Feasibility of a community action model oriented to reduce inequalities in health

Abstract

Objective

To assess the feasibility and achievements of a systematic community action model, Health in the Neighbourhoods, in two deprived areas of Barcelona.

Methods

The feasibility of the model implementation in two neighbourhoods was assessed. The model developed three stages aiming: (1) to make alliances with partners and stakeholders, (2) to develop a participatory needs and assets assessment, and (3) to plan, implement and evaluate interventions on the community prioritised needs. The feasibility of the model at each stage was assessed through the percentage of achievement of 18 indicators. It was evaluated between 2007 and 2011.

Results

The achievement of the indicators exceeded an average of 75% in both neighbourhoods. In stage 1 community working groups were set up. In stage 2 a comprehensive assets and health needs assessment was done through quantitative and qualitative methods, as well as participative prioritizations of community health problems. In stage 3, the community working groups defined an action plan and a number of interventions against the prioritised problems, based on evidence and local assets reviews. Interventions were developed, implemented and evaluated.

Conclusion

This structured model, including a small set of indicators, enabled the implementation of a community action model with neighbourhoods’ stakeholders. The model showed flexibility to adapt to neighbourhoods’ characteristics and the objectives were successfully met. The alliances and partnerships with community and municipal sectors promoted the sustainability of most interventions.

Introduction

The determinants of health have to do with the socioeconomic and political context, with individual socioeconomic position and other intermediate factors such as housing, income, psychosocial circumstances, behavioural and biological factors, and the health system [1], [2].

Since the 1990s various studies have been conducted in Spain on social inequalities in health and have shown inequalities in morbidity and mortality, in health related behaviours, and in health services utilisation as functions of social class, age and gender, and area of residence [3]. Barcelona city has a long tradition of studying social inequalities in health [4] and in the establishment of some public health intervention programmes [5].

Policies and actions to reduce social inequalities should include socioeconomic policies in a number of spheres: reduction of differences in income and unemployment, investment in public services such as health services, education, transport, housing or social security [6]; and increasing the participation of the actors [7].

Some of the policies focusing the renovation of neighbourhoods or urban areas have got impacts on some determinants of health. This has been related to improvements in housing conditions, environment, job opportunities, education, health and reduction of violence among others [8], [9], [10], [11], [12]. Some of the first experiences on social inequalities in health in neighbourhoods were developed in the United Kingdom, the Health Action Zones [8] and in the Netherlands [13], implementing interventions to increase the effectiveness, efficiency and responsiveness of services.

Community participation reduces social inequalities in health and strengthens community's capacities and participation in health related decisions [7], [14], [15], [16]. Few of those experiences have been evaluated, and most of them have been centred on specific interventions. This may be related to the difficulties of getting quantitative outcomes, especially in small populations like neighbourhoods, and, also, to the lack of shared theoretical models behind many of the experiences. Community action in health encompasses the participation of many actors [17], from formal organisations to neighbourhoods associations, groups and individuals [9], as well as collective efforts to increase control and to improve health determinants [18]. The participation of local agents and stakeholders has been considered a key element of community action [19], not only for the design of interventions to respond to the needs of the population but also for their implementation and sustainability [20].

Evaluation of community action ought to take into account the phases of the process, the specific settings, the execution of strategies, the collection of data, and the evaluation of the success or failure of the particular interventions [21]. Moreover, some authors consider the participative process and participation as a result in itself [22].

Health in the Neighbourhoods is a strategy of the Catalonian Department of Health developed in 2005, within the framework of the Catalonia Neighbourhoods Law (Law 2/2004), designed to improve underprivileged neighbourhoods. Catalonia is one of Spain's 17 autonomous communities. Its capital city, Barcelona, is the second largest city in Spain, with 1,616,000 inhabitants. To date (April 2012) Neighbourhoods Law has benefited 142 neighbourhoods, 12 of them in Barcelona, developing urban renewal and reinforcement of social and economic networks. Neighbourhoods Law acts on some social determinants of health, as urban renewal, housing, public equipments, accessibility or other and these policies on disadvantaged areas are expected to reduce social inequalities in health [10], [12].

Health in the Neighbourhoods [23] is a complementary project carried out in the neighbourhoods benefited by the Neighbourhoods Law. In Barcelona, Health in the Neighbourhoods begun in 2007 as a political responsibility shared by the Public Health Agency of Barcelona, the organism responsible for health care in the city (Consorci Sanitari de Barcelona) and the city Council. So far, Health in the Neighbourhoods has been implemented in twelve neighbourhoods. The first two were Poble Sec (November 2007) and Roquetes (February 2008). In these two neighbourhoods, an evaluation of the community action model was conducted since the beginning to June 2011, and this is the topic dealt with in the present article.

The community action model Health in the Neighbourhoods consists of a systematic sequence of elements to enable and facilitate the design, the implementation and the evaluation a community action project, with the participation of community stakeholders along all the process. This model established three phases (Fig. 1).

• Alliances with partners and stakeholders: The model envisaged to get initial alliances with politicians, technicians and professionals involved in different areas related with health. It also promoted the creation of a working group (or incorporation into an existing one) which leaders all phases [24], involving social, health, community agents, and professionals of Community Development Plans, being open to the participation of other stakeholders.

• Health needs and assets assessment through: (a) a quantitative analysis based on health indicators of the neighbourhood in comparison with its own district and the Barcelona, based on information available in a variety of sources (municipal census, national censuses, birth and mortality registers, notifiable diseases, drug information systems, health services and the Barcelona Health Survey); (b) a qualitative diagnosis based on the consultation to different actors and neighbours to identify the perceived health problems and determinants. Qualitative methods had to be flexible enough to adapt to contexts and, at the same time, to achieve information saturation. Interviews had to be held with key informants, nominal groups of professionals and representatives of entities and discussion groups of neighbours in order to get a good representation of the vulnerable citizens and collectives; (c) a participative prioritisation of the health problems; and (d) an inventory of available resources and assets.

• Planning, implementation and evaluation of the interventions: An intervention plan had to be defined based on: (a) consensus of the working group over objectives in order to ensure tackling the prioritised problems; (b) a literature review of effective interventions carried out by health professionals addressed to the prioritised health problems; (c) available resources, to decide whether to develop new actions or to adapt existing ones; (d) a participative prioritisation and planning of intervention by the working group; (e) a description of interventions including evaluation plans; and (f) the evaluation of the interventions.

According to a revision of effective policies and actions that tackle social inequalities in health, this model may promote community participation in making health related decisions [16], [25]. It also links different levels and sectors, an essential factor to tackle inequalities [26] and to maintain the interventions [19]. Moreover, this model promotes effectiveness through evidence based decision-making [27], [28] and the evaluation of the process and the outcomes of the interventions.

The aim of the this article is to assess the feasibility and achievements of a systematic community action model, Health in the Neighbourhoods, in two deprived areas of Barcelona.