Equity in Health. Tools for Action

Transcription

1 Equity in Health Tools for Action NOVEMBER 2004

2

3 Tools for Action Equity in Health - Tackling Inequalities Contents Page Foreword 3 1. Introduction 5 2. Partnership Working Introduction Policy context Tools/Frameworks 9 2.3a: Assessing Strategic Partnerships Tool b: The Working Partnership Tool c: A Framework for Building Successful Partnerships Experiences of Partnership Working Community Participation Introduction Policy context Tools/Frameworks a: A Tool for Consultation b: A Tool for Participation The Ladder of Participation c: Wheel of Participation d: Community Empowerment Planning Framework e: WHO Tools for Participation Experiences of Community Participation Evaluation Introduction Policy context Tools/Frameworks a: Essential Elements and Key Steps in Evaluation b: Theory of Change Approach c: Social Capital Model and Indicators Experiences of Evaluation 84

4 Tools for Action Equity in Health - Tackling Inequalities Page 5. Health Impact Assessment (HIA) Introduction Policy context Tools/Frameworks a: Resource for HIA Steps Involved in Completing a HIA a.1: Screening a.2: Scoping a.3: Appraisal a.4: Influencing the Decision-Making Process a.5: Monitoring and Evaluation Experiences of Health Impact Assessment Indicators of Inequalities Introduction Policy context Tools/Frameworks a: Local Basket of Inequalities Indicators Experiences of Sourcing Indicators 150

5 Foreword This publication is the last in a series leading from the Equity in Health Tackling Inequalities programme, which Belfast Healthy Cities facilitated in 2002/03. The programme aimed to assist statutory, voluntary and community organisations to promote action to tackle inequalities in health, and centred on a seven day training programme with 42 participants from key agencies working within the Eastern Health and Social Services Board area. The programme was developed to meet the requirements of action on inequalities set by the WHO Healthy Cities Network, of which Belfast is a member. It was also supported by the Eastern Health and Social Services Board (EHSSB), as part of their implementation of the objectives set in Investing for Health, which has, as its overall goal, the reduction of inequalities. Training days focused on the following topics: Understanding Inequalities; Monitoring and Evaluation; Health Impact Assessment; Current Research and Indicators; Partnership Working and Creative Consultation. 4 The training days are reflected in the chapters of this publication. Each chapter contains the following headings: Introduction; Policy context; Tools/Frameworks. Many of the tools/frameworks which are outlined within this publication were presented at the Equity in Health training days. Where gaps have been identified these have been selected from a literature review. The publication also outlines some of the experiences and lessons from participants on the Equity programme as well as lessons identified from both Belfast Healthy Cities and the European Healthy Cities movement in general. The overall aim of this publication is to provide an easily understood guide on tools/frameworks to assist professionals primarily working within the statutory, voluntary and community sectors, in their efforts towards tackling inequalities in health and implementing Investing for Health objectives. This publication may also be of interest to colleagues working within the WHO European Healthy Cities Network.

6 Tools for Action Equity in Health - Tackling Inequalities We would like to express our warm thanks to Ruth Fleming, Health Development Manager, and to Jonna Monaghan, Information Development Officer in Belfast Healthy Cities office, for the compilation of this publication. Andrew Hassard Chairperson Joan Devlin Programme Director 5

7 1. Introduction Background to Health/Inequalities in Health There is now general consensus that there is a wide range of factors which impact on our health, factors more commonly known as determinants. The key determinants of health include social and educational opportunities, financial resources, housing conditions, nutrition, employment circumstances, environmental conditions and access to health services. These broad determinants of health are clearly outlined in Whitehead and Dahlgren s model of health (see below). General socio-economic, cultural and Education Agriculture and food production Work Environment Social Living and Working conditions and Individual community lifestyle Age, sex and constitutional factors environmental conditions networks factors Unemployment Water and sanitation Health care services Housing 6 Source: Dahlgren and Whitehead, 1991

8 Tools for Action Equity in Health - Tackling Inequalities 7 Inequalities in Health Investing for Health (IfH), the public health policy for Northern Ireland, defines inequalities in health as a result of many factors: Health is an outcome which results from a whole range of influences in everyday life. Inequalities in these determinants are responsible for inequalities in health. The IfH policy includes a range of actions and targets to address the determinants of health and inequalities. The World Health Organization defines equity and inequity as follows: Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided. Inequity refers to differences in health which are not only unnecessary and avoidable, but in addition are considered unfair and unjust.

9 2. Partnership Working 8 Partnerships and joined-up working with a wide range of stakeholders will be crucial in improving the state of our health DHSSPS (2002) Investing for Health Strategy.

10 Tools for Action Equity in Health - Tackling Inequalities 2.1 Introduction In recent years there has been increasing support for intersectoral partnerships, with particular emphasis placed on partnership working between the statutory, voluntary and community sectors. This chapter aims to provide the policy context which encourages partnership working as well as provide readers with a number of tools/frameworks to help assess if existing partnerships are successful. Practical examples are given of the successes, benefits and challenges of partnership working at the end of the chapter Policy Context In December 1998, Building Real Partnership, Compact Between Government and Voluntary and Community Sector in Northern Ireland (DHSSPS, 1998) was published, which formally acknowledged the voluntary and community sector as key partners in the delivery of Government objectives. In April 2003, Government published the final draft of Partners for Change, which details how Government departments will put the Compact into practice. This report is monitored annually, and its first Monitoring Report which was released in January 2004 indicates that during 2004, the Voluntary and Community Unit will `develop a Good Practice Guide on Partnership. Shortly before the Northern Ireland Assembly was suspended, the Northern Ireland Executive issued its Draft Programme for Government 2003/2004 (September 2002) which states its support for partnership working between the public sector and social partners in business, the trade unions and the voluntary and community sector (OFMDFM, 2002). It also states the Government s position in providing opportunities for the various partners to influence thinking on policy development and work with the Government in the delivery of policies and programmes. Direct Rule Administration adopted Programme for Government and recently produced a Priorities and Budget for , which recognises the importance of planning and partnership at a local level and emphasises its commitment to working in partnership. It explains how it will continue to support and facilitate better partnership working with the community and voluntary sector by creating an enabling environment for the sector s medium and long term sustainability. This takes account of the recommendations from the

11 Task Force Report on Resourcing the Voluntary and Community Sector: Pathways for Change (Department for Social Development, December 2003) and Partners for Change: Government s Strategy for Support of the Voluntary and Community Sector (Department for Social Development, March 2003). Investing for Health (2002) the cross-departmental public health strategy for Northern Ireland, highlights that partnerships and joined up working with a wide range of stakeholders from the public, private, voluntary and community sectors is crucial in improving the state of our health and in achieving targets set in the policy document. It emphasises the importance of building on the experience of existing partners and highlights the importance of developing the capacity of partners which involves raising awareness of the determinants of health as well as developing skills in collaborative working. Examples of initiatives which are very much based on partnership working include: Healthy Cities, Healthy Living Centres, Sure Start, Health Action Zones, Community Safety Partnerships, Local Strategic Partnerships, Area Partnership Boards, Investing for Health Partnerships, Local Health and Social Care Groups, Childcare Partnerships and at a Government department level the Ministerial Group on Public Health Tools/Frameworks In this section two toolkits for assessing partnership working are outlined as well as a framework for building successful partnerships. 2.3a: Assessing Strategic Partnership The Partnership Assessment Tool 2.3b: The Working Partnership Tool 2.3c: A Framework for Building Successful Partnerships

12 Tools for Action Equity in Health - Tackling Inequalities 2.3a: Assessing Strategic Partnership The first toolkit Assessing Strategic Partnership The Partnership Assessment Tool was developed in 2003 by Nuffield Institute for Health on behalf of the Office of the Deputy Prime Minister in England. The assessment tool is based on six partnership principles which are seen as essential for successful partnerships. These include: Recognising and accepting the need for partnership Developing clarity and realism of purpose Ensuring commitment and ownership Developing and maintaining trust Creating clear and robust partnership arrangements Monitoring, measuring and learning The purpose of the tool is to assess the views of the partners based on these principles, facilitate shared learning and highlight areas of conflict which can be explored further to provide the opportunity to develop more effective working. 11 Four stages are outlined in the tool: Stage 1: Preparation This involves agreeing the purpose of the exercise, and deciding how the exercise will be facilitated and actioned. Stage 2: Undertaking the Assessment Partners will be made familiar with the assessment material and complete the rapid partnership appraisal sheets. This involves scoring their level of agreement/disagreement with a number of statements (see table 1) relating to the principles (and principal elements) outlined above.

