Community briefing paper v 3 20161110[1]

Director:ChristineHancockCANMezzanine,7–14GreatDoverStreet,LondonSE14YR,UnitedKingdom;Tel+44(0)2030967706

www.c3health.org;Twitter@c3health

C3CollaboratingforHealthisaregisteredcharity(no.1135930)andacompanylimitedbyguarantee(no.6941278),registeredinEnglandandWales.

HealthyLives

Communities

April2016

ThisworkisfundedbytheHealthFoundationandproducedbyC3CollaboratingforHealth.TheHealthFoundationisanindependentcharitycommittedtobringingaboutbetterhealthandhealthcarefor

peopleintheUnitedKingdom.

1.Executivesummary 2

2.Introduction 3

3.Thebigissues:thecurrentposition 4

3.1Comparinglikewithlike:anecologicalfallacy? 4

3.2Promotingcommunityempowerment,engagementandparticipation 6

3.3Socialinteractions 9

3.4Environmentalfactors 12

3.5Focusingonprevention 13

4.Whatworksandwhatdoesn’t? 14

4.1Research-basedevidence 14

4.2Whatishappeninginpractice?Practicalevidence 21

5.Challengesandgaps 29

6.Talkingpoints 31

Annex1:Keyplayers 33

Annex2:Evidencetables 35

Table1:Engagementandparticipation 35

Table2:Place-basedinterventions 37

Table3:Socialmediaande-health 40

Table4:Mentalhealthandsocialisolation 43

Table5:Environment 45

Table6:Ruralhealth 51

References 52

2 Communitiesbriefingpaperwww.c3health.org

1.ExecutivesummaryTheaimofthisbriefingpaperistoprovidebackgroundinformationandanoverviewofthecurrentevidenceonthebenefitsofpromotinghealthybehavioursinlocalcommunities.Liketheotherpapersinthisseries(onEarlyYears,ChildrenandYoungPeople,andWorkplaceHealth),itisarapidreview,notafull-scalesystematicreviewoftheliterature.

Recentlegislativeandstructuralchangeshavecreatedopportunitiesforpublichealthandhealthcaretobecomemorecommunitycentred–buttherearemanywaystofostergoodhealththatgowellbeyondthehealthsystemitself.Section2introducestheunderlyingrationalefortacklinghealthatverylocallevel,asstatedintheMarmotpolicyobjectiveof‘creatinganddevelopinghealthyandsustainableplacesandcommunities’.

Section3reviewsthe‘bigissues’attheintersectionofthecommunityandhealth.Itbeginsbylookingathow‘community’isdefinedinthepaper(ageographical,neighbourhood-basedapproach,ratherthancommunitiesofinterest,ageorethnicity)andhighlightingtheneedtoberigorousinunderstandingsimilaritiesanddifferencesbetween,forexample,urbanandruralcommunities.Inequalitiesinthesocialdeterminantsofhealthareattheheartofmanyhealthissuesatlocallevel–forexample,poorhealthliteracy,whichgoeswellbeyondunderstandinginstructionsfromhealthprofessionals:itisaboutknowinghowtoleadahealthylife.Butevenwherethereisknowledge,knowingdoesnotmeandoing–andengagingcommunitiestotakeactiontomakeiteasiertobehealthylocallyisessential,includingthroughidentifyingandempoweringlocalpeopletotaketheleadthemselves,improvingthephysicalenvironment,andencouragingsocialinteractionsusingface-to-facesocialnetworksandsocialprescribing(whichcanhelptoovercomesocialisolation,itselfamajorriskfactorforillhealth).

Giventheincreasingemphasisontheneedtoaddresshealthlocally,researchinto‘whatworksandwhatdoesn’t’inpromotingcommunityhealthissurprisinglysparseacrossmanyimportantareas,asisclearinsection4.1,whichlooksatthereviewevidence(thisissupportedbytheeightEvidenceTablesinAnnex2).Section4.2breatheslifeintothedata,presenting12casestudiescoveringstrengtheningcommunities,volunteer/peerroles,partnership/collaborationandsmartaccessofcommunityresources.Thereareexamplesofempowerment/engagement,socialprescribing,andenvironmentalandpreventativefactors,drawnfromacrosstheUnitedKingdomaswellasfromEuropeandtheUnitedStates,andallinvolvesomelevelofevaluation.

Theissueofevaluationisathreadrunningthroughoutthepaper,highlightedparticularlyinsections5(challengesandgaps)and6(talkingpoints).Thereisanurgentneedtoimproveevaluationofprojects,nolongertryingtorelyontraditionalrandomisedcontrolledtrialsandothersuchapproaches,butmovingtowardsmethodsthatcanbettercapturethecomplexchallengesofandopportunitiesforhealthatneighbourhoodlevel.Wemustbewillingtoputhumanandfinancialresourcesintowhatweknowworkstomakechangesustainableoverthelongterm,harnessingthemanyassetsthatarealreadyembeddedwithinlocalcommunities.Realchangewillrequiremovingawayfromamedicalparadigmandfindingbetterwaysofworking(andmeasuringwhatworks)toimprovehealthwherepeopleactuallylivetheirlives.


2.Introduction‘[T]hecommunity–inthefullestsense:aplaceandallitscreatures–isthesmallestunitofhealth…

tospeakofthehealthofanisolatedindividualisacontradictioninterms’(Berry2002)

Suchstatementshighlightthepotentialofcommunitiesforpublichealth,andalthoughrecentlegislativeandstructuralchangeshavecreatedopportunitiesforpublichealthandhealthcaretobecomemorecommunitycentred(PHE2015a),therearemanywaysinwhichhealthcanbeencouragedthatgowell

beyondthehealthsystemitself.Butwhatdoweactuallymeanbycommunities,andhowcanthispotentialbeactualised?

Theconceptofcommunityhidesgreatcomplexity,withdefinitionslargelydrawingoutthreeaspects:

• sharedlocationorplace–thisdefinitionfocusesongeography,andmayalsobereferredtoaslocalityorneighbourhood;

• sharedcharacteristics–ininterestor‘elective’communities,peopleshareacommoncharacteristicotherthanplace;theyarelinkedtogetherbyfactorssuchasreligiousbelief,sexualorientation,occupationorethnicorigin;and

• senseofattachment–thisreferstoasenseofbelongingtoaplace,grouporidea(inotherwords,whetherthereisa‘spiritofcommunity’)(Smith2001).

Eachofthesesensesofcommunitycananddoesoverlap.Forinstance,peoplefromoneethnicgrouporwithasharedbehaviouralcharacteristicmaycongregateinaparticularareaofatown.However,theliteratureforeachofthesetopicareasisvast,requiringthisbriefingpapertotakeamorefocusedapproach.

Inpublic-healthterms,oneofthekeychallengesistoidentifywherethepotentialinterventionpointsare–namely,whereactioncanbetakentopromoteandimprovethehealthoftheindividualandthepopulationasawhole.Forthatreason,thispaperisfocusingontheconceptualisationofcommunityasshared

locationorplace.ThisapproachisinlinewithoneofthesixkeythemesoftheMarmotReview,FairSociety,HealthyLives(Marmot2010):‘createanddevelophealthyandsustainableplacesandcommunities’.Thispaperwillbeparticularlyconsideringtheevidenceonhowtoidentifyandutilisetheintersectionpoints–suchasschools,pharmacies,sociallandlordsandotheragencies–whichactasaninterfacebetweentheindividualandcommunityinfrastructure.Wherethedatahasbeenpresentedinotherpapers,forexampleonthepotentialroleofworkplaces,thiswillbesignposted,ratherthanre-presentedhere.

TheWorldHealthOrganizationhighlightsthat23percentofglobaldeathsareduetomodifiableenvironmentalfactors(Prüss-Ustünetal.2016)–sowherewelivehasamajorimpactonhealth.AsMarmot’sreportshavedemonstrated,socialandeconomicfeaturesofneighbourhoodshavebeen,andcontinuetobe,linkedwithmortality,generalhealthstatus,healthbehavioursandotherriskfactorsforchronicdisease,aswellaswithotherimportanthealthindicators.IntheUnitedKingdom,asanexample,intheleastdeprivedareas,peopleaged80–84reportbetterratesofhealththanthose20yearstheirjuniorinthemostdeprivedareas(ONS2014a).

Akeyunderlyingrationalefortheapproachadoptedbythisbriefingpaperistheneedtoidentifyevidenceforlocalactionthatcanempowercommunitiesandaddressthesocialgradientinhealthin

neighbourhoods(Marmotetal.2010).ThisbuildsontheadvicefromtheWorldHealthOrganization’sGlobalActionPlanonNon-communicableDiseasesthat‘empowermentofpeopleandcommunities’isessentialintacklingchronicdisease(WHO2013).ThereisalsoastrongcallinthenewSustainableDevelopmentGoals(Goal16)for‘responsive,inclusive,participatoryandrepresentativedecision-makingatalllevels’,includingcommunitylevelwherebasicneedsaremet(UN2015).Policyatinternationalandnationallevelmustbedeliveredthroughactionlocallytocreateanenvironmentinwhicha‘cultureofhealth’canthriveinschools,workplaces,neighbourhoodsandhomes(RJWF2016).


Otherpapersinthisserieslookspecificallyatdefinedstagesofthelifecourse–EarlyYears,ChildrenandYoungPeople,andpeopleintheWorkplace.Forthisreason,thispaperwillonlytouchlightlyontheseareas,insteadhighlightingapproachestoaddressingthesystemicchallengesassociatedwithlivinginneighbourhoodsatallages,focusingonthetypesofpreventionactivitiesthatcanoccurincommunities(healtheducation,structuralinterventions,tacklingsocialisolation,usingnewtechnologies,etc.).Ineffect,thepurposeofthispaperistolookattheevidenceaboutwaystosupportpeopleintheenvironmentsinwhichtheylive,navigatingtheirexperiencesandmeetingthelifestylechallengestheyfaceonadailybasis,suchasbuyingandpreparingfoodonalowbudget,adoptingactivelifestylesforthemselvesandtheirfamilies,andnotsmokingordrinkingtoexcess.

3.Thebigissues:thecurrentpositionThissectionsetsoutthebigtheoreticalandpracticalissuesinimprovinghealthofcommunities.Section4.1thensetsoutwaysinwhichtheresearchcommunityhasbeguntotakeontheseissues–andsection4.2providespracticalexamplesineacharea,12casestudiesofinnovationinhealthinlocalcommunities.

3.1Comparinglikewithlike:anecologicalfallacy?

‘Community’meansdifferentthingstodifferentpeople.Inthemodernworld,thiscomplexityisfurtherenhancedwiththeadventofnewtechnologyandgreateraccesstotransportlinks,makingitpossibletotakeamuchmorefluidapproachtodefininganddelimitingacommunity.Discussionsoncommunitieswithintheacademicliteraturereflectthisfluidity,whichinturnaffectstheinterpretationoftheliteratureandtheabilitytoapplythekeyfindingstoothercommunitiesandsettings.

Toooften,thereisalackofclarityaboutwhatismeantby‘community’withinprojectsandstudies,makingitmoredifficulttodeterminewhoisincluded,whoisexcluded,andwhetherweareinfactcomparinglikewithlike,evenwithostensiblysimilarprojectsandinterventions.Thisinturnaffectsconfidenceinthegeneralisabilityorpotentialapplicability,replicabilityorsustainabilityoffindingstoothercommunities.Evenwhereprojectsgivedetailsoftheethnicity,backgroundorsizeofthepopulationincludedwithintheirproject,thismayhidesignificantculturaldiversity,skewingofpopulationdistribution,orsocioeconomicfactors,whichinturnmayaffectconfidenceinthetransferabilityofapparentlyeffectiveinterventionstoothercommunities.Furthermore,muchoftheliteraturefocusesonsmall-scaleprojects,withinaverylimitedpopulation–oftenclearlydefinedbyasharedcharacteristic(suchasHIVstatus),withfewerexamplesoflarger-scaleprogrammesworkingacrossdiversepopulationswithinadefinedgeographicalarea(South2014).

Thelackofasystematicapproachtoaddressinggeographicalcommunityhealth,supportedbytheuseoftheexistingclassifications,maybecreatingandsustainingan‘ecologicalfallacy’–thefailuretorecognisethatnoteveryonelivinginadeprivedareaisdeprived,andthatmanypeoplewhoareexperiencingtheeffectsofdeprivationdonotliveindeprivedareasatall(thisisillustratedbythedifferencesbetweenurbanandruralareas–seetheboxonthenextpage).Oftenthereismorevariationwithinareasthanthereisbetweenthem.Andinsomecases,theremaybehiddensimilarities,forwhichwehavenodirectevidence–suchasattitudestowardsfood(portionsizes,diet,takeawaysetc.)andthepropensitytotraveltotakepartinpositiveactivities:a500mroamingdistance(a6–10-minutewalk)isasfarasmany(particularlychildren)willtravelfromtheirhome(Shawetal.2015;Charriereetal.2016)

Thisaddsweighttotheneedforamoresystematicapproachtogeographicalcommunityinterventions,witharobustapproachtoidentifythepopulationsubgroupswithineachgeographicalarea,andtomaptheassetswithinanareasothatappropriateinterventionpointscanbeidentifiedandusedeffectively.


Ruralversusurbancommunities

Tousethedistinctionbetween‘rural’and‘urban’communitiesasanexample,therearenumerousdefinitionsandconceptualisationsintheliteratureofwhatconstitutesrural/urban,andthewayinwhichtheseconceptsaredefinedandunderstoodinfluencestheapproachtakentoprojectsandprogrammes,withmuchoftheliteratureonhealthycommunitiesandinterventionsfocusingontheexperiencesofpeoplelivinginurbanenvironments(reflectingtheconcentrationofthepopulationintownsandcities).Nevertheless,theUKgeographicallandscapeisstillpredominantlyclassifiedasrural,althoughthepopulationisnotevenlydistributed,withthemajorityofthepopulationlivinginurbanareas(Clokeetal.1997)(seeTableA).Measuresusedintheliteraturetodistinguishruralandurbanareasgenerallynotepopulationdensity,accessibilityoffacilities,landusage,andthesizeofthelocalsettlements.

TableA:Urbanandruralareascompared

Measure Urban Rural

Populationdensity(ONS2013)

81.5percent(45.7million)(EnglandandWales)

18.5percent(10.3million)(EnglandandWales)

Populationprofile(ONS2013)

Medianageis37

84.7%werebornintheUK

77.2%arewhiteBritish

Medianageis45

94.9%werebornintheUK

95%arewhiteBritish

Healthperception Generallyreportlowerlevelsofhealththanpeopleinruralareas(Riva2009)

Proportionofresidentsreportinggoodhealthrangedfrom77.4%intheNorthEastto83.8%inLondon(ONS2011)

Morelikelytoreportbetterlevelsofhealththanthoseinurbanareas(Riva2009)

NorthEasthadthelowestproportionofruralresidentsreportinggoodhealth(76.9%);theSouthEasthadthehighestproportion(84.4%)(ONS2011)

Variablehousingavailabilityandgentrificationofareas

Housingstockoftenpoorerinurbanareas

Housingoftenprohibitivelyexpensiveandthecostoflivingoftenhigherinruralcommunities

Limitedemploymentopportunities

Unemploymentratesininner-cityareasmaybedisproportionatelyhigher

Rangeofavailablejobsandtrainingopportunitiesoftenlowerinruralareas

Accesstoservices Generallygoodaccess,althoughpopulationdensitymaybeanissueforwaitingtimes

Declineandcentralisationofservices(localshops,pub,primaryschool),poortransportlinksandissuesofisolationinruralcommunities(Manthorpeetal.2008),andhealth-carefacilities(GPsurgery,pharmacy,hospital)maynotbenearby

Notallruralorurbanareasexperiencethesamechallenges,anddescriptionsoftheproblemsofinnercitiesorruralareasmayfailtocapturethediversityofexperienceoftheresidents(Pateman2011;Kennyetal.2013).Therearesignificanthealthinequalitieswithinsmallruralareas,despitethereportsofbetterperceivedhealthstatus,andtheseinequalitiescannotbeexplainedsolelybythecharacteristicsofthelocalpopulations,i.e.therewasaneighbourhoodeffectoverandabovethatofthepopulationcharacteristics(Rivaetal.2009).


3.2Promotingcommunityempowerment,engagementandparticipation1

3.2.1Anassetsapproach

‘Anassetsapproachtohealthanddevelopmentembracesapositivenotionofhealthcreationandindoingsoencouragesthefullparticipationoflocalcommunitiesinthehealthdevelopmentprocess’(ScottishGovernment2009).

Oneofthekeychallengestobeaddressedincreatinghealthycommunitiesistheneedtofocusthephysicalassetsandskillsoftheresidentsonthepreventionofchronicdiseasesandreducinghealth

inequalitieswithinandbetweenlocalareas.Asalutogenicapproach2thatfocusesonassets(TableB)ratherthanperceiveddeficitscanbesuccessfulinimprovinghealthandwellbeing(ScottishGovernment2009).Thereareexamplesofthisworkinginpractice,buttodateithasnotbeensystematicallydeveloped,withprojectsinmanycommunitiessufferingfromshort-termorterminalinsecurityoffundingandhenceprovingtobeunsustainable.

TableB:Whatisanasset?

Ahealthassetisanyfactororresourcewhichenhancestheabilityofindividuals,communitiesandpopulationstomaintainandsustainhealthandwellbeing.Theseassetscanoperateattheleveloftheindividual,thefamilyorcommunityasprotectiveandpromotingfactorsthatcanactasabufferagainstlife’sstresses(MorganandZiglio2007).

Anassetisanyofthefollowing:

• thepracticalskills,capacityandknowledgeoflocalresidents;

• thepassionsandinterestsoflocalresidentsthatgivethemenergyforchange;

• thenetworksandconnections–‘socialcapital’–inacommunity,includingfriendshipsandneighbourliness;

• theeffectivenessoflocalcommunityandvoluntaryorganisations;

• theresourcesofpublic-,private-andthird-sectororganisationsthatareavailabletosupportacommunity;and

• thephysicalandeconomicresourcesofaplacethatenhancewellbeing.

Source:IDEA2010.

Identifying,harnessingandincreasingtheskillsandcommitmentofcommunityleadersandstakeholderstodevelopandpromotelastingstrategiesthathelppeoplemakehealthychoiceswheretheylive,learn,workandplayiscrucialtoasalutogenicapproach.Empoweringpeopleprovidesenergyfornewwaysofchallenginghealthinequalities,valuingcommunityresilience,andrecognisingandstrengtheningexistingcommunitynetworksandexpertise.Theboxonthefollowingpageprovidesanexampleofanassetapproachinpractice:cancerchampions.

1TheNationalInstituteforHealthandCareExcellence(NICE)usestheterms‘communityengagement’and‘communitydevelopment’almostinterchangeably.Thekeydefiningcharacteristicappearstobethatengagementisatop-downprocess,anddevelopmentisabottom-upprocess(Fisher2016).2‘Salutogenesis’describesanapproachfocusingonfactorsthatsupporthumanhealthandwellbeing,ratherthanonfactorsthatcausedisease.


3.2.2Communityempowerment

Communityempowermenthaslongbeenacentralplankofhealth-promotiondiscourse,referringbothtotheprocessofenablingcommunitiestotakecontrolovertheirownlivesand,theoreticallyatleast,theoutcome(Kennyetal.2013).Itismorethantheinvolvement,participationorengagementofcommunities;itimpliescommunityownershipandactionthatexplicitlyaimsatsocialandpoliticalchange.Itrecognisesthatifsomepeoplearegoingtobeempowered,thenotherswillbesharingtheirexistingpowerandgivingsomeofitup(Baumetal.2008).Wherecommunitiesareempoweredthereoughttobevisibleevidenceofaboostinlocaldemocraticparticipation;increasedconfidenceandskillsamonglocalpeople,highernumbersofpeoplevolunteeringintheircommunities,andmoresatisfactionwithqualityoflifeinalocalneighbourhood.

