Research

The health impacts of climate change are distributed inequitably, with marginalized communities typically facing the direst consequences. However, the concerns of the marginalized remain comparatively invisible in research, policy and practice. Participatory action research (PAR) has the potential to centre these concerns, but due to unequal power relations among research participants, the approaches often fall short of their emancipatory ideals. To unpack how power influences the dynamics of representation in PAR, this paper presents an analytical framework using the metaphor of ‘puppeteering’. Puppeteering is a metaphor for how a researcher-activist resonates and catalyses both the voices (ventriloquism) and actions (marionetting) of a marginalized community. Two questions and continuums are central to the framework. First, who and where the puppeteer is (insider and outsider agents). Second, what puppeteering is (action and research; radical and managerial). Examples from climate change and health research provide illustrations and contextualizations throughout. A key complication for applying PAR to address the health impacts of climate change is that for marginalized communities, climate change typically remains a few layers removed from the determinants of health. The community’s priorities may be at odds with a research and action agenda framed in terms of climate change and health.

Background: There have been increasing calls for collaboration between Indigenous health practitioners (IHPs) and allopathic health practitioners (AHPs) in Africa. Despite this, very few successful systems exist to facilitate formal collaboration. Direct relationships between providers, and at a health systems level are crucial to successful collaboration, but the nature and extent of these relationships have yet to be adequately explored.

Objective: To explore the relationship between IHPs and AHPs in Africa, and to discuss the implications of this for future collaboration.

Methods: An interpretive qualitative synthesis approach, combining elements of thematic analysis, meta-ethnography, and grounded theory, was used to systematically bring together findings of qualitative studies addressing the topic of collaboration between Indigenous and allopathic health practitioners in Africa.

Results: A total of 1,765 papers were initially identified, 1,748 were excluded after abstract, full text and duplicate screening. Five additional studies were identified through references. Thus, 22 papers were included in the final analysis. We found that the relationship between Indigenous and allopathic health practitioners is defined by a power struggle which gives rise to lack of mutual understanding, rivalry, distrust, and disrespect.

Conclusion: The power struggle which defines the relationship between IHPs and AHPs in Africa is a hindrance to their collaboration and as such could partly account for the limited success of efforts to foster collaboration to date. Future efforts to foster collaboration between IHPs and AHPs in Africa must aim to balance the power disparity between them if collaboration is to be successful. Since this would be a novel approach, decision-makers and organisations who trial this power balancing approach to facilitate collaboration should evaluate resultant policies and interventions to ascertain their feasibility and efficacy in fostering collaboration, and the lessons learnt should be shared.

Background: Interlocking planetary health crises can reveal the complex nature of human and environmental interactions and highlight the importance of broader health ecosystems. Reductionist approaches to human health overlook broader systems factors, such as informal economies and environmental factors. However, these systems play an key role in the promotion of health and prevention of infectious diseases such as HIV and malaria. To better understand these factors, we applied a community and health asset ecosystem approach to infectious disease prevention, drawing on systems thinking and asset-based methods.

MethodsL We did a systematic review and qualitative synthesis, including English-language literature from community and participatory programmes in low-income and middle-income countries worldwide that were focused on Sustainable Development Goal 3.3, with no date restrictions. We applied a systems-minded, asset-based approach to analysis, to construct a community and health asset ecosystem and understand how community and health systems assets come together to prevent infectious diseases in dynamic, multilevel, and non-linear ways.

Findings: We included eight papers in the final review, which were original qualitative and quantitative research articles and systematic reviews from community-based HIV and malaria prevention interventions. Systems of health assets spanned micro, meso, and macro levels, and were identified across the informal community setting and the formal health system setting. Community assets represented primary (those inherent to the individual or community), secondary (knowledge, technologies, and rules to harness primary resources), and tertiary (higher-level community processes promoting quality and stewardship of local assets) resources. Process factors driving the success of community programmes involved partnerships, engagement, sufficient resource availability, and community leadership.

Interpretation: Beyond identifying systems of local assets for health, our approach emphasises the process of how these assets are best converted into meaningful outcomes. The community and health asset ecosystem reflects the complex human–environmental interface and sheds light on how individuals or communities can effectively and sustainably place a claim on assets necessary to achieve health. Funding None.

