Resilience as a major asset to improve population health and wellbeing: a summary of studies and international experiences

Introduction

Resilience is a combination of assets, capabilities and positive adaptation that enables people and communities to cope with adversity. Resilience is an asset that helps individuals and communities to prepare and anticipate potential future threats or seize opportunities to protect and promote their health and wellbeing. Strengthening resilience deserves to be prioritised in programmes and policies to promote and protect population health, tackle health inequities, improve social justice and human rights. This article provides a short summary of the main resilience studies and international experiences in public health, community and system development. There is no doubt that the current COVID-19 pandemic is showing daily the importance of individual, community and system level resilience that is outlined in this contribution.

From deficit-focused to assets-based approaches

In an article written by one of the authors with Professor Antony Morgan in 2007, it was argued that people as well as social systems do not develop because of their deficits, but rather on the strength of their assets and resilience capacities (Morgan & Ziglio, 2007). In that article it was pointed out that asset-based approaches are required to complement the deficit model, with the emphasis being on complementing, rather than replacing.  Since that publication awareness has increased that action to nurture health assets (including the strengthening of resilience) is essential to increase the performance of health and social services and public health programmes. The impact of these can be hampered by overusing the ‘deficit model’. This is an approach that focuses solely on the deficits of individuals and communities. In the health field deficits are measured in negative terms, usually on the basis of mortality and morbidity data. This approach is very prominent in interventions that are based only on what does not work in a community. It overlooks what works well and the potential health assets of the population that can be utilised to achieve more effective health promotion programmes and public health policies. (Morgan and Ziglio, 2007; 2010).

The approach that was recommended in that 2007 publication has been taken up and further refined in studies and practical experiences around the world. The publication Health Assets in a Global Context (Davis et al, 2010) is a compendium of the these studies and experiences. On issues related to resilience in the area of development and sustainability several publications by the Overseas Development Institute are worth mentioning (Lovell et al., 2015; Bahadur et al., 2015). Publications by the Rockefeller Foundation; Oxfam, and the Enrich network (O’Sullivan et al., 2016) add to the increasing literature on resilience in the health and wellbeing domains. These are excellent examples of the conceptual development as well as practical applications of the asset approach and its link with action to strengthen resilience.

In the United Kingdom an outstanding contribution to the asset approach has been made by Jane Foot and Trevor Hopkins in the publication A Glass Half Full - how an asset approach can improve community wellbeing (Foot and Hopkins, 2010).  In the UK there are a number of ground breaking publications particularly on community-based actions related to resilience. This development has inspired progress in UK as well as elsewhere (Friedly et al., (2009); Foot, (2012); Bartley (2013); South, (2015); Hopkins and Rippon (2015). In Scotland the publication by the Glasgow Centre for Population Health, Resilience for population health - transformation in people and communities is an excellent work with practical policy implication for community resilience.   The recent document by Public Health Wales “Resilience: understanding the interdependence between individual and communities” is also worth mentioning (2019).

Defining resilience as a health asset

Various definitions of resilience can be found in the scientific literature. Notwithstanding their differences, they all point to the fact that resilience is related to processes and skills that result in good individual and community health outcomes, in spite of negative events, serious threats and hazards (Masten, 2001; APA, 2009; Bartley, 2013). More recently this definition has been broadened to include action to strengthen the resilience of communities and social systems (Blanchet et al., 2016; WHO, 2017b).

In the health field the concept of resilience was originally referred to in terms of children and young people but has since been broadened to incorporate adults and elderly people (Werner, 1977; Schoon, 2006; Masten et al., 2010; Hildorn et al., 2010; Southwick et al., 2014).

Three reports published by the European Office of the World Health Organization have extensively explored the issue of resilience as an asset for population health and sustainable development outcomes (WHO, 2017a; 2017b; 2018). In these reports the importance of system-level resilience is explored with specific focus on population health, the UN’s Agenda 2030 and its seventeen Sustainable Development Goals (WHO, 2017b).

