Anna Cronin de Chavez

Community‐led action is of increasing interest for policy, local government, and the design of adaptation under a changing climate. Previous research has shown how community‐led responses to climate impacts, such as flooding and heat, can be important in mitigating their ill health and wellbeing effects. But the evidence base on the character and nature of such actions by communities is at present scattered. In this paper, we review the international peer‐reviewed evidence on the form, character, and challenges of community‐led action for key climate‐related risks facing many localities across world regions both now and in the future. We bring particular focus on the role that community‐led responses play in supporting or mitigating health and wellbeing impacts, identifying common themes on their benefits in the face of climate‐related risks, including: the use of localized knowledge for both planning and recovery from events; their importance for identifying and supporting vulnerable people; and the relevance of community‐led action for advancing generalized resilience. We conclude that greater value could be placed on the unique knowledge, decision making, innovation, flexibility, and opportunities that community‐led adaptation offers. This article is categorized under: Vulnerability and Adaptation to Climate Change > Institutions for Adaptation Vulnerability and Adaptation to Climate Change > Values‐Based Approach to Vulnerability and Adaptation

Background: Community-Based Rehabilitation (CBR) promotes a comprehensive, person-centred approach to addressing health and social needs in low-resource settings. This review investigates the effectiveness of CBR for people with mental health conditions in low- and middle-income countries (LMICs), with the primary objective of assessing CBR’s impact on quality of life.Methods: We carried out a systematic review covering randomised and non-randomised studies of interventions that hold to principles of CBR in LMICs. The project was informed by people with lived experience from the sub-Saharan African countries. In addition to extracting and presenting narrative and quantitative data, we carried out a meta-analysis, risk of bias assessment, and GRADE analysis to assess certainty of evidence for practical application. We followed PRISMA guidelines and registered the protocol prospectively on PROSPERO.Findings: 12,210 individual studies were screened from major databases. After applying inclusion and exclusion criteria, we extracted data from 22 papers.The average summary effect, presented in a forest plot, suggests that CBR tends to be effective, with a weak effect, in both the psychosis and common mental health conditions group, in improving outcomes such as quality of life, symptom severity, functioning, and social outcomes related to participation and networking. For the main outcome (quality of life), we found a Standardized Mean Difference, SMD of -1.13, 95% confidence interval (CI): -2.25 to -0.00, p-value: 0.05, I2= 92%) for psychosis. For common mental health conditions, SMD was -0.50, 95% CI: -0.80 to -0.20, p=0.001, I2= 57%. Few of the studies paid adequate attention to the meaningful participation of communities or people affected, as recommended in CBR guidance.Interpretation: The meta-analysis demonstrated small but consistent benefits. More research is needed to understand which factors influence the wide variance in effect size across studies, eg whether outcomes are explained by different populations, study designs or interventions.

Background and purpose Early years experiences shape a child’s physical, cognitive and emotional development. Spending time in greenspaces offers benefits for children’s development, but access and use can be limited in urban settings. There is increasing interest in the health and developmental benefits of Forest Schools for primary-aged children, but little is known about the benefits for pre-school children. This study aims to identify these and explore the processes and activities associated with a Forest School intervention for early years children that may influence outcomes. Methods This paper reports on an ethnographic approach involving 65 hours of observations with two cohorts of 10 3-year-olds attending 11 weekly Forest School sessions in an urban setting. The children attending had little or no previous experience of natural spaces. 14 in-depth interviews were conducted with parents, and nursery and Forest School staff. The data were analysed using thematic analysis, and outcomes were identified using the Early Years Foundation Stage Statutory Framework. Results Despite logistical challenges, the intervention benefitted age-specific health and development outcomes, particularly personal, socio- and emotional development, verbal communication, and mathematics. Unexpected benefits were observed among nursery staff and parents attending Forest School. Conclusion Forest Schools are a promising and feasible method to improve nature connectedness and development in children aged 3 years and support school readiness. The maintenance and protection of urban woodland spaces are paramount to facilitate this.

