Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa.

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE: Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India. METHODS: We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically. RESULTS: CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD. CONCLUSION: Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Mutuality as a method: advancing a social paradigm for global mental health through mutual learning.

PURPOSE: Calls for "mutuality" in global mental health (GMH) aim to produce knowledge more equitably across epistemic and power differences. With funding, convening, and publishing power still concentrated in institutions in the global North, efforts to decolonize GMH emphasize the need for mutual learning instead of unidirectional knowledge transfers. This article reflects on mutuality as a concept and practice that engenders sustainable relations, conceptual innovation, and queries how epistemic power can be shared. METHODS: We draw on insights from an online mutual learning process over 8 months between 39 community-based and academic collaborators working in 24 countries. They came together to advance the shift towards a social paradigm in GMH. RESULTS: Our theorization of mutuality emphasizes that the processes and outcomes of knowledge production are inextricable. Mutual learning required an open-ended, iterative, and slower paced process that prioritized trust and remained responsive to all collaborators' needs and critiques. This resulted in a social paradigm that calls for GMH to (1) move from a deficit to a strength-based view of community mental health, (2) include local and experiential knowledge in scaling processes, (3) direct funding to community organizations, and (4) challenge concepts, such as trauma and resilience, through the lens of lived experience of communities in the global South. CONCLUSION: Under the current institutional arrangements in GMH, mutuality can only be imperfectly achieved. We present key ingredients of our partial success at mutual learning and conclude that challenging existing structural constraints is crucial to prevent a tokenistic use of the concept.

The clinical impact of early detection of ESBL-producing Enterobacterales with PCR-based blood culture assays.

BACKGROUND: Starting January 4, 2021, our health system core microbiology laboratory changed blood culture identification (BCID) platforms to ePlex BCID from BioFire BCID1 with the additional capability to detect the blaCTX-M-Type gene of ESBL-producing organisms. Clinical outcomes of ESBL bloodstream infections (BSI) after implementing ePlex BCID were unknown. METHODS: Patients with ESBL BSI were compared pre and postimplementation of ePlex BCID in this 11-hospital retrospective analysis (BioFire BCID1 in 2019 vs ePlex BCID in 2021). The primary outcome was time from the Gram stain result to escalation to a carbapenem. Secondary outcomes included in-hospital mortality, 30-day readmission rate, length of stay (LOS), and the duration of antimicrobial therapy. RESULTS: A total of 275 patients were analyzed. The median time of Gram stain result to escalation to carbapenem was reduced from 44.5 hours with BioFire BCID1 to 7.9 hours with ePlex BCID (P < .001). There were no significant differences in mortality, 30-day readmission, or LOS. The duration of antimicrobial therapy for ESBL BSI was lower in the ePlex BCID group (from 14.4 days to 12.7 days, P = .014). CONCLUSIONS: Timely detection of the blaCTX-M-Type gene by BCID provides valuable information for the early initiation of appropriate and effective antimicrobial therapy. Although it was not associated with lower mortality, 30-day readmission, or LOS, it may have benefits such as decreasing antimicrobial exposure to patients.

Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE) protocol.

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.

Efficacy of Mandibular Advancement Device in the Treatment of Obstructive Sleep Apnoea by Evaluating Upper Airway Space Volume Using CBCT.

OBJECTIVE: To evaluate the efficacy of mandibular advancement device as a treatment of mild to moderate obstructive sleep apnoea and to evaluate the change in upper airway space volume by using cone beam CT (CBCT). STUDY DESIGN: In vivo observational study. Place and Duration of the Study: Department of Prosthodontics, Crown and Bridge, Sri Aurobindo College of Dentistry, Indore (M.P), India, from March 2017 to January 2021. METHODOLOGY: Patients with mild to moderate obstructive sleep apnoea patients using Berlin questionnaire were selected. Pre- and posttreatment-CBCT analysis was done to compare the changes in superior and inferior upper airway space before and after using mandibular advancement device. The pre and postoperative CBCT were also compared using a paired t-test for the quantitative variables. After two months, the patients were asked to complete a self-administered questionnaire to assess their sleep improvement, initial symptoms regression, and effectiveness of the mandibular advancement device. RESULTS: On comparative evaluation of the pre- and post-CBCT, the mean score before the mandibular advancement device placement was found to be 7.77+2.79 cc, whereas the mean score after the mandibular advancement device placement was found to be 9.75+3.34 cc (p<0.001). Significant volumetric change was seen in upper airway space after receiving treatment for the two months. The patient noticed a substantial improvement in their sleep as well as a reduction in the original symptoms. CONCLUSION: This study showed statistically significant volumetric change in the upper airway space and reduction in their symptoms after treatment with the mandibular advancement device (MAD). KEY WORDS: Obstructive sleep apnoea syndrome (OSA), Continuous positive airway pressure (CPAP), Cone beam computed tomography, Mandibular advancement device (MAD), Upper airway volume.

