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Collective efficacy measures for women and girls in low- and middle-income countries: a systematic review

BMC Women's Health volume 22, Article number: 129 (2022) Cite this article

Abstract

Background

Prior research has shown collective efficacy to be a key determinant of women’s well-being. However, much of the work around measuring this construct has been done in high-income geographies, with very little representation from low- and middle-income countries (LMIC). To fill this gap, and guide future research in low resource settings, we aim to summarize best evidence measures of collective efficacy for women and girls from LMICs.

Methods

Following PRISMA guidelines, we systematically searched five databases for English language peer-reviewed literature on measures of collective efficacy, published between 1 January 2009 and 25 August 2020. In addition, we sought expert input for relevant papers in this area. Research staff screened titles, abstracts, and full-text articles in a double-blind review. Inclusion criteria were: (i) original quantitative analysis, and (ii) sample limited to women/girls only (≥ 100), residing in LMICs.

Results

We identified 786 unique articles, 14 of which met inclusion criteria. Eligible studies captured a diversity of population groups, including pregnant women, recent mothers, adolescent girls, and female sex workers, from across national settings. Two broad constructs of collective efficacy were captured by the measures: (i) group dynamics, and (ii) collective action. All 14 studies included items on group dynamics in their measures, whereas seven studies included items on collective action. Four studies validated new measures of collective efficacy, and seven provided evidence supporting the relationship between collective efficacy and outcomes related to women’s well-being. Overall, measures demonstrated good reliability and validity when tested, and those testing for associations or effects found a positive relationship of collective efficacy with women’s health behaviors.

Conclusion

The past decade has resulted in a number of new collective efficacy measures demonstrating good validity in terms of their associations with key health outcomes among women and girls from across LMIC settings, but there remains no standard measure in the field. Those that exist focus on group dynamics, but less often on collective action. A standard measure of collective efficacy inclusive of group dynamics and collective action can support better understanding of the value of women’s collectives across national settings and populations.

Peer Review reports

Background

Women’s collectives have been shown to be an important driver in improving women’s sexual, reproductive, and maternal health, child health, and women’s safety from gender- based violence [1,2,3,4]. These studies built upon research documenting the value of women’s collectives for their financial security and livelihood [5,6,7], as well as political participation [8]. Systematic reviews of the literature on effectiveness of collectives highlight that the mechanism though which they achieve these outcomes could be via improved collective efficacy [9,10,11]. Collective efficacy is also regarded as an essential component of the gender empowerment process as it creates power and agency to develop and maintain group level change; it has a direct bearing on population health and socio-economic indicators, especially for women and girls [12]. Unfortunately, lack of a standard measure of collective efficacy for use in low- and middle-income countries (LMIC), and specifically for women and girls, has likely hindered our understanding of collectives.

Measurement of collective efficacy requires clarity of the concept. In the field of psychology, Bandura defines collective efficacy as, "a group's shared belief in its conjoint capability to organize and execute the courses of action required to produce given levels of attainment" [13]. Collective efficacy relies on both group capacities, and the processes toward achievement of shared goals [14, 15]. A significant amount of research on collective efficacy has focused on its neighborhood-level prevalence, in the context of crime prevention. Sampson et al. [16] has defined it as “social cohesion among neighbors combined with their willingness to intervene on behalf of the common good”. Thus, while social networks and social capital are the foundation of collective efficacy, a notion central to this construct is the desire to intervene as a group, and a capacity for informal control. Prior research posits that collective efficacy is best captured by the two distinct yet overlapping constructs, social group dynamics and desire to take action, which are in turn influenced by elements of social capital, empowerment, and civic engagement [17]. Group dynamic characteristics can include social support, solidarity, connection, group engagement, dialogue, trust, decision-making and deliberation, identification with the group, and shared goals. These factors are directly related to the desire to take action or collective action; at a community or group level, the desire and capacity to intervene for the common good will depend on the extent of solidarity, engagement, and mutual trust within the group members [18]. Socially cohesive communities encourage the practice or implementation of collective action. In contrast, a member is unlikely to be willing to intervene or participate in collective action in a context where people mistrust or fear each other, and experience a lack of solidarity. In the current study, we review articles that include measures related to either one, or both sub-constructs of collective efficacy- group dynamics, and collective action.

