What makes us healthy? The assets approach in practice Thursday 11 th April 2013 Middlesbrough

Trevor Hopkins Freelance Consultant

Outline What are the ‘deficit’ and ‘asset’ approaches ‘A glass half-full’ Principles, values and key themes Appreciative Interviewing/Appreciative Inquiry ‘What makes us healthy? Evidence Action Evaluation Asset mapping A note of caution

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. Margaret Mead – US Anthropologist

The dilemma... Clients and consumers have deficiencies & needs Citizens have capacities and gifts

A deficit approach Much of the evidence currently available to describe health and address health inequalities is based on a deficit model This is a ‘pathogenic’ approach to health and well-being The deficit approach focuses on the risks, problems, needs and deficiencies in individuals, families and communities Professionals then design services to ‘fix’ the problems As a result the community and individuals can feel disempowered or can become ‘service dependent’ People become passive recipients of expensive services

Features of a deficit approach Policymakers see professional systems or institutions as the principal tool for the work of society In Public Health practice this approach has focused on ‘risky behaviours’ and ‘lifestyle factors’ “The collective term for these behaviours is the subject of much debate, with professionals from different fields preferring different terminology, each having a view about what is pejorative and what is not.” (Clustering of unhealthy behaviours over time – King’s Fund, August 2012) Services are targeted at specific needs & problems, communities and individuals become ‘segmented’

An assets approach Values the capacity, skills, knowledge, connections and potential in individuals, families and communities It is a ‘salutogenic’ approach which highlights the factors that create and support resilience and well-being It requires a change in attitudes and values Professional staff have to be willing to share power Organisational silos and boundaries get in the way of people- centred outcomes and community building Never do for a community what it can do for itself

Features of an assets approach Changing from servicing people’s needs to facilitating their aspirations Redressing the balance between needs and assets or strengths A shift in emphasis from the causes to ‘the causes of the causes of the causes’ A move from targeted to universal approaches Solutions that are developed by people and communities not by specialists and professionals

A glass half-full: How an asset approach can improve community health and well-being

The Principles Assets: any resource, skill or knowledge which enhances the ability of individuals, families and neighbourhoods to sustain health and wellbeing. Instead of starting with the problems, we start with what is working, and what people care about. Networks, friendships, self esteem and feelings of personal and collective effectiveness are good for our wellbeing. “Focusing on the positive is a public health intervention in its own right” Professor Sarah Stewart-Brown, Professor of Public Health at Warwick Medical School speaking at a conference on ‘Measuring Well-being’ 19 January 2011 at Kings College

Values for an Asset Approach Identify and make visible to health-enhancing assets in a community See citizens and communities as the co-producers of health and well-being rather than the recipients of services Promote community networks, relationships and friendships Value what works well Identify what has the potential to improve health and well-being Empower communities to control their futures and create tangible resources

Key themes The defining themes of asset based ways of working are that they are: Place-based Relationship-based Citizen-led...and that they promote social justice and equality

This requires a big shift in emphasis Changing from servicing people’s needs to facilitating their aspirations A move from targeted to universal approaches Redressing the balance between needs and assets or strengths A shift in emphasis from the causes to ‘the causes of the causes of the causes’ Solutions developed by people and communities not by specialists and professionals

‘Appreciative’ Interviewing

Appreciative interviewing Can you tell a story of a time when you made a positive change to improve your own health and wellbeing? What do you believe is now the single most important thing that positively influences your own health and wellbeing? Now turning to your work; can you tell a story of how you involved others as equal partners in bringing about real and sustainable change? Imagine your community telling stories about how you have worked together as equal partners to achieve your dreams of a healthy community. What would these stories be?

Appreciative Inquiry

“Good organisations know how to preserve the core of what they do best. Preserving the right thing is key. Letting go of other things is the next step” David Cooperrider

Defining Appreciative Inquiry Appreciative – Valuing, recognising the best in people or the world around us, affirming past and present strengths, successes and potentials Inquiry – The act of exploration or discovery or to ask questions and be open to seeing new potentials and possibilities.

Agenda Reflection – remembering times when our culture, values and identity made us proud. Affirmation - inquiring into those strengths and how we can use them to create the future Action – practical planning towards the future

Some background Traditional approaches to development: Identify problems, barriers, gaps Maybe analyse why the problems exist Propose solutions Create an action plan Also …assign blame Focus attention on what is missing, and Can sap energy and motivation

When to use Appreciative Inquiry When there is a complex situation which needs some collective will to address When you want to bring people together to work on something of mutual interest. When you want to build a vision of the future as well as work with others to make things happen in the short-term. When you want to deliver a shared vision, improved relationships and working together.

When not to use Appreciative Inquiry When one person is clear about a desired outcome. When there is no interest in involving others in a creative way or when their opinions are not valued. When there is no interest in sharing responsibility or decision-making. When it is important to involve all key stakeholders and you cannot recruit a good core group. It cannot deliver a pre-formed solution. Each community develops its own response to its own situation.

