FIELD PROJECTS

Stage two focused on translating the conceptual understanding of community positive health, developed during the project's initial phase, into actionable metrics and strategies tailored to local contexts and needs.

The process began with the validation of health concepts and indicators identified in stage one, utilizing feedback from community members and opinion leaders. This led to the synthesis of a refined set of indicators, incorporating both globally recognized health metrics and locally significant determinants such as cultural and knowledge-based resources.

Measurement was a key focus of stage two, with the aim of establishing a shared understanding of each health building block and developing community-driven approaches to assess changes in health status. This involved detailed discussions around the definition of each indicator, the identification of meaningful changes, and the exploration of local data sources and tools for measurement.

Priority setting was another critical component of this stage, guiding the community in identifying and ranking health priorities. This process illuminated the specific health domains and resources deemed most crucial by the community, facilitating a targeted approach to resource allocation and intervention design. By scoring the importance, availability, and perceived agency over these resources, the project was able to identify areas where community capacity-building and external support could have the most significant impact.

Overall, stage two advanced the project's objective of fostering positive health within Kenyan communities by operationalizing the concept of community positive health into measurable and prioritized action plans. This stage not only deepened the engagement with community members but also laid the groundwork for the development of a practical toolkit and a new index for measuring community positive health, promising to enhance the efficacy of health interventions and support sustainable health outcomes.

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.

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.

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.

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.

In all areas of the world, civil society organisations (CSOs) work to mitigate the detrimental impacts of multiple challenges including climate change, social inequity, regional geopolitics, and extractive economic systems. While such challenges exacerbate localised experiences of health, social and environmental inequity - CSOs utilise local knowledge and resources to respond and address such challenges simulataneously. Translocal Health explores the responses of five partnership CSOs in terms of building livelihoods, well-being, environmental protection, and health to address the current and future global planetary health crises. Through using a trans-local approach, we hope to demonstrate and harness the power of acting at a local level in the midst of larger system challenges.

We proposed to use the Stema HPS approach (Human-centred design, Participatory research, and Systems-thinking) to work with Sunrise Health Services and its communities to identify local community resources (discover), plan how these might come together into locally-driven interventions (define), encourage participation at all levels in the initiatives (deliver), and report on how these initiatives have changed community health and wellbeing (evaluate).

The Khuluma model is a digital psychosocial support intervention that has been successful in South Africa. It is a closed peer-to-peer messaging service for adolescents with HIV in Pretoria and Cape Town.

Stema is keen to explore how digital spaces of care complement the physical spaces that adolescents have to encounter to look after their health. This includes thinking about networks of care and support for complex health conditions such as HIV, where mental health and issues of stigma are significant barriers to good care.

We employ design research tools such as participatory mapping, user journeys, day in the life stories and photo diaries to capture health holistically in adolescents. This allows us to understand the complexities and specificities of the adolescent experience.

The research is an intervention in education and empowerment, and the aim is to also stage an intervention realising and enacting what a space of care is for the group. Spaces of care may be physical or virtual. This concept of 'spaces of care' for HIV was explored through a series of maps describing patient journeys within the city. This project explores resourcefulness through studying the interaction between technology, design and systems in this community.

Orus is a farming community in the East Pokot region of rural Western Kenya. It is located approximately 45km North of Tanglebei, a small market town with a basic health centre, accessible by a rough dirt road.

The community of Orus covers a vast spread of land and is comprised of around 20 homesteads. Each homestead is comprised of a polygamous family group: men may have multiple wives, who live in separate huts around a central area. The homesteads are comprised of a number of manyattas (wood structure/scaffolding, mud walls and thatched roofs), a central communal area, storage huts, and fenced areas for livestock. The community also has a central water tower (which charges 10 shillings - 1 cent - per billycan of bore water), a primary school (two buildings, one unused and decrepit but with functional solar panels), and an unused hospital building.

A mixed methods, exploratory and participatory approach was undertaken in Orus to uncover resourcefulness within this community to improve health and wellbeing.

In the remote region of Yiben in Northern Sierra Leone, most people never considered going to a health facility, and instead used local medicine. This was due to long distances, lack of access to transport, poverty, opportunity and costs. Multiple informal systems of healthcare existed in the community, mainly involving the use of herbs and leaves from the surrounding jungle. Knowledge about the traditional medicine has been passed down through families and practiced by local healers (soothsayers) and traditional birth attendants. In a bid for access to modern healthcare, the community instigated and built a health clinic in 2016. It is now serviced as a Maternal and Child Health Post under the government health system. Overall, there is still a very low level of health knowledge but an openness to learning and a high rate of interaction with the health facility.

In 2018, we partnered with the Yiben Community leadership, Set4Life Australia, and the local government to investigate community and health system development in three key areas:

1. Understanding health needs and behaviours, including mapping critical barriers to health access
2. Ways to strengthen the health services, such as capacity-building for volunteer community health workers and developing systems of education to help bridge traditional systems and the formal health system
3. Developing theories and tools around resourcefulness to support others working on health interventions in similar settings

‍

In the Napo River of Peru, poverty and geographic remoteness collide to pose a significant and often insurmountable barrier to healthcare. There are very few health facilities within reach of many river communities. River transport to health facilities is expensive and unaffordable for many. Access to basic medicines is near impossible. Where there are no formal models of healthcare delivery, local community health volunteers (known as agentes communitarios de salud, or promotores) fill this gap. Promotores are voluntary, elected health leaders in Napo River communities, who act to support health and wellbeing for those who can't access the healthcare system.

Promotores and community members have identified access to medicine as a key health issue in the Napo River and have expressed interest in and dedication to the idea of community-based pharmacies (known locally as botequins) to bring medicine and medical treatment closer to the community.

Stema has partnered with DB Peru and Altro Foundation to develop a decentralised, community-led medication procurement, storage, and delivery system. The project is placing small botequins in five rural communities which will be stocked and managed according to community needs, financed by the community, and delivered by trained promotores.