Extensively drug-resistant Pseudomonas aeruginosa panophthalmitis from contaminated artificial tears.

Pseudomonas aeruginosa is one of the common gram-negative organisms that cause severe invasive infections in different organ systems. P. aeruginosa has unique intrinsic mechanisms to develop antimicrobial resistance quickly, making it extremely difficult to treat. We report a case of extensively drug-resistant (XDR) P. aeruginosa panophthalmitis due to contaminated artificial tears. This report investigates the role of systemic and intravitreal antimicrobials, summarizes the resistance mechanisms of P. aeruginosa, and provides an overview on cefiderocol, a novel antimicrobial that targets multidrug-resistant (MDR) and XDR Gram-negative pathogens.

Improving mental ill-health with psycho-social group interventions in South Asia-A scoping review using a realist lens.

This scoping review aimed to synthesise current evidence related to psycho-social groups as part of community-based mental health interventions in South Asia. We used a realist lens to pay attention to the contexts and mechanisms supporting positive outcomes. We included studies published from January 2007 to February 2022 that: were based in communities in South Asia, included a group component, reported on interventions with a clear psychosocial component, targeted adults and were implemented by lay community health workers. Two reviewers extracted data on intervention components, groups and facilitators, participant demographics and enabling contexts, mechanisms and outcomes. Expert reference panels including people with lived experience of psycho-social disability, mental health professionals and policy makers confirmed the validity and relevance of initial review findings. The review examined 15 interventions represented by 42 papers. Only four interventions were solely psycho-social and nearly all included psychoeducation and economic support. Only 8 of the 46 quantitative outcome measures used were developed in South Asia. In a context of social exclusion and limited autonomy for people with psychosocial disability, psychosocial support groups triggered five key mechanisms. Trusted relationships undergirded all mechanisms, and provided a sense of inclusion, social support and of being able to manage mental distress due to improved skills and knowledge. Over time group members felt a sense of belonging and collective strength meaning they were better able to advocate for their own well-being and address upstream social health determinants. This led to outcomes of improved mental health and social participation across the realms of intrapersonal, interpersonal and community. Psychosocial groups merit greater attention as an active ingredient in community interventions and also as an effective, relevant, acceptable and scalable platform that can promote and increase mental health in communities, through facilitation by lay community health workers.

Developing relevant community mental health programmes in North India: five questions we ask when co-producing knowledge with experts by experience.

Knowledge co-production can improve the quality and accessibility of health, and also benefit service users, allowing them to be recognised as skilled and capable. Yet despite these clear benefits, there are inherent challenges in the power relations of co-production, particularly when experts by experience (EBE) are structurally disadvantaged in communication skills or literacy. The processes of how knowledge is co-produced and negotiated are seldom described. This paper aims to describe processes of co-production building on the experiences of EBE (people with lived experience of psychosocial or physical disability), practitioners and researchers working together with a non-profit community mental health programme in North India. We describe processes of group formation, relationship building, reflexive discussion and negotiation over a 7-year period with six diverse EBE groups. Through a process of discussion and review, we propose these five questions which may optimise co-production processes in communities: (1) Who is included in co-production? (2) How can we optimise participation by people with diverse sociodemographic identities? (3) How do we build relationships of trust within EBE groups? (4) How can we combine psychosocial support and knowledge co-production agendas in groups? and (5) How is the expertise of experts by experience acknowledged?

Participatory mental health interventions in low-income and middle-income countries: a realist review protocol.

