Measuring the resilience of health systems in low- and middle-income countries: a focus on community resilience

Engaging communities as partners in health crisis response: a realist-informed scoping review for research and policy

BACKGROUND

Health is increasingly affected by multiple types of crises. Community engagement is recognised as being a critical element in successful crisis response, and a number of conceptual frameworks and global guideline documents have been produced. However, little is known about the usefulness of such documents and whether they contain sufficient information to guide effective community engagement in crisis response. We undertake a scoping review to examine the usefulness of conceptual literature and official guidelines on community engagement in crisis response using a realist-informed analysis [exploring contexts, mechanisms, and outcomes(CMOs)]. Specifically, we assess the extent to which sufficient detail is provided on specific health crisis contexts, the range of mechanisms (actions) that are developed and employed to engage communities in crisis response and the outcomes achieved. We also consider the extent of analysis of interactions between the mechanisms and contexts which can explain whether successful outcomes are achieved or not.

SCOPE AND FINDINGS

We retained 30 documents from a total of 10,780 initially identified. Our analysis found that available evidence on context, mechanism and outcomes on community engagement in crisis response, or some of their elements, was promising, but few documents provided details on all three and even fewer were able to show evidence of the interactions between these categories, thus leaving gaps in understanding how to successfully engage communities in crisis response to secure impactful outcomes. There is evidence that involving community members in all the steps of response increases community resilience and helps to build trust. Consistent communication with the communities in time of crisis is the key for effective responses and helps to improve health indicators by avoiding preventable deaths.

CONCLUSIONS

Our analysis confirms the complexity of successful community engagement and the need for strategies that help to deal with this complexity to achieve good health outcomes. Further primary research is needed to answer questions of how and why specific mechanisms, in particular contexts, can lead to positive outcomes, including what works and what does not work and how to measure these processes.

Practical strategies to achieve resilient health systems: results from a scoping review

BACKGROUND

This paper presents the results of a systematic review to identify practical strategies to create the institutions, skills, values, and norms that will improve health systems resilience.

METHODS

A PRISMA 2020 compliant systematic review identified peer-reviewed and gray literature on practical strategies to make health systems more resilient. Investigators screened 970 papers to identify 65 English language papers published since 2015.

RESULTS

Practical strategies focus efforts on system changes to improve a health system's resilience components of collective knowing, collective thinking, and collaborative doing. The most helpful studies identified potential lead organizations to serve as the stewards of resilience improvement, and these were commonly in national and local departments of public health. Papers on practical strategies suggested possible measurement tools to benchmark resilience components in efforts to focus on performance improvement and ways to sustain their use. Essential Public Health Function (EPHF) measurement and improvement tools are well-aligned to the resilience agenda. The field of health systems resilience lacks empirical trials linking resilience improvement interventions to outcomes.

CONCLUSIONS

The rigorous assessment of practical strategies to improve resilience based on cycles of measurement should be a high priority.

Enhancing community health system resilience: lessons learnt during the COVID-19 pandemic in Uganda through the qualitative inquiry of the COVID Task Force

Objective

This study aimed to explore the elements of a resilient community health system during the COVID-19 pandemic and discuss whether the frameworks described in previous studies can be applied to real-world situations with those who implemented the Community Engagement Strategy, a strategy to make health systems work in their communities during health crises in Uganda.

Methods

Focus group discussions (22 participants in total) were conducted with COVID Task Force members in four districts in Uganda in March 2022. These districts implemented a Community Engagement Strategy to ensure that health systems in their communities continued to function during health scares, and have been evaluated to ensure that the strategies have been implemented.

Results

A thematic analysis was applied. From the results some factors which can enhance the resiliency of community health systems were identified: including health "knowledge," "communication," "governance," and "resources" health. The most important elements changed depending on the phase of the outbreak. VHTs are the key players in the transition from knowledge-and resource-oriented initiatives to communication and governance by community residents.

Conclusion

COVID-19, a new infectious disease, provides lessons for a resilient community health system. First, the health system should be flexible enough to be able to change the elements on which it is focused, and second, VHTs play an important role in the flexibility of the health system. This suggests that it is time to assess whether VHTs are still able to continue their activities after the pandemic is over, and whether the environment, including financial and non-financial support, has improved.

A systematic review of cross-cultural measures of resilience and its promotive and protective factors

As psychological resilience has been increasingly recognized as contextually constructed, mixed methods studies that map out local ecologies of resilience have become increasingly common. However, the direct adaptation of quantitative tools for cross-cultural use based on qualitative findings has been relatively lacking. The current review aims to provide an overview of existing measures of resilience used cross-culturally and to synthesize the protective and promotive factors and processes (PPFP) of resilience identified within these measures into a single resource. A January 2021 search of PubMed for studies of the development of psychological resilience measures that excluded studies of non-psychological resilience yielded 58 unique measures. These measures contain 54 unique PPFP of resilience, ranging from individual to communal-level characteristics. This review is intended to serve as a complementary tool for adapting standardized measures for stakeholders requiring an assessment tool that is attuned to their context for mental health risk assessment and intervention evaluation.

