Summary of the impact

Research conducted within the University of East London's Institute of Health and Human Development (IHHD) is reshaping the development, commissioning, delivery and evaluation of interventions to address the wider determinants of health and health-inequalities, and has had impacts on public policy, service design and, ultimately, public health and wellbeing. Grounded in close relationships with policy-makers and end users, UEL's primary research into community development and co-production has informed the design of health improvement interventions, delivered through the cross-institutional, community-based Well London project. Research findings have driven Big Lottery funding priorities, contributed to parliamentary debates on health, informed NICE and Local Government guidance, shaped Marmot Review Team and NESTA policy, and led health authorities to commission new services and adopt new approaches to service delivery.

Underpinning research

In 2006, Adrian Renton (Professor of Public Health and Director of UEL's IHHD) co-wrote a successful bid for £9.46m of Big Lottery Wellbeing Funding for the development and evaluation of a four-year (2007-2011) programme to improve lifestyles, mental health and wellbeing, and community cohesion in London. `Well London' used a community development approach to deliver a set of complex health interventions in the most deprived neighbourhoods of 20 London Boroughs. Target areas were characterised by the presence of a high proportion of black and minority ethnic (BME) residents, unemployment, ill health and poor physical environments.

The programme was delivered by an alliance of seven public, voluntary and education sector organisations, among which UEL was the sole academic partner. The remaining six partners were: London Health Commission; London Sustainability Exchange; Central YMCA; Groundwork London; Arts Council England, London; and South London and Maudsley NHS Foundation Trust. UEL was responsible for the design, management and delivery of Well London's community engagement and development strand, and for the evaluation of the programme as a whole, a task for which £1.43m of the total grant was set aside. These contributions fell broadly into three areas:

CADBE (Community Engagement, Assessment, Design, Brokerage, Enterprise)
Well London was delivered on a platform of community engagement, assessment, design, brokerage and enterprise (CADBE), later referred to as Community Engagement, Assessment, Design (CEAD). The innovative CADBE/CEAD approach combined asset-based community engagement and development, positive psychology methods and work with schools and the police, alongside traditional health promotion approaches. This novel approach was designed and managed by UEL on the basis of established strengths in project managing programme consortia and community networks. More specifically, Renton's team brought extensive experience of community development approaches to intervention design and participatory action research among hard-to-reach groups and black and minority ethnic communities. Renton had previously pioneered innovative approaches in this field, including the training and deployment of community-recruited interviewers to overcome cultural and linguistic challenges.

CADBE was used to work with community and other stakeholders in the Well London intervention areas to identify local needs and priorities, determine the principles for delivering projects, and bring this information — together with other data about the target area — into project implementation documents guiding the delivery of local interventions. It consisted of the following processes which included training local volunteers (approx. 100 in Phase 1) in community interviewing and engaged, in total, more than 2600 residents:

• Identifying and working in partnership with 20 local co-host community organisations in each of the intervention areas, e.g. the Noel Park Neighbourhood Team in the Haringey site and City Gateway in the Tower Hamlets site.
• Community profiling — including gathering census, routine statistical and documentary information about the local population demographic and health status, and mapping assets in the target areas. This generated baseline profiles to inform intervention development.
• Street and door step interviews to gain insights into local residents' understanding of their community's health needs and encourage their participation in Well London's later stages.
• Running 40 community cafes with residents, based on the World Cafe methodology (a structured conversational process for large group dialogue) [1]. These constituted the core mechanism for identifying community needs
• Running 20 community action planning workshops with residents and stakeholders based on methodologies such as Appreciative Inquiry, Visual Mapping, and Open Space.
• Organising 20 feedback meetings with local residents.
• Producing multimedia documentation, including hosting 118 Video Workshops to train local residents to make their own films about their local area and projects.

Non-experimental evaluation
The CADBE programme also coordinated end-of-project evaluations by UEL researchers and other Well London partners and organisers of the project's impact on health, well-being and the wider social determinants of health across its 20 sites. The evaluation was also used to make recommendations for further development and improvements to the model. It involved self-reported participant questionnaire surveys, stakeholder interviews, case studies, and qualitative research on community cohesion [2,3].

