Research

GOAL, The Rand Corporation, University College London, and The Harvard Humanitarian Initiative, sponsored by Irish Aid, are hosting “From Crisis to Resilience”, a webinar series that aims to spark interest and explore the emerging lessons and best practices for building resilience in the most challenging of environments - fragile and conflict-affected contexts.

Learning and investing in resilience at various stages, and within critical socio-economic systems, is crucial to ensuring the preservation of gains in the well-being and development of people in the face of shocks, and to shift from humanitarian assistance towards long-term resilient development.

This 90 min webinar will explore innovations, evidence, and lessons learned when applying a systems approach to build resilience in fragile and conflict-affected urban contexts. Our panel of experts will draw on years of experience and lessons learned from the field in Latin America.

Panelists from GOAL, Harvard Humanitarian Initiative (HHI), World Bank Group and USAID will aim to answer the following questions:

• Are high-risk informal urban settlements to be considered as fragile and conflict-affected contexts?
• What is working or not when building resilience in informal urban settlements?
• What new ideas or approaches in systems thinking are emerging to progress resilience in informal urban settlements?This webinar is free and open to all.

Recording available here: https://www.goalglobal.org/resilience/

Background: Communities play a central role in strengthening their health, but conventional community health promotion often adopts paternalistic and top-down approaches. Conversely, agentic approaches are critiqued for tasking marginalized communities to create change without opportunities. Taking into consideration these shortcomings, we ask how communities may be most effectively and appropriately supported in their pursuit of health.

Methods: We review community health literature to articulate how community health is understood, moving from negative to positive conceptions; determined, moving from a risk-factor orientation to social determination; and promoted, moving from conventional to agentic approaches. We develop the concept of resourcefulness as a pathway to strengthen positive health, and explore how this approach may be applied in diverse communities through fieldwork in Kenya, Peru, Trinidad and Tobago, and the US.

Results: Through resourcefulness-based approaches to community health, communities cultivate agency to 1) conceptualize what constitutes their health and assets and 2) pursue and sustain health agendas driven by local priorities, needs, and learning, while they also work to 3) change power imbalances that drive inequitable patterns of resource distribution and 4) nurture ecologically sound relationships with their local environment.

Conclusions: We discuss how resourcefulness addresses tensions between resource use and sustainability, and how communities leverage partnerships for change. We make practical suggestions to apply resourcefulness as a process-based, place-based, and relational strategy, while recognizing that contexts and scale matter and limit the viability of community-based solutions.

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Communities are powerful and necessary agents for defining and pursuing their health, butoutside organizations often adopt community health promotion approaches that are patronizing and top-down. Conversely, bottom-up approaches that build on and mobilize community health assets are oftencritiqued for tasking the most vulnerable and marginalized communities to use their own limited resourceswithout real opportunities for change. Taking into consideration these community health promotionshortcomings, this article asks how communities may be most effectively and appropriately supported inpursuing their health. This article reviews how community health is understood, moving from negative topositive conceptualizations; how it is determined, moving from a risk-factor orientation to socialdetermination; and how it is promoted, moving from top-down to bottom-up approaches. Building onthese understandings, we offer the concept of ‘resourcefulness’ as an approach to strengthen positivehealth for communities, and we discuss how it engages with three interrelated tensions in communityhealth promotion: resources and sustainability, interdependence and autonomy, and community diversityand inclusion. We make practical suggestions for outside organizations to apply resourcefulness as aprocess-based, place-based, and relational approach to community health promotion, arguing thatresourcefulness can forge new pathways to sustainable and self-sustaining community positive health.

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Climate change is linked to a variety of locally evident health effects. Local health systems and related services are struggling to deal with current impacts and will have to do much more in the future. Prominent topics identified by local health systems are heat-humidity stress, infectious disease, and linked food-water security. In many settings around the world, formal institutions such as governments and businesses may provide limited responses, especially for those most in need. Consequently, grassroots organisations are taking initiatives to try to translate available knowledge into action for themselves. Activities cover, for instance, environmental monitoring and participatory development to determine which climate change-related actions for mitigation and adaptation would be most suitable to support local health systems. Being non-profit, often informal, and with limited resources, these organisations face classic community collective action problems of incentivising members to create and manage systems outside formal institutions such as markets and governments.  One formal system including and connecting climate change and health is the United Nations, within which several mechanisms for the 2030 agenda sit. The 2030 agenda's relevance for local action is not always clear, especially thinking beyond 2030 when considering the development and implementation of long-term, local, sustainable solutions in less affluent locations. Two case studies are examined here, both of which are isolated with severe resource constraints: Sitka, Alaska and Toco, Trindad and Tobago. Semi-structured interviews with local environmental groups presented their concerns and opportunities regarding climate change, health, and sustainability to and beyond 2030. Lessons emerged that typical ideas from sustainability such as “participatory processes” and “resilience” might not always be as meaningful for long-term local action as might be assumed from global knowledge. Ways forward for local health systems in the context of climate change are suggested based on the groups’ experiences and advice.

The field of community health promotion encompasses a wide range of approaches, including bottom-up approaches that recognise and build on the agency and strengths of communities to define and pursue their health goals. Momentum towards agent-based approaches to community health promotion has grown in recent years, and several related but distinct conceptual and methodological bodies of work have developed largely in isolation from each other. The lack of a cohesive collection of research, practice, and policy has made it difficult to learn from the innovations, best practices, and shortcomings of these approaches, which is exacerbated by the imprecise and inconsistent use of related terms. This article provides a review of three agent-based approaches to promotion community health: asset-based approaches, capacity building, and capabilities approaches, noting the theoretical origins and fundamental concepts, applications and methodologies, and limitations and critiques of each. This article discusses their commonalities and differences in terms of how they conceptualise and approach the promotion of community health, including a critical consideration of their limitations and where they may prove to be counterproductive. This article argues that agent-based approaches to community health must be met with meaningful opportunities to disengage from the structures that constrain their health.

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.