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

1

Agampodi et al. [36]

To develop and validate an instrument to measure social capital among pregnant women in low- and middle- income countries—the Social Capital Assessment Tool for Maternal Health (LSCAT-MH)

Cross-sectional

Purpose: measures development and validation

Setting: Sri Lanka

Purposive sample of 439 pregnant women

Age: 85.0% of the women of age 20–35 years

Education: 1.3% up to grade 5 or less, 24.2% up to grade 10, and 7.3% had university education

Study developed and validated a 24-item measure of social capital for pregnant women which consisted of four factors:

• Neighbourhood networks: includes four items that assess structural bonding, or the informal social networks such as having someone to consult for information/knowledge, meeting friends/relatives in the neighbourhood, connecting with friends on telephone, and having someone to console when stressed

• Domestic and neighbourhood cohesion: includes nine items that assess cognitive bonding such as couple and family arguments, nature of relationship with the neighbourhood with regards to receiving love and support

• Social contribution: includes six items that assess bonding and bridging ties such as taking responsibilities for social activities, and helping others in the community

• Social participation: includes three items that assess structural bridging such as participation in cultural events and showing solidarity in the case of neighbourhood problem

Two types of response scales were tested; five-point Likert (Fully agree, agree, neutral, disagree, fully disagree) and five-point adjectival (always, often, sometimes, rarely and never). The adjectival scale performed better as reported by the respondents

Reliability:

Cronbach's alpha = 0.94 Intraclass correlation (ICC) for test–retest reliability = 0.71

Validity:

Construct validity established with a significant negative correlation (correlation coefficient, r =  − 0.269, p = 0.000) with the Edinburgh Postpartum Depression Scale

Face validity assessed and found adequate

Not applicable

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Group dialogue

• Trust

• Identification with the group

2

Firouzbakht et al. [39]

To validate the Persian version of the workplace social capital questionnaire, for a sample of female health care workers in Iran

Cross-sectional

Purpose: measures validation

Setting: Iran

Multi-stage random sample of 440 female nurses in hospitals and health care centres, with at least one year of work experience

Mean age: 35.9 (SD 8.4) years. Education: 77.3% had a bachelor’s degree

Study validated an 8-item measure of workplace social capital, which consisted of two factors:

• Group coherence: includes five items that assess whether members of the work unit build on each other's ideas, co-operate, and feel accepted and understood by each other

• Committed management: includes three items that assess the respondents’ relationship with the supervisor in terms of trust and support

A five-point Likert scale ranging from 1 to 5 (“totally disagree” to “totally agree”) was used for responses to the items

Reliability:

Cronbach’s alpha = 0.80

Validity:

Construct validity established with a two- factor solution that explained 65% of the total variance. Fit statistics were acceptable: GFI = 0.953, CFI = 0.973, RMSEA = 0.090

Content validity established via assessment of the items by experts

Not applicable

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Trust

3

Salehi et al. [42]

To validate the Trust and Control-Self-efficacy scales for a sample of young women living in Iran

The original measure was used in the British General Household Survey (GHS)

Cross-sectional

Purpose: measures validation

Setting: Iran

Cluster convenience sample of 391 women

Age range: 18 to 35 years (mean 27.3, SD 4.8 years)

Education: 76.4% of women with a university degree, and 49% women single

Study validated a 20-item measure of Trust, which consisted of four factors:

• Trust in media: includes six items that assess whether the respondent trusts TV, radio, and local newspapers

• Trust in institutions: includes eight items that assess whether the respondent trusts different institutions including the government, parliament, police, and bank

• Trust in neighbourhood: includes four items that assess whether the respondent trusts their neighbourhood, or believes the neighbourhood is helpful

• General trust: includes two items that assess whether the respondent believes that most people can be trusted

A five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) was used for the first, third, and fourth subscales. The second subscale had Likert response categories ranging from 1 (do not trust at all) to 10 (trust completely). Scores are added for an overall measure

Reliability:

