Starting from the bottom: Using participatory action research to rebuild community mental health services in Colombia

经济和社会文化因素是减轻精神健康问题负担的核心因素。在受武装冲突不成比例影响的哥伦比亚领土(称为PDET社区)，贫穷和歧视加上长期遭受暴力，是心理健康状况不佳的结构性决定因素。因此，支持和改善PDET地区的精神卫生社区护理是冲突后重建工作中的一项主要任务，因为这可能导致重新融入民间社会和经济。让当地人更好地了解他们是如何思考和应对心理健康需求和服务的，是制定适当应对措施的关键。然而，提供精神卫生保健的机构在与当地民众有效沟通和合作方面还有很长的路要走。为了解决这个问题，我们将在两个PDET社区开展参与式干预，将日常公民和服务使用者与精神卫生系统结合在一起，以应对精神痛苦的社会决定因素，并改善当地的精神卫生服务。我们将与社区组织合作，调查在社区和机构之间建立合作行动以促进和改善精神健康服务所需的途径、机制和资源。我们的干预将加强哥伦比亚卡奎塔的两个PDET社区的社区精神卫生保健系统：La MontañIta(我们将在那里与前哥伦比亚革命武装力量-人民军战斗人员组成的社区合作)和弗洛伦西亚-卡奎塔(我们将与包括受害者、战斗人员和普通公民在内的社区合作)。干预将包括三个工作包：1)诊断阶段，在此阶段，我们将确定社区和卫生服务对精神健康、精神困扰和福祉的知识、态度和做法，以及地图政策、可用的服务及其成本。我们还将与社区合作，让他们对干预的内容拥有发言权。2)利用参与性学习行动周期提供干预措施；这将在社区和卫生服务机构的人们之间建立共同生产的共享空间。在这些周期中，他们可以讨论与精神卫生状况不佳有关的关键问题，确定优先事项、地方对策和联合行动的途径，以改善社区精神卫生服务。3)评估干预措施和当地解决方案对个人和社区心理健康和心理社会健康的社会、健康和经济影响。根据评估活动的结果，我们将运行模拟，以评估在WP2中(A)实施和(B)计划的行动的成本效益或成本效益。通过将社区参与者和卫生机构聚集在一起，我们的研究将有助于发展对精神健康服务的信任，并在受政治暴力、贫困和对精神疾病的污名严重影响的地区改善服务的覆盖范围、获得机会和质量。据我们所知，这是哥伦比亚第一次大规模实施解放军周期以改善社区精神健康的研究。它将产生一种可以推广到其他PDET城市的方法，并为哥伦比亚精神卫生服务的长期可持续性做出贡献。

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.