However,makingcommunityempowermentoperationalremainsathornychallenge.Itisdifficulttomeasure,andoftendifficulttoimplement,overlappingwithothertheoreticalperspectivessuchascommunitycapacityandsocialcapital.

Oneofthekeychallengesisaroundthelegitimacyofrepresentation(Kennyetal.2013).Thereissignificantevidenceshowingthatinmanycasesindividualswhohavethetime,energyandmotivationtobecomeinvolvedininterventionsandprogrammes,mayinfactnotbesupportedbytherestofthecommunity,leavingariskthatdominantminoritiesmaydictatecommunityneedsunlessadequateprecautionsaremadetoinvolveasmanypeopleaspossible.Acarefulmappingofthehumanaswellasfinancial,environmentalandotherassetsofacommunity–mappingofbothpeopleandplace–canhelptoaddressthis,althoughcommunities(andorganisationsworkingwithcommunities)mayhavelimitedunderstandingofhowtoidentifytheseresources.

Anumberoftechniquescanbeusedsinglyandcorporatelyfordiscoveringandmobilisingcommunityassets(IDeA2010):

• assetmapping(developingandutilisingamaporinventoryofcommunityresources,skillsandtalentstocreatenewpartnershipsandre-energiseexistingsupportmechanisms);

• asset-basedcommunitydevelopment(locatingcommunityassets,buildingrelationships,mobilisingresidents,identifyingastrategicgoal,andleveragingresourcestodrivechange);

• appreciativeinquiry(consultativetechnique,focusingonwhatworks);

• story-telling(informalwaytocollectexperiences);

• WorldCafé(engagementtechnique,particularlyusefulinconferences,communitiesandworkshops);

• participatoryappraisal(localpeopletrainedtoresearchviews,knowledgeandexperienceofneighbourhoodstoinformneedsassessmentandappraisal);and

Anassetapproach:cancerchampions

TheDepartmentofHealthhasadaptedanassetapproachinanumberofitscommunityprogrammes.Oneoftheseisthecancerchampionsprogramme,withlocalvolunteerstrainedtosupportpeopletotalkaboutcancersignsandsymptoms,dispelcancermythsandencouragepeopletotalktotheirGP.Theprogrammerecognisesthatlocalpeoplehaveknowledge,skillsandnetworksthatcanbemobilisedtoimprovehealth.OneexampleistheNorthEastLincolnshireCommunityHealthProject,alocalcancerchampionprojectthatisconceived,planned,testedandcarriedoutsolelybyvolunteersfromthelocalcommunity,whodrawontheirexistinglocalnetworkstoaccesspeople.Theimpacthasbeennotable–inthefirsttwoyearsoftheproject,thenumberoftwo-weekwaitreferralsforcervicalandbowelcancerincreasedby25percentand31percentrespectively,andby66percentforprostatecancer(IDeA2010).


• open-spacetechnology(meetingwithnofixedagenda–participantsdeterminethereal-timeneedonwhichtofocus).

Seesection4.2.5,casestudy9,fortheexampleofCHESS®,anasset-mappingtool,andhowitwasusedtosupportchildren’swellbeingineastLondon.

Communitydevelopmentworkerscanplayanimportantroleinhelpingcommunitiesidentifylocalassets,aswellasfacilitatingplansandco-creatingactivitieswithlocalpeopletoenablechange.Theyworkasalinkbetweenthecommunityandarangeofotherlocal-authorityorvoluntary-sectorproviders,includingpolice,teachersandsocialworkers.

Thescopeoftheagendatoo,canbeachallenge.Manyhealth-improvementinitiativesbeginwithring-fencedfundingforashort-termprojectonaspecificchallenge,suchaspromotingphysicalactivity.Ineffect,theagendahasalreadybeenset,andtheprocessofinvolvingthecommunityismoreaboutengagementthanempowerment.Trueempowermenttakesabottom-upapproach,withthecommunityitselfaskedtoidentifythekeychallenges,whichwouldthenbeaddressedusingthecommunity’sownassets,supportedbyotherservicesandorganisations.Asset-basedapproachesareanintegralpartofcommunitydevelopmentinthesensethattheyareconcernedwithfacilitatingpeopleandcommunitiestocometogethertoachievepositivechangeusingtheirownknowledge,skillsandlivedexperienceoftheissuestheyencounterintheirownlives.

Mobilisingexistingcommunityassetscanhelptoalleviatetheeffectsoflong-termdisadvantage.AjointreportbyPHEandNHSEnglandmakesacompellingcasefor‘afamilyofapproaches’toharnesstheenergywithincommunitiesaspartofashifttomoreperson-andcommunity-centredworkingpatterns.Suchinterestdemonstratestheincreasingpolicyfocusoncommunities,indicatingthisapproachwillbecomeincreasinglyimportant(PHE2015a).

3.2.3Communityengagement

Theconceptofcommunityengagementcoversabroadrangeofactivities.3NICE(2014)identifiesfivegenericapproaches(Figure1,column1),whichinturnimplyaroleforthemembersofthecommunity:(Figure1,column2).

Figure1:CommunityEngagementPyramidshowingtieredapproachestocommunityengagement

Sources:NICE2014andBLF2014.

3Seealsosection4.1.2forthelackofclarifyaroundcommunity‘empowerment’and‘engagement’.

• Providerofservices- deliveringservicesCommunitycontrol

• Decision-maker- developingsolutionsDelegatedpower

• Contributortomanagement-commentingondecisionsCo-production

• Advisoryrole,providingguidanceandadvice-beingasked

Consultation

•Userandbeneficiaryofservices,etc.-beinginformed

Informationprovisionandexchange


Whilelower-levelengagement(suchasinformationsharing)canimproveawareness,uptakeandeffectivenessofservices,higher-levelengagementenablingmoredecision-makinginthecommunitybythecommunity,ismorelikelytobuildconfidence.Bothapproachescanimprovehealth,butcommunityengagementworksbestwhereitisanongoingcumulativeprocessenablingrelationshipsandtrustto

buildandstrengthenovertime(see,forexample,PHE2015aandNICE2014).

Keycommunity-engagementcomponentsthataffecthealthoutcomescanincluderealpower-sharing,collaborativepartnerships,bidirectionallearning,incorporatingthevoiceandagencyofbeneficiarycommunitiesinresearchprotocol,andusingbiculturalhealthworkersforinterventiondelivery(Cyriletal.2015).NICEhasalsoproducedaguidelineonimprovinghealthandwellbeingthroughcommunityengagement(seebox).

3.3Socialinteractions

JohnDonnefamouslysaid‘nomanisanisland’and,facedwiththeincreasingcomplexityandinter-relationshipsofmodern-daysociety,supportedbytheadventofnewtechnology,thisquotecontinuestoresonate.Thereisasignificantandgrowingevidencebaseshowingthatsocialinteractions–betheyface-to-faceoronline–canimpactpositivelyonthehealthofindividuals,familiesandcommunities,improvingconfidenceandabilitytomakedecisionsabouttheirownhealth.

3.3.1Socialnetworks

Goodsocialnetworks–thewebofrelationshipswithfamily,partner,friendsandcolleagues–havepositivecognitive,emotional,behaviouralandbiologicalinfluencesonourhealth(Dodds2016).Thereisgoodevidenceacrossarangeofhealthandwellbeingconditionsthatactivesocialnetworksimprovepopulationresilience(Fisher2016;Bartley2006),reducingtheriskofexperiencingmental-healthissues(Jenkinsetal.2008),depression(MorganandSwann2004)andsupportingpeopletocopebetterwitheconomicproblems(Bartley2006).Inaddition,thereareothersocietalbenefits(Fisher2016)withevidencetoshowreducedrisksofdelinquency(Sampsonetal.1997),crime(Fulbright-AndersonandAuspos1986),andpositiveassociationswithemployability(ClarkandDawson1995)andsocialcohesion(Fulbright-AndersonandAuspos1986).Butthebenefitsarenotrestrictedtoindividuals–socialnetworksmaycascadeandamplifytheeffectofinterventionsbeyondtheimmediateparticipantsinasocialinteraction(Perkinsetal.2015).However,socialnetworkscanalsohavenegativeeffectsthatcanspreadunhealthybehaviours(ChristakisandFowler2007;ChristakisandFowler2009),suchasobesity(section4.1.3.1).

NICEGuidance:CommunityEngagement:ImprovingHealthandWellbeingandReducingHealth

Inequalities

ThislatestguidelinefromNICEcoverscommunityengagementapproachestoreducehealthinequalities,ensuringthathealthandwellbeinginitiativesareeffectiveandhelpinglocalauthoritiesandhealthbodiesmeetstatutoryobligations(NICE2016).Itincludesrecommendationson:

• ‘overarchingprinciplesofgoodpractice–whatmakesengagementmoreeffective?

• developingcollaborationsandpartnershipsapproachestoencourageandsupportalliancesbetweencommunitymembersandstatutory,communityandvoluntaryorganisationstomeetlocalneedsandpriorities;

• involvingpeopleinpeerandlayroles–howtoidentifyandrecruitpeopletorepresentlocalneedsandpriorities;

• makingcommunityengagementanintegralpartofhealthandwellbeinginitiatives;and

• makingitaseasyaspossibleforpeopletogetinvolved’.


Socialnetworksarechangingrapidly.Competitionforhousingandjobsoutsidelocalareashasmeantthatfamilynetworkshavebecomedispersedoverwideareas,withsocialrepercussionsincludinglonelinessatallages.

Aswellasthesechangestosociety,face-to-faceinteractionsarebeingsupplementedbymoretechnologicalengagement.Theuseofdigitalandsocialmediaisincreasingyearonyear,witharound90percentofadultsovertheageof16(OFCOM2015)nowpersonallyusingamobilephone(andtwo-thirdsowningasmartphone),withincreasedusageofmobiletechnologytoaccesstheinternet,forpeer-to-peersupport,appointments,etc.Thepositivebenefitsofsocialmediaandsocialnetworkingcanincludefacilitationofsocialconnectionsamongpeerswithsimilarexperiencesandincreasedawarenessofpreventionprogrammes,crisishelplines,andothersupportandeducationalresources(Luxtonetal.2012).However,anumberofstudiesofthehealthbenefitsofsocial-mediausage,haveexpressedconcernsthatitmayalsobehavingadetrimentalimpactonhealthinsomecases,suchassuicidebehaviours(Luxtonetal.2012)andmentalhealthinadolescents(Sampasa-KanyingaandLewis2015)(seealsosection3.5oftheChildrenandYoungPeoplepaperinthisseries).

However,peoplewhoare‘communitycommunicators’(WoodandFowlie2013)–thetowncriersoftoday–continuetobeattheheartofcommunities,spreadingthewordaboutwhatisgoingonlocally,andmakinglinksandbuildingtrustandengagementbetweenresidentsandservicesandopportunities(seeNeighbourhoodHealthWatch,casestudy6).

3.3.2Socialisolation

Socialisolationhasrootsatsocietal,communityandindividuallevels–andisontheincrease.Thepercentageofhouseholdsoccupiedbyjustonepersonmorethandoubledtobetween1972and2008,thedivorceratehasalmostdoubledinthepast50years,andlocalcommunityfacilitiessuchaspostofficeshaveclosed.Thesefactors,andothers,translateintoloneliness:asurveyin2010foundthat10percentofpeopleoftenfeellonely,athirdhaveaclosefriendorrelativewhotheythinkisverylonely,andhalfthinkthatpeoplearegettinglonelieringeneral(MentalHealthFoundation2010).Andsocialisolationcanhaveveryseriousconsequencesforhealth:asystematicreviewconcludedthat‘individualswithadequatesocialrelationshipshavea50percentgreaterlikelihoodofsurvivalcomparedtothosewithpoororinsufficientsocialrelationships’–thisiscomparabletotheimpactofgivingupsmoking,andgreaterthanthatofobesityandphysicalactivity(Holt-Lunstadetal.2010).

Anyonecanexperienceloneliness,butitisahealth-inequalitiesissueforcommunitiesbecausesomeindividualsorgroupsmaybemorevulnerablethanothers,influencedbyfactorsincludingphysicalandmentalhealth,migrantstatus,levelofeducation,employmentstatusandage(PHE2015b).Socialdisadvantageislinkedtomanyofthelifeexperiencesthatincreasetheriskofsocialisolation.4Forexample,inthemostdeprivedareas10percentof25–29-year-oldsandover50percentofthoseaged65–69haveadisability–doubletherateintheleastdeprivedareas.Similarly,menandwomenaged40–44inthemostdeprivedareasarearoundfourtimesmorelikelytohave‘notgood’healthcomparedtotheirequivalentintheleastdeprivedareas(ONS2014a).

Neighbourhoodcharacteristicscanalsohaveanimpactonsocialisolation,atanystageofthelifecourse.Deprivedareas,forexample,oftenlackadequateprovisionofpublicspaces,creatingbarrierstosocialengagement.Theclosureofpubs(animportantarenaforsocialinteraction)(Dunbar2016)orpoortransportlinksinruralareasmayunderminetheabilityofresidentstobuildandmaintainsocialconnections.

Thereisalsoevidencethatsocialisolationmayhaveacumulativeeffect.Isolationinchildhoodcanbeariskfactorforimpairmentoffutureadolescentandadultinteractions,withanegativeimpactonfuturementalwellbeing,creatingaviciouscirclethataffectsfutureexperienceofsocialisolation.Lifeeventssuchasthe

4Ruralpoverty,socialexclusion,andlevelsofillhealthandneedamongstparticulargroups(forexample,thegrowingnumbersofolderpeople,familieswithyoungchildrenandtheyoungerunemployed)areoftenhidden.


lossofalovedone,caringresponsibilitiesordisablingconditionsmayalsocontributetoareductioninsocialcontact,andcontributetosocialisolation(Figure2).

Figure2:Theimpactofsocialisolationacrossthelifecourse

Source:PHE2015b.

3.3.3Socialprescribing

Itisincreasinglyclearthatthehealth-caresystemcontributesonlyinasmallway–around20percent–toourhealth,withafurther10–20percentfromourgenes,anduptoastaggering60percentfromourbehaviour,socialcircumstancesandtheenvironment(McGovernetal.2014).However,theoverwhelmingmajorityofsociety’shealthinvestmentsgotothehealth-caresectorforclinicalservicesor(decreasingly)public-healthinterventions.In2015,only5.4percentofhealth-relatedresearchexpenditurebythelargestgovernmentandcharityfunderswasdedicatedtoprimarydiseasepreventionorhealthpromotion(UKCRC2015).

Socialprescribingisonemethodthathasbeenusedtogoodeffecttoencouragepositivesocialinteractions,particularlyamongthosewhodonotenjoygoodhealth.Itisamethodforthehealth-caresystem‘toaccesspragmaticsolutionstomeetthegrowingneedsofpeoplelivingwithlong-termphysicalandmentalhealthconditionswhenmedicationisnotalwaysappropriateornecessary’(SocialPrescribingNetwork2016),linkingpatientswithmedicalandnon-medicalsourcesofsupportwithinthecommunity,suchasopportunitiesforartsandcreativity,physicalactivity,learningnewskills,volunteering,mutualaid,befriendingandself-help,aswellassupportwith,forexample,employment,benefits,housing,debt,legaladvice,orparentingproblems.

Asocial-prescriptionapproachgetstotheheartofthesocialdeterminantsofhealth–the‘causesofthecauses’(Marmot2010)–andprovidesaconduitforhealthprofessionalstousetodirectpatientstowardsbetterhealth.AsSirMichaelMarmothasnoted,‘Whytreatpatientsandsendthembacktotheconditionsthatmadethemsick?’(BBBC,undated).

Socialprescribingisusuallydeliveredviaprimarycare–forexample,through‘exerciseonprescription’or‘prescriptionforlearning’–althoughthereisarangeofdifferentmodelsandreferraloptions.However,despiteexamplessuchastheBromleybyBowCentre(section4.2.3,casestudy4)thatshowthatsocialprescribinghasbeeneffective,full-scaleimplementationoftheconcepthasnotbeenachieved.Thishighlightsasignificantissueforcommunities–evenwherethereisevidencethatsomethingisworking,


sustainabilityandroll-outofeffectiveinitiativesisoftennotachieved(atopictakenupinmoredetailinthefinalpaperinthisseries).

3.4Environmentalfactors

Social,economicandphysicalconditionswithinlocalneighbourhoodscancontributetopoorcommunityhealthoutcomes,forexamplebyfacilitatingsedentarylifestyles(Renaldsetal.2010;McCormackandShiell2011),makingitmoredifficultforpeopletoaccessfreshfruitandvegetables(Balletal.2015),orbyfacilitatinggamblingbehaviours.(Hanrahan2013;ScotPHN2014).Understandingandactingontheenvironmentalfactorsthathelptoshapehowpeopleliveandworkisnecessaryifthereistobeastepchangeinhealthinequalitiesandincommunityhealthoutcomes.

‘Environment’is,inmanyrespects,acatch-allphrase,encompassing:

• thenaturalenvironment(factorssuchasair,noise,water,greenspace);

• thebuiltenvironment(internalandexternalfactorsassociatedwithhousing(e.g.damp),roadsandtransportsystems,buildings,infrastructure(accesstoshops,medicalfacilities,etc.)),and

• socioeconomicandculturalfactors(characteristicsofsocietiesandcommunitiesandneighbourhoods,urbandensityandperceptionsofcriminalactivity,etc.).

Thelandscapeofacommunitycanbeovertlyhazardoustothehealthoftheresidents–butitcanalsoacttoimprovehealthoutcomes(TableC).

TableC:Examplesofeffectsofthephysicalenvironmentonhealth

Naturalenvironment

• Airpollutionisknowntoberesponsibleforaround2.5%ofmortalityinsomeruralareastoover8%insomeLondonboroughs5(PHE2014).Reducingairpollutionlevelsreducestheburdenofdiseasefromstroke,heartdisease,lungcancer,andbothchronicandacuterespiratorydiseases,includingasthma(WHO2014).(SeealsotheEarlyYears(section3.1)andChildrenandYoungPeople(section3.2.5)papersinthisseries.)

• Excessivenoisecaninterferewithdailyactivities,disturbsleep,andprovokechangesinsocialbehaviour.TheWHOreportsthattrafficnoisealoneisharmfultothehealthofalmosteverythirdpersonintheWHOEuropeanRegion,withonefifthofEuropeansregularlyexposedtosoundlevelsatnightthatcouldsignificantlydamagehealth(WHO2016a).

• Contactwithsafe,greenspacescanimproveanumberofaspectsofmentalandphysicalhealthandwellbeing,aswellasvarioussocialandenvironmentalindicators(FPH/NaturalEngland2010).Forexample:

• contactwithgreenspacesandnaturalenvironmentscanreducesymptomsofpoormentalhealthandstress,andcanimprovementalwellbeingacrossallagegroups;and

• accesstogreenspacescanincreaselevelsofphysicalactivityforallages,includingencouragingactivetransport,andincreaselevelsofcommunityactivityacrosssocialgroups.

Builtenvironment

• Theadversehealtheffectsoflivingincoldhomesandfuelpovertyarewelldocumented.Acausallinkhasbeenidentifiedbetweenfuelpovertyandadversephysicalandmentalhealthandwellbeingoutcomes,includingincreasedriskofdeathincoldweather(excesswintermortality),increasedriskofrespiratoryillness,impairedmentalhealthandsocialisolation(MarmotReviewTeam2011).

• Therewere1,780roaddeathsintheyeartoSeptember2015intheUnitedKingdom–a3%riseon2014(DfT2015).

