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October 30th, 2014

Embedding research in local contexts: local knowledge, stakeholders’ participation and fieldwork design.

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It is not always easy for researchers to explain how and why a research project is important to local people whose interests may be diverse or in conflict. Viewing fieldwork as a process of constructive communication with all the stakeholders for better understanding of local situations with a broader context, this post argues that the balance and interface between research focus and common interests of relevant stakeholders must be found at the beginning of the fieldwork. It raises questions about the nature of fieldwork and roles of local stakeholders in the process: Why do we need the participation from multiple stakeholders? How can they make a contribution to the fieldwork? What attitude, approach and preparation could be helpful for the researcher in order to conduct an effective and successful fieldwork? The aforementioned questions are addressed via a field research experience in Italy, which involved adjusting the research focus and involved wide participation from local people including Chinese migrant workers, writes Bin Wu .

A good beginning of fieldwork is largely dependent upon how a researcher explains his/her research aims and relevance to local people, which requires a good understanding and use of local knowledge. Local knowledge is even more important for fieldwork in a complicated or transitional society, such as China or Chinese society to which available academic references or theories may not be appropriate in light of high complexity, low trust, interest conflicts and rapid changeable environments. This raises questions about the roles of local knowledge and stakeholders’ participation in the fieldwork design and implementation, a vital condition for an effective and successful fieldwork.

Local knowledge here is broadly defined as a sum of facts, concepts, beliefs and perceptions used by local people to reflect or interpret the world around them. Different from abstract or general knowledge which has been widely adopted or circulated within academic circles, local knowledge are created by and accumulated within local people. It may not be necessarily limited to a specific location or group but normally unfamiliar to scholars. Essentially, it reflects the way local people observe, measure and reflect on their surroundings, their solutions or coping strategies as well as how they validate new information. Local knowledge is different from ‘traditional knowledge’ or ‘indigenous knowledge’, used in a negative way to reflect local people who live in areas isolated from the rest of the world or their knowledge systems which are static and do not interact with other knowledge systems.

Based upon the broad definition of local knowledge highlighted above, the two extremes of fieldwork strategies can be distinguished from each other: academic-driven and community-based. The former treats a fieldwork as a process of information collection from “samples” or sampled population for the purpose of theoretical testing in which local people have nothing to do but provide genuine information/data requested by the researcher. The latter refers to a mutual process of learning, communication and interaction between the researcher and local people for common interests. The differences of two approaches can be illustrated in Table 1 below.

Table 1 Role of local knowledge in fieldwork: contrast of two approaches:

Source: created by author.

A number of hypotheses can be drawn from Table 1 for the purposes of observing or comparing two types of fieldwork design and practices.

• The role of local knowledge in the development of relevant theories . For the academic-driven fieldwork, there is almost no space for local knowledge to play except the sampling process. By contrast, the local knowledge in the community-based fieldwork plays an important role, similar to, if not more important than, literature review. In other words, the researcher in the latter prepares to amend, revise or even resign the fieldwork in order to interface with local knowledge
• The scope and role of stakeholders. For the academic-driven one, there is a clear division between the researcher and researched. One more to be added is the presence of the gatekeeper who allows the researcher to access the field. Differently, community-based fieldwork requires the participation of all stakeholders to ensure the balance of all groups’ voices to be heard. No rejection to a research focus in the former, the latter gives an emphasis on a big picture before narrowly concentrating on a specific group.
• The nature of research process . The differences of two approaches are rooted in a different understanding about the nature and sources of theoretical development. Instead of one-way research hypotheses and information collection in the convenient approach, local people and practitioners in the second approach are treated as important members to advise or join the research team to ensure local knowledge be properly accounted.
• The ends of fieldwork are unsurprisingly different . The academic-driven fieldwork ends at reliable and accurate data for academic purposes, which may not necessarily have clear implications for policy makers in general and local stakeholders in particular. Differently, the community-based fieldwork has distinguished advantages in terms of significance to local community, a pre-condition to attract the participation of local people, which does not necessarily lose the rigour in data collection and verification.

It is worth noting that the community-based fieldwork does not totally conflict with the academic-driven fieldwork. Furthermore, there is no clear division between the two fieldworks but more likely, a range of variations between the two ends. Depending upon many factors such as geographic, economic, social and political environments as well as research themes and aims. Moreover, different approaches may have both advantages and disadvantages, and it is a good idea to combine the two approaches in fieldwork practices. For the case of fieldwork in China or Chinese society, generally, an emphasis should be given to the community-based fieldwork due to the lack of a big picture as well as many factors such as extreme complexity and diversity, rapid development and transition, an increasing degree of tension and conflicts, segmentation, segregation and fragmentation, as well as vulnerability and no voices of migrant workers.

The necessity and feasibility of the community-based fieldwork in the Chinese context can be illustrated and analysed via a genuine field research experience on the working conditions of Chinese owned factories in Veneto, Italy.

In relation with frequent “amnesties” of irregular immigrants, Italy has become an attractive destination for Chinese entrepreneurs and migrant workers since the 1990s. It has resulted in a rapid growth of Chinese-owned family businesses, especially factories in textile, garment and leather industries in which all employees are new Chinese immigrants who are isolated from the local society. To understand the working conditions of Chinese owned factories and impact on Chinese migrant workers, a collaborative research project was proposed and funded by Padova University in 2006 for conducting an empirical study in Veneto, an industrial cluster of Italy.

As a principle researcher from Cardiff University, I faced a number of challenges in designing the fieldwork. Firstly, I did not have any experience in either international migration or overseas Chinese studies before as my expertise was in global labour market for seafarers. Secondly, Chinese sweatshops abroad is a new phenomenon with little English literature available except Chinese entrepreneurship or forced labour studies. Thirdly, I knew nothing about local language and culture of Wenzhou, the predominant sending source of new Chinese owners and entrepreneurs in Italy. Finally, I tried to get the access to Chinese factories via local Chinese community organisations, which were actually social clubs of Wenzhounese businessmen. But it did not work effectively.

Following measures were taken to cope with the above challenges: (1) a short visit to the sending community (Qiaoxiang) in Wenzhou City to familiarise the migratory culture and society and gain support from local government agencies in Qiaoxiang; (2) a pilot observation was arranged in a Chinese factory afterwards via a home stay for two nights in a local Chinese community leader’s family who lived with more than 10 Chinese migrant workers, a common pattern for local Chinese family factories (3) social network building via a local Chinese Bar to familiarise and search for an access to the local Chinese society; (4) an access to Chinese business registration information stored in Italian authority for the purpose of the sampling process to select the targeted Chinese factories in Veneto.

The above measures, however, were not enough to make a significant break-through in field design until an opportunity appeared. During the period of the preparation, I learnt that local police closed down three traditional Chinese medicine (TCM) shops in the downtown area because they involved medical treatments to Chinese migrants without proper licenses. However, no alternative services were provided for Chinese patients who were unable to speak Italian. Given the fact that access to local medical services is not only an urgent need for many Chinese migrant workers but also a common concern by all Chinese groups, I decided to adjust the focus of fieldwork research from the working conditions of Chinese factories to the needs and access of Chinese migrants to local medical services. Compared with the original theme, the new direction seemed neutral, which was acceptable by all groups, both Chinese business owners and migrant workers.

Key Elements

Under a new direction and research focus, a strategy for the fieldwork implementation emerged which contained following elements:

• An “advisory board” was established which included: an Italian academic partner and experts in occupation health and safety, an Italian trade union officer, an Italian banker for international trade and supply chain, Chinese community leaders, Chinese TCM doctors, Chinese property developer, and Chinese migrant worker representatives. The roles of those members included advice or comments on draft questionnaires, strategy and methods in information collection, workplace observation, and interpretation of field observation.
• Two-tier survey. workplace observation and questionnaire or group discussion. A sample of 25 Chinese factories was randomly selected based upon official enterprise registration information. It would be impossible to get the access via random sampling if the theme of research was focused on the working conditions themselves. A team of 3-4 persons who were “advisory board” members conducted the workplace observation. Depending upon the situation, questionnaire and/or group discussion were taken place for migrant workers to be involved in the project voluntarily.
• Comparative perspective. Geographic information of Chinese registered factories, however, cannot be treated as a sampling frame for workplace observation as a large number of new or small Chinese businesses may not have been properly registered. Nonetheless, the geographic information was used to select a sampling zone in which all Chinese enterprises nearby regardless of registration were observed and compared. So were a few Italian enterprises nearby which recruited Chinese migrant workers to produce similar products but with different working conditions.
• Publicity to mobilise Chinese community participation via both Italian and Chinese media. A public press meeting was held in Padova in the early stage of the fieldwork for the purposes of disseminating survey messages and encouraging the participants and voices of different groups from the local Chinese community, including Chinese entrepreneurs who saw the potential benefits for their businesses.
• Encouraging the participation and contribution from local students whose parents were owners/entrepreneurs of Chinese factories in Veneto. Once learnt about the background and theme of this research, according to our observation, most of them were interested and keen to offer their support by encouraging their parents or migrant workers to participate.

Within one month of the fieldwork (including one week pilot study) in the Veneto region, we managed to visit 28 factories including 3 Italian factories. Only one Chinese factory refused our entry. Our workplace observation involved a total of 279 Chinese migrant workers with a different degree of contribution: some filled in the questionnaires while others joined group discussions. We managed to conduct 76 in-depth interviews or focus group meetings, of which over half were occupied by migrant workers. The rest consisted of the representatives from other groups, including traditional Chinese medicine (TCM) doctors, Chinese business owners, and community leaders who were also businessmen with a title of chair or vice-chairs of local Chinese community associations.

Concluding remarks

The narrative of my fieldwork experience in Veneto, Italy provides a hard evidence to illustrate the necessity and feasibility of the community-based fieldwork, which brings local knowledge into the process of fieldwork design and implementation. It is vital for a researcher to identify a common theme that is shared by all stakeholders, or establish clear interfaces with different groups of interests so that local people can participate in and contribute to it. Such theme or research focus cannot be clearly defined unless the researcher becomes familiar with the local situation, resources and constraints from different angles or perspectives of different interest groups. The more complicated and diverse the field, the more important is the need for community-based fieldwork design and implementation. So in addition to convenient fieldwork design and practices, this paper calls for more attention to practising community-based fieldworks when researching in a Chinese context.

Related Publications

Wu, B. and Zanin, V. (2009) Healthcare needs of Chinese migrant workers in Italy: A survey report on Chinese-owned workshops in Veneto. CPI China Discussion Paper No.48. Available online at: http://www.nottingham.ac.uk/cpi/documents/discussion-papers/discussion-paper-48-healthcare-chinese-migrants-italy.pdf

Wu, B. and Sheehan, J. (2011) Globalisation and Vulnerability of Chinese Migrant Workers in Italy: Empirical Evidence on Working Conditions and their Consequences.  Journal of Contemporary China  20(68), 135-152

Wu, B. and Liu, H. (2014) Bringing class back in: class consciousness and solidarity amongst Chinese migrant workers in Italy and the UK .  Ethnic and Racial Studies  37(8): 1391-1408

About the author

Dr. Bin Wu is a Senior Research Fellow and founder of a newly established Centre for Chinese Migrant Studies (CCMS), in School of Contemporary Chinese Studies, University of Nottingham. His research interests and expertise include rural sustainability and farmer innovation; Chinese migration and integration in China and abroad; Chinese student mobility, global citizenship and higher education reform.

For citation: Wu, B. (2014) Embedding research in local context: local knowledge, stakeholders’ participation and fieldwork design. Field Research Method Lab at LSE (30 October 2014) Blog entry. URL:  https://blogs.lse.ac.uk/fieldresearch/2014/10/30/embedding-research-in-local-context

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Home » Context of the Study – Writing Guide and Examples

Context of the Study – Writing Guide and Examples

Table of Contents

Context of the Study

The context of a study refers to the set of circumstances or background factors that provide a framework for understanding the research question , the methods used, and the findings . It includes the social, cultural, economic, political, and historical factors that shape the study’s purpose and significance, as well as the specific setting in which the research is conducted. The context of a study is important because it helps to clarify the meaning and relevance of the research, and can provide insight into the ways in which the findings might be applied in practice.