Three levels of resilience for health and wellbeing outcomes

In the scientific literature three levels of resilience are usually identified: individual, community and system (Ziglio, Azzopardi-Muscat, et al., 2017)

The American Psychological Association defines individual-level resilience as the process of adapting well in the face of adversity, trauma, tragedy or threats. It also includes coping with significant stress caused by problematic and toxic relationships within the family or the workplace and the capacity to bounce back from difficult experiences (APA, 2009). Similarly, community resilience is seen as the ability of social groups to withstand and recover from unfavourable circumstances.

Community resilience is usually associated with social relationships and the activation of local resources that enable communities to cope with, counteract and anticipate unhealthy stressors (Sherried et al., 2010; WHO, 2012; South, 2015). The latter may include social and economic factors such as poverty, natural disasters, isolation and other challenging circumstances. Community assets such as levels of solidarity and mutual trust among its members, the quality of social networks and other salutogenic resources have proven to be protective and promoting factors to health and wellbeing (Lindström et al., 2006; Kawachi, 2010; Magis, 2010; Hopkins et al., 2015).

A recent WHO compendium with inspirational examples of supportive environments for resilient communities is a useful resource describing international experiences of how resilience can be strengthened at all the three levels outlined above (WHO, 2018). Analysing initiatives in 13 countries the compendium illustrates that building resilience is shaped by the availability of supportive environments. Interventions to strengthen resilience are more effective when supported by environments that promote and protect population health and wellbeing (WHO, 1986). The WHO compendium describes several inspirational examples that demonstrate the importance of supporting environments for resilience strengthening at community level. Some of these have been collected within the UK context (Rippon et al., 2018; Wharton et al., 2018; Bezeczky et al., 2018).

Supportive environments are essential for people to increase control over the determinants of their health. The notion of being in control is intrinsically linked to individual, community and system-level resilience. The level of control (or lack of it) that a person has over her/his life is a key factor in the social determination of health and health inequities (WHO, 2008; Whitehead et al., 2012, 2014).

The concept of system-level resilience originated in studies in the field of ecology and ecosystems (Holling, 1973). System-level resilience is defined as the capacity of a system to absorb, adapt, anticipate and transform when exposed to external threats or shocks that bring about new challenges and opportunities while retaining control over its remit and pursuit of its primary objectives and functions. Resilient systems develop the capacity to absorb, anticipate or recover from shocks, while adapting and transforming positively their structures and means of operating (Mitchell, 2013).

Strengthening system-level resilience is particularly dependent on the capacity of a given system to manage the internal and external factors that have an influence on its development (Walker et al., 2004). Strengthening health system resilience is seen as instrumental to tackling current and future patterns of ill-health; creating conditions for the protection and promotion of health; the reduction of health inequities; and increasing preparedness to deal with unexpected risks to population health (Kieny et al, 2014).

Four main types of resilience capacities

There are four types of capacity that can be applied to the three levels of resilience. They are defined as absorptive, adaptive, anticipatory and transformative (Ziglio, et al., 2017).

• Adaptive capacity refers to the ability of individuals, communities and systems to adjust to disturbances and shocks.
• Absorptive capacity is the ability to absorb and effectively cope with disturbances and shocks. It is the capacity to manage and recover from adverse conditions, drawing on available skills, assets and resources. It must be pointed out that resilience at individual, community or system level is not limited to “reactive” capacity. There is increasing interest in ‘pro-active’ resilience capacities, described as anticipatory and transforming (2017b).
• Anticipatory capacity is the ability to predict and reduce disturbances and risks by means of pro-active action to minimise vulnerability.
• Transformative capacity applies mainly - though not exclusively - to systems. It refers to their ability to transform their structures and means of operating to better address change and uncertainty. It is the ability to develop systems that are more suited to the new or changing conditions. In public health this capacity is very important when technological and medical breakthroughs, cultural or demographic changes can render existing policies and practices rapidly obsolete or untenable (WHO, 2017a; 2017b).

