Cocreating Action to Improve Rationality in the Health System

Overview

Despite widespread recognition of social, economic, or environmental health determinants, health action remains heavily dominated by individual-level solutions (e.g., medication, patient counselling, vaccination). This study aims to stimulate changes in health system functioning by demonstrating how the cocreation of actions to address psychological well-being, cardiovascular health, and antimicrobial resistance from within the community can alleviate the burden on primary care services, reduce medicalisation and increase health equity. The scientific approach uses mixed methods and incorporates theory from multiple disciplines. This study will appraise how the current system addresses psychological well-being, cardiovascular (CV) health, and rational use of antibiotics using a population survey, a survey of patients collecting their medication at community pharmacies, aggregate health service indicators on medication consumption and primary care consultations, and qualitative methods exploring stakeholders' perceptions.The investigators will undertake community-based participatory research to engage citizen scientists in the cocreation of community-led actions to promote psychological well-being, CV health, and prevent antimicrobial resistance. The design, implementation, and evaluation of the actions will apply an assets-based approach and apply theories and frameworks from implementation science in an iterative manner over 3 years. Finally, the impact of the cocreated actions will be analysed, considering effectiveness and broader contextual issues such as initiative adoption, implementation, and maintenance. The investigators will use a before-after comparison of survey indicators, an interrupted time-series analysis of health service data and qualitative analysis. The goal is to demonstrate how the integration of community action with attention to the social determinants of health, can lead to a more rational approach to health care and ultimately improve health and health equity.

This study seeks to cocreate actions that address three major health issues within the community to reduce medicalisation and help unburden primary healthcare services. The first issue is related to psychological well-being and the overuse of anxiolytics and antidepressants. Mental health problems are one of the greatest public health challenges in the European Region, affecting about 25% of the population every year and some estimates place Spain, where this research takes place, as the highest per-capita consumer of anxiolytic medication in the world. The second issue relates to addressing CV health and over-reliance on medication to treat CV risk factors as "pre-diseases". While CV disease continues to be the leading cause of adult mortality worldwide, there is a rise in overdiagnosis and overtreatment of CV risk factors in primary care and limited CV health promotion at community level. The third issue is to promote rational use of antibiotics and reduce the risk of antimicrobial resistance, an issue considered to be in the top 10 global public health threats today. As the title of this study suggests, the investigators question whether the current approach to these important public health issues is truly rational. Health action remains heavily dominated by individual-level solutions (e.g., medication, patient counselling, vaccination) despite widespread recognition of the social, economic, or environmental factors that determine health. Health professionals frequently acknowledge the importance and potential of non-pharmacological community-based interventions, yet barriers exist to put them into practice. Even the way that the public health system is conceptualised leads to overemphasize the importance of the health services as the accountable component for providing health and well-being. In fact, there are numerous organizations and individuals who develop actions in areas that are not directly recognizable as part of the health system (e.g., senior citizens clubs, urban planners, cultural centres), but which greatly facilitate the effectiveness of the system and have the potential to produce significant health and wellbeing benefits. The project will apply a "systems thinking" approach and consider that any organization, person, or action that influences the physical or social environment has the potential to influence health and wellbeing, and thus could be considered part of the public health system if they are incorporated into the decision-making domains that have a primary desire or interest in maximizing health. Important, yet frequently underestimated, health systems components are found in the community. Identifying and activating health promoting resources in the community is a legitimate and effective way to improve health and health equity. It forms the basis of a substantial body of research and practice on health promotion with community assets. A community can also be characterised and described by its level of social capital, which in itself is a key component of community resources, as well as a determinant of physical and mental health. It includes the perceptions that people have about the level of interpersonal trust, exchange and reciprocity in their community, as well as the density of their social networks and patterns of civic engagement. This study put forward an ambitious plan to show how the power of the community and its members can be harnessed to cocreate actions that move them from a predominant biomedical vision to a truly rational health system. Engaging the community in research or practice is acknowledged as a powerful tool to elicit meaningful and sustainable change. Furthermore, it is an effective way to reduce inequity. In this line, increasing attention is centred on developing citizen science initiatives that move beyond engaging citizens in data collection, and towards citizens having a meaningful input in all phases of the research, including design and translation of the findings into practice. The community-based participatory research model has proven useful in this endeavour. This study considers here that deep community engagement in research can improve critical health literacy (CHL), not just among the citizen scientists but among the community as a whole. CHL refers to individuals or communities that are able to critically appraise information, understand the social determinants of health and have skills oriented towards collective social and political action. The issue is paramount to the problem addressed here as CHL is widely assumed to lead to a more effective and efficient use of health services. In light of these considerations, the research proposed seeks to foster the complexity and dynamism of the health system by integrating community action and attention to the social determinants of health. This will refocus how psychological wellbeing, CV health, and antimicrobial resistance are approached. Together with citizen scientists the investigators will cocreate community actions in each of these 3 areas and will show how they can ultimately impact health and health equity. The objectives are: Overall objective: To determine the impact on health and health equity of a series of cocreated actions to improve rationality in the health system. Specific objectives: 1. To generate rigorous quantitative and qualitative epidemiological data on the current health systems approach to address psychological wellbeing, CV health, and antimicrobial resistance. 2. To cocreate actions to promote psychological wellbeing, CV health, and rational use of antibiotics with a community approach. 3. To assess the impact of the cocreated actions on health and health equity at local population level.