Experimental evaluation
In 2007, Renton secured £740k of peer-reviewed Wellcome Trust funding (plus a further £186k in 2012) to support the delivery of a cluster randomized controlled trial to measure outcomes at whole population level and elucidate pathways of influence between Well London's intervention activities and health outcomes [4]. It provided a rare opportunity to embed an experimental trial methodology within a complex social intervention. The 20 intervention areas were matched by 20 randomly selected `control' areas, and measures of physical activity, diet, mental health and social cohesion collected at the project's start and end, and compared to assess impact [5, 6]. The trial was complemented by a longitudinal qualitative study based on interviews with residents of target areas. Findings will be published in December 2013.

References to the research

Grants
Big Lottery Wellbeing Fund (2007). Well London CADBE. 2007-2012, £9.46m (£1.43m to UEL) Renton Wellcome Trust (2007). Cluster RCT of Well London. 2007-2012, £740,000 Renton Wellcome Trust (2012). Cluster RCT of Well London, further analysis. 2011-2012, £186K.

Details of the impact

Impacts on the Well London programme itself
The CADBE programme designed and implemented by UEL was the starting point for delivering the portfolio of community-led Well London projects in each of the 20 intervention areas, the total population of which is around 35,000. UEL researchers informed the design and delivery of the Well London projects by researching and documenting starting levels of healthy eating, healthy physical activities and mental wellbeing, and by ensuring that interventions were attuned to the target communities' self-reported and evolving needs. The questionnaires used in the UEL CADBE-coordinated evaluation showed wide-ranging benefits:

• 80% of respondents reported an improved understanding of mental wellbeing
• 86% felt more positive
• 83% had been helped to increase physical activity
• 63% had been helped to gain access to healthy food
• 60% had been helped to make more healthy eating choices

The case studies and interviews conducted as part of this evaluation identified further individual and community-level benefits, including greater confidence and opportunities for social networking, enhanced community cohesion and improved links to local officials and service providers. Other stakeholders (local councillors, police and public health officials) cited improved health behaviours and improved relationships between communities and official bodies [a]. Findings from the baseline results of the trial facilitated understanding of how healthy behaviour change is effected and helped improve the design of the Well London Phase 2 programme [b].

Impacts on public policy via contributions to policy debate and formulation
Both the Well London programme broadly, and the results of UEL's CADBE component in particular, have informed discussion, debate and policy formulation among parliamentary policy makers, the National Institute for Clinical Excellence, Local Authorities, NHS commissioning organisations, Royal Society of Public Health, Institute for Health Equity, the Greater London Authority, and the National Endowment for Science Technology and the Arts (NESTA). These stakeholders' current interest in and use of community engagement and development approaches is evident in various initiatives including the Big Society and Localism which have advocated community empowerment, and the Marmot Review on addressing health inequalities through action on the social determinants of health. Community engagement approaches — such as that developed by UEL for Well London — appeal particularly because of their potential to reduce health inequalities and facilitate the more efficient use and integration of health and community resources. Against the backdrop of this increasingly intense political interest in the use of community engagement and development, Well London has been cited by the City of Westminster Local Government Improvement Unit as a case study of good practice in the new Public Health environment [c] and in NESTA's report on transforming Healthcare [d].

The CADBE programme specifically was also cited in a November 2011 House of Lords debate on the Health and Social Care Bill as `an excellent example of how to undertake a strategic needs assessment across health and social care that is driven by local communities and brings together commissioners, providers and the university sector to work alongside those communities in making a real difference to health and well-being' [e]. During the same debate, Well London more broadly was held up as an exemplar of effective community engagement and development in identifying and addressing needs across health and social care to improve health and wellbeing.

The CADBE programme also formed the basis for Well London receiving the highest level Royal Society of Public Health Award for Health Promotion in 2011. Responding to the presentation of that award to the Well London Partnership, Prof Sir Michael Marmot acknowledged that "empowering individuals and communities, and giving people a voice is integral to addressing health inequalities. I am delighted the Partnership has achieved well-deserved recognition for its work" [f]. The Marmot Review Fair Society, Healthy Lives also emphasises the importance of participatory decision-making to ensuring that local health service delivery is able to effectively tackle social inequalities in health. Marmot's recommendations to develop community capacity to enable and promote healthy behaviours constitute a strong endorsement of the CADBE approach.