Structure of Context of the Study

The structure of the context of the study generally includes several key components that provide the necessary background and framework for the research being conducted. These components typically include:

• Introduction : This section provides an overview of the research problem , the purpose of the study, and the research questions or hypotheses being tested.
• Background and Significance : This section discusses the historical, theoretical, and practical background of the research problem, highlighting why the study is important and relevant to the field.
• Literature Review: This section provides a comprehensive review of the existing literature related to the research problem, highlighting the strengths and weaknesses of previous studies and identifying gaps in the literature.
• Theoretical Framework : This section outlines the theoretical perspective or perspectives that will guide the research and explains how they relate to the research questions or hypotheses.
• Research Design and Methods: This section provides a detailed description of the research design and methods, including the research approach, sampling strategy, data collection methods, and data analysis procedures.
• Ethical Considerations : This section discusses the ethical considerations involved in conducting the research, including the protection of human subjects, informed consent, confidentiality, and potential conflicts of interest.
• Limitations and Delimitations: This section discusses the potential limitations of the study, including any constraints on the research design or methods, as well as the delimitations, or boundaries, of the study.
• Contribution to the Field: This section explains how the study will contribute to the field, highlighting the potential implications and applications of the research findings.

How to Write Context of the study

Here are some steps to write the context of the study:

• Identify the research problem: Start by clearly defining the research problem or question you are investigating. This should be a concise statement that highlights the gap in knowledge or understanding that your research seeks to address.
• Provide background information : Once you have identified the research problem, provide some background information that will help the reader understand the context of the study. This might include a brief history of the topic, relevant statistics or data, or previous research on the subject.
• Explain the significance: Next, explain why the research is significant. This could be because it addresses an important problem or because it contributes to a theoretical or practical understanding of the topic.
• Outline the research objectives : State the specific objectives of the study. This helps to focus the research and provides a clear direction for the study.
• Identify the research approach: Finally, identify the research approach or methodology you will be using. This might include a description of the data collection methods, sample size, or data analysis techniques.

Example of Context of the Study

Here is an example of a context of a study:

Title of the Study: “The Effectiveness of Online Learning in Higher Education”

The COVID-19 pandemic has forced many educational institutions to adopt online learning as an alternative to traditional in-person teaching. This study is conducted in the context of the ongoing shift towards online learning in higher education. The study aims to investigate the effectiveness of online learning in terms of student learning outcomes and satisfaction compared to traditional in-person teaching. The study also explores the challenges and opportunities of online learning in higher education, especially in the current pandemic situation. This research is conducted in the United States and involves a sample of undergraduate students enrolled in various universities offering online and in-person courses. The study findings are expected to contribute to the ongoing discussion on the future of higher education and the role of online learning in the post-pandemic era.

Context of the Study in Thesis

The context of the study in a thesis refers to the background, circumstances, and conditions that surround the research problem or topic being investigated. It provides an overview of the broader context within which the study is situated, including the historical, social, economic, and cultural factors that may have influenced the research question or topic.

Context of the Study Example in Thesis

Here is an example of the context of a study in a thesis:

Context of the Study:

The rapid growth of the internet and the increasing popularity of social media have revolutionized the way people communicate, connect, and share information. With the widespread use of social media, there has been a rise in cyberbullying, which is a form of aggression that occurs online. Cyberbullying can have severe consequences for victims, such as depression, anxiety, and even suicide. Thus, there is a need for research that explores the factors that contribute to cyberbullying and the strategies that can be used to prevent or reduce it.

This study aims to investigate the relationship between social media use and cyberbullying among adolescents in the United States. Specifically, the study will examine the following research questions:

• What is the prevalence of cyberbullying among adolescents who use social media?
• What are the factors that contribute to cyberbullying among adolescents who use social media?
• What are the strategies that can be used to prevent or reduce cyberbullying among adolescents who use social media?

The study is significant because it will provide valuable insights into the relationship between social media use and cyberbullying, which can be used to inform policies and programs aimed at preventing or reducing cyberbullying among adolescents. The study will use a mixed-methods approach, including both quantitative and qualitative data collection and analysis, to provide a comprehensive understanding of the phenomenon of cyberbullying among adolescents who use social media.

Context of the Study in Research Paper

The context of the study in a research paper refers to the background information that provides a framework for understanding the research problem and its significance. It includes a description of the setting, the research question, the objectives of the study, and the scope of the research.

Context of the Study Example in Research Paper

An example of the context of the study in a research paper might be:

The global pandemic caused by COVID-19 has had a significant impact on the mental health of individuals worldwide. As a result, there has been a growing interest in identifying effective interventions to mitigate the negative effects of the pandemic on mental health. In this study, we aim to explore the impact of a mindfulness-based intervention on the mental health of individuals who have experienced increased stress and anxiety due to the pandemic.

Context of the Study In Research Proposal

The context of a study in a research proposal provides the background and rationale for the proposed research, highlighting the gap or problem that the study aims to address. It also explains why the research is important and relevant to the field of study.

Context of the Study Example In Research Proposal

Here is an example of a context section in a research proposal:

The rise of social media has revolutionized the way people communicate and share information online. As a result, businesses have increasingly turned to social media platforms to promote their products and services, build brand awareness, and engage with customers. However, there is limited research on the effectiveness of social media marketing strategies and the factors that contribute to their success. This research aims to fill this gap by exploring the impact of social media marketing on consumer behavior and identifying the key factors that influence its effectiveness.

Purpose of Context of the Study

The purpose of providing context for a study is to help readers understand the background, scope, and significance of the research being conducted. By contextualizing the study, researchers can provide a clear and concise explanation of the research problem, the research question or hypothesis, and the research design and methodology.

The context of the study includes information about the historical, social, cultural, economic, and political factors that may have influenced the research topic or problem. This information can help readers understand why the research is important, what gaps in knowledge the study seeks to address, and what impact the research may have in the field or in society.

Advantages of Context of the Study

Some advantages of considering the context of a study include:

• Increased validity: Considering the context can help ensure that the study is relevant to the population being studied and that the findings are more representative of the real world. This can increase the validity of the study and help ensure that its conclusions are accurate.
• Enhanced understanding: By examining the context of the study, researchers can gain a deeper understanding of the factors that influence the phenomenon under investigation. This can lead to more nuanced findings and a richer understanding of the topic.
• Improved generalizability: Contextualizing the study can help ensure that the findings are applicable to other settings and populations beyond the specific sample studied. This can improve the generalizability of the study and increase its impact.
• Better interpretation of results: Understanding the context of the study can help researchers interpret their results more accurately and avoid drawing incorrect conclusions. This can help ensure that the study contributes to the body of knowledge in the field and has practical applications.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Article Contents

• 1. Introduction
• 2. A plurality of communities
• 3. The International Research Integrity Survey—data and methods
• 4. Empirical results
• 5. The cosmopolitan academic and research integrity regulations
• 6. Solidarity
• 7. Discussion—fluid, multiple, and situated identities
• 8. Conclusion—towards a realistic regulatory framework for research integrity
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Disentangling the local context—imagined communities and researchers’ sense of belonging

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Serge P J M Horbach, Mads P Sørensen, Nick Allum, Abigail-Kate Reid, Disentangling the local context—imagined communities and researchers’ sense of belonging, Science and Public Policy , Volume 50, Issue 4, August 2023, Pages 695–706, https://doi.org/10.1093/scipol/scad017

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It is generally agreed that researchers’ ‘local context’ matters to the successful implementation of research integrity policies. However, it often remains unclear what the relevant local context is. Is it the institutions and immediate working surroundings of researchers? Or, do we need to pay more attention to researchers’ epistemic communities if we want to understand their ‘local context’? In this paper, we examine this question by using the International Research Integrity Survey with more than 60,000 respondents. Survey responses indicate that academics identify with both their geographical local units (‘polis’) and their more transnational epistemic or scholarly communities (‘cosmos’). Identification with scholarly communities tends to be strongest. We embed the survey results in the academic literature by proposing a theoretical understanding of academics’ ‘local context’ based on Beck’s notion of cosmopolitanism and Durkheim’s concept of solidarity. We conclude with considerations on how to successfully implement research integrity policies.

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The Power of Local Context and Stakeholder Engagement in Research

Frankline kibuacha | jun. 29, 2023 | 3 min. read.

Integrating research within local contexts and actively involving stakeholders in fieldwork design is crucial for achieving effective and successful outcomes. This article explores the significance of embracing local knowledge and stakeholder participation in research and emphasizes their role in generating meaningful contributions. By striking a balance between research objectives and the interests of stakeholders, researchers can unlock valuable insights and ensure their work is grounded in the local context.

Understanding Local Context:

Local context refers to the collective understanding, beliefs, and perceptions held by communities to interpret their surroundings. It goes beyond widely circulated knowledge and is unique to specific local contexts. Researchers can benefit from incorporating local knowledge into their work as it provides alternative theories, unique perspectives, and invaluable insights. By tapping into the knowledge of local communities, researchers can enrich their research findings and make them more relevant and applicable to the local context.

The role of stakeholder engagement:

Stakeholder engagement plays a vital role in the research process. By involving relevant stakeholders from the outset, researchers can align their objectives with the common interests of those directly affected by the research. This inclusive approach fosters mutual understanding, collaboration, and the co-creation of knowledge. Engaging stakeholders ensures that research outcomes are not only academically rigorous but also address the real needs and concerns of the local community. The active participation of stakeholders enhances the relevance and impact of the research findings.

Why local context and stakeholder engagement are important.

Local knowledge and stakeholder engagement offer several advantages in research projects.

• Enriched understanding of the local context: Local knowledge provides researchers with insights that may challenge or enhance existing theories and prejudice, particularly in complex or transitional societies. By incorporating local knowledge, researchers gain a deeper understanding of the unique cultural, social, and historical factors that shape the local context. This understanding helps refine research questions and methodologies, ensuring they are relevant and appropriate for the specific context.
• Context-specific and comprehensive approaches: Researchers can develop context-specific approaches that better explain and address local phenomena by integrating local knowledge into research. Local knowledge provides alternative perspectives and viewpoints that may not be captured by abstract or widely circulated knowledge. This process enriches academic discourse and contributes to developing comprehensive and nuanced theories.
• Identification of research priorities : Stakeholder engagement ensures that research addresses the concerns and needs of the community. By actively involving stakeholders, researchers gain valuable insights into the priorities, challenges, and aspirations of the local community. This participatory approach increases the relevance and impact of the research findings. It allows researchers to focus on topics that truly matter to the community and generates research outcomes that are more likely to lead to positive change.
• Enhanced data quality and validity: Engaging stakeholders in the research process improves the quality and validity of the data collected. Stakeholders possess local knowledge, lived experiences, and intimate familiarity with the local context, which can inform data collection strategies and help ensure that relevant information is captured accurately. Involving stakeholders as active participants in data collection reduces potential biases and enhances the credibility and reliability of the research findings.
• Actionable recommendations: Stakeholder engagement fosters a sense of ownership and collaboration in the research process. By actively involving stakeholders in data analysis and interpretation, researchers can co-create actionable recommendations that are more likely to be accepted and implemented by the community. This collaborative approach ensures that research outcomes translate into tangible benefits and positive changes for the community.
• Increased community support and sustainability: Engaging stakeholders builds trust, fosters relationships, and promotes a sense of shared responsibility between researchers and the community, particularly for development and aid research. When stakeholders feel valued and included, they are more likely to support and participate in future research endeavors. This long-term engagement contributes to the sustainability of research initiatives and creates a foundation for continued collaboration and knowledge sharing.

Implementing successful fieldwork:

Implementing successful fieldwork requires careful planning and execution. A team comprising experts, community members, and local enumerators helps ensure a well-rounded perspective and inclusive decision-making. At GeoPoll, for example, our staff are primarily based in the regions where we collect most data . We have over 10,000 trained interviewers for CATI and face-to-face surveys for additional local context in data collection.

While there may be variations in research approaches , combining academic-driven research with a community-based approach yields valuable results. Academic-driven research focuses on hypothesis testing and theoretical frameworks, while a community-based approach emphasizes collaboration, mutual learning, and communication with local communities. By combining these approaches, researchers can validate academic theories with local knowledge, ensuring the research is rigorous, relevant, and impactful.

Geopoll’s approach to local context:

In conclusion, integrating research within local contexts and involving stakeholders in fieldwork design is critical for achieving impactful and meaningful outcomes. Local knowledge provides researchers with unique insights and alternative theories, enhancing the relevance and applicability of their work. Engaging stakeholders ensures that research objectives align with the needs and interests of the community, leading to actionable recommendations and positive change. By embracing local knowledge and involving stakeholders, researchers can unlock valuable insights and make a lasting impact in their respective fields.