Background: Conventional community health promotion strategies often rely on top-down strategies and disease-specific fixes without engaging with the full spectrum of the social determinants of health.

Agentic approaches to support community health incorporate a broader understanding of positive health and community strengths alongside their health challenges and needs.

This research reviews key community health and development approaches based on assets, capacity building, and capabilities with the goals of 1) moving toward a relevant and consistent community health lexicon, and 2) identifying effective and sustainable strategies to support the social determinants of community health amidst global challenges like climate change, structural racism, and neoliberalism.

Methods: Synthesis review of community health literature on agentic approaches: assets, capacity building, and capabilities. Fieldwork in geographically isolated and socioeconomically marginalized communities in Kenya, Peru, Trinidad and Tobago, and the US (Alaska and the Gulf Coast). Participatory methodologies (participatory planning, learning, and action) and co-production of research-action components. In-person and remote interviews.

Findings:

Contemporary global challenges engage with local factors: Political decision-making outside of communities and without their input; Social conditions that exclude and marginalize certain groups; Economic poverty and lack of opportunities; Environmental degradation and conditions that are hazardous and in flux; Geographic remoteness.

Communities also face barriers to collective action: Culture of dependence on top-down management led by “experts”; Self-perception of lack of knowledge and capacity; Local skills and resources not valued internally and/or externally; Poverty, lack of access to resources, and remoteness; High opportunity cost for participating in or leading activities for change; Lack of or only partial responsibility for the health challenges they face.

These complex and systemic challenges call into question conventional approaches to community health promotion that are top-down and depend on technical, one-size-fits-all solutions

Agentic approaches to community health build on community assets, capacities, and capabilities for people to define and meet their own health needs and goals

Communities can leverage key assets to address health challenges and improve their holistic health, including in extreme and marginalized settings: Collaborative networks and community connections; Shared values and interests and desire to provide support; Inclusive knowledge production; Understanding of social determinants and root causes; Local materials and systems of governance.

Conclusions: Agentic approaches provide pathways to address complex and systemic challenges to community health

Mindset: The process of shifting toward an agentic mindset is an iterative two-way process that builds confidence and mutual trust, and it involves gradually developing an understanding of how to transform local realities in socioenvironmentallysustainable and self-sustaining ways.

Long-term partnerships: Partnerships work to strengthen the building blocks of and opportunities for health by building on longstanding and inclusive community networks, and relationships are nurtured through long-term two-way engagement.

The planetary health concept describes the relations between health and climate. The inequities thatconnect these two domains are experienced most by low-resource and vulnerable populations, e.g.the impact of drought on subsistence livelihoods and associated mental health issues. Climate justiceand health justice are framed through capabilities and integrated with ecofeminist approaches.Spatial justice is introduced as the ability to conceptualise how these interconnected injusticesare mediated through environments. The integration of these theories can provide a justice-basedplanetary health approach that could overcome several barriers. Design and spatial practice offerprocesses and tools to understand the complexity of planetary health across scales, systems andrelations; and to generate design solutions that promote equity and justice. Practical examplesof Global South design projects are presented that connect health and climate. The example of amaternal health project in rural Kenya shows how a conceptual design framework for a justice-basedplanetary health can contribute to the planetary health.

Background: The Lancet Planetary Health Commission and Rockefeller Foundation report highlights threeglobal challenges to the future health of our planet and the living things that inhabit it. TheSTEMA resourcefulness approach aims to address some of the imaginationchallenges andknowledge failures by proposing a framework that takes an ecosystem approach to healthburdens in low-resource settings, looking at how innovations can address gaps betweenformal and informal health systems through a series of case studiesin order to create adecision-making framework.

Methods: A case study synthesis of innovative, community led health interventions in low-resourcesettings was conducted to understand what are the components and processes that lead tointerventions being most resourceful. 15 projects were studied remotely, and 2 case studieswere studied first hand through involvement in the interventions themselves, these tookplace in the Peruvian Amazon and rural Sierra Leone.A mixed methods approach of analysis was taken to draw out direct and indirect healthoutcomes of interventions, combining the expertise of global health, health science,architecture and inclusive design researchers.

