Research

The field of global health is founded on a deficit-based conceptualisation of health that overlooks the inherent value of communities, leading to top-down interventions that struggle to reach their full potential for effecting positive change. It remains unclear the extent to which current global health metrics follow this trend and reinforce it, or whether they encourage strategies to shift toward the World Health Organisation’s positive conceptualisation of health beyond the absence of disease. This white paper provides a scoping review of mainstream public health measures and the indicators that they contain, as well as an introduction to holistic health measures, found through academic search engines and grey literature. Indicators were compiled and sorted into thematic categories for comparison. The analysis found that most widely-used health metrics measure change in the burden of specific diseases, aggregated into population-wide statistics, neglecting the social and environmental determinants of health. There was little overlap in the indicators used by these frameworks, with each one measuring disparate topics. Holistic frameworks, founded on more inclusive concepts of health, contain promising ideas but lack impact, in part due to their lack of quantification. This research informs Stema’s vision for a new approach to global health, using concepts such as resourcefulness and novel participatory methods fused with data science to create truly innovative approaches to understanding, measuring, and ultimately pursuing health in ways that uplift and support communities to thrive.

Colombia’s mental health services have a complex history shaped by 60 years of armed conflict, a predominantly clinical approach to mental health, and social factors such as ineq- uities and stigma. The 1990 Caracas declaration proposed a shift towards decentralised community mental health services and interventions based on the recovery approach and emphasis on social determinants of mental health in the Americas. Colombia has adopted these approaches in its legal and practical framework in recent years, but implementation has been uneven. This systematic review aims to contribute to mental health services understanding in Colombia by examining the barriers and facilitators to the implementation of mental health services in Colombia. A search was conducted to explore available peer- reviewed studies on Colombian mental health services across five databases (Medline, PubMed, Scopus, Scielo and BVS) on quantitative and qualitative research papers pub- lished in the last ten years and without language restrictions. The Consolidated Framework for Implementation Research (CFIR) was used to structure the analysis and identify barriers and facilitators during the implementation of mental health services. We adapted the CFIR to attend to gender, race and age informed by the Socio-Political Economy of Global Mental Health framework, given the importance of these factors to the Colombian health landscape. Finally, narrative synthesis was used to summarise the data. 1 530 records were identified, and 12 articles met all inclusion criteria and were included in the analysis. 8 papers described substance use disorders services, 11 involved multidisciplinary healthcare pro- fessionals, and 7 were implemented at a local scale. The primary barriers to implementation were the lack of coordination, high workloads, and low funding. Facilitators included the use of protocols, and the involvement of communities, stakeholders, users, and external cham- pions. Findings suggest the continued importance of community and recovery approaches and efforts to improve coordination between multi-sector actors involved in the mental health spaces (e.g., public, and private organisations, users and their families).

Little is known on how community-based responses to planetary health crises, such as the COVID-19 pandemic, can integrate concerns about livelihoods, equity, health, wellbeing, and the environment. We used a translocal learning approach to co-develop insights on community-based responses to complex health and environmental and economic crises with leaders from five organisations working with communities at the front line of intersecting planetary health challenges in Finland, India, Kenya, Peru, and the USA. Translocal learning supports collective knowledge production across different localities in ways that value local perspectives but transcend national boundaries. There were three main findings from the translocal learning process. First, thanks to their proximity to the communities they served, community-based organisations (CBOs) can quickly identify the ways in which COVID-19 might worsen existing social and health inequities. Second, localised CBO actions are key to supporting communities with unique challenges in the face of systemic planetary health crises. Third, CBOs can develop rights-based, ecologically-minded actions responding to local priorities and mobilising available resources. Our findings show how solutions to planetary health might come from small-scale community initiatives that are well connected within and across contexts. Locally-focused globally-aware actions should be harnessed through greater recognition, funding, and networking opportunities. Globally, planetary health initiatives should be supported by applying the principles of subsidiarity and translocalism.

The planet is currently undergoing rapid and substantial change, but, across the globe, people’s health is not affected evenly by the impacts of climate change. Poverty and marginalization mediate the relationship between climate change and human health, meaning that potential adverse human health outcomes are not an inevitable consequence of climate change. Rather, they result from a culmination of political decisions, which are routinely made far away from and without the people most affected, without much understanding of or interest in their perceptions and lived experiences, or the varied local changes that affect their health. Local early warning systems, incorporating anticipatory action and response capacities, hold the potential to empower communities to reduce their health risks, but marginalized communities are routinely left out of decision-making, making these systems prone to failure. This research investigates health disaster risks and methods for building inclusive community-based early warning and response systems in three extreme low-resource, conflict-affected, and climate change-impacted communities in Kenya. By working together with community health leaders, this coproduced research identifies how communities conceptualize their place-based and positive health, which encompasses understandings of health beyond the absence of disease and recognizes the fundamental interdependence and collective nature of health. Through this lens, we use participatory methods to identify how health challenges, including climate change, impact the social and environmental determinants of health, and how these changes can effectively be measured, monitored, and acted upon. This research asserts the importance of taking a “first-mile approach”, where communities meaningfully participate in every part of the early warning system process, including contributing their understanding of health and health risks, observations and monitoring, preparedness and response, and communication of early warnings. Improving early warning systems for health in complex settings is essential to close the climate change-human health justice gaps, and it is also pivotal for global health security given that such settings are often zones of disease emergence and re-emergence.