• Trust in media: Cronbach’s alpha = 0.92

• Trust in institutions: Cronbach’s alpha = 0.93

• Trust in neighbourhood and General trust (combined):

Cronbach’s alpha = 0.73

Validity:

Construct validity established with factor analysis; Trust scale had chi-square value 2.238, CFI 0.967, TLI 0.959, and RMSEA 0.056

Not applicable

GROUP DYNAMICS:

• trust

4

Kuhlmann et. al. [35]

To validate measures related to three domains: women’s empowerment, health workers’ empowerment, and negotiated spaces, or engagement between power holders and citizens

Cross-sectional (baseline survey of an RCT evaluation)

Purpose: measures validation

Setting: Malawi

Cluster sample of 1951 women aged 15–49 who had given birth in the last 12 months

Mean age: 25.7 years

Education: 30% were illiterate

The first domain, women’s empowerment tested four measures related to collective efficacy:

• Community support in times of crisis: includes four items which asses how sure the woman is about someone in their community supporting them if they are pregnant and bleeding

• Social cohesion: includes six items which assess whether the woman can rely or trust their community members for borrowing money, dealing with a violent situation etc

• Collective efficacy: includes four items that assess women’s confidence in how well community members and health workers could work together for improving health outcomes in the community

• Social participation & collective action: measured using three separate questions that assess whether the woman has had membership with, or received any help from, an organized group in their community, or joined other people to improve health services

The third domain, negotiated spaces, included one relevant measure:

• Mutual responsibility for & support of services: includes five items which ask women who they thought could have the most impact to make changes in five areas related to maternal health including being treated with respect, visits by health worker, and getting funding to improve health services. Options included community members with health workers and government officials, community members alone etc

Reliability:

• Community support in times of crisis:

Cronbach’s alpha = 0.83

• Social cohesion:

Cronbach’s alpha = 0.67

• Collective efficacy: Cronbach’s alpha = 0.90

• Social participation & collective action: Cronbach’s alpha = Not applicable (individual questions, not a scale)

• Mutual responsibility for & support of services:

Cronbach’s alpha = 0.73

Validity:

All final items had factors loadings > 0.4 in exploratory factor analysis. No other details provided

Not applicable

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Group dialogue

• Trust

• Group decision-making/deliberation

• Shared goals

COLLECTIVE ACTION

• Group organizing

5

Carrasco et al. [31]

To examine the associations between social cohesion and a) consistent condom use and b) sexually transmitted infections (STIs) among female sex workers (FSW) living with HIV in the Dominican Republic

Cross-sectional (uses data from the follow- up survey of a cohort study)

Purpose: association analysis

Setting: Dominican Republic

Non-random hybrid sample of 228 FSWs living with HIV, participating in the multilevel intervention Abriendo Puertas in 2013 in Santo Domingo

Mean age 37 years (range 30–43)

Education: 120 (53.91%) had education 0–7th grade, 103 (46.19%) had 8th grade to university

The key independent variable, social cohesion, was a 11-item measure that assessed trust, solidarity, and reciprocity among the FSWs

Items asked FSWs if they could trust other FSWs with regards to sharing their HIV status, if they could count on other FSW for borrowing money, accompanying to the hospital, finding a place to stay, supporting in use of condoms, and dealing with a violent customer

A 5-point Likert-scale was used to capture the response (strongly disagree, disagree, agree, strongly agree, do not know)

Reliability:

Cronbach’s alpha = 0.81

Validity:

No statistics for validity are provided in the current study

Study used multivariable logistic regressions to test the hypothesized associations

Results show:

• Social cohesion significantly

associated with consistent condom use (CCU) between FSWs living with HIV and their clients in the last month (adjusted odds ratio (AOR) = 1.65, 95% confidence interval (CI): 1.11–2.45) and STI prevalence among FSWs (AOR: 3.76, 95% CI: 1.159–12.162)

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Trust

• Identification with the group

6

Kuhlmann et al. [32]

To examine the associations between strength of community mobilization in a given geographic cluster and a) consistent condom use and b) perceptions of fairness, among FSW