5BecauseofuncertaintyintheincreaseinmortalityriskassociatedwithambientPM2.5,theactualburdensassociatedwiththesemodelledconcentrationscouldrangefromapproximatelyone-sixthtoaboutdoublethesefigures.


Socialandculturalenvironment

• Neighbourhoodcontextplaysanimportantroleinthedevelopmentoftheperceptionsofcrime,andthefeelingofsafetyofresidents.Thishasanimpactonbothmentalandphysicalwellbeing,forexample,withphysicalactivityrestrictedto‘safeareas’(seealsosection3.2.4oftheChildrenandYoungPeoplepaperinthisseries).

Thereisagoodunderstandingofthesourcesofmostenvironmentalrisks,andUKlegislativeapproacheshavebeenputinplacetorespondtosystemicchallenges.Forexample,sourcesofairpollutionincludepowerstations,traffic,householdheating,agricultureandindustrialprocesses,andlegislativeandpolicymeasurestoaddressitincludethepromotionofactivetravel,aswellasinfrastructuralapproaches,suchasreducingfossil-fueluse(RCP/RCPCH2016).

However,policyandplanningneedstobeapproachedwithcare,asplanningpoliciescan,andhave,resultedincommunityfragmentationbyemphasisingtheneedsoftheindividualoverthoseofthecommunity,makingitdifficultforpeopletodevelopandsustainsocial-supportnetworks(JRF2008).Proximitytoappropriateamenitiescanpromote(ordeter)peoplefrommakinghealthychoices,facilitatetimelyaccesstohealthservices,andpotentiallyexacerbatethepotentialforharmfulorprotectivebehaviours.

Planningprofessionalshavelongworkedcollaborativelywithenvironmental-healthprofessionalstoreduceandmitigatetheimpactsofactivitiesthatnegativelyaffecthumanhealth,butarguablythefocushasbeenonavoidanceofpollutionordanger,arecentexamplebeingeffortssuchaszoningtopreventanoverabundanceoffast-foodoutlets(LondonFoodBoard/CIEH2014;TCPA2016).However,attentionisalsonowturningtotheprovisionofinfrastructureandservicesthathaveapositiveimpactonhumanhealth,suchasqualityopenspace.Forexample,ifanareahasnosafewalkingroutes,roadtrafficaccidentsmayrise,andsedentarybehavioursmaybefurtherencouraged.

Thereisaneedforthishealth-promotionlenstobeemployedmorewidely,recognisingawidevarietyofhealthchallenges,whichwouldactiontheWorldHealthOrganization’scallfora‘whole-of-government,

whole-of-society,health-in-all-policies’approach(WHO2013).

3.5Focusingonprevention

Lifestylebehavioursknowntoresultinpooreroutcomesinadulthoodaregenerallyestablishedinlatechildhoodandadolescence(seealsosection3.2oftheChildrenandYoungPeoplepaperinthisseries).These‘risky’behavioursincludesmoking,alcoholandillicitdruguse,andsexualrisktaking(McPhersonetal.2013)(TableD).Easeofneighbourhoodaccess,andfamilialandpeerexposurescanincrease–ormitigateagainst–thelikelihoodofuptakeofmanyofthesebehaviours.

TableD:Lifestylebehaviours

Smoking

SeealsotheChildrenandYoungPeoplepaper,section3.6.2

• Smokinginitiationisassociatedwithawiderangeofriskfactorswithinthecommunity,includingtheeaseofobtainingcigarettes,smokingbyparents,siblingsandpeers,socioeconomicstatusandexposuretotobaccomarketing(ASH2015;RCP2010;Ofsted2013)

• Deathratesfromtobaccoaretwotothreetimeshigheramongdisadvantagedsocialgroupsthanamongthebetteroff(ASH2015).

• Long-termsmokersbeartheheaviestburdenofdeathanddiseaserelatedtotheirsmoking.Longtermsmokersaredisproportionatelydrawnfromlowersocioeconomicgroups.(ASH2015)

Alcohol


Alcoholuseisacommunityandhealth-servicechallenge,contributingtomultiplesocialharms(Cairnsetal.2011).Theseinclude:

• pooreducationalperformance,riskysexualbehaviourandteenagepregnancy(Newbury-Birchetal.2009;OECD2009);


• crimeanddisorder(HomeOffice2004;Hibelletal.2009);

• hospitaladmissions:n2013/14,therewereanestimated1.06millionadmissionsrelatedtoalcoholconsumptionwhereanalcohol-relateddisease,injuryorconditionwastheprimaryreasonforhospitaladmissionorasecondarydiagnosis.Thiswasanincreaseof5%onthepreviousyear,and115%since2003/4(HSCIC2015b).

Teenagepregnancy


• Under-18conceptionrateswerehighestinthemostdeprivedpartsofEnglandin2009–11(ONS2014b).

Obesity

SeealsotheEarlyYearspaper,section3.4.1andtheChildrenandYoungPeoplepaper,section3.2.1

• Thereisastrongrelationshipbetweendeprivationandchildhoodobesity.AnalysisofdatafromtheNationalChildMeasurementProgramme(NCMP)showsthatobesityprevalenceamongchildreninbothreceptionandyear6increaseswithincreasedsocioeconomicdeprivation(PHE2016).

• Amongadults,too,obesityprevalenceofthemostdeprived10%ofthepopulationisapproximatelytwicethatoftheleastdeprived10%(PHE2016).

Physicalactivity

• Streetconnectivity,land-usemixandresidentialdensityarethreelarge-scalefeaturesofneighbourhooddesignsthatarecommonlystudiedfortheirassociationswithphysicalactivity,bothforrecreationandactivetravel.Forexample:

• participantslivinginhigh-comparedtolow-walkableneighbourhoods(basedonfactorsabove)accumulateover750morestepsaday,accountingforapproximately8%ofrecommendeddailysteps(Hajnaetal.2015);and

• astrongindependentpositiveassociationwasfoundbetweenweeklyfrequencyofwalkingfortransportandtheobjectivelyderivedneighbourhoodwalkabilityindex(Owenetal.2007).

Understandinghowbesttosupportcommunitiestoaddresslifestyleissuesisafoundationalrequirementformakingprogressonhealthinequalities.Butitisalsocrucialthatweunderstandwhereincommunities

theproblemsaremostprevalent.Forexample,whilesmokingratesaredroppingacrosstheUnitedKingdomasawhole,therateinthemostdisadvantagedcommunities(men:32.9percent;women26.1percent)ismuchhigher–morethandouble–peopleinthehighestsocioeconomicquintile(men14.3percent;women10.2percent)(ONS2014c).Consideringcommunitiesasageographicalsettingishelpfulinthatitsupportsactionwhichcanaddressneighbourhoodeffects,butaninequalitieslensisstillneededtoensurethatsomeoftheresidentsarenotinadvertentlydisadvantagedbyapproachesthatfocusongeography,ratherthanpopulationsub-groups.

4.Whatworksandwhatdoesn’t?

4.1Research-basedevidence

ThissectiondrawsparticularlyontheevidenceprovidedinthesystematicreviewsandotherstudiespresentedintheEvidenceTables(Annex2).Forexamplesof‘whatisbeingdoneinpractice’currentlyaroundtheUnitedKingdom,seethecasestudiespresentedinsection4.2.


4.1.1Comparinglikewithlike:definingcommunities

CommentatorssuchasSirMichaelMarmotnotethatcommunitiescanbeanimportantdeterminantofhealthoutcomes.Neighbourhoodsarewherepeople‘live,workandplay’,aswellaswheremuchofourhealthandhealthbehavioursaredetermined–andthereforewhereinterventionsandpreventionneedtobebased.Thewayinwhichacommunityorneighbourhoodisdefinedcaninfluencepatternsofinclusionandexclusion,andcanhavesignificantcostsintermsofaccesstocommunityinfrastructure,servicesandcommunitycohesion(Allman2015;MacQueenetal.2001)(seealsoboxbelow).Understandingthepotentialinterventionpointswithinaneighbourhood(schools,placesofworship,pharmacies,workplaces,socialclubs...)andhowthisrelatestothepotentialapplicationofnewtechnologiesandtypesofinterventionwithinaneighbourhoodsettingisthereforeessentialifprogressistobemadeandsustained.

AstheSPOTLIGHTstudiesdemonstrate,6arobustunderstandingofthewayinwhichpeopledefine,limit

andexperiencetheirneighbourhoodsisneeded,ifwearetoeffectivelyinterrogatetheinteractionbetweencontextualfactorsandpatternsoflifestylechallenges,suchasobesity(Charreireetal.2016).Thisstudydemonstratedthattherewasanassociationbetweengenderandlengthofresidenceandtheperceivedsizeoftheneighbourhood.Womengenerallysawtheirneighbourhoodasbeingsmallerthantheirmalecounterparts,whilepeoplewhohadlivedinanarealongergenerallysawtheirneighbourhoodasbeinglarger.Inaddition,residentialdensitywasfoundtobeakeyfactorindeterminingtheperceivedsizeofaneighbourhood,withpeoplelivinginlower-densityareasdescribingtheirneighbourhoodaslargerthanthoselivinginhigher-densityareas.7Thisperceptionofthesizeofaneighbourhoodcanhaveconsequencesintermsofthelikelihoodofresidentsaccessinghealth-careservices(Valléeetal.2014)andperceptionsofavailablespaceforphysicalactivity(Smithetal.2010;Stewartetal.2015).

Insummary,oneofthekeychallengesintheUnitedKingdomisthat,todate,therehasbeenlimited

systematicengagementacrosscommunities,withalargeamountoftheavailabledatabeingfocusedonactivitywithinsubsectionsofacommunity,ratherthanmainstreamcommunityprogrammes,whichengagewidelywithdiversepopulations(South2014).Moresystematicengagementisneededifrealprogressistobemade,withthe‘community’definedinawaythatisasinclusiveaspossible.Afurtherchallengeisthatmanylocal(successful)initiativesareneverreportedinthepeer-reviewedliterature.Amoresystematicapproachwillenableustocapturethisandlearnfromwhathasbeenshowntoworklocally,aswellaswhathasbeenshowntoworkwithintheliterature(PHE2015a).

Ruralversusurban8

Anexampleofachallengetodefining‘community’appearwhenlookingaturbanversusruralhealthinthepeer-reviewedliterature,asmuchoftheliteraturereflectsonaruralexperiencevastlydifferenttotheUKexperience.TheliteratureisdominatedbyevidencefromtheUnitedStates,Australiaand(movingtonon-English-speakingarea)ChinaandcountriesinAfrica(see,forexample,MacKinneyetal.2014;Fraser2006;Ranasinghe2014),wherethedistancetoneighbours,sizeofsettlements,andproximityoflocalservicescanoftenbymeasuredinhours,ratherthanmiles.ThisunderminesconfidenceinthegeneralisabilityoffindingstoaUKcontext.Evenwhererelevantliteratureisfound,therearelargevariationsinthedefinitionsandcontextsofpractice.ComparinginterventionsinremoteareasofScotland,forexample,withinterventionsinruralareasinOxfordshirehighlightsvastlydifferentcontexts.Furthermore,ingeneral,moststudiesseemtofocusonsupportforpeoplewhoareageing

6TheSPOTLIGHTproject(‘sustainablepreventionofobesitythroughintegratedstrategies’)wasafour-yearcollaborationineightcountries,investigatingindividualandcontextualdeterminantsofobesity,andwaysinwhichtheneighbourhoodenvironment(i.e.localcommunity)canaffectobesityprevention(SPOTLIGHT2016).7Factorsthatcouldcontributetothisincludetheproximityofaccesstoservices,availabilityoftransporttoservices,andthelevelofawarenessofthelocalareathathasbeendevelopedovertime.8Itshould,however,benotedthatthisbriefingpaperisbasedonarapidreviewofliterature–amoresystematicreview,focusingoneachareawithinthedocumentasadiscretetopiccouldhighlightaverydifferentstory.


(withotheragegroupslesswellresearched)oronalimitedrangeofservices(ratherthantakingacomprehensive,systematicapproachtocommunityhealthandwellbeing).

4.1.2Promotingcommunityengagementandparticipation

Asystematicreviewoftheevidenceoncommunityengagement(O’Mara-Evesetal.2013)suggeststhattherearethreebroadapproachestocommunityengagementintheliterature:

• theoriesofchangeforpatient/consumerinvolvement;

• theoriesofchangeforpeer/lay-deliveredinterventions;and

• theoriesofempowermenttoreducehealthinequalities.

Peer/lay-deliveredinterventionstendtohavegreatereffects,butthesystematicreviewfoundinsufficientevidencetotestpossiblereasonsforthis(suchasinterventionintensityandexposureeffects)–anotherexampleofthelackofdataandevidencetosupportinterventions,whichtoooftengoundertheradarandarethereforenoteasilyaccessedasexemplars.

Inaddition:

• mostoftheavailableliteraturewasnotfromtheUnitedKingdom(themajoritywerefromtheUnitedStates),meaningthatthetransferabilityoffindingsfromstudieswouldneedfurtherconsideration;

• relativelyfewoutcomeevaluationswereaccompaniedbyrobustprocessevaluations,anddiversityindefinitionsetc.acrossstudiesmeantthatcross-studycomparisonsweremoredifficult;

• community-designedinterventionsweregenerallymoreeffectiveandconsideredtobemoreacceptablebythecommunity;and

• itwasnotpossibletogivearobustconclusionontheeconomiceffectivenessofengagementmodels.Whereeconomicevaluationswereavailable,theywerelargelyonpeer-ledinterventions,spreadacrossawiderangeoftopics,withveryfewstudiesreportingontheeconomicevaluationofempowermentprojects.Moststudiesweremethodologicallylimited.

However,thisreviewhasshowntheremaybeafurtherissuetoconsider.Oneofthekeychallengesisthat,throughoutthepeer-reviewedliterature,theconceptsofcommunityempowermentandcommunityengagementappeartobeusedquiteflexiblyandinterchangeably.Manystudiestalkaboutempoweringcommunities,butonfurtherexplorationthefocushasactuallybeenonengagementofcommunitymemberswithpre-setinitiatives,ratherthanbottom-upempowermentperse.Others(see,forexample,Cyriletal.2015)focusonmoresubstantiveapproaches,suchasrealpower-sharingandcollaborativepartnerships.

Greaterconsistencyisneededonwhatismeantbyempowermentandengagement,andhowtheycanbemeasuredtoensurecomparisonoflikewithlike.Astrongcasecanbemade(Cyriletal.2015)fortheneedtodevelopnewandinnovativeapproachestomeasuretheimpactofcommunityengagementonhealthoutcomes,butarguablythereisanequallystrongcasefortheneedtohavesimilarrobustmeasuresforcommunityempowerment.

Examplesofinitiativeswhereempowermentstrategiesappeartohavebeenusedtogreateffectinclude:

• ayouthviolencepreventionstrategy(Reischletal.2011)and

• HIVprogrammedevelopmentinlow-andmiddle-incomecountries(Kerriganetal.2015).

Onesystematicreviewlookingspecificallyatcommunityengagementnotedthatitcouldhavebothnegativeandpositiveoutcomesfortheindividual.Positiveoutcomesincluded‘personalempowerment’,butnegativeoutcomesincludedstressandexhaustion,asinvolvementdrainedparticipants’energyaswellastheirtimeandfinancialresources.Thephysicaldemandsofengagementwerereportedasparticularlyonerousbyindividualswithdisabilities.Consultationfatigueanddisappointmentwerenegativeconsequencesforsomeparticipantswhohadexperiencedsuccessivewavesofengagementinitiatives.For


someindividuals,engagementmayinvolveaprocessofnegotiationbetweengainsandlosses(Attreeetal.2011)

Muchoftheliteratureavailableoncommunity-healthinitiativesnotedastrongcommunity-engagementfocus,particularlyinterventionsfocusedonpromotingphysicalactivity(especiallyactivetravel)andaddressingunhealthyeating.However,oneoftherecurrentchallengesevidentintheliteraturewasidentifyingwhoexactlywasincludedwithintheintervention,asmanystudiesfailedexplicitlytodefinethescopeofparticipants.Forexample,anumberofreviewshighlightedthatthedataonadolescentswasoftenbundledupwithotherage-groups(Hagelletal.2015;Sleddens2014).Inaddition,manyinterventionslackclarityaboutthedesiredbehaviouraloutcomes,orreportongenericoutcomemeasures.Thisisunfortunate,astheuseofdifferentoutcomemeasurescaninfluencetheinterpretationofinterventioneffectiveness(Charlebois2012).

Ineffect,whilethepotentialtoinfluencelifelongbehaviourssupportsthedesignofeffectiveandage-appropriateinterventionsforchildrenandadolescents,thereisaneedforclarityonthedesign,purposeandscopeofinterventionstoincreaseconfidenceintheirreplicability,andpotentialforlong-lastingchange.Forexample:

• veryfewfoodliteracyprogrammeshavedemonstratedapositiveimpactondietarybehaviourstodate(BrooksandBegley2014);and

• areview(Bourke2014)ofadolescentdietaryinterventionsfoundonlyoneinterventionthatreportedalastingstatisticallysignificantincreasedconsumptionoffruitandvegetables.

Thissuggeststhattheremaybelimitedacademicevidenceavailableonwhichtodraw,highlightinganotherrecurrentchallenge.Muchoftheevidenceoncommunityinitiativesmaynevermakeitintotheacademic

press.Accessingthisevidenceisafurtherchallenge(section5.3).

Thereare,however,somefactorsacrossthestudiesthatseemedtoberelatedtomoreeffectiveoutcomes:

• thecapacityandwillingnessofserviceusersandthepublictogetinvolved;

• theskillsandcompetenciesofpublicsectorstaff;and

• thedominanceofprofessionalculturesandideologies.

4.1.3Socialinteractions

4.1.3.1Socialisolationandsocialnetworks

Enhancingpeersupportandgroupactivitiesimprovessocialconnectivity,andwithitimproveshealth.Connectingtoothers,andgivingandreceivingsupport,arelinkedtoimprovedhealthandwellbeingoutcomes,withsocialisolationandlonelinesslinkedtoanincreasedriskofnegativehealthbehaviourssuchasincreaseddrinking,comforteating,andlowerratesofphysicalactivity(Nesta2016).

Anumberofstudieshavelookedatthewayinwhichsocialnormsandnetworkscanbeinfluentialinchangingandsupportinghealth-promotingbehaviours.Smokingcessation,forexample,canbeencouragedthroughsocialnetworks(Hitchmanetal.2014).Socialnormsarechangingaroundsmoking(notablyfollowingthebanonsmokinginpublicplacesin2007),andtheinfluenceofpeerrelationshipsisclear:smokingcessationbyaspousedecreasedindividuals’chancesofsmokingby67percent,byafriendby36percent,andbyaco-workerinasmallfirmby34percent(ChristakisandFowler2007).

However,negativebehaviourscanalsobeinfluencedthroughsocialnetworks.Astudyofover12,000peopletoinvestigateclusteringofobesityconcludedthattheriskofobesityisincreasedevenatthree

ACharterforCommunity

DevelopmentinHealth

Inrecognitionthathealthandotheragenciesmustinspireandengagethecommunitytoamuchgreaterextenttodeliverhealth,theNHSAlliancehasproducedaCharterforCommunityDevelopmentinHealth(NHSAlliance2014).Itcallsondecision-makersactivelytodevelopcommunity-ledpartnerships,withcommunitydevelopmentworkersprovidingexpertsupportasneeded,andlisteningtoandrespondingtolocalpeople.


degreesofseparation(i.e.theriskofanindividualhavingobesityis10percenthigherifhis/herfriendsoffriendsoffriendsareobese).Inaddition,weightgaininonepersonwasassociatedwithweightgaininhisorhersocialnetwork:anindividual’schancesofbecomingobeseincreasedby57percentifheorshehadafriendwhobecameobeseinagivenintervalandby37percentifhis/herspousebecameobese.‘Obesityappearstospreadthroughsocialties’(ChristakisandFowler2007).