13 Stage 3: Analysis and Feedback During this stage, individual responses will be analysed by firstly adding up the scores given to each of the appraisal sheets and from this assessing whether the partnership is working well or not. This information is then fed back to the partners, allowing time to share, discuss, interpret the findings and agree the next steps. Stage 4: Action Planning for Alternative Findings This stage depends on the results of stage 3. If the partnership is assessed as working well (score of between 19-24) the partners may only need to set a timescale for future regular reviews. If the assessment shows there is concern in relation to some elements of the partnership (score between 13-18) then a decision needs to be made of how to address these concerns. If there are significant areas of concern (realised by a score of 12 or less) then a detailed plan of action needs to be formed by the partners (see below for the scoring grid). Scoring Grid Put total score for each principle in appropriate segement below and shade in that segment. 12 A B C 7-12 D 6 Principle 6 D C B A Principle 1 5 Principle Principle 2 4 Principle A B C D 3 Principle AGGREGATE PROFILE SCORE = (Total of all six principles) Date:...

14 Tools for Action Equity in Health - Tackling Inequalities 13 The six partnership principles, including the elements of the principles, and the rapid appraisal sheet to be completed during the assessment, are as follows: Principle 1: Recognising and Accepting the Need for Partnership Elements: Identifying principal partnership achievements Identifying the factors associated with successful partnership working Identifying the principal barriers to partnership working Acknowledging whether the policy context creates voluntary, coerced or mandatory partnership working Acknowledging the extent of partners interdependence to achieve some of their goals Acknowledging areas in which you are not dependent upon others to achieve your goals.

15 Table 1: Rapid Appraisal Sheet for Principle 1 (Recognising and Accepting the Need for Partnership) To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? Strongly agree Agree Disagree Strongly disagree Comments There have been substantial past achievements within the partnership The factors associated with successful working are known and understood The principal barriers to successful partnership working are known and understood The extent to which partners engage in partnership working voluntarily or under pressure/mandation is recognised and understood 14 There is clear understanding of partners interdependence in achieving some of their goals There is mutual understanding of those areas of activity where partners can achieve some goals by working independently of each other Scores Scoring Key: Strongly Agree 4; Agree 3; Disagree 2; Strongly Disagree 1

16 Tools for Action Equity in Health - Tackling Inequalities Principle 2: Developing Clarity and Realism of Purpose Elements: Ensuring that the partnership is built on shared vision, shared values and agreed service principles Defining clear joint aims and objectives Ensuring joint aims and objectives are realistic Ensuring that the partnership has defined clear service outcomes Partners reasons for engaging in the partnership are understood and accepted Focus partnership effort on areas of likely success 15

17 Table 2: Rapid Appraisal Sheet for Principle 2 (Developing clarity and realism of purpose) To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? Strongly agree Agree Disagree Strongly disagree Comments Our partnership has a clear vision, shared values and agreed service principles We have clearly defined joint aims and objectives These joint aims and objectives are realistic The partnership has defined clear service outcomes 16 The reason why each partner is engaged in the partnership is understood and accepted We have identified where early partnership success is most likely Scores Scoring Key: Strongly Agree 4; Agree 3; Disagree 2; Strongly Disagree 1

18 Tools for Action Equity in Health - Tackling Inequalities Principle 3: Ensuring Commitment and Ownership Elements: Ensuring appropriate seniority of commitment Securing widespread ownership within and outside partner organisations Ensuring sufficient consistency of commitment Recognising and encouraging individuals with networking skills Ensuring that partnership working is not dependent for success solely upon these individuals Rewarding partnership working and discouraging and dealing with those not working in partnership 17

19 Table 3: Rapid Appraisal Sheet for Principle 3 (Ensuring commitment and ownership) To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? Strongly agree Agree Disagree Strongly disagree Comments There is a clear commitment to partnership working from the most senior levels of each partnership organisation There is widespread ownership of the partnership across and within all partners Commitment to partnership working is sufficiently robust to withstand most threats to its working The partnership recognises and encourages networking skills 18 The partnership is not dependent for its success solely upon individuals with these skills Not working in partnership is discouraged and dealt with Scores Scoring Key: Strongly Agree 4; Agree 3; Disagree 2; Strongly Disagree 1

20 Tools for Action Equity in Health - Tackling Inequalities Principle 4: Developing and Maintaining Trust Elements: Ensuring each partner s contribution is equally recognised and valued Ensuring fairness in the conduct of the partnership Ensuring fairness in distribution of partnership benefits Ensuring the partnership is able to sustain a sufficient level of trust to survive external problems which create mistrust elsewhere Trust built up within partnerships needs to be high enough to encourage significant risk taking Ensuring that the right people are in the right place at the right time 19

21 Table 4: Rapid Appraisal Sheet for Principle 4 (Developing and maintaining trust) To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? Strongly agree Agree Disagree Strongly disagree Comments The way the partnership is structured recognises and values each partner s contribution The way the partnership s work is conducted appropriately recognises each partner s contribution Benefits derived from the partnership are fairly distributed among all partners There is sufficient trust within the partnership to survive any mistrust that arises elsewhere 20 Levels of trust within the partnership are high enough to encourage significant risk-taking The partnership has succeeded in having the right people in the right place at the right time to promote partnership working Scores Scoring Key: Strongly Agree 4; Agree 3; Disagree 2; Strongly Disagree 1

22 Tools for Action Equity in Health - Tackling Inequalities Principle 5: Creating Clear and Robust Partnership Arrangements Elements: Transparency in the financial resources each partner brings to the partnership Awareness and appreciation of the non-financial resources each partner brings to the partnership Distinguishing single from collective responsibilities and ensuring they are clear and understood Ensuring clear lines of accountability for partnership performance Developing operational partnership arrangements which are simple, time-limiting and task oriented Ensuring the prime focus is on process, outcomes and innovation 21

23 Table 5: Rapid Appraisal Sheet for Principle 5 (Creating clear and robust partnership arrangements) To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? Strongly agree Agree Disagree Strongly disagree Comments It is clear what financial resources each partner brings to the partnership The resources, other than finance, each partner brings to the partnership are understood and appreciated Each partner s areas of responsibility are clear and understood There are clear lines of accountability for the performance of the partnership as a whole 22 Operational partnership arrangements are simple, time-limited and task oriented The partnership s principal focus is on process, outcomes and innovation Scores Scoring Key: Strongly Agree 4; Agree 3; Disagree 2; Strongly Disagree 1

24 Tools for Action Equity in Health - Tackling Inequalities Principle 6: Monitoring, Measuring and Learning Elements: Arranging a range of success criteria Developing arrangements for monitoring and reviewing how well the partnerships service aims and objectives are being met Developing arrangements for monitoring and reviewing how effectively the partnership itself is working Ensuring widespread dissemination of monitoring and reviewing findings amongst partners Celebrating and publicising partnership success and root out continuing barriers Reconsider/revise partnership aims, objectives and arrangements 23

25 Table 6: Rapid Appraisal Sheet for Principle 6 (Monitor, Measure and Learn) To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? Strongly agree Agree Disagree Strongly disagree Comments The partnership has clear success criteria in terms of both service goals and the partnership itself The partnership has clear arrangements effectively to monitor and review how successfully its service aims and objectives are being met There are clear arrangements effectively to monitor and review how the partnership itself is working There are clear arrangements to ensure that monitoring and review findings are, or will be, widely shared and disseminated amongst the partners 24 Partnership successes are well communicated outside of the partnership There are clear arrangements to ensure that partnership aims, objectives and working arrangements are reconsidered and, where necessary, revised in the light of monitoring and review findings Scores Scoring Key: Strongly Agree 4; Agree 3; Disagree 2; Strongly Disagree 1

26 Tools for Action Equity in Health - Tackling Inequalities 25 This toolkit outlines a very clear process and robust principles to aid discussion on the success of the partnership and encourages further thinking into the development of more effective working. Further information on how to access the full document detailing the tool can be found at the end of this chapter. 2.3b: The Working Partnership Tool The second toolkit The Working Partnership was developed in 2003 by the Health Development Agency (HDA) which is a National Health Service (NHS) special health authority, established to support and enhance national efforts to improve health in England. The Working Partnership can be used to assess performance of partnership working and develop areas for improvement, and is a resource for people whose job is to support partnership development and improve the quality of partnership working. It is a reconfiguration of another assessment tool called the Verona Benchmark which was produced by World Health Organisation in 1998 to enable partnerships to assess their progress against evidence-based criteria. The Working Partnership is made up of six key elements which are seen as factors that make partnerships more effective. The HDA chose these elements based on evidence produced by the Audit Commission (1998), Geddes (1998) and Pratt et al (1998). The six key elements include: Leadership Organisation Strategy Learning Resources Programmes The Assessment Process Partnerships can use this assessment toolkit to perform either a short or a more in-depth assessment process.

27 Short Assessment The short process allows partnerships to assess themselves by answering six to eight key questions for each of the six elements. The Working Partnership document describes what each element means, what is important to look for during the assessment process and a template for partners to complete. Findings from the assessment should be reviewed to identify strengths and areas for improvement and then develop a shared action plan which can be monitored and reviewed through time. This continuous improvement cycle can enable the partnership to build shared ownership and commitment to partnership activities, recognise and share good practice, and develop measures for keeping track of progress over time (HDA, 2003). The following section describes the six elements of good practice in partnership working, which is further broken down into 3-4 sections, and the short assessment templates outlining the assessment questions that can be used to demonstrate performance and delivery at different levels. The in-depth assessment tool is a longer and more detailed process and therefore is not outlined in this report but is available on the HDA website ( The in-depth assessment tool is recommended for reviews of partnerships which are investing significantly in assessment. 26 Short Assessment Templates As part of the short assessment process partners would complete the following templates under each of the six elements. It is implied within the document that the process of answering the questions in the templates takes the form of group discussion.