INTRODUCTION: The launch of the Movement for Global Mental Health brought long-standing calls for improved mental health interventions in low-and middle-income countries (LMICs) to centre stage. Within the movement, the participation of communities and people with lived experience of mental health problems is argued as essential to successful interventions. However, there remains a lack of conceptual clarity around 'participation' in mental health interventions with the specific elements of participation rarely articulated. Our review responds to this gap by exploring how 'participation' is applied, what it means and what key mechanisms contribute to change in participatory interventions for mental health in LMICs. METHODS AND ANALYSIS: A realist review methodology will be used to identify the different contexts that trigger mechanisms of change, and the resulting outcomes related to the development and implementation of participatory mental health interventions, that is: what makes participation work in mental health interventions in LMICs and why? We augment our search with primary data collection in communities who are the targets of global mental health initiatives to inform the production of a programme theory on participation for mental health in LMICs. ETHICS AND DISSEMINATION: Ethical approval for focus group discussions (FGDs) was obtained in each country involved. FGDs will be conducted in line with WHO safety guidance during the COVID-19 crisis. The full review will be published in an academic journal, with further papers providing an in-depth analysis on community perspectives on participation in mental health. The project findings will also be shared on a website, in webinars and an online workshop.

Short Term Outcomes of Head and Neck Oncology Surgery During Covid-19 Pandemic: Experience from a Tertiary Cancer Care Centre in North India.

With the entire world in the midst of COVID-19 pandemic, several health care facilities have stopped or delayed performing elective surgeries in order to cater to ever increasing number of COVID-19 patients. Moreover, there were initial reports of poor surgical outcomes in patients who underwent surgery and were found to be positive for COVID-19 infection in post-operative period. In this study, we have evaluated the short-term outcomes of head and neck oncology patients operated in our institute following a strict screening protocol and conducting COVID-19 testing by Reverse transcriptase polymerase chain reaction once the test was available. 68 patients operated between 1st April and 30th September, 2020 (COVID-19 era, study group) were compared with 59 patients operated during 1st October, 2019 to 31st March 2020 (Non COVID-19 era, control group). The comparison between the groups was done by measuring 30 days complication rate as defined by Dindo-Clavien classification. 10.3% of patients developed complications in study group as compared to 8.5% of patients in control group which was statistically non-significant (p = 0.7). Importantly, none of the patients developed any sign or symptom suggestive of COVID-19 infection in post-operative period in study group. Head and neck oncology related cancer procedures including complex reconstruction can safely be performed during COVID-19 era by proper screening and pre-operative testing for COVID-19. We also suggest use of N95 masks and face shields as bare minimum in order to ensure the safety of health care workers even after a negative COVID-19 report.

Exploring Community Mental Health Systems - A Participatory Health Needs and Assets Assessment in the Yamuna Valley, North India.

BACKGROUND: In India and global mental health, a key component of the care gap for people with mental health problems is poor system engagement with the contexts and priorities of community members. This study aimed to explore the nature of community mental health systems by conducting a participatory community assessment of the assets and needs for mental health in Uttarkashi, a remote district in North India. METHODS: The data collection and analysis process were emergent, iterative, dialogic and participatory. Transcripts of 28 in-depth interviews (IDIs) with key informants such as traditional healers, people with lived experience and doctors at the government health centres (CHCs), as well as 10 participatory rural appraisal (PRA) meetings with 120 people in community and public health systems, were thematically analysed. The 753 codes were grouped into 93 categories and ultimately nine themes and three meta-themes (place, people, practices), paying attention to equity. RESULTS: Yamuna valley was described as both 'blessed' and limited by geography, with bountiful natural resources enhancing mental health, yet remoteness limiting access to care. The people described strong norms of social support, yet hierarchical with entrenched exclusions related to caste and gender, and social conformity that limited social accountability of services. Care practices were porous, pluralist and fragmented, with operational primary care services that acknowledged traditional care providers, and trusted resources for mental health such as traditional healers (malis) and government health workers (accredited social health activists. ASHAs). Yet care was often absent or limited by being experienced as disrespectful or of low quality. CONCLUSION: Findings support the value of participatory methods, and policy actions that address power relations as well as social determinants within community and public health systems. To improve mental health in this remote setting and other South Asian rural locations, community and public health systems must dialogue with the local context, assets and priorities and be socially accountable.