Face-to-facesocialnetworksarekey,butsocialinteractionisexpandingintothedigitalage,andthereisevidencetoshowthatsocialmediacanbeaneffectivetoolforsupportingbehaviourchange.Forexample,astudyoftheeffectivenessofsocialmediainsupportingpeopletostopsmokingfoundthatFacebookwasauseful,cost-effectiverecruitmentsourceforyoungadultsmokers.Adspostedvianewsfeedpostswereparticularlysuccessful,withtheconclusionbeingthatthiswasbecausetheywereviewableviamobilephone(Ramoetal.2014;Ramoetal.2015).Theutilityofmobilephones(Whittakeretal.2012)andcomputeraids(Chenetal.2012)hasalsobeenexplored,withsimilarlypositiveresults.

Therearealsohundredsofthousandsofhealthappsandwebsitesavailable,claimingtosupportpeoplewithahugerangeofhealthandlifestylechallenges–supportthatcanhappenathomeorinthelocalcommunity.However,healthprofessionalsandothershaveexpressedconcernsaboutthequalityofmanyapps–theyareoftenoflimitedfunctionality,developedrapidly,notbasedonevidenceofefficacyorbehaviour-changeprinciples,withlittleevaluation,andfewaredesignedtoaddressareasofgreatestneed(Boulosetal.2014).

Thereareinherentdifficultiesinregulatingapps–includingtheneedtoregulatewithoutstiflinginnovation(AMS/RAE2015).TheNHSiscurrentlyintheprocessofdevelopingabenchmarkinglibraryforhealthapps–butthisisstillinitsearlystages(NHS2016b)–andeffortsarebeingmadeinaccreditationandassessmentofhealthapps(forexample,Stoyanovetal.2015).Improvinge-healthliteracyandtacklingdigitalexclusion(seebox)isalsorequiredtonavigatesuccessfullytheplethoraofappsavailable–forexample,of552alcohol-relatedappsidentifiedintheUnitedKingdom,overhalfwereentertainmentappsandonly14percentfocusedonalcoholreduction(Craneetal.2015).

Therearealsoincreasingnumbersoflocallybasedactivitiesforwhichsupportandawarenesshavebeenbuiltonline,andhaveanecdotalbenefitstophysicalandmentalhealth,eveniftheyhavenotbeenformallystudied.Theriseofparkrunisonesuchexample,aweekly5kmrunthat,asofApril2016,hasnearly950,000peopleregistered,andisparticipatedinbyaround90,000peopleaweekinalmost400locations(mostlyintheUnitedKingdom,butspreadingabroad)–andiswidelyseenasfriendlyandfun,aswellashealthpromoting.(Seealsothefinalpaperinthisseries.)

4.1.3.2Socialprescribing

Socialprescribinghasthepotentialtobecomefullyintegratedasapatientpathwayforprimary-carepracticesandtostrengthenthelinksbetweenhealth-careprovidersandcommunity,voluntaryandlocalauthorityservicesthatinfluencepublichealth,includingleisure,welfare,education,culture,employmentandtheenvironment(forexample,urbanparks,greengymsandallotments).9Socialprescribingcanhaveanimportantimpactonlifestyleandhealth(Daysonetal.2013),andmayresultin:

9However,thefieldofevidenceonsocialprescribingappearstobequitelimited:anAthenssearchofsixelectronicdatabasesdidnotidentifyanypeer-reviewedliterature,althoughaGooglesearchdidpickupsomepapers,which

Addressingdigitalexclusion

AccordingtoNHSdataondigitalparticipation,some9.5millionpeoplelackbasicdigitalnumeracyskills,and6.5millionpeoplehaveneverbeenonline.Thoseexperiencingdigitalexclusiontendtobeolder,poorerandmorelikelytobedisabled:peoplewhoarealreadyatriskoftheexperienceofhealthinequalities(TinderFoundation2015).TheDigitalParticipationschemeisworkingwithcommunityorganisationsaswellasnationalpartnerstosupporthard-to-reachpeople,andprovidetraining,withaviewtosupportingpeopletobettermanagetheirhealthineverydaylife.


• increasedawarenessofskills,activitiesandbehavioursthatimproveandprotectwellbeing;

• increaseduptakeofarts,leisure,education,volunteering,sportingandotheractivitiesbyvulnerableandat-riskgroups;and

• increasedlevelsofsocialcontactandsocialsupportamongmarginalisedandisolatedgroups.

Itcanalsoimprovemedicalcare,suchasreducedlevelsofinappropriateprescribingofantidepressantsformildtomoderatedepression,reducedwaitinglistsandhospitalattendance(inRotherham,A&Eattendanceamongthosereferredtosocialprescriptionfellby21percentinsixmonths).

4.1.4Environmentalfactors

Theeffectivedesignanduseofthephysicalinfrastructureofcommunitiesiskeytohealthierlifestyles–suchascreatinganenvironmentthatisnolongerobesogenic(seealsotheChildrenandYoungPeoplepaperinthisseries,section3.2.3)andwhichisaccessibleandattractivetoallages:astheRoyalInstituteofBritishArchitectsnotesonitswebsite,‘thepopulationisincreasingandoursocietyisgrowingolder.Let’sdesignbuildingsandcommunitiesthataremindfulofthehealthimpactsonresidents.’

Forexample,thehealthandeconomicbenefitsofgreenspacecouldbeconsiderable–provisionofgreenspacetobringabouta1percentchangeinthesedentarypopulationhasbeenestimatedtohaveaneconomicvaluerangingfrom£479–1442millionperyear,dependingonwhetherolderpeople(75+)areincludedorexcluded(Lavinetal.2006).Neighbourhoodsthatarecharacterisedasmorewalkable,eitherleisure-orientedordestination-driven,areassociatedwithincreasedphysicalactivity,increasedsocialcapital,loweroverweight,lowerreportsofdepression,andlessreportedalcoholabuse(Renaldsetal.2010).

Differentneighbourhooddesignscanenableandencourage(ordiscourage)communityconnections(Lavin2006;Leyden2003;CaveandCoutts2002).Inparticular,mixed-useandpedestrian-orientedneighbourhooddesignspromotesocialinteractionthroughenablingresidentstoperformdailyactivitieswithouttheuseofacar,andincreasedtrafficvolumereducessocialinteraction.WiththeadventofthenewHealthyTownsinitiative(NHS2016a),thereisanopportunitytoshapethehealthofcommunitiesinanewway.Ensuringthesenewtownsreceiveappropriatesupportandadequatelyevaluatetheimpactofthefocusonhealthiscrucialtosettingarobustfoundationforfuturereplicationandextensionoftheprojectelsewhere.

Localcouncilsarealsolookingforwaysinwhichtotackleobesitythroughplanningregulations(TCPA2016).NICEhasproducedguidanceon‘Physicalactivityandtheenvironment’(aimedatallorganisationswithresponsibilityforthebuiltenvironment),whichsetsoutanumberofrecommendationsonenvironmentalchangetoencouragephysicalactivity,includingplanningchangesandtrafficengineering(NICE2008).Planningpowersarealsobeingusedtopreventtheestablishmentofnewfast-foodtakeaways,thenumberofwhichincreasedby45percentbetween1990and2008,andwhicharemostdenselysituatedinlow-SESneighbourhoods–althoughthisisbestcombinedwithothereffortssuchasworkingtoprovideincentivesandrewardsforimprovedcontentoftakeawaymenusinthecontextofcommunity-widehealthyweightstrategies(LGA2016).

4.1.5Focusingonprevention

Muchoftheliteratureemphasisestheneedtoworkinpartnershipwiththecommunitytooptimisehealthoutcomes.Understandingwhoarethemaincommunityactors,andwherearetheinterventionpoints,underpinsasset-mappingapproaches(section3.2).(Theworkplaceisalsoacommunity-basedplaceforinterventions,butisdealtintheWorkplacebriefingpaperinthisseries.)

suggeststhatthereisincreasinginterestintheconcept.Atpresent,thegreyliteratureismoreprevalentthanthepeerreviewedliterature.


4.1.5.1Faith-basedinstitutions

Anumberofstudieshavelookedatthepotentialroleoffaith-basedinstitutions(churches,mosques,temples,etc.)inhealthpromotion(GaliatsatosandHale2015;Hemmingetal.2016;Opalinskietal.2015;Kaplanetal.2006).Faith-basedinstitutionshaveauniquelinktotheircongregation,beingstable,prominentandinfluential.Anumberofkeyfactorsarenotedasfundamentaltosuccess:

• engagementoftheleadershipoftheplaceofworship;

• theuseofthestructuresoftheplaceofworshipasvenuesforeducationandintervention;and

• changesinpoliciesoftheplaceofworship.

Pre-existingrelationshipswithinthecommunityandtheprominentagenda-settingroleplayedbyfaithleadersareimportant.Giventhedemonstratedabilitytopullpeopletogether,tomotivateandtoinspire,thereisgreatpotentialforfaith-basedinterventions,andmodelsdevelopedthroughsuchinterventions,topromotecommunityhealthandaddresshealthinequalities.

4.1.5.2Communitypharmacies

InMarch2015,(HSCIC2015a),therewere11,674communitypharmaciesinEngland,anincreaseof1,802(18.3percent)since2005/6(HSCIC2015a).Inrecentyears,governmentpolicyhaspromotedtheroleofthecommunitypharmacyinpublichealth–theyarelocatedintheheartofthecommunity,haveclosecontactwiththepublic,andarerelativelyeasytoaccess.Systematicreviewsreinforcetheirpotentialinhealthpromotion,withevidenceofeffectivenessformanagingconditionssuchasdiabetesand

hypertension,andforpreventiveservicesincludingweightmanagement,osteoporosispreventionand

smoking(Georgeetal.2010;Brownetal.2016a).However,furtherevaluationofeffectivenessisneededforalcoholmisuseandobesity(Brownetal.2016a),andthereisalsoaneedfortrainingtoincreasepharmacists'confidenceinprovidinghealth-promotionservices(Eadesetal.2011).

4.1.5.3Schools

Schoolsareattheheartofcommunities,andcanbethesettingforarangeofinterventionapproachesanddeliverymethods.Thesecaninclude:

• educationalapproaches,withadefinedcurriculumonspecifictopics–suchasassembliesfocusingonalcohol,withinformationprovidedabouttherisksofalcohol,itsdamagingeffectonfamilies,communities,etc.Thesegenerallyaimtoimproveawarenessoftherisksassociatedwiththebehaviourandencouragepositiveattitudes,whilestrengtheningexistingknowledgeandskills;

• social-normsapproachesthattargetspecificbehaviours,correctingmisconceptionsofbehaviours;

• provisionoflife-skillstraining,suchasaroundsayingnotodrugs,encouragingcriticalthinking,strengtheningsocialskillsandresistancestrategies;

• peer-to-peerdeliveryofeducation;and

• community-systemsapproaches(Vicaryetal.1996).

Inaddition,thereisgoodevidencearoundtheuniversalprovisionoffreeschoolmealsasbenefitingchildren’shealthandperformance(seeChildrenandYoungPeople,section4.3.1.1).

4.1.5.4Preventioninterventions

Manystudiesreportsomebehaviouraloutcomes(forexample,TableE).However,evaluationofeffectivenessisoftenlimited,withlittletonoreportingofprocessevaluation,andalackofconsistencyinidentifyingbehaviouraloutcomes–again,acommonproblemforthoseinterestedincommunity-basedhealth,andonedealtwithinthefinalpaperinthisseries.


TableE:Communityinterventions:lifestylebehaviours(examples)

Smoking • Communitypharmacy-deliveredsmoking-cessationinterventionsincludingbehaviouralsupportand/orNRT,areeffectiveandcosteffective,particularlywhencomparedwithusualcare.However,thewidevarietyofinterventionsprecludedtheabilitytoevaluateeffectivenessbyspecifictypesofinterventions(Brown2016b).

Alcohol • Alcoholeducationinschoolstendstohaveonlysmallpositiveeffects(Jonesetal.2007;Foxcroftetal.2011)–seealsoChildrenandYoungPeople,section4.3.3.1(casestudy6)).

• Theroleofalcoholeducationaspartofamulticomponentalcoholinterventionstrategyhasnotbeenexaminedindetail(ISM2009).

• Thereisinsufficientevidencetoassesstheeffectivenessofcommunitypharmacy-basedinterventionsforalcoholreduction(Brown2016b).

Druguse • Skills-basedprogrammesinschoolshelptodeterdruguse(Faggianoetal.2008).

Sexualrisktaking

SeealsotheChildrenandYoungPeoplepaper,section4.3.3.3

• Findingsshowedthatparent-basedinterventionswereinconsistentlyeffectiveatreducingyoungpeople’ssexualriskbehaviours.Preliminaryevidencesuggeststhateffectivenesswasgreaterinthosestudiesaimingtoaffectmultipleriskbehaviours.However,thismaybeduetolongerprogrammedeliveryandfollow-uptimes;furtherevidenceisrequired(Downingetal.2011).

• multicomponentschool-basedinterventions,forexample,includingschoolpolicychanges,parentinvolvement,andworkwithlocalcommunities,areeffectiveforpromotingsexualhealthandpreventingbullyingandsmoking(Shackletonetal.2016).

Obesity • Placesofworshipcanbeasuccessfulmechanismforpromotinghealth,specificallyaroundnutrition,amongstblackcommunitiesintheUnitedKingdom.Aninterventioninwhichonechurchtookanactiveeducationalapproach,andthecontrolchurchonlygaveoutaleaflet,foundthatthecongregationsofbothestablishmentsreportedbetternutritionandsomeweightloss(AdinkrahandBahkta2013).

• Evidencefromaheterogeneousgroupofweight-managementinterventionssuggestthatcommunitypharmacy-deliveredweight-managementinterventionsareaseffectiveassimilarinterventionsinotherprimary-caresettings,atleastintheshortterm,andhavesimilarprovidercosts(Brown2016b).

Benefitsof

community

engagement

• Thefindingsofarapidreviewsuggestthatthemajorityof‘engaged’individualsperceivedbenefitsfortheirphysicalandpsychologicalhealth,self-confidence,self-esteem,senseofpersonalempowermentandsocialrelationships(Attreeetal.2011).

• 21/24(87.5%)hadpositivelyimpactedhealthbehaviours,publichealthplanning,healthserviceaccess,healthliteracy,andarangeofhealthoutcomes(Cyriletal.2015).

• theYESstudyfoundpositivebenefitsfromengagingandempoweringyouthtoplanandimplementyouthviolencepreventionprogrammes(Reischletal.2011).

4.2Whatishappeninginpractice?Practicalevidence

ThissectionfocusesonpracticalexamplesandcasestudiesofprojectsintheUnitedKingdomandfurtherafield,whichillustratethechallengesandresearchareasidentified.Theseexamplesareeithercommunity-basedprojectsinitiatedbyhealthorganisations(suchasCCGs)orcommunity-basedprojectsthatarenotestablishedbythehealthservice,buthave(eitherintentionallyorasasideeffect)healthbenefit.Thelatterinclude,forexample,engagementincommunity-healthactivitiesbylocalsportsteams,suchasLeyton


OrientTrust’smental-healthinitiative‘CopingthroughFootball’,orwiderinitiativessuchasFitFans,anetworkofmentor-ledaspirationalcommunity-basedweight-lossprogrammes,deliveredinconjunctionwithlocalprofessionalandamateursportsclubs).However,asisnotedmanytimesinthisbriefingpaper,manylocallybasedactivitiesarenotadequatelyevaluated(forexample,section5.3).

Fundingforthecase-studyinitiativesisdrawnfromawiderangeofsources,bothpublic-,private-andthird-sector,butsustainabilityisoftenachallenge.ThekeyplayerslistedinAnnex1(andwithmoredetailprovidedintheDebateGraphaccompanyingthisseriesofpapers)includessomefunders–suchastheUnitedKingdom’s48accreditedcommunityfoundations,whichhelpindividuals,families,entrepreneurs,companies,charitiesandpublic-sectorbodiesconnectwith,supportandinvestintheirlocalcommunities.

The13exampleshavebeenchosentoillustratethebreadthofactivitiesacrossthecountry,andtodemonstratethewiderangeofdifferentapproachesthatcanbetakentocommunity-centredwellbeingsetoutinFigure2.

Figure2:Community-centredapproachesforhealthandwellbeing

Source:PHE2015a

Successfulinitiativesfallintomultiplecategories,butsomespecificexamplesareasfollows(thecasestudynumberappearsinbrackets):

• strengtheningcommunities:BromleybyBow(4),MorganStanleyHealthyLondon(9),ShapeUpSomerville(11)

• volunteerandpeerroles:BeaconProject(1),NeighbourhoodHealthWatch(6)

• collaborationsandpartnership:WellLondon(3),BoxChicken(7),Viasano(12)

• accesstocommunityresources:C2ConnectingCommunities(2),RoslistonForestryCentre(8).


4.2.1Promotingcommunityempowerment,engagementandparticipation

Casestudy1:TheBeaconproject

TheBeaconprojectontheBeaconandOldHillEstateinFalmouth,Cornwalltookplaceinthemid-1990s,andhasbeentheinspirationformanyothersuccessfulcommunity-leddevelopmentprojects(includingC2ConnectingCommunities–casestudy2).Thephysicalconditionsontheestatewereverypoorandthecommunitywasrifewithvandalism,crimeandextremelypoorhealth.HealthvisitorsHazelStuteleyandPhilipTrenowethrealisedthattheestatehadbeenabandonedbythestatutoryagencies,andsetouttore-engageandreconnectpublicservicesandthecommunity(Stuteley2002).

Fivelocaltenantswiththeskillsnecessarytoengagetheirpeerswereidentified,whoreceivedtraininginsubmittinggrantapplicationsandformingandmaintainingaconstitutedcommittee.Thisgroupsubsequentlysetupaformaltenantsandresidentsassociation.Theyproducedanewsletterandhadone-to-onechatswithallhouseholds,informingresidentsabouttheplansfortheestate.Sessionswerethenheldforlocalpeopletoestablishthemainproblemsaffectingtheirhealth,suchascrime,poorhousingandunemployment.Meetingsbetweenresidentsandrelevantagenciesfollowed,whichledtoconstructivere-engagementbetweenresidentsandthelocalauthority,police,andyouthandsocialservices.

By2000,theoverallcrimeratehaddropped50percentandunemploymentlevelsby71percent.Housingimprovementsmeantchildhoodasthmadecreasedby40percent,postnataldepressionfellby70percentandbreastfeedingratesincreasedby30percent(HealthComplexityGroup2016).

VitaltotheBeaconProject’ssuccesswasitscollaborativeapproach,involvingthecommunityconcernedfromtheveryoutsetandcontinuouslythroughouttheprocess.Theprojectwasrecentlyrelaunched,butfurtherinformationisnotyetavailable.

Casestudy2:C2ConnectingCommunitiesandtheNewingtonhousingestate

C2ConnectingCommunitiesisaframeworkforcreatingtransformativechangeindisadvantagedcommunities.C2isevidence-based,bothfromexperienceinthefieldandreflectivepractices,andatitsheartiscommunityinvolvementandenablingacommunityvoice.Itformsaresident-ledpartnershipthatissupported,butnotdirected,byserviceproviders.Residentsareinvitedtoalisteningeventwherelocalissuescanbediscussedbetweenthemandserviceprovidersinanon-hierarchicalway,andfromthisaresident-ledpartnershipisformedandactionbasedonthefeedbackbegins.