With staff based in the regions where we operate and more than 10,000 trained interviewers worldwide, our projects are grounded in local context and expertise in survey methodology. This enables us to understand the intricacies of each unique context and tailor our research methodologies accordingly. That’s how robust, relevant, and impactful our research is.

Contact us for more information about our local coverage.

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Adapting clinical practice guidelines to local context and assessing barriers to their use

Associated data.

The knowledge-to-action cycle represents a framework for the implementation of knowledge. 1 As discussed in the first article in this series, the action phases of this cycle were derived from a review of 31 theories of planned action. 2 Included in this cycle ( Figure 1 ) are the processes needed to implement knowledge in health care settings. In this paper, we address the adaptation of the knowledge to the local context and assessment of barriers to and facilitators of the use of knowledge. The action cycle is a dynamic and iterative process with each phase informing the others.

The knowledge-to-action cycle.

Why adapt guidelines for local use?

Using the best evidence is a fundamental aspect of quality health care and valid guidelines for clinical practice are an important tool to inform evidence-based practices. Guidelines are derived from synthesized evidence that has been translated into specific practice-oriented recommendations. 3 The production of guidelines has been promoted and supported by governments and professional organizations as a mechanism for reducing variations in practice. Many countries have infrastructure at the national or regional level dedicated to synthesizing evidence and producing guidelines, as well as incentives designed to support practices guided by current recommendations of guidelines. 4

The goals of these initiatives differ depending on the political context and the health care system. For instance, in the United Kingdom, the National Health Service has infrastructure and incentives to deliver care guided by recommendations of guidelines. National bodies such as the National Institute for Health and Clinical Excellence 5 are dedicated to synthesizing evidence and producing guidelines for use within the National Health Service. To assess the uptake and adherence to guideline-based care, auditing functions exist across trusts (i.e., regions) in the National Health Service. Despite these efforts, evaluation of these strategies for implementation show that overall conformity of practices lags behind expectations. 6

Although high-quality guidelines may be seen as necessary, they are not sufficient to ensure evidence-based decision-making. Uptake of knowledge does not occur with simple dissemination and usually requires a substantive, proactive effort to encourage use at the point of decision-making. 7 The gap between valid recommendations of guidelines and delivery of care based on this evidence may be due to numerous barriers. For instance, clinicians may not have the requisite skills and expertise to implement a recommended action (e.g., being unfamiliar with how to initiate or titrate a new medication), or the setting may not have the mandatory equipment or its staff the time to deliver a guideline’s recommendation. 3

Although guidelines provide evidence in a more usable form for clinicians than a plethora of primary studies, an important and additional necessary step is the adaptation of the guideline to the local context of use. National and international bodies have made major efforts to improve the quality and rigour of guidelines, 8 , 9 but less investment has been made in understanding how guidelines can be targeted to the local context of health care. By local, we mean a continuum of contexts that could range from a single clinic to a hospital, region or nation.

Customizing a clinical practice guideline to a particular organization may improve acceptance and adherence. Active involvement of the end-users of the guideline in this process has been shown to lead to significant changes in practice. 10 – 13 For example, local and regional adaptations of international evidence-based practice guidelines have become mandatory for the care of patients with cancer in France. 14 For many regions and territorial jurisdictions, de novo development of guidelines is not feasible because of lack of time, expertise and resources, and thus taking advantage of existing high-quality guidelines is sensible. 15 – 17

Adaptation of existing high-quality guidelines for local use is an approach with the potential to reduce duplication of effort and enhance applicability. National guidelines often lack details on applicability and description of the changes in the organization of care required to apply the recommendations. 18 Adaptation of evidence may promote local uptake of evidence through a sense of ownership by the end-users who are engaged in this process. However, customizing a guideline to local conditions could weaken the integrity of the evidence base. We outline a systematic, participatory approach for evaluating and adapting available guidelines to a local context of use while maintaining the quality and validity of the guideline. Whether evidence is provided in the format of syntheses of knowledge, patient decision aids or clinical practice guidelines, end-users must consider if or how it could be adapted to the local context and the same principles can be applied to ensure these factors are considered before implementation of the evidence.

To illustrate how to adapt guidelines, we will use a recent study that was performed to improve community care of individuals living with venous ulcers of the leg. 10 , 13 Regional managers of home care were concerned about costs of supplies, amount of nursing time, and frequency of visiting for clients with ulcers of the leg. A regional task force was developed to review existing practice guidelines to help guide the care plan. The task force identified that many of these guidelines were from international bodies and would require adaptation to the local context.

How are guidelines adapted for local use?

Existing guidelines can be evaluated and customized to fit local circumstances through an active, systematic and participatory process. This process must preserve the integrity of the evidence-based recommendations when differences in organizational, regional or cultural circumstances may legitimately require important variations in recommendations. 8 , 9 , 14 – 16 , 19 In adapting a guideline, consideration is given to local evidence, such as specific health questions relevant to a local context of use; to specific needs, priorities, legislation, policies and resources; to scopes of practice within the local health services; and to fit within existing models of delivery in the targeted setting. Adapting the guideline to this local evidence is assumed to improve uptake of the guidelines.

Returning to our example involving care of ulcers of the leg, the task force collectively assessed the quality of individual guidelines and their recommendations. They developed a protocol that was feasible to implement locally and that was endorsed by stakeholders. The guideline was condensed to a one-page algorithm to enhance use by the clinicians, and documentation forms were created for collection of clinical data. For example, to streamline the process of assessment and facilitate application of evidence-based care, documentation forms were created to collect information about the cause of the ulcer, with venous symptoms and history on one side of the page and arterial symptoms on the other.

With the exception of a few studies such as this collaboration for care of ulcers of the leg, 10 , 13 , 17 no validated process for the adaptation of guidelines has been documented. Recently, the Canadian work 16 in this area was integrated with an international initiative known as the ADAPTE collaboration ( www.adapte.org ). 19 This collaboration is a group of researchers and developers, implementers and users of guidelines whose aim is to enhance the use of research-based evidence through more efficient development and implementation of practice guidelines. The ADAPTE process was developed to facilitate the creation of efficient, high-quality adapted guidelines. The process engages end-users in the guideline adaptation process to address specific health-related questions relevant to its context of use. The goal is to establish a standard of being transparent, rigorous and replicable based on the following core principles:

• Respect of evidence-based principles in the development of guidelines, 20
• Use of reliable and consistent methods to ensure the quality of the adapted guideline, 9 , 19
• Participation of key stakeholders to foster acceptance and ownership of the adapted guideline and ultimately promote its use, 13 , 14
• Consideration of context during adaptation to ensure relevance for local practice and policy, 13 , 21
• Transparent reporting to promote confidence in the recommendations of the adapted guideline, 9 , 20
• Use of a flexible format to accommodate specific needs and circumstances, 18 , 22 and
• Respect for and acknowledgement of guideline materials used as sources.

What is the ADAPTE process?

The ADAPTE process consists of three main phases, including planning and set-up, adaptation, and development of a final product ( Box 1 ). The set-up phase outlines the necessary tasks to be completed before the process of adaptation, including identifying necessary skills and resources, and designing the panel. The panel should include relevant end-users of the guideline, such as clinicians, managers and patients.

Box 1. Phases, modules and steps in the adaptation of a guideline using the ADAPTE process. A scenario of care of patients with leg ulcers is included as an example

PHASE I — Set-up

Module: Preparation

This group will determine the scope of the project, terms of reference and a working plan. (Example: A regional task force was formed that comprised home care nurses, family physicians and specialists involved in the care of patients with leg ulcers [i.e., hematologist, dermatologist]).

Criteria can include prevalence of disease; evidence of underuse, overuse or misuse of interventions and existence of an evidence-based guideline. (Example: A review was performed of the extent of community-based care of chronic wounds. The most prevalent type of wound was identified as venous leg ulcer. The existence of high-level evidence for management was confirmed.)

Determine if a guideline is available. (Example: A systematic search was performed. Numerous high-quality guidelines available from credible agencies [RCN, SIGN, RNAO] were identified.)

Resources to consider include a high level of commitment by members of the panel, funds to cover costs of meetings, and qualified people to manage the project. Necessary skills include expertise in content, critical appraisal, retrieval of information, implementation and policy. (Example: A need for input from family physicians, nurses and specialists was identified. Methodological support for the panel by local researchers was negotiated.)

Tasks include development of terms of reference, declaration of competing interests and process for consensus, identification of endorsement bodies, determination of authorship of the guideline and development of strategies for dissemination and implementation. (Example: Members of the group decided to function as a working group and share authorship, providing reports to the home care authority and nursing agencies involved.)

The plan may include details of the topic, membership of the panel, declaration of competing interests and a proposed timeline. (Example: A plan and a timeline for completion were agreed upon by the working group.)

PHASE II — Adaptation

Module: Scope and purpose

Focus on the Population of interest, the Intervention of interest, the Professions to which the guideline is to be targeted and the Outcomes and Health care setting of interest (PIPOH). (Example: Using the PIPOH approach, the group decided that the population of interest was people with venous leg ulcers; the interventions of interest were assessment and management of these patients; the professions targeted were community nurses; the outcome of interest was healed ulcers; and the health care setting was the community.)

Module: Search and screen

Search for relevant guidelines, systematic reviews and reviews of health-related technology that have been published since the guideline. (Example: The group of researchers searched for relevant guidelines.)

Perform a preliminary screening to determine if the guidelines retrieved are relevant to the topic. (Example: The working group identified 8 relevant guidelines.)

Use the rigour dimension of the AGREE tool to assess the quality of the guideline. Include for further assessment only those that are of highest quality.

Module: Assess guidelines

Use the AGREE instrument to assess quality. We suggest that 2 to 4 members do this step independently.

Review the search and dates of publication of the guideline to ascertain inclusion of the most current evidence. This step requires input from an information scientist and content experts. (Example: Four guidelines for management of leg ulcers were eliminated after assessment of rigour and currency.)

Content can be considered in either of 2 formats: recommendations provided and grouped by guideline or recommendations grouped by similarity (e.g. topic covered). (Example: Assessment of a leg wound was compared and in all of the high-quality guidelines, an ABPI was taken along with a detailed clinical assessment.)

Assess the search strategy and selection of evidence supporting the recommendations, the consistency between selected evidence and how developers summarize and interpret the evidence, and the consistency between the interpretation of the evidence and the recommendations. (Example: The ABPI was supported with high-level evidence in 4 guidelines.)

• 15. Assess the acceptability and applicability of the recommendations.

Module: Decision and selection

Provide the panel with all documents summarizing the review, including the AGREE results and recommendations. (Example: The AGREE scores were displayed on bar graphs to easily differentiate quality scores. The recommendations for assessment and management were synthesized on a matrix of recommendations including the levels of evidence.)

Consider the following options: reject the whole guideline; accept the whole guideline, including summary of evidence and recommendations; accept the summary of evidence; accept specific recommendations; modify specific recommendations. (Example: One main guideline was used because the recommendations compared well with the other high-quality guidelines and the practice-based recommendations were well-stated.)

Module: Customization

Prepare a draft document respecting the needs of the end-users and providing a detailed explanation of the process used to derive the recommendations. (Example: The co-chair of the working group compiled the results of the deliberations and wrote the local protocol.)

PHASE III — Finalization

Module: External review and acknowledgement

Include targeted users of the guideline, such as clinicians, managers and policy-makers. Ask whether they agree with recommendations, whether gaps exist, whether the guideline is acceptable and whether it has any resource-related implications. (Example: A copy was circulated for comment to all family physicians and home care nurses in the region.)

Engage relevant professional organizations and societies to endorse the guidelines. (Example: Home care authority and nursing agencies endorsed the protocol as “usual care” for referrals for care of leg ulcers.)

Send the adapted guideline to the developers, especially if changes were made to the recommendations. (Example: No substantive changes were made to recommendations so this step was not undertaken.)

Cite references for all source documents in the final document and ensure that any necessary copyright-related permissions are obtained. (Example: The key guidelines used for the local protocol were cited.)

Module: After-care planning

Decide on a date for review and a plan for a repeat search and modification. (Example: An update 3 years after the initial local protocol was undertaken but no new evidence was found to change the recommendations.)

Module: Final production

Include details on tools for implementation, including information for patients. The final document should be easily accessible to end-users. (Example: A formal, guideline-style protocol was written. Additionally, a 1-page algorithm was developed for community nurses and physicians to use.)

Note: RCN = Royal College of Nursing; SIGN = Scottish Intercollegiate Guidelines Network; RNAO = Registered Nurses Association of Ontario; PIPOH = Population, Intervention, Professions, Outcomes, and Health care setting; AGREE = Appraisal of Guidelines Research and Evaluation; ABPI = ankle-brachial pressure index.