28 Tools for Action Equity in Health - Tackling Inequalities The Working Partnership - Element 1: Leadership effective leadership involves attention to: Developing and communicating a shared vision Embodying and promoting ownership of and commitment to the partnership and its goals Being alert to factors and relationships in the external environment that might affect the partnership 27

29 Table 1: Short Assessment Template for Key Element 1 - Leadership Action Undertaken Leadership Key Areas None Limited Action Planning Satisfactory Comments (Ideas for Action) Date* Vision A: Does the partnership have adequate representatives from all partner agencies? B: Do partnership working methods take account of the different perspectives and contributions of all partners? Commitment C: Has the overall level of resources available to the partnership been agreed? D: Is there clarity about how constitutional and other key decisions are reached within the partnership? Relationships E: Is the partnership aware of other local or regional partnerships that address similar issues or target populations? F: Is the partnership aware of the communication and decisionmaking procedures of other partner organisations? *For Action/review 28

30 Tools for Action Equity in Health - Tackling Inequalities The Working Partnership Element 2: Organisation clear and effective systems are needed for: Public participation in partnership processes and decision-making Flexibility in working arrangements Transparent and effective management of the partnership Communication in ways and at times that can be easily understood, interpreted and acted on 29

31 Table 2: Short Assessment Template for Key Element 2 - Organisation Action Undertaken Organisation Key Areas None Limited Action Planning Satisfactory Comments (Ideas for Action) Date* Participation A: Does the partnership monitor community and voluntary sector participation in its processes? B: Does the partnership offer opportunities for partners to develop participatory skills in working with community representatives? Flexibility C: Are working practices flexible enough to enable effective participation by all key players? D: Does the partnership fund participation in partnership meetings and other activities by community group and voluntary sector members? Management E: Does the partnership have clear operating procedures and terms of reference? F: Can all partners freely express their own interests and needs, even when they differ from those of others? Communication G: Have responsibilities for communication been assigned within the partnership and partner organisations? H: Does the partnership make reports and presentations easily accessible for users? *For Action/review 30

32 Tools for Action Equity in Health - Tackling Inequalities The Working Partnership Element 3: Strategy the partnership needs to implement its mission and vision via a clear strategy informed by local communities and other stakeholders which focuses on: Strategic development to agree priorities and define outcome targets Sharing information and evaluation of progress and achievements A continuous process of action and review 31

33 Table 3: Short Assessment Template for Key Element 3 - Strategy Action Undertaken Strategy Key Areas None Limited Action Planning Satisfactory Comments (Ideas for Action) Date* Strategic Development A: Does the partnership identify and prioritise local concerns? B: Do the partnership s plans link with partner organisations policies and strategies? Information and Evaluation C: Do partner organisations have the capacity to undertake evaluation to help monitor progress? D: Does evaluation activity assess shared outcomes as well as individual organisational targets? Action and Review E: Does the partnership meet regularly to review its processes and achievements? F: Are partnership policy and strategy modified in line with findings from review processes? *For Action/review 32

34 Tools for Action Equity in Health - Tackling Inequalities The Working Partnership Element 4: Learning partner organisations need to attract, manage and develop people to release their full knowledge and potential by: Valuing people as a primary resource and supporting innovation Development and application of knowledge and skills 33

35 Table 4: Short Assessment Template for Key Element 4 - Learning Action Undertaken Learning Key Areas None Limited Action Planning Satisfactory Comments (Ideas for Action) Date* Valuing People A: Does the partnership have a human resources policy agreed by all partner organisations? B: Does the partnership have access to multi-disciplinary training in partnership skills? Knowledge and Skills C: Have partnership representatives identified the knowledge and skills they bring to the partnership? D: Are the interests, skills and strengths of staff taken into consideration by the partnership when tasks are assigned? Innovation E: Are mechanisms in place to ensure sharing of good practice between partner organisations? F: Are members in partner organisations encouraged to innovate and develop their roles in working for and with local communities? *For Action/review 34

36 Tools for Action Equity in Health - Tackling Inequalities The Working Partnership Element 5: Resources the contribution and shared utilisation of resources, including: Building and strengthening social capital Managing and pooling financial resources Making information work Using information and communication technology appropriately 35

37 Table 5: Short Assessment Template for Key Element 5 - Resources Action Undertaken Resources Key Areas None Limited Action Planning Satisfactory Comments (Ideas for Action) Date* Social Capital A: Can community representatives influence partnership decisions that affect their community? B: Has the partnership developed appropriate relationships with other relevant networks and partnerships? Financial Resources C: Does the partnership review the financial contributions to partnership work made by partner organisations? D: Are some aspects of the partnership s work funded through pooled budgets? Information E: Does the partnership have a clearly defined and agreed information and knowledge management policy? F: Do partner organisations have a shared information profile? Technology G: Do partner organisations have a common policy and strategy for the introduction of new information technology? H: Have partner organisations attempted to integrate electronic information systems? *For Action/review 36

38 Tools for Action Equity in Health - Tackling Inequalities The Working Partnership Element 6: Programmes partners seek to develop coordinated programmes and integrated services that fit together well. This requires attention to: Realising added value from joint planning Focused delivery Regular monitoring and review 37

39 Table 6: Short Assessment Template for Key Element 6 - Programmes Action Undertaken Programmes Key Areas None Limited Action Planning Satisfactory Comments (Ideas for Action) Date* Planning A: Are the priorities selected by the partnership based on the principle of reducing inequalities? B: Are appropriate participatory methods used to stimulate active community engagement in planning? Delivery C: Does the partnership identify the specific tasks and actions required to implement its programmes? D: Are clear lead roles agreed for taking forward partnership actions? Monitoring E: Are short-term impacts and long-term outcome targets identified and measured for all programmes? F: Is the partnership effectively monitoring the development, attainment and performance of its programmes? *For Action/review 38

40 Tools for Action Equity in Health - Tackling Inequalities 39 In-Depth Assessment An in-depth assessment process can be performed by the partnership. This is a similar process to the short assessment and involves partners answering a series of questions, ranging from 13 to 27 questions, for each element. Partners may choose only to complete an in-depth assessment on one of the elements rather than all six after they have completed the short assessment and have identified an area which needs further examination. If the partners decide to complete an in-depth assessment on all six elements, the HDA suggest that a specific assessment team is set up to facilitate this comprehensive assessment. Within the in-depth assessment booklet produced by the HDA a number of ideas for action in terms of early/further steps and examples of good practice are listed. The in-depth assessment templates differ slightly from the short assessment templates, the difference being the addition of a scoring system between 0-5 given to each of the questions listed which vary between 13 and 27 questions. Conclusion The Working Partnership is a good example of an assessment tool which is adaptable by giving the choice between a short or a more indepth assessment depending on the timescale available, resources and the depth of assessment required. It provides clear and concise information and documentation needed for an assessment, and goes one step further by providing ideas for action for partnerships of how to assess and improve current partnership working and practice. The full document can be downloaded from the HDA website (

41 2.3c: A Framework for Building Successful Partnerships The Workers Educational Association for Northern Ireland currently run a training course called Building Successful Partnerships and have developed a pack under the same title which can be used by partnerships to enhance their effectiveness. During the developmental stages of this pack research was completed to inform the process. Key findings which were identified as impacting on partnership building are as follows: Working Interdependently - trust is central to partnership working. Time and resources should be allocated to allow partners to get to know more about each other, their organisation, and sectors. Visioning, Planning and Review - it is important to identify and involve all the key stakeholders in the process. Those leading partnerships need to clarify a common vision, values and objectives from the beginning, and the use of skilled facilitators can aid this process. On review of partnership progress, it is important to evaluate the quality of the process used, the relationships built as well as outcomes achieved. Structures: creating the right structure for a partnership is essential. This involves establishing procedures and systems to allow agreement and documentation of aims, performance indicators and evaluation processes, as well as ensuring the partnership is made up of a wide range of stakeholders. 40 Meetings: these need to be well facilitated by a chair who ensures everyone can have their voices heard. The chair will also need to be skilled in dealing with controversy and conflict. Decision Making: power imbalances should be acknowledged and where possible minimised. A transparent decision making process as well as an independent chair can help in this process. Members Development: Induction processes for new members can assist them in quickly becoming effective partners resources should be set aside to facilitate this. Equality Issues: it is important to address potential barriers to participation for instance, by avoiding the use of jargon, having a neutral venue which is accessible, meeting child-care needs and ensuring access to interpretation/signing where appropriate. It is also necessary to have a balance of skills in a partnership which are valued equally. Staffing: where staff members are employed within the partnership it is important to have clear line management systems in place, a good working relationship with the chair and opportunities for peer support.

