Framing the future: Ensuring vulnerable island communities are engaged

Abstract

Objective

Statements such as the Bridgetown Declaration¹ serve as a wake-up call for action to address the significant mental health needs in small island developing states. Overarching frameworks and action plans have been developed to support nations to promote mental health and build resilience for their populations in the region, and while these frameworks and action plans provide direction, translating them into grassroots change can be a challenge. At the Creating Futures 23 conference, delegates from the Oceania region were invited to participate in a plenary workshop entitled Framing the Future. Three questions were posed for workshop participants to respond to in relation to their perceived priorities, opportunities and innovations to support mental health in their local communities. This paper provides a summary of the workshop participants’ responses.

Conclusion

Community-led innovations, with programs tailored for small island communities, were seen as grassroots solutions in the Oceania region. Engagement with small island communities by policy makers and leaders was considered essential for effective, sustainable and community-led mental health initiatives to realise the objectives of high-level, overarching frameworks and action plans.

The Oceania region is a vast expanse comprising 22 independent countries and territories over 22,000 islands, ¹ each with its own unique cultural tapestry. The combined population of the Pacific region is just 44 million people. Pacific Island countries and territories (referred to as small island developing states in the Bridgetown Declaration) are classified as having multiple interrelated vulnerabilities, that is, economic, environmental and social, and thus there is a need to strengthen resilience. ² Climate change and severe weather events are impacting the mental health of individuals, resulting in food shortages, infrastructure loss, separation of families, dislocation from communities and forced migration. ³ Good mental health is crucial for resilience, productivity and societal well-being, and building a resilient mental health system is essential for the region’s viability. The Bridgetown Declaration ¹ acknowledges the disproportionate challenges for people living in small island developing states and seeks urgent global action for the promotion of mental health, and the prevention and treatment of mental health challenges for people living in these regions.

The Regional Framework for the Future of Mental Health in the Western Pacific 2023–2030 (the Regional Framework) ⁴ seeks to refocus, transform, and embed mental health into all aspects of life in the region. Refocusing on grassroots approaches, community-based partnerships, and innovation through inter-sectoral collaboration are seen as ways to empower communities to address systemic inequalities and stigma. Transformation entails transitioning mental health support to community-based ecosystems, emphasising co-design and integration into universal healthcare. Embedding mental health into all aspects of daily life requires partnerships, social interventions and innovative solutions tailored to local contexts. As part of the Creating Futures 23 conference held on 18 October 2023, a 1.5-h long workshop entitled Framing the Future was held to explore how the objectives, priorities and strategies in regional and global frameworks were reflected at grassroots level. The workshop used a facilitated small group discussion approach to explore participants’ perceptions of grassroots priorities and innovative strategies to promote mental health in small island states. A summary of the discussions was delivered to the wider Creating Futures 23 conference audience, comprising 38 participants from the countries of Fiji, Papua New Guinea, Tonga, Federated States of Micronesia, Cook Islands, Papua New Guinea, Solomon Islands, New Zealand, Australia and South Africa. The majority of participants at the conference were female with backgrounds in nursing, psychiatry, academia, patient advocacy and policy development for government agencies. Of these, a subset of 14 participants, all women, attended the Framing the Future workshop. Participants in the workshop were randomly allocated into three small discussion groups and presented with key questions. The authors (who were also the workshop developers) were assigned to record the discussion points in note form. The summary of responses is presented below in descriptive form and synthesised for brevity with salient quotes highlighted.

Workshop question 1: What do you see as the top priority for mental health in your country?

Participants identified ‘increasing mental health and wellbeing awareness through community education’ as a top priority. Community education was seen as a way to ‘change attitudes and reduce stigmatisation’ in order to reduce disconnection and associated vulnerability for people with lived experience of mental health challenges. It is noted that combating stigma is a key priority in the Regional Framework ⁴ and promoting mental health literacy is seen as a way to empower communities with the knowledge, tools and skills to enhance their overall mental health and wellbeing. Participants also described education for general healthcare workers as another key priority for their communities. This involved the provision of ‘mental health training for health professionals’. Another priority identified by participants in the workshop was the need to increase the specialist mental health workforce by providing ‘funding for more mental health roles’, such as nurses, medical officers, psychologists and counsellors. Aligned with these priorities, participants described the need for an overall review of ‘current workforce models’ to ensure there were sufficient resources provided to meet communities’ needs. It is noted that strengthening the number and capacity of the nursing workforce in Pacific Island nations is a key focus of WHO’s Global strategic directions for nursing and midwifery 2021–2025. ⁵ The priorities identified by workshop participants were consistent with the broad objectives of the Regional Framework ⁴ and the WHO Comprehensive Mental Health Action Plan 2013–2023 (Mental Health Action Plan). ⁶ These objectives include the provision of integrated and responsive mental health care services in the places that people live and work, implementing strategies for mental health promotion and prevention, increasing healthcare workers’ mental health knowledge and skills, and challenging stigma and discrimination.