The phase of adaptation assists in moving from selection of a topic to identification of specific clinical questions; in searching for, retrieving and assessing guidelines; in decision-making around adaptation; and in preparing the draft version of the adapted guideline. Assessment of the retrieved guidelines involves evaluation of their quality (i.e., using the AGREE [Appraisal of Guidelines Research and Evaluation] instrument 9 , 23 ), currency (i.e., how up-to-date they are) and consistency (i.e., congruence of the recommendation with the underlying evidence). Assessment also consists of the examination of the acceptability (i.e., to clinicians and patients) and applicability (i.e., feasibility of applying recommendations) of the guidelines’ recommendations within the proposed context of use. This evaluation provides an explicit basis for informed and transparent decision-making around the selection and modification of guidelines used as sources. This process can result in different alternatives ranging from adopting a guideline unchanged, to translation of language and adaptation of format, to modification and updating of single recommendations, to the production of a customized guideline based on various guidelines used as sources. The finalization phase includes external review, feedback from relevant stakeholders, and consultation with the developers of source guidelines. Establishing a process for updating the adapted guideline and writing the final document are the last stages.

The ADAPTE process is supported by tools on the ADAPTE website, including a manual and toolkit. For each module, the manual provides a detailed description of the aims and tasks, the products and deliverables, and the skills and organizational requirements necessary to undertake the tasks. An example related to the adaptation of guidelines for screening for cervical cancer is provided throughout the modules. In the toolkit, 19 tools or instruments are offered to help structure the process and collect necessary information for decision-making.

For example, tool number 2 offers a comprehensive search strategy to help in identifying existing guidelines by searching websites of sources of guidelines (e.g., guideline-related clearing-houses, known developers’ sites, specialty organizations) and MEDLINE. Tool number 6 helps a group convert the topic of the guideline into a set of clear and focused key questions before the process of adaptation. Tool number 15 proposes a series of structured questions and criteria to guide the assessment of and discussion on whether a recommendation of a guideline is applicable or acceptable in the planned context of use and to identify the organizational changes that may be needed to deliver the recommendation. Steps and tools are flexible and have been designed to allow for alteration in the sequence in which they are used to fit with users’ time or restraints in resources.

Adapting a guideline or other tool of knowledge is a key component of the knowledge-to-action cycle. The adaptation process also integrates other steps of the cycle, including assessment of barriers to and facilitators of use of knowledge, which is necessary both for adapting and implementing the guideline.

Key concepts for assessment

The use of a framework is important for assessing barriers because it helps researchers and practitioners identify research questions, generate testable hypotheses, assess outcomes using valid and reliable instruments and make valid inferences from their results. A framework would ensure that researchers can elaborate theory-based interventions that have the potential for increasingly effective implementation of knowledge into clinical practice. 24 More importantly, the use of a framework also provides the foundation for the tools that help busy clinicians implement practice guidelines.

One of the more often-cited conceptual frameworks regarding barriers to use of knowledge in health care is the Clinical Practice Guidelines Framework for Improvement by Cabana and colleagues. 25 This framework was based on an extensive search of the literature for barriers to adherence by physicians to clinical practice guidelines and was organized according to knowledge, attitudes and behaviour of physicians. 26 Of 5658 potentially eligible articles, Cabana and colleagues identified 76 published studies describing at least one barrier to adherence to clinical practice guidelines. The included articles reported on a total of 293 potential barriers to adherence to guidelines by physicians. These barriers included unawareness of the existence of the guideline ( n = 46), unfamiliarity with the recommendations of guidelines ( n = 31), disagreement with the recommendations ( n = 33), lack of self-efficacy (i.e., feeling one is unable to carry out the recommendations) ( n = 19), outcome expectancy (i.e., the perception that health outcomes will be changed if the recommendations are followed) ( n = 8), inability to overcome the inertia of previous practice ( n = 14) and presence of external barriers to following the recommendations ( n = 34). 25

Espeland and Baerheim 27 proposed a revised and extended classification of barriers based on the Clinical Practice Guide-lines Framework for Improvement. 27 They based their classification on interviews with focus groups of Norwegian general practitioners about factors affecting adherence to clinical practice guidelines for ordering diagnostic images for back pain. Newly identified barriers were lack of expectancy that adherence to guidelines will lead to the desired process of health care, emotional difficulty with adherence, improper access to actual or alternative health care services and pressure to do otherwise from health care providers and organizations. 27

More recently, the Clinical Practice Guidelines Framework for Improvement was expanded. In a study targeting the identification of barriers to and facilitators of implementing shared decision-making in clinical practice, each type of barrier was provided with a specific definition. 28 The intention was to standardize the reporting of barriers to and facilitators of use of knowledge in the context of health care. 28 Barriers were defined as factors that would limit or restrict implementation of shared decision-making in clinical practice. 29 More importantly, the Clinical Practice Guidelines Framework for Improvement was transferred into a list of potential facilitators of use of knowledge in clinical practice. 28 Facilitators were defined as factors that would promote or help implement shared decision-making in clinical practice.

Sometimes we forget that the same factor may sometimes be identified both as a barrier to and as a facilitator of use of knowledge, showing the importance of developing a more comprehensive and integrated understanding of both barriers and facilitators concurrently. 30 , 31 The Clinical Practice Guidelines Framework for Improvement was further extended to include the attributes of innovation as proposed by the Diffusion of Innovation theory. 32 As a result, except for the barrier known as lack of awareness (i.e., not knowing of the existence of a guideline) and the facilitator known as awareness (i.e., knowing about a guideline), the other factors initially proposed by the Clinical Practice Guidelines Framework for Improvement were potential barriers or facilitators. One new barrier, “forgetting” (i.e., inadvertently omitting to attend to something) was also identified.

This revised version of the Clinical Practice Guidelines Framework for Improvement was used in a systematic review of barriers to and facilitators of implementing shared decision-making in clinical practice. 33 The framework was applied successfully in extracting data from 41 publications covering 38 unique studies. 33 The corresponding definitions of each of the potential barriers to and facilitators of use of knowledge in the health care context are provided in Appendix 1 (available at www.cmaj.ca/cgi/content/full/cmaj.081232/DC1 ).

Tools for assessment

To clearly identify barriers to and facilitators of use of knowledge in health care practices, assessment of them in a valid and reliable fashion is needed. Considerable interest exists in the idea of instruments for valid and reliable assessment of barriers to and facilitators of use of knowledge that can be used by various end-users who are trying to implement knowledge. Based on the Clinical Practice Guidelines Framework for Improvement, a tool to assess barriers to adherence to guidelines for hand-specific hygiene was developed and tested on a group of 21 clinicians of infectious disease. 34 The tool uses a six-point Likert scale and has two sections: attitudinal statements about practice guidelines in general and specific statements regarding hand hygiene. The survey was administered twice, at two-week intervals. The tool known as Attitudes Regarding Practice Guidelines was found to have good reliability. 34 However, the authors concluded that their tool needed to undergo further testing and adaptation as a general measure of potential barriers to adherence to practice guidelines. 34

One of us (FL) completes regular audits of practice as part of a primary health care group. In a large, urban site for teaching family medicine (i.e., with 20 clinical teachers and 24 residents in family medicine as well as three nurses), the residents recently completed an audit of ambulatory care of patients with type 2 diabetes mellitus. One of the clinical teachers supervised a group of four residents in the completion of this audit. Residents reviewed the relevant practice guidelines and assessed their quality using the AGREE checklist. Based on this appraisal of quality, they retained the recommendations of the guidelines of the Canadian Diabetes Association. Based on these recommendations, they created a grid for extracting data on whether the recommendations were implemented. Forty patient charts were chosen randomly and the percentage of cases that followed the recommendations of guidelines was calculated.

The results of the audit were presented to the health care team for discussion. For example, results showed that a test for glycosylated hemoglobin was performed every three months, as recommended by the guidelines of the Canadian Diabetes Association (i.e., level D, consensus) in only 30% of cases. Based on the Clinical Practice Guidelines Framework for Improvement, discussion by the group revealed that barriers perceived by health care providers included lack of agreement with the recommendation because it was too rigid or artificial, factors associated with environment such as not having enough staff to carry out the recommendation, lack of agreement with the applicability of this recommendation to the population served by the practice based on the characteristics of the patient because some patients had very stable results in the past, and external factors, such as perceived inability to reconcile patient preferences with compliance to this recommendation.

This scenario shows that groups of providers in real clinical settings can take advantage of this checklist to identify barriers to carrying out recommendations in guidelines for practice. Once the barriers are made explicit, solutions can be expected to be brought forward for the benefit of patients. Without ignoring that one solution usually does not fit all, this checklist has the potential to help groups of providers reconcile their diverse perspectives because it is evidence-based, extensive and explicit.

Gaps in the implementation of evidence

Although many current research-based initiatives focus on implementing guidelines and assessing factors influencing use of knowledge in health care practices, many challenges remain that will need to be addressed by rigorous research. First, evaluation of the ADAPTE process is needed to determine its impact on the implementation of guidelines. Second, validated methods are needed to assess barriers to and facilitators of the translation of research into clinical practice. 29 , 35 , 36 Researchers and clinicians may want to consider using existing models that have been tested, such as the Clinical Practice Guidelines Framework for Improvement (i.e., in its latest version), to conduct studies on barriers to and facilitators of assessment. 25 Lastly, more will need to be done to reconcile the recommendations of practice guidelines to the sharing of care-related decisions with patients — the core concept of patient-centred care.

The book Knowledge Translation in Health Care: Moving from Evidence to Practice , edited by Sharon Straus, Jacqueline Tetroe and Ian D. Graham and published by Wiley-Blackwell in 2009, includes the topics addressed in this series.

• Clinical practice guidelines can be adapted to local circumstances and settings to avoid duplication of efforts and optimize use of resources.
• The ADAPTE process is an approach to adapting guidelines to local contexts through the explicit participation of relevant decision-makers.
• Assessing barriers to and facilitators of the use of knowledge is closely linked to the adaptation and uptake of the evidence.

Articles to date in this series

• Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ 2009;181:165–8.
• Brouwers M, Stacey D, O’Connor A. Knowledge creation: synthesis, tools and products. CMAJ 2009.DOI:10.1503/cmaj.081230
• Kitson A, Straus SE. The knowledge-to-action cycle: identifying the gaps. CMAJ 2009.DOI:10.1503/cmaj.081231

Supplementary Material

Funding: No external funding was received for this paper.

ADAPTE Group

Melissa Brouwers, George Browman, Jako Burgers, Bernard Burnand, Margaret B. Harrison, Béatrice Fervers, Ian Graham, Jean Latreille, Najoua Mlika-Cabanne, Louise Paquet, Raghu Rajan, Magali Remy-Stockinger, Anita Simon, Joan Vlayen and Louise Zitzelsberger

Competing interests: None declared.

Contributors: Margaret Harrison, Béatrice Fervers and Ian Graham, who are founding members of the ADAPTE group, were involved in the development of the methodology of the manuscript, and conceptualized and drafted the section on adaptation of guidelines. France Légaré and Ian Graham were involved in the conceptualization and drafting of the section on assessment of barriers. All of the authors critically revised the manuscript and approved the final version submitted for publication.

This article has been peer reviewed.

• Research article
• Open access
• Published: 09 November 2016

Understanding the local context and its possible influences on shaping, implementing and running social accountability initiatives for maternal health services in rural Democratic Republic of the Congo: a contextual factor analysis

• Eric M. Mafuta 1 , 2 ,
• Lisanne Hogema 2 ,
• Thérèse N. M. Mambu 1 ,
• Pontien B. Kiyimbi 3 ,
• Berthys P. Indebe 4 ,
• Patrick K. Kayembe 1 ,
• Tjard De Cock Buning 2 &
• Marjolein A. Dieleman 2 , 5  

BMC Health Services Research volume  16 , Article number:  640 ( 2016 ) Cite this article

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Social accountability has to be configured according to the context in which it operates. This paper aimed to identify local contextual factors in two health zones in the Democratic Republic of the Congo and discuss their possible influences on shaping, implementing and running social accountability initiatives.

Data on local socio-cultural characteristics, the governance context, and socio-economic conditions related to social accountability enabling factors were collected in the two health zones using semi-structured interviews and document reviews, and were analyzed using thematic analysis.

