Fellowship Report Recommendations - Social Capital and Well-being

Better late than never (!) - here are the conclusions and recommendations from my Fellowship report to WCMT. You can read the full report here:

a)     There is a need for a holistic approach to improved well-being which takes into account the wider social determinants of health. This requires partnership working across sectors (health, social care, housing, education) to avoid ‘silo’ working which can be issue specific. Community Health Centres in North America are one mechanism for the potential delivery of this.

b)    There are weaknesses associated with vertical health improvement activities focused on single lifestyle issues (e.g. smoking, obesity) in that they ignore the wider social determinants of health. To help reduce health inequalities, health improvement activities need to be as much about addressing the social and material circumstances in which people live as about addressing specific health needs. There is a need for greater emphasis on the importance of ‘place’ as where people live and work has a huge impact on health. A short film produced by Sudbury Community Health Unit in Ontario highlights the case in point[1].

c)     Addressing health and well-being needs requires an understanding of those factors which have an impact on health from a community perspective. This recognises that concepts of health and well-being differ in different communities. What communities need to stay healthy may be different and need to be explored and understood for interventions to be effective. There is a need to consider a process of identifying the indicators that impact on health and well-being through consultation with community members. An example of this is People Assessing Their Health (PATH) programme.

d)    There is a need to recognise and capitalise on the role of community assets in promoting well-being, particularly amongst those populations in most need. Many strengths and resources exist within all communities and are often unrecognised and ‘untapped’. Often the process of simply identifying assets in communities and individuals can lead to increased empowerment and recognition of what people can do for themselves. Examples of approaches which identify and mobilise assets include: Neighborhood Matching Fund (Seattle), Community Planning Teams (Ontario).

e)     Effectively engage with communities. Bringing community members together in forums such as Community Planning Teams (Ontario) and Community Action Teams (Seattle) are mechanisms for engaging with communities and identifying and mobilising individual and community assets which can serve to improve well-being and what communities can do for themselves to meet their needs with existing assets and resources.

f)     There is a strong rationale for involving people in health improvement activities and a clear link to the reduction of health inequalities. There are many models for involving communities in improving health and well-being via roles such as Community Health Champions, Peer Supporters Community Advocates (see section 3.4 for examples). These roles also are a potential vehicle for the building of social capital in communities.

g)    To better understand and articulate, ‘what works’ in addressing health inequalities, relevant evidence needs to be interpreted and communicated in an accessible and timely way to the right people. The National Collaborating Centre for Determinants of Health (NCCDH)[2] in Canada translates and shares information and evidence about the social determinants of health with practitioners, policymakers and researchers with a view to improving practice and outcomes.

h)     Gardening projects have the potential to influence a range of health and well being outcomes;

·         Healthy eating – through growing and using and eating fresh produce.

·         Help reduce food poverty issues (Food Banks) and provide an income.

·         Physical Activity – Gardening can be hard work and requires physical excretion.

·         Mental Health – brings people together to work together and share skills and knowledge.

·         Gardens can be a social space for people to meet, use the produce, cook meals and build social capital.

i)      Language matters! When it comes to talking about health inequalities and disparities, the way concepts are framed is important, especially when targeting policy makers and funders. Talking about assets and ‘fairness’ and ‘opportunity’ can be more helpful than talking about ‘problems’ or ‘needs. Similarly, using the language of an asset based approach which talks of strengths instead of weaknesses, partners instead of consumers, collaborations instead of silo provision, abilities and capacities instead of disabilities, citizens instead of clients – can be empowering in itself.

j)      The recent focus on strong communities/networks and social capital as a key determinant of health should not be ignored. An outcome of ‘improved social capital’ could be a more explicit and central aim of funded projects and programmes aimed at reducing health inequalities. It is recognised that measurement of social capital indicators is not always straight forward but there are examples and tools we can learn from, including the Communities Count Partnership[3] in King County, Washington which measures a number of social capital indicators e.g. Participation in life enhancing activities, Social support, Neighborhood cohesion, Involvement in community organizations and Community service (volunteering).

k)     Funders and commissioners of health improvement activities should seek to:

