Chapter 15 Health promotion in neighbourhoods
Overview
As we have seen in other chapters in this part, healthy settings are physical and social settings, which serve as supportive environments for health and health promotion activities. This chapter examines the concept of neighbourhood and how different factors – physical, social and economic – contribute to the concept. The linked concept of social capital to describe neighbourly relationships and networks is explored. The popularity of neighbourhood in different policy and practice arenas in recent years, and the usefulness of the neighbourhood as a setting for health promotion, are discussed. Neighbourhoods include different levels or structures such as the neighbourhood environment, services and people, which may all be used as a springboard for health promotion. Examples of various initiatives which focus on the neighbourhood setting are given as examples of good practice. Evaluating such a multidimensional strategy poses many challenges, and issues regarding the evaluation and evidence base for neighbourhood health promotion are discussed.
Healthy Cities are arguably the best known and largest of the settings approaches. The programme is a long-term international development initiative that aims to place health high on the agendas of decision-makers and to promote comprehensive local strategies for health improvement and sustainable development. The Healthy Villages programme addresses similar directives as the Healthy Cities programme in rural areas. Health is again defined by the area’s residents; however, the generally accepted definition of a healthy village includes a community with low rates of infectious diseases, access to basic health care services, and a stable, peaceful social environment (see http://www.who.int/healthy_settings/types/en/index.html). In addition, the holistic and multifaceted linking of activities that characterizes the settings approach is used in schools, workplaces, hospitals (discussed in other chapters in this part) and also universities, markets, islands and homes. The neighbourhood provides a link between these and the other settings explored in this part. Neighbourhoods have been identified as important settings for health promotion in a number of English policy documents.
The environment we live in, our social networks, our sense of security, socio-economic circumstances, families and resources in our local neighbourhood can affect individual health
(Department of Health 2004, p. 77).
BOX 15.1Defining neighbourhoods
Neighbourhoods are defined as small localities with a distinct identity forged by a community of people who know each other and the provision of essential services such as post offices, shops and health centres. Lay networks and support systems are an important element. Neighbourhoods will often be bounded by geographical features such as major roads, railways or green areas and may be urban or rural. The key factor is that residents define their local neighbourhood themselves and feel they have an investment in its future, the services provided and its appearance. In the modern world where transactions are increasingly fragmented and anonymous, and where the overarching symbols of community, such as religion and nationhood, are less cohesive and meaningful, the role of the neighbourhood in promoting identity and self-esteem is more important. Neighbourhoods provide the immediate environment where people live, work and play, and for many more vulnerable groups, such as older people and those on low income, most of their lives are lived in one neighbourhood.
A recent research study (Robertson et al 2008) found that neighbourhood identity is established at an early stage in each neighbourhood’s history and is resilient to change. Neighbourhood identity is largely based on residents’ social class and status, which in turn is often based on men’s employment patterns, as well as physical characteristics such as housing. Neighbourhoods are often internally differentiated and the sense of community is based on everyday social interactions and networks of friends, families and neighbours. Neighbourhoods therefore combine objective and subjective components.
There are many ways to get to know neighbourhoods, ranging from the objective gathering of statistics to the subjective collection of people’s thoughts, feelings and memories. Local statistics on topics such as housing and crime are collected (see www.statistics.gov.uk) and can be used to compare different neighbourhoods. Community profiles or observation walks, where notes are taken of local facilities, the physical environment, transport routes and social networking opportunities, provide a more holistic picture of neighbourhoods.
Why neighbourhoods are a key setting for health promotion
The public health White Paper Choosing Health: Making Healthy Choices Easier (Department of Health 2004) dedicates a chapter to communities (focusing on neighbourhoods) and makes a commitment to working through local communities to reduce inequalities in health. Why might neighbourhoods be identified as a key route through which to tackle health inequalities?
Neighbourhoods are a key setting for health promotion because they provide the infrastructure for health. Neighbourhoods are where the physical and social environments interact with service provision to provide an overall environment which has enormous potential to support people’s health. Neighbourhoods include:
Identifying what exactly it is about neighbourhoods that has an impact on well-being is difficult. Research suggests that people value neighbourhoods for their effect on quality of life, reflected through aspects such as friendliness, safety and quiet (Bowling et al 2006; Office of National Statistics 2007). In addition to providing the context for health, neighbourhoods are a popular setting because they are seen as a means to engage people in addressing their own health needs. A neighbourhood focus therefore fosters empowerment and independence, which are themselves health-promoting.
BOX 15.4Community development in Koonawarra
Healthy Cities Illawarra Australia is part of the World Health Organization Healthy Cities programme launched in 1987. In 1999 the Koonawarra area was highlighted as having particular health and social issues and needs. Further research and collaboration with stakeholders (including residents, local MPs and service providers) led to a range of strategies. Achievements to date include:
The physical environment
Many aspects of the physical environment, such as buildings and land use, affect health. Transport patterns and car usage are linked to health. Cars contribute to climate change and have a negative impact on individuals’ health. For example, in one rapidly developing area of China, those who bought a car gained 1.8 kg in weight (Rice & Grant 2007). Tackling issues such as dependence on private cars can seem a daunting proposition. UK car users, although a smaller percentage of the population than in other European countries, use their cars more frequently. However, the importance of weaning ourselves away from overdependence on cars has been recognized in a number of policies (Department for Transport 2000, Department of Health 2004) and strategies to combat this dependence and encourage active means of transport have been proposed (Department for Transport 2004, Department of Health 2005). Goals include ensuring the provision of high-quality routes for walkers and cyclists and making public spaces and the countryside seem more attractive.