The contexts of the two health zones were similar and characterized by the existence of several community groups, similarly structured and using similar decision-making processes. They were not involved in the health sector’s activities and had no link with the health committee, even though they acknowledged its existence. They were not networked as they focused on their own activities and did not have enough capacity in terms of social mobilization or exerting pressure on public authorities or providers.

Women were not perceived as marginalized as they often occupied other positions in the community besides carrying out domestic tasks and participated in community groups. However, they were still subject to the local male dominance culture, which restrains their involvement in decision-making, as they tend to be less educated, unemployed and suffer from a lack of resources or specific skills.

The socio-economic context is characterized by subsistence activities and a low employment rate, which limits the community members’ incomes and increases their dependence on external support.

The governance context was characterized by imperfect implementation of political decentralization. Community groups advocating community rights are identified as “political” and are not welcomed. The community groups seemed not to be interested in the health center’s information and had no access to media as it is non-existent.

Conclusions

The local contexts in the two health zones seemed not to be supportive of the operation of social accountability initiatives. However, they offer starting points for social accountability initiatives if better use is made of existing contextual factors, for instance by making community groups work together and improving their capacities in terms of knowledge and information.

Peer Review reports

Maternal mortality remains a major public health issue in developing countries including the Democratic Republic of the Congo (DRC) [ 1 ], a country classified among fragile and conflict-affected states [ 2 , 3 ]. Current estimations place the maternal mortality ratio (MMR) in DRC at about 846 maternal deaths per 100,000 live births [ 4 ]. Nearly two-thirds of this is due to direct obstetrical complications including hemorrhage, eclampsia, sepsis, obstructed labor, and unsafe abortion [ 5 , 6 ]. The remaining one-third is due to indirect causes or pre-existing medical conditions made worse by pregnancy or delivery such as malaria, anemia, hepatitis, HIV-AIDS, tuberculosis, and malnutrition [ 6 , 7 ]. Pregnancies are also occurring too early, too close, too late or too many times as suggested by the high fecundity (6.6 children per woman), early fecundity among adolescents (21.2 %) and the short inter-genesic interval (27.1 % births) [ 4 ]. Other factors associated with maternal mortality involve health systems weaknesses [ 8 , 9 ], including the poor availability of reproductive health goods and services [ 10 ], socio-cultural barriers [ 7 , 11 ], and armed conflicts [ 7 , 12 ].

To address this high maternal mortality, DRC subscribed to the recommendations of the Safe Motherhood Initiative (SMI) [ 6 , 13 – 16 ], International Conference on Population and Development, and the fifth Millennium Development Goal (MDG 5). Implemented SMI interventions led to a real improvement of maternal health indicators [ 7 , 17 – 19 ] but still fell short of the 2015 MDG 5’s target [ 1 , 4 ]. The low achievement of SMI targets has led some authors to call for significant efforts to improve and expand existing survival measures known to stem maternal deaths. They have encouraged setting up additional measures such as taking into consideration the perception of women [ 6 ] and removing financial barriers [ 6 , 20 , 21 ]. They also propose integrating global health priorities interventions, for example HIV services and antenatal care provision [ 6 , 22 ]. Other authors suggested adding new interventions that target the providers’ behavior and responsiveness [ 13 , 14 , 23 – 25 ] in line with social accountability initiatives [ 26 , 27 ].

Social accountability is defined as “accountability that relies on civic engagement i.e. in which citizens and/or civil society organizations participate directly or indirectly in exacting accountability” [ 28 ] and holding politicians, policy makers and healthcare providers responsible for their performance [ 28 – 31 ]. According to Lodenstein et al. (2013), social accountability comprises two main components. The first is citizen engagement, which includes individual participation in service provision and expressing one’s expectations and concerns in an effort to influence government policy, governance processes or other public services such as health services (voice). The second is citizen oversight, which includes involving citizens in the collective monitoring and evaluation of health services and the performance of health service providers, sanctioning when poor performance occurs and rewarding when the performance is perceived as being good [ 32 ].

In DRC, as in many developing countries, the beneficiary population is involved in health services including maternal healthcare through community participation. Community participation is one of the pillars of the national health policy, based on primary health care strategies [ 33 ]. In general, the rationale for community participation in health is to better respond to communities’ needs, designing programs that take into account contextual influences on health, and increasing public accountability for health [ 33 ]. In this article, we draw references to social accountability as one form of community participation and as discussed in literature [ 28 , 32 , 33 ].

As part of community participation, social accountability is viewed as a process of empowerment and as a social practice, in which communities are actively involved in changing the conditions that affect their health. Several authors such as Bukenya et al. (2012), Lodenstein et al. (2013), and Joshi (2014) argue that social accountability interventions and their effects are influenced by contextual factors, such as societal values, gender relations, levels of political stability and health system characteristics [ 32 , 34 , 35 ]. According to Thindwa et al. (2003), these contextual factors can assist or hinder the community, individuals or groups in promoting the community’s interests [ 36 ]. This indicates a need to understand the various local settings that can support or hinder the implementation and outcome of a social accountability intervention that aims to improve maternal health services.

This paper aimed to answer the following research question: What existing local contextual factors can influence the shaping, the implementation or the running of a social accountability initiative and the capacity of the community members, specifically women, to be engaged in it?

A multiple case-study approach was employed to identify local contextual factors and discuss their possible influences on shaping, implementing and running social accountability initiatives at local level using qualitative research methods. It was conducted from May to June 2013 in two health zones (HZ) of DRC, the Muanda HZ (Kongo Central) and the Bolenge HZ (Equateur). These HZ were purposively selected. The case study inclusion criteria were: 1) health zone in post-conflict situation currently involved in sustainable development activities; and 2) the presence of health sector partners implementing or planning to implement health interventions including social accountability components for more than 4 years, targeting amongst others the improvement of maternal health. Details of the selected HZ are described in Table  1 .

An initial exploratory discussion were held separately with HZ officers and main community leaders to map out key community actors involved in maternal health at the local level, from which a representative sample was purposively selected to participate in the interviews. Among these community actors included public officers such as health services providers, political and administrative authorities, HZ authorities, and community representatives such as community leaders, community group members, women groups members, health committee members, and community health workers. The project managers of the NGO projects in both HZ were also included in the sample. Participants were purposively selected using maximum variation and identified from the pool of actors listed above. Selection was based on gender, age, involvement at community level activities in relation to health or other administrative functions. The selected individual were then approached through community health workers (CHWs) or HZ officers in-charge of community activities to participate in the interviews. No contacted individual refused to participate.

The interview guides were based on a conceptual model built on the framework and key concepts from Thindwa et al. (2003) enriched by those drawn from Marston et al. [ 33 ], McCoy et al. [ 37 ], Bukenya et al. [ 34 ], and Lodenstein et al. [ 32 ]. The framework from Thindwa et al. distinguishes four contextual factors that can enable or constrain the capacity of community members to engage in community development activities at the national and local levels in a sustained and effective manner. These factors are “the legal and regulatory framework; the political and governance context; socio-cultural characteristics; and economic conditions”. They in turn influence the “enabling elements” which are: “the freedom of citizens to associate (Association); their ability to mobilize resources to fulfill the objectives of their organizations (Resources); their ability to voice i.e. formulate, articulate and convey opinion collectively (Voice); their access to information, necessary for their ability to exercise voice, engage in negotiation and gain access to resources (Information); and the existence of spaces and rules of engagement for negotiation and public debate” (Negotiation). In this study, we put together the legal and regulatory framework with the political and governance context, and we extend the concept of resources beyond financial ones. We used this framework to explore if the context in the selected districts in DRC is enabling the shaping and implementation of social accountability interventions/mechanisms. Some variables related to community participation drawn from Marston et al. [ 33 ], McCoy et al. [ 37 ], Bukenya et al. [ 34 ], and Lodenstein et al. [ 32 ] were used to further operationalize the main factors in the framework, such as societal values, status of women, health committee recognition by the community and its interface role. The interview guides were adapted, pretested, and validated for the DRC local settings and for maternal health by the study team (see Table  2 ).

Data were collected through individual semi-structured interviews and a document review. At each study site the research team interviewed selected actors. Face-to-face interviews were held in a quiet place away from other people to optimize privacy, and lasted 35 min on average. They were conducted in French or Lingala, and tape-recorded with the participants’ permission. There were no follow-up interviews as these were single-round interview discussions.

A documentary review was used to collect information on the health center’s activities, community groups’ activities, and socio-economic, political, and demographic data using a data collection form. Documents reviewed included the health center’s annual reports, health projects’ annual reports, health committee’s monthly reports, and some national policy documents.

Recorded in-depth interviews were transcribed verbatim. The interviewers proofread the transcribed work to cross-check accuracy of content since the interview transcripts were not returned for participant check and comment. The interview transcripts and data extracted from the documents were analyzed using the thematic approach [ 38 ], based on our context analysis conceptual model. A coding plan was developed using data from the first three interview transcripts and the core concepts of the conceptual model. Two members of the research team read and re-read each transcript thoroughly and assigned codes to each section of the text. Data processing was performed using Atlas-ti 6.1.1© software (ATLAS-ti GmbH, Berlin). Thematic analysis was performed to build a common and comprehensive understanding of the local context with respect to themes expressed by community members, triangulated by those coming from providers and public officers and the document review. Four steps were taken to enhance the credibility of the study: the research team received training in interview techniques, the interview guides were pre-tested and adapted accordingly; the results and interpretations were critically discussed by the research team and shared with local health partners and participants. The interview guides were written in French, translated into Lingala, and translated back into French.

The section starts with a description of the participants followed by three sub-sections presenting research results according to the specific contexts: socio-cultural, governance and socio-economic. In this presentation, findings from the two sites are presented together if they are similar, and separately when they differ between the sites.

In total, 35 semi-structured interviews were conducted with participants in the two sites. Table  3 presents an overview of the participants according to the type of their organization and expertise.

Socio-cultural characteristics

Existing community associations and groups.

The interviews revealed that the communities in the two sites have several formal and informal community organizations, associations, and groups of varying sizes, hereafter referred to as community groups. While their exact number is not known, they all have a similar structure: an executive committee supported by a general assembly. Almost all of the community groups have statutory documents such as internal regulations and statutes, which guide the group’s decision-making process. However, only formal community groups have submitted their statutory documents to the local administrative office for authorization. Decision-making within existing community groups takes place through meetings and the plenary assembly. Most of them asserted that by collecting their members’ expectations or views, which were discussed and debated during meetings, the final decisions were made by consensus. The interviews revealed that community groups did not take into account the views of non-members.

Apart from the health committee, all other community groups have a special focus and can be broadly classified into five main categories: (i) Financial support groups such as local mutual aid associations (LMAA), groups for mutual financial/professional support called “ristourne”, and community health insurance schemes; (ii) Faith-based groups such as faith-based youth’s or women’s associations and churches; (iii) Collective or common-interest groups such as associations of vulnerable persons, youth associations, women’s associations; (iv) Groups working on local development issues : nongovernmental organizations (NGO), community groups for development; and (v) Activity-based groups such as dialogue structures with firms, cooperatives, village committees, groups advocating the right of natives/professional groups. Brief descriptions of the main community groups obtained from the interviews are provided in Additional file 1 .

These community groups were distributed differently across the research sites. Not all participants were aware of the existence of every community group. We used radar charts to indicate the percentage of specific community groups that were mentioned by participants (Fig.  1 ). In the chart, community groups which have similar goals are grouped together. In Bolenge, the most frequently mentioned community groups were financial support groups (48.5 %) and activity-based groups (30.3 %). In Muanda, the most frequently mentioned ones were activity-based groups (50.0 %) followed by groups working on development issues (25.0 %).

Distribution of community groups in % of references made by participants in the two sites

The study allowed us to compile a list of actors (individual or groups) that could be involved in maternal health according to the participants’ opinions. The majority of the participants at both sites mentioned the community groups’ leaders, apart from health providers and members of the health committee. An interesting finding is that users were mentioned as actors in Bolenge but not in Muanda.

Experiences in social mobilization and networking

Many participants from community groups within the two health zones declared that their groups had participated directly or indirectly in solving community problems, although there were few perceived social mobilization activities within the community. Existing community groups seemed to be focused only on their core activities and rarely extended their activities to mobilize citizen and state actors to engage in community activities or extended their activities to the health sector. Most community group members explained that their groups were not involved in the health sector’s activities and had never taken decisions concerning health nor public health service provision. They stated that the community members’ engagement in the health sector was organized around the health committee.

