Supporting communities of practice – A Journey to effective problem-solving

Disclaimer

The views expressed in this article are those of the authors. Publication in Gates Open Research does not imply endorsement by the Gates Foundation.

Introduction

Despite significant gains and the potential for new technologies to accelerate progress in the fight against HIV, many countries face substantial challenges in preventing new infections and providing treatment and care to those living with HIV¹. Alongside questions of resourcing and sustainability^2,3, the path to long-term epidemic control requires enabling country ownership and an effective transition to programs that are well integrated with community needs, desires, and innovations⁴. This means ensuring that local communities are engaged to their full potential, and innovations are systematically identified, catalyzed, and scaled up. It is therefore essential to leverage local knowledge and innovation so that communities are empowered to develop and own programmatic solutions⁵.

Nevertheless, promising new approaches and ideas do emerge at the local level, often incubated by communities of practice (CoPs) – groups of people with a common area of interest who share with each other the resources and knowledge that they develop. The LISTEN model (Local Initiatives Scaled Through Enterprise Networks)ⁱ offers a structured process to encourage and support local ownership of problem-solving initiatives through CoPs^6,7. It operates from the understanding that well-developed and effective CoPs at the community level are the foundation for sustainable approaches that can reach the most socially remote and vulnerable members of a country’s population. LISTEN has been pioneered by local country teams to address HIV prevention in Kenya⁶, Eswatini, and Malawi, supported by a consortium of institutions and organizations, including the Amsterdam Institute for Global Health and Development, the Center for Global Health Practice and Impact at Georgetown University Medical Center, DesireLine, Final Mile Consulting, CooperSmith and PATH.

In this Open Letter we describe our observations of the work of CoPs implementing the LISTEN model at the local-community level in Kenya and Eswatini, countries with a high prevalence of HIV and significant numbers of new infections annually⁸. (Malawi is not included here because the LISTEN model had not yet been introduced at the time of our visits to the two other countries.) Building on Étienne Wenger’s theory of CoPs as an expression of social learning, we propose a framework for systematically understanding the stages that a CoP may go through as it develops its capacity to identify and solve problems and develop and implement good practices, and the support that the CoP may need at each stage.

Communities of practice and the LISTEN model

The concept of a CoP, developed by Etienne Wenger and Jean Lave, sees learning not as an individual process but as a social one, situated in a cultural and historical context⁹. Learning can thus take place in any area of endeavor and is not limited to formal education¹⁰. The concept of the CoP has been particularly influential in the areas of education and organizational studies¹¹. Wenger defines a CoP as a group of people who interact regularly (community) around a shared interest (domain) and develop a shared repertoire of knowledge and resources (practice)^5,10. This practice may be to help each other solve everyday problems and share ideas; to develop, validate, and disseminate specific practices or knowledge; or to foster unexpected ideas and innovations.

A CoP may be formed within an already existing group or organization, or it may be created from scratch to address a specific issue. In either case, Wenger identifies several stages in its development⁵:

The LISTEN model slightly modifies the three components in Wenger’s definition: LISTEN conceptualizes a CoP as a group of people organized around a key purpose (e.g., health, economic empowerment, public safety, etc.) and a delivery point (any interface between the supply and demand of those services). “Group of people” clarifies that in the LISTEN model, those coming together need not previously have been a formalized community or organization; “key purpose” highlights the problem-solving aspect of the work (rather than simply developing knowledge or pursuing an interest for its own sake); and “delivery point” adds emphasis to the model’s focus on interactions among people within a system, rather than the role that an individual performs.

The LISTEN model has three aims: to 1) to facilitate the development and support of CoPs at the local-community, regional, and national levels to integrate systematic processes for continuous improvement; 2) to improve the collection and use of data by each CoP to ensure that CoPs’ approaches to problems and innovations are evidence-based; and 3) to enable CoP’s uptake and use of human-centered design to accelerate and scale up both current and new solutions. Human-centered design is a systematic approach to problem-solving which prioritizes the experience, knowledge, perspectives, and values of the people directly affected by the issue in co-designing solutions, rather than imposing solutions from outside. In this respect it is aligned with concepts of community engagement endorsed by WHO¹². Specifically, human-centered design involves developing a thorough understanding of the problem area, identifying stakeholders’ specific needs, co-creating solutions with the stakeholders to address those needs, and iteratively testing and refining the potential interventions.

In the LISTEN model, trained facilitators identify and engage with existing groups or organizations relevant to the primary goal (entry point) of the LISTEN implementation effort, e.g., healthcare facility teams or youth groups when HIV prevention is the focus. Working with existing groups or organizations to facilitate their development toward operating as a CoP is preferred, as they are already motivated and organized around their primary purpose. However, in some cases where a group or organization would be helpful but is lacking, it may be opportune to engage individuals (e.g., members of a village community) in developing themselves into a CoP around a common issue.