Community groups are taking initiatives to adapt to a changing climate. These organizations differ from businesses and governments by being non-profit, often informal, resource limited, and reliant on volunteer labor. How these organizations facilitate collective action is not well known, especially since they do not necessarily solve common pool resource governance, but rather improve common pool resources through collective action. In fact, at first glance, community groups seem to not have the means for solving collective action problems used routinely in industry and government, such as paying people for cooperation or punishing them for lack of it.

This article investigates how community groups solve collective action problems though data gathered across 25 organizations in three sites – Sitka, Alaska, USA; Toco, Trinidad; and a global site of distributed citizen science organizations. We found that community groups used positive reinforcement methods common to industry and used little punishment. Groups also engaged in mechanisms for collective action, such as relying on altruistic contributions by few individuals, that generally are not considered commonplace in businesses and governments. We conclude by discussing implications from this study for collective action theory and for how policymakers might learn from community groups to address climate change.

In Kenya we are co-leading a research project to enhance community resourcefulness andto define community positive health and the systems of resources that support this. Through a multi-site research project, we worked with different groups of community members across three diverse field sites in Baringo, Siaya, and Nakuru counties. We used a systems thinking approach and a mixture of qualitative (78 focus discussion groups), participatory (67 activities, such as cognitive mapping, community timelines, tree diagrams, patient journeys, and walking interviews). Preliminary research findings identified the building blocks of community positive health and how communities leveraged these building blocks into a functioning community-level system. Community positive health, community identity and vision were described as strictly interdependent with a complex network of natural resources and affected by their depletion. These preliminary results show that large-scale planetary health challenges reach small-scale community systems of positive health. Communities provided information-rich insights on how their systems of positive health have become steadily impacted over recent decades by local environmental and climate changes. Planetary health concepts and challenges shape community positive health, identity and vision, by limiting the availability and agency over natural resources. Findings will be refined in a further stage of research to co-produce a pilot-tested, validated toolkit to enable resourcefulness-based approaches to community planetary health.

Background: Beyond the health system, people draw on a complex system of everyday community resources to strengthen human and environmental health. These resources, and the community members who use them, are often overlooked by traditional approaches to planetary health. We aimed to apply a resourcefulness approach to define community positive health and the systems of resources that support this, and to define ways in which communities can pursue and sustain health agendas driven by local priorities.

Methods: Through a multi-site, mixed-methods research project, we worked with different groups of community members across three diverse field sites in Kenya, in the Baringo, Siaya, and Nakuru counties. We used a mixture of qualitative (78 focus discussion groups), participatory (67 activities, such as cognitive mapping, community timelines and mapping, tree diagrams, patient journeys, and walking interviews), and data-driven approaches to understand community concepts of positive health and collaboratively define the building blocks that shape community positive health.

Findings: Preliminary research findings indicated that community positive health was defined by building blocks that included nutrition, clean water, education, and adequate local infrastructure. Crucially, these building blocks were underpinned by intangible community resources, such as culture, knowledge, and social cohesion. With cognitive mapping, we understood how communities leveraged these building blocks into a functioning community-level system. However, one of the greatest challenges felt by each community was the detrimental effects of climate change, contributing alongside human action and inaction to droughts, floods, and natural resource degradation.

Interpretation: This initial stage of research defined community positive health and uncovered systems of local resources. Findings will be refined in a further stage of research to co-produce a pilot-tested, validated toolkit to enable resourcefulness-based approaches to community positive health. This output will be supported by an inclusive knowledge-building process that will set the stage to support communities to make more effective decisions about the use of local resources.

Background: Communities draw on interlocking resources and informal systems to strengthen their health, but these are overlooked by conventional top-down health promotion. Stema is a research-based organisation that uses the following approaches to enable communities to create their own definition of health and improve the efficiency of agendas informed by local priorities and the SDGs, whilst working to change power imbalances that drive inequitable patterns of resource distribution.

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In the community, people work in their everyday lives to create health, drawing on community resources that aren’talways considered part of a ‘health system’. The everyday community resources that people draw on to createhealth are many and varied. These resources can be thought of as a complex system. Some resources may be wellknown, but others may be under-utilised, and require a systematic approach to help unlock their potential.Communities are often the most effective and appropriate agents of change for issues that affect their health andthe health of the environment they live in. A local and community-centred approach to developing interventions isessential for long-term sustainability. However, those at the frontline rarely have a stake in designing relevant healthinterventions, and the informal health systems they already use are often overlooked. In addition, community members or local decision-makers face a lack of accessible data, and struggle to choose effective and sustainable interventions without a deep understanding of the local context.Working across three diverse field sites in Kenya, this study used a mixture of participatory approaches to understand community concepts of positive health (community health building blocks) and ways in which communitiescan pursue and sustain health agendas driven by local priorities. The results of this research will be used to develop 45a community toolkit and decision-making platform to fill gaps in community information and to support communityled action for people’s and ecosystems’ health.