In2012C2wasimplementedintheNewingtonhousingestateinRamsgate,Kent,formingtheresident-ledNewingtonBigLocalPartnership(NBLP2014).NBLPhasa10-yearplanforNewingtonthatcoversthreethematicareas:health,wealthandhappiness.AnexampleofanNBLPsuccessisreclaimingtheCopse,alocal1.2-acreareaofwoodland.Thegreenspacehashostedmanyoutdoorcommunityactivitiesandthousandsofpeoplevisitedin2014/15.AnotherexampleistheCommunityChefproject,whichsupportedresidentscookinghealthymealsonlimitedbudgets.Feedbackfromparticipantsshowedthatthecookingskillswereveryusefulintheireverydaylives,thattheirconfidenceincreasedand,thatthesharedactivitieshelpedcommunitycohesion.

InSeptember2015theNewingtonBigLocalprojectwasreviewedbyresidents.AchievementslistedincludeddispellingthebadreputationthatNewingtonhadformerlyhad,bringingbackcommunityspirit,residentsusingandbuildingnewskills,andpeoplefeelingmoreconfident,betteratspeakingoutandsharingtheirideas(NBLP2015).


Casestudy3:WellLondon

WellLondon–withthestrapline‘Communitiesworkingtogetherforahealthiercity’–providesaframeworkforcommunitiesandorganisationstopartnertoimprovehealthandwellbeing,buildresilienceandreduceinequalities.EstablishedwithfundingfromTheBigLottery,itoperatesverylocally,atneighbourhoodlevel–todate,in30deprivedareasacrossLondon,includingBrent,Camden,TowerHamletsandSouthwark.Itworkswithresidentstoestablishlocalneeds(ratherthanimposingideas)andempowersthemtocomeupwiththeirownsolutionsandsupporteachothertolivehealthierlives.Italsointegrateswithandaddsvaluetoexistinglocalprogrammes–partneringwithgrassrootsorganisationsandinvolvingpeoplealreadyembeddedwithin(andtrustedby)thelocalcommunity.Thispartnershipapproachbuildscommunityspiritandconnectspeopleofallages,andincreasesindividualandcommunityknowledgeandskills.Thisalso–crucially–buildscapacity,whichcreatessustainability.

ActivitiessupportedbyWellLondonincludeartsandcraftsworkshops,theuseof‘communityactivators’toencouragepeopletocometophysical-activitysessions(forallages),establishingahealthylocalcafé(whichalsorunscookingsessionsandgiveshelpinbudgeting)andafruitandvegetablestall,andrunningalocalwomen’slifeskillsgroup.Theprojectsareallpromotedlocally–forexample,byGPsdirectingpatientstophysical-activityopportunities.Researchindicateasignificantimpact–forexample,83percentofparticipantshadbeenhelpedtoincreasephysicalactivity,63percenthadbeenhelpedtogainaccesstohealthyfood,and80percentreportedimprovedunderstandingofmentalwellbeing.

Evaluation(withtheUniversityofEastLondon)hasbeenongoing(e.g.WellLondon/UEL2013),focusingonthenatureofandimpactonparticipants(includingalongitudinalcohortstudy),andhasbeenusedtodeveloptheprojectfurther.Currently,plansarebeingdevelopedforevaluatingtheprojectasitscalesup,includingfurtherevidenceofeffectivenessandcost–benefit,andhowtheWellLondonframeworkcouldbescaledupacrosslargergeographicalareas.

4.2.2Socialnetworks,socialisolationandsocialprescribing

Casestudy4:SocialprescribingattheBromleybyBowCentre

TheBromleybyBowCentreisacharityinadeprivedareaofTowerHamlets,EastLondon,thatprovidesadistinctive,holisticandeasilyaccessiblerangeofintegratedservicesinoneplace.Theservicesavailablestretchfromhealthcareforlocalresidentstoopportunitiestosetupyourownbusiness;fromsupportwithcredit-carddebtstobecomingastained-glassartist;fromlearningtoreadtogettingafirstjob.

TheBromleybyBowCentrewasfoundedontheprinciplesofsocialprescribing.Patientsarereferredtonon-medicalsourcesofsupportthroughlocalservices,programmesandprojects,suchashealthy-eatinggroupsorartsandcrafts,befriendingservicesandtohealth,wellbeingandhealthylifestylessupport,socialwelfareoremploymentprogrammes.GPs,nurses,health-careassistantsandreceptionstaffoftenhaveanunderstandingofthewiderneedsoftheirpatients,andsocialprescriptionenablesthemtoimproveoverallpatienthealthandwellbeing.

Animpactreportfoundsignificantbenefits,forexample80percentofpeopleofpeoplewhotookpartinthePoLLeNproject(People,Life,LandscapeandNature–usingsocialandtherapeutichorticulturetoimprovewellbeingthroughengagementinthenaturalenvironment)reportedimprovedphysicalandmentalhealthovera12-monthperiod,and58percentofpeopleofpeoplewhocompletedtheMyWeightcourselost5percentormoreoftheirbodyweight(BBBC2011).AreportintotheeffectivenessoftheCentrehasalsobeencommissionedjointlywithPublicHealthEngland.

TheBromleybyBowCentrehasasignificanttrackrecordofdevelopingandsharinginnovativepracticebothnationallyandinternationally.Ithascontributedtoanumberofnationalpolicyinitiatives,includingthedevelopmentofthenationalSureStartandChildren’sCentreprogramme,theHealthTrainerinitiative,TacklingHealthInequalitiespoliciesandtheHealthyLivingCentreprogramme.


Casestudy5:LocalAreaCoordinationinDerby

Since2012,small-scalelocalinterventionhasbeendeliveringdramatichealthimprovementsinDerbythroughLocalAreaCoordination(LAC)projects.Localareacoordinatorsworkautonomously,gettingtoknowpeopleatriskofrequiringformalservices,supportingpeoplewhoarevulnerableasaresultofphysical/learningdisability,mental-healthissues,sensoryimpairmentorage-relateddifficulties.Theygivesupportwith(forexample)buildingrelationshipswithothersinthecommunity,accessingarangeofinformationandservices,buildingconfidence,andhelpingtoenvisionwhatagoodlifelookslikeandprovingsupportinorganisingthestepstoachieveit.Byworkingtogether,theyareabletofocusonanindividual’smainpriorities–forexample,aresidentwantingtogetoutofhisflatandmakesomefriends,orhelpingpeopletofeelsafe,secureandmoreconfident.

EvaluationbytheUniversityofDerbyshowedthat,whenimplementedaccordingtoitscorevalues,principlesandmethodology,LACproducesverypositiveoutcomes.Overaperiodof10–12months,workingwithapproximately50people,theevaluationestimatedtherehadbeenan£800,000savingtohealthandsocialcareasaresultofpeople’suseoftheformalsystembeingdelayedordivertedentirely(Frisby2015).AnevaluationreportfromMarch2016showedthatLACserviceusersreportedimprovedhealthandwellbeing,lesssocialisolation,andincreasedconfidenceandindependence(ThinkLocalActPersonal2016).

LAChasalsobeenrolledoutinadiverserangeofUKlocations,includingCumbria,Gloucestershire,theIsleofWight,Leicestershire,NeathPortTalbot,Suffolk,Swansea,ThurrockandWalthamForest.

Casestudy6:NeighbourhoodHealthWatch

TheNeighbourhoodHealthWatchmodelisthebrainchildofalocalGPwhodecidedthat,althoughmanycommunitiesalreadydomuchtohelponeanother,moresupportwouldempowerthemtodomore.EachNHHWbringstogethertheNHS,Police,FireandRescue,thevoluntarysectorandthelocalauthoritytoenablecommunitiestoaddresshealthandwellbeingneeds,suchasreducingsocialisolation,increasingresilience,connectingcommunitysupportforhealth,andpromotingvolunteering.Theyvaryinsizefromjustafewhousestoallthehousesinalocalarea.

EachNHHWisledbyalocalresident–avoiceforthecommunity–organisingregularmeetingstodiscussissuesanddecideonaction.Itprovidesasettingforconversationsbetweencommunitymembers(someofwhommayhavegoodknowledgeofrelevanthealthareas)andactsasa‘bridge’toinformationandserviceproviders(includingcharitiesandlocalbusinesses)whoaretryingtoaccessthecommunity,butfindithardtoreachthosemostinneed.NHHW‘goodneighbours’undertakeindividualactionssuchasclearingsnow,offeringliftstoshopsormedicalappointments,orcheckingalliswellwithpeoplewholivealone.

Theinitialpilotsitesweremonitoredcloselytoidentifymechanismsofdevelopmentandtoidentifykeysuccesscharacteristics.Therealitiesofeachsiteprovedtobedifferent,soeachNHHWhasadifferentfocus(inBudleigh,forexample,a‘foodneighbours’schemeencouragespeopletocookanextraportionoffoodforsomeonewithoutaccesstohotfood).

TheprojecthasbeenevaluatedbySWAcademicHealthScienceNetwork(2015),butdata-gatheringischallengingbecauseitisvolunteer-ledandformalevaluationwouldchangetheroleofthevolunteers(makingitmoreonerous)andthevoluntarynatureoftheproject.NHHWshavealsostruggledtocontinuewhencoordinatorsmoveontoanotherrole.

NHHWscurrentlyoperateindependently(aninitialquarterlysteeringgroupmeetingnolongertakesplace),butasimplemodelhasbeendevelopedthatestablisheskeycorecomponents,allowingNHHWstobeestablishedelsewhere(NHHW2016).


4.2.3Environmentalfactors

Casestudy7:BoxChickenproject:creatingnew,healthytakeawayservices

Fast-foodoutletsthatserveunhealthytakeawayfoodareverycommoninmanyareasoftheUnitedKingdom,andoftenespeciallysoinareaswithhigherlevelsofdeprivation–chickenshops,inparticular,areoftenaplacewhereyoungpeoplecongregatewhentheyhavenowhereelsesociabletogo.In2012,thecharitablefoundationandtrustShiftsetouttotacklethisbyworkingcollaborativelywithpartnersacrosspublichealth,fastfoodandnutritiontoredesigntheseenvironments(Shift2016).Theworkinvolvescreatingnewtakeawayservicesservingtasty,affordablefoodthatisalsohealthy,andworkingwithexistingfast-foodoutletsandlocalpublic-healthteamstomakethefoodalreadyavailablehealthier.Shiftwantstomakehealthyfoodoptionsjustasvisible,tastyandcheapastheunhealthyoptions.

ShiftfirstcompletedayearofresearchandconsultationinLondoncommunitiesandinOctober2013openedamobilefoodoutletcalledBoxChicken,servinghealthyandaffordablechickenmealsoverafour-weekperiodinNewham,EastLondon.Thispilotreceivedoverwhelminglypositivefeedback,andwasfollowedbyfurthertrialsthatwereallevaluated(Shift2015).Usingthisexperienceandtheevaluationfeedback,ShiftisnowworkingonapropositionforanewUKhealthyfastfoodbranch,andhasalsodevelopedamethodologyanddigitaltoolthatassessesandmapsfast-foodoutletsinspecificareas,designshealthimprovementstotheseoutletsandthenassessestheseimprovementsandtheirhealthimpact.Shiftiscurrentlyworkingwithapublic-healthteaminEastLondontorefineandtestthisserviceandhopestorollitoutacrosstheUnitedKingdom.

Casestudy8:Transformingthelocalenvironment:TheNationalForestandRoslistonForestryCentre

TheNationalForestisaprojecttocreateaforest,‘woodlandbywoodland’,acrossa200-square-mileregionoftheMidlands(NationalForest2014).Theprojectbegan25yearsago,duringwhichtimeforestcoverhasrisenfromjust6percentto20percent(theaimisforathird),and8.5milliontreeshavebeenplanted.TheForestisgrowingacrosspartsofDerbyshire,LeicestershireandStaffordshire,anareawithinwhichsome200,000peoplelive.In2015,theForestitselfhad7.5millionvisitors,andpracticallyeverychildlivingwithintheForesthasbeeninvolvedinitatsomepointthroughschool.Todate,mostofthefundingfortheNationalForestCompany(theorganisationchargedwithcreatingTheNationalForest)hasbeenfromDefra;theNFChasrecentlybecomeacharity,andwillbefocusingincreasinglyonlocalandnationalpartnershipsforsustainability.

TheForestareaisbecominganincreasinglypopularplacetoliveandwork,withtheForestitselfproviding‘socialglue’forthelocalcommunity.Healthandwellbeing,aswellasimprovingthelocalenvironment,underpinsmanyinitiatives,includingplanting/tendingtreesandthemanywalkingandcyclingtrails(including40milesofnewbicycletrailsputinplacebycyclingcharitySustrans,andthedevelopmentofa75-milewalkingtrail,theNationalForestWay).

RoslistonForestryCentre,forexample,runsawiderangeofactivitiestoencouragepeopleofallagestogetoutandabout–tacklingsocialinclusionaswellasphysicalhealth:‘TeddyWalks’aimedatyoungchildren,NordicWalking,walkingclubs,TaiChi,pushchairwalksandseniorcycling.Therearedrop-inactivitiesintheschoolholidaysandaholidayclub.TheCentreworkswithcommunitygroups,disabilityorganisationsandothercharities,corporategroupsandwithschools.

Althoughformalevaluationissometimesdifficulttoachievewithoutdisruptingtheeffectivenessoftheactivities,itisevidentfromstrikingqualitativeevidencethatthisisahugelybeneficialpartnershipforthehealthandwellbeingofthosewholiveandworkintheForest.


4.2.4Focusingonprevention

Casestudy9:MorganStanleyHealthyLondon

InFebruary2015,investmentbankMorganStanleylauncheditsHealthyLondonprogramme,aimingpositivelytoimpactchildren’shealthinPoplar,EastLondon,justashortdistancefromitsflagshipLondonheadquarters.MorganStanleybeganbypartneringwithlocalcharitiesandwithDrPaulSacherandC3CollaboratingforHealth.Sixmonthswasspentlisteningtolocalresidents’concerns,challengesandaspirationsfortheirchildren’shealth,andadetailedasset-mappingoflocalphysical-activityandfoodoptionswasundertakenusingtheCHESS®tool(C3CollaboratingforHealth2015a).TherecommendationsfromthisengagementprocessdrovetheplanningandexecutionoftheHealthyLondonproject.

Anumberofkeythemesemergedfromtheconversationswithlocalresidents.Languagebarriersandinaccessibleinformationwereidentifiedasobstaclesforfamiliesaccessingservicessuchashealthcare.Therewasalsoadesireamongresidentstogainbetterunderstandingofhealthissues,especiallyrelatedtonutrition.Theoverabundanceoffast-foodoutletsandtheincreasingratesofchildhoodobesitylocallywereseenasproblemsbyresidents.Thefindingshighlightedtheimportanceoffun,healthyplayforchildren,butmanyresidentscommentedthatopportunitiesandfacilitiesarelimitedinthecommunity–physical-activityopportunitiesforchildrenhavefallenoverthelastgeneration.

Today,throughtheHealthyLondonprogramme,thousandsofchildrenandparentshavegainedaccesstohealtheducationandacommunityhealthadviser,therearethreedifferentplaygroundsbeingbuilt(andeventswillbeheldineach,supportedbylocalresidents),andhealthymeals,nutritionadvice,healthylifestyleeducationandexerciseprogrammesareavailable–resourcesthatarecrucialtochildrengettingashealthyaspossibleastartinlife(MorganStanley2015).

Casestudy10:GoGolborne

GoGolborne(RBKC2016)isacommunity-basedhealthylifestyleinitiative,launchedin2015andduetocontinueforatleastthreeyears,partoftheRoyalBoroughofKensingtonandChelsea’seffortstoimprovechildhealth.Golborneisoneofthemostdeprivedareasoftheborough(andLondon).

ThemethodologyfortheinitiativeisinspiredbytheEPODEmodel(seealsocasestudy12belowandintheChildrenandYoungPeoplepaperinthisseries,section4.3.1.4,casestudy5)–aninternationalprogrammetopreventchildhoodobesity,thatinvolvesestablishinganetworkoflocalorganisationstomakeiteasiertoeathealthilyandtakephysicalactivityinallsettingswherechildrenandfamilieslive,learnandplay.Theinitiativewillrunadifferentcommunity-widesocialmarketingcampaigneverysixmonths,withotheractivitiesincludingenvironmentalimprovementstosupporthealthychoices(suchasinstallingplaygroundequipmentforolderchildren),trainingandcapacitybuilding(workshopsonkeynutritionandphysicalactivitytopics,andexpertinputtodevelophealthy-eatingpolicies),andincreasedsupportfromschoolnursesforhealthpromotion.Aschemeofsmallgrantsforlocalcommunityorganisationshasalsobeenestablished.Cross-departmentalworkingisencouraged–forexample,theCouncilissupportingmarkettraderstoacceptHealthyStartvouchersforfruitandvegetables.Anawardschemetosupportandrecognisegoodpracticeamongstcommunitysettingsisbeingpiloted.

GoGolborne’sfirstcampaign–5ADAY–beganinNovember2015.Over1,500childrentookpartinachallengetoeat5ADAYfor20days,cookingworkshopswereheldinalocalcafé,anda5ADAYmagazinehasbeendistributedtoparents.5ADAYgrantshavealsobeenawarded,enablingtheVentureCentretoprovidefreshfruitandvegetablesnacksforchildren,andprovidingfundingforlocalvolunteerstorunafter-schoolfoodgrowing/cookingclubsforfamilies.

Atthisearlystage,robustevidenceofimpactisnotyetavailable–aninitialindependentevaluationbytheUniversityofKentisdueinSeptember2016,butfeedbacktodate–fromlocalagencies,childrenandparents–hasbeenpositive.


Casestudy11:CollectiveimpactintheUnitedStates–ShapeUpSomerville

ShapeUpSomerville(SUS)isacampaignacrossthetownofSomerville,Massachusetts,to‘buildandsustainahealthier,moreequitablecommunity’.Itbeganasastudytoimprovelevelsofoverweightandobesityamongschoolchildrenbutnowencompassesthewholecommunity(a‘collectiveimpact’approach),focusingparticularlyonlowersocioeconomicgroups(ShapeUpSomerville2013).

Keytoitssuccessisstrongpartnershipswithcivicandcommunitystakeholders.Itisrunbyadirectorandcoordinatorsupportedbyasteeringcommitteeincludingcitydepartments(schools,housinginfrastructureetc.),community-basedgroups(suchasearlyyearsorganisationsandcommunityhealthproviders)andsomeprivate-sectororganisations.ThemayorhassupportedSUSsincecomingtoofficein2004–andSUSisnowembeddedasaconduitbetweencommunityandcity.

Threeformalstudiesofchildren'sweighthavebeencarriedout.Thefirstsurvey(2003–4)foundthattheBMIpercentileforfirst-tothird-gradersfellbyapproximatelyonepointcomparedwithcomparisoncommunities.The2010–11studysawadecreaseinobesityfrom30to28percent,with17percentofstudentsmovingoutoftheobesecategoryintoahealthierweightcategory(ShapeUpSomerville2012–13).

SUStodayhasthreemainaims:accesstohealthyfood(includingaMobileFarmer’sMarketanda‘healthyrestaurant’programme),healthequityandactiveliving.Futureplansincludeensuringprogrammesreachallage-groupsandcultures,andtacklinghealthinequality(in2011,35.6percentofeighth-gradeHispanicchildrenand23.6percentofwhitechildrenwereobese).

Therearechallengesoffunding,asinitiativesarereliantongrantsandfundersforimplementation(suchastheRobertWoodJohnsonFoundation),andtheacademicpartnersthatproducedthestudiesontheBMIdataarenolongerinvolved(C3CollaboratingforHealth2015b).