The prevalence of common perinatal mental disorders in Vietnam ranges from 16.9% to 39.9%, and substantial treatment gaps have been identified at all levels. This paper explores constraints to the integration of maternal and mental health services at the primary healthcare level and the implications for the health system’s responsiveness to the needs and expectations of pregnant women with mental health conditions in Vietnam. As part of the RESPONSE project, a three-phase realist evaluation study, we present Phase 1 findings, which employed systematic and scoping literature reviews and qualitative data collection (focus groups and interviews) with key health system actors in Bac Giang province, Vietnam, to understand the barriers to maternal mental healthcare provision, utilization and integration strategies. A four-level framing of the barriers to integrating perinatal mental health services in Vietnam was used in reporting findings, which comprised individual, sociocultural, organizational and structural levels. At the sociocultural and structural levels, these barriers included cultural beliefs about the holistic notion of physical and mental health, stigma towards mental health, biomedical approach to healthcare services, absence of comprehensive mental health policy and a lack of mental health workforce. At the organizational level, there was an absence of clinical guidelines on the integration of mental health in routine antenatal visits, a shortage of staff and poor health facilities. Finally, at the provider level, a lack of knowledge and training on mental health was identified. The integration of mental health into routine antenatal visits at the primary care level has the potential help to reduce stigma towards mental health and improve health system responsiveness by providing services closer to the local level, offering prompt attention, better choice of services and better communication while ensuring privacy and confidentiality of services. This can improve the demand for mental health services and help reduce the delay of care-seeking.

Background: Implementing medicines pricing policy effectively is important for ensuring equitable access to essential medicines and ultimately achieving universal health coverage. However, published analyses of policy implementations are scarce from low- and middleincome countries. This paper contributes to bridging this knowledge gap by reporting analysis of implementation of two medicines pricing policies in Ghana: value-added tax (VAT) exemptions and framework contracting (FC) for selected medicines. We analysed implications of actor involvements, contexts, and contents on the implementation of these policies, and the interplay between these. This paper should be of interest, and relevance, to policy designers, implementers, the private sector and policy analysts. Methods: Data were collected through document reviews (n=18), in-depth interviews (n=30), focus groups (n=2) and consultative meetings (n=6) with purposefully identified policy actors. Data were analysed thematically, guided by the four components of the health policy triangle framework. Results: The nature and complexity of policy contents determined duration and degree of formality of implementation processes. For instance, in the FC policy, negotiating medicines prices and standardizing the tendering processes lengthened implementation. Highly varied stakeholder participation created avenues for decision-making and promoted inclusiveness, but also raised the need to manage different agendas and interests. Key contextual enablers and constraints to implementation included high political support and currency depreciation, respectively. The interrelatedness of policy content, actors, and context influenced the timeliness of policy implementations and achievement of intended outcomes, and suggest five attributes of effective policy implementation: (1) policy nature and complexity, (2) inclusiveness, (3) organizational feasibility, (4) economic feasibility, and (5) political will and leadership. Conclusion: Varied contextual factors, active participation of stakeholders, nature, and complexity of policy content, and structures have all influenced the implementation of medicines pricing policies in Ghana.

Introduction: Pregnancy and postpartum-related mental health problems pose serious public health threat to the society, but worryingly, neglected in sub-Saharan Africa (SSA). This review will assess the burden and distribution of maternal mental health (MMH) problems in SSA, with the aim to inform the implementation of context sensitive interventions and policies. Methods and analysis: All relevant databases, grey literature and non-database sources will be searched. PubMed, LILAC, CINAHL, SCOPUS and PsycINFO, Google Scholar, African Index Medicus, HINARI, African Journals Online and IMSEAR will be searched from inception to 31 May 2023, without language restriction. The reference lists of articles will be reviewed, and experts contacted for additional studies missed by our searches. Study selection, data extraction and risk of bias assessment will be done independently by at least two reviewers and any discrepancies will be resolved through discussion between the reviewers. Binary outcomes (prevalence and incidence) of MMH problems will be assessed using pooled proportions, OR or risk ratio and mean difference for continuous outcomes; all will be presented with their 95% CIs. Heterogeneity will be investigated graphically for overlapping CIs and statistically using the I ² statistic and where necessary subgroup analyses will be performed. Random-effects model meta-analysis will be conducted when heterogeneity is appreciable, otherwise fixed-effect model will be used. The overall level of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation. Ethics and dissemination: Although no ethical clearance or exemption is needed for a systematic review, this review is part of a larger study on maternal mental health which has received ethical clearance from the Ethics Review Committee of the Ghana Health Service (GHS-ERC 012/03/20). Findings of this study will be disseminated through stakeholder forums, conferences and peer review publications. PROSPERO registration number: CRD42021269528.