42 Tools for Action Equity in Health - Tackling Inequalities 2.4 Experiences of Partnership Working Within this section the views of participants on the Equity in Health Programme are outlined, as well as lessons learnt in the practical application of partnership working from both the experiences of Belfast Healthy Cities and Healthy Cities in Europe. Equity in Health Programme (2002/03) Workshop activity during the Equity in Health training days provided the following collated responses from participants on the programme in relation to the successes, benefits and challenges of partnership working that they have experienced. Successes of Partnership Working 41 Partnership working: Influenced policy development and change with the organisation Closed gaps and improved service provision, providing a seamless service across organisations Re-orientated services towards priority issues of need Facilitated the pooling of resources and access to new resources Developed joined up planning Widened organisational vision Resulted in a sustained partnership Achieved objectives set Allowed for greater appreciation of joined up working Developed knowledge and skills Helped gain recognition of the vital contribution from a range of partners and sectors Encouraged partnership working practice to become mainstreamed within organisations Maximised organisation s strengths Provided a vehicle to put health on the agenda of other agencies

43 Benefits of partnership working Partnership working can: Facilitate integrated planning and better coordination of services, potentially leading to projects having a greater impact Create an opportunity to influence policy Provide a good opportunity to try new initiatives Optimise use of resources by pooling resources Avoid duplication of service provision Make connections with other partners for ongoing work Allow for the sharing of information, experience, knowledge and skills as well as the development of a shared vision Provide solutions to problems that one agency alone may not be able to achieve Facilitate reflective thinking Provide an opportunity to network with others Challenges of partnership working Challenges include: Maintaining sustainability Securing resources Making the move from project work to core business Keeping things realistic Ensuring outcomes are driven by partnerships rather than by funding Finding a common agenda and common ground Maintaining a power balance and moving beyond tokenism Creating a collective environment which values all contributions Tackling resistance to change Ensuring that all partners are clear about their role and contribution and that the organisation the person represents is committed to the partnership Involving all stakeholders, keeping people involved and sharing responsibilities Keeping champions Overcoming cultural/organisational/procedural difficulties and barriers between partners Maintaining enthusiasm and commitment to the work of the partnership 42

44 Tools for Action Equity in Health - Tackling Inequalities Belfast Healthy Cities Experience: An Integrated Approach to Health Planning In February 2002 Belfast Healthy Cities published Planning for a Healthy City which outlines the city health development planning process and sets out strategies and areas for action by Belfast Healthy Cities partners within the city. Part of the process involved establishing strategic planning groups to develop the plans and actions outlined in the publication. 43 Some of the challenges in developing integrated plans for health include: Ensuring the whole group gets recognition for the work undertaken and not just the organisation that leads each action point Agreeing the sharing of resources Finding a way to enhance the capacity of all partner organisations, especially those with limited experience of intersectoral working Securing and maintaining top level agreement to the integrated planning process Ensuring autonomy is given by Chief Executives/Permanent Secretaries to representatives of organisations on planning groups to make decisions and agree action Ensuring all parties are aware of the time commitment necessary for partnership working and that representatives are allocated time within their work schedule to carry out the role effectively Maintaining momentum and commitment throughout the process Recognition by all parties that partnership working and integrated planning is often a long process and may not resolve problems quickly Setting realistic timeframes for both the induction of intersectoral groups and for the completion of intersectoral programmes Securing resources to implement action plans. This is often due to the fact that there is no specific budget allocated by organisations to such development. Sourcing resources which target topics that are not specifically government or public sector targets but rather are topics of community interest

45 Working with organisations with very different organisational cultures Establishing structures to provide opportunities for consistent intersectoral communication Establishing structures to provide opportunities for obtaining new skills e.g. training opportunities Encouraging participation by organisations whose main area of work is not directly linked with promoting health Lessons Learnt from Healthy Cities in Europe In the review of 15 years of the Healthy Cities movement, factors that Healthy Cities highlighted as leading to their success over the years included: A supportive political environment e.g. from Chief Executives, politicians, and local government Community participation, especially in the development of the city health plan Achievement in relation to partnership working, based on the experience that success breeds success Committed healthy city staff who were dedicated, creative, competent and enthusiastic Common goals and interests identified with the partners which enhanced cooperation and resource sharing The value of partnership working for health being endorsed by regional government policies Being a member of the WHO network was also seen as important factor for success which has been a catalyst in sustaining enthusiasm; providing vision, motivation, assessment and tools to use; sharing of information, knowledge and skills between cities; and being part of the network was seen as being an important political lever in reaching and influencing top level decisions. 44 Healthy Cities highlighted that while working in partnership, it is necessary to secure that all partners are visible and receive a fair share of acknowledgement for their contribution.

46 Tools for Action Equity in Health - Tackling Inequalities 45 References Audit Commission (1998) A Fruitful Partnership, Audit Commission, London Department of Health, Social Services and Public Safety (DHSSPS) (1998) Building Real Partnership, Compact between Government and the Voluntary and Community Sector in Northern Ireland Department for Social Development (2003) Pathways for Change, A Position Paper by the Task Force on Resourcing the Voluntary and Community Sector, December Department for Social Development (2003) Partners for Change, Government s Strategy for Support of the Voluntary and Community Sector , March Department for Social Development (2004) Monitoring Report for Partners for Change, Government s Strategy for Support of the Voluntary and Community Sector Department of Health, Social Services and Public Safety (2002) Investing in Health, March Geddes M (1998) Achieving Best Value Through Partnership, Best Value Series No.7, University of Warwick, London Northern Ireland Office (2004) Northern Ireland Priorities and Budget OFMDFM (September 2002) Northern Ireland Executive Draft Programme for Government Office of the Deputy Prime Minister, UK (2003) Assessing Strategic Partnership The Partnership Assessment Tool documents/page/odpm_locgov_ pdf or contact the Strategic Partnering Taskforce on telephone number Pratt J, Plamping D, and Gordon P (1998) Partnership: Fit for Purpose?, King s Fund, London Health Development Agency (2002) The Working Partnership, Workers Educational Association (2000) Building Successful Partnerships Research Support Materials

47 Other Suggested Reading Funnell R, Oldfield K, and Speller V, (1995) Towards Healthier Alliances - A Tool for Planning, Evaluating and Developing Healthy Alliances, Health Education Authority, Wessex Institute of Public Health Medicine Partnership Framework A Model for Partnerships for Health, Institute of Public Health in Ireland, January 2001, Governance in Partnerships Checklist of Good Practice, Department of Health, UK, 2001, (not available on-line) Information network for regeneration partnerships, Making the net Work and Partnerships Ltd these 2 organisations aims to help other organisations, networks or neighbourhoods plan and use the net effectively, and 46

48 Tools for Action Equity in Health - Tackling Inequalities 3. Community Participation 47 A process by which people are enabled to become actively and genuinely involved in defining the issues of concern to them, in making decisions about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change WHO (2002)

49 3.1 Introduction The term community can be defined as a group of people who share an interest, a neighbourhood, or a common set of circumstances (Smithies and Webster, 1998). WHO have defined community participation as A process by which people are enabled to become actively and genuinely involved in defining the issues of concern to them, in making decisions about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change (WHO, 2002). Within this chapter five different tools/frameworks will be outlined which may be helpful in assessing the level to which the community participates in organisational plans as well as providing tools to empower the community and encourage participation. 3.2 Policy Context The Healthy Cities Network has promoted community participation since it was established in Community development approaches are commonly used to promote community participation. For many years now Government has endorsed the importance and relevance of community development approaches. Pathways for Change (2003), the position paper produced by the Voluntary and Community Unit (VCU) within the Department for Social Development (DSD) highlights the important part voluntary and community action plays in civic society by encouraging active participation by individuals and groups in decisions that affect their lives, enhancing quality of life and encouraging people to work together to solve common problems. 48 The more recent report of the task force on resourcing the voluntary and community sector, Investing Together, suggests that long-term stable funding should be made available for the support of local community development activity and that additional resources of 25m per year, in the form of a community investment fund, should be established for the support of this activity (Voluntary and Community Unit, Department for Social Development, 2004).

