title: Understanding communication pathways to foster community engagement for health improvement in North West Pakistan.
abstract: This paper describes the community engagement process undertaken to ascertain the focus, development and implementation of an intervention to improve iodised salt consumption in rural communities in North West Pakistan. The Jirga is a traditional informal structure, which gathers men respected within their community and acts in a governing and decision-making capacity in the Pukhtoon culture. The Jirga system had a dual purpose for the study: to access men from the community to discuss the importance of iodised salt, and as an engagement process for the intervention.
  
  
  
  A number of qualitative data collection activities were undertaken, with Jirga members and their wives, male and female outreach workers and two groups of women, under and over 40 years old. The aim of these was to highlight the communication channels and levers of influence on health behaviour, which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement.
  
  
  
  Communication channels are described within local families and the communities around them. The key influential role of the Jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies. Engaging Jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community. Gendered decision-making processes within the household have been highlighted as restricting women's autonomy. Whilst in one respect our data confirm this, a more complex hierarchy of decisional power has been highlighted, whereby the concept of 'wisdom'- an amalgamation of age, experience and education- presents important possibilities. Community members with the least autonomy are the youngest uneducated females, who rely on a web of socially and culturally determined ways to influence decision-making.
  
  
  
  The major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement. The process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study.
authors.affiliation: Faculty of Health and Life Sciences, Northumbria University Coach Lane Campus East (H005), Longbenton, Newcastle upon Tyne, NE7 7XA, UK. monique.lhussier@northumbria.ac.uk.
authors.forename: Monique
authors.identifier: 0000-0001-9383-2356
authors.initials: M
authors.lastname: Lhussier
authors.affiliation: International Institute of Nutritional Sciences and Applied Food Safety Studies, School of Sport and Wellbeing, University of Central Lancashire, Preston, UK.
authors.forename: Nicola
authors.initials: N
authors.lastname: Lowe
authors.affiliation: International Institute of Nutritional Sciences and Applied Food Safety Studies, School of Sport and Wellbeing, University of Central Lancashire, Preston, UK.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Westaway
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Community Health and Midwifery, University of Central Lancashire, Preston, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Dykes
authors.affiliation: School of Nursing, University of Central Lancashire, Preston, UK.
authors.forename: Mick
authors.initials: M
authors.lastname: McKeown
authors.affiliation: Abaseen Foundation, Peshawar, Khyber Pakhtunkhwa, Pakistan.
authors.forename: Akhtar
authors.initials: A
authors.lastname: Munir
authors.affiliation: Abaseen Foundation, Peshawar, Khyber Pakhtunkhwa, Pakistan.
authors.forename: Saba
authors.initials: S
authors.lastname: Tahir
authors.affiliation: Khyber Medical University, Khyber Teaching Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan.
authors.forename: Mukhtiar
authors.initials: M
authors.lastname: Zaman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003142:Communication; D003256:Community Participation / Q000523:psychology*; D003657:Decision Making; D005260:Female; D015438:Health Behavior; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D007455:Iodine / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010154:Pakistan; D012424:Rural Population / Q000706:statistics & numerical data*; D017673:Sodium Chloride, Dietary / Q000009:adverse effects*
chemical_list: D017673:Sodium Chloride, Dietary; D007455:Iodine
keywords: Communication; Community engagement; Health improvement; Influence; Iodised salt