Findings: Health burdens in low-resource setting have complex, interrelated, social, environmentaland cultural causes and barriers. The most successful interventions involve a deepunderstanding of the ‘socio-ecological’ health system that operates in that intervention’sspecific context, often incorporating inclusive design approaches. In order to understandthis context, we have developed a resourcefulness framework that determines the pre-conditions or barriers to health in a local context, and then the resources that could bemobilised to overcome those gaps.

Interpretation: The framework usually addresses a specific health concern, but the ecosystem approachoften generates secondary or even unexpected health outcomes of the given intervention,contributing to long term resilience and resourcefulness of a community’s healthecosystem.

STEMA proposes an alternate approach to thinking about innovation in healthcare. Through locating our work in low-resource settings, we have found that interventions and innovations that improve health or access to healthcare often develop outside of the formal or dominant health system, and often draw on resources and factors not usually considered components of healthcare innovations, such as the wider determinants of health.

Here we will present two of our case studies, a health clinic in a remote village in Northern Sierra Leone and a series of community health posts/pharmacies in the Peruvian Amazon, and initial insights into working between design and health research in low-resource settings. ‍

Purpose: To improve health and/or access to healthcare in low-resource settings through conducting community-led focused research and design, developing a framework for building community resourcefulness with regards to health.

Methods: A mixed methods and exploratory approach was taken, conducting a health systems needs assessment at the different levels of the existing formal system and participatory research and co-creation activities with the communities to discover how they access care through employing people-centred design techniques such as ‘user’ journeys of care and other visual exercise to understand people’s perceptions of ‘good’ health. ‍

Results: Our initial findings indicated that communities rely on a multitude of informal systems to provide care, and accessing formal health services is difficult due to both distance and cost.

In Peru, the medicine-delivery spaces are being co-designed with a local architect and the communities and offer both a community and social space as well as a secure, clean storage place for medications. The physical design will be accompanied by a training programme and evaluations of access to essential medicines.

In Sierra Leone, the existing clinic is being modified to provide a private, clean space for giving birth and to meet necessary state regulations around birth spaces. This is to be accompanied by training for the community health workers and health education programmes.‍

Conclusions/Implications:‍

We propose that an integrated and place-based health system should be co-created to form connections between the multiplicity of health systems, building trust, cohesion and sustainability which are essential factors of increasing universal health coverage and improving the wider determinants of health. Furthermore, interventions become most innovative when they are able to mobilise locally-available resources to develop the resourcefulness of the community.

Health systems in low resource settings operate under a growing burden of health needs. The utilization of resources in an innovative, efficient and integrated way is becoming more important than ever to accomplish the goal of achieving UHC, contributing to health equity and improving access to quality essential health-care services. Despite rapid advances in technology, design and social innovation, these do not always translate into sustained or improved health outcomes.  

Since the launch of the SDGs in 2015, researchers and policy-makers around the world have been trying to find strategies to achieve high-quality, accessible and culturally appropriate health interventions. However, there are still more than 400 million people globally that lack access to essential health-care, mainly in low and middle-income countries. Resource availability is not enough; we must think beyond this towards health systems innovation.

Although innovations have been positioned as essential to overcoming health inequity, they must be informed by the local context, and involve the full participation of those receiving it; otherwise, indiscriminate use of technology may reinforce social inequities. They must be designed for and coordinated with the community, considering their perceived needs to ensure acceptance, effectiveness and sustainability.

To bridge theory and practice we have developed a framework that is simultaneously context-specific (and patient centered) and internationally relevant/comparable. It brings together academic literature, field work and case studies. It starts from the assumption that only with the support and motivation of community members can we achieve a sustainable change by recognizing their social and cultural norms while maximizing the efficient use of local resources. It connects three fundamental dimensions: a people-centered and integrated health system, the local health systems constraints and barriers, and adequate, available and accessible innovations. By tackling each dimension and maintaining the communities at the center we are bridging the gap between evidence and implementation, and thus contributing to sustainable health systems towards UHC.

This is a first step in the development of a decision-support system that bridges academic and practical, local and global, as well as public and private spheres to optimize health service provision. With an exponential increase in health innovation, there is a need to coordinate actions from researchers, entrepreneurs, policy-makers and the private sector to interface global innovation with the cultural, social and economic variability between contexts.

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