‘Community people are the most powerful resources’: qualitative critical realist analysis and framework to support co-produced responses to zoonotic disease threats with(in) Nepali communities

Background Co-production between researchers, service providers, and members of affected communities is an old concept renewed by current efforts to decolonise global health, reduce exploitative practices, and develop more sustainable, context-relevant interventions to address global health issues. Working with communities– how ever defined– is central to healthcare improvement but engaging with communities and identifying priorities remains challenging for disease control professionals. Co-production aims to help ensure community members have some control over the design and implementation of any intervention, and greater ownership of processes and outcomes. We aimed to identify what would encourage co-production of activities to prevent potential transmission of zoonoses.

Methods In this qualitative study, we (British and Nepali researchers) interviewed 73 participants from six communities across Nepal, with 10 participating in photovoice. We also interviewed 20 healthcare professionals and policymakers, 14 representing human and six representing animal health. We interpreted data using reflexive thematic analysis.

Results Thirty-nine people in six communities participated in interviews, with another 34 in 5 focus groups. We generated three overarching themes: (i) constrained healthcare-seeking behaviours, (ii) experience of community programmes, and (iii) community priorities and co-production. Community participants, despite strong opinions and desire to participate in disease control interventions, had experienced little or no attempt by intervention organisers to engage them in design, implementation, evaluation, or accountability. Most had no experience of programmes at all. Participants highlighted the significance of working in ‘local’ languages, respecting religious and cultural realities, relating initiatives to lived experience, and ensuring that local leaders are involved.

Conclusions Meaningful co-production requires recognising communities– through legitimate leadership/representation– as expert and equal partners who can ‘work alongside’ at all stages of any initiative. Implications from this research include the importance of promoting trust in communities through inclusion of influential community members (community health volunteers, traditional medicine practitioners, women’s group leaders); the use of indigenous languages; the acceptability of different media for interventions (theatre, drama); and the need to be pragmatic about available resources, to manage the expectations of community members.