50 Tools for Action Equity in Health - Tackling Inequalities 49 The Northern Ireland Executive s Programme for Government acknowledges the significant and crucial contribution the voluntary and community sectors make to society and reinforce their commitment to sustaining the work of these sectors within Building on Progress, Priorties and Plans for Investing for Health, the regional public health strategy for Northern Ireland, states that community involvement is crucial to the future success of the strategy. It also indicates that individuals must be able to contribute directly to the development of policies and programmes that influence their health and that capacity must be built within the community for all groups to be able to do this (DHSSPS, 2002). A twenty-year vision for health and well-being in Northern Ireland is currently being developed by the DHSSPS and it is anticipated that a section within this strategy will focus on engaging with people and the development of an integrated policy for public engagement. In relation to community development work, the twenty-year strategy proposes to build on existing policy i.e. Mainstreaming Community Development in the Health and Personal Social Services (1999). This latter document identifies examples of good practice in community development approaches, covers monitoring and evaluation of community development and sets out 18 recommendations to give advice on the means by which the Department, Health Boards and Trusts should further promote and employ community development approaches. The twenty-year strategy also aims to make the current Investing for Health strategy its central plank for implementation. 3.3 Tools/Frameworks In this section the following five tools/frameworks will be outlined: 3.3a: A Tool for Consultation 3.3b: A Tool for Participation The Ladder of Participation 3.3c: Wheel of Participation 3.3d: Community Empowerment Planning Framework 3.3e: WHO Tools for Participation

51 3.3a: A Tool for Consultation In 2001 the Office of the First Minister and Deputy First Minister (OFMDFM) developed guidance for NI public authorities on methods of consultation with the public. The purpose of the guide was to make written consultations more effective, opening up decisionmaking to as wide a range of people and organisations as possible. Within the document 7 criteria are identified as being important to consider during consultations. Criteria 1) Timing and resourcing: Timing and resourcing of consultation should be built into the planning process for a policy (including legislation) or service from the start, so that it has the best prospect of improving the proposals concerned, and in order that sufficient time is allowed at each stage. Criteria 2) Clarity: It should be clear who is being consulted, about what issues/questions, in what timescale and for what purpose. Criteria 3) Simplicity: A consultation document should be as simple and concise as possible. It should include a summary, in two pages at most, of the main issues/questions it seeks views on. It should make it as easy as possible for readers to respond, make contact or complain. 50 Criteria 4) Availability and accessibility: Documents should be made widely available, with the fullest use of electronic means (though not to the exclusion of others), and effectively drawn to the attention of all interested groups and individuals. It should also state that the document is available on request in accessible formats and these should be listed. Criteria 5) Timing for responses: Sufficient time should be allowed for considered responses from all groups with an interest. Twelve weeks should be the standard period for a consultation with eight weeks being the minimum. Criteria 6) Analysis of responses: Responses should be carefully and openmindedly analysed, and the results made widely available, with an account of the views expressed, and reasons for decisions finally taken. Criteria 7) Monitoring and evaluation: Public Authorities should monitor and evaluate consultations. They should designate a consultation co-ordinator who will ensure that the central consultation website is up to date.

52 Tools for Action Equity in Health - Tackling Inequalities 3.3b: A Tool for Participation The Ladder of Participation There are many levels at which organisations can consult with the community. The Ladder of Participation (Brager and Specht, 1973) illustrates how these levels have been promoted in community development and health approaches for a number of years. Organisations should strive to achieve a high level of community control where possible. Ladder of Participation Control Participant s Action Examples High Has control Organisation asks community to identify the problem and make all key decisions on goals and means. Willing to help community at each step to accomplish goals. 51 Has delegated authority Plans jointly Advises Is consulted Receives information None Organisation identifies and presents a problem to the community. Defines limits and asks community to make a series of decisions which can be embodied in a plan which it will accept. Organisation presents tentative plan subject to change and open to change from those affected. Expects to change plan at least slightly and perhaps more subsequently. Organisation presents a plan and invites questions. Prepared to change plan only if absolutely necessary. Organisation tries to promote a plan. Seeks to develop support to facilitate acceptance or give sufficient sanction to plan so that administrative compliance can be expected. Organisation makes plan and announces it. Community is convened for informational purposes. Compliance is expected. Community told nothing. Low (Source: adapted from Brager and Specht, 1973)

53 Some organisations are still working solely at the bottom half of the ladder rather than seriously aiming to achieve higher. High level control, however, is not always possible or appropriate. Tsouros and Farrington (2003) suggest that different political, social, economic and organisational contexts may create different conditions, offering different opportunities and constraints. 3.3c: Wheel of Participation The Wheel of Participation was developed by Davidson (1998) in recognition of the previously mentioned constraints. It was developed to assist community planning and encourage innovative practice. It distinguishes objectives and techniques under the four quadrants of empowerment, information, participation and consultation. South Lanarkshire Community Partners also use this wheel of participation within their community plan and suggest that the skills used at the early stages of the wheel are built upon and are essential foundations to the success of stages elsewhere on the wheel, for example good quality information is an integral part of a successful participation approach (South Lanarkshire Community Partners, 2004). 52 Wheel of Participation INDEPENDANT CONTROL EMPOWERMENT ENTRUSTED CONTROL MINIMAL COMMUNICATION INFORMATION LIMITED INFORMATION DELEGATE CONTROL GOOD QUALITY INFORMATION LIMITED DECENTRALISED DECISION MAKING LIMITED CONSULTATION PARTICIPATION PARTNERSHIP EFFECTIVE ADVISORY BODY GENERAL CONSULTATION CUSTOMER CARE CONSULTATION (source:

54 Tools for Action Equity in Health - Tackling Inequalities d: Community Empowerment Planning Framework The development of programmes to improve the health and well-being of the population often take either a bottom-up or top-down approach similar to the ladder of participation outlined in 3.3b. Laverack and Labonte (2000) have produced a framework that organisations can use to help them include the issues and concerns of the community as well as community empowerment goals, whilst using a top-down approach to programme development. Five stages are outlined in this framework. Stage 1: Overall Programme Design Using strategic and participatory planning approaches which encourage the involvement of the community from the very beginning can make this stage more empowering. Relationships can be built up with the community and resources made available to build capacity depending on needs identified. Programme planners need to take into consideration the additional time that needs to be allocated to ensure the above is realistically achieved and that the programme size to ensure the production of short term visible successes before moving on to complex initiatives. Attention should be given to how the programme will meet the needs of marginalized groups/community. Stage 2: Objective Setting Objectives should be set which reflect how the programme will empower the community, for example, objectives relating to the quality of participation, and the extent to which the community has decisionmaking authority within programme planning and implementation. Stage 3: Strategy Selection A wide range of strategies can be used within programmes to achieve the objectives set. Examples include training, information giving, awareness raising campaigns and so forth. Labonte (1990) suggests that the process of community empowerment involves 5 elements: a) Empowerment b) Development of small mutual groups c) Development or strengthening of community organisations d) Development or strengthening of inter-organizational networks e) Political action

55 Strategies should be chosen which will empower the community at these different levels. Stage 4: Strategy Implementation and Management It is important to assess progress and success of community empowerment interventions during implementation of the programme. For instance does the programme: improve stakeholder participation increase problem assessment capacities develop local leadership build empowering organisational structures improve resource mobilisation strengthen stakeholder ability to ask why increase stakeholder control over programme management create an equitable relationship with outside agents. Stage 5: Programme Evaluation Evaluation methods should be chosen which actively involve the community. Empowerment outcomes could be determined by the community themselves at the programme planning stage and used to evaluate progress during and at the end of the programme. Adequate time and resources need to be given to evaluation to make it meaningful. 54 This framework can help organisations build community empowerment from the beginning into programmes aimed at improving the health and well-being of the community they serve. Further information on this framework can be found at:

56 Tools for Action Equity in Health - Tackling Inequalities Community Empowerment Planning Framework (Labonte, 2000) 1. Programme design phase Empowerment characteristics How has the programme design taken into - time consideration the empowerment - size characteristics? - Attention to marginalised Identification Appraisal Approval Programme track Empowerment track 2. Programme objectives How are the programme objectives and community empowerment objectives accommodated together within the programme? Objectives Community empowerment objectives Level of control and choice over health and life decisions Strategic approach How does the strategic approach of the programme link and strengthen the strategic approach for community empowerment? Strategy Strategic approach Individual empowerment small groups organisations networks social and political action 4. Implementation How does the implementation of the programme achieve positive and planned changes in the operational domains? Management Operational domains Planned and positive changes in the operational domains: participation, organisational structures, links with others, resource mobilization, leadership, outside agents, programme management, asking why, problem assessment 5. Evaluation of the programme outcomes How is the programme evaluation appropriate for community empowerment? Evaluation Evaluation of the community empowerment outcomes Participatory evaluation techniques used for community empowerment

57 3.3e: WHO Tools for Community Participation Community participation is a challenging process and one that needs commitment to perform effectively. There are many methods or tools which can be drawn on from community development approaches which can help illustrate how community participation can be facilitated. During 2002, WHO Regional Office for Europe produced a document on community participation approaches and techniques. Within this document tools are categorised under 5 headings: 3.3e.1 Assessing needs and assets 3.3e.2 Agreeing on a vision 3.3e.3 Generating ideas and plans for action 3.3e.4 Enabling action 3.3e.5 Monitoring and evaluation. A selection of tools have been summarised under these 5 headings. 3.3e.1: Assessing Needs and Assets Getting communities involved in assessing their own needs helps all parties gain a greater understanding of the priorities for action, and the capacity within the community to meet these needs. 56 Community profiles are a good method of collecting information to inform decision-making. five main stages are involved in the development of a community profile: Preparation - this involves securing commitment, setting up of an intersectoral steering group, and agreeing aims, objectives, process, timescale and resources. Collection of data - both qualitative and quantitative data should be collected including the opinions and experiences of the community. Information can be categorised under a variety of headings. The following heading were used within a recent community profile developed by Belfast Healthy Cities: health and health behaviour; education; transport; environment; emergency services; employment; health and social services provision; voluntary and community provision. This provides an example of the type of headings that could be used within a community profile which considers the wider determinants of health.