Casestudy12:Awhole-of-societyexample–ViasanoinBelgium

Viasano(the‘healthyway’)isanongoing,community-basedprogrammetotackleobesityandoverweightinchildrenthathasbeenrolledoutin20citiesacrossBelgium.ItusesEPODEmethodology(Borysetal.2012)toembedhealthierlifestylesovertime–workingwiththewholecommunity,notjustwithchildrenthemselves,tocreatealocalenvironmentthatsupportshealth.

Theprogrammeisrunatlocallevelbyaprojectmanagerwithalocalsteeringcommittee(teachers,healthprofessionals,localmedia,paediatricians,localassociationsandresidents)developViasanoideas,whicharedeliveredbylocalpeople.Theprivatesectorisalsoinvolved(regulatedbyanethicalcharter)–suchasgrocersprovidinghealthyproductsforevents.

InMouscronandMarche-en-Famenne,astudywasundertakenonchildrenaged3–6tocomparechangesinBMIwiththerestofthecountry’sFrench-speakingcommunity.In2007,13.6percentofthechildrenwereobese/overweight;by2010thishadfallento11.2percent–arelativedecreaseof18percent.In2007,4.1percenthadobesity;by2010thisfellto3.8percent–arelativedecreaseof7percent.Incontrast,ratesremainedstableinthecomparisonpopulation(Vincketal.2015).

Recentactionsinclude:acampaigntoimprovethehealthinessofschoollunchboxes,workshopsonmanyaspectsoffood(includingfornurseryworkersontheimportanceofeatingfruitandvegetables,andaworkshoponhealthyeatingwithlittlemoney);renovationofgreenspaceinanareaofsocialhousing;and‘AWeektoEatBetterandMoveMore’–includinglocalrestaurantsprovidinghealthyfood,takeawayfruitatschoolcanteens,sportingactivitiesforchildren,andtalksonphysicalactivity(Viasano2016).

Themainchallengeistomaketheprogrammesustainable–changestohabitsandhealthdonothappenovernight,sotheinitiativemustbelongterm,embeddeddeepwithinthelocalcommunity.


5.ChallengesandgapsThereisplentyofnarrativeaboutpreventionandworkingincommunities,butitappearsthatmovementtodatehasbeenlimited.Thereasonsforthisaremanyandvaried–butsolutionsmaybemoresimplethanwethink,ifthesystem(andthehumanandphysicalassetswithinit)canbeputtogooduse.

5.1Comparinglikewithlike?

Althoughthevolumeofliteratureavailableoncommunitiesisvast,therangeofdefinitionsandlackofclarityinwhichdefinitionisbeingappliedmeanthattheuseoftheconceptof‘community’hidesgreaterdiversitythanisimmediatelyapparent.Thereisaneedforamoresystematicapproachtogeographicalcommunityinterventions,witharobustframeworkforidentifyinganddelimitingcommunities,whichwillenablecross-communitycomparability.

5.2Promotingasset-basedapproachestocommunityhealth

Oneofthekeychallengesisensuringthatpeopleinthecommunityaresupportedandenabledto

participateeffectively.Organisationsworkinginandwithcommunitieshavetobecomeresponsivetowhatmatterstopeoplewithincommunities.NICEhaspublishedanumberofguidelinesdefininggoodpracticeinthisarea–forexample,guidancetolocalauthoritiesonhowtoengagewithpeopleintheirlocalareas(NICE2014)and,mostrecently,guidelineson‘Communityengagement:improvinghealthandwellbeingandreducinghealthinequalities’(seesection3.2.3).However,whilemuchofthisguidancewouldhavegeneralapplicabilitytopeopleworkingwithincommunities,itsuseremainslargelyinahealthsilo,failingtoreachthenon-clinical,community-basedorganisationsthatareessentialtoleadinghealthylives.Considerationneedstobegivenastohowbesttosupportdiverseorganisationstolearnfromexistingbestpracticeincommunityengagement,goingwellbeyondthetraditionalpublic-healtharenatoinvolve‘unusualsuspects’whohaveanimpactonhealth.Communitiesandresidentsneedtobesupported,nurturedandinspiredfirsttodeveloptheconfidencetotalktotheirlocalauthorities,housingassociations,anddecision-makerstotellthemwhatisimportanttothem,andsecondlytotakeactionthemselves.Providersoftheassetsthemselves–suchaslocalsportsassociations–mayalsoneedadviceinhowbesttotargettheircommunities.

However,fullystretchedpublic-healthteamsmaylacktheskillsandtimethatwouldenablethistotakeplace.Despitenowbeinglocatedwithcouncilservices,thereisoftenlimitedknowledgeinhowtomakeconnectionsbetween,andaccessresourcesfrom,otherdepartmentstomakepublichealtheveryone’sbusiness(seealsothefinalpaperinthisseries).Beyondthis,thecreativityandinnovationneededtoengageandempowercommunitiesandworkplaceseffectivelyisoftennotevident–althoughtherearesomeexemplars(seealsosection5.4below).

5.3Theneedtoimproveevaluationofprojects

Despitethelargeamountofliteraturethathasbeencollectedonhealthycommunities,thereisaseriouslackofevidenceaboutwhatworkstopromotecommunity-healthoutcomesinthepeer-reviewedliterature.10Manysystematicreviewsfocusondescribingtheproblems,talkingabouttherelationshipsbetweendeprivationandhealthoutcomes,andtherehasbeenalackoffocusonprevention.Wherestudiesareavailable,theygenerallyfocusonsmallsub-populations(acommunityofinterest)andthereislimitedconsiderationofgeographicalcommunities,andworkingwithdiversepopulations.Thearenaismademorecomplexbytheemergenceofnewtechnologyandimprovedtransportlinks,meaningthatprojectsworkingoncommunitiesareoftenunabletodisaggregatefindingsrobustlytoconsidertheneighbourhoodeffectasadistinctphenomenon.

10Thisisalsoanimportantissueintheotherareascoveredbythesebriefingpapers–see,forexample,Workplace(section5.5.2),EarlyYears/ChildrenandYoungPeople(section5.4)–andiscoveredinthefinalpaperintheseries.


Astheprevioussectionshaveshown,greaterclarityisneededaboutthescopeofinterventions,thedesiredoutcomes,andtheaudiencescoveredbytheinterventions.Anumberofprojectshavelookedatestablishingmetricsformeasuringtheimpactofcommunity-healthimprovementinitiativesthatcanbeutilisedacrosspopulationgroups.AUSreport,forexample(CDC2013),notedthat‘anaccurateportraitofacommunity’shealthcanalwayshelpresidents,communitygroups,andprofessionalorganizationsprioritizepreventionactivitiesandbuildcoalitionstomakeimprovementsandaddressexistingproblems’.Thisreporthighlightedtherangeofmetricsthatcanbeusedtofacilitatecomparisons,andpromotecollaborationthroughasharedunderstandingofthefactorsthatinfluencehealth.Interestingly,manyofthesefactorsfocusedondescribinghealthstatus–forwhich,intheUnitedKingdom,PublicHealthEnglandprovidesagoodrepositoryofappropriatedata.

Oneofthekeychallengesappearstobeconfusionaboutwhatcommunityempowermentreallymeans,andhowtoputitintopractice.Theevidencesearchfoundlittleharddatademonstratingrobustmeasurementofinterventionsthathavebeendrivenbycommunities.Thereisaneedforinnovativeapproachestomeasuretheimpactofcommunityempowermentonhealthoutcomestosupportandinformfutureactivity.Manyofthereviewsaccessedinthecourseofthisstudycommentedonthechallengesassociatedwithdefiningthepopulationlevel,andthatthisinturneffectedtheabilitytogeneraliselearningbasedonthefindingsfromstudies.Communityempowermentandpreventionis,itappears,hardtomeasure.Thereisaneedtodevelopinnovativeapproachestomeasurecommunityengagementandempowermentandtheirimpactonhealthoutcomesinamorerigorousway(Cyriletal.2015).

TheCentreforPublicHealthatLiverpoolJMUUniversityhasproducedausefulresource(BatesandJones2012)forconsideringhowbesttomonitorandevaluatecommunityprojects.Thisreport,producedtoinformongoingandfuturecommunity-basedgreenprojects,couldalsobeusedtoinformamoreconsistentapproachtothemonitoringandevaluationofothercommunityprojects,providinglinkstoresourcesandtoolsthatprovidepracticaladviceandmoredetailonhowtomonitorandevaluateprojects.Giventhatoneofthechallengesraisedinthisbriefingpaperistheneedtobeclearonwhatbasisreplicationisbeingrecommended,thissuggeststhatconsiderationneedstobegiventohowbesttosupporttherobustevaluationofcommunityprojectstosupportcross-comparisonsofinterventionsanddecisionsaboutfuturereplicabilityofprojects,particularlyinaresource-constrainedworld.

Ensuringrobustevaluationisbuiltintoallcommunityprojectsremainsachallenge.Notallprojectsaredestinedtobewrittenupintheacademicliterature.Thegreyliteratureprovedtobemorerewarding,highlightinganumberofsmall-scaleprojects,whichoninitialinvestigationseemedpromising.However,manyoftheseprojectsranonlyforashortperiodoftime,werenotscaleduporrobustlyevaluated,andhaveoftenceasedactivity.Publicisinggoodpracticeneedstobecomeapriority–andthecasestudiesinsection4.2areagoodplacetostart.

Afurtherchallengeisthatevaluationtakestime,effortandexpertise–andarequirementtogatherinformationcouldthreatentheviabilityofsomeinitiativeswheretheyareledbyvolunteerswithlittlesparetimetodevotetodatagathering.

Finally,thereisadangerofaviciouscirclebeingcreated,withthelackofevidenceformingabarrierto

actionandpreventingthebuildingoftheevidencebase.Butthereisarealopportunityhere:notonlywillasuccessfulandcarefullyevaluatedinitiative,facilitatedbycross-sectoralworking(funders,academics,implementersandlocalorganisationsandresidents),benefitthecommunitywithinwhichitisrun,ithasthepotentialtobeanexemplarforothers.

5.4Sustainability

Lackofresources–bothhumanandfinancial–remainsaconstantrefrain,witheventhemostsuccessfulandwell-knownprogrammesstrugglingtobecomesustainable(see,forexample,MEND(highlightedinthefinalpaperinthisseries)andShapeUpSomerville(aUSexample–casestudy11).Grantsformanynewinitiativesareprovidedonaproject-by-projectbasisovershorttimescalesandwithonlyshort-term


objectives,ratherthanbuildingcapacitywithinthecommunityitselftocontinuetheprogrammesandcreatelong-termchangefromwithin.

Programmesareoftensiloed–forexample,tacklingobesitywithoutlookingatotherlifestyleissues–and,withshrinkingenvelopesofresourceavailableforfundinghealth-promotioninitiatives,considerationneedstobegiventohowbesttomaximisetheimpactoffundingacrossthepublic-healthlandscape.Thereisaneedforapublic-healthworkforceskilledinseekingoutlimitedfunding,willingtopartnerwithlocalauthorities,charitiesandotherstofindlong-termsolutions–theworkofProfessorKateArdern,directorofpublichealthforWigan,andherteam,hasbeenanexemplarhere.

However,oncecommunityassetshavebeensuccessfullyunleashed,initiativesmayprovetobemore

sustainablethanwasanticipated.

5.5Actingonwhatweknowworks

Socialprescribinghasthepotentialtobecomeafullyintegratedcommunitypathwayforhealthandwellbeing.Yet,despiteitslonghistory(BromleybyBow,forexample,hasbeeninpracticeforabout30years–casestudy4,above)anddespitebeingwellknownforitssuccess,ithasyettoachievemainstream

statusacrosstheUnitedKingdom.Investigatingwhythisisthecase–andovercomingthebarriers–willbecrucialinreplicating(ortranslating)successfulmodelsacrossthecountry.(Thisisdiscussedfurtherinthefinalpaperinthisseries.)

5.6Afailureofimagination

Finally,andcrucially,therehasbeenafailureofimaginationandaconsequentdearthofaction.Thehealthsystem–boththeNHSandpublichealth–areseverelyoverstretched,andtimeisnotbeinggiventotakeastepbacktoreflectonhowtopreventtheriseinchronicdiseasesthatisthreateningtoengulfthehealthservice(10percentofNHSexpenditureisalreadyspentontreatingdiabetesanditscomplications–aconditionaroundhalfofcasesofwhichcouldhavebeenpreventedordelayed).Despitecallstothecontraryin,forexample,theFiveYearForwardView,toooftenhealthissuesaresiloed,ratherthanaholistic,‘causesofthecauses’approachbeingputinplace–expectingpeopletobecomehealthywhileliving,learningandworkinginthesameenvironmentthatmadethemillinthefirstplace.

Canwemakethecaseforhealth,ratherthansickness,andchangethemedicalparadigmincommunities?Currently,spendingontheNHSisringfencedandthatforpublichealthisnot–andthereislittlecallforadifferentfocusandanalternative(lessmedicalised)offerinhealth–butthisisnotsurprising,asthepublicdonotknowthatmodelssuchasthatspearheadedbyBromleybyBowcouldbearealityintheirlocalcommunity.

6.Talkingpoints• Thebigquestionis:howcanwecreateasystemintheenvironmentinwhichwelive,learn,workand

playthatcreatesandfostershealth?

• Howdowemoveawayfromamedicalparadigm,inwhichpeoplearerootedindoctor/patientrelationships(underminingtheirabilitytotakecontroloftheirownhealthandwellbeing)?

• Whatarethebestwaystoactivateassetswithinlocalcommunities,whichareattheheartofsustainingchangeoverthelongterm?

• Howdoweengagefullystretchedpublic-healthteamininvestingskillsandtimetomakeconnectionsacrossdepartmentsandtoengageandempowercommunities?

• Thereisalargegapbetweenwhatsocietyprovidestoimprovehealthandwhatcommunitieswant.Whatwouldhappenifthedesign,implementationandevaluationofhealthinterventionsbecamesomethingwedowithcommunitiesratherthantothem?

• Whatarethebestwaystogatherevidenceon‘whatworks’?


• Howcan‘whatworks’bestbetranslatedappropriatelyfordifferentcommunities?

• Wouldusingalifecourselensoverlaidovertheconceptofplacebehelpfulinaddressingwhethertherearesubgroupswithinthepopulationwhoareparticularlyvulnerabletotheeffectsofneighbourhoodcharacteristics?–e.g.programmesdirectedatthehealthofolderpeople,tobeultimatelyeffective,willneedtoworkwiththoseimprovinghealthofyoungerpeople–particularlyconditions(suchasobesityorsmoking-relateddiseases)thathavetheiroriginsinriskfactorsinearlierlife.


Annex1:KeyplayersTherearemanyorganisations–includingprofessionalsocieties,academicinstitutions,thinktanks,charities,foundations,networks,statutorybodiesandfunders–workingincommunityhealthandempowerment.Theresourceslistedbelowareselectedfromthelargenumberavailable,andashortdescription,URLand(whereappropriate)importantpublicationsoftheorganisationsappearintheDebateGraphmappingthataccompaniesthisscopingproject.([email protected].)

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• Aesop

• AmericanAcademyofChildandAdolescentPsychiatry

• AmplifyNorthernIreland

• ASH–ActiononSmokingandHealth

• AwardsforAll(BigLotteryFund)

• Barnado's

• BeattheStreet

• BigLotteryFund

• BillandMelindaGatesFoundation

• BritishAssociationforEarlyChildhoodEducation

• BritishHeartFoundation

• BritishNutritionFoundation

• Bromley-by-BowCentre

• BusinessintheCommunity

• CEDAR–CentreforDietandActivityResearch

• CentreforAgeingBetter

• CentreforLongitudinalStudies

• CFIW–CommunityFoundationinWales

• ChildrenandYoungPeopleScrutinyCommittee

• ChildrenandYoungPeople’sHealthOutcomesForum

• ChildrenandYoungPeople’sServicesCommittees

• Children'sSociety

• Collaborate

• CommunityCatalysts

• CommunityDevelopmentCharterforHealth(NHSAlliance)

• CommunityEnergyWales

• CommunityHealthandLearningFoundation

• CommunityNI(NICVA)

• ConnectingCommunitiesC2(HealthComplexityGroup)

• DepartmentforCommunitiesandLocalGovernment

• DepartmentforEducation

• DepartmentofHealth

• EarlyInterventionFoundation

• EconomicandSocialResearchCouncil

• EPODE

• FacultyofPublicHealth

• FitFans

• FoodCoops

• GroundworkCommunitySpacesProgramme

• HealthandSocialCareInformationCentre

• HealthBehaviourinSchool-AgedChildrenNetwork

• HealthComplexityGroup

• HealthyLondonPartnership(NHS)

• HealthyNewTowns(NHS)

• HELP–HealthEmpowermentLeverageProject

• HENRY–HealthExerciseandNutritionfortheReallyYoung

• InControl

• InclusiveChange

• InclusiveNeighbourhoods

• InstituteofAlcoholStudies

• InternationalDiabetesFederation

• JamieOliverFoodFoundation

• JosephRowntreeFoundation

• LAC–LocalAreaCoordinationNetwork

• LEAP–LambethEarlyActionPartnerships

• LGAKnowledgeHub

• LivingStreets

• LocalGovernmentImprovementandDevelopment

• Locality

• MedicalResearchCouncil

• MentalHealthFoundation

• MIND

• MyCommunity

• MyTimeActiveUK

• NationalCentreforHealthandClinicalExcellence(NICE

• NationalFoundationforEducationalResearch

• NationalInstituteofMentalHealth

• NAVCA–NationalAssociationforVoluntaryandCommunityAction

• NCVO–NationalCouncilforVoluntaryOrganisations

• NeighbourhoodHealthWatch

• Nesta

• NewLocalGovernmentNetwork

• NHSAlliance

• NICVA–NorthernIrelandCouncilforVoluntaryAction

• NutritionSociety


• PembrokeHouse

• PreventionandEarlyInterventionNetwork

• PublicHealthEngland

• RANDEurope

• RobertWoodsJohnsonFoundation

• RoyalCollegeofMidwives

• RoyalCollegeofNursing

• RoyalCollegeofPaediatricsandChildHealth

• RoyalCollegeofPsychiatrists

• RoyalSocietyforPublicHealth

• SavetheChildren

• SCDC–ScottishCommunityDevelopmentCentre

• SHINEHIT–SupportingHealthyInclusiveNeighbourhoodEnvironments

• SPOTLIGHT

• StreetGames

• SupportingCommunities

• SureStart

• TheYoungFoundation

• ThinkLocalActPersonal

• ThrivePlymouth

• TinderFoundation

• TrussellTrust

• TudorTrust

• UKCF–UKCommunityFoundations

• UnderstandingCommunityHealth(HealthProfiles)

• Voice4ChangeEngland

• WCVA-WalesCouncilforVoluntaryAction

• WellLondon

• WellcomeTrust

• WhatWorksCentreforWellbeing

• WorldHealthOrganization

35 www.c3health.org

Annex2:EvidencetablesTable1:Engagementandparticipation

Intervention Overview Reference Conclusions

Effectivenessofparticipatory

approaches

Systematicreview.17electronicdatabasesweresearched

andinclusion/exclusioncriteriaandqualityappraisal

criteriaapplied.5,451referenceswereidentified,reduced

to2,155onceduplicateswereremoved.Onlyeight

paperscoveringsevenstudieswererelevantandincluded

intheanalysis.Onlytwostudiesmetmorethanhalfof

therelevantquality-appraisalcriteria.