·         encourage the identification and mobilizing of community assets

·         embed and promote the principles of community engagement in any new work

·         encourage building social capital as an aspect of any proposal

As an example, the criteria for funding applications to True Sport Foundation states that all projects should; i) Enhance a sense of belonging to the community, ii) Allow neighborhood residents to give back to the community (e.g. Volunteering); iii) Build skills, knowledge and ability to continue to strengthen the community in the future

l)      Good commissioning should engage with communities. Projects funded by the Neighborhood Matching Fund[4] (NMF) in Seattle are an example of good commissioning practice which engages communities. As a core criterion, the NMF require that all projects are: fun, engaging and empowering and reflect all sectors in the community (e.g. different age groups, ethnic groups, gender, locations, housing type). They must also encourage people to have access to the project planning process – not just the finished work.

m)   In the UK, many opportunities exist for advancing these ideas in the following areas:

• Area based working & multi agency service planning which could provide a structure for asset based approaches.
• More innovative commissioning & service delivery around the wellbeing agenda via Consortium of voluntary/community sector and Health and Well being Boards (HWBB).
• ‘Localism’ which encourages disaggregated services and delivery down to neighbourhood level wherever possible.
• Develop rich and vibrant JSNAs (Joint Strategic Needs Assessments) which offer a clear picture of the strengths and assets of communities rather than a description of the needs and problems. Consider the use of JSAAs - Joint Strategic Assets Assessments – instead.

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[1] http://www.sdhu.com/content/healthy_living/doc.asp?folder=3225&parent=3225&lang=0&doc=11749#video

[2] http://www.nccdh.ca/

[3] http://www.communitiescount.org/

[4] http://www.seattle.gov/neighborhoods/nmf/

New Publications on Lay Engagement in Public Health

Good news! Colleagues at the Centre for Health Promotion Research at Leeds Metropolitan University have  had two papers on  lay  engagement in public health programmes published in high quality, peer-reviewed academic journals. Think they will be well worth a read if this is your bag...

Both articles focus on the subject of lay or citizen engagement in the delivery of public health programmes and will help disseminate the  findings from the People in Public Health Project to those involved in third sector research, policy making or practice.

Details of the two are as follows:

 

1) ‘Citizens bridging the gap? Interpretations of volunteering roles in two public health projects’  

Published in Voluntary Sector Review. It explores the role of volunteers in a neighbourhood health project in a disadvantaged housing estate and a sexual health outreach project. Using interviews conducted with a variety of stakeholders it examines the rationale for citizen engagement in the delivery of public health programmes.

Reference: South, J., Branney, P., Kinsella, K., (2011) ‘Citizens bridging the gap? Interpretations of volunteering roles in two public health projects’ Voluntary Sector Review, Volume 2, Number 3, pp. 297-315(19)

2) ‘Lay perspectives on lay health worker roles, boundaries and participation within three UK community-based health promotion projects’ .

Published in Health Education Research. This examines the perspectives of community members receiving services delivered by lay health workers.  It draws from qualitative interviews with programme recipients from a breastfeeding peer support service, a walking for health scheme and a neighbourhood health project.

Reference: South, J., Kinsella, K., Meah, A., (2012) Lay perspectives on lay health worker roles, boundaries and participation within three UK community-based health promotion projects. Health Education Research; doi: 10.1093/her/cys006

Click the links to access the abstract,  Full Text or PDF for this paper.

Social Capital Measurement Framework

I heard from Lucy at the Angus Gillis Foundation in the Eastern Cape today. I visited AGF back in October whilst in South Africa for my WCMT fellowship and spent a really useful day with Lucy and colleague Kath, learning about their work with Positive Health Champions (read the post here).

Anyway...Lucy got in touch to let me know how they'd been using some of our work and thinking around demonstrating social capital as part of their evaluation planning and to do some thinking around how they capture their own impact as an organisation. Lucy said:

"We started by using the first three layers of the framework to identify examples and illustrative anecdotes in our own work. Then we discussed the different categories to see how relevant they are for the work that we do and whether we would make any amendments or additions. It was SUCH a useful tool and proved a great starting point around which to frame our thinking. It also turns out that the different dimensions of social capital that you have identified make a lot of sense in our own programme. We’re going to take it forward by using a very slightly adapted framework to help us identify, capture and communicate our impact and to formalise our M&E systems."