Cross-sectional

Purpose: evaluation

Setting: India

Convenience sample of 1986 female sex workers from 104 geographic clusters receiving a community mobilization intervention for FSWs

Mean age: 29.19 (SD 0.18)

Mean education: 3.40 years (SD 0.19). 53% worked in urban areas. 81% had children

The key mediator for the analysis, collectivisation (hypothesized as a group of mediating variables for the relationship between community mobilization and outcomes), was assessed via the following variables:

• Collective identity: includes a single item that asked FSWs if they had attended a public event where they could be identified as FSW

• Collective efficacy: includes two separate variables. First variable included a single item that asked if FSWs would work together if problem affected the group. The second variable included four items that assessed whether the FSWs work well together to achieve their shared goals

• Collective agency: includes four items which asked FSWs if they have stood up for another FSW in need

• Collective action: includes seven items on whether the FSW participant had ever joined the collective to demand entitlements

• Social cohesion: includes 12 items on whether the FSW participant had ever shared issues or concerns with other FSWs, or relied on them in any way

The key treatment variable, strength of community mobilization (i.e., FSW participation in mobilization activities) assessed proportion of target population participating in programme activities, programme implementation, programme management, crisis response, and decision-making, as well as governance processes, leadership, and ownership

Reliability:

• Collective identity: single item, no Cronbach’s alpha

• Collective efficacy: Cronbach's alpha = 0.75

• Collective agency: Cronbach's alpha = 0.76

• Collective action: Cronbach's alpha = 0.80

• Social cohesion:

Cronbach's alpha = 0.69

• No reliability statistics provided for community mobilization

Validity:

• No statistics for validity are provided for the measures of collectivisation

• The community mobilization measure was validated in development via key informant interviews and organization documents

Study used multi-level structural equation modelling, with propensity score reweighting to simulate a randomized dose–response

Results show:

•No significant effect of community mobilization on consistent condom use or fair treatment among FSWs

•A significant indirect effect of community mobilization on consistent condom use mediated through social cohesion (b = 1.63, SE = 0.75, β = 0.31, p < 0.05)

A direct effect of strength of community mobilization at the cluster level on collective identity (b = 1.11, SE = 0.45, β = 0.40, p < 0.05), and social cohesion (b = 0.57, SE = 0.15, β = 0.36, p < 0.01)

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Group dialogue

• Identification with the group

• Group decision-making/deliberation

• Shared goals

COLLECTIVE ACTION:

• Group organizing

• Leadership and voice

7

Parimi et. al. [33]

To examine the association between FSWs’ degree of community collectivisation and a) self-efficacy, and b) utilisation of STI services

Cross-sectional

Purpose: association analysis

Setting: India

Convenience sample of 1986 FSWs from 104 geographic clusters receiving a community mobilization intervention for FSWs

Mean age: 29.19 (SD 0.18)

Mean education: 3.40 years (SD 0.19)

53% worked in urban areas. 81% had children

The key independent variable, collectivisation, was assessed via the following:

• Collective efficacy: includes four items that assessed whether the FSWs work well together to keep each other safe, increase condom use with clients, speak up for their rights, and improve their lives

• Collective agency: includes four items which asked FSWs if they have stood up to police, madam/broker, local goon, and clients or any other sexual partner, for another FSW in need

• Collective action: includes six items on whether the FSW participant had ever joined the collective to demand entitlements such as voters’ card, bank account, and health insurance

Reliability:

• Collective efficacy: Cronbach's alpha = 0.79

• Collective agency: Cronbach's alpha = 0.76

• Collective action: Cronbach's alpha = 0.76

Validity:

• No statistics for validity are provided

Study used multivariate logistic regression models to examine the hypothesized relationships

Results show:

•Collective efficacy increases self-efficacy among FSWs (AOR: 3.8; 95% CI: 2.8—5.1)

•Collective agency increases self-efficacy among FSWs (AOR: 2.8, 95% CI: 2.3—3.4)

