valuing the health and wellbeing aspects of community empowerment (ce) in an urban regeneration...

Health Economics & Health Technology Assessment

Valuing the health and wellbeing aspects of Community Empowerment (CE) in an Urban Regeneration context using economic evaluation techniques

May 2016

Camilla Baba

Supervisors: Dr. Emma McIntosh & Prof. Carol Tannahill


• Defining ‘community empowerment’ and ‘urban regeneration’?• Urban regeneration programmes as a form of PHI• Current UK Urban Regeneration Policy • Identifying community empowerment as an outcome and intermediate

outcome of urban regeneration programmes» Systematic review with narrative synthesis» Secondary analyses of Glasgow’s GoWell programme (empowerment

question)

• Measuring and valuing community empowerment» Economic evaluations of urban regeneration» Discrete Choice Experiment (DCE) Methodology» Results

• Implications for policy and practice

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Presentation Overview

Health Economics & Health Technology Assessment 3

What is ‘community empowerment’ (CE)?

“Community empowerment is a process where people work together to make change happen in their

communities by having more power and influence over what matters to them” (COSLA and Scottish

Government, 2009:8).

“By Empowerment I mean our aim should be to enhance the possibilities for people to control their

own lives” (Rappaport, 1987:119).


“Realising the potential of people and places is at the heart of the Scottish Government's approach to regeneration.

Successful regeneration demands a combination of economic development, housing and environmental investment, better

public services, improved workforce skills, support for community involvement, a commitment to environmental

quality and good design; and respect for local identity and the historic features which contribute to it”

(Scottish Government, 2009).

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What is ‘urban regeneration’?


“Urban environments typically constructed for social and cultural reasons, can create health inequalities within the urban landscape [...] urban regeneration is an

important public health intervention and that by changing the urban physical, social and economic environment this can facilitate health development for

disadvantaged communities” (MacGregor, 2010:38).

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Urban regeneration programmes: A form of Population Health Intervention


• Since the 1990s UK policies have sought to promote a more participatory approach, encouraging communities to have a direct impact on the decision-making process

» Examples are of this are evident in publications such as ‘Promoting Effective Citizenship and Community Empowerment’ (ODPM, 2006),

» ‘An Action Plan for Community Empowerment’ (DCLG, 2007) ,» ‘Communities in Control’ (DCLG, 2008),» Local Government’s White Paper entitled ‘Strong and Prosperous

Communities’ (DCLG, 2006).

• June 2015 Scottish Government passed the ‘Community Empowerment (Scotland) Act’

» A clear commitment to strengthening participation » Promoting active citizenship , give community bodies new rights

Key motivation for this is the health and wellbeing gains it could provide

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Community empowerment in UK urban regeneration policy


Laverack, G. (2006). Improving Health Outcomes through Community Empowerment: A review of the Literature. Journal of Health, Population and Nutrition 24, 113-120.

Woodall et al. (2010). Empowerment and Health and Well-being: Evidence Review. Leeds: Centre for Health Promotion Research.

Wallerstein, N. (2006). What is the evidence on effectiveness of empowerment to improve health? Copenhagen: WHO Regional Office for Europe.

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CE linked to health and wellbeing


How do we identify, measure and value community empowerment in urban regeneration programmes to

inform future resource allocation decisions?

Key question


Measuring community empowerment (1)

“I do not propose to offer a laundry list of potential measures applicable in all circumstances; such an exercise is almost futile, as good measures are likely to be context-dependent” (Khwaja, 2005:267)

Key points: Context specific elements and

interpretation of CE

An end OR a means to an end?


Next steps…• Can urban regeneration lead to empowerment gains (is CE an end

outcome)?• What are its ‘elements’ within an urban regeneration context?• Within urban regeneration is CE a pathway to health gains (a

process)?

» Systematic review with Narrative Synthesis » Secondary GoWell analysis» Discrete Choice Experiment (DCE)

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Measuring community empowerment (2)


Review hypothesis:Regeneration in urban city neighbourhoods can act as the catalyst to unite individuals, create community social cohesion and promote empowerment.

The research question: Can urban regeneration lead to empowerment gains in affected residents/communities?