However, some past experiences of participation in community activities by these groups exist at both sites: for example, by supporting and mobilizing their members to contribute to the building of the local school. Two types of community groups, those working on local development issues and activity-based groups, seemed to manifest more social mobilization and advocacy for action than other community groups. They had both benefitted from technical/financial support and capacity building provided by external partners such as international NGOs and enterprises, which were more present in Muanda. Nevertheless, some participants (health providers and public officers) asserted that those social mobilization activities were rarely initiated by the community members themselves but were organized and piloted by external organizations.

With respect to networking, it is apparent from the data that very few relationships were established between the local groups themselves, between the local groups and external NGOs, and between the local groups and governmental bodies. There was no shared networking platform between the groups, and they did not conduct joint activities.

Furthermore, some participants pointed out that the community groups did not have enough capacity and expertise to express their views or to exert pressure on the public authorities or health providers. A few participants, mainly the community group representatives, thought the opposite, asserting that it was the ineffectiveness or the lack of responsiveness from health providers and public authorities which dissuaded them and made them less pro-active. Other participants argued that they lacked a champion to take their expectations and needs to the health providers/public authorities. Some community group representatives explained that the community groups’ capacity to express views or exert pressure was also hindered by their inability to build cross-boundary alliances or coalition with other groups, as local authorities use the strategy to individualize the population’s demands or dismantle the most active groups.

“Local associations did not sufficiently manifest their capacity to be the voice of the community in front of authorities or other persons. We think that the community voicing does not function and authorities would not response to our request. We had not yet identified a community group that could speak up and influence the decision-making.” ( Male, community group member)

However, several community group representatives stressed that some groups working on local development issues and some activity-based groups in Muanda had benefitted from training and were currently contracted by the Muanda Funds Holding Agency, a partner of Cordaid, to monitor the health center’s performances through a community verification survey.

Cultural diversity and marginalized population

Both health zones house a large number of tribes and ethnic groups (more than 10). Participants perceived that this multiplicity of tribes and ethnic groups did not constitute a problem for the constitution and functioning of community groups.

“Our village comprises inhabitants that came from other tribes such as …The cultural identity and customs of each person do not affect the functioning of our community groups. This large variety of cultures does not influence the function of our groups.” (Male, community group member)

Nevertheless, health project managers and health providers revealed that sometimes friction occurred between natives and non-natives, particularly in affluent locations such as Muanda.

“Here, we sometimes have some problems. Natives are …and did use to call other people foreigners and sometimes marginalize them.” (Female, community group member)

When asked about marginalized groups, most people mentioned the Pygmies in Bolenge and Basolongo in Muanda. Participants asserted that members of those groups were less integrated with other community groups, had their own social system, were generally more vulnerable, less educated, and poorer, and had less access to employment. According to a public officer, the government made efforts in terms of sensitization and education to reduce marginalization and increase their integration with other groups. Despite these efforts, some community group members explained that people from these marginalized groups did not become members of existing community groups for financial, religious, or personal reasons.

Women’s status and participation in community groups’ activities

With respect to women’s status, many participants asserted that women were not marginalized in the community, arguing that women often occupy important positions in the communities and are not solely consigned to domestic tasks.

“The women participate in management or within the associations, a woman can be president, vice president, advisors and men are members as well.” (Male, community group member) “In the community, it is true that before women were less considered than men. However, nowadays with the action of non-governmental organizations, the effort of the state through the education of women, they are equal. A woman can realize what she wants depending on competences and skills she has. For example, the in-charge of the health center is a lady…” ( Female, community group member)

The interviews revealed that women participated in the community groups. With respect to their composition, the local communities have groups with only women or only men as members, and others that included both men and women. In the latter category, women participated in decision-making during the general assembly and plenary and were also elected to governing bodies. However, most of the time, women were appointed to positions such as treasurer, social assistant, caregiver or group’s advisor, which, according to some participants are associated with the traditional view that women have a higher caring capacity and sense of righteousness and honesty.

Nevertheless, a few participants stated that there are differences between men and women. A health provider from Bolenge, for example, asserted that women did not effectively participate in decision-making in the local society, linking this situation to the local culture of male dominance. As an example, this health provider stated that women more often come to the health center accompanied by their husbands or their mothers-in-law and were rarely the chairperson in groups that included both men and women.

“Women are not really involved in decision making. It is the culture. Very often, when they are sick, they are always accompanied by them husbands when coming to the hospital. But I am not informed with regard to the decision-making within the associations where the women and the men are members” ( Female, Health provider)

Very few participants argued that a woman could only be more active and autonomous in their local community if she had led a business with financial resources, possessed specific skills and competencies, occupied a political or economic position in society, or was well educated. However, most participants recognized that women at the local level rarely satisfied the above-mentioned conditions.

“In reality, men and women are equal. The issue is that women in our environment…do not have the required competences or educational level for being effectively involved in decision-making.” (Male, community group member)

Some participants associated the perception of the improvement of women’s status with some community groups’ activities such as local NGOs that focused on women’s empowerment, and with the national education policy that encourages the education of girls, at least to the primary school level. They also mentioned some barriers to women’s empowerment and education such as the challenging socio-economic situations which prevent families from schooling their children, especially girls, and local customs which encourage early marriage.

“Yes, women are very important, women here often work in fishery, the land/field or trading, thus they don’t study. We don’t really have women capable of working or expressing themselves very well. Often when women go to …there, that is all, they get married there and they have their life there. Here, women are not emancipated, maybe less than 20 % of them work, mainly as small traders.” (Female, Women’s community organization)

Existing media and access to information

The interviews also revealed that media which could enable a large number of community members to be reached were relatively non-existent at the community level. Neither papers nor radio broadcasting or television were found at the local level. Even if some inhabitants could organize radio reception from a city situated in the neighborhood (more than 15 km away), these stations rarely broadcast local information. Health-related information exchanges are mainly based on interpersonal communication and sensitization, conducted by community health workers or in small-scale health education meetings organized in the health center. Except for members of the health committees, community members did not have access to information about the health center’s activities and asserted a lack of interest because they did not work at the health center. Alternatively, they thought that health providers would not appreciate their interest.

Governance context

The two research sites are both located in health zones, which are part of the territory’s administrative system. Moreover, though the Congolese constitution prescribes the implementation of decentralization, several participants asserted that decentralization is not effective and local political entities have not yet been installed, such as the local councils and local elected representatives necessary for local political participation. They stated that the power and decision-making are still centralized at the national level or at the provincial level, and they expected more from the decentralization, such as the facilitation of administrative procedures and resource allocation.

“Nothing more has changed with respect to the decentralization, and it is not effective yet.” (Male, community group member)

Despite this, most participants asserted that the political situation does not prevent the organization of interest groups. Some participants stated that the local political context sometimes favors group formation, even though community groups have to follow certain regulations and require authorization from the local political authorities, in order to hold public meetings and implement their activities.

“The political level currently does not cause a problem for community groups. Existing groups have to respect the law. They must make themselves known to the political authority and follow the political and administrative regulations… by paying taxes and charges prescribed by the law.” (Male, public officer)

Some participants revealed that certain community groups, specifically those committed to human rights and community interests, are not welcomed by the authorities at the national or local level. They stated that the authorities readily considered a group committed to advocating the population’s interests, such as the right to health care or to education, as “political” because then it becomes the responsibility of the national government. These participants also added that the government or local authorities therefore considered that demanding one’s rights was equal to being critical of the government.

“Community groups have to refrain from “bad” activities. If not, the state will intervene. The state can get involved if the groups address political matters, speak negatively of the government, or in case of public disturbances as well or open conflicts among members or in the community.” (Male, public officer)

This understanding of the commitment to human rights as a political activity induced several community groups to declare their apolitical nature and assert the freedom of their members from affiliation to any political party. Moreover, some participants (10/35) argued that the governance context could have a negative effect on the functioning of community groups especially during election times, as it drives the community groups away from their primary goals, patronizing them through donations and gifts to take a political position and to work for political parties.

“The negative influence of the political context occurs during electoral propaganda, several people follow politicians who could give them money and gifts instead of getting involved in community engagement. They are sure to be beneficiaries of the generosity of politicians… The community participation disappears almost entirely during these periods of intense political activity .” (Male, Health Zone management team)

As an element of governance, some participants acknowledged that community activities associated with health were organized by the health committee, as required by the national health policy. They asserted that a health committee is composed of community health workers, whose members were responsible for community participation activities and acted as “bridges” between the community and the related health center. However, some participants claimed that the health committee was dependent on the health center team, which provides funding and directions for its activities. They also stated that most of the health committee members were not elected by the community but were chosen by the nurse in charge of the health center, and therefore, they concluded that the health committee members were not really representative of the community’s opinions.

With respect to the relationship between community groups and the health committee, participants stated that community groups did not have links to the health committee. However, they recognized that most of the health committee members and community health workers were also members of community groups, even though these groups did not seem to use this co-membership to develop links with the health committee or vice versa, and to be involved in health activities.

Socio-economic conditions

There are some differences in the socio-economic conditions in the two sites. In Bolenge, there is neither a safe water supply nor electricity, and the majority of the population work in subsistence agriculture, fishing, or farming. The local wages are very low. The annual average per capita income is less than $298. The few people with a regular salary worked mainly as civil servants in the education or health sector with very low salaries [ 39 ]. The Muanda HZ, on the other hand, is a region with increasing oil production and profits from a strategic trading position between the borders of Angola and Congo Brazzaville. Muanda houses the agencies of several enterprises and banks. Firms which produced oil provided electricity and safe water to several villages and sometimes offered seasonal working opportunities to the local populations. These firms sometimes invested in local initiatives through the local development committee they established.

Despite these differences, the majority of community members at both sites are very poor. Most of them did not have enough financial resources to fund community activities and were inclined to believe that external partners always have funding to give them or to invest in their community projects or activities. Neither site received subsidies from the government.

The principal aim of this multiple case study were two-fold. The first aim was to identify local contextual factors in two DRC health zones. The second aim was to discuss their influence on the shaping, the implementation and the running of social accountability at the local level. To this end, we used a conceptual model adapted from Thindwa et al. [ 36 ] enriched by concepts drawn from Marston et al. [ 33 ], McCoy et al. [ 37 ], Bukenya et al. [ 34 ], and Lodenstein et al. [ 32 ] which allowed us to identify contextual factors that are necessary for community engagement and to match them with enabling elements for social accountability (Additional file 2 ).

This study has highlighted some enabling and constraining factors as being important in the shaping, the implementation and the running of a social accountability initiative at the local level.

Enabling factors

This study shows that “Association” is facilitated by socio-cultural characteristics such as the existence of formal and informal community groups, the willingness of the population to support each other, previous positive experiences with community engagement, and the involvement of women in community groups. Governance factors which support “Association” at both sites include the existence of a regulatory framework for community groups, acceptance of community groups by the local authorities, and the national recognition of community health committees as legitimate health governance bodies. The socio-economic conditions in Bolenge motivated community members to form groups in order to pool their meager resources through mutual aid associations.

Potential capacities to mobilize “Resources” to fulfill their objectives exist in Bolenge and Muanda in terms of socio-cultural characteristics such as the co-membership of several community groups; a history of social mobilization activities by some community groups; and the use of discussion and debates for decision-making within community groups. In addition, in Muanda oil firms and NGOs supported some local community groups in the form of capacity building in organization and funding.

Regarding “Negotiation”, potential space and rules of community engagement exist as health committees are the legal interface between the community groups and the health providers, although currently these committees do not function optimally according to respondents.

Constraining factors

Regarding “Association”, constraining socio-cultural characteristics include the lack of networks and platforms between groups. In addition, community groups seem to have a narrow focus on their own core activities and insufficient capacity for community mobilization.

Concerning “Resources”, socio-economic conditions of limited employment opportunities and meagre income from subsistence farming prevent community members from contributing to community projects. This situation, associated with a lack of government funding, makes community groups dependent on external financial support.

Regarding “Voice” and access to “Information”, limitations were found in the low coverage of radio and other media at rural levels. It was also observed that community members did not seem interested in information related to the health services’ performance. An underlying reason might be the low socio-economic conditions and corresponding low level of education among community members, especially women. An additional socio-cultural constraint is the weak capacity and expertise of community groups to express their views or to exert pressure on service providers.

Constraints in “Negotiation” play out in the governance context as local authorities hinder community groups that are promoting the interests of citizens. Additional “Negotiation” constraints include the selection of health committee members by public health providers rather than community members, and the neglected interface function of health committees. The authorities even employ active strategies to individualize the population’s demands and dismantle the most active community groups promoting community interests. In addition, decentralization is not fully implemented, and decision-making regarding the health services and other basic services takes place at the central level, which limits people’s influence on the decision-making and accountability of local authorities.