 Lucy sent some great pictures of the process too:

And...as a reminder, here's the framework I shared with them so you can see the links.

Great to know the framework has been useful and that my visit was mutually beneficial in so many ways!

Back in Blighty...

I left a sunny, warm, blue skied Cape Town on Sunday evening and landed in a grey, cold Manchester on Monday morning. Still - after a great and inspiring 3 weeks - it was good to be home.

I was also pleased to have a couple of publications waiting in my inbox which will help share the learning from my fellowship.

The first is an article based on learning from the North American leg of my trip which I wrote for the Centre for Local Economic Strategies (CLES) 'New Start' publication. You can access this CLES publication here.

The second is a feature on social capital which I wrote for Altogether Better's National Newsletter (see page 8). The newsletter also features an article on Asset Based Community Development, showcasing some of the work undertaken by our Sheffield project and an interview with ABCD expert, Cormac Russell (see page 7). Click here to download the newsletter.

A new take on ABCD - Asset Based Citizen Led Development?

The Ikhala Trust in Port Elizabeth is small grants funder that is all about identifying and mobilising community assets. Thier vision is to, "build self reliant, secure and virbrant communities through a holistic, sustainable and positive intervention." Through the provision of small grants to community organisations, Ikhala enables and empowers communities to gain what they need by building on what they have (to paraphrase Moses Coady!).

Mrs Bono (Seki) and Bernie Dolley (Ikhala)

I spent a useful and informative day with Bernie Dolley, Director of Ikhala. Bernie told me that, "the importance of human relations is at the heart of what Ikhala does" and that what people value most is, "to be respected, listened to and appreciated". So Ikhala is about building some central elements of social capital - networks, relationships and trust. As an organisation they see people as 'asset rich', which Bernie sees as essential to enabling change.

Bernie went on to tell me that Ikhala,  "works on the principle of sowing where people have already laid a foundation."  A grant will not be given unless social cohesion and mobilization are already demonstrated by the community, so the  grants reinforce and build on communities existing assets and mobilization. This approach differs from mainstream development approaches that tend to focus on deficits oriented and release large sums of money to  fill deficit gaps 



I asked Bernie about Ikhala's use of Asset Based approaches. ABCD commonly stands for Asset Based Community Development but Ikhala prefer to talk about Asset Based Citizen Led Development.  Bernie likes to think of ABCD as,  "an attitude and a state of mind - not a system to be followed." She went on, "It's more about how you see and value the world."  Appreciative Inquiry is one of the tools commonly used in ABCD and Ikhala have used this from the beginning to ask questions of communities using an asset based lens - such as:

• What are we proud of about our communities?
• Who has inspired us?

Bernie says she is often deeply humbled by people's responses to these questions and by the range of assets and resources they bring - especially as these are people from very poor communities who are often deemed to have 'nothing'. She sees ABCD as ultimately being about giving power to people in communities - which aims to, "shift the culture from one of dependency to one of hopes and inspiration." and Ikhala clearly has a role in enabling that to happen in the Eastern Cape. You can read more about Ikhala's work here.

Volunteer (aged 80!) cooking up meals

Whilst grants are relatively small in terms of financial contribution, they enable communities to make a big difference. We visited the Seki Women's Foundation which Ikhala helps to fund. They provide meals to local people from the New Brighten township (where they are located) 3 days a week. The local school also sends pupils identified in need  of a meal (school meals are not provided in state schools in the area). Mrs Bono, the founder of Seki, told me, "I know and am glad these children get to eat 3 days a week....but I have no idea what they do for food on other days. It's really a worry...". Many of the children were dressed in school uniforms and shoes that were in a poor state and really needed replacing. Ikhala also helps by providing school shoes and clothing for the children where possible.

