This commentary is written by the co-editors of the Collection entitled "Rethinking Public Health Approaches to Crisis Response: Putting People First". Specifically, in the call for submissions, we welcomed articles that detailed the actions, experiences, models, and mechanisms of involvement of community members and local knowledge in response to any clearly defined public health crisis, as a manifestation of how health systems are "putting people first". This commentary is a reflection on the seven papers eventually accepted for that Collection. The papers cover diverse settings, from South Korea and Saudi Arabia to sub-Saharan Africa and a variety of conflict settings. Collectively, these papers show a continuing gap in scholarship that convincingly progresses our thinking on approaches to achieve a people-centred public health crisis response. Nonetheless, the papers identify specific examples of local actions, including generating community trust for preventative actions and experiential learning in emergency care, showing how community involvement influences government legitimacy, intervention feasibility and societal recovery. Two papers present critical challenges for us: to build trust at the grass-roots level and to use health as a peacebuilding tool. These papers extend our understanding of the epidemic response beyond the conventional global health security paradigms and underscore the importance of shifting to a new paradigm that is people-centred and peace-led as the best way to protect future generations and their health. At a time of huge funding cuts to global health and development, and shifting political commitments to international solidarity, local citizen-led action to re-imagine health and well-being beyond security and national interest becomes simultaneously more challenging and crucial than ever before.

Background Madagascar has been seriously affected by climate change with a particular impact on population health, wellbeing, and livelihoods. The country is prone to cyclones with floods as immediate consequences creating a cascade of crises. This study aims to understand how stakeholders (state and Non-Governmental Organisations) engage with communities to respond to cyclone-related shocks, how communities themselves respond, and what factors facilitate or hinder these partnerships.Methods This qualitative study collected data though In-Depth Interviews (IDIs) from community members, Key Informant Interviews (KIIs) from stakeholders, and Focus Group Discussions (FGDs) from community members in Ambanja district of Madagascar. Data collection was guided by a realist-informed approach collecting data specific to Context, Mechanisms, and Outcome (CMO) of community engagement and involvement (CEI) for the response to cyclone-related crises. Data were presented as narrative summaries before going thorough framework analysis.Results This study identifies three pathways enabling community resilience. First, timely cyclone early-warning communication from trusted stakeholders from local actors and supporting Non-Governmental Organisations (NGOs) facilitates community involvement and saves lives during cyclone events. Second, embedded NGOs who are committed to working with communities play a pivotal role in building trust and delivering jointly long-term interventions essential for sustained resilience. Third, existing community social capital-including local knowledge, labour and solidarity networks-represents vital yet underutilised resources for effective intervention design. However, two fundamental challenges systematically undermine resilience-building efforts. Most significantly, the predominance of short-term partnerships means that only a few NGOs engage in long-term interventions, leaving substantial community needs unmet and limiting resilience to survival rather than at levels to thrive. Additionally, ignoring local knowledge and social norms leads to waste of resource through non-sustainable interventions, exemplified by water facilities that were rapidly destroyed because stakeholders failed to incorporate community insights about flood-resistant design.Conclusions Whilst communities possess considerable adaptive capacity, and strong social solidarity, greater resilience requires sustained institutional commitment to longer-term engagement and support to address community needs. This needs a systematic integration of existing community knowledge and networks, rather than continued reliance on short-term, externally designed interventions that neither build upon local strengths nor address underlying vulnerabilities.