58 Tools for Action Equity in Health - Tackling Inequalities 57 Analysis and interpretation of data - this stage involves the analysis and interpretation of data to help identify community need and resources. It is common to distinguish between needs defined by professionals and those defined by the community and needs compared to another community or service. Presentation of results - results should be presented in a clear, concise, accurate and appropriate way. Using the results - results should be used to inform decisionmaking, assist in planning and construct appropriate responses. 3.3e.2: Agreeing on a Vision One method of enabling stakeholders to agree on a vision for the future is called Future search. This tool can be used with a wide diversity of stakeholders to create a shared vision, and consists of 5 stages. Firstly stakeholders review the past by identifying key events in their history, their community and country using timelines. Secondly stakeholders explore the present using the technique of mind-mapping. Issues and trends affecting the community are identified. Stakeholder groups agree on priority trends and discuss what could be done about them. Views on what they are proud of or sad about in their community are also explored. In the third phase stakeholder groups are mixed and time is spent creating ideal future scenarios as well as identifying barriers. Fourthly the small groups and then the whole group identify a shared vision and explore what projects could help achieve the vision. The last stage involves making action plans and stakeholders give commitment to this action. More information on this tool can be found on 3.3e.3: Generating Ideas and Plans for Action One method of gathering ideas which will feed into the decision making process is the Work Book Method. This method was developed in Norway and involves using two work books. The first is to gather and record opinions of the community on what improvements are needed in their community. Drawing on the information gathered in the first work book a second work book is distributed amongst the community detailing the key issues identified in the first stage of the process and presenting a range of alternative solutions. The community consider and set priorities among these alternatives by filling in the book.

59 3.3e.4: Enabling Action Community networks can act as a vehicle for communities to share experiences and ideas, support and learn from each other, share resources and build bridges between communities. There are four main steps in the creation of a network. 1) Firstly it is important to have the desire for a network and the support of the community as well as political and organisational support from key agencies. 2) The second step involves setting up a planning group to help establish the network and source and secure resources. A first network meeting is arranged often focussing on an issue of concern across a number of communities. 3) To support the further development of the network the group need to agree on action and develop a plan. Agreement also needs to be made on the methods of networking which will be used, for example newsletters, electronic communication, workshops, and the support needed to facilitate these such as workers, office space, training, and additional resources. 4) The network should be focussed on supporting community action at a grassroots level as well as working with policy makers to ensure they are aware of community concerns and needs e.5: Monitoring and Evaluation Monitoring and evaluation is vital to ensure that community participation is both meaningful and effective. Story-dialogue is one way of structuring story-telling to help reflect and learn from practice. It can be used to generate insights which could be used for problem-solving, planning, developing knowledge or evaluation. The first step in the process involves choosing a theme which will generate discussion. A case story is then written which reflects the personal experience of the individual and contains elements of description, explanation and reflection. The case story is then told and the audience reflects on a number of questions which generates structured dialogue. An example of the type of questions that may be asked include: Description: what do we see happening? Explanation: why do you think it happens? Synthesis: so what have we learned? Action: now what can we do? Responses to these questions are then recorded onto insight cards.

60 Tools for Action Equity in Health - Tackling Inequalities Story-dialogue can be used for evaluation purposes by helping form a case study. This occurs when a number of case stories are linked together and other information is added such as participant-observer field notes, reports and minutes - this information may relate to details of the community setting and past experiences of the topic in focus. By joining case stories together this helps create a diversity of views and enables greater insight into the lessons which can be learnt. 3.4 Experiences of Community Participation Equity in Health Programme (2002/03) Workshop activity during the Equity in Health training days provided the following responses from participants on the programme in relation to the key elements for successful community participation that they had experienced. 59 Key elements for successful community participation Honesty in relating to one another Provision of information in a way that everyone can understand Clarity of purpose and setting realistic expectations Acknowledgment of others views and the diversity of these views Secure adequate resources Ensure all stakeholders are involved in the whole process (planning and delivery) making it an inclusive process Provide commitment to act on the results of consultation Demonstrate how views have been taken on board by providing evidence that actions link to issues identified at a consultation level Feedback of results of consultation honesty about what can be acted on A range of methodologies considered Avoid raising unrealistic expectations Address unequal levels of power Share decision making Transparency Continuous communication/information flow - two way communication Facilitate opportunities for dialogue Skilled facilitators Win/win approach Allow for community involvement beyond consultation

61 Key elements for successful community participation (continued) Create a safe environment Leadership which includes vision and commitment to the process Strategic development to agree and define outcomes Identify priorities rather than shopping lists Continuity in building relationships Demonstrate accountability Empowerment and capacity building consider community needs, knowledge and learning Set regular review dates Be open to creativity and change Look and learn from best practice elsewhere Provide information in an understandable way, simple and open Respect the pace of the group and tailor participation to the group s needs Remove physical barriers to participation e.g. using suitable venues Build capacity and training of staff to raise confidence in consulting with community Avoid duplication with other agencies (and other services within own organisation), link up with other agencies to take collaborative approach. Need to agree how different opinions will be taken on board or measured. Include people in developing the consultation process. Be aware of the equality issue in the consultation process. 60 It is a challenging process to take on-board all of the abovementioned key elements for successful community participation; however a rewarding one for those who take it seriously. Many of the key elements highlighted in the table above centre around sharing the power base and being open to suggestions that the community make. Difficulties can arise when the various parties involved differ significantly in their view of what is needed and what is realistic within the resources available. Developing clear and concise terms of reference at the beginning of any partnership work with the community should assist in clarifying many of the factors listed in the table such as expectations, roles/responsibilities, defined objectives/outcomes and so on.

62 Tools for Action Equity in Health - Tackling Inequalities 61 WHO suggest that community participation can strengthen democracy, empower people, mobilise resources and energy, provide opportunities for creative and innovative thinking and decisionmaking and ensure the ownership and sustainability of interventions and programmes (WHO, 2002). With these rewards in mind greater energy should be given to ensuring community participation is a key objective for all sectors. Support for Local Community Development Approaches There is a large number of community and voluntary organizations in Northern Ireland which over the years have become very sophisticated. Two well known examples of bodies/networks which have been set up to support these organizations are the Northern Ireland Council for Voluntary Action (NICVA) and Community Development and Health Network (CDHN). Northern Ireland Council for Voluntary Action (NICVA) NICVA is an umbrella body for voluntary, community and charitable groups in Northern Ireland. They provide over 1000 affiliated members with information, advice and training on a wide range of issues from management consultancy and finance, through to policy development and lobbying. They also represent the interests of over 5000 voluntary and community groups in Northern Ireland through a comprehensive range of services. In their work they adopt a community development approach and attempt to empower local communities to pursue their own needs and agendas (NICVA website, accessed June 2004,

63 Community Development and Health Network (CDHN) CDHN is one example of a network which was set up to support people develop healthier communities. CDHN has 4 strategic aims: To sustain and extend a significant inter-sectoral membership network that is complementary, democratic, member led, active and influential. To provide leadership to promote action on the links between poverty, inequality, community development and health and demonstrate how community development is an appropriate and valid method in support of action on health inequalities. To promote and support creativity, innovation, development, application and understanding of community development and health practice. To sustain and continually develop CDHN as an organisation that both fulfils its responsibilities and delivers its aims efficiently and effectively, offering value for money in ways that contribute to social capital. 62 CDHN understands that a community development approach to health: "recognises the central importance of the social support networks. It is a process by which a community defines its own health needs to bring about change. The emphasis is on collective action to redress inequalities in health and enhance access to health care." (source: CDHN website, accessed June 2004,

64 Tools for Action Equity in Health - Tackling Inequalities 63 Issues Affecting the Success of Participatory Approaches The Health Development Agency in 1998 completed research into how community participation could improve health. This research took the form of workshops and major issues were identified as affecting the success of participatory approaches. These include: There is a need to share and learn from past experience of community participation Problems can occur around defining communities and the issues and problems to be addressed by projects - the community and professionals may conflict on this Common definitions of health, quality and community interests need to be made as definitions may vary between lay/professional people It is important to listen to local voices rather than just ask questions designed by professionals Further consideration needs to given to how participation can be encouraged, and to the identification of the barriers to participation and how these could be resolved In relation to initiating and sustaining participation, resources are needed, and community expectations should be managed it should be remembered that community participation is a long-term process and sustainability is needed A balance should be found between the community getting involved in identifying and defining problems and also getting involved in problem solving Support networks are needed within the community to encourage dialogue and provide training where necessary to help bridge the gap between theory, policy and practice Methods of evaluating the process of participation need to developed Organisational capacity needs to be built-up to implement participatory approaches Suggestions as to how community participation could be sustained included ensuring support was available at a senior level from within organisations towards participatory approaches and the establishment of these approaches as part of professional practice. Case studies could be presented as examples of successful practice and communities could be taught about the participation process and approaches.