Getting a good meal at the Seki Foundation

The Seki project's 'soup kitchen' is run by a small group of older women (some in their 80s) who prepare, cook and serve the hot meals. Bernie explained how they keep a register of who attends and so, if someone is missing, they will visit the home or make enquiries about their well being to make sure all is well. They also try to identify people who may be unwell or in need of some other support and signpost them to other sources of help where needed. They also have a role in identifying children who may be having problems at home and will alert the necessary services. In addition to providing the meals, the Seki Centre also has a community garden in the grounds which provides some of the food for the meals. All Ikhala projects are encouraged to have a community garden to help address issues of food poverty and encourage sustainability.

The Goodness of Gardening

On Wednesday this week, I spent an inspiring and thought provoking morning with Rob Small of Abalimi Bezekhaya ('Farmers of Hope') in Cape Town.

Abalimi is an urban micro-farming organization operating in the townships of Cape Town. Abalimi teaches people how to create their own garden, grow - and potentially sell - their own vegetables, and feed their families.

Abalimi means "the Planters" in Xhosa, the predominant language among the target communities worked with. Through a series of programs, Abalimi helps to alleviate poverty (though increased food security and generation of jobs / income), empower communities and promote a better state of wellbeing. As Albalimi's newsletter (Sept 2009) states, this is often challenging work in communities where people are very poor and, in trying to survive, are, "often divided and disempowered, easily distracted and always looking for greener pastures."

However, almost 30 years since Albalimi began, it continues to support both home gardens, through providing people with training, advice, seedlings and manure to help establish their own gardens and also larger, community gardens. Through the home gardening projects, people gain more confidence and are able to move on and build themselves a new life.  

We visited two of the community gardens and met some of the farmers and gardeners, all working hard to tend the crops. Some of the produce from the community gardens is sold to the veg box scheme which supplies locally produced, reasonably priced, organic vegetables to customers in Cape Town. It also provides the farmers with an income and an incentive to keep farming!  As Rob explained, for these people, the garden is not just a 'nice to have', it is central to sustainability and poverty reduction. The gardens also provide an opportunity for community members to come together and to work together for both their individual benefit (through increased physical activity, improved healthy eating, social interaction, learning to run a business, etc) and for the greater good of the community (much of the produce is shared with community members).

Can you help?

It costs just £60 to establish one new township home vegetable garden or a new community market garden (including training, trees and follow up support). Please do consider a donation if you can support this fantastic work.

Want to know more?

You can view a CNN clip about Abalimi 's work, as explained by one farmer leader Christina Kaba here.

'We are Abalimi. We are the Farmers.' is a short documentary film about Albalimi made by American volunteer Matt Miller and Travis Blue. View it here.

Health Champions in the Eastern Cape

I saw 3 giraffes and 2 warthogs on my way to work yesterday….not something you see every day but what a great start to an informative and inspiring day spent with Lucy O’Keeffe and Kath Court from the Angus Gillis Foundation (AGF). AGF are based in Grahamstown in the Eastern Cape, considered to be the poorest province in the country with 72% of the population living in poverty and a third (32%) of households having an income of less than R200 (£20) per month.

Like Altogether Better, the AGF takes an empowerment approach, as illustrated in this quote from their website:

“The Angus Gillis Foundation facilitates and does not drive development in communities because we believe that, with the right support, community champions can drive their own development, thus bringing about genuine and lasting change” (Angus Gillis Foundation, 2011)

The AGF works with 12 communities in the Eastern Cape and facilitates development using asset based approaches which emphasise people's existing skills and capacities. They take a truly holistic approach operating 4 key programmes: 1) Self-help groups 2) Education 3) Economic Development and 4) Health.

Whilst the health and social needs in the Eastern Cape are very different to those in Yorkshire, AGFs Positive Health programme, facilitated by Kath Court, has many similarities with Altogether Better. They even have their own Community Champions and Positive Health Champions! I was keen to meet some of them and find out about their work. Kath told me that the Positive Health programme aims to, “provide communities with as much information as possible, to enable them to achieve optimal physical, mental and spiritual well-being. It's about presenting methods of preventing illness and staying healthy.”