Walking the Way to Health
Walking the Way to Health was launched by the British Heart Foundation and Natural England to encourage people to take part in locally designed walks. Health care professionals are encouraged to ‘prescribe’ pedometers to act as an incentive. The benefits of this programme include:
The impact of housing on health has been known since the 19th century and the role of housing as a key determinant of health is discussed in our companion volume (Naidoo & Wills 2005). Poor-quality housing is often sited in deprived neighbourhoods with few local amenities. Graffiti, litter, boarded-up premises and dog mess are all signs of a neglected environment which, in turn, affects people’s perception of the safety of their neighbourhood, and hence their willingness to be active participants within it. These issues often rank high on community’ agendas.
A national strategy on neighbourhood renewal included a 10-year programme to tackle unemployment, crime and poor physical environments, and to manage housing in neighbourhoods (the New Deal for Communities (NDC)). NDC areas are relatively disadvantaged and all NDC initiatives include integrated health programmes. The NDC strategy has a £50 million budget and covers 39 localities with populations of approximately 8000–10 000 people.
The social environment
The quality of life in a community is a powerful determinant of health. By studying several healthy communities, Wilkinson (1996) has identified several factors which contribute to that quality of life.
Quality of life in communities
The small town of Roseto, Pennsylvania, USA (1600 people) is cited as an example of a community with markedly lower death rates from heart attacks than neighbouring areas. The population of Roseto is made up of Italian-Americans descended from migrants from the Italian town of Roseto in Southern Italy. It differed from other towns because it was ‘remarkably close knit … with a sense of common purpose … [with] a camaraderie which precluded ostentation [and] … a concern for neighbours ensuring no one was ever abandoned … the family as the hub and bulwark of life provided a security and insurance against any catastrophe’. Roseto’s considerable health advantage only seems explicable in relation to these social characteristics. As the younger people moved away, community and family ties broke down and people became more concerned with material values and conspicuous consumption (Bruhn & Wolf 1979, cited in Wilkinson 1996, p. 116).
Social capital refers to social cohesion and the cumulative experience of relationships, with both those known to us and those who are strangers, that are characterized by mutual trust, acceptance, approval and respect. People are social beings and the quality of social interaction is vital to both personal and communal well-being. Social capital provides the foundation for collective action in the public sphere for the public good. Although definitions of social capital vary, the main indicators are:
Community networks may be built around activities associated with school, leisure or living in a particular locality. Parents, especially mothers, have been identified as particularly active in forging neighbourhood links (Robertson et al 2008). In addition to their primary purpose, buildings such as schools or leisure facilities are often used to house additional community events and networks. The closure of services such as schools and post offices therefore has a negative impact on neighbourliness, and this might help to explain the strength of feeling voiced whenever communities are threatened with the closure of such amenities.
There is evidence that building social capital is only possible above a certain threshold of income. If people are preoccupied with survival in its crudest meaning (i.e. ensuring they are fed, warm, sheltered and safe) they will be unable to focus beyond, on broader communal issues. The fact that social capital is not always benign also has to be acknowledged. Drug dealing and criminality on many housing estates rely on strong, closely integrated networks.
BOX 15.7The following criteria have been identified as central to the building of cohesive communities. To what extent are they evident where you live?
If social capital and trust are at the positive end of a neighbourhood quality-of-life spectrum, crime and fear of crime are at the opposite negative end.
Research has linked poorer self-rated health with what have been called neighbourhood psychosocial stressors – fear of crime, feeling unsafe, nuisance from neighbours, drug misuse and youngsters hanging around (Agyemang et al 2007). What neighbourhood activities could be undertaken to improve health?
Effective measures might include:
Both crime and the fear of crime are health hazards and are associated with negative effects, including depression and mental ill health. It has been suggested that negative effects are both direct, e.g. stress and depression, and indirect, e.g. mental health linked to social isolation and feelings of vulnerability. Acts of thoughtlessness and disregard, such as excessive noise or petty disputes, although less severe than violence or the threat of violence, can have a large impact on quality of life. The UK government has launched the Respect programme to tackle antisocial behaviour. It includes a range of actions, including working with ‘problem families’, keeping public spaces clean and safe and ensuring that victims and witnesses of antisocial behaviour are protected and supported.
Services
An adequate service infrastructure is essential to the health and life of a neighbourhood. If essential services, such as shops and post offices, are not available locally, people are forced to travel outside the area, leading to a loss of social contacts as well as incurring additional costs (time and travel). This has been recognized by many communities fighting to retain local schools or shops and by the Social Exclusion Unit (1998) in its NDC. However, many planning decisions appear not to recognize this fact. In particular, the increase in out-of-town supermarkets has had a severe impact on both small local shopping outlets and traffic rates.
