1. An assets-based approach to improving local health & well-being Thursday 12 th December 2013 Redcar www.assetbasedconsulting.net

2. Outline of the day Asset-based approaches – ‘A glass half-full?’ Appreciative Interviewing – practical session Principles, values and key themes Salutogenesis & Asset Based Community Development Individual & community asset mapping – practical session What makes us healthy? Evidence, Action, Evaluation Local case study Challenges to and limitations of the approach Exploring local implementation for improved outcomes

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

4. 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?

5. 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’ Some people become passive recipients of expensive services

6. 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 targeted at specific needs & problems means communities and individuals are often ‘segmented’

7. 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 better for itself

8. Salutogenesis Developed by American Israeli medical sociologist Aaron Antonovsky from the 1970s Working with women who were holocaust survivors Health is not a “state” as defined by the World Health Organization (1946) Sense of Coherence (SOC) 1992 Generalized Resistance Resources (GRRs) 1987 The ‘river of life’

9. Sense of Coherence Comprehensibility Manageability Meaningfulness

10. Generalized Resistance Resources Found within people as resources bound to their person and capacity but also to their immediate and distant environment as of both material and non-material qualities The key factor is not what is available but to be able to use and re-use them for the intended purpose GRRs provide a person with meaningful and coherent life experiences as resources at their disposal. They are genetic, constitutional and psychosocial. They include material, knowledge/ intelligence, ego identity, coping strategy (rational, flexible, far sighted), social support, ties, commitment (continuance, cohesion, control), cultural stability, magic, religion/philosophy/ art (a stable set of answers) and a preventive health orientation.

11. Salutogenesis - the factors

12. Features of an assets approach Change from servicing people’s needs to facilitating their aspirations Redress the balance between needs and assets or strengths A shift in emphasis from the causes and the causes of the causes to ‘the causes of the causes of the causes’ A shift from targeted to more universal approaches Solutions that are developed by and with people and communities not just by specialists and professionals

13. A glass half-full: http://www.assetbasedconsulting.co.uk/Publications.aspx How an asset approach can improve community health and well-being

14. 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 well-being. “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

15. Values for an Asset Approach Identify and make visible the health-enhancing assets in a community See citizens and communities as the co-producers of recovery, 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 recovery, health and well-being Empower communities to control their futures and create tangible resources

16. 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

17. Asset Based Community Development John McKnight & John Kretzman – Northwestern University, Chicago (1993) In thousands of face to face conversations on the doorsteps of American households they found two divergent paths: assets and deficits Start with people’s skills, knowledge and passions; connect them to others and build connections, social participation, and collective efficacy. At least four critical determinants of health are the products, not of divine providence nor, organised medicine but of determined communities, working together to affect behaviour, relationships and policies.

18. 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

19. Circles of friends and support “When we seek for connection, we restore the world to wholeness. Our seemingly separate lives become meaningful as we discover how truly necessary we are to each other” Margaret J. Wheatley

20. Circles of friends and support ‘Circles of support and personalisation’ (no date) Max Neill & Helen Sanderson www.helensandersonassociates.co.uk/media/75948/circlesofsupportandpersonalisation.pdf

21. ‘Using an assets approach for positive mental health and well-being’ (2012) Institute for Research and Innovation in Social Sciences Connecting and using circles

22. Community asset mapping The actual and potential assets of: Individuals Associations Organisations ‘Building Communities from the Inside Out’ (1993) John P Kretzman & John L McKnight

23. Creating a community asset map The actual and potential assets of: Individuals – heart, head & hand Associations Organisations

24. Using an assets approach for positive mental health and well-being’ (2012) Institute for Research and Innovation in Social Sciences

25. 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

26. Primary Assets Secondary Assets Potential Assets Analysing assets

27. 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.

28. Commonalities between salutogenesis and ABCD They both share a focus on working with peoples’ capacities and resources. Health is seen as a product of the mobilisation of community and individual assets and resources The assets that McKnight &Kretzmann value align closely with the resources that salutogenic thinkers have demonstrated to be the sources of health and wellbeing. Both approaches are interested in mobilising the whole community to create health – rather than limiting the subjects of health promotion to those deemed to be at risk, or unhealthy. Both approaches see health and well-being as a product of social action. They reinforce the case that health inequality is a product of income and other inequalities.

29. Commonalities between salutogenesis and ABCD Both put a high value on a sense of belonging, capacity to control, finding meaning and self-worth – these psychosocial assets promote well-being and health but they also bring connected individuals and flourishing communities. Both put a high value on social relationships – the networks and connections in a community that reduce isolation and vulnerability to shocks. Both start with a premise that strong communities – whether of geography, identity or interests – generate resources, through fundraising, mutual aid, lobbying power, voice and empowerment.

30. “What makes us healthy?” The assets approach in practice: http://www.assetbasedconsulting.co.uk/Publications.aspx Evidence Action Evaluation

31. 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.

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

33. 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.

34. 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.

35. 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

36. Evaluation To evaluate health asset based activities requires a new approach. Instead of studying patterns of illness amd dependence, we need ways of understanding patterns of health, recovery 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.

37. 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 - 2008) 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)

38. 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 challenge is responding to people’s needs in ways that do not undermine choice and self-determination In England the move of Public Health 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.

39. 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.” www.assetbasedconsulting.co.uk