Table 3

Key themes and power-related lessons learnt from SRH literature

ResistanceSome programmes faced community resistance as some community members felt that the programme undermined cultural or religious tradition. Programme implementers addressed (though did not eliminate) this resistance by working with opinion leaders from the start, and in some cases, by integrating these opinion leaders into programme activities; failing to do so seemingly undermined the programme.46 75 95 111 151
Due to prevailing gender norms, men were reluctant to engage in programmes that addressed ‘women’s issues’, and this was lessened by framing the programme as working on issues of community importance, as opposed to women’s concerns.72 95 116
Many papers noted that involving men helped programmes to achieve their goals, particularly those that aimed directly or indirectly to influence gender relations of power.49 51 65 81 119 123 152
Engaging mothers in law was an effective way to influence gender relations of power in the household.76
Resistance can engender non-linear effects, as actors with power initially push back against an effort.45
StigmaThe act of bringing stigmatised SRH issues out into the open for discussion—in small groups or at the community level—can foment a change in power relations.25 38 39 41 45 79 84 116
Relying on community representatives as legitimate spokespeople for stigmatised issues might help to ensure that these issues are discussed and that decision-makers listen.38
Open discussion of stigmatised issues (HIV in this case) may lead to increased polarisation when the issue in question is already polarised.122
Programme exposureSome papers speculated whether a higher ‘dose’ of the programme might more effectively provoke changes in power relations.52 53 56 57 107 151 152
Gender and other norms may limit particular groups’ exposure (ie, their ability to participate) to the programme; this should be addressed in programme design.96
Limitations of programmes addressing only individual/interpersonal levels, benefits of a multilevel approachA multilevel intervention might be more successful in changing the power relations and other structural factors that limited the programme’s success.48 57 70 84
Systematically addressing several levels of the health system and use of a political economy analysis buttressed programme success. Deliberately engaging stakeholders at multiple levels also gave programme implementers a clearer picture of power relations and how they play out.85 153
The provision or existence of high-quality material, human and other resources may be critical to enable or facilitate change, including ensuring that health providers do not perpetuate stigma.57 71 89
The combination of mass media messaging, community mobilisation and interpersonal engagement in informal spaces (eg, market and spontaneous community meetings) can work synergistically to shift power dynamics. However, this informal interpersonal engagement did not work in all settings, perhaps due to cultural differences41 46 111 113
Combining support for community activism and efforts to engage local government and service providers can support an ‘enabling environment’ for change.75
Grassroots effortsProgrammes led by grassroots NGOs and activists underlined the effectiveness of collective action by the marginalised in demanding rights and shifting power relations, as well as the emancipatory potential of marginalised populations recognising their ‘right to have rights’. These efforts can be more effective when collective actors confront multiple structures that ‘reproduce(d)and maintai(n)their marginality’ rather than just the direct determinants,45 p103).25 41 43 45
Programmes led by organisations that modelled non-hierarchal relationships with communities helped community members to perceive themselves as part of an organised effort to effect change.37 43
Papers regarding programmes that were not obligated to ensure programme fidelity noted that programme learning and real-time adaptation were key to ensuring the programme addressed contextual factors and changing power dynamics.37 40 85 87
NGO monitoring efforts must negotiate power dynamics at multiple levels, including generalised commitment from the state at higher levels of the health system, and resistance from front-line providers who feel judged.42
A long-term community-based advocacy programme built the political capabilities of the women participating, making it more likely that they demanded change from political, state and community actors regarding a number of issues over the medium and long terms.37
Public policy/governanceLack of legislation or poor implementation of legislation undercut the programme’s effectiveness.84 114 127
  • SRH, sexual and reproductive health.