Conducted between November 2012- March 2014Mixed methods review (qualitative and quantitative)

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Systematic review with narrative synthesis


Platform (database host) Databases accessed

ProQuest ASSIA, IBSS, Sociological Abstracts, Social Services

Abstracts,

EBSCOhost Psychology and Behavioral Sciences Collection,

N/A SocIndex (accessed through EBSCOhost); Copac,

OpenGrey, Social Care Institute for Excellence

(SCIE), Scopus, Joseph Rowntree Foundation (JRF),

and Web of Science (WoS).

Databases Searched


Systematic review with narrative synthesis results

Next Step:Use of the Mixed-Methods Appraisal Tool (MMAT) developed by the Centre for Participatory Research at McGill University, Canada (Pace et al., 2012).


• A sense of inclusion and opportunity to participate in decision-making processes;

• Stakeholders acknowledging the time commitments expected of residents and thus seeking flexible partnerships;

• A sense of belonging to the community and area;• A sense of trust in stakeholders and the knowledge that there is transparency in

the decision processes and that their views, existing networks and connections are valued;

• Stakeholders offering funding and support to help communities (capability building);

• Information and awareness about decisions regarding the regeneration programme.

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Narrative Synthesis results


• Now have IDENTIFIED elements of CE within an urban regeneration context

• Can be regarded as an outcome of urban regeneration programmes

• However – is there a link to health and wellbeing within an urban regeneration context?

• How can we MEASURE and VALUE CE?

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Next Step


Baba, C., Kearns, A., McIntosh, E., Tannahill, C. & Lewsey, J. (2016). Is empowerment a route to improving mental health and wellbeing in an urban regeneration (UR) context? Urban Studies .

“A research and learning programme that aims to investigate the impact of investment in housing, regeneration and neighbourhood renewal on the health and wellbeing of individuals, families and communities over a ten- year period”

4270 participants 2011 GoWell Community Health and

Wellbeing Survey Personal circumstances Neighbourhoods perceptions Community State of health

Link between CE and health and wellbeing within urban regeneration


The empowerment question within the GoWell survey asks respondents to consider:

How much do you agree or disagree with the following statement: ‘On your own, or with others, you can influence

decisions affecting your local area?’

Five response categories were used: strongly disagree, disagree, no opinion/unsure, agree and strongly agree.

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GoWell survey measure


SF-12


Response categories:All of the timeOften Some of the timeRarelyNever

Warwick Edinburgh Mental Wellbeing Scale (WEMWBS)


Results – CE and Mental health (1)

Disagree No opinion/unsure Agree Strongly AgreeOn your own, or with others, you can influence decisions affecting the local

area

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00

10.00

Empowerment as a predictor of mental health (MCS)

Upper CI

MCS

(coe

f)


Disagree No opinion/unsure

Agree Strongly Agree

On your own, or with others, you can influence decisions affecting the local area

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00

10.00 Empowerment as a predictor of mental health (WEMWBS)

Upper CI

WEM

WBS

sco

re in

crea

se (c

oef)

Results – CE and Mental health (2)


• Increased participation in local decision-making • Sense of trust in stakeholders • Sense of belonging and feeling part of the local neighbourhood• Residents’ time commitment• Stakeholders help and support• Information and knowledge

• CE can be both a desired outcome (end) of urban regeneration programmes AND an intermediate outcome (process) linked to general health and mental wellbeing

CE elements identified in an urban regeneration context


Currently, there are two economic evaluations of regeneration which incorporated CE. 1. ‘Valuing the Benefits of Regeneration’ report conducted by Tyler et al. (2010) on behalf of

the Department of Communities and Local Government (DCLG). This study was commissioned to explore how to value the benefits of regeneration and compare them with their relevant costs.

» Community development activities » Volunteering, investment in community organisations, formal participation and

community facilities.» Bring about stronger, more active and better connected communities

2. Such challenges and limitations from a lack of available evidence were reported in 2015’s evaluation of the impact on health inequalities of approaches to community engagement in the New Deal for Communities regeneration initiative by Popay et al. (2015).

» Use of retrospective data led to costings based on “unwarranted assumptions about the equivalence of information extracted from the documents at different points in time”

» Best practice examples » Inconsistent data meant assumptions were used as information was not readily

available

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Previous valuations of CE within urban regeneration


“Discrete choice experiments are an attribute based measure of benefit that is based on the assumptions that firstly, healthcare interventions, services, or policies can be

described by their characteristics (or attributes) and secondly, an individual’s valuation depends on the levels of these characteristics” (Ryan, 2004:360).