Lucy (left) and Kath (right) from AGF with Health Champion, Novulo
in the herb garden at the Community Centre

The Health Champions are people from within the community who have leadership potential, have good language skills and have developed the necessary health related knowledge. Kath told me how the self-help groups (SHG) which AGF established are often where the Champions are identified and first emerge. Through the SHGs, the women  begin to start sharing their problems and discuss social issues in the group. This helps a new relationship of trust and togetherness to develop so the SHGs  become a breeding ground for social capital as well as future community champions!

We travelled to the Brandeston community (situated within a private game reserve) to meet with Noluvo, a Positive Health Champion working in the community. Noluvo showed me around their community centre which housed a number of facilities for use by community members including a simple gym, a knowledge centre/library, a crèche and pre-school, a herb garden, and the workshop of the Siyakhula Doll Cooperative, run by women from the local area as a means of generating income.  Kath later explained to me how, before her involvement with the self help group and becoming a Health Champion, Noluvo would not have had the confidence to talk to a stranger such as me, "the strides she has made in terms of her knowledge, confidence and ability to engage with others have been huge."

We arrived at the Centre lunch time as the children were tucking into a healthy meal. Kath explained how the Centre used to provide the food mixed together, like in a stew or a soup, but that she had worked with the Champions and the children to explain the different food groups and why each was important in health terms. The children were proudly able to tell me that carrots were good for their eyesight, that the potato (carbohydrate) gave them energy and that the chicken (protein) made them strong. Kath had encouraged the workers to serve the food on a plate with separate sections which helped remind the children about the importance of different food groups (see photo above).

We then went on to a nearby community, Kalkeni, to meet Nomhlobo (see photos left and below), a retired nurse who had grown up in the area and moved back in recent years. She now works as a Positive Health Champion and told me how she helped with a range of health issues in the community including child health, nutrition, keeping active and sexual health. Nomhlobo felt strongly that people should be encouraged to help themselves and be self-sufficient, not always relying on help from outside. She explained how she had a role in encouraging people to grow and cook their own food and showed me the goats they were breeding which were then sold on to generate income.

Positive Health Champion - Nomhlobo

Our last stop was to meet Lindi in Glenmore (see photo to the left) – a community of around 2000 people. Lindi, in addition to working at the community run bakery, is also a Positive Health Champion. She attends the local health clinic (staffed by 3 nurses) every day to provide advice and support to people, she also runs workshops for community members on a range of different topics including child development, hygiene, gardening skills and parenting. She also provides 1:1 support and advice to people in their own homes when they are too sick to attend the clinic. Lindi told me how her own knowledge and confidence had grown enormously since becoming a Champions - and how she got great satisfaction from sharing her knowledge to help people.

On the way back, we stopped by at one of the safe play places for children. Kath explained how they had been taught about the importance of hand washing and, on Kath's instruction, all the children rushed outside to the hand washing bucket and duly washed their hands. Kath  explained how the children  were also 'champions' and in teaching them about basic health and hygiene, they will grow up as a future generation who value the importance of health and of keeping healthy and also understand and share what they can do to help with this.

Waiting in line to wash their hands.

There is much to be learnt from the AGF asset based approach to development. They deliberately avoid using any external material resources in the initial stages as this is seen as contrary to the Self Help concept. Although the people AGF work with are very poor, their personal assets and natural potential to manage their lives is identified and mobilized.  AGF see development as, "not about resources but about unlocking human potential". Conventional approaches often assume that poor people have no assets, AGF is clear that this is not the case and that they must first work with the assets people have and affirm them that they can do it. Then when they are strong, material resources can be introduced responsibly.

Worker in the Dolls Workshop

“As outsiders we cannot empower the weaker section, only they can empower themselves, to make choices or to speak out on their own behalf. We can walk alongside them, introduce resources responsibly when they are needed, and provide necessary training, support and motivation.” (Angus Gillis Foundation, 2011)

Wise words and important learning for us in the UK, especially at a time when external resources are scarce, and where the culture is often one of 'provider' and 'client' rather than one of  true empowerment.