The situation described here seems unfavorable and presents limitations to shaping, implementing and carrying out social accountability for health service improvement.

Several authors underlined the importance of some contextual factors necessary to enable the harmonious implementation and smooth running of social accountability, which are lacking in these health zones, such as the existence of a coalition and social mobilization [ 26 , 28 , 33 , 35 , 40 – 44 ]. Other authors stressed the importance of the capacity of community groups to express their views or to exert pressure on health providers or on the public authorities [ 45 , 46 ], a well-functioning health committee [ 45 , 47 ] especially considering the limited influence of health providers [ 48 , 49 ], competent decentralization [ 45 , 50 ], and the role of the media in providing access to information [ 28 ] as enabling factors of social accountability.

Regarding constraints, several authors have also identified some contextual factors that can hinder social accountability such as the low status of women [ 26 , 44 , 51 , 52 ] and the identification of social actions promoting citizens’ interests as a political activity.

However, the existing context in the two health zones in DRC could offer several starting points to initiate social accountability in local maternal health services [ 36 ]. Better use could be made of existing community groups for enabling the local context through strengthening coalition building among themselves and between them and the health committee in line with Falisse et al. (2012) in Burundi [ 48 ] and Dasgupta (2011) in India [ 26 ], and building capacity in terms of an interface role, of generating and using information about the health center’s performance, of knowledge/information about entitlements and the health service performance in line with experience provided in the social accountability literature [ 44 , 46 , 49 , 53 , 54 ].

To proceed, one option is to use the co-membership of some community members in the health committee and in existing community groups as an entry point for building coalitions, which is a process of negotiation, building interactions, and creating common trust among existing actors and groups [ 55 ]. One way of strengthening coalition-building is through the use of participative approaches, such as the interactive learning and action approach. For instance, Swaans et al. (2009) in South Africa, Björkman and Svensson (2009) in Uganda, and Dasgupta (2011) in India provide an overview of a coalition-building process around HIV and agriculture, community monitoring of health care and maternal health. In DRC the coalition could be built around the health committee and community health workers, as they are perceived by other community members as bridges between the community and the health providers with the support of the HZ management team and health partners. This coalition could support community mobilization strategies to enhance participation at the local level and strengthen existing community groups.

The second line of action is capacity-building. This can be done through the involvement of community groups using participatory approaches in generating information on their own views and concerns, in discussing them with health committee members and health providers, and by making information available to them [ 37 , 56 ]. Capacity-building of community groups can also be done by involving them in community problem-solving. They would then be involved in defining, implementing, monitoring, and evaluating health activities. Some examples of successful capacity-building interventions in local settings using participative approaches are provided by Swaans et al.(2008) in South Africa [ 57 ], Björkman and Svensson (2009) in Uganda [ 53 ], Katahoire et al. (2015) in Kenya [ 58 ], and Manandhar et al. (2004) in Nepal [ 22 ].

The capacity-building would also concern the health committee. It can be used to support its interface role better [ 59 ], which is necessary to facilitate communication and dialogue between community members and health providers through training and supervision [ 45 , 50 ]. The women should occupy a special place in these initiatives so as to improve their capacities to be pro-actively engaged in decision making and involvement in these health initiatives.

Implication for policy

Contextual factors such as described in the present study are more likely to be somewhat found at the local level in several low-and middle income countries, as reported in existing literature from Benin [ 23 , 51 ], Burundi [ 48 ], Uganda [ 58 ], Tanzania [ 60 ] and India [ 26 , 44 ]. This highlights that the conceptual model as adapted can be used in other setting in order to generate information about local contexts. This information can be used to shape more appropriate actionable interventions with regard to social accountability.

Study limitations

Generalization of our findings is limited because of its case study nature and the small number of health zones in which the study took place. In addition, we did not have data on all contextual factors provided by the conceptual model and did not explore the effects of national-level contextual factors on local settings [ 28 ]. However, the findings in our study are largely in line with the literature, and the participants’ responses were largely overlapping. The study thereby provides useful starting points for further research on contextual factors influencing the shaping, the implementation and the functioning of social accountability initiatives in local settings. Second this study is the first to provide in-depth insights of local level contextual factors [ 44 ]. Previous studies contributed more to national and subnational levels [ 26 , 34 – 36 , 59 ]. Third, the modified conceptual model could be used as an analytical tool in other context different from DRC.

Research team and reflexivity

The researcher in charge of interviewing participants was a medical doctor, trained in maternal health practice and with a background in quantitative methodology. He and most of the respondents were of the same age. He introduced himself as a researcher from the local university. He noted his impressions after the interviews, and they were discussed during a daily debriefing meeting with his supervisors. His notes were included in the data analysis. The latter was mainly conducted by the first author and the second author, who has a social sciences background. Their backgrounds could have influenced the data analysis and interpretation. To reduce these influences, the data analysis was conducted using the framework and involved extensive interaction with supervisors. They read the narrative on their own terms, and judged how they were responding emotionally and intellectually to this person. They put themselves, their background, history, and experiences in relation to the respondent and inserted their findings into the framework. This allowed the authors to examine how their assumptions and views might affect their interpretation of the respondent’s words, or their writing about the person. Research team members had no relationship with participants prior to study commencement. Participants learned about researchers and the research during consent administration. All the stages of data analysis were supervised by three supervisors with experienced in qualitative data analysis, and the findings were discussed with a Social, Policy and Administration Sciences specialist from the University of Kinshasa, DRC.

The local contexts in the two health zones seemed not to be supportive of the shaping and implementation of social accountability initiatives. However, they offer starting points for social accountability initiatives if better use is made of existing contextual enabling factors, for instance by making community groups work together and improving their capacities in terms of knowledge and information.

Abbreviations

Community Health Workers

Democratic Republic of the Congo

Health Zone

Local mutual aid associations

Millennium Development Goal

Maternal mortality ratio

Nongovernmental organizations

Safe motherhood Initiative

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Acknowledgements

The authors are grateful to the district health authorities and health facility managers in Muanda and Bolenge HZs, and to community members who generously shared their time and insights for this research. They are also grateful to Professor Mpwate, Faculty of Social, Policy and Administration Sciences, University of Kinshasa, who generously commented on and discussed the findings with the first author. Authors thank Ibukun O. Adepoju, Mary N. Mwangome and Vibian Angwenyi for their comments.

This study was made possible by the support of the Wotro program (its aim is improving maternal health services responsiveness and performances through social accountability mechanisms in DRC and Burundi). Wotro IMCH is managed by the VU University Amsterdam (VU) and Royal Tropical Institute, Amsterdam (KIT). The findings of this study are the sole responsibility of the authors and do not necessarily reflect the views of the Government of the Netherlands. The study sponsors played no role in the collection, analysis, or interpretation of data; in the writing of the paper; or in the decision to submit it for publication.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request as they are in French. However, a summary of the main points covered in these interviews was translated into English and uploaded as a Additional file 3 .

Authors’ contributions

MEM, DM and MNT designed the project and conceptualized the study question, MEM collected the data. MEM and HL conducted the analysis and drafted the manuscript. MEM, HL, DM, MNT, KP, IB, and DCBT contributed to the interpretation of the analysis. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Written informed consent was obtained from all participants to publish information containing some individual person’s data such as age, sex, occupation, location as they were important for understanding the research study.

Ethics approval and consent to participate

The study received ethical approval from the Kinshasa School of Public Health Institutional Review Board. The necessary administrative authorizations were obtained at the provincial and local levels. All participants were fully informed about the nature and implications of the study, and granted voluntary written consent to participate. None of them received a payment for participation. All research procedures were conducted in accordance with the Helsinki Declaration.

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Eric M. Mafuta, Thérèse N. M. Mambu & Patrick K. Kayembe

Athena Institute, Faculty of Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands

Eric M. Mafuta, Lisanne Hogema, Tjard De Cock Buning & Marjolein A. Dieleman

Kongo Central Health Province Division, Muanda, Democratic Republic of the Congo

Pontien B. Kiyimbi

Agence d’Achat de performances, Muanda, Kongo Central, Democratic Republic of the Congo

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Royal Tropical Institute, Amsterdam, The Netherlands

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Correspondence to Eric M. Mafuta .

Additional files

Additional file 1:.

Brief description of main community associations and groups as emerged from interviews. (DOCX 13 kb)

Additional file 2:

Contextual Factors analysis conceptual model/Mapping of Data. (DOCX 14 kb)

Additional file 3:

Interview guide translated in English. (DOCX 24 kb)

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Mafuta, E.M., Hogema, L., Mambu, T.N.M. et al. Understanding the local context and its possible influences on shaping, implementing and running social accountability initiatives for maternal health services in rural Democratic Republic of the Congo: a contextual factor analysis. BMC Health Serv Res 16 , 640 (2016). https://doi.org/10.1186/s12913-016-1895-3

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Received : 12 January 2016

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DOI : https://doi.org/10.1186/s12913-016-1895-3

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Public health should better recognise local and contextual research

What is our objective when we conduct research in public health? We conduct public health research to reduce disease and injury incidence. We conduct public health research to have a real impact on people on the ground and save lives. Our field is full of passionate, talented researchers who have dedicated their lives to bettering those of others.

In order for public health research to be impactful on the ground, it needs to be applied in contexts where it is most needed. A key concept in the implementation of solutions to public health problems is contextual adaptability, where policy and ground-level interventions need to be adapted to the local context in which they are implemented. Hence, each time a public health solution is developed for a region or population group, a range of studies need to be conducted in that local context to understand it. We need to understand specific patient needs of the population, ways of setting up supply chains, appropriate methods of staff recruitment and training, and a range of other factors that change between contexts. We need to do this through conducting policy analyses, using co-design processes with local communities, conducting pilot programs, and undertaking process evaluations. These findings aren’t necessarily generalisable to other contexts but can provide some useful insights to other implementers for what issues may emerge.

Despite the importance of this research in ensuring public health research has ground impact, the development and publishing of context-specific research appears to be disincentivised in the academic system, with increasing focus on the external validity of studies.

Academia is obsessed with novelty. Unfortunately, local research may not always add some new theoretical insight – often it provides insights on how existing and well-established public health solutions and principles may be applied to a new context. Many journals and peer reviewers may not find this novel enough as its additional contribution to the literature is limited. However, I argue that these articles should be recognised for what they are – the actual application of public health to the real world, and evidence of the usefulness of our discipline in affecting people’s lives.

Academia is also overly interested in generalisability – reviewers often want to know where else study findings can apply. The underlying assumption to this question is that by finding generalisable evidence for the development and effectiveness of public health solutions, we can skip a few steps in other contexts when applying public health solutions. However, often even when we think our findings from one context can be applied to another, this still needs to be checked in case there are contextual differences we are not aware of. In the end, even findings that appear generalisable may not be until they are validated in a new setting. Hence, the focus on generalisability is in some ways obsolete.

Another issue with disincentivising local and contextual research is that it is inequitable against local researchers. Much of the local research is done by researchers based in low-and middle-income countries (LMICs) with lower levels of funding, but who have great depth of knowledge in their context. By not allowing them opportunities to publish in high-impact journals, we perpetuate the cycle of high-income country supremacy in academia. It is essential that good research that impacts lives through sound methods be rewarded. Enabling these researchers to publish local research also develops their track records and provides opportunities for LMIC researchers to be more competitive in much-needed grants for these low-resource contexts.

Lastly, disincentivising local and contextual research prevents us from building a strong evidence base for effective interventions . Take my own field of study, child drowning. Most of the ‘effective’ interventions identified by the World Health Organization have not been rigorously evaluated through the gold standard of randomised controlled trials (RCTs), or even non-randomised trials. For example, children’s swim and rescue classes are often cited as an important intervention for drowning reduction, but there is no published trial of this intervention measuring its effect on drowning risk. The lack of support for localised trials means we do not have the evidence to solve health problems in the most effective way possible. How can we build the evidence base we need unless localised trials are repeatedly run, published and compared across a range of contexts? These trials need to be incentivised by the academic ecosystem.

Public health research can benefit from addressing discrimination against local and context-based research. It is an issue of equity, a requirement in order to build stronger evidence bases for effective interventions, and an opportunity for the field to showcase the real change it can bring to people’s lives.

Conflict of Interest

The author declares no conflict of interest.