Resilience at system-level can be strengthened by the introduction of new financial mechanisms to increase the economic sustainability of the system to anticipate and counteract possible future crises (WHO2017b). System resilience is about the capacity of a system to transform dysfunctional and obsolete practices that do not allow the system to perform in accordance to its mission. Many lessons on how to increase resilience at system level are sadly learnt from the catastrophic impact of Covid-19. The pandemia has once more demonstrated that our individual and collective health is inextricably linked to that of our family members and neighbourhood. It has shown the critical role of civil society level of solidarity, community action and mutual support. It has clearly highlighted the key importance of system level resilience of our institutions. The latter include the action of governments, the functioning of public health, the work of health care providers, school teachers, delivery service people, grocery store clerks, factory workers, and the voluntary sectors, among others (RWJF, 2020)

If the Covid-19 is showing in a dramatic way the importance of the four types of capacity resilience outlined earlier, the role of system level resilience is salient in basically all domains dealing with health and wellbeing. A very good example here is the mounting awareness of the need to address system level gaps to better perform prevention of child neglect and abuse (WHO, 2006; Council of Europe, 2011). Several studies have shown that in many countries the way in which forensic interviews are conducted with abused children may contribute to retraumatization of child victims of abuse (Anderson et al 2010); CJEWILSP, 2014). In addition, the healing process of abused children is often jeopardised by the lack of coordination, cooperation and integration of action involving sectors such as health, social services, police and criminal justice and others. Such system deficiencies do not create a supportive environment for healing and resilience. Thus, in order to pursue a more effective approach to the prevention of child abuse, maltreatment and neglect radical and innovative action is needed. Examples of transformative capacity in this domain have been inspired by Iceland’s Barnahus (Ziglio et al., 2017). This approach is fortunately impacting to change obsolete country practices in the field child abuse prevention and the healing processes related to the strengthening resilience and recovery of the victims of abuse (PROMISE, 2020).

An increased role of health promotion and health literacy can be instrumental in strengthening resilience for individuals and communities; resulting in better access to services and enabling their more beneficial use. Resilience-transforming capacity could be applicable to a wide range of policies and creating supportive conditions for improved health and wellbeing (Kickbusch et al., 2012; 2014).

Considerations for proper inclusion of resilience within the asset approach

The first consideration is related to the specifications that should be made when resilience is used in connection to the asset approach. These specifications should include clarity about the nature of the risks or the causes of the vulnerabilities that resilience is meant to address. Another specification is clarity about the level or context in which action designed to improve resilience should have impact (that is, individual-, community- or system-level resilience). Furthermore, efforts should be made to clarify the type of processes and measures that are intended to be used to strengthen resilience. Unwanted side-effects as a result of the measures undertaken should always be highlighted. These processes and measures can differ according to the level and capacities of resilience that are to be strengthened.

The second consideration is related to the importance of linking resilience to supportive environments.  Strengthening resilience doesn’t happen in a vacuum. Collaboration among policy sectors and the full engagement of civil society are crucial for the development of supportive environments and for strengthening resilience and tackling inequities (Popay et al., 2018).

The third consideration is related to taking a system-level approach to resilience building. Action here should include credible efforts to change unhealthy social, environmental and economic conditions and toxic power relationships. Structural action is often needed to create opportunities for people and communities to promote and protect their health. Resilience-building and the promotion of health are political processes in addition to scientific and professional domains (WHO, 2017a; 2017b). The adoption of pro-resilience policies in sectors such as health, environment, education, benefits, housing, urban design, transport, agriculture and labour policy is highly desirable. These are policy areas in which progress should be made to develop appropriate know-how, professional skills and accountability mechanisms, as well as a legislative framework to facilitate pro-resilience policies. (WHO, 2017b).

The final consideration is related to the realisation that resilience is not a personal or community unmodifiable characteristic. It is the result of a developmental process that can become stronger over time and be accelerated by other health assets and supportive environments.  Strengthening resilience should be based on a holistic view of the context in which individuals, communities and systems cope with, and anticipate, problems to protecting and promoting health. Action designed to strengthen resilience should be planned not just as a reaction to health threats. Most importantly it must be proactive and create the conditions for resilience to flourish at individual, community and system levels.