Background Environmental hazards like floods, droughts and landslides pose serious public health and wellbeing consequences for populations, especially vulnerable communities in countries with low adaptive capacity. Empirical evidence from peer-reviewed literature and official climate change assessments indicates that, alongside high interannual climate variability, Uganda has experienced observable climate change over the past 50 years. This changing and increasingly variable climate poses challenges to population health in diverse ways, including through the transmission of infectious diseases. This study explored local perceptions of the impact of climate variability and change on the prevalence of infectious diseases like typhoid fever, malaria, and diarrhoeal diseases in three districts: Amudat, Bududa, and Katakwi in Eastern Uganda. Relatively few integrated and empirical studies have been conducted in Uganda to assess the specific climate-related health risks faced by local communities. Methods A cross-sectional survey of 341 respondents was conducted to collect data from households. Data were collected using Kobo software, exported, cleaned and analysed with SPSS 28.0 Results Populations in the three study districts perceived drought, floods, and landslides as significant hazards, though with varying levels of exposure, frequency, and severity. Strong associations were found between environmental hazards and occurrences of infectious diseases. Floods, significantly increased the reported prevalence of malaria (Chi-Square = 12.901, p < 0.005), typhoid fever (Chi-Square = 14.215, p < 0.003), and diarrhoeal diseases (Chi-Square = 8.407, p < 0.038). Similarly, drought severity is significantly associated with higher rates of diarrhoeal diseases (Chi-Square = 14.548, p < 0.002), whereas no significant associations were observed for malaria (Chi-Square = 4.182, p > 0.242) or typhoid fever (Chi-Square = 4.739, p > 0.192). Landslides were significantly associated with diarrheal diseases (Chi-Square = 7.846, p < 0.049), but not with malaria (Chi-Square = 2.603, p > 0.457) or typhoid fever (Chi-Square = 3.277, p > 0.351). Most respondents experienced the negative interactive effects of multiple environmental hazards on their health status. The increased prevalence of diarrhea was attributable to floods, drought, and landslides; cases of typhoid fever were increased by floods rather than by drought or landslides. Malaria was more influenced by floods. Conclusion Environmental hazards affected population health in the three districts by increasing the risk of waterborne diseases, such as diarrhea, during severe droughts and landslides. Floods exacerbated waterborne and vector-borne diseases by creating ideal conditions for mosquito breeding and water contamination. There is an urgent need for multihazard-targeted interventions, including improved access to water, sanitation, and hygiene (e.g., regular handwashing with soap, safe water access and use, boiling water, proper sanitation, community WASH sensitization supported by local public health outreach), as well as disaster preparedness strategies, to reduce the health burdens of environmental hazards and enhance community resilience in these regions.

Introduction: Madagascar is among the most vulnerable countries in Africa to climate-related hazards, exposed to an average of 3–4 cyclones yearly with serious damage and exacerbation of existing socio-economic vulnerabilities. This review explores how community members were involved and supported in responding to cyclones in Madagascar.Methods: This is a scoping review of published and grey literature specific to cyclone and related crisis-response in Madagascar. Searches were conducted in standard publications databases (PubMed, Scopus, Google Scholar), agency websites and through professional contacts. Resulting documents were screened for information on interventions involving communities in cyclone response.Results: Evidence of the nature of engagement of communities in cyclone response remains sparse but falls into two categories: immediate response to cyclones' effects on health and livelihoods; and longer-term response to the effects of cyclones on food production, general health (including infectious diseases) and environment including ecosystem and water resources. In immediate emergency-response phase, most activities focus on informing affected people, but partnership and coordination emerge as key to ensuring that local, regional and international efforts are streamlined and community level response committees receive coordinated support. In longer-term actions, building food and livelihoods systems resilient to cyclones, is key. Although communities develop coping strategies, their poverty and vulnerability mean that they need significant external support to build resilience. Embedded NGOs provide the best evidence of more collaborative involvement of communities, but information is lacking on how stakeholders and communities interact, work together or are empowered to take ownership of interventions for their resilience during cyclone.Conclusion: While coordinated partnerships are effective during acute crises, strengthening long-term, community-led engagement before, during, and after cyclones is essential for building resilience in a context of recurrent climate shocks. Long-term interventions including funding of embedded NGOs must be priorities and integrated into national plans for disaster management which must also enable meaningful involvement of communities in a continuous preparedness process.