65 Lessons Learnt from Healthy Cities in Europe Community participation is seen as a key element in the development of a healthy city. The global health policy Health 21 (1998) advocates the use of a participatory health development process involving individuals, groups and communities and institutions and highlights the need for multisectoral action to empower these groups in order to sustain health (WHO, 1998). Empowerment is a term which is frequently used in the development of programmes and is defined as a continual process that enables people to understand, upgrade and use their capacity to gain better control over and gain power over their own lives (Schuftan,1996). To ensure community participation is effective, commitment, understanding, resources and the development of competencies are necessary. Support is needed at an operational level to build capacity as well as the development of networks and infrastructures to facilitate participation. Equally important is the need for mechanisms to ensure participation feeds into organisations policy development. 64 Much experience has been gained and documented over the last 15 years by cities which have been a part of the European Healthy Cities Network. Some of the results of a survey which was completed in 2003 taken from the experiences of 47 cities in relation to community participation are highlighted below. Providing information to local people is seen to be important. Methods which cities use to keep local people informed include: websites, healthy city newsletter, newspapers, health sector magazines, TV, radio, groups/schools, topic leaflets and stalls/displays (these are listed in descending order of frequency of use). It is felt that the most effective channels of communicating information is via the TV or newspaper. However the best way to contact vulnerable groups is through word of mouth via voluntary groups, and schools etc. The most common methods used by cities to consult local people include questionnaires and public meetings followed by working and focus groups. Some cities also use methods such as drama, quizzes, personal visits and rapid appraisal assessments. The survey highlights the importance of providing feedback to all those

66 Tools for Action Equity in Health - Tackling Inequalities involved in any consultation as this is vital in establishing a meaningful and long-term dialogue. It is important to support community members to participate in decision-making. One way to help achieve this is to ensure representation of voluntary/community groups on steering committees. Another method is to set up and use community forums as a vehicle to feed into steering committees this will allow many more people to have a say in the development of programmes/policies. For this to work it is vital to have clear mechanisms to feed back the views of the community forum to the steering committee. Having at least 2 members of the steering committee at all forum meetings will help facilitate this. Community participation must be part of a long-term strategy and considered at every stage of the life of a project. 65 Successful participation should work to a community timescale rather than an organisational timescale to enable the feeling of ownership by the community (Tsouros and Farrington, 2003). Successfully involving the community in decision-making is a continuous learning process and requires flexibility and commitment.

67 References Brager G and Specht H (1973) Community Organizing, Columbia University Press, New York Davidson S (1998) Spinning the Wheel of Empowerment, Planning, Vol 1262, 3 April, p14-15 Northern Ireland Executive, Building on Progress, Priorities and Plans for ( Department of Health, Social Services and Public Safety (DHSSPS) (2002) Investing for Health Department of Health, Social Services and Public Safety (DHSSPS) (1999) Mainstreaming Community Development in the Health and Personal Social Services, Community Development Working Group, Report to the Targeting Health and Social Need Steering Group Department of Health, Social Services and Public Safety (DHSSPS) (2004) Our Future Health A Twenty Year Vision for Health and Wellbeing in Northern Ireland , Draft document for discussion Labonte R (1990) Empowerment: Notes on Professional and Community Dimensions, Canadian Review of Social Policy, Vol 26, p64-75 Laverack G and Labonte R (2000) A Planning Framework for Community Empowerment Goals within Health Promotion, Health Policy and Planning, Vol 15, No. 3, p ( Northern Ireland Executive (2002) Draft Programme for Government OFMDFM (2001) Guide to Consultation Methods for Northern Ireland Public Authorities, Draft Version, November Northern Ireland Executive ( ) Programme for Government ( Schuftan C (1996) The Community Development Dilemma: What is really Empowering, Community Development Journal, 31 (3), p Smithies J, Webster G, (1998) Community Involvement in Health: from Passive Recipients to Active Participants, Aldershot, Ashgate South Lanarkshire Community Partners, Wheel of Participation, website accessed June

68 Tools for Action Equity in Health - Tackling Inequalities 67 Tsouros A D, Farrington J L (2003) WHO Healthy Cities in Europe: A Compilation of Papers on Progress and Achievements A working Document, Copenhagen WHO (1998) Health 21 The Health For all Policy Framework for the WHO European Region, Copenhagen, WHO Regional Office for Europe, ( 22_1) WHO (2002) Community Participation in Local Health and Sustainable Development: Approaches and Techniques, Copenhagen, WHO Regional Office for Europe ( Voluntary and Community Unit (December 2003) Pathways for Change A position paper by the task force on resourcing the voluntary and community sector Voluntary and Community Unit, Department for Social Development, (October, 2004) Investing Together - Report of the Task Force on Resourcing the Voluntary and Community Sector

69 4. Evaluation 68 Evaluation - an assessment of whether or not you have achieved what you set out to do Meyrick and Sinkler (1999)

70 Tools for Action Equity in Health - Tackling Inequalities 4.1 Introduction Evaluation is simply defined as as assessment of whether or not you have achieved what you set out to do (Meyrick and Sinkler, 1999). It involves making judgements about the value of a programme/project. Within this chapter the policy context for evaluation is outlined, as well as three examples of tools/frameworks to assist in planning and carrying out evaluation. Local experiences of the successes and difficulties experienced in evaluation are highlighted at the end of the chapter Policy Context Public sector Within Northern Ireland the Department of Finance and Personnel (DFP) has produced guidance for Government departments in relation to appraisal, evaluation, approval and management of policies, programmes and projects this is called the Northern Ireland Practical Guide to The Green Book (2003). It conforms with the principles laid out in the UK Green Book which is the HM Treasury s guide to appraisal and evaluation in central Government, but is tailored more to the needs of Northern Ireland. Within the Practical Guide DFP recommend that whenever a policy, programme or project is completed it should undergo a comprehensive evaluation. They also suggest evaluation should be led by individuals who have not been involved in its management or implementation. Branches within DFP monitor completion of post-project evaluations and review samples of these evaluations from time to time by way of quality assurance. The Office of the First Minister and Deputy First Minister (OFMDFM) are also responsible for monitoring policy within Northern Ireland. For example OFMDFM is responsible for evaluating the overall progress of New Targeting Social Need (TSN) which is the main policy within Northern Ireland aimed at tackling poverty and social exclusion. All Departments and key statutory bodies are required to draw up Action Plans on how they will implement it. The evaluation undertaken by OFMDFM takes place within a framework that encompasses all of these Action Plans. All Government departments are required to complete an Economic Appraisal on all decisions and proposals for spending or saving of public money, including EU funds. Economic Appraisal is a tool for achieving

71 value for money and satisfying public accountability requirements. It is a systematic process for examining alternative uses of resources, focusing on assessment of needs, objectives, options, costs, benefits, risks, funding, affordability and other factors relevant to decisions (Department of Finance and Personnel (DFP), 2003). Departments are advised to use the results of appraisals in prioritising of their spending plans (DFP, 2003). The Northern Ireland Audit Office provided support to the Northern Ireland Assembly (while it was operating) in its task of holding Departments and their Agencies to account for their use of public money and effective local government audit. The Northern Ireland Audit Office is independent of Government and is responsible for external auditing of central government bodies in Northern Ireland, including Northern Ireland Departments and their Executive Agencies and a wide range of other public sector bodies, including Executive Non-Departmental Public Bodies and health and personal social services bodies. The Audit Office also authorises the issue of money from the Northern Ireland Consolidated Fund to enable Northern Ireland Departments to meet their necessary expenditure. 70 In July 2003 the Government s Chief Social Researcher s Office within the Cabinet Office (London, UK) produced guidance notes for policy evaluation and analysis called the Magenta Book. Although this book was designed primarily for Government policy evaluators and analysts it hopes to be of use to those beyond this remit. The book defines policy evaluation, provides guidance on social research methods and the range of methods used in policy evaluation, and guidance on how to use summative and formative, quantitative and qualitative methods of policy evaluation (Cabinet Office, 2003). In August 2003 the Cabinet Office also released a report outlining a framework for assessing qualitative research useful in qualitative evaluation. Voluntary and community sector in Northern Ireland The Voluntary and Community Unit (VCU), was established in the mid 1990s to monitor the impact of the voluntary sector and increase the effectiveness of the sector through encouraging effective practice, for example, developing methods for monitoring and evaluation. Initially known as the Voluntary Activity Unit it was placed within the Department of Health, Social Services and Public Safety. However, in the late 1990 s with the establishment of the NI Assembly it later became the Voluntary

72 Tools for Action Equity in Health - Tackling Inequalities 71 and Community Unit and sat within the Department for Social Development (DSD). In 1996 this unit published Guidance for Government Departments on Commissioning and Conduct of Evaluations of Voluntary Organisations which outlined general evaluation arrangements. Also in 1996 the Social Services Inspectorate produced A Pilot Quality Standards Framework for the Evaluation of Voluntary Organisations which was primarily designed to provide guidance for their own inspectors but was also seen as a source of reference for voluntary organisations evaluating their own activities. More recently VCU work has included supporting a task force established in February 2003 to develop a position paper Pathways for Change which considers issues around the future support of the Voluntary and Community sector and the potential for using a Social Investment Approach as a model for public support for these sectors. This approach involves the identification of achievable long-term outcomes, and would focus on the quality of outputs and their relevance to identified outcomes. Voluntary and community organisations could expect to be more rigorously assessed in the achievement of agreed outcomes. Community Evaluation Northern Ireland (CENI) works within Northern Ireland to provide a range of services in monitoring and evaluation to the voluntary, community and statutory sectors. Their services include information and advice, evaluation consultancy, training and support, and research and development work. In recent years there has been a stronger emphasis for the contribution of social capital to be taken into consideration in the planning stages of evaluation. The social capital approach is supported by a number of Government policy documents. For example the Consultation Document on Funding for the Voluntary Sector (Harbison Report, Department for Social Development, 2001) identified social capital as one of the elements necessary for the sector to sustain its contribution to the public welfare, and highlighted that the development of social indicators would strengthen the ability of the sector to demonstrate value for money. Partners for Change Government s Strategy for Support of the Voluntary and Community Sector (2001) also highlighted the importance of building community capacity, promoting active citizenship, and the need for comprehensive methods of evaluation to show added value.

