Title: Starting from the bottom: Using participatory action research to rebuild community mental health services in Colombia
Funder: Economic and Social Research Council

Abstract: Globally, the burden of mental health conditions is growing, shaped by gaps in services. In LMICs, 75% of the population lacks access to any form of care (Semrau et al., 2019). The COVID-19 pandemic exacerbates these challenges, as intersecting social realities deepen distress, increase incidence of mental health disorders, and overburden health systems (Burgess, 2020). In Colombia, political violence, poverty and displacement further aggravate this burden. Previous research shows that victims of armed conflict are more likely to suffer from mental health disorders (Tamayo-Agudelo & Bell, 2019) with poverty explaining 86% of mental health inequalities in the country (Cuartas et al, 2019). This is recognised by national priorities related to Colombia's peace accord, which includes providing accessible and quality services to rural populations (campesinos) who have been heavily affected not only by the armed conflict but also by the State's neglect (Kroc Institute, 2020).Yet, mental-health care systems are challenged by how they hear and respond to what marginalised communities think and experience as drivers of mental distress (Burgess, 2020; Montenegro & Cornish, 2018; Burgess & Fonseca, 2020, WHO 2013). Scaling-up services is important but a partial response; sustainable solutions towards achieving mental health and wellbeing require dialogue between institutions and communities (Campbell and Burgess, 2012). Our main objective is to develop and implement an intervention that establishes opportunities for communities affected by conflict to improve their mental wellbeing, through active engagement with mental health services structures. Using the co-production principles of Participatory Learning Action (PLA) cycles, our project will implement and evaluate a participatory intervention to strengthen community mental health care systems in two PDET communities in Caquetá-Colombia. To achieve this we will build on our existing partnership with two local organisations - Corporación Manigua, a women's organisation with experience designing and implementing projects with marginalised communities (Florencia) and Cooperativa Multiactiva para el Buen Vivir y la Paz del Caquetá (COOMBUVIPAC), that represents a community of FARC-EP ex-combatants living in the municipality of La Montañita. We will establish dialogue between community actors and health service representatives to increase access to, and quality of, services to improve mental health and wellbeing, through PLA cycles. Central to the intervention is to leverage and integrate different types of knowledge and expertise, including lived experiences, in the design and implementation of community mental health services. Our aims are: (1) To design and implement PLA cycles to create trust and joint action between community and institutional level actors (via dialogical processes) to achieve effective community mental health services. (2) To evaluate the intervention in terms of process, outcomes and simulations of the total cost (cost-benefit) and cost-effectiveness of the intervention at individual, community, and health services levels. (3) To produce a toolkit/manual based on the findings of the intervention to guide institutions in the development and scaling up of community mental health services.

Lay abstract: Economic and socio-cultural factors are central for reducing the burden of mental health problems. In Colombian territories disproportionally affected by armed conflict (called PDET communities), poverty and discrimination combine with exposure to chronic violence as structural determinants of poor mental health. As such, supporting and improving mental health community care in PDET territories is a major task within post-conflict reconstruction efforts, because it can lead to reintegration in civil society and the economy. Engaging local people to better understand how they think and respond to mental health needs and services is key in developing an adequate response. However, institutions that deliver mental health care have a long way to go when it comes to communicating and partnering effectively with local populations. In order to address this problem, we will develop a participatory intervention in two PDET communities, that will bring everyday citizens and service users together with mental health systems to respond to social determinants of mental distress, and improve local mental health services. We will work in partnership with community organisations to investigate the pathways, mechanisms and resources required to establish collaborative action between communities and institutions for promoting and improving mental health services. Our intervention will strengthen community mental health care systems in two PDET communities in Caquetá-Colombia: La Montañita (where we will work with a community of former FARC-EP combatants) and Florencia-Caquetá (where we will work with a community that includes victims, combatants and everyday citizens). The intervention will run along three work packages: 1) A Diagnostic phase, where we will identify knowledge, attitudes and practices of communities and health services towards mental health, mental distress and wellbeing, as well as map policy, available services and their costs. We will also work with communities so they can have a say about the content of the intervention. 2) The delivery of the intervention, using Participatory Learning Action cycles (PLA-cycles); this will establish shared spaces of co-production between people in the community and in health services. In these cycles, they can debate key issues related to poor mental health, establish priorities, local responses and pathways of joint action towards improving community mental health services. 3) Evaluation of the social, health, and economic impacts of the intervention and local solutions on individuals and community mental health and psychosocial wellbeing. Based on results of evaluation exercises we will run simulations to assess the cost-benefit or the cost-effectiveness of the actions that are (a) implemented and (b) planned in WP2. By bringing together community actors and health institutions, our research will contribute to the development of trust in mental health services, and improve the reach, access and quality of services in areas heavily impacted by political violence, poverty and stigma towards mental ill health. To to best of our knowledge, this is the first study to implement PLA cycles at scale for community mental health improvement in Colombia. It will produce a method that can be scaled up to other PDET municipalities and contribute to the long-term sustainability of Colombian mental health services.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: MENTAL HEALTH