About the author

Medhavi Gupta is a PhD student at the George Institute for Global Health. She specialises in injury prevention research focussing on drowning and road traffic injuries and has applied a range of innovative methods in her work. Her current PhD project involves the design and evaluation of drowning prevention programs in India and Bangladesh.

Handling Editor:  Neha Faruqui

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Every local context around a project is unique and research shows that understanding and adapting to the local context is key for a project to achieve its goals.

Local contexts are complex and include for example how to create and maintain trustful social relations, local systems for land use and to understand local political processes. Local communities are diverse and local relations of power need to be understood if projects are to be welcomed locally and achieve expected social and economic benefits.

Click on the arrow below each question to read about more concrete examples of problems that can happen.

Questions to ask

Has the project been designed by, or in close collaboration with, the affected people so that the project design visibly includes affected people’s values, norms and needs and the local context in general?

For example, has it been analysed if the tree species to be planted are suitable to the local climate and soil conditions? If trees are expected to reduce erosion or provide shade, is it described in what way erosion is a current problem, or shade a current need, in that local context? Are payment mechanisms organized so that money will not be captured by an elite?

Does the project description mention that local communities are diverse and that different groups may benefit more from the project than others? 

For example, if landless people, or people with no land title document or only small land plots cannot take part in the project, how will the risk of conflict and inequality be dealt with? If incomes from carbon credits goes to certain groups who are (over-)represented in local leadership, how can other groups (such as landless, youth, widows and other low status or poorer individuals) benefit equally? If people whose trees die or do not grow fast enough could miss out on carbon incomes, what measures will be taken to avoid negative impacts? Is distribution of project payments within households or project groups discussed (research shows that persons with higher status often control monetary incomes)?

Is there a description of the local market for expected project products?

For example, if pine trees are to be planted, is there a local demand for pine timber and does the national legislation allow for trade with pine timber? If fruit is to be sold, does the local population have access to a market for doing this?

Warning signs

The project has no or little previous experience from the area or other socially, culturally and ecologically similar areas.

For example, the project is to be carried out in a rural area in Tanzania, but the actor in charge of developing the project is from the US with no previous experience of working in Tanzania.

The problems and solutions described are written in a very general manner, not adapted to context and without a deeper discussion about what causes the problems.

For example, the problem is described as being local people’s agricultural expansion into forests and it will be solved with planting more trees, while not investigating the reasons behind that expansion.

Groups within the particular project site that are less likely to benefit are not clearly identified and/or no plan exists on how to deal with uneven impacts for these different groups.

For example it is only stated that “vulnerable groups will be included”.

Continue and select another theme in your guide:

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Scientific References

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How teaching developed in local and global contexts enriches learner communication skills: simplifying approaches to teaching & learning series (part 3).

Last Updated on October 26, 2022

This post is part of a 6-part series highlighting how we, as IB teachers, can bring Approaches to Teaching to our classroom and challenge learners to engage in Approaches to Learning.

In the first two installments of the series, we introduced inquiry and we focused on conceptual understanding (Approaches to Teaching)  that can improve the learners’ research and thinking skills respectively (Approaches to Learning). While these instructional strategies would make a great fit for many topics within your subject, every now and then you want to shake things up and hit additional teaching and learning goals.

Connecting Approaches to Teaching with Approaches to Learning

This third installment addresses how teaching developed in local and global contexts enriches learners’ communication skills . If you have Middle Years Programme (MYP) experience, note that there is a different approach to teaching through contexts in the Diploma Programme (DP). In MYP, “global contexts” involve broad concepts with a universal impact that the learners should embrace. In DP, “local and global contexts” are used in a more literal way. Students’ local contexts can be their family, school, community, or even their country, while global contexts refer to international or universal frameworks.

The IBO traditionally connects instruction throughout different contexts with developing learners’ thinking skills (contextualized learning) (IBO, 2015). We can go beyond that and take advantage of the cultural contrast that occurs within and across these contexts to challenge learners’ communication skills, regarding both the content and form of the conveyed information. Here are 3 context-oriented instructional strategies you can try in your classroom:

Help learners appreciate the complexity and uncertainty associated with an idea

Let’s tackle the most prominent issue: what are “communication skills?” Communication suggests an important strand of our cross-contextual and durable skills, also known as “ soft skills .” In the long list of these highly requested dispositions, sometimes it’s hard to define each skill accurately. For example, we tend to confuse our communication skills with our  “social skills” because communication is strongly linked to our interpersonal relationships. However, communication is not merely an ability that connects us with others, but also a virtue that allows us to understand a variety of written or oral forms and contents in different contexts.

This is a huge issue for our learners, but we usually sweep it under the rug. Think of all the written examinations in which your learners responded incorrectly because they didn’t fully comprehend the questions. Think of all the spoken instructions you have given for a task and learners didn’t follow. Do these situations occur again and again just because of our learners’ ignorance or laziness?

We may hesitate to accept this for learners at the DP level, but these recurring incidents may reflect a lack of communication skills . Statistics for the general population of 15-year-old learners indicate low performances in basic abilities. “About 20% of learners in OECD countries, on average, do not attain the baseline level of proficiency in reading. This proportion has remained stable since 2009” (OECD, 2018).

And, on the other side of communication, we often reprimand them for not expressing their views with clarity. Their oral and written responses may not always reflect their level of understanding, but whatever they deliver should be assessed as it is. And here comes learners’ most famous argument for claiming marks: “You know that’s what I meant…”. Instead of trying to read between the lines to justify one or two extra marks, how about enhancing their communication skills?

💡 Give a written or verbal stimulus (problem, graph, document, song, movie abstract…) that leaves room for multiple interpretations and walk them through a discussion for the information it communicates.

Point out the most prominent elements they all need to comprehend and make a list with the learners’ suggestions for the rest.

Use this process to show your method for breaking down the information received. If there is complexity or uncertainty in the piece you presented, the different approaches will activate your learners . You can make this challenge more interesting if you begin from local contexts and expand to global ones. The forms of communication can be diverged and draw your learners’ attention.

Encourage learners to be globally engaged

Prompting our learners to develop their inquiry in local and global contexts, especially if they can be linked with real-life issues, can challenge their pre-existing representations on several matters and concepts, which helps them to reorganize their understanding on the basis of a more universal, internationally-minded perspective. This is a core aspect of the constructivist approach: “Knowledge is seen as dynamic, ever-changing with our experiences” (Bada, 2015).

It is important that learners develop their skills through a universal perspective that goes beyond the information that their textbook – or Google and YouTube – provide. When your teaching is developed in both local and global contexts, you show learners the different forms of communication needed as we move from a personal, local, or national perspective to an international or global one.

This is an excellent opportunity to integrate “international-mindedness” into our instruction . This is another concept we may come across now and then without clear instructions about how to make it work in the classroom. In the IB wheel, it is placed in the outer circle because it characterizes (or should characterize) all the elements included in the program. The components of international-mindedness are multilingualism, intercultural understanding, and global engagement.

Although the term seems a bit one-sided, international-mindedness is not about degrading local contexts at the expense of global ones. On the contrary, it attempts to harmonize them by encouraging learners “to learn more about their own culture and national identity as well as to be respectful and understanding of others, thus becoming global citizens” (Belal, 2017). 

💡 As a homework assignment, ask learners to work on a subject-specific topic from two different standpoints: locally and globally. They have to discover their personal viewpoint but also try to walk in someone else’s shoes to tackle the same task.

Learners approach this task interculturally: from their own “local” perspective, and by adopting an alternative “global” view. How would a teenager from a diverse cultural background face this topic? What are the possible similarities and differences between the two contexts? In this framework, even the formulation of hypotheses demands serious research skills and open-mindedness, so welcome any learners’ suggestions.

Have them present their work in written and oral forms, but let them choose the educational technology tools most appropriate for their tasks . We deal with digital natives, so they will probably surprise you with the use of blogs, interactive software, and other forms of instant communication.

We should encourage such initiatives because they give our learners a safe place to build upon their communication skills. They should work with a variety of sources, before adjusting information in their final product. During their presentation, they will have to effectively communicate their material and perspectives to the class and be the key participants in a discussion, which may include many debatable questions.

Promote opportunities for learners to see an issue from multiple perspectives

These assignments can be expanded as reflection activities, by including third parties in learners’ projects. Your learners have taken one familiar (local) and one “strange” (global) approach to their topic and have argued about them in the classroom.

💡 How about “testing” their ideas with a person who comes from a different culture? Introducing such testimonials would definitely add value and impact to their assignment.

This suggestion is directly connected with another important goal you can set in this instructional framework. I refer to “global learning”, “a student-centered activity in which learners of different cultures use technology to improve their global perspectives while remaining in their home countries” (Gibson, Rimmington, & Landwehr-Brown, 2008). This concept integrates technology into the learning process, as a means for global reach for the discovery of global perspectives.

To achieve this universality, you don’t have to find an Aboriginal Australian with an internet connection (although that would be cool). What matters is simply the addition of a voice outside learners’ daily locality. For example, when discussing the solution to a problem in math or science, a Japanese teacher may suggest a diverse course of action due to their learner-centered problem-solving approach. And if you are debating human resource strategies, a Finnish educational administrator may surprise you with their proposals based on hiring only those applicants that have a genuine interest in the job (Crehan, 2016).

For this communication to be successful, our learners have to master a range of relevant skills. First, before reaching out to an expert, they must have acquired a sufficient understanding of their sources. Then, when contacting the person they’re curious about connecting with, they need to be ready to articulate a coherent and meaningful question.  Learners’ communication endeavors can go one step further if they respond to the answers they receive with follow-up questions. This way, they demonstrate their active listening, work on their question refinement, and develop a conversation .

If you think this process might be a bit time-consuming, consider this: you work on improving learners’ communication skills while you go on with your content, but now your content is enriched, and your class is motivated . This investment will pay off during the next examination and beyond, including when composing a sound Extended Essay, coping with the assessed tasks of Theory of Knowledge (ToK), and establishing connections with Creativity-Activity-Service (CAS) projects.

Use the 100mentors app to bring the world in your classroom, and make the global feel local:

This course of action suggests a straightforward implementation of Approaches to Teaching and Learning on two challenging strands: enhancing learners’ communication skills while developing your instruction in local and global contexts – now it can be done. With 100mentors, your learners can now develop, measure, and certify soft skills that are crucial in all academic and professional contexts.

Bada, S. O. (2015). Constructivism Learning Theory: A Paradigm for Teaching and Learning. Journal of Research & Method in Education , 6 , 66–70.

Belal, S. (2017). Participating in the International Baccalaureate Diploma Programme: Developing international mindedness and engagement with local communities. Journal of Research in International Education , 16 (1), 18–35.

Crehan, L. (2016). Cleverlands: the secrets behind the success of the world’s education superpowers . London: Unbound.

Gibson, K. L., Rimmington, G. M., & Landwehr-Brown, M. (2008). Developing Global Awareness and Responsible World Citizenship With Global Learning. Roeper Review , 30 (1), 11–23.

IBO. (2015). Approaches to teaching and learning. Retrieved September 23, 2019, from https://xmltwo.ibo.org/publications/DP/Group0/d_0_dpatl_gui_1502_1/static/dpatl/guide-teaching-developed-in-local-and-global-contexts.html

OECD. (2018). PISA 2015 Results in Focus . Retrieved September 23, 2019, from https://www.oecd.org/pisa/pisa-2015-results-in-focus.pdf

Pepy Meli, PhD

Pepy is a University and IB Diploma Programme Physics teacher, with an MA and Ph.D. in Science Education. She is currently a Postdoctoral Researcher in teachers' STEM education. As the Head of Research at 100mentors, she empowers educators to turn theory into practice with educational technology solutions.

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Local Contexts is committed to Indigenous sovereignty and ethical data governance; we believe that naming and addressing the violence of settler-colonialism and its ongoing effects is central to the work that we do. The legacy of settler-colonialism has manifested in the structural exclusion and erasure of Indigenous people within institutions that steward collections of Indigenous heritage and data. The (mis)information or absence of information within these institutions and their systems continues to pose enduring challenges that adversely affect Indigenous communities. 

We have responsibilities and obligations to support Indigenous peoples, communities, and organizations. In our efforts to overcome the legacies of settler-colonialism, Local Contexts was developed to create effective and recognized pathways for implementing and maintaining Indigenous data rights and facilitate ethical relationships and enable collaboration with stewards of Indigenous collections.

We ask you to acknowledge these truths and join us in our commitment to acting as respectful guests within the homelands in which we live and work. 

To learn more about Indigenous homelands visit www.native-land.ca .

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