• DCE’s are an attribute-based stated preference method to establish measure of value Attributes, levels & scenarios are identified using:

- systematic review methods, statistical design software, online survey company

• The DCE approach is rooted in economic theory and can be used to measure the strength of preference for attributes & levels as well as quantify the trade-offs between attributes

• The inclusion of a ‘payment vehicle’ such as money or time allows the trade-offs between attributes to be measured on common scale thus facilitating direct comparisons of ‘value’ between attributes

Methodology: Discrete Choice Experiment (DCE)


Qualitative methods often used for this stage Systematic review with narrative synthesis results Specialist opinions and guidance sought

» ID 1: An ex-housing officer who had previously worked in neighbourhoods undergoing regeneration in Glasgow and continues to volunteer with local community groups;

» ID 2:A librarian for NHS Scotland who works with communities in Scotland and arranges local consultation meetings they provided invaluable preliminary insight;

» ID 3: The NHS Greater Glasgow and Clyde Community Engagement Advisory group and patient panels;

» ID 4: A Network Development Officer for the West and Central Voluntary Sector Network (WCVNS) and community group leader committee.

Face validity testing

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Identifying ‘attributes’


Community Empowerment features LevelsInclusionThe extent to which you are included in community decision making processes (e.g. through local meetings, regular email/telephone contact).

You never have the opportunity participate You have the opportunity to participate sometimes You have the opportunity to participate regularly

Trust in StakeholdersThe extent to which community decision making processes are explained and transparent and whether your views are included in local decisions.

Decision making processes are not explained and no consideration of your views is evident

Some decision making is explained and some consideration of your views is evident

Decision making processes are fully explained; you can see consideration of your views in local decisions

Sense of belongingHow well you know your neighbours and how valued you feel as a member of the local community.

You do not know your neighbours and do not feel a valued member of the community

You know some of your neighbours and feel a valued member in the community

You know all your neighbours well and feel a valued member of the community

CE elements (1)


Residents time commitmentAmount of your own time you have to give up to ensure your views are heard.

0 hours every month

4 hours every month 16 hours every month

Resources/fundingThe level of stakeholder provided opportunities and resources for communities to develop skills/expertise and gain new community assets.

None - there is no help or support of any kind

Some – limited help and support is available

Yes - help and support is available

Information/knowledgeYour level of knowledge of issues and developments in the urban regeneration programme.

You are not informed about the regeneration programme

You are somewhat informed about the regeneration programme

You are fully informed about the regeneration programme

CE elements (2)


• Convenience sample pilot» Validity testing » UK representative sample (n=20)

• Phased approach to main survey» Phase 1 (n = 34)» Phase 2 (n = 302)» Reliable prior estimates from which to create a D-efficient design » Use of actual preference knowledge i.e. ‘priors’ as the basis of the design

results in more accurate preference information which in turn means the design is suited to a smaller sample size and/or fewer questions.

» The lower the D-error scores the more efficient the design. The most D-efficient designs are built on informative priors rather than assuming that parameters are uniform and all equal to zero (how orthogonal designs are created), are considered to be statistically more efficient

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DCE: Methods


• Conducted November 2014 – January 2015• advice gained from attendance on the ‘Design and analysis of discrete

choice experiments’ course run by London School of Hygiene and Tropical Medicine (LSHTM) August 2014

• Based on the 2011 census results, the pilot respondents were representative of the UK population (based on age and gender). That is, 11 participants were female (51%) whilst 9 were male (49%).

• Likelihood of choosing CE where they are able to participate in decision-making, trust stakeholders, have access to information, have to dedicate less time and stakeholders provide funding and resources.

• In theory it is expected that, all else equal, people would prefer to pay less for a good or service. The same assumption can be made about time.

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Convenience sample results


Main survey example choice-set


• ‘Cheap-talk’• In order to reduce this bias and to make the choice task as realistic as possible, clearly describing

the choice context is paramount. This is also known as ‘cheap-talk’. This contextual information helps respondents familiarise themselves with the good or service in question, and its characteristics and which can reduce the occurrence of random errors in the task due to misinterpretation or lack of understanding.

• Validity testing • Reliability check refers to repeating a choice-set later in a choice task by presenting the same

scenarios yet reversing scenarios. • Consistency checks are choice-sets where one scenario is constructed to be theoretically more

attractive to respondents than the other.