73 Investing Together - Report of the Task Force on Resourcing the Voluntary and Community Sector (2004) recommended the the social captial indicators, developed by CENI (and outlined in section 4.3c) were adopted and promoted across Government and the volunary and community sector as a key part of the framework for the measurement of voluntary and community based activity (Voluntary and Community Unit, Department for Social Development, 2004). 4.3 Tools/Frameworks Within this section three tools/frameworks will be outlined: 4.3a: Essential elements and key steps in evaluation 4.3b: Theory of Change Approach 4.3c: Social Capital Model and Indicators 4.3a Essential Elements and Key Steps in Evaluation Before undertaking any evaluation it is important to consider: Why evaluate the reasons for undertaking an evaluation. For instance is it to inform the planning process, to provide feedback for those involved or provide funders with evidence of success or all of these reasons? 72 What needs to be evaluated and what evaluation tools will be used to gather information When the evaluation will take place formative (ongoing) or summative (at the end) Who will undertake the evaluation and manage the process, who will set the criteria for evaluation, who wants the evaluation e.g. funders, and who will the evaluation report be distributed to. How will the findings be presented. It is also essential to consider the cost of evaluation and ensure this is built into a business plan. Costs may include: time to prepare questions; time to locate participants, time to distribute, collect, and analyse the data; costs in relation to venues e.g. for focus groups, travel, administration and printing costs and the cost of disseminating the evaluation report.

74 Tools for Action Equity in Health - Tackling Inequalities Key Questions in Evaluation Some of the key questions to consider in carrying out an evaluation of the planning and implementation of a project include (Martin, 2002): Were all the objectives achieved? What went well and why? What hindered progress internal or external? What was helpful or unhelpful about the project plan? Was the budget managed well was the project completed within budget? Was the timing managed well was the project completed within the timescale set? What needs to be changed? Basic Steps in Evaluation There are 4 basic steps to take when planning and implementing an evaluation. 73 Step 1 Step 2 Step 3 Step 4 Setting aims and objectives to highlight what the project aims to achieve Identifying indicators of success both short and long-term Monitoring and assessing progress towards the aims and objectives. This involves choosing research tools in order to gather both qualitative and quantitative information e.g. questionnaires, interviews, case studies, focus groups, statistical packages. It is important to consider who is going to gather the information, how will it be administered and who will analysis the data. Disseminating and acting on the results reflecting on the successes and limitations of a project should feed into future planning. This will assist in improving future work and identifying any change that is needed (Meyrick and Sinkler, 1999).

75 Evaluation Process The Office of the First Minister and Deputy First Minister (OFMDFM) outline within their Practical Guide to Policy Making in Northern Ireland, 10 key parts which the evaluation process can be broken down into. 1. Planning an evaluation Evaluation should be planned before a programme starts. It is important to consider what questions the evaluation will address and who should undertake it. The costs of performing the evaluation should not outweigh what will be gained from the evaluation in terms of lessons learnt. 2. Establishing the scope and purpose of the evaluation 3. Establishing the rationale, aims and objectives of the policy or programme 4. Specifying measures and indicators these will include how to measure effectiveness, efficiency and value for money as well as setting indicators of success 5. Establishing a baseline for comparison this will allow before and after comparisons to be made Defining assumptions - this might involve defining assumed causal relationships between a policy/programme and its outcomes as well as referring to external environmental influences 7. Identifying side effects and distribution effects these may be effects (beneficial or otherwise) beyond those originally envisaged for the policy/programme. Impact assessments could be used during this stage 8. Analysis of both quantitative and qualitative data may be important. Measuring the cost benefit is also important 9. Evaluating the outcome this stage involves making recommendations that suggest further actions that need to be taken e.g. what needs to be modified within the programme, whether the programme is to be terminated or succeeded by another. These recommendations should feed into reappraisals or appraisals of new proposals. 10. Presentation and dissemination of results the evaluation process and outcome should be documented and the report disseminated to senior management as well as all staff concerned with future project design, planning, development and management.

76 Tools for Action Equity in Health - Tackling Inequalities b: Theory of Change A Theory of Change is an innovative approach to design and evaluate social change initiatives. This approach has been developed in both the USA and the University of Glasgow in Scotland and has been used in the evaluation of Health Action Zones in the UK. A Theory of Change approach helps organisations clearly lay out the steps involved in achieving long-term goals by identifying the interventions, preconditions and pathways necessary for an initiative to succeed. It should reflect in reality what it takes to bring about long-term goals. The Theory of Change encourages all the stakeholders to work together from the very beginning of an initiative to debate how it can best produce the desired outcomes and the processes that lead to these outcomes. Connell and Kubisch (2002) suggest that a theory of change approach is not an evaluation method that stands on its own but rather is an approach to evaluation which relies upon and uses many methodologies that have been developed and refined over the years quantitative and qualitative, impact and process oriented, traditional and nontraditional, for information collection, measurement, and analysis. In the planning process to help generate a theory of change a number of questions need to be considered. These form the steps involved in developing a theory of change. What are the long-term outcomes which the project seeks to accomplish? What are the resources or conditions needed to achieve these? What activities or interventions should be initiated to achieve the desired outcomes? What resources are required to implement the activities, and how can these resources be secured? Also what support is required to ensure these activities are effective? What are the indicators which will assist in measuring outcomes and performance?

77 For community projects or initiatives the most difficult part of the process is defining the intermediate activities and outcomes and linking these to long-term outcomes. The process of developing a theory of change is intended to help in evaluation of initiatives by defining the long-term measurable outcomes first and backward mapping the links between activities/interventions and outcomes. This creates a set of connected outcomes known as pathways of change which sets out a clear picture of how change is predicted to occur, and in what sequence. The following chart shows the process of backward mapping. Step 6 Resource Mapping Step 5 Initial Activities Step 4 Early Outcomes Step 3 Intermediate Outcomes Step 2 Penultimate Outcomes Step 1 Long-term Outcomes During the process of creating the pathway of change it is important to document all the assumptions about what conditions and resources are needed to make the initiative successful, and what internal or external factors may hinder progress. It is up to the practitioner to choose what methods are used to collect and measure both qualitative and quantitative data to assist in building the theory of change. According to Connell and Kubisch (2002) a good theory of change should be: Plausible the evidence gathered as well as common sense should suggest that the activities, if implemented, would lead to the desired outcomes Doable are there resources available to carry out the initiative e.g. economic, technical, political, institutional and human resources Testable the theory of change should be specific and complete to enable an evaluator to track its progress in credible and useful ways 76

78 Tools for Action Equity in Health - Tackling Inequalities 77 There are many benefits to using a Theory of Change approach. For instance it should provide guidance for an evaluator on when it is important to collect information as the theory of change will outline when activities should occur and when their intended outcomes should occur, as well as providing measurable indicators to measure success and performance. A theory of change approach can be used to sharpen planning or to identify areas that are unclear or conflicting. It can provide formative (ongoing) feedback to implementers and funders and can be used as a template to guide both internal and external evaluation over the course of an intervention or project. A theory of change can set the project activities in their wider socio-political context and can increase understanding as to why and how an activity is, or is not, effective in any given context. This in turn can aid policy learning. The approach can be a powerful tool for promoting collaboration as all of the stakeholders get involved in the process from the beginning of a project and the process helps gain a common understanding of the long-term goals, agreement about what is defined as success, and what it takes to get there. Further information on the theory of change can be found at 4.3c: Social Capital Model and Indicators The Voluntary and Community Unit recently commissioned work into Evaluating Community-based and Voluntary Activity in Northern Ireland (2003). From this research a Social Capital Model for evaluation was outlined which recognises the need to meet shortterm targets but also highlights the importance of building social capital. Social Capital refers to social connections including networks, norms and trust that enables participants to act together more effectively to pursue shared objectives (Putnam, 1995). It also considers the degree to which people take part in group life, the level of trust people feel when participating in such groups and the links or connections between groups which give access to wