of the key implementation barriers and suggest how they would be eliminated to ensure the success of the project [3]. Further, the guidelines articulate the basic norms and values that would be used to maximize the returns of the engagement such as ownership, volunteerism, and the development and strengthening the virtues of partnership such as collaboration, cooperation, and decisions through consensus.

Prior to embarking on the implementation of the CBM4Tanzania research project, the guidelines were carefully developed by the academic study team and subjected review by all members of the project team including community-level stakeholders. The review process paralleled the translation of the English version of the guidelines’ booklet, ‘Community-Based Monitoring: A Guide for the Community-Based Monitoring for Improving Accountability and Service Delivery in Rural Primary Health Care Research Project, Kasulu District -Tanzania’ [27] into Kiswahili which is a native language. The translation involved the efforts to use simple plain language terms that would be understood by community-level stakeholders who would be interested including ordinary community members. Lay translation as a strategic tactic in community engagement aims at demystifying the science by replacing technical jargons with the words that are used by communities in their day-to-day activities. However, it is also a strategic tool for depoliticizing engagement and reducing the chances for science adulteration because a ‘lay understanding’ of the messages reduces the chances of successful manipulation of information for political purposes [31]. On their side, politicians speak carefully taking into account the fact that community-level stakeholders including ordinary citizens are well aware of the purpose, ownership, and expected outcomes of the engagement activities in progress.

The 51-page guidebook provided information on the findings of the study that had motivated the study team to design the CBM intervention, a simplified understanding of the essence and importance CBM approach, principles of Community-based monitoring, and the actual process and practices in doing community-based monitoring. This made political party leaders and candidates extremely cautious when they presented the causes of healthcare challenges in the communities and the solutions, they would offer to eliminate the challenges. In both the 2019 grassroots elections and the 2020 general elections, attendees of campaign rallies had substantive questions that focused on the extent to which candidates would contribute to improved accountability for resources use and service delivery. This shows the increased awareness that the role of politicians, if elected would not be miraculous in terms of making healthcare services available. Instead, it would be making the healthcare systems and facilities accountable and responsive to the needs of the communities. Therefore, having in place clear guidelines that have been internalized by community-level actors empowers the communities to counter politicization of the discourse and narratives about the existing health problems and how they would be successfully approached.

The guidelines further documented the tools to be used by stakeholders for documentation in the course of implementing the research project and related engagement activities’ records. Most of these tools were in form of checklists and forms. The forms for example, were prepared to document the organization of the day-to- day engagement activities, progress made in conjunction with the implementation mile stones, and the resolutions regarding what should follow as well as the agreed roles of each stakeholder towards the next step [27]. The use of these guidelines made the implementation of project activities uniform across the eight study villages. A clear and unbiased understanding of the CBM principles such as decision by consensus and following clearly documented procedures reduced the chances for manipulation and the use of political power to influence decisions.

While the existence of clear guidelines is one thing and their internalization and use in the day-to-day engagement research context is another thing. Therefore, the two should not be confused. The challenge before community engagement researchers is, therefore, making the implementing stakeholders at community level to understand and institutionalize the use of those guidelines. If clear, internalized, and consistently followed; community engagement guidelines provide controls that bring the implementing partners to shared expectations and help them to set the lines of accountability for specific actions and resources’ contribution by each partner. In that way, arbitrariness of actions that would potentially increase competition and erode collaboration is effectively controlled making engagement activities less political and more scientific. In this case, chances for science adulteration by politics are reduced in favour of demystified, participatory, and co-produced scientific knowledge that is easy for the communities to put in practice and sustain.

Strategic use of the Community Advisory Committee

Community Advisory Committees (CAC) play an instrumental role in ensuring the success of community engagement research. If objectively thought and formulated, such committees become the best instrument for protecting community interests against the private interests of influential actors such as politicians. Further, CAC are formulated to protect local voices, empower study participants, and buffer the research projects against pressures from political actors’ attempt to manipulate the flow of information regarding the research and its findings [33]. However, whether the CAC will serve as a tool for dealing with politics and controlling the contribution potential of politics to science adulteration in community engagement research is not something that happens automatically. It rather depends on the extent to which the design, composition, and roles assigned to the CAC are strategic enough to shrine the project against politicization and operating under the pressure from political actors.

Strategies and different tactics were adopted to ensure that the CAC played a protective role in the planning and implementation of the CBM4Tanzania research project and the contribution of such measures were self-revealing. The CBM4Tanzania project CAC had eight members who were recruited from the eight study villages in the district. The members included both those in political positions, professionals including health workers, and representatives of the dominant political groups in the communities. Table 1 summarizes the profiles of the members of the CAC for the CBM4Tanzania research project.

The choice of committee members followed a careful process of soliciting the names of unshakable and influential personalities who were credited by community members and community-level stakeholders for their contributions to livelihood improvement. This was done through community dialogues and the initial JPRM sessions where 19 names were obtained before selecting the 9 after consultation and discussion with different primary healthcare stakeholders in the district. As part of its functions, the CAC had to collect and discuss information about the implementation of the project to ensure its success. All the members had both knowledge and agency as agents of social change and transformation. Even those in political functions were regarded to be individuals who were reliable enough to stand for the truth when there is misinformation about the project and related engagement activities. They were, indeed, people who could visit and office at grassroots and district levels and easily request and get any information required for facilitating the implementation of the project.

Where there was misinformation, the CAC chairperson and secretary took initiatives to communicate and put the information right. The stature of the CAC and the personalities of its members made the CBM4Tanzania research project reserve and maintain its identity as a non-political, non- partisan, and non-government initiative that sought to develop the capacities of an ordinary community member to monitor the use of resources and the quality of services. Overly, the CAC served an important facilitative role in terms of ensuring that political interference and the potential for political manipulation are kept to the minimum. This was also associated with social legitimacy and political approval that the project relished throughout its implementation.

Ensuring Diversity in all Engagement Platforms

Sometimes known as engagement forums, community engagement takes place through different platforms such as the mainstream and social media, community dialogues, townhall meetings, and specific stakeholders’ meetings [34]. Therefore, these platforms can be open to attract unspecified participants or closed and for specifically invited participants. Some engagement platforms tend to attract both targeted and untargeted individuals. Community dialogues and outreach activities such as football competitions and traditional dance shows can attract anyone in the community as well as people from outside the study communities. Invitees to closed platforms such as that have specifically identified stakeholders whose input is deemed to be crucial in terms of knowledge generation as well as legitimization of the research and related engagement activities.

Diversity of the engagement platforms or forums refers to the inclusion and representation of different community groups whose viewpoints, belief, values, needs, expectations, influence, and interests are saliently different [35]. We sought to maintain diversity in all the forums we organized for engagement during both data collection and dissemination activities. For instance, two political identities namely the ruling and opposition politics were dominant during 2019 and 2020 since there were for grassroot and national elections. Therefore, differences in political opinion, policies, and party ideologies dominated most of the activities that were going on in these study communities including the day- to-day economic activities such as market day gatherings, saving and credit group meetings, worship, burial, and other grassroots development planning meetings.

Out project used four main engagement platforms. These were: community outreach activities (football and traditional dance shows), community dialogue meetings, joint and reflection meetings (JPRMs). These platforms are described in details in Table 2.

As a way of moderating the effect of these competing political viewpoints and possible science adulteration, we ensured that invitation to community dialogue meetings were public to allow people from all political parties to participate. In the case of JPRMs, we took time to understand the political affiliation of all the stakeholders and ensured that neither the ruling or opposition parties would dominate and direct the agenda of our meetings. Apart from the two dominant party-based identities, other community-level stakeholders who participated in our monthly JPRMs were religious leaders from different religious congregations that existed in the communities. They included the Muslims, Christians of the catholic and those of the Evangelical denominations, and other small belief groups commonly known as the ‘born again’ churches. In addition, we also invited representatives of organized interest groups such as the traditional healers, Community-Based Organizations (CBOs), and Civil Society Organizations (CSOs). This kind of diversity allowed the engagement teams to focus on the analysis of the health problems and relevant solutions focusing on the general needs of the communities rather than preferences and interests of an individual political group in the community.