Prior research has noted collective efficacy to be situated rather than global; efficacy is present relative to a specific task, or a type of task [16, 19]. As such, measures should, and will vary based on the context in which collective efficacy is studied. Majority research has viewed collective efficacy as existing relative to neighborhood-level crime, and civic problems. Collective efficacy in the context of women's issues, or women's rights, is a relatively lesser focused field of work. Although, understanding the dimensions of group dynamics and collective action are particularly important for socially disadvantaged and politically disenfranchised groups, including women, given the value of collectives in providing “safety in numbers”. The existing measures of collective efficacy specifically for women groups, have largely come from high-income countries [16, 20,21,22]. Analysis of collective efficacy has been more limited in LMICs due to lack of established measures, and lack of rigorous measure development from within these countries [9]. Given the socially and culturally specific nature of collective efficacy as a phenomenon, research on using and developing context specific measures from LMICs is needed, particularly for purposes of monitoring and evaluation [23].

To support the use of best evidence measures, as well as to inform development of new measures for this important and growing area of work, we conducted a systemic review of the literature, and utilized expert input to identify measures of collective efficacy for women and girls in LMICs. We assessed the nature and psychometrics of identified measures, and the population of focus. In order to provide a comprehensive understanding of the context in which the different measures have been implemented, where available, we also examined the application of collective efficacy measures to outcomes for women's well-being.

Methods

We conducted a systematic review of the literature to assess quantitative measures of collective efficacy, following the PRISMA Statement checklist [24]. The predefined protocol and full search strategy are available online, in our PRISMA registration and protocol [25].

Literature search

Five electronic bibliographic databases [PubMed (pubmed.gov), Embase (embase.com), PsycINFO (ProQuest), Sociological Abstracts (ProQuest), and Family & Society Studies Worldwide (EBSCO)] were searched for peer-reviewed literature related to measures of collective efficacy, published from January 2009 to August 25, 2020. Our search strategy was developed by a library subject specialist, and combined terms related to community, social capacity and action, LMICs, tests or measurement tools, and psychometrics, or validity and reliability. Search terms were developed to characterize collective efficacy based on review of theoretical concepts of collective efficacy which posit that efficacy is captured by measures of capacity (thinking you can do it and being able to do it) and action [14, 16, 26, 27]. Our search strategy is provided in Additional file 1. To identify additional studies, we gathered input from experts working on collective efficacy and gender empowerment, and are a part of the larger Evidence based Measures of Empowerment for Research on Gender Equality (EMERGE) project at the Centre in Gender Equity and Health at University of California San Diego. EMERGE maintains a large repository of existing measures related to women and girls’ health, with the broader goal of identification and evaluation of quantitative measures of gender equality and empowerment [28].

Inclusion and exclusion criteria

Studies were included if they showed evidence of any original quantitative data analysis (including but not limited to psychometric properties i.e. reliability or validity) on collective efficacy, and the sample size was women/female only, with at least 100 participants in an LMIC setting. We excluded studies which had no quantitative data analysis (e.g. only provides qualitative data, case study, reviews of literature etc.), had sample size less than 100 participants, or had population groups that included men, or men and women together, were not in English language, or were conducted in non-LMIC only, or were clearly off topic.

Data extraction and quality assessment

Studies were reviewed by trained research assistants who used Covidence to review their eligibility, following a double-blind review process [29]. Any disagreements were resolved by the senior author of the study. The technology used on our project included the Yale MeSH analyzer as well as the duplicate detection capability of Covidence. We also used EndNote for pulling full-text combined with a tool called FolderMerge to allow for a bulk upload of PDFs to Covidence. Due to the non-clinical or experimental nature of this review, an established quality assessment guideline was not practicable. However, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement, guidelines for reporting observational studies, were adapted to ensure key aspects of the studies were assessed during data extraction to indicate quality of the studies [30]. We conducted a qualitative synthesis of the findings and extracted the following information from each study: year of study, research question, study design, study sample including study settings, measures in the study that are about, or related to collective efficacy, psychometrics for the relevant measures, study results, and key concepts of collective efficacy. Based on above described theoretical understanding, we focused on the following main constructs and sub-constructs of collective efficacy: Construct 1. Group dynamics (including group engagement, support, solidarity, connection, dialogue, trust, decision-making and deliberation, identification with the group, and shared goals) and Construct 2. Collective action (including group organizing, action, leadership, and voice). For psychometrics, we extracted all information provided by the authors regarding reliability and validity of the measures of interest.