A management perspective on resilience in healthcare: a framework and avenues for future research

Recent major health shocks, such as the 2014-16 Ebola, the Zika outbreak, and, last but not least, the COVID-19 pandemic, have strongly contributed to drawing attention to the issue of resilience in the healthcare domain. Nevertheless, the scientific literature appears fragmented, creating difficulties in developing incremental research in this relevant managerial field.To fill this gap, this systematic literature review aims to provide a clear state of the art of the literature dealing with resilience in healthcare. Specifically, from the analysis of the theoretical articles and reviews, the key dimensions of resilience are identified, and a novel classification framework is proposed. The classification framework is then used to systematize extant empirical contributions. Two main dimensions of resilience are identified: the approach to resilience (reactive vs. proactive) and the type of crisis to deal with (acute shocks vs. chronic stressors). Four main streams of research are thus identified: (i) proactive approaches to acute shocks; (ii) proactive approaches to chronic stressors; (iii) reactive approaches to acute shocks; and (iv) reactive approaches to chronic stressors. These are scrutinised considering three additional dimensions: the level of analysis, the resources to nurture resilience, and the country context. The classification framework and the associated mapping contribute to systematising the fragmented literature on resilience in healthcare, providing a clear picture of the state of the art in this field and drawing a research agenda that opens interesting paths for future research.

Resilience of front-line facilities during COVID-19: evidence from cross-sectional rapid surveys in eight low- and middle-income countries

Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks.

The moderating role of Covid-19-related support on urban livelihood capitals: Evidence from suburban Accra

In the Global South, the COVID-19 crisis has compelled varied efforts to quickly address the pandemic's impact on urban livelihoods. Families, friends as well as public, private, and civil society organizations have mobilized various resources to avert the pandemic's onslaught on the survival of the urban vulnerable. Indeed, there is a burgeoning ‘pandemic urban scholarship’ that shed insights on COVID-19 risks, local responses, and impacts on everyday urban life. Yet, it is unclear how many of these responses are affecting urban livelihoods. This paper thus investigates the impact of COVID-19 on urban livelihood capitals (financial, human, social, and physical) and analyses the moderating role of COVID-19-related support (from families, friends, government agencies, faith-based and non-governmental organizations) to address the pandemic's impact on these capitals. Drawing on a quantitative study in Adenta Municipality of the Greater Accra Region, Ghana, the study finds a negative association between COVID-19 impacts and all urban livelihood capitals. Crucially, COVID-19-related support only reduced the negative impact of the pandemic on financial capital, and not on the other forms of capital. The study suggests that building post-pandemic community resilience warrants the need to transition from the usual reactive, fragmented support to integrated, holistic, and contextually embedded long-term strategies that consider the multi-dimensionality of everyday urban life.

What is 'community resilience'? Responding to COVID-19 in rural Zimbabwe

Based on real-time recording and reflection of responses to the COVID-19 pandemic, this article identifies the features of ‘community resilience’ across sites in rural Zimbabwe. The findings confirm the importance of local knowledge, social networks and communication, as highlighted in the literature. In addition, a number of other aspects are emphasised, including the importance of adaptable livelihoods, innovation and collective learning. Flexible adaptation was especially important for responding to lockdowns, as livelihoods had to be reconfigured in response to public health measures. Meanwhile, innovation and shared learning was vital for generating local treatment responses to the disease. In the Zimbabwe context, these adaptation and innovation capabilities emerge from a particular historical experience where resilience in the face of harsh economic conditions and in the absence of state support has been generated over years. This is often a more resigned coping than a positive, empowering, transformational form of resilience. While adaptation, innovation and shared learning capabilities proved useful during the pandemic, they are not evenly spread, and there is no singular ‘community’ around which resilience emerges. The article therefore argues against seeing ‘community resilience’ as the magic bullet for disaster preparedness and response in the context of pandemics. Instead, the highly differentiated local practices of adaptation, innovation and shared learning—across gender, age and wealth differences—should be seen as an important complement to public, state-led support in health emergencies and so are part of a wider, plural health system.