The appreciative cycle

...building the path as we walk it

“What makes us healthy?” The assets approach in practice: Evidence Action Evaluation

Evidence 1. There is growing evidence for the importance of health assets, broadly defined as the factors that protect health, notably in the face of adversity, and for the impact of assets based approaches Individuals do not exist in isolation; social factors influence individuals’ health though cognitive, affective, and behavioural pathways. The quality and quantity of individuals social relationships has been linked not only to mental health but also to both morbidity and mortality. It is comparable with well established risk factors for mortality. There is an increased likelihood of survival for people with stronger social relationships.

Meta analysis: comparative odds of decreased mortality The relative value of social support/ social integration Source: Holt-Lundstad et al 2010

Evidence 2. Stress buffering – relationships provide support and resources (information, emotional or tangible) that promote adaptive behavioural or neuroendocrinal responses to acute or chronic stressors e.g. illness, life events. Social relationships may encourage or model healthy behaviours, thus being part of a social network is typically associated with conformity to social norms relevant to health and social care. In addition being part of a social network gives individuals meaningful roles that provide self esteem and purpose to life.

Action 1. Assets require both whole system and whole community working. Instead of services that target the most disadvantaged and reduce exposure to risk, there is a shift to facilitating and supporting the well-being of individuals, families and neighbourhoods. It requires all agencies and communities to collaborate and invest in actions that foster health giving assets, prevent illness and benefit the whole community by reducing the steepness of the social gradient in health.

Action 2. Asset mapping Toronto framework for mapping community capacity Joint Strategic Assets Assessment Time-banking Social prescribing Peer support Co-Production Supporting healthy behaviours Community development to tackle health inequalities Network building Resilient Places Appreciative Inquiry Asset based service re-design Assets – embedding it in the organisation Workforce and organisational development

Evaluation To evaluate health asset based activities requires a new approach. Instead of studying patterns of illness, we need ways of understanding patterns of health and the impact of assets and protective factors. Methods that seek to understand the effects of context, the mechanisms which link assets to change and the complexities of neighbourhoods and networks are consistent with the asset approaches. The participation of those whose assets and capacities are being supported will be a vital part of local reflective practice.

Two questions to ask: Does it work? Is it worth it?

Does it work? There is a spectrum of models for answering questions about impact, ranging from high level national data sets to methods that ask about local and individual impacts: Taking the temperature of local communities The Well-being and Resilience Measure (WARM) Measuring mental wellbeing Mental well-being impact assessment; a toolkit Warwick-Edinburgh Mental Well-being Scale (WEMWBS) North West Mental Well-being Survey 2009 Measuring community empowerment The Toronto Indicators of Community Capacity The ‘Outcomes Star’

Is it worth it? There is a small field of methods for establishing cost effectiveness which in time will generate evidence about work that aims to strengthen both social and psychosocial assets: A business case for community development The Health Empowerment Leverage Project (HELP) Evidence for the economic benefits of capacity building The Building Community Capacity for Putting People First Project Cost effectiveness of promoting mental wellbeing The All Wales Mental Health Promotion Network Social Return on Investment (SROI)

Asset Mapping

Asset mapping Can be done with: Individuals – circles of friends/support Communities – Community asset mapping Organisations – using Appreciative Inquiry Forming new and expanding connections to bring about change

Asset mapping The actual and potential assets of: Individuals Associations Organisations

Creating an asset map The actual and potential assets of: Individuals – heart, head & hand Associations Organisations

Primary Assets Secondary Assets Potential Assets Analysing assets

Adding more depth As well as individuals, associations and organisations, in a community this can also include: The physical assets The economic assets The cultural assets

Community asset mapping process Meet the people who will become the core group Contact individuals or groups who are active in the community Collate the assets and talents of individuals in the community Identify the resources and assets of local associations, clubs and volunteers Map the assets of agencies, including the services they offer.

Asset mapping exercise HeartHandsHead Individuals Organisations Associations Me

Challenges & limitations

The material basis of inequalities Health inequalities are a symptom, an outcome of inequalities in power, money and resources “Achieving a more equitable distribution of power requires collective social action.” (Closing the gap in a generation: health equity through action on the social determinants of health: WHO ) Both assets approaches and the well-being debate are associated with a non-materialist position The problem is not that assets approaches address psychosocial and cultural determinants but if they do so without emphasising the material basis of inequalities in life chances “It’s perhaps a cheap point to note that income in the higher echelons of public health situates these professionals well in the top decile, where the feeling that life is meaningful is daily reinforced by material reward. And the social and emotional distance between those who design interventions and those who experience them widens.” (‘Reasons to be Cheerful the count your assets approach to public health’ Lynne Friedli (2011)

Reasons to be cheerful? Asset approaches speak to the resistance of deprived communities to being pathologised, criminalised & ostracised. Being described in public health reports in terms of multiple deficits, disorders and needs. Concepts like co-production challenge the ‘professional gifted model’, empower citizens and involve recognition of their knowledge, skills and potential There are conversations to be had about reclaiming the language of assets, perhaps as part of struggles to regain community co-operation The problem is not dependency, dependency is a fact of the human condition, not a moral failing. The problem is responding to people’s needs in ways that do not undermine choice and self-determination In its heart public health knows this. The move into the political world of local government is an ideal opportunity to insist on a fairer distribution of material wealth as this remains the key determinant of poor health

Questions and discussion

It takes everyone to build a healthy, strong and safe community. “The asset approach is a set of values and principles and a way of thinking about the world.”