Workshop question 2: How can broad frameworks be localised and made relevant for your local context?

The significance of high-level strategic frameworks such as those outlined in the Regional Framework ⁴ and Mental Health Action Plan ⁶ may be overlooked by individuals and communities if their effects are not directly experienced. The small group discussions during the Framing the Future workshop explored how the principles and actions outlined in these high-level frameworks could be applied at the local level. Participants identified strategies such as ‘in-country planning’, which included an ‘analysis of the current strengths and needs’ specific to the unique culture and practices of local communities. Included in this suggestion was the need to ‘hear the voices of people with lived experience of mental health challenges’. Another strategy proposed by participants involved ‘refining nursing and other health discipline curricula’ to meet the specific needs of individual countries. A curriculum in this context was understood as a ‘broad framework’ which could be made more relevant for the local context. Due to the constraints of the workshop model, it was not possible to explore this concept in greater depth. Both the Regional Framework ⁴ and the Mental Health Action Plan ⁶ have a focus on creating a varied and skilled workforce to address the specific needs of a community. The strategies identified in the small group discussions at the Framing the Future workshop spoke of localised solutions, supported by local evidence and were closely aligned with the Regional Framework’s mission to find ‘solutions that are grounded in the local context and shared community values, informed by insights from people with lived experience and everyday citizens’ (4, p. 33). The need for local planning is consistent with the principles of community engagement and is exemplified in the work of important agencies such as The Pacific Community (SPC) (formerly the South Pacific Commission), which was established in 1947. The SPC is the primary scientific and technical organisation fostering development in the Pacific region and is owned and governed by 27 country and territory members who come together annually to review progress of SPC’s work. The Public Health Division of the SPC is recognised for their scientific and technical expertise, and the effectiveness with which they apply their expertise in response to the specific development needs of member countries.

Workshop question 3: What innovative community-led strategies are already happening in your country?

Community leaders play a vital role in fostering social capital and trust within their communities, and the effectiveness of these roles stems from their close ties and active involvement in the communities they serve. ⁷ Several community-led innovations were described by participants in the workshop. These included a description of the adaptation of the World Health Organization mental health gap action programme (WHO mhGAP) for child and adolescent mental health. The standard WHO mhGAP program seeks to expand services for mental, neurological and substance use disorders in low- and middle-income countries. ⁸ The community-led adaptation for child and adolescent mental health was made to compensate for limited mental healthcare infrastructure for young people in Pacific Island nations. ⁹ Another innovative community-led strategy was an alcohol and other drug day program in Papua New Guinea (PNG), which sought to reduce the need for punitive approaches to change problem behaviours in PNG communities. Alcohol and other drug use is associated with high levels of injury-related deaths in PNG, including traffic accidents, assaults and domestic violence. ¹⁰ The use of telehealth was described by a participant as another innovative and effective strategy for addressing the mental health needs of communities in the Pacific region. It is noted, however, that while telehealth has the potential to enhance the accessibility and affordability of healthcare service, logistic and infrastructure challenges make it hard for this technology to reach remote communities which, arguably, have the highest need. ¹¹ An outreach mental health awareness program in Nauru for people with high needs, but who are hard to access, such as people with refugee status, was described in the workshop as an example of a community-led innovation. Mental healthcare in Nauru is poorly resourced in terms of both infrastructure and personnel, and mental illness is stigmatised and misunderstood, leading to critical deficits in mental healthcare for the Nauruan people and refugee populations in this country. ¹²

The community-led strategies described above were of varying scales and complexity, yet all reflected the objective of the Regional Framework ⁴ to engage and empower communities with tools to enhance protective factors and diminish mental health risk factors at a local level. Due to conference time constraints, it was not possible to explore these community-led strategies in greater detail, and the authors make a strong recommendation for further forums to showcase the efforts and impact of innovative community-led initiatives by, and for, vulnerable communities in the Pacific region. Organisations such as the World Federation for Mental Health (WFMH) act as beacons of advocacy for vulnerable populations; championing mental health as a universal human right and raising awareness of critical mental health issues. ¹³ The WFMH promotes awareness and mobilises action to address mental health disparities worldwide through strategies such as World Mental Health Day on 10 October, which help to raise awareness of the mental health challenges that impact vulnerable populations.

Conclusion

The value of high-level mental health strategies and frameworks can be lost if their impact is not felt by communities on the ground. The Framing the Future plenary workshop held at the Creating Futures 23 conference engaged participants from the Oceania region in a dialogue about what they perceived to be the priorities, opportunities and innovate approaches for promoting mental health in their local communities. Participants’ perceptions aligned closely with the objectives of the Regional Framework, ⁴ and the WHO Mental Health Action Plan. ⁶ Translating the objectives of overarching strategies, frameworks and action plans into strategies for change, means listening to vulnerable communities to identify local solutions that address their unique needs. This is especially true in relation to hearing the voices of people with lived experience of mental health challenges. Engaging and empowering small island communities is a critical step towards building resilient mental health systems that can support their unique cultural and population needs.