Assessing Response Readiness to Health Emergencies: A Spatial Evaluation of Health and Socio-Economic Justice in Pakistan

COVID19 pandemic has put the global health emergency response to the test. Providing health and socio-economic justice across communities/regions helps in resilient response. In this study, a Geographic Information Systems-based framework is proposed and demonstrated in the context of public health-related hazards and pandemic response, such as in the face of COVID19. Indicators relevant to health system (HS) and socio-economic conditions (SC) are utilized to compute a response readiness index (RRI). The frequency histograms and the Analysis of Variance approaches are applied to analyze the distribution of response readiness. We further integrate spatial distributional models to explore the geographically-varying patterns of response readiness pinpointing the priority intervention areas in the context of cross-regional health and socio-economic justice. The framework's application is demonstrated using Pakistan's most developed and populous province, namely Punjab (districts scale, n = 36), as a case study. The results show that ~ 45% indicators achieve below-average scores (value < 0.61) including four from HS and five from SC. The findings ascertain maximum districts lack health facilities, hospital beds, and health insurance from HS and more than 50% lack communication means and literacy-rates, which are essential in times of emergencies. Our cross-regional assessment shows a north-south spatial heterogeneity with southern Punjab being the most vulnerable to COVID-like situations. Dera Ghazi Khan and Muzaffargarh are identified as the statistically significant hotspots of response incompetency (95% confidence), which is critical. This study has policy implications in the context of decision-making, resource allocation, and strategy formulation on health emergency response (i.e., COVID19) to improve community health resilience.

Global emotional and spiritual well-being and resilience of Advanced Practice Nurses during the COVID-19 pandemic: A cross-sectional study

Aim

To evaluate the impact of the COVID‐19 pandemic on the emotional and spiritual well‐being and resilience of a global sample of Advanced Practice Nurses.

Design

A web‐based cross‐sectional mixed methods study. Survey data were collected from Advanced Practice Nurses globally over a 2‐month period ending on 31 August 2020.

Methods

The Warwick‐Edinburgh Mental Well‐being Scale, FACIT‐12 Spiritual Well‐being Scale and Connor‐Davidson Resilience Scale 10 were used to quantify emotional and spiritual well‐being and resilience of Advanced Practice Nurses' globally. The survey was distributed internationally using snowball sampling via a secure platform (Qualtrics). Results were analysed using various bivariate tests for associations and group differences.

Results

Nine hundred and twenty‐eight Advanced Practice Nurses from 53 countries participated in the study. Study participants reported meaningfully lower scores in resilience and emotional well‐being compared with non‐pandemic scores. Participants from countries with well‐developed Advanced Practice Nurses roles reported lower resilience and well‐being scores compared with those from countries where Advanced Practice Nurses roles are still being developed. Each scale revealed significant positive associations with the other scales.

Conclusions

Emotional and spiritual well‐being and resilience of Advance Practice Nurses has been significantly impacted during the COVID‐19 pandemic. Regardless of their work location, work hours, credential or demographics, the APNs in our study reported lower levels of resilience and mental well‐being compared with typical scores on the instruments.

Are Pandemics Gender Neutral? Women's Health and COVID-19

In December 2019, coronavirus disease 2019 (COVID-19) emerged as a health crisis in Wuhan, China, and was later declared by the World Health Organization (WHO) as a Public Health Emergency of International Concern. As it spread and its death toll increased, on the 11th of March 2020 it was declared a pandemic at 4,369 deaths worldwide, and cases and deaths have since surged. With gender disparities already known to leave women and their health at the margins of society during outbreaks, it is important to understand how COVID-19 affects women's health. In this article, we discuss how the COVID-19 pandemic can create vulnerabilities for women and their health and further exacerbate long-existing inequalities and social disparities. These include gender-based roles, economic and food security, violence, work pressure, and access to health and healthcare facilities. These issues have significant repercussions on the physical and mental health of women. To focus our lenses on these issues, we draw lessons from three specific examples of past outbreaks: 1918 Flu pandemic, Zika virus disease, and Ebola virus disease. We conclude by stating how public health responses and strategies for COVID-19 can be inclusive to women's health.

Exploring Two Decades of Research in Community Resilience: A Content Analysis Across the International Literature

INTRODUCTION

Community resilience (CR) has gradually become a hot topic in uncertain times, especially in the last five years. The current study presents a systematic review based on content analysis to present a knowledge graph of CR research over the last 20 years.

METHODS

We use an approach of Leximancer to conduct the content analysis to explore the intellectual foundations, research context, topics, and methods of CR literature based on 583 published studies.

RESULTS

The results show that framework research of CR is a hot topic throughout the last 20 years. In the first stage (from 2001 to 2015), CR connected with the themes of "framework, disaster, change, and model". Comparatively, in the second stage (from 2016 to 2020), the themes of "social capital, capacity, and framework" are more salient connecting with CR. Additionally, the study detected that the key issues varied across countries. Specifically, research in the US focused on the social support dynamic, while in Australia, recovery from the disaster was the predominant theme. Furthermore, in the UK, studies mostly explore resilience issues in the background related to flooding.