Introduction:Gender equity and community engagement are increasingly recognised as important for the implementation of equitable One Health (OH) actions, yet no published studies examine how these are operationalised in policies and programmes. We analyse policy content and stakeholder perspectives on community engagement and gender equity in OH policies and programmes in Guinea, Liberia, Nigeria and Sierra Leone. Methods:Mixed methods encompassed: content analysis of OH documents (7 core and 9 supporting); key informant interviews (KIIs) with policy stakeholders (n = 47) and focus group discussions (FGDs) with community members (n = 34 FGDs) to examine perspectives on gender and engagement. Inductive and deductive analyses were conducted, and interpretation of findings were discussed at all-team meetings to enhance validity. Results:All countries have national OH strategic plans. All except Liberia contain substantive mention of community engagement, but only Sierra Leone provides any operational details. No country operationalises gender equity in their OH policies, although Sierra Leone has taken steps towards this and has a Gender Equality Act.Across all countries, policy stakeholders highlighted community engagement as indispensable to OH implementation but showed little urgency in tackling challenges and completely overlooked gender equity, which highlights a critical gap.Community members revealed how community engagement in OH is gendered across all contexts. Cultural norms often limited women's full participation, though this improved over time, while women's lower literacy limited their leadership roles and ability to report disease cases, with Nigeria an exception.Trust emerged as fragile but foundational to OH engagement. In all countries, community trust was mediated by chiefs, elders, and religious leaders, but trust in surveillance activities could be lost when government response or action to OH reporting was lacking. Conclusions:Gender-equitable community engagement is a structural necessity for effective One Health programmes. Our research has shown that there is potential for OH actions to be transformed at the community level through strong, inclusive engagement with women as equal partners.

Introduction Climate and environmental stresses have a disproportionate impact on women and girls, acting as a trigger for intimate partner violence (IPV) and compromising access to needed sexual and reproductive health and rights (SRHR) services. Little is known about the impact of cross-sector programmes and services, and programmes responding to these linked crises remain siloed. This paper examines the effect of a novel partnership between environmental protection and livelihoods NGOs and government health services providing integrated programmes in a climate-stressed rural district in Uganda.Methods Qualitative research examined whether and how integrated programmes could lead to improvements in IPV, SRHR and wider gender equity in eight villages in Rukiga, Uganda. Forty-four focus group discussions in integrated and non-integrated ("parallel") sites gathered lived experiences comparing pre- and post-intervention between April 2021-December 2023.Results Over time, although participants still described food insecurity, poverty and IPV (prevalent at baseline) many also reported positive shifts in IPV-triggers including gender-dynamics and male attitudes towards family planning (FP). Overall, participants in integrated sites reported increased male acceptance of family planning-reducing a potential IPV trigger - and greater community support for women's economic participation. Integrated delivery that engaged all adults in livelihoods as well as reproductive health activities helped disrupt gendered information (and practice) silos and promote greater reported community cohesion supporting women's legitimate participation in economic activities alongside better male support for women's reproductive rights.Discussion Findings suggest that integrated programmes pairing climate-resilient livelihood strategies with rights-based family planning and reproductive health services can enhance reproductive choice for women and help address root-causes of IPV, reproductive coercion and abuse by partners. Protecting women's reproductive rights and wider social wellbeing in the context of severe climate stress means health services and systems must move beyond siloed SRHR programming and service delivery, to embrace partnerships with organisations tackling linked livelihoods and wider wellbeing issues. To be effective, health services and systems must explicitly embed gender-responsive and justice-oriented approaches that ensure the safety of women while addressing persistent inequalities, resource scarcity, and power dynamics.

Climate change is making droughts more frequent and severe, creating serious challenges for health systems and vulnerable communities worldwide. From 2015 to 2018, the Western Cape Province, South Africa, faced an extreme drought that nearly led to "Day Zero"-a point when water supplies would run out. Despite this crisis, documentation of the drought overlooks the health sectors response. To understand how health decision-makers managed this drought, in-depth interviews with 31 people from the health sector and other related fields were conducted. Transcripts were anonymized, transcribed, and deductively and inductively coded. A thematic analysis grouped the findings into four large themes with sub-themes of enabling factors. The study revealed that the health sector played a vital role by ensuring hospitals and clinics had water, reducing water use in facilities, and working closely with other sectors to protect community health. Interestingly, the most critical factors in managing the crisis were not just physical resources like procuring water tanks or fixing pipes in hospitals but the "software" of the health system: strong relationships, good communication, and shared values among health workers and decision-makers. These elements, albeit complex, enabled quick and effective action during the drought, and remained responsive to population needs that allowed for an effective health system response. The findings provide important lessons for making health systems more resilient to future droughts and other climate-related challenges.