Impacts on health service policy, commissioning and delivery
As well as contributing to policy discussion and formulation relating to community engagement and wellbeing more broadly, the CADBE approach has also informed the development of specific health service guidelines affecting the provision of care across the UK. A summary of the Well London approach was presented via Renton's provision of expert testimony at a November 2012 NICE review, convened to develop guidance on working with local communities to prevent obesity. The subsequent NICE Guidance, which are used by the NHS, Local Authorities, employers, voluntary groups and other organisations involved in delivering care or promoting wellbeing, clearly endorses the approach taken by Well London [g].

The Well London CADBE approach has also influenced a shift amongst London-based NHS and Local Authority commissioning bodies towards using community development approaches to promote health and wellbeing, and modifying environmental drivers of health behaviours. This endorsement of community engagement and development approaches is evident, for example, in the fact that, in 2013, Well London received follow-on funding for implementation of the CADBE approach in nine new neighbourhoods across 9 London Boroughs. This will support the delivery of Well London to a further 15,000 residents across London, with additional funding provided by 9 PCTs (total £500,000 over 2 years) [h].

Interest in and the utility of the CADBE approach to health service providers has been further endorsed by the recent provision of funding by the Francis Crick Institute (the UK Centre for Medical Research and Innovation) for the UEL team to contribute community engagement and development activities [i] delivered at the Institute. These included training in community interviewing delivered for 10 local residents between February and July 2013 as part of the Institute's development of its community Living Centre in Camden, set up to help improve health and wellbeing in one of the most deprived parts of London [j].

Sources to corroborate the impact

[a] For reported benefits of the Well London programme to participants: Renton A, Findlay G, Sheridan K, Tobi P, et.al. (2013). The Well London Programme Phase 1: 2007-2011. Participant, Project, Community and Programme Level Evaluation. Institute for Health and Human Development, University of East London. Peer reviewed report. Available on request.

[b] For impacts on the development of Phase 2: Renton A, Phillips G, Daykin N, Yu G, Taylor K, Petticrew M (2012). Think of your art-eries: arts participation, behavioural cardiovascular risk factors and mental wellbeing in deprived communities in London. Public Health, 126: 57-64. http://doi.org/pp5; and Yu G, Renton A, Schmidt E, Tobi P, Bertotti M, Watts P, Lais S, (2011). A multilevel analysis of the effect of bonding social capital on leisure time physical activity: evidence from 40 disadvantaged areas in London. Health and Place, 17(5): 1023-9. http://doi.org/fp3rt9

[c] For citation in the City of Westminster Local Government Improvement Information Unit report `A Dose of Localism: the Role of Councils in Public Health' (2013): http://bit.ly/19RgSyz pp. 8-9

[d] For citation in the 2009 NESTA report `The Human Factor: How transforming healthcare to involve the public can save money and save lives': http://bit.ly/1binCCz p. 23

[e] For citation of the CADBE programme in the House of Lords Committee debate on the Health and Social Care Bill (30 Nov 2011): http://bit.ly/tTq3gZ (column 348-9)

[f] Health Promotion Awards 2011: recognising today's Health Promotion. Perspectives in Public Health, January 2012; vol. 132, 1: pp. 14-15. Copy available on request.

[g] For contribution of the research to the NICE Guidance Obesity: working with local communities (issued November 2012): http://www.nice.org.uk/nicemedia/live/13974/61622/61622.pdf p. 56

[h] For (re-) commissioning of Well London: http://bit.ly/1adFm0y Copies of letters of agreement/confirmation by London Boroughs for UEL to deliver the Well London programme in their areas are also available on request.

[i] For the delivery of community development training activities for the Francis Crick Institute:
http://bit.ly/17sC8fr

[j] For training delivered through the Francies Crick Institute Residents and Research Shaping Living Centre services. Community, Issue 11; June 2013: http://bit.ly/1aS0Arg p 7