Evansetal.2010

Thestudiesfellintotwodistinctgroups:fourused

qualitativemethodstoillustratethecomplexitiesof

effectivecommunityparticipation;threeclaimed

successfortheirparticipativeinitiativewithout

providingadequateevidencetosubstantiatesuch

claims.Thissystematicreviewdemonstratesthat

thereisverylittleevidenceinthepeer-reviewed

literatureofparticipatoryapproachesbyUKpublic-

healthunitsorofsuchapproacheshavingany

noteworthyimpactonhealthandsocialoutcomes.

Impactofcommunity

engagementonindividuals

Rapidreview,guidedbyNICE’spublic-healthmethods

manual,adaptedtosuitthediversityoftheevidence.A

totalof22studieswereidentifiedcontainingempirical

dataonsubjectiveexperiencesofcommunity

engagementforindividuals

Attreeetal.2011

Thefindingsoftherapidreviewsuggestthatthe

majorityof‘engaged’individualsperceivedbenefits

fortheirphysicalandpsychologicalhealth,self-

confidence,self-esteem,senseofpersonal

empowermentandsocialrelationships.Setagainst

thesepositiveoutcomes,however,theevidence

suggeststhatthereareunintendednegative

consequencesofcommunityengagementforsome

individuals,whichmayposearisktowellbeing.

Theseconsequencesincludedexhaustionandstress,

asinvolvementdrainedparticipants’energylevelsas

wellastimeandfinancialresources.Thephysical

demandsofengagementwerereportedas

particularlyonerousbyindividualswithdisabilities.

Communityengagementin

healthinitiatives

Systematicreview–toexaminethemagnitudeofthe

impactofcommunityengagement(CE)onhealthand

healthinequalitiesamongdisadvantagedpopulations,

whichmethodologicalapproachesmaximisethe

effectivenessofCE,andcomponentsofCEthatare

acceptable,feasible,andeffectivewhenusedamong

Cyriletal.2015

21ofthe24(87.5%)studieshadpositivelyimpacted

healthbehaviours,public-healthplanning,health-

serviceaccess,healthliteracy,andarangeofhealth

outcomes.KeyCEcomponentsthataffectedhealth

outcomesincludedrealpower-sharing,collaborative

partnerships,bidirectionallearning,incorporating



disadvantagedpopulations.24studiesmetinclusion

criteria.

thevoiceandagencyofbeneficiarycommunitiesin

researchprotocol,andusingbiculturalhealth

workersforinterventiondelivery.Thefindings

suggestthatCEmodelscanleadtoimprovedhealth

andhealthbehavioursamongdisadvantaged

populationsifdesignedproperlyandimplemented

througheffectivecommunityconsultationand

participation.

Effectivenessofcommunity

healthworker-led

interventions

Systematicreviewofliteraturefrom1998to2008.It

included53studiesonoutcomesofcommunityhealth

worker(CHW)interventionsandsixoncostorcost-

effectiveness.

Viswanathanetal.

2010

Foroutcomes,limitedevidence(fivestudies)

suggeststhatCHWinterventionscanimprove

participantknowledgecomparedwithalternative

approachesornointervention.Thereviewfound

mixedevidenceforparticipantbehaviourchange(22

studies)andhealthoutcomes(27studies),andlow

ormoderatestrengthofevidencesuggestingthat

CHWscanincreaseappropriatehealth-care

utilisationforsomeinterventions(30studies).Six

studieswitheconomicinformationyielded

insufficientdatatoevaluatethecost-effectivenessof

CHWinterventionsrelativetootherinterventions.

Communitybehavioural

normsasachallengefor

evidence-basedsmoking-

cessationprogrammes

Retrospectivecohortdesignusingpropensityscore

matchingofNurse-FamilyPartnership(NFP)clientsand

local-areamatchedcomparisonwomenwhosmoked

cigarettesinthefirsttrimesterofpregnancy.Birth

certificatedatawereusedtoclassifysmokingstatus.The

mainoutcomemeasurewassmokingcessationinthe

thirdtrimesterofpregnancy.Multivariablelogistic

regressionanalysisexamined,overtwotimeperiods,the

associationofNFPexposureandtheassociationof

baselinecountyprenatalsmokingrateonprenatal

smokingcessation.

Matoneetal.2012

Followingstatewideimplementationacross

Pennsylvania,programmerecipientsofNFP

demonstratedincreasedsmokingcessation

comparedtocomparisonwomen,withastronger

programeffectinlateryears.Thesignificant

associationofcountysmokingratewithcessation

suggeststhatcommunitybehaviouralnormsmay

presentachallengeforevidence-basedprogrammes

asmodelsaretranslatedintodiversecommunities.


Table2:Place-basedinterventions


Community-basedrestaurant

interventions

SystematicreviewthatsearchedallyearsofPubMedand

WebofKnowledgethroughJanuary2014fororiginal

articlesdescribingorevaluatingcommunity-based

restaurantinterventionstopromotehealthyeating.This

reviewincluded27interventionsdescribedin25studies

publishedsince1979.Itextractedsummaryinformation

andclassifiedtheinterventionsintoninecategories

accordingtothestrategiesimplemented.Summaryscores

weredevelopedtodeterminethelevelofevidence

(insufficient,sufficient,orstrong)supportingthe

effectivenessofeachcategory.

ValdiviaEspinoetal.

2015

Mostinterventionstookplaceinexclusivelyurban

areasoftheUnitedStates.Themostcommon

interventioncategoriesweretheuseofpoint-of-

purchaseinformationwithpromotionand

communication(n=6),andpoint-of-purchase

informationwithincreasedavailabilityofhealthy

choices(n=6).Onlythelattercategoryhad

sufficientevidence.Theremainingeightcategories

hadinsufficientevidencebecauseofinterventions

showingno,minimal,ormixedfindings;limited

reportingofawarenessandeffectiveness;low

volumeofresearch;orweakstudydesigns.No

interventionreportedanaveragenegativeimpacton

outcomes.

Conclusion:Evidenceabouteffectivecommunity-

basedstrategiestopromotehealthyeatingin

restaurantsislimited,especiallyforinterventionsin

ruralareas.Toexpandtheevidencebase,more

studiesshouldbeconductedusingrobuststudy

designs,standardisedevaluationmethods,and

measuresofsales,behaviourandhealthoutcomes.

Communitypharmacies’role

inpromotinghealthin

communities

Systematicsearchofinternationalpeer-reviewed

literature.Thesearchperiodwasfrom1January1991to

30July2009.Overall,itreviewed115articlesonan

abstractlevelandretrieved45ofthoseasfull-textarticles

forbackgroundinformationreviewandinclusionintothe

evidencereport.32%werefromtheUnitedKingdom.

Georgeetal.2010

Evidenceofeffectivenessforcommunitypharmacy/

communitypharmacistinterventionsexistsforlipid,

diabetesandhypertensionmanagement,andfor

preventiveservicessuchasweightmanagement,

osteoporosispreventionandfluimmunisation

services.Factorsfoundtoimpedethegrowthof

communitypharmacistsareinsufficientintegration

ofcommunitypharmacistinputintohealth-care

pathways,poorrelationshipamongpharmacistsand

physicians,lackofaccesstopatientinformation,

timeconstraintsandinadequatecompensation.



Pharmacyandpublichealth 10electronicdatabasesweresearched.Therewasno

restrictiononlanguageorcountry.Supplementary

searchesincludedwebsite,greyliterature,studyregisters,

bibliographiesandcontactingexperts.

Brownetal.2016a

Communitypharmacy-deliveredinterventionsare

effectiveforsmokingcessation,anddemonstrate

thatthepharmacyisafeasibleoptionforweight-

managementinterventions.Giventhepotential

reach,effectivenessandassociatedcostsofthese

interventions,commissionersshouldconsiderusing

communitypharmaciestohelpdeliverpublic-health

services.

School-basedhealth

promotion

Systematicreview–searched12databasestoidentify

reviewspublishedafter1980.Datawerereviewedbytwo

researchers.Qualitywasassessedusingamodified

AssessingtheMethodologicalQualityofSystematic

Reviewschecklistandresultsweresynthesisednarratively

Shackletonetal.

2016

Thesynthesessuggestthatmulticomponentschool-

basedinterventions–forexample,includingschool

policychanges,parentinvolvement,andworkwith

localcommunities–areeffectiveforpromoting

sexualhealthandpreventingbullyingandsmoking.

Thereislessevidencethatsuchinterventioncan

reducealcoholanddruguse.Economicincentivesto

keepgirlsinschoolcanreduceteenagepregnancies.

Schoolclinicscanpromotesmokingcessation.There

islittleevidencethat,ontheirown,sexual-health

clinics,antismokingpolicies,andvariousapproaches

targetingat-riskstudentsareeffective.

Druguseinterventionsin

schools

Systematicreview.RCTsandCCTsevaluatingschool-

basedinterventionsdesignedtopreventsubstanceuse

werereviewed.Datawereextractedindependentlyby

tworeviewers.Qualitywasassessed.Interventionswere

classifiedasskills,affective,andknowledgefocused

Faggianoetal.2008

Comparedwithusualcurricula,skills-based

interventionssignificantlyreducemarijuanauseand

harddruguse,andimprovedecision-makingskills,

self-esteem,peerpressureresistanceanddrug

knowledge.Comparedwithusualcurricula,affective

interventionsimprovedecision-makingskillsand

drugknowledge,andknowledge-focused

programmesimprovedrugknowledge.Skills-based

interventionsarebetterthanaffectiveonesin

improvedself-efficacy.Nodifferencesareevident

forskillsvsknowledge-focusedprogrammesondrug

knowledge.Affectiveinterventionsimprove



decision-makingskillsanddrugknowledgetoa

higherdegreethanknowledge-focusedprogrammes.

Communitypharmacyand

healthpromotion

Systematicreview.Fiveelectronicdatabaseswere

searchedforarticlespublishedinEnglishbetween2001

and2010.Titlesandabstractswerescreenedbyone

researcheraccordingtotheinclusioncriteria.Paperswere

includediftheyassessedpharmacystafforconsumer

attitudestowardspharmaceuticalpublichealth.Full

papersidentifiedforinclusionwereassessedbyasecond

researcheranddatawereextractedbyoneresearcher

Eadesetal.2011

Pharmacystaff:Mostpharmacistsviewedpublic-

healthservicesasimportantandpartoftheirrole,

butsecondarytomedicine-relatedroles.

Pharmacists'confidenceinprovidingpublic-health

serviceswasonthewholeaveragetolow.Timewas

consistentlyidentifiedasabarriertoproviding

publichealthservices.Lackofanadequate

counsellingspace,lackofdemandandexpectation

ofanegativereactionfromcustomerswerealso

reportedbysomepharmacistsasbarriers.Aneed

forfurthertrainingwasidentifiedinrelationtoa

numberofpublic-healthservices.

Consumers:Mostpharmacyusershadneverbeen

offeredpublic-healthservicesbytheirpharmacist

anddidnotexpectthemtobeoffered.Consumers

viewedpharmacistsasappropriateprovidersof

public-healthadvicebuthadmixedviewsonthe

pharmacists'abilitytodothis.Satisfactionwasfound

tobehighinthosethathadexperienced

pharmaceuticalpublichealth.

Roleofpharmacyin

promotingcommunityhealth

Asystematicreviewoftheresearchliteraturecovering

theperiodJanuary1990-August2011inclusive,usingfive

databases.Atotalof377paperswereincluded.

Brownetal.2012

Thetopicsofcontraception,cardiovasculardisease

prevention,diabetesandsmokingcessation

accountedfor40%ofincludedpapers.Theliterature

supportstheintroductionofspecificcommunity

pharmacyservices,targetedatcustomergroups,

bothwithandwithoutpre-existingdiseases.Good

evidenceexistsforsmokingcessation,cardiovascular

diseaseprevention,hypertensionanddiabetes.

Somegoodevidenceexistsforinterventionson

asthmaandheartfailure.Theevidencesupporting

weightmanagement,sexualhealth,osteoporosis

detection,substanceabuseandchronicobstructive



pulmonarydiseaseisweakandneedsdevelopment.

Thereisstrongevidencefortheroleofcommunity

pharmacyinarangeofservices,notonlyaimedat

improvinggeneralhealth,butalsomaintainingthe

healthofthosewithexistingdisease

Table3:Socialmediaande-health


Socialmediaandhealth

interventions

Facebookwasexaminedasamechanismtorecruityoung

adultsforasmoking-cessationintervention.Anad

campaigntargetingyoungadultsmokerstestedspecific

messagingbasedonmarkettheoryandsuccessful

strategiesusedtorecruitsmokersinpreviousclinical

trials(i.e.informative,calltoaction,scarcity,social

norms),previouslysuccessfulads,andgeneralmessaging.

Imageswereselectedtotargetsmokers(e.g.litcigarette),

appealtothetargetage,varydemographically,andvary

graphically(cartoon,photo,logo).Facebook’sAds

Managerwasusedoversevenweeks,targetedbyage

(18–25),location(UnitedStates)raandlanguage(English),

andemployedmultipleadtypes(newsfeed,standard,

promotedposts,sponsoredstories)andkeywords.

Ramoetal.2014

Facebookisauseful,cost-effectiverecruitment

sourceforyoungadultsmokers.Adspostedvia

newsfeedpostswereparticularlysuccessful,

probablybecausetheywereviewableviamobile

phone.Effortstoengagemoreethnicminorities,

youngwomen,andsmokersmotivatedtoquitare

needed

Socialmediaandbehaviour

change

Participantswereenrolledintostudy-run,three-month

secretFacebookgroupsmatchedonreadinesstoquit

smoking.Cigarettesmokers(n=79)aged18–25whoused

FacebookonmostdayswererecruitedviaFacebook.All

participantsreceivedtheinterventionandwere

randomisedtooneofthreemonetaryincentivegroups

tiedtoengagement(commentingingroups).Assessments

werecompletedatbaseline,3-,6-and12-monthsfollow-

Ramoetal.2015

Retentionwas82%(65/79)at6monthsand72%

(57/79)at12months.Frombaselineto12-months

follow-up,therewasasignificantincreaseinthe

proportionpreparedtoquit(13%to46%).Overa

thirdreducedtheircigaretteconsumptionby50%or

greater,andtwo-thirdsmadeatleastone24-hour

quitattemptduringthestudy.Inanintent-to-treat

analysis,13%self-reportedseven-dayabstinence



up.Analysesexaminedretention,smokingoutcomesover

12months(seven-daypointprevalenceabstinence,≥50%

reductionincigarettessmoked,quitattemptsand

strategiesused,readinesstoquit),engagement,and

satisfactionwiththeintervention.

(8%verifiedbiochemically)at12-monthsfollow-up.

Intheirquitattempts,11%usedanicotine

replacementtherapyapprovedbytheFoodand

DrugAdministration,while18%usedanelectronic

nicotinedeliverysystemtoquit(e.g.electronic

cigarette)

Mobilephonesand

behaviouralchange

Systematicreview Whittakeretal.2012

Fivestudieswithatleastsix-monthcessation

outcomeswereincludedinthisreview.Three

studiesinvolveapurelytext-messagingintervention

thathasbeenadaptedoverthecourseofthese

threestudiesfordifferentpopulationsandcontexts.

Onestudyisamulti-armstudyofatext-messaging

interventionandaninternetQuitCoachseparately

andincombination.Thefinalstudyinvolvesavideo-

messaginginterventiondeliveredviathemobile

phone.Whenallfivestudieswerepooled,mobile-

phoneinterventionswereshowntoincreasethe

long-termquitratescomparedwithcontrol

programmes,usingadefinitionofabstinenceofno

smokingatsixmonthssincequitdaybutallowingup

tothreelapsesoruptofivecigarettes.

Computerandelectronicaids

forsmokingcessation

SixelectronicdatabasesweresearcheduptoDecember

2009.Searchstrategieswerereported.Searcheswerenot

limitedbylanguage.Referencelistsofincludedstudies

andrelevantsystematicreviews,andregistriesofongoing

trials,weresearched.Expertsinthefieldwerealso

contacted.

Chenetal.2012

60RCTsandquasi-RCTswereincluded.Numbersof

participantsandquality-assessmentresultswere

reportedinfull,butnooverallsummarywas

reported.

Comparedwithnointerventionorgenericself-help

material,interventionsusingelectronicaids

significantlyincreasedthelikelihoodofachieving

prolongedabstinenceorpointprevalence

abstinencefromsmoking,measuredatthelongest

follow-up.Themixed-treatmentcomparisonshowed

asmallbutstatisticallysignificantpositive

interventioneffectontimetorelapse.



Extensivefurtherresultswerereported,including

recommendingresearchontheimpacton

effectivenessofinvolvingusersinthedesignof

interventions,andonhowelectronicaidscouldbe

appliedinroutinepracticeandinthecommunity.

Suicideandsocialmedia Discussionpaper.Providesanoverviewofwaysthatsocial

mediacaninfluencesuicidalbehaviour,bothnegatively

andpositively,andevaluatestheevidenceoftherisk.It

alsodiscussesthelegalcomplexitiesofthisimportant

topicandproposesfuturedirectionsforresearchand

preventionprogrammesbasedonapublic-health

perspective.

Luxtonetal.2012

Theroleofsocialmediaanditspotentialinfluence

onsuicide-relatedbehaviourisarelativelynewand

evolvingphenomenonthatsocietyisonlybeginning

toassessandunderstand.Theemergingdata

regardingtheinfluenceoftheInternetandsocial

mediaonsuicidebehaviourhavesuggestedthat

theseformsoftechnologymayintroducenew

threatstothepublicaswellasnewopportunitiesfor

assistanceandprevention.Becausesocialmediaare

mostlycreatedandcontrolledbyendusers,the

opportunityforsurveillanceandpreventioncanbe

extendedtoallusers.Tohelpfacilitatethisuser-

drivenapproachtosurveillanceandprevention,all

social-mediasitescouldadoptsimple-to-use

methodsforuserstoreportmaliciouswebsitesand

activitiesofotherusers.Moreover,thepublic

promotionofdirectandeasyavenuesforpeopleto

accesshelpthroughsocialmediasitesshouldbea

priority.Public-healthcampaignsthatleveragethe

internetandsocialmediatoraiseawarenessofthe

issueinschools,collegesandothersettingsmight

alsobebeneficial.

Creationofnewsocial

networksforolderpeople

Examinesthelinkbetweenhealthandcultivatingsocial

tiesusingnewlongitudinaldatafromtheNationalSocial

Life,Health,andAgingProject(NSHAP),whichrecorded

changesinolderadults'confidantnetworkrostersovera

periodofaboutfiveyears.Mostrespondents(81.8%)

addedatleastonenewnetworkmemberduringthestudy

Cornwelland

Laumann2015

Longitudinalanalysessuggestthattheadditionof

newconfidantsisassociatedwithimprovementsin

functional,self-ratedandpsychologicalhealth,net

ofbaselineconnectednessaswellasanynetwork

lossesthatoccurredduringthesameperiod.

Networklosseswereassociatedwithphysicalbut

notpsychologicalwellbeing.Thesefindings



period,andmost(59.4%)cultivatedmultiplenew

confidantrelationships.

underscoretheimportanceofdistinguishing

betweenconcurrentprocessesthatunderliesocial

networkchangeinlaterlife,andhighlighttheneed

foradditionalresearchonthemechanismsbywhich

networkchangemayimprovehealth.

Table4:Mentalhealthandsocialisolation


Socialrelationshipsand

mortalityrisk

Meta-analyticreviewacross148studies(308,849

participants)todeterminetheextenttowhichsocial

relationshipsinfluenceriskformortality,whichaspectsof

socialrelationshipsaremosthighlypredictive,andwhich

factorsmaymoderatetherisk.

Holt-Lunstadetal.

2010

Therandomeffectsweightedaverageeffectsize

indicateda50%increasedlikelihoodofsurvivalfor

participantswithstrongersocialrelationships.This

findingremainedconsistentacrossage,sex,initial

healthstatus,causeofdeath,andfollow-upperiod.