•Collective action increases self-efficacy among FSWs (AOR: 2.5, 95% CI: 1.8—3.5)

Overall collectivisation increased the likelihood of seeking STI treatment from government facility

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Group dialogue

• Identification with the group

• Group decision-making/deliberation

• Shared goals

COLLECTIVE ACTION

• Group organizing

• Leadership and voice

8

Story [44]

To examine the association between social capital and the utilization of antenatal care, professional delivery care, and childhood immunization

Cross-sectional

Purpose: association analysis

Setting: India

Multi-level sample of 10,739 women in 2293 villages or urban neighbourhoods. Mean age: 27.4 years

Education: 42% women never attended school

5% belonged to General caste and 79% Hindus

The key independent variable of the analysis, social capital, included six factors:

• Intergroup bridging ties: includes five items and examines the respondents' membership in development groups, including women's groups; youth clubs, sports groups, reading rooms; trade unions, business or professional groups; self-help groups; and credit or savings groups

• Intragroup bonding ties: includes two items and examines the respondents' membership in any religious, caste, or festival organization

• Political participation: includes two items that measured whether the respondent or anyone in the household attended a public meeting and whether anyone in the household is an official of the local committee

• Social networks: includes three items and examines if the respondent knows or is related to any person of importance like doctors, teachers or government officials

• Social cohesion: includes two items and examines if there is any conflict in the respondents' community

• Collective efficacy: includes a single item that asked respondents if they believed that their community bonds together to solve problems

Reliability:

The measures were not tested for reliability in the current study

Validity:

EFA was conducted and the six-factor solution explained 82.6% of the variance. All items had factor loadings greater than 0.4

Study used multilevel logistic regression models to examine the hypothesized relationships

Results show:

• Intergroup bridging ties associated with higher odds of four or more antenatal care visits (Odds Ratio (OR): 1.22; p < 0.05), and immunization of child (OR: 1.18; p < 0.05)

• Intragroup bonding ties associated with lower odds of four or more antenatal visits (OR: 0.83; p < 0.05), immunization of child (OR: 0.86; p < 0.05) and higher odds of professional delivery care (OR: 1.19; p < 0.05)

• Collective efficacy associated with higher odds of professional delivery care (OR: 1.12; p < 0.05), and lower odds of four or more antenatal care visits (OR: 0.90; p < 0.05)

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

9

Emery et al. [43]

To examine the associations of aspects related to partner control and gender norms with bystander intervention against intimate partner violence (IPV). Collective efficacy was included as a covariate in the analysis, defined as neighbourhood solidarity and neighbourhood informal social control

Cross-sectional

Purpose: association analysis

Setting: China (Beijing)

(Study also included a sample from a non-LMIC, South Korea; findings discussed here are for the sample from China only)

Random probability proportional-to-size (PPS) cluster sample of 301 married/co-habiting women in China

94.68% were married

Mean age: 42.82 years

Mean education: 12.65 years

Collective efficacy was a covariate in this analysis, and included two sub-scales: neighbourhood solidarity and neighbourhood informal social control

• Neighbourhood solidarity: includes four items which assess whether people in the neighbourhood care if the respondent has a problem, can be trusted, and are willing to help

• Neighbourhood informal social control: includes four items which assess whether the woman can rely on their neighbours to do something if there was any violence or trouble in the neighbourhood

Reliability:

• Neighbourhood solidarity:

Cronbach’s alpha = 0.87

• Neighbourhood informal social control:

Cronbach’s alpha = 0.86

Validity:

No statistics for validity are provided in the current study

Study used multilevel regression models to test the hypothesized associations

Results show:

• Neighbourhood informal social control significantly associated with protective bystander behaviour against IPV in Beijing. Protective behaviour referred to intervening by trying to calm down the perpetrator of IPV by talking to them

• No significant association observed for either of the two sub-scales of collective efficacy with punitive bystander behaviour, which referred to calling the police or threatening the perpetrator

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Trust

10

Kumar et al. [7]