Prevalence of Molecular Subtypes in Operated Cases of Breast Cancer and Its Clinicopathological Correlation: A Single Institute Study from a Tertiary Cancer Centre in North India.

Breast cancer has emerged as a major health problem among women in India. There are few Indian studies which have looked at prevalence of molecular subtypes of breast cancer in Indian population. The primary objective of our study was to find out the prevalence of various molecular subtypes in operated cases of breast cancer patients presenting to us. Three hundred sixty patients who were operated in our department were analysed. Clinicopathological features of all cases were recorded. Classification into various molecular subtypes was done using St. Gallen 2013 criteria. Luminal B HER2 negative was the predominant molecular subtype in our study population constituting 30.3% of patients. The percentage of aggressive subtypes, viz. triple negative breast cancer and HER2 enriched, were 21.7% and 11.4% respectively. Only 19.4% of patients in our study population had tumour size ≤ 2 cm with nodes being positive in 56.9% of our patients at presentation. Data from our study and other studies published from India show that the two most aggressive subtypes of, viz. triple negative breast cancer and HER2 enriched, may be more prevalent in our population as compared to western population.

Prognostic factor for recurrence in esophagus cancer patients who underwent surgery for curative intent: A single-institution analysis.

OBJECTIVE: The purpose of this study is to analyze predisposing factors for a higher risk of recurrence in esophageal cancer patient who underwent surgery for curative intent and to do survival analysis of prognostic factors. MATERIALS AND METHODS: Between February 2018 and March 2020, we retrospectively identified 28 cases staged T1b to T4a managed electively at our institute as per multidisciplinary management plan. Demographic, clinical, radiological, operative, histopathological parameters, upfront surgery done or not, type of preoperative, and adjuvant treatment used and whether neoadjuvant or adjuvant therapy was planned along with waiting time for surgery, were assessed as potential risk factors. End point of study was to find potential risk factors for recurrence and to do their subgroup survival analysis. RESULTS: The recurrence rate in our study was 25% with a mean follow-up of 24 months. The median time of recurrence was 8.5 months, all recurrence occurred within 1 year. Overall DFS at 2 years was 72%. On univariate analysis, following prognostic factors were associated with high risk of recurrence, male sex X2 (1) =4.42, p = 0.035; histology subtype of adenocarcinoma X2 (1) = 7.07, p = 0.008; margin positive X2 (1) =3.76, p = 0.05; presence of lymph vascular invasion (LVI) X2 (1) =7.88, p = 0.005; presence of perineural invasion (PNI) X2 (1) =5.97, p = 0.015; postoperative T size >4 cm X2 (1) =3.86, p = 0.049; and nodal positivity X2 (3) =13.47, p = 0.004. CONCLUSIONS: Male sex, adenocarcinoma histological subtype, positive resected margin, presence of LVI and PNI, postoperative T size >4 cm, and high postoperative nodal positivity and whether neoadjuvant versus adjuvant therapy given (on K. M analysis) were the identified predictors of recurrence which compromised DFS.

Role of Bone Turnover Markers in Osteoporosis Therapy.

Bone turnover markers fill a clinical need that improves comprehensive care of metabolic bone health and osteoporosis. Creating a standard process for drawing them that reduces modifiable variability improves their precision and clinical usefulness. Creating a standard process for interpreting them by applying statistical significance improves their clinical applicability. Understanding what causes them to increase and decrease can help elucidate secondary causes of osteoporosis. Monitoring them can assess patient adherence to therapy for a silent disease that will progressively become louder with an aging global population.

Escherichia coli, a common constituent of benign prostate hyperplasia-associated microbiota induces inflammation and DNA damage in prostate epithelial cells.

