At a glance: The CLAHRC NWC Health Inequalities Assessment Toolkit (2017):Coordinators: Popay, J. Porroche-Escudero, A., Sadler, G. and Simpson, S. Lancaster: The National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care North West Coast

This card is an abridged version of the full toolkit for busy professionals so that they can quickly identify and understand the information they need. Visit the website here: www.hiat.org.u

United Kingdom (England). Supporting local systems to tackle the social determinants of health inequalities

Developing system approaches to resilience is not an easy option. The Neighbourhood Resilience Programme (NRP) described in this inspirational example from the northwest of England highlights some of the main challenges and opportunities for such an innovative approach. As the authors conclude, such an approach demands time, energy, commitment and imagination from all involved. The example throws light on the possibility to move beyond traditional, individual, topic-based approaches to collaborative partnerships with residents, local workers and institutions. It addresses major issues and works on key social, environmental, cultural and economic elements that characterize local neighbourhood systems that impact on resilience, health and well-being. The on-the-ground work of the authors and their partners at community level maintains that strengthening resilience that impacts on health and the reduction of health inequities requires such a system perspective. Although in its early phase of development, several powerful lessons can be drawn from NRP and its system perspective. Such lessons are useful for action that aims to strengthen resilience to promote health and well-being and to address social and economic determinants of inequalities. These lessons are essential for developing resilient neighbourhood systems

The CLAHRC NWC Health Inequalities Assessment Toolkit (2015) Coordinators: Popay, J. Porroche-Escudero, A., Sadler, G. and Simpson, S. Lancaster: The National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care North West Coast and Lancaster University

Auditing and monitoring our health inequalities focus The Health Inequalities Impact Assessment Toolkit (HIAT) HIAT functions as a lens through which to assess the extent to which a piece of work proposed within CLAHRC has potential to reduce health inequalities. We have developed this health inequalities toolkit to help ensure that all our activities have potential to contribute to reducing health inequalities. The HIAT document explains why we are focusing on the reduction of health inequalities and provides guidance on the use of the HIAT. There are also links to resources that may help those using HIAT to assess whether the work they wish to undertake is as sensitive as it can be to health inequalities and that it maximises the impact it can have on reducing these. CLAHRC NWC staff and partners developed the HIAT in a series of workshops during 2014-2015. This version (Version 1) of the HIAT was piloted until 31 May 2015 and is being refined based on feedback. This will enable us to refine the tool and related materials. The HIAT is novel and innovative as it has been specifically developed to apply to research design and delivery rather than for the commissioning of, or delivery of services

Systems resilience:improving public health through collaboration and community based participatory research

Throughout the UK severe funding cuts are straining the capacity of local governments, National Health Service and voluntary organisations to improve public health and reduce health inequalities. At times like this, the word ‘resilience’ is invoked as a neoliberal mantra similar to “individual or community responsibility”. Decreased public funding for services increases pressure on individuals and communities to cope with socioeconomic adversity without external support. We argue that resilience must be understood in relation to systems. Promoting individual or community resilience alone is not enough to reduce health inequalities locally. Resilience needs to be understood as a characteristic of people who live and work in areas and the organisations that employ them. Enhanced resilience at a systems levels, underpinning engagement between paid workers and communities, is essential to release collective capabilities to influence and respond to structural pressures. We argue that enhanced system resilience has the potential to improve the social drivers of health inequalities and leads to improvements in collective and individual health. In this presentation we describe the experience of the public health team within the NIHR Collaboration for Leadership in Applied Health Research and Care for the North West Coast (CLAHRC NWC). We introduce a system resilience framework and describe how we are testing this in 9 relatively disadvantaged neighbourhoods in the North West of England. We discuss a number of innovative features of this work. It seeks to nurture egalitarian collaboration between residents, Local Authorities, community and organisations to understand, and influence, action that can promote system resilience. Residents conduct local enquires to help plan for action to enhance system resilience and help evaluate the impact of changes put in place

Health in All Policies in South Australia:what has supported early implementation?

Health in All Policies (HiAP) is a policy development approach that facilitates intersectoral responses to addressing the social determinants of health and health equity whilst, at the same time, contributing to policy priorities across the various sectors of government. Given that different models of HiAP have been implemented in at least 16 countries, there is increasing interest in how its effectiveness can be optimized. Much of the existing literature on HiAP remains descriptive, however, and lacks critical, empirically informed analyses of the elements that support implementation. Furthermore, literature on HiAP, and intersectoral action more generally, provides little detail on the practical workings of policy collaborations. This paper contributes empirical findings from a multi-method study of HiAP implementation in South Australia (SA) between 2007 and 2013. It considers the views of public servants and presents analysis of elements that have supported, and impeded, implementation of HiAP in SA. We found that HiAP has been implemented in SA using a combination of interrelated elements. The operation of these elements has provided a strong foundation, which suggests the potential for HiAP to extend beyond being an isolated strategy, to form a more integrated and systemic mechanism of policy-making. We conclude with learnings from the SA experience of HiAP implementation to inform the ongoing development and implementation of HiAP in SA and internationally