To examine whether group structure and process of women’s self-help groups (SHGs) are associated with the effectiveness of the SHG, with regards to its financial performance as well as relationships within the group

Group structure and process are assessed in terms of group norms, participatory leadership, trust during financial transactions, group attendance, association with bank and federation, transparency, group cooperation and cohesion

Cross-sectional

Purpose: association analysis

Setting: India

Multi-stage sample of 2636 women from 210 functional SHGs

Mean size (# of members) of the SHGs 12.5

Mean length of association with a bank 55.4 months. Only 1.2% of WSHG members from the General caste, 70.7% signature literate, and 58.7% involved in agricultural activities as their primary occupation

The key mediator in the analysis, group structure and process, refers to the underlying pattern of norms, roles, stable relationship patterns among members, and the interactive activities of group members among themselves and with the outside environment. It was assessed via the following variables

• Awareness about group norms: includes five items that asked members about their awareness of meeting procedures, their roles, their leaders' roles, bookkeeping procedures, and about loans, savings, and fines

• Leadership: includes four items that asked members about their closeness to leaders, their extent of leadership, and presence of leadership rotation within the group

• Trust in financial transactions: includes three items that asked members about their trust on each other in depositing money and transactions with the bank, and their trust on leaders on financial decisions

• Co-operation: includes three items that asked members if the group members support and help each other in different situations

• Group cohesiveness: includes four items that asked members if the group prefers to work collectively or alone, and if given a chance they might join another group

Reliability:

Cronbach’s alpha for the constructs related to collective efficacy not provided

ICC for awareness about group norms, trust in financial transactions, and leadership ranged from 0.64 to 0.73

ICC for co-operation and group cohesiveness ranged from 0.68 to 0.77

Validity:

Factor analysis generated a single factor solution that explained 82.86% of the total variance. All items had a factor loading of 0.90

Study used partial least squares structural equation modelling to assess the hypothesized relationships

Results show:

• Aspects related to collective efficacy (group structure and process) associated with effectiveness of women’s self-help groups (SHGs), with regards to its financial performance or profits made (t = 73.24; p < 0.001)

GROUP DYNAMICS:

• Group support

• Group solidarity

• Trust

COLLECTIVE ACTION

• Leadership and voice

11

Lippman et al. [40]

To examine the association between community mobilization and incident HIV among adolescent girls and young women

Repeated cross-sectional

Purpose: association analysis

Setting: South Africa

Random sample of 2292 HIV‐negative adolescent girls and young women. (data collected in two rounds of surveys in 2012 and 2014)

Mean age in 2012: 15.5 (SD 0.18). 26.6% have had sexual intercourse. At first round of data collection, 3.1% had engaged in transactional sex in past 12 months

Study uses a Community Mobilization Measure (CMM), which assesses efforts by a group/collective/community to take action towards achieving a shared goal. CMM is composed of seven domains:

• Shared concern: includes 10 items that asks about shared concerns regarding HIV that can help community mobilize around this issue to improve access to resources, quality of care, and social inclusion

• Critical consciousness: includes 11 items that captures any shared concerns in a community that connect people, and that people can mobilize to address

• Organizational structures and networks: includes 14 items that examines the concrete elements in the community through which mobilization or organizing can occur, such as groups, platforms for information dissemination, or even buildings where people can convene, as well as those recognized by other structures to allow for voices to be elevated

• Leadership: includes 10 items that assess both equity in opportunity to lead and have voice in mobilization efforts (i.e., inclusivity in leadership) and opportunity for the collective to take a leadership role in guiding change

• Collective action: includes six items that asks about the efforts of collectivisation for social change

• Social cohesion: includes six items that examines how much the members of the given group or collective connect with one another and align/identify with the group. This can be linked to shared trust or a sense of community or affiliation

• Social Control: includes eight items that assesses how much community members are willing to intervene when community issues arise, for the public good. This is an informal means of social control