The model links CoPs, both horizontally (i.e., CoPs working at the same level, such as village CoPs), so that they can learn from one another, and vertically, so that CoPs closer to local communities can call upon the support they need from higher levels of the system (e.g., village CoPs supported by regional or national government ministries). LISTEN facilitators also work with the CoPs to identify data and information relevant for measuring themselves against their goals, e.g., the rate of HIV infection in their community, to help them prioritize and stimulate their problem-solving efforts. The process by which a facilitator engages with the CoP is a responsive one, developed through respect and understanding between them. The facilitator supports the group in identifying and prioritizing their challenges, analyzing the root causes, designing responses to address these, linking CoPs to one another (horizontally) for mutual learning, and linking them with external resources and support (vertically) where needed. This emphasis on strengthening systems both horizontally and vertically through intentional interactions is the reason the LISTEN model conceptualizes a CoP as having delivery points, rather than Wenger’s more general term “practice”. At the same time, the facilitator learns through their interaction with the CoP and adapts their guidance according to the CoP’s own practice and that of other CoPs with common goals or similar practices.

In contexts of scarce resources, varied assets, and diverse communities, we see the engagement and support of local stakeholders in leading and owning the problem-solving process as critical to the development of effective interventions for HIV prevention and treatment. CoPs can develop expertise in identifying their local community’s key challenges and selecting solutions that can be implemented within their community. In doing so, they can take on accountability for the results, and also begin to hold the elements of the system meant to serve them accountable to do so in a responsive, rather than directive, way. By equipping communities with the LISTEN model and helping them develop problem-solving skills to address their own challenges, we hope to create a more sustainable process for finding solutions.

The problem-solving journey of a CoP

We engaged with four CoPs in Kenya, and four newly formed CoPs in Eswatini, as they adopted the LISTEN model. In each country, with government agreement, LISTEN supported the Ministry of Health to hire or assign facilitators for the LISTEN process. The facilitators received online training in human-centered design, and in-person training in the LISTEN process.

The Kenyan groups were selected with the guidance of the National AIDS Control Council and county health departments, with a view to engaging with communities that were particularly vulnerable to HIV and helping them develop into CoPs. We drew upon the experiences of a group working to retain adolescents living with HIV in treatment, at Nazareth Hospital in Kiambu; and a faith-based organization comprised of youth representatives of various churches engaged in HIV prevention work, also in Kiambu. We also studied two organizations of fisherfolk and an organization of boda boda drivers (motorbike delivery and ride providers) in Homa Bay. This is an area where residents are at high risk of HIV, including through the exchange of sex for needed products and services (e.g., fish and transportation). In Eswatini, CoPs were formed in three separate locations, as well as a cross-community CoP established among a group of “Community Champions” (members of the three CoPs), who were brought together to conceptualize and design some quick and effective solutions to problems they faced, including HIV prevention. In each case in both countries, the LISTEN model was first presented to leaders of the groups or communities, and they agreed to try working with the process to identify and address challenges facing them.

Through observation of the LISTEN process and in-depth discussions with the CoP members, we adapted Wenger’s framework to understand the key stages that local-level CoPs such as these go through as they develop, and how the LISTEN model can support their problem-solving journey. Our framework incorporates Wenger’s stages of a CoP’s development, as well as concepts from theories of social mobilization¹³, collective efficacy¹⁴, and intrinsic motivation¹⁵. Since CoPs evolve through different stages of development and within different contexts, with varying needs for support, this framework provides a structure that can in future be used to develop tools appropriate for each CoP’s context. The framework is thus an integral part of the human-centered design approach underlying the LISTEN model. It is also based on our observations and in-depth discussions with members of the eight CoPs. It describes four stages in the problem-solving journey of a CoP.

Tools for the problem-solving journey

Our observations of the CoPs in Kenya and Eswatini, and the mapping of their problem-solving journeys, suggest types of tools that might support CoPs at each stage of the journey. While the tools proposed below are not HIV-specific, they will support the integration of human-centered design into the problem-solving process. These process-based tools can therefore be leveraged to address a range of social issues including HIV and water access. The examples given below are concepts that would be agreed upon, developed, tested, and refined by and with CoPs themselves, following the human-centered design approach that underpins the LISTEN model.

Conclusion

We propose this problem-solving journey framework as a way to apply the theories of learning of Wenger and others within a practical public-health problem-solving space. Our framework is based on the theory and observation that people at the grassroots know what problems they face and are best positioned to identify the best solutions for their context, try them out, and adopt or create metrics to learn from successes and failures. CoPs offer them the chance to solve problems together, with a process grounded in human-centered design, consciously evaluating what they are doing and how they are doing it via data and a continuous improvement process, and linking horizontally to learn from each other and vertically to get the support they require. In this way, programs become less top-down, with the higher levels of health services and government services acting as supporters – rather than initiators – of effective solutions. As LISTEN moves into its second phase, indicators will be developed to evaluate the effectiveness of this approach.

Given the urgency of problems such as the COVID-19 pandemic, and HIV prevention and treatment in many countries, and the hitherto limited success of CoPs in innovating and disseminating promising practices, it is critical to equip communities not only to become CoPs, but also to effectively carry out the problem-solving process. The types of tools we have suggested can support CoPs at the appropriate stages in their journey, and a goal of the next phase of LISTEN is to develop and apply such tools. When communities are equipped with problem-solving skills to address their own challenges, they can create a more sustainable process for finding solutions.

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