Understanding area-based community empowerment initiatives as events systems and the implications for evaluating their potential to affect health inequalities

Background Evaluation of community empowerment initiatives for their effects on health inequalities presents a paradox to researchers. By definition, such initiatives aim to empower people to influence decisions that affect their lives. However, once empowered, people might not necessarily take the decisions that the originators of the intervention desired. The inability to control the implementation of an intervention goes against all the basic principles of intervention trials. We studied a community empowerment initiative, using a systems approach, to see whether any ensuing diversity of implementation could be used as an advantage rather than be a problem for an evaluation design. Methods We conducted qualitative in-depth case studies in ten intervention neighbourhoods in England, including a total of 150 resident interviews and ethnographic observation, interviews with the national organisations involved, and a review of plans from 30 intervention sites. Data were coded in NVivo (version 10) in a pre-defined thematic framework. Narrative memos were developed and compared and contrasted across sites. Findings The initiative's overarching objective was to increase confidence and skills to enable residents to identify priorities and take action in their neighbourhoods. Our fieldwork found that the core objective was pursued in different ways: building connections across people living or working in the neighbourhood, promoting social participation, improving or so-called lifting an area's external reputation, achieving material improvements (eg, parks), and addressing debt or unemployment. Diversity in starting points of local area systems also contributed to divergence in the aspirations that residents identified, the actions being taken to achieve them, and the change in processes that ensued. Interpretation Understanding interventions as events in systems offers an approach that shifts the focus of assessment from what works to what happens when an intervention interacts with multiple local systems. This approach reveals how and why the intervention adapts over time as communities develop new capacities and learn from early implementation. The resulting diversity created across different sites can be exploited for evaluation purposes—for example, by creating internal comparators. This diversity offers potential for understanding how such interventions unfold over time and the differential health and social effects that might ensue. Funding This paper presents independent research funded by the National Institute for Health Research (NIHR) School for Public Health Research

Development of a framework for identifying and measuring collective control as a social determinant of health: findings from an evaluation of a natural policy experiment in empowerment

Background Interventions to develop community-level empowerment and participation are advocated within public health strategies that emphasise the importance of control as a social determinant of health. Approaches to defining and measuring collective control, however, are limited. We developed and applied a contextually specific framework for identifying the emergence of collective control in the early stage of a UK area-based community empowerment initiative. Methods Existing conceptualisations of collective control were used as a basis for development of a logic model, and then framework, for identifying emergent markers of control at the level of intracapability, intercapability, and extra group action. The concepts of power within, power to, and power with were used as overarching categories under which markers of collective control capability and action were identified. The framework was applied to qualitative data generated by our team for this primary analysis from in-depth case studies carried out in ten intervention neighbourhoods in England. Data included contextual area information, 150 interviews, ethnographic observation, participatory group exercises, and the review of 30 local intervention plans. Data were coded in NVivo (version 10) with a predefined thematic framework. Narrative memos were developed and compared and contrasted within and across sites. Ethics approval for the study was awarded by Lancaster University on behalf of Liverpool and Lancaster Universities Collaboration for Public Health Research, and by each individual research institution. Findings Application of the framework showed that collective control manifested in different ways and to varying degrees across field sites. We observed the emergence of new forms of group organising and decision making; the development of collective efficacy and linkages with other organisations; and the beginnings of community action taking place. The emergence of collective control was shaped by existing relationships between residents and histories with local organisations, as well as through features of the intervention itself, such as the provision of tailored support from national organisations. The processes of developing collective control for those involved were unstable, subject to struggle, and part of a continuing, dynamic, nonlinear process. Interpretation The conceptual framework helped identify shifts in collective control capability emergent within and between community groups leading to group action, as a result of the introduction of the intervention. These shifts were nevertheless precarious and temporal, suggesting a need for approaches that capture complex collective empowerment processes in flux. Funding This research was supported by the National Institute of Health Research (NIHR) School for Public Health Research. Contributors RP contributed to data collection, the development of the conceptual framework, data analysis and interpretation, and led on the writing of the abstract. MC, ME, SL, LO, SS, AT, and EH contributed to data collection, the development of the conceptual framework, data analysis and interpretation, and the writing of the abstract. LO and EH co-ordinated fieldwork and analysis activities. JP and MW conceived the idea for the study, led on the planning and development of the study, and advised on data collection, analysis, and interpretation, and on the development of the conceptual framework. All authors approved the final version of the abstract. Declaration of interests We declare no competing interests. Acknowledgments The views expressed are those of the authors and not necessarily those of the National Health Service, NIHR or Department of Health