Measure was originally developed by Lippman et al., 2016⁴² for young adults in South Africa, via construct mapping for item development, inclusive of both formative research and expert inputs. Once the measure was developed cognitive interviews were conducted to ensure clarity and face validity, and then pilot tested it with 101 participants aged 18–35 in their target community. Following details are from the original and not the reviewed article

Reliability:

Raykov's ρ was used to assess reliability

• Shared Concern about HIV in the community: Raykov's ρ = 0.85

• Critical Consciousness: Raykov's ρ = 0.93

• Leadership:

Raykov's ρ = 0.92

• Organizations/Networks: Raykov's ρ = 0.81

• Collective Action: Raykov's ρ = 0.84

• Social Cohesion: Raykov's ρ = 0.81

• Social Control:

Raykov's ρ = 0.89

Validity:

Confirmatory factor analyses were conducted, based on findings from the EFA on pilot data. A seven-factor solution with good fit resulted from these analyses, which created the subscales for this measure

* All scales except for the social control scale showed good inter-correlation, suggesting that six of seven scales represent community mobilization. Possibly, this is because the social control scale was originally developed for the United States and is not effectively capturing a meaningful construct in this context. (See Sampson et al., 2002 for original measures on social cohesion and social control.)

Study used logistic regression analysis to assess the hypothesized relationships

Results show:

• For every additional standard deviation of community mobilization at the village‐level, there was 12% lower HIV incidence (Risk Ratio (RR): 0.88, 95% CI: 0.79—0.98) after adjusting for individual, household and community characteristics. The specific scales of community mobilization associated with lower HIV incidence were critical consciousness (RR: 0.88; 95% CI: 0.79—0.97) and leadership (RR: 0.87; 95% CI: 0.79—0.95)

GROUP DYNAMICS:

• Group support

• Group solidarity

• positive group dynamics

• Social support and connection

• Group dialogue

• Identification with the group

• Group decision-making/deliberation

• Shared goals

COLLECTIVE ACTION

• Group organizing

• Leadership and voice

12

Karlan et al. [41]

To evaluate a savings-led microfinance programme which aimed to improve financial services, microenterprise activity, income, female empowerment, consumption, and the ability to cope with shocks

Cluster RCT

Purpose: evaluation

Setting: Ghana, Uganda, Malawi

The evaluation included four surveys: household survey, adult survey, village survey, and market survey. For a sample of 13,502 households, adult women were interviewed (adult survey) to collect information on gender issues and community involvement

One of the outcomes of the analysis is the community participation index, which examines women’s involvement in community affairs, including raising an issue before any person of authority, and participation in community meetings and social groups

Not tested for reliability and validity

Study used independent ordinary least squares regression models, with a pooled model controlling for baseline values of the outcomes

Results show:

• The savings-led microfinance intervention had no significant impact on the construct related to collective efficacy—community participation of women. (intervention processes included enabling formation of savings group with regular meetings for decisions regarding contribution of savings)

GROUP DYNAMICS:

• Group support

• Group dialogue

13

Saggurti et al. [38]

To evaluate effects of a health behaviour change intervention with self-help groups (SHGs), aimed to increase women’s collective empowerment and improve MNCH practices among economically marginalized groups in India

Pre-post quasi-experimental

Purpose: evaluation

Setting: India

Multi-stage cluster sample of 545 SHG women who participated in intervention, in Bihar, India. (n = 374 intervention or WSHG members, n = 171 control)

Mean (SD) age at baseline: 25 ± 5 years

Education: Only 10% of the women

had formal education

One of the outcomes for this evaluation study was collectivisation, assessed as including collective efficacy, agency, action and cohesion around maternal and child health

• Collective efficacy: includes four items that assess whether the WSHG members believed in working together to bring positive changes around health

• Collective agency: includes three items related to WSHG members assisting other members to seek/demand healthcare services or services from local administrative agencies

• Collective action: includes eight items measuring the strategic and organized activities of SHGs to increase the members’ presence or enact its agenda for change

• Group cohesion for health: includes three items related to provision or receipt of any maternal and child health services from an SHG member