Results

We identified 1,555 articles via database searching, and 23 articles through expert input. Of these, 786 were unique citations. Two coders independently reviewed these papers, and 14 studies met all inclusion criteria for analysis (Fig. 1).

Fig. 1
figure 1

PRISMA flowchart showing study selection process for the systematic review

Full size image

Population sub-groups: The 14 studies included different population sub-groups, and represented a diverse geography, with countries in South Asia, sub-Saharan Africa, the Middle East, and the Caribbean (Table 1). Three studies included measures for female sex workers (FSW) in India and Dominican Republic [31,32,33], while two studies used measures for recent mothers in Malawi [34, 35]. Remaining studies covered pregnant women in Sri Lanka [36], self-help group (SHG) members in India [37, 38], female nurses in Iran [39], HIV‐negative adolescent girls in South Africa [40], and general adult female population in Ghana, Uganda and Malawi [41], Iran [42], China [43], and India [44]. All except one [40] focused on adult women, with the average age ranging from 15 to 40 years across studies.

Table 1 Eligible studies from systematic review of collective efficacy measures in low- and middle- income countries
Full size table

Collective efficacy sub-constructs: Most of the studies included multiple measures, or measures capturing different sub-constructs of collective efficacy [32,33,34,35,36,37,38,39,40, 42,43,44]. Unique measures were seen across studies, with the exception of two articles that used data from the same study with FSWs in India [32, 33]. All 14 studies captured group dynamics; seven also included collective action.

We observed variance in the objectives and study design of the eligible research. Four studies focused on measures development and validation, with the remaining being association analyses or evaluation studies. Nonetheless, most (12 studies) provided some psychometric data to be included in our analyses. In the following section, we outline the key populations of focus, psychometrics, and key concepts of collective efficacy of focus for each study, by study design.

Validation studies

As seen in the Rows 1–4 of Table 1, validation studies were conducted with women in Sri Lanka, Malawi and Iran, including pregnant women and new mothers, health workers, and the general female population [35, 36, 39, 42]. These studies captured sub-constructs of collective efficacy, including social capital, trust, and empowerment. All measures demonstrated good internal reliability and validity. Measures ranged in length from eight to 24 items, with the longer measures more comprehensively assessing group dynamics and connectivity. The measure from Sri Lanka with pregnant women assessed social capital, capturing elements of neighborhood networks, domestic and neighborhood cohesion, social contribution, and social participation [36]. A measure developed with young women in Iran assessed a single component of group dynamics- trust [42]. Only one of the four measures included a measure of collective action in the form of organizing, with a sample of new mothers in Malawi [35]. While this measure was a longer measure, with 24 items, it comprised of subscales to capture aspects of group support, group cohesion, perceptions of group capacity to have impact, and collective action. It included items measuring women's confidence in how well members can work together for a specific goal or impact, thus capturing the capacity to 'act together'.

Association analyses

Seven studies focused on associations between collective efficacy and health and economic outcomes for women and girls (Table 1, Rows 5–11), with four studies capturing both group dynamics and collective action.

Three studies from Dominican Republic [31] and India [32, 33] focused on FSWs. The study in the Dominican Republic used an 11-item measure of a component of group dynamics—group cohesion (e.g., trust and solidarity with other FSWs); the measure demonstrated good internal reliability but was not tested for validity. This study showed a significant association between group cohesion and consistent condom use. The two studies from India used more comprehensive measures of collective efficacy, including items for both group dynamics, and collective action [32, 33]. These studies analyzed data from the same intervention, and hence had similar measures. A four-item measure of collective efficacy was used, that assessed whether the FSWs worked well together to achieve their shared goals. Studies also captured measures of collective agency (four items on standing up to someone in power to help another FSW), and collective action (six items on demanding entitlements via a group or collective of FSWs). The measures showed good internal reliability but were not tested for validity. However, the studies demonstrated significant associations between aspects of collective efficacy and consistent condom use, sexual self-efficacy, and willingness to engage in STI treatment. Another study from India found women’s social capital to have a significant positive relationship with maternal and child health outcomes [44]. Social capital was measured with 15 items, with six distinct factors that captured bridging and bonding ties, social networks and cohesion, and perceived community bonds for collective action. The measure was not tested for reliability but showed adequate validity, with the six factors explaining over 80% of the variance in factor analysis. One study with married or cohabiting women in China used an eight-item measure of collective efficacy with good reliability. It captured two factors related to group dynamics: neighborhood solidarity, and neighborhood informal social control [43]. The second factor, a measure of trust and perceived support from one’s neighborhood, was found to be significantly associated with women’s bystander behavior against intimate partner violence.