As temperatures rise due to climate change, so do adverse health effects. In response, many countries, including South Africa, have developed heat health action plans to address these threats to public health. In the Western Cape province, increasing heat events necessitate a well-coordinated response across governance levels and sectors. Understanding how heat risks are governed, particularly at subnational and local levels, is critical for safeguarding public health and building resilience to future climate challenges. This study draws on 31 in-depth interviews and cross-references a previous policy document analysis to examine how South African decision-makers, both within and outside the health sector, at the Western Cape provincial and municipal levels, manage heat-related health risks. Using an adapted Multiple Governance Framework, the analysis investigates how subnational and local stakeholders work to manage heat-related health risks, some of which are aligned with South Africa's 2020 Heat-Health Action Guidelines. The findings reveal that despite the existence of the Action Guidelines and recognition among Western Cape decision-makers of the urgency of heat-related health risks, implementation remains fragmented. While provincial and municipal stakeholders are actively working to mitigate the health impacts of extreme heat, subnational and local actors were not involved in developing the Heat-Health Action Guidelines limiting their applicability at the local level. The analysis further highlights governance challenges and opportunities that emerge across system, organizational, and individual scales, emphasizing the significant role of decision-makers' perceptions in shaping responses. Strengthening coordination, defining departmental roles, and enabling local adaptation of policy strategies will be essential for improving heat-health action. By addressing these governance gaps, decision-makers in the Western Cape can manage current and future heat-related health risks and communities can be better equipped to withstand the increasing frequency and intensity of extreme heat events.

Climate adaptation strengthens and builds the resilience of health systems to future climate-related shocks. Adaptation strategies and policies are necessary tools for governments to address the long-term impacts of climate change and enable the health system to respond to current impacts such as extreme weather events. Since 2011 South Africa has national climate change policies and adaptation strategies, yet there is uncertainty about: how these policies and plans are executed; the extent to which health policies include adaptation; and the extent of policy coherence across sectors and governance levels. A policy document analysis was conducted to examine how South African climate change, development and health policy documents reflect the health adaptation response across national and Western Cape levels and to assess the extent of coherence across key health and environment sector policy documents, including elements to respond to health-related climate risks, that can support implementation. Our findings show that overall there is incoherence in South African climate adaptation within health policy documents. Although health adaptation measures are somewhat coherent in national level policies, there is limited coherence within Western Cape provincial level documents and limited discussion on climate adaptation, especially for health. Policies reflect formal decisions and should guide decision-makers and resourcing, and sectoral policies should move beyond mere acknowledgement of adaptation responses to a tailored plan of actions that are institutionalized and location and sector specific. Activities beyond documents also impact the coherence and implementation of climate adaptation for health in South Africa. Clear climate risk-specific documents for the health sector would provide a stronger plan to support the implementation of health adaptation and contribute to building health system's resilience.

Abstract Background Infectious disease outbreaks like Ebola and Covid-19 are increasing in frequency. They may harm reproductive, maternal and newborn health (RMNH) directly and indirectly. Sierra Leone experienced a sharp deterioration of RMNH during the 2014–16 Ebola epidemic. One possible explanation is that donor funding may have been diverted away from RMNH to the Ebola response. Methods We analysed donor-reported data from the Organisation for Economic Cooperation and Development (OECD)’s Creditor Reported System (CRS) data for Sierra Leone before, during and after the 2014–16 Ebola epidemic to understand whether aid flows for Ebola displaced aid for RMNH. We estimated aid for Ebola using key term searches and manual review of CRS records. We estimated aid for RMNH by applying the Muskoka-2 algorithm to the CRS and analysing CRS purpose codes. Results We find substantial increases in aid to Sierra Leone (from $484 million in 2013 to $1 billion at the height of the epidemic in 2015), most of which was earmarked for the Ebola response. Overall, Ebola aid was additional to RMNH funding. RMNH aid was sustained during the epidemic (at $42 m per year) and peaked immediately after (at $77 m in 2016). There is some evidence of a small displacement of RMNH aid from the UK during the period when its Ebola funding increased. Conclusions Modest changes to RMNH donor aid patterns are insufficient to explain the severe decline in RMNH indicators recorded during the outbreak. Our findings therefore suggest the need for substantial increases in routine aid to ensure that basic RMNH services and infrastructure are strong before an epidemic occurs, as well as increased aid for RMNH during epidemics like Ebola and Covid-19, if reproductive, maternal and newborn healthcare is to be maintained at pre-epidemic levels.