Not tested for reliability and validity

Study used Difference—in—Difference (DID) to evaluate intervention effects

Results show:

• The behaviour change intervention with self-help groups (SHGs) increased collective efficacy levels among its members (DID: 17percentage points (pp), p < 0.001)

• No significant impacts of the intervention observed for collective agency, collective action, and group cohesion

GROUP DYNAMICS:

• Group support

• Group solidarity

• Positive group dynamics

• Social support and connection

• Group dialogue

• Identification with the group

• Group decision-making/deliberation

• Shared goals

COLLECTIVE ACTION

• Group organizing

14

Gullo et al. [34]

To evaluate the effects of a community mobilization intervention on women's reports and experiences of health governance, defined as consisting of aspects such as trust in health workers, power sharing, mutual responsibility, collective efficacy, and the presence of a safe motherhood committee or community action group. Study also aimed to assess the relationship of these indicators of health governance with a) modern family planning, b) home visit from a community health worker, and c) satisfaction with health services

Two-armed cluster randomized controlled trial (RCT), Purpose: evaluation, secondary analysis

Setting: Malawi

Cluster sample of 1300 women aged 15–49 who had given birth in the last 12 months (N = 651 in intervention [20 clusters], N = 649 in control [20 clusters])

50% of the women under the age of 25 years. Less than two-thirds functionally literate. About 50% lived over one hour from the nearest health facility with basic emergency obstetric care available

One of the outcomes for this evaluation, health governance, was assessed via eight scales:

• Trust in health workers: includes six items that asks about the degree to which respondents perceive health workers as caring, considerate, and attempting to provide the best care possible

• Power sharing: includes three items that assess level of involvement, voice, and decision-making powers of community members and health workers

• Mutual responsibility: includes five items that assess whether the respondents believe that women and health workers together have an impact on services between community and health workers

• Joint monitoring and transparency: includes six items that assess whether community members and health workers identify and address concerns

• Equity and quality: includes six items that assess the breadth of community participation, particularly from vulnerable groups, and perceptions of inclusivity

• Collective efficacy: includes five items that assess women’s confidence in how well community members and health workers could work together

• Collective action: includes seven items that assess the perceived improvement in maternal and child health care services because of collective action

• Perceived value of Governance Score Cards: includes five items that assess the perceived improvement in maternal and child health care services because of the community intervention

Reliability:

• Trust in health workers:

Cronbach's alpha = 0.80

• Power sharing: Cronbach's alpha = 0.79

• Mutual responsibility: Cronbach's alpha = 0.65

• Joint monitoring and transparency:

Cronbach's alpha = 0.93

• Equity and quality: Cronbach's alpha = 0.84

• Collective efficacy: Cronbach's alpha = 0.82

• Collective action: Cronbach's alpha = 0.93

• Perceived value: Cronbach's alpha = 0.92

Validity:

Exploratory factor analysis (EFA) was conducted on the set of items which generated an 8-factor solution. EFA models were fit using Mplus with varimax rotation

Study used a local average treatment effect (LATE) analysis, and effects of the intervention were estimated based on compliance/attendance (rather than intent-to-treat)

Results show:

• At end line, intervention relative to control participants were more likely to report awareness of the Community Action Group or Safe Motherhood Committee (p = .03)

• Among women in the intervention areas who were aware of the intervention, intervention participation was associated with trust in health workers (negative association, p = 0.49), mutual responsibility (negative association, p = 0.005), participation in negotiated spaces (p < .001), joint monitoring and transparency (p = 0.029), equity and quality (p < 0.001), collective action (p < 0.001), awareness of the Community Action Group or Safe Motherhood Committee (p < 0.002), and community help (p = 0.020)

• Collective action was positively

associated with home visits (p = .001) and modern family planning use (p = .05), but negatively associated with satisfaction

with services (p = .009)

GROUP DYNAMICS:

• Positive group dynamics

• Group dialogue

• Trust

• Group decision-making/deliberation

• Shared goals

COLLECTIVE ACTION

• Group organizing