Another study used a 19-item measure to capture group dynamics, assessing group structure and processes of women’s SHGs (trust in the SHG’s processes, leadership, and group cohesiveness) in India [37]. The measure had good reliability and validity, and demonstrated a significant relationship between SHGs’ group structure and processes, and financial health of the SHGs.

A study from South Africa provided the most comprehensive assessment, with a measure for Community Mobilization, which included 55 items that assessed seven distinct aspects of collective efficacy across both group dynamics and collective action [40]. The results were quite robust, with higher community mobilization at the village level associated with lower HIV incidence. The subscales predictive of this outcome were critical consciousness (shared goals in the collective), and women’s leadership (an indicator of mobilization). The measure demonstrated very strong reliability and validity scores and was developed with both theory and rigorous science, described in the original measure development and validation study [45].

Intervention evaluation studies

As seen in the Rows 12–14 of Table 1, three evaluation studies that included measures of collective efficacy examined the impact of SHGs and a community mobilization program. An evaluation study of an SHG program in India included measures for both our sub-constructs of collective efficacy- group dynamics and collective action [38]. This study used eight sub-scales to measure aspects of trust, positive group dynamics, group efficacy, and collective action or group organizing. Measure showed good reliability and validity, and results indicated a positive impact of the community mobilization program on key aspects related to collective efficacy. The study demonstrated a significant increase in women’s collective efficacy due to the program. The evaluation study of a health-related community mobilization intervention in Malawi presented more comprehensive measures and robust psychometric results [34]. This measure included questions on group engagement and dialogue, trust, shared goals, as well as on collective action and organizing.

Discussion

The current systematic review suggests a growing literature on measurement of collective efficacy from LMICs, with 14 reviewed studies from diverse geographies and population groups. The studies were published on or after 2012, although our review period dates to 2009. We found all studies to include measures related to group dynamics, while seven studies also captured dimensions of collective action. All except two studies included unique measures of collective efficacy. This is the first review to identify and examine measures of collective efficacy for women from LMICs, a context where aspects related to community relationships and engagement have shown to be protective factors for women’s health [46, 47]. Overall, measures demonstrated good reliability and validity when tested [35, 36, 39, 42], and those testing for associations or effects found a positive relationship between collective efficacy and women’s health and economic outcomes. However, gaps remain, both in terms of availability of a standard measure, harmonization of the available measures, and expanding our knowledge regarding different elements of collective efficacy beyond aspects of group dynamics, covering group support and group solidarity.

Our review demonstrates heterogeneity in measures for collective efficacy. While the reviewed body of work indicates promising results, a lack of consistency in measurement instruments impedes the ability to harmonize findings. Only two of the 14 reviewed studies included similar measures. The current heterogeneity could be attributed to the studies measuring different elements or sub-constructs of the two building blocks of collective efficacy, as identified by us. Although, for the few studies measuring the same construct, such as social capital, measurement instruments varied [36, 39, 44]. This heterogeneity makes summarization of results difficult. It makes drawing of valid conclusions regarding the different elements of collective efficacy and its impact on specific health outcomes, challenging. Another aspect to consider with regards to results synthesis is geographical diversity of measures. Five of the 14 studies in our review were from India [32, 33, 37, 38, 44]. For countries where tested, validated, and robust measures already exist, future research should consider adaptation of these measures instead of investments in development of new measures. Alternately, countries with no prior validated measures could focus on testing or development of measures to contribute to a comprehensive understanding of collective efficacy across different populations.

Our review found a greater focus of existing literature on aspects of collective efficacy related to group dynamics. Cognitive aspects including perceived group support, group solidarity, and trust, were frequently included in the measurement instruments [31, 39, 42, 44]. Whereas, we observed less representation of studies on community mobilization and collective action. Other key elements of collective efficacy, including informal social control, and social regulation also need to be explored by future research [48]. Further, the reviewed studies examined collective efficacy as a static or cross-sectional construct. None of the studies assessed it as a dynamic construct, where the sense of efficacy could undergo revisions based on new information received from group members [49]. This idea, and its implications, have been studied to some extent in self-efficacy [50], but is yet to be accounted for, in collective efficacy literature.