Significantdifferenceswerefoundacrossthetypeof

socialmeasurementevaluated:theassociationwas

strongestforcomplexmeasuresofsocialintegration

andlowestforbinaryindicatorsofresidentialstatus

(livingaloneversuswithothers).

Conclusions:Theinfluenceofsocialrelationshipson

riskformortalityiscomparablewithwell-established

riskfactorsformortality.

Focusoneffectivenessof

community-basedheart-

healthinterventionson

depressionoutcomesamong

homeboundelderly(64years

andolder)withheartdisease

Systematicreview.15studiesmetinclusioncriteriaandall

measureddepressionoutcomes.Studiesdifferedinscope

andmethodologicalrigourandsamplesizesvariedwidely.

Problemsintreatmentfidelityandmaskingofgroup

assignmentwerenoted.Greatvariabilitywasfoundin

depressionoutcomesduetothedifferencesin

methodologyandintervention.

Kang-YiandGellis

2010

Mixedevidenceforcommunity-basedheartdisease

interventionsondepressionoutcomeswasfound.

Futureresearchshouldincludesub-analysisofeffect

sizesofinterventionsondepressionoutcomesby

differentdemographiccharacteristicsofthestudy

sample,commondepressionoutcomemeasures,

anddifferentfollow-upperiods.



Mentalhealthandtheelderly Systematicreviewtoreportontheeffectivenessofcrisis

resolution/hometreatmentteamsforolderpeoplewith

mental-healthproblems.

Tootetal.2011

Outcomessuchaslengthofhospitalstayand

maintenanceofcommunityresidencewere

reviewed,butevidencewasinadequatefordrawing

conclusions.Thescopingexercisedefinedthree

typesofhometreatmentservicemodel:generic

hometreatmentteams;specialistolderadultshome

treatmentteams;andintermediatecareservices.

Thesehometreatmentteamsseemedtobe

effectivelymanagingcrisesandreducingadmissions.

Thisreviewhasshownalackofevidenceforthe

efficacyofcrisisresolution/hometreatmentteamsin

supportingolderpeoplewithmental-health

problemstoremainathome.

Communitymentalhealth

andtheelderly

Systematicliteraturereviewundertakentocollate

existingevidenceregardingthestructuresandprocesses

ofCMHTsforolderpeopleandtoevaluateevidence

linkingapproachestoeffectiveness.Relevantpublications

wereidentifiedviasystematicsearches,bothelectronic

andmanual.SearcheswerelimitedtotheUnitedKingdom

fordescriptionsoforganisationandpracticebutincluded

internationalliteraturewherecomparisonsbetween

differentCMHTarrangementswereevaluated.45studies

metinclusioncriteria,with44beingUK-based.

Abendsternetal.

2012

Themostrobustevidencerelatedtoresearch

conductedinexemplarteams.Limitedevidencewas

foundregardingtheeffectivenessofmanyofthe

coreattributesrecommendedinpolicydirectives,

althoughtheirpresencewasreportedinmuchofthe

literature.Thecontrastbetweenpresentationand

evaluationofattributesisstark.Whilesomegaps

canbefilledfromrelatedfields,furtherresearchis

requiredthatmovesbeyonddescriptionto

evaluationoftheimpactofteamdesignonservice-

useroutcomesinordertoinformfuturepolicy

directivesandpracticeguidance.


Table5:Environment


Environmentalfactors

mitigatingagainstfruitand

vegetableconsumption

Datafromsevenexistingstudies,identifiedthrough

literaturesearchesandknowledgeofco-authors,which

collectedmeasuresofbothneighbourhood-levelSESand

fruitandvegetableconsumption,wereused.Logistic

regressionwasusedtoexamineassociationsbetween

neighbourhood-levelSESandbinaryfruitandvegetable

consumptionseparately,adjustingforneighbourhood

clusteringandage,genderandeducation.Asmuchas

possible,variablesweretreatedinaconsistentmannerin

theanalysisforeachstudytoallowtheidentificationof

patternsofassociationwithinthestudyandtoexamine

differencesintheassociationsacrossstudies.

Balletal.2015

Neighbourhoodsocioeconomicdisadvantagemay

differentiallyimpactonaccesstoresourcesinwhich

produceisavailableindifferentcountries.

Neighbourhoodenvironmentshavethepotentialto

influencebehaviourandfurtherresearchisrequired

toexaminethecontextinwhichtheseassociations

arise.

Environmentandobesity Firstofaseriesofpapers(SPOTLIGHT)lookingat

environmentandobesity.

Lakerveldetal.2016

Ithasbeenpositedthatunhealthyobesogenic

lifestylebehavioursareanormalresponseto

environmentalcharacteristicsthatmayinfluencean

individual'slevelofphysicalactivity(e.g.throughthe

availabilityofopportunitiestowalk,

interconnectivityofstreets,proximityofparks)and

dietarybehaviours(e.g.throughavailability,

accessibilityandaffordabilityoffoods).Certain

environmentsmaybemore‘obesogenic’thanothers

–morelikelytopromoteandfacilitateunhealthy

obesity-promotingbehaviours,leadingtoweight

gaininindividualsandacrosspopulations.

Accordingly,environmentalfactorsofferamultitude

ofopportunitiesforthereductionofobesity

prevalence.

Self-definitionof

neighbourhoodandobesity

Aninnovativetoolwasdevelopedintheframeworkofthe

SPOTLIGHTprojecttoidentifytheboundariesof

neighbourhoodsasdefinedbyparticipantsinfive

Europeanurbanregions.Theaimsofthisstudywere(i)to

describeself-definedneighbourhood(sizeandoverlap

Charreireetal.2016

Self-definedneighbourhoodsizevariesaccordingto

bothindividualfactors(age,educationallevel,length

ofresidenceandattachmenttoneighbourhood)and

contextualfactors.Thesefindingshave

consequencesforhowresidentialneighbourhoods



withpredefinedresidentialarea)accordingtothe

characteristicsofthesamplingadministrative

neighbourhoods(residentialdensityandsocioeconomic

status)withinthefivestudyregionsand(ii)todetermine

whichindividualor/andenvironmentalfactorsare

associatedwithvariationsinsizeofself-defined

neighbourhoods.

aredefinedandoperationalisedandcaninformhow

self-definedneighbourhoodsmaybeusedin

researchonassociationsbetweencontextual

characteristicsandhealthoutcomessuchasobesity.

Virtualauditofareasto

identifyobesogenicfeatures

inurbanareas

Usingdatafromavirtualauditofobesity-relatedfeatures

carriedoutinfiveurbanEuropeanregions,thisstudy

aimedto(i)describethisinternationalvirtualaudit

datasetand(ii)identifyneighbourhoodpatternsthatcan

synthesisethecomplexityofsuchdataandcompare

patternsacrossregions.Datawereobtainedfrom4,486

streetsegmentsacrossurbanregionsinBelgium,France,

Hungary,TheNetherlandsandtheUnitedKingdom.It

usedmultiplefactoranalysisandhierarchicalclustering

onprincipalcomponentstobuildatypologyof

neighbourhoodsandtoidentifysimilar/dissimilar

neighbourhoods,regardlessofregion.

Feuilletetal.2016

Fourneighbourhoodclustersemerged,which

differedintermsoffoodenvironment,recreational

facilitiesandactivemobilityfeatures,i.e.thethree

indicatorsderivedfromfactoranalysis.Clusterswere

unequallydistributedacrossurbanregions.

Neighbourhoodsmostlycharacterisedbyahighlevel

ofoutdoorrecreationalfacilitieswere

predominantlylocatedinGreaterLondon,whereas

neighbourhoodscharacterisedbyhighurbandensity

andlargenumbersoffoodoutletsweremostly

locatedinParis.NeighbourhoodsintheRandstad

conurbation,GhentandBudapestappearedtobe

verysimilar,characterisedbyrelativelylower

residentialdensities,greenerareasandaverylow

percentageofstreetsofferingfoodandrecreational

facilityitems.Theseresultsprovide

multidimensionalconstructsofobesogenic

characteristicsthatmayhelptargetat-risk

neighbourhoodsmoreeffectivelythanisolated

features.

Mismatchbetweenperceived

andobjectivelymeasured

environmentalobesogenic

featuresinneighbourhoods

Investigatedtheagreementbetweenperceivedand

objectivelymeasuredobesogenicenvironmentalfeatures

toassess(1)theextentofagreementbetweenindividual

perceptionsandobservablecharacteristicsofthe

environmentand(2)theagreementbetweenaggregated

perceptionsandobservablecharacteristics,andwhether

thisvariedbytypeofcharacteristic,regionor

Rodaetal.2016

Overall,agreementwasmoderateandvariedby

obesogenicenvironmentalfeature,regionand

neighbourhood.Highestagreementwasfoundfor

foodoutletsandoutdoorrecreationalfacilities,and

lowestagreementwasobtainedforaesthetics.In

general,abettermatchwasobservedinhigh-

residential-densityneighbourhoodscharacterisedby



neighbourhood.Cross-sectionaldatafromtheSPOTLIGHT

project(n = 6,037participantsfrom60neighbourhoodsin

fiveEuropeanurbanregions)wereused.Residents'

perceptionswereself-reported,andobjectivelymeasured

environmentalfeatureswereobtainedbyavirtualaudit

usingGoogleStreetView.

ahighdensityoffoodoutletsandrecreational

facilities.Futurestudiesshouldcombineperceived

andobjectivelymeasuredbuiltenvironment

qualitiestobetterunderstandthepotentialimpact

ofthebuiltenvironmentonhealth,particularlyin

low-residential-densityneighbourhoods.

Builtenvironmentandhealth Systematicreview.23articleswereincluded. Renaldsetal.2010

Neighbourhoodsthatarecharacterisedasmore

walkable,eitherleisure-orientedordestination-

driven,areassociatedwithincreasedphysical

activity,increasedsocialcapital,loweroverweight,

lowerreportsofdepressionandlessreported

alcoholabuse.

Builtenvironmentand

physicalactivity

Systematicreview.20cross-sectionaland13quasi-

experimentalstudiespublishedbetween1996and2010

wereincluded.

McCormackand

Shiell2011

Land-usemix,connectivityandpopulationdensity

andoverallneighbourhooddesignwereimportant

determinantsofphysicalactivity.Thebuilt

environmentwasmorelikelytobeassociatedwith

transportationwalkingcomparedwithothertypesof

physicalactivityincludingrecreationalwalking.

Threestudiesfoundanattenuationinassociations

betweenbuiltenvironmentcharacteristicsand

physicalactivityafteraccountingforneighbourhood

self-selection.

Naturalenvironmentand

physicalactivity

Systematicreview.Analysisandintegrationof90selected

studieswereperformedusingthetheoryofplanned

behaviour(TPB).

CalogiuriandChroni

2014

Theavailabilityofanaturalenvironmentand

attractiveviewsofnaturewithinanindividual’s

livingenvironmentareimportantcontributorsto

physicalactivity,yetattentionshouldfocuson

personalcharacteristicsandenvironmentalbarriers.

Policyandinfrastructuralinterventionsshouldaim

toguaranteeaccessandmaintenanceofthenatural

environment,aswellasinformationand

programmingofsocialactivities.Socialcampaigns

viamediaandhealthinstitutionsshouldhighlight

hownaturecanbeasourceofmotivationfor



maintainingaphysical-activityroutine,reducing

stressandachievingaestheticandhealthgoals

Influencesondiet Narrativestudy.Onecohortstudy,threeintervention

studiesandtwocross-sectionalstudieswereincluded.

TheUKstudywasfromSouthampton.

Inskipetal.2014

Awoman’seducationisastronginfluenceonher

ownandherchildren’shealthbehaviours.Women’s

dietsvaryacrossethnicgroupsandaccordingto

numberofchildren,butpsychologicalfactors,such

asself-efficacyandsenseofcontrol,whichmaybe

amenabletomodification,arepowerfultoo,

particularlyinwomenwithlowereducational

attainment.Maternalinfluencesonchildren’s

behavioursarestrong.Differencesexistininfant

feedingacrosscountries,andthereareapparent

urban/ruraldifferencesinchildren’sdietsand

physicalactivity.

Deprivationandhealthrisk

behaviourinneighbourhoods

Systematicreviewofrecentstudiesonhealth-risk

behaviouramongadultswholiveindeprived

neighbourhoodscomparedwiththosewholiveinnon-

deprivedneighbourhoodsandtosummarisewhatkindof

operationalisationsofneighbourhooddeprivationwere

usedinthestudies.Theinclusioncriteriaweremetby22

studies.

Algrenetal.2015

Theavailableliteratureshowedapositive

associationbetweensmokingandphysicalinactivity

andlivingindeprivedneighbourhoodscompared

withnon-deprivedneighbourhoods.Inregardtolow

fruitandvegetableconsumptionandalcohol

consumption,theresultswereambiguous,andno

cleardifferenceswerefound.Numerousdifferent

operationalisationsofneighbourhooddeprivation

wereusedinthestudies.Substantialevidence

indicatesthatfuturehealthinterventionsindeprived

neighbourhoodsshouldfocusonsmokingand

physicalinactivity.Itissuggestedthatalcohol

interventionsshouldbepopulationbasedrather

thanbasedonthespecificneedsofdeprived

neighbourhoods.Moreresearchisneededonfruit

andvegetableconsumption.

Advocacyinneighbourhoods

forhealthydietsforolder

people

DescribestheNeighborhoodEatingandActivityAdvocacy

Teamproject,acommunity-basedparticipatoryprojectin

low-incomecommunalhousingsettingsinSanMateo

Bumanetal.2012

Advocacygroupsarefeasibleamongolderadultsto

improvefoodandphysical-activityenvironments.



County,CA,asonemethodforengagingolderadultsin

foodandphysical-activityenvironmentandpolicychange.

Builtenvironmentandobesity

–interventionsoverview

Systematicreviewofthepublishedscientificliterature,

screeningforstudieswithrelevancetodisadvantaged

individualsorareas,identifiedbylowsocioeconomic

status,blackraceorHispanicethnicity.Asearchfor

relatedtermsinpublicationdatabasesandtopically

relatedresourcesyielded45studiespublishedbetween

January1995andJanuary2009withatleast100

participantsorarearesidentsthatprovidedinformation

on1)thebuiltenvironmentcorrelatesofobesityor

relatedhealthbehaviourswithinoneormore

disadvantagedgroupsor2)therelativeexposurethese

groupshadtopotentiallyobesogenicbuilt-environment

characteristics.

Lovasietal.2009

Uponconsiderationoftheobesityandbehavioural

correlatesofbuilt-environmentcharacteristics,

researchprovidedthestrongestsupportforfood

stores(supermarketsinsteadofsmaller

grocery/conveniencestores),placestoexercise,and

safetyaspotentiallyinfluentialfordisadvantaged

groups.Thereisalsoevidencethatdisadvantaged

groupswerelivinginworseenvironmentswith

respecttofoodstores,placestoexercise,aesthetic

problems,andtrafficorcrime-relatedsafety.One

strategytoreduceobesitywouldinvolvechanging

thebuiltenvironmenttobemoresupportiveof

physicalactivityandahealthydiet.Basedonthe

authors'review,increasingsupermarketaccess,

placestoexercise,andneighbourhoodsafetymay

alsobepromisingstrategiestoreduceobesity-

relatedhealthdisparities.

Environmentandobesityin

children

Systematicreviewofquantitativeresearchexamining

builtandbiophysicalenvironmentalvariablesassociated

withobesityinchildrenandadolescentsthroughphysical

activity.15quantitativestudiesmettheinclusioncriteria.

Themajorityofstudieswerecross-sectionaland

publishedafter2005.

Duntonetal.2009

Forchildren,associationsbetweenphysical

environmentalvariablesandobesitydifferedby

gender,age,socioeconomicstatus,population

densityandwhetherreportsweremadebythe

parentorchild.Accesstoequipmentandfacilities,

neighbourhoodpattern(e.g.rural,exurban,

suburban)andurbansprawlwereassociatedwith

obesityoutcomesinadolescents.Formost

environmentalvariablesconsidered,strong

empiricalevidenceisnotyetavailable.

Neighbourhoodwalkingand

environment

SystematicsearchforarticlespublishedpriortoMay2014

ontheassociationbetweenwalkability(basedon

GeographicInformationSystems-derivedstreet

connectivity,land-usemix,and/orresidentialdensity)and

Hajnaetal.2015

Meta-analysisoffourofthesesixstudiesindicates

thatparticipantslivinginhigh-comparedtolow-

walkableneighbourhoodsaccumulate766more

stepsperday.Thisaccountsforapproximately8%of



dailysteps(pedometeroraccelerometer-assessed)in

adults.Themeandifferencesindailystepsbetween

adultslivinginhigh-versuslow-walkableneighbourhoods

werepooledacrossstudies.

recommendeddailysteps.TheresultsofEuropean

andAsianstudiessupportthehypothesisthathigher

neighbourhoodwalkabilityisassociatedwithhigher

levelsofbiosensor-assessedwalkinginadults.

Neighbourhoodwalkability

andenvironmentalfactors

Australiansurveywith2,650adults,proximitygenerated

withGISdatabases.

Owenetal.2007

Astrongindependentpositiveassociationwasfound

betweenweeklyfrequencyofwalkingfortransport

andtheobjectivelyderivedneighbourhood

walkabilityindex.Walkabilitywasrelatedtohigher

frequencyoftransportwalking,irrespectiveof

neighbourhoodself-selection.


Table6:Ruralhealth


Ruralhealthandemergency

serviceutilisation

Systematicreview.Scientificdatabases,grey

literatureandselectedreferencesweresearched.

Studyqualityandbiaswasassessed.Afterscreening,

33studiesmettheeligibilitycriteria,ofwhicheight

wereRCTs,13wereobservationalstudiesof

unplannedcareusebeforeandafternewpractices

wereimplementedand12comparedintervention

patientswithnon-randomisedcontrolpatients.

Brainardetal.2016

Eightofthe33studiesreportedmodeststatistically

significantreductionsinunplannedemergencycareuse

whiletworeportedstatisticallysignificantincreasesin

unplannedcare.Reductionswereassociatedwith

preventativemedicine,telemedicineandtargeting

chronicillnesses.Costsavingswerealsoreportedfor

someinterventions.Relativelyfewstudiesreporton

unscheduledmedicalcarebyspecificallyrural

populations,andinterventionswereassociatedwith

modestreductionsinunplannedcareuse.Futureresearch

shouldevaluateinterventionsmorerobustlyandmore

clearlyreporttheresults.

Ruralhealthpromotionin

primary-caresettings

Australiansystematicreview.Includesninestudies. Crouchetal.2011

Threetrialscomparedtheeffectsofinterventionson

physicalactivity,oneonsmokingandfiveonmultiplerisk

factors.Studiesfollowinginterventionstargetingphysical

activityreportedthatwomen'sphysicalactivitycanbe

increasedandthattheseincreasescanbesustainedat12

months.Whilethereweredecreasesinbloodpressureat

sixmonths,studieswithafive-yearfollow-upfoundno

decreasesforbothsystolicanddiastolicbloodpressure.

Overallresultsofstudiesintodietarymodification

programsalsodidnotsustainaneffectoveralonger

periodoftime.

Conclusion:Theresultsofthisreviewsuggestthatinrural

areas,lifestyleinterventionsdeliveredbyprimarycare

providersinprimary-caresettingstopatientsatlowrisk

appearedtobeofmarginalbenefit.Resourcesandtimein

primarycaremightbebetterspentonpatientsathigher

riskofcardiovasculardisease,suchasthosewithdiabetes

orexistingheartdisease.

52 www.c3health.org

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Community briefing paper v 3 20161110[1]

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