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心理健康问题负担的核心。在哥伦比亚受武装冲突影响的地区（称为"流离失所者社区"），贫困和歧视与长期暴力相结合，成为精神健康状况不佳的结构性决定因素。因此，支持和改善残疾人和少数民族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，因为这可以使他们重新融入民间社会和经济。让当地人参与进来，更好地了解他们如何思考和应对心理健康需求和服务，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人口进行有效沟通和合作方面还有很长的路要走。为了解决这一问题，我们将在两个PDET社区开展参与性干预，将日常公民和服务使用者与精神卫生系统联系在一起，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，研究在社区和机构之间建立合作行动所需的途径、机制和资源，以促进和改善精神健康服务。我们的干预措施将加强哥伦比亚卡克塔两个残疾人社区的社区精神卫生保健系统：La Montañita（我们将与前哥伦比亚革命武装力量-人民军战斗人员社区合作）和Florencia-Caqueta（我们将与包括受害者，战斗人员和普通公民的社区合作）。干预措施将围绕三个工作包进行沿着：1）诊断阶段，我们将确定社区和卫生服务对精神健康、精神痛苦和福祉的知识、态度和做法，以及地图政策、可用服务及其成本。我们还将与社区合作，使他们能够对干预的内容发表意见。2)利用渐进式学习行动周期（PLA周期）提供干预措施;这将在社区和卫生服务部门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健康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，以改善社区精神健康服务。3)评估干预措施和当地解决方案对个人和社区精神健康和心理健康的社会，健康和经济影响。根据评估工作的结果，我们将进行模拟，以评估（a）在WP 2中实施和（B）计划的行动的成本效益或成本效益。通过汇集社区参与者和卫生机构，我们的研究将有助于发展对精神卫生服务的信任，并改善受政治暴力严重影响的地区的服务范围，可及性和质量，贫困和对精神疾病的污名化。据我们所知，这是第一项在哥伦比亚大规模实施PLA周期以改善社区心理健康的研究。它将产生一种方法，可以推广到其他残疾人发展、教育和培训城市，并有助于哥伦比亚心理健康服务的长期可持续性。

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.