Majority of the studies that aimed to test associations focused on health outcomes of women. We note only one study that looked at economic outcomes related to financial health of SHGs. Even with regards to health outcomes, the value of the current work is limited to reproductive, maternal, and child health outcomes. Other outcomes of importance which could be impacted by collective efficacy, are missing from the literature; these could include empowerment and individual agency, political leadership, and environment and sustainability [51, 52]. Our review also indicates gaps with regards to specific sub-populations, including adolescents and marginalized women groups. Thirteen of the 14 studies measured collective efficacy and its correlates among adult women. Adolescence is a formative life stage, and community related factors including collective efficacy during this period could have long-lasting health impacts for young individuals. Similarly, collective efficacy for marginalized groups might have different meanings and consequences, and is worth exploring.

While our study highlights important findings regarding measures of collective efficacy, it has few limitations. Our review included studies published in English; it is possible that inclusion of literature from other languages could increase the breadth of the review. Next, our review was limited to studies which included only women and girls in their sample, excluding work that focusses on measures of collective efficacy for a general population in LMICs. However, given the unique role of collectives on women’s health and well-being, as is evident from the research around SHGs and other collectives, a limited focus on measures that are developed specifically for women is necessary and critical. Third, our review focused on LMICs, where there might be a limitation in availability of research reports. Interventions on collective action, and community mobilization could be capturing these constructs in their monitoring or evaluation efforts, but not necessarily publishing findings as peer-reviewed literature. Finally, while the focus of this study was to provide insight into measures of collective efficacy, findings from this review also demonstrate the utility of collective efficacy with regards to its impacts on women's well-being. Future research should examine the associations between collective efficacy and key outcomes related to specific issues, such as health or economics, for further insight. Such focus was beyond the scope of the current study, but may prove important for more concrete guidance for future interventions.

Conclusions

Collective efficacy is a key construct with regards to its implications for women’s well-being in low-resource settings. The current measurement science in this field shows promise, particularly for measures of one sub-construct of collective efficacy—group dynamics. Measures capturing collective action, or group organizing are still limited. While these measures can be adapted and applied in other settings, further research is needed to support harmonization and standardization of specific elements of collective efficacy, to focus on under-measured dimensions of collective efficacy, and to include broader segments of society with an intersectional lens.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

LMIC:

Low- and Middle-Income countries

STROBE:

Strengthening the Reporting of Observational Studies in Epidemiology

EMERGE:

Evidence based Measures of Empowerment for Research on Gender Equality

FSW:

Female Sex Worker

SHG:

Self-Help Group

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Acknowledgements

We are grateful for the contributions of Alyssa Brodsky, Arnab K Dey, Taylor Wyrick, and Lilibeth Ramirez, for serving as reviewers of eligible papers. We appreciate the contributions of Rupa Jose and Kathryn Barker for their feedback on the qualitative synthesis of the findings. All contributors worked for the University of California San Diego's Center on Gender Equity and Health at the time of their contributions.

Funding

This study was funded by the Bill and Melinda Gates Foundation Grant No. OPP1163682. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Authors and Affiliations

  1. Center On Gender Equity and Health, School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA

    Nabamallika Dehingia, Anvita Dixit & Anita Raj

  2. Joint Doctoral Program in Global Health, San Diego State University and University of California San Diego, San Diego, CA, USA

    Nabamallika Dehingia & Anvita Dixit

  3. Biomedical Library, University of California San Diego, San Diego, CA, USA

    Karen Heskett

Authors
  1. Nabamallika Dehingia
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  2. Anvita Dixit
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  3. Karen Heskett
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  4. Anita Raj
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Contributions

AR led the development of the research design and the search strategy essential for systematic review. KH guided the systematic review process. ND and AD screened titles and abstracts, and conducted the full text review for eligibility. Any disagreements were resolved by discussions with AR. ND and AD carried out, and AR checked, data extraction and synthesis of findings. ND, AD, and AR wrote the first draft of the manuscript. KH contributed to writing revised drafts of the manuscript. AR guided overall conceptual design of the study. All authors read and approved the final manuscript.

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Correspondence to Nabamallika Dehingia.

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Supplementary Information

Additional file 1:

Search strategy for the review.

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Dehingia, N., Dixit, A., Heskett, K. et al. Collective efficacy measures for women and girls in low- and middle-income countries: a systematic review. BMC Women's Health 22, 129 (2022). https://doi.org/10.1186/s12905-022-01688-z

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Keywords

BMC Women's Health

ISSN: 1472-6874

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