Identify some examples of capacity building in a local community with which you are familiar.
Examples that you might have included are:
In all these examples the neighbourhood has become the focus for the creation of networks and for linking health and regeneration.
There is great potential in building health into community activities, such as adult education, leisure activities and cultural activities. The following example shows how community arts can collaborate with health workers to promote neighbourhood health.
Bolton street library
Residents of a Bolton estate took part in a 2-week project to create a ‘street library’. The library was created by interviewing people about the book they would like to write or make. Interviews were recorded and transcribed and then printed as mini-books with a card cover. Participants commented on their sense of achievement and the opportunity to get to know their neighbours (www.beacons.idea.gov.uk).
It could be argued that any neighbourhood development work has the potential to promote health by increasing social contacts and trust, or social capital. Additional spin-offs in terms of direct support for healthy lifestyles are common, as the following example shows.
Community gardens
Community gardens exist in many nations and in both urban and rural areas. They may fulfil a number of functions, including leisure gardens, child and school gardens, healing and therapy gardens, demonstration gardens and those concerned with ecological restoration. They are actively supported by specific communities, reflecting some form of mutual aid and communal reciprocity, probably having had a fair degree of altruism in getting them started and, very often, supported by charitable or municipal grant aid. They may also be grassroots initiatives aimed to revitalize low- to moderate-income neighbourhoods in urban settings. Community gardens have been shown to improve health by increasing participants’ access to fruit and vegetables, providing the opportunity for regular exercise and communal interaction, and enabling economic self-reliance through using the gardens for training and recreation purposes and selling surplus produce (McGlone et al 1999; Ferris et al 2001).
Evaluating neighbourhood work
You have been asked to evaluate a neighbourhood development programme that has included reconfiguring local transport networks in order to encourage active forms of transport and neighbourliness. The programme includes different elements: setting up cycle routes and road-calming measures (e.g. speed bumps and narrowing of roads), a walk-to-school project and walking buddies to encourage older people to exercise. How would you go about evaluating such a programme? What challenges would you have to address?
Evaluation of neighbourhood and community work is extremely difficult for several reasons. Firstly, neighbourhood work involves long-term processes to promote social cohesion and regeneration. Funding long-term evaluation projects, and maintaining continuity of focus and resources, is difficult. Many projects are set up under time-limited funding initiatives, which then compromises their sustainability (e.g. Healthy Living Centres were funded through lottery money). Projects may find they are diverted from their core business into fund-raising in order to keep going. Funding streams may also specify certain activities or outcomes, leading to the neglect of long-term activities to build community capacity and networks.
In any consideration of the effect of neighbourhood on health it is very difficult to separate the effects of compositional factors (those relating to the kinds of individual being studied, including their socioeconomic status and lifestyles) from the effects of contextual factors (those relating to the environment) (Kawachi & Berkman 2003). There is a clear bias in research towards considering the impact of compositional factors. The complexity of relationships between individuals and environments, plus the long timescale in which effects become apparent, militates against research into contextual factors. There are some attempts to carry out research into contextual factors, including multilevel analysis, but it remains very difficult to attribute cause and effect in neighbourhood work.
Finally, the complexity of neighbourhood work is also a factor leading to difficulties in evaluation:
Responding to diverse evaluative expectations, while sustaining research integrity and rigour, requires a pragmatic multi-methods approach, responsiveness to local context, regular communication between funders, community stakeholders and evaluators, and flexible, reflective practice (Adams et al 2007).
However, even given these caveats, the evidence base for neighbourhood work having a positive impact on health is rather thin. Notions such as deprivation amplification (whereby low social class leads to poor access to amenities) have been challenged by the literature, which finds that the reverse can be the case (Macintyre & Ellaway 2003). Reviews differ as to the extent of area effects on health from modest to significant (Pickett & Pearl 2001; Riva et al 2007).
Conclusion
The neighbourhood provides a valuable setting for accessing many vulnerable groups, including older people and people on low income. Neighbourhoods are real-life settings with the potential for priorities to be defined by residents rather than professionals. Addressing health on a neighbourhood basis is attractive because it means addressing core determinants of health, such as the social fabric and quality of people’s lives. It is important that in the new focus on neighbourhood settings the opportunity to address people’s self-defined needs is taken. It would be easy to use neighbourhoods merely as a means of professional outreach work, but this would be to neglect one of the great strengths of this setting.
Many members of the primary care team (especially health visitors and GPs) regard themselves as working with neighbourhood communities. How might their role change if they were to focus on community capacity building and building social capital?
Whilst there are many advantages to working within a neighbourhood setting, it is not a universal panacea. Many factors which affect people’s lives are determined at national level, e.g. level of benefit entitlement or availability of employment. However, the neighbourhood setting does offer opportunities for creative and imaginative ways of working which support the core principles of health promotion – participation, equity, empowerment and collaboration.