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.

Background Outbreaks of infectious diseases like Ebola virus disease, Lassa fever, and COVID-19 have severely strained infrastructural systems and social services across West Africa. We investigated the disruptions caused by emerging outbreaks on access to healthcare, health outcomes, and livelihoods in West Africa. Method A mixed-methods approach was utilized, conducting extensive studies in Nigeria, Sierra Leone, Guinea, and Liberia through structured questionnaires, in-depth interviews with key informants, and focus group discussions. Using a device-to-cloud system guided by GIS for randomized sampling across the four nations, this technique allowed us to comprehensively analyze implications across imposed lifestyle changes on health and wellbeing due to disrupted healthcare. Results Our findings indicate drastic shifts in food consumption patterns and healthcare access. In Guinea, self-reported “Once Daily” meals astonishingly surged from 148 to 775 individuals (p<0.001), with analogous substantial increases observed in Liberia and Sierra Leone. Nigeria exhibited a varied response, with notable rises both in “Once Daily” and “Twice Daily” meal frequencies (p<0.001), reflecting broad dietary adaptations out of necessity. Additionally, there was a significant decrease in consumption of traditional protein sources like bushmeat, beef, and mutton, mainly because of disrupted supply chains and heightened concerns over food insecurity. Conversely, fish consumption slightly fell possibly due to its perceived safety or accessibility amidst the outbreak. Healthcare services faced severe disruptions, particularly acute in Sierra Leone and Liberia compared to Guinea and Nigeria. The interruption of services drastically impacted everything from immunization rates to mental health, with a rise in reported anxiety and depression alongside public dissatisfaction towards the healthcare disruptions. Conclusion This study demonstrates the dramatic effects of infectious disease outbreaks on health access and diets in West Africa. The research calls for integrating health initiatives with social protection to strengthen the resilience of societies to meet all types of health challenges. It is imperative districts establish robust health systems and social security mechanisms to counter future public health crises. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Funding for this study was provided by the International Development Research Centre(IDRC) under the Collaborative One Health Research Initiative on Epidemics (COHRIE). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Sierra Leone Ethics and Scientific Review Committee reviewed and approved the study protocol. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as [ClinicalTrials.gov][1]. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors [1]: http://ClinicalTrials.gov

Although Population-Health-Environment (PHE) approaches have been implemented and studied for several decades, there are limited data on whether, how and why they work. This study provides a process evaluation of the 'Healthy Wetlands for the Cranes and People of Rukiga, Uganda' project, implemented by an NGO-local hospital consortium. This programme involved a research design element, testing two delivery modalities to understand the added benefit of integrating conservation, livelihoods and human health interventions, compared to delivering sector support services separately (as is more usual). The process evaluation sought to understand how the programme was implemented, the mechanisms of impact, how it was shaped by the context in which it was delivered and whether there were discernable differences across the two delivery arms. Methods involved key informant interviews with implementing staff and community educators, a review of programme documents and secondary qualitative analysis of interviews and focus groups with community members. The findings include a statistically significant increase in the reach of the programme, in both service delivery and sensitization activities, when the sectors were fully integrated. It appears that this comparative advantage of integration is because of the improved acceptability and motivation among stakeholders, and increased initiative (and agency) taken by community-based peer educators and community members. We argue that the 'software' of the programme underpins these mechanisms of impact: trust-based relationships embedded in the system enabled coordinated leadership, supported local staff agency and encouraged motivation.

In the autumn of 2014, with the 2013-16 West Africa Ebola epidemic spiralling out of control, the United Kingdom announced a bespoke military mission to support-and in some ways lead-numerous Ebola response functions in Sierra Leone. This study examines the nature and effect of the civil-military relationships that subsequently developed between civilian and military Ebola response workers (ERWs). In total, 110 interviews were conducted with key involved actors, and the findings were analysed by drawing on the neo-Durkheimian theory of organisations. This paper finds that stereotypical opposition between humanitarian and military actors helps to explain how and why there was initial cooperative and collaborative challenges. However, all actors were found to have similar hierarchical structures and operations, which explains how and why they were later able to cooperate and collaborate effectively. It also explains how and why civilian ERWs might have served to exclude and further marginalise some local actors.