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DCE additional features


DCE UK-wide survey

Conducted May 2015

Online survey panel provider and host ResearchNow (http://www.researchnow.com/) was used to collect responses from UK adult respondents aged 16 years or older.

49% men51% women

Three-quarters of respondents (75%) had not lived in an area undergoing urban regeneration whilst 25% had previously experienced urban regeneration.

17 Non-demanders

None failed the validity tests

http://www.researchnow.com/

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Attributes β (SE) P-value 95% CI

InclusionYou never have the opportunity participate - - -

You have the opportunity to participate sometimes 0.63 (0.34) 0.05 -0.03, 1.29

You have the opportunity to participate regularly 0.6 (0.1) 0.001 0.41, 0.79

Trust in StakeholdersDecision making processes are not explained and no consideration of your views is evident - - -

Some decision making is explained and some consideration of your views is evident 0.31 (0.23) 0.17 -0.14, 0.76


0.66 (0.15) 0.001 0.37, 0.95

Sense of belongingYou do not know your neighbours and do not feel a valued member of the community - - -

You know some of your neighbours and feel a valued member in the community 0.99 (0.6) 0.05 -0.18, 2.16

You know all your neighbours well and feel a valued member of the community 0.67 (0.12) 0.001 0.44, 0.89

Resources/fundingNone – there is no help or support of any kind - - -

Some – limited help and support is available 0.08 (0.16) 0.63 -0.24, 0.40

Yes – help and support is available 0.32 (0.09) 0.001 0.14, 0.50

Information/knowledgeYou are not informed about the regeneration programme - - -

You are somewhat informed about the regeneration programme 0.56 (0.23) 0.02 0.10, 1.02

You are fully informed about the regeneration programme 0.78 (0.09) 0.001 0.60, 0.95

Residents’ time commitmentAmount of your own time you have to give up to ensure your views are heard. -0.05 (0.01) 0.001 -0.29, -0.1Likelihood ratio 165.70Pseudo R2 0.3Prob > chi2 0.00Number of observations 658

ResultsDCE Results (1)


• Respondents more likely to chose a scenario:» Give up less time, » Have the opportunity to participate, » Decision making processes are explained (with

their views being considered), » Know their neighbours, » Have help and support from stakeholders,» Are informed about the regeneration programme» Stronger preferences for attributes ‘Inclusion’ and

‘Sense of belonging’ first level of ‘improvement’ (from the lowest (worst) level).

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DCE Results (2)


Inclusion Trust in Stakeholders Sense of Belonging Resources/ funding Information/ knowledge0

5

10

15

20

25

30

35

Relative importance of each CE attribute (%)

CE Attributes

Pref

eren

ce (%

)

DCE Results (3)


You know some of your neighbours and feel a valued member in the community

You are fully informed about the regeneration programme

You know all your neighbours well and feel a valued member of the community


You have the opportunity to participate sometimes

You have the opportunity to participate regularly

You are somewhat informed about the regeneration programme

Yes – help and support is available

0 2 4 6 8 10 12 14 16 18 20

Respondents willingness to give up time for changes in levels of CE attributes from the reference level

Hrs/month

Ranked willingness to give up time


• It is possible to ‘identify, measure and value’ attributes of community empowerment within an urban regeneration context

• The DCE survey results provide initial recommendations for future allocation of resources for CE promotion within urban regeneration

» HOWEVER, the results also highlight the importance of stakeholders understanding the communities current ‘baseline’ levels of CE. Results indicated that it may not always be ‘worthwhile’ investing in the ‘best’ level of the CE elements i.e. attainment of moderate levels is highly valued in relation to the additional value to achieve the highest levels

» Through a detailed understanding of the affected communities and residents it will be possible use these results to tailor the optimal configuration of attributes to generate CE and resulting health gains

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Conclusions (1)


These results demonstrate the opportunities DCEs provide when trying to ‘distill’ complex concepts such as CE into clear recommendations when there currently is a lack of available evidence to draw from.

This research provides the first value set for attributes of CE specifically for inclusion in economic evaluations of urban regeneration programmes

Combining these ‘values of time’ with monetary values of time these results can be combined with the cost of CE generating activity within a cost-benefit analysis framework

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Conclusions (2)


Thank [email protected]@CamillaBaba

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