BACKGROUND: The role of microbiota in the pathophysiology of benign prostate hyperplasia (BPH), especially in creating an inflammatory milieu may not be avoided. The major objectives of this study were to investigate the microbial composition of BPH tissues, its association with inflammation and check the effect of clinically isolated bacteria on prostate epithelial cells. METHODS: The study includes 36 patients with a pathological diagnosis of BPH. Following strict aseptic measures, tissues were collected after transurethral resection of prostate, multiple pieces of the resected tissues were subjected to histopathological analysis, bacterial culture and genomic DNA extraction. Microbial composition was analyzed by culture and/or next-generation sequencing methods. Annotation of operational taxonomy unit has been done with an in-house algorithm. The extent of inflammation was scored through histological evaluation of tissue sections. The effect of clinical isolates on nuclear factor-κB (NF-κB) activity and induction of DNA-damage in the prostate epithelial cells were evaluated. RESULTS: Histopathological analysis of the BPH tissues showed the presence of inflammation in almost all the tissues with a varied level at different regions of the same tissue section and the level of overall inflammation was different from patients to patients. Microbial culture of tissue samples showed the presence of live bacteria in 55.5% (20 out of 36) of the patient tissues. Majority of the isolates were coagulase-positive Staphylococcus, E. coli and Micrococcus spp. Further, V3 16S rRNA sequencing of the DNA isolated from BPH tissues showed the presence of multiple bacteria and the most common phylum in the BPH tissues were found to be Proteobacteria, Actinobacteria, Firmicutes, and Bacteroidetes. The E. coli, isolated from one of the tissue was able to activate NF-κB and induce DNA damage in prostate epithelial cells. Phospho-histone γH2A.X staining confirmed the presence of cells with damaged DNA lesion in BPH tissues and also correlated with the severity of inflammation. CONCLUSION: Our study has shown that the BPH tissues do have a divergent microbial composition including the commonly found E. coli (phylum Proteobacteria), and these bacteria might contribute to the BPH-associated inflammation and/or tissue damage. The BPH-associated E. coli induced NF-κB signaling and DNA damage in prostate epithelial cells in vitro.

Magnetic nanoparticles for amalgamation of magnetic hyperthermia and chemotherapy: An approach towards enhanced attenuation of tumor.

Targeted cancer therapy facilitates localizing the action of chemotherapeutic drugs at the tumor site enhancing the therapeutic efficacy and reducing the side effects to the healthy cells. The homing property of mesenchymal stem cells (MSCs), towards the tumor tissues makes them a potential cell-based delivery system for targeted cancer therapy. Along with chemotherapy, hyperthermia has gained interest as a treatment modality of cancer due to the higher sensitivity of the cancer cells towards heat and also due to its action on tumor cells to enhance sensitization towards chemotherapy or radiotherapy. In the current study, we have shown the multifaceted application of magnetic nanoparticles (MNPs) as a drug delivery vehicle to deliver anti-cancer drug paclitaxel and also as an inducer for magnetic hyperthermia under alternating magnetic field. The combined approach of paclitaxel loaded MNPs and hyperthermia demonstrated enhanced therapeutic efficacy as compared to any single therapy. Further, we have employed MSCs as carrier for these drugs loaded MNPs to achieve targeted and uniform distribution of the MNPs at the tumor site. We have evaluated the efficacy of the system in in vitro and in vivo prostate tumor model. The in vivo tumor study shows uniform distribution of drug loaded MNPs with use of mesenchymal stem cells as a delivery vehicle and combination of hyperthermia and MNP mediated drug delivery results in better tumor remission.

Co-production of a pictorial recovery tool for people with psycho-social disability informed by a participatory action research approach-a qualitative study set in India.

Mental health problems are recognized as a leading cause of disability and have seen increased allocations of resources and services globally. There is a growing call for solutions supporting global mental health and recovery to be locally relevant and built on the knowledge and skills of people with mental health problems, particularly in low-income countries. Set in Dehradun district, North India, this study aimed to describe first, the process of co-production of a visual tool to support recovery for people affected by psycho-social disability; second, the key outputs developed and third, critical reflection on the process and outputs. The developmental process consisted of participatory action research and qualitative methods conducted by a team of action researchers and an experts by experience (EBE) group of community members. The team generated eight domains for recovery under three meta-domains of normalcy, belonging and contributing and the ensuing recovery tool developed pictures of activities for each domain. Challenges to using a participatory and emancipatory process were addressed by working with a mentor experienced in participatory methods, and by allocating time to concurrent critical reflection on power relationships. Findings underline the important contribution of an EBE group demonstrating their sophisticated and locally valid constructions of recovery and the need for an honest and critically reflective process in all co-productive initiatives. This study generated local conversations around recovery that helped knowledge flow from bottom-to-top and proposes that the grass-root experiences of participants in a disadvantaged environment are needed for meaningful social and health policy responses.