Background: A secure parent-infant relationship lays the foundations for children’s development, however there are currently no measurement tools recommended for clinical practice. We evaluated the clinical utility of a structured assessment of the parent-infant relationship (the Maternal Postnatal Attachment Scale, MPAS) in a deprived, multi-ethnic urban community in England. This paper answers the question: what are health visitors’ views on the parent-infant relationship, and experiences of piloting the MPAS? It explores the barriers and facilitators to implementation, and complements the paper on psychometric properties and representativeness reported in Dunn et al (2022). Methods: Semi-structured interviews were conducted with 11 health visitors and data were analysed using thematic analysis. Results: Health visitors saw identification and support of the parent-infant relationship as an important part of their role, and reported benefits of the MPAS, including opening conversation and identifying and reporting concerns. Challenges included timing and workload, the appropriateness of language, perceived intrusiveness and understanding of the questions, and the length of the tool. Suggestions for improvements to the tool were put forward. Conclusions: The experiences, benefits and challenges identified help to explain results in Dunn et al, and the wide-ranging challenges identified would hinder assessment of the parent-infant relationship in routine practice. Further work with health professionals and parents has been undertaken to co-produce an acceptable, feasible and reliable tool for clinical practice.

Background: A secure parent-infant relationship lays the foundations for children’s development, however there are currently no measurement tools recommended for clinical practice. We evaluate the clinical utility of a structured assessment of the parent-infant relationship (the Maternal Postnatal Attachment Scale, MPAS) in a deprived, multi-ethnic urban community in England. This paper answers the question: what are health visitors’ views on the parent-infant relationship, and experiences of piloting the MPAS? It explores the barriers and facilitators to implementation, and complements the paper on psychometric properties and representativeness reported in Dunn et al (submitted). Methods: Semi-structured interviews were conducted with 11 health visitors and data were analysed using thematic analysis. Results: Health visitors saw identification and support of the parent-infant relationship as an important part of their role, and reported benefits of the MPAS, including opening conversation, and identifying and reporting concerns. Challenges included timing and workload, the appropriateness of language, perceived intrusiveness and understanding of the questions, and the length of the tool. Suggestions for improvements to the tool were put forwards. Conclusions: The experiences, benefits and challenges identified help to explain results in Dunn et al, and the wide-ranging challenges identified would hinder assessment of the parent-infant relationship in routine practice. Further work with health professionals and parents has been undertaken to co-produce an acceptable, feasible and reliable tool for clinical practice.

Introduction Health systems responsiveness is a key objective of any health system, yet it is the least studied of all objectives particularly in low-income and middle-income countries. Research on health systems responsiveness highlights its multiple elements, for example, dignity and confidentiality. Little is known, however, about underlying theories of health systems responsiveness, and the mechanisms through which responsiveness works. This realist synthesis contributes to bridging these two knowledge gaps. Methods and analysis In this realist synthesis, we will use a four-step process, comprising: mapping of theoretical bases, formulation of programme theories, theory refinement and testing of programme theories using literature and empirical data from Ghana and Vietnam. We will include theoretical and conceptual pieces, reviews, empirical studies and grey literature, alongside the primary data. We will explore responsiveness as entailing external and internal interactions within health systems. The search strategy will be purposive and iterative, with continuous screening and refinement of theories. Data extraction will be combined with quality appraisal, using appropriate tools. Each fragment of evidence will be appraised as it is being extracted, for its relevance to the emerging programme theories and methodological rigour. The extracted data pertaining to contexts, mechanisms and outcomes will be synthesised to identify patterns and contradictions. Results will be reported using narrative explanations, following established guidance on realist syntheses. Ethics and dissemination Ethics approvals for the wider RESPONSE (Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam) study, of which this review is one part, were obtained from the ethics committees of the following institutions: London School of Hygiene and Tropical Medicine (ref: 22981), University of Leeds, School of Medicine (ref: MREC19-051), Ghana Health Service (ref: GHS-ERC 012/03/20) and Hanoi University of Public Health (ref: 020-149/DD-YTCC). We will disseminate results through academic papers, conference presentations and stakeholder workshops in Ghana and Vietnam. PROSPERO registration number CRD42020200353. Full record: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200353.