DISCUSSION

Our findings provide a comprehensive picture of CR research covering the last 20 years and put forward thoughts and recommendations for future resilience studies considering 1) obstacles within daily life, 2) resilience set within organizational perspectives, and 3) cultural context.

Evidence of health system resilience in Myanmar during Cyclone Nargis: a qualitative analysis

OBJECTIVE

The aim of this study is to improve the understanding of the characteristics of health system resilience in Myanmar's response to Cyclone Nargis and to explore ways to improve resilience at the system level.

DESIGN AND SETTING

This is an explanatory qualitative study exploring the institutional capacity of resilience in Myanmar's health system. Analysis proceeded using a data-driven thematic analysis closely following the framework method. This process enabled comparisons and contrasts of key emergent themes between the participants, which later generated key results describing the foundational assets, barriers and opportunities for achieving resilience in Myanmar.

PARTICIPANTS

The study comprised of 12 in-depth interviews conducted with representatives from international organisations and non-governmental organisations (NGOs). The inclusion criteria to recruiting the participants were that they had directly been a part of the Cyclone Nargis response at the time. There was a balanced distribution of participants across UN, bilateral and NGOs, and most of them were either Myanmar citizens or expatriates with extensive working experience based in Myanmar.

RESULTS

Key findings elucidate the characteristics of resilience that have been salient or absent in Myanmar's response to Cyclone Nargis. Strong social capital and motivation propelled by its deep-rooted culture and religion served as Myanmar's greatest assets that filled major gaps in the system. Meanwhile, its postcolonial and military legacy posed barriers towards investing in building its long-term foundations towards resilience.

CONCLUSIONS

This study revealed that resilience in the health system can be built through strategic investments towards building the foundations of resilience to better prepare for future shocks. In the case of Myanmar, social capital and motivation, which surfaced as its foundational assets, can be channelled into opportunities that can help achieve its long-term health goals, accelerating its journey towards resilience in the health system.

Adult attachment, stress-coping, and resilience in first-generation immigrants in the United States

Introduction

Previous studies have shown correlations between adult attachment, stress-coping, and resilience, but little is known about how attachment and stress-coping affect resilience, particularly among first-generation immigrants. This study explored relationships among adult attachment, stress-coping, and resilience for first-generation immigrants.

Method

A quantitative cross-sectional design was used to assess associations between adult attachment and stress-coping with resilience among first-generation immigrants. Thirty-five participants answered an online Qualtrics survey. A simple linear regression analysis was conducted to analyze the results.

Results

The results indicated statistically significant correlations between avoidance scores and annual household income but not between resilience and education, resilience and income, and stress-coping scores and education and income. Positive reinterpretation growth was positively correlated with resilience, while denial and behavioral disengagement were negatively correlated. Adult attachment and number of years in the United States were not significantly statistically related to resilience.

Conclusion

The findings indicate high income may be associated with attachment avoidance, and increases in positive coping strategies and decreases in negative coping strategies are associated with resilience among first-generation immigrants. Understanding influences on first-generation immigrants to engage in stress-coping skills may inform the development and implementation of occupational therapy, including programs and interventions for successful client-centered outcomes.

Development and Implementation of Societal Influences Survey Questionnaire (SISQ) for Peoples during COVID-19 Pandemic: A Validity and Reliability Analysis

The emergence of Coronavirus disease 2019 (COVID-19) had rapidly spread since FEB/MAR 2020. Policy to prevent transmission of COVDI-19 resulted in multi-dimensional impact on social interaction. We aimed to develop a beneficial survey tool with favorable quality and availability, the Societal Influences Survey Questionnaire (SISQ), to evaluate social influences on people during this pandemic. The SISQ was developed with 15 items and 4-point Likert scales consisting of five factors. These include social distance, social anxiety, social desirability, social information, and social adaptation. Construct validity and reliability were performed to verify the SISQ. A total of 1912 Taiwanese were recruited. The results demonstrated that the SISQ has acceptable reliability, with Cronbach’s alphas ranging between 0.57 and 0.76. The SISQ accounted for 58.86% and satisfied the requirement of Kaiser–Mayer–Olkinvalues (0.78) and significant Bartlett’s Test of sphericity. Moreover, the confirmatory factor analysis fit indices also indicated the adequacy of the model. As for multiple comparison, females scored higher than males in factor of social distance. Unemployed participants and those without partners scored higher in several domains of factors. The survey method and survey instrument prove reliable and valuable, also providing different categories of assessment results regarding social influences and their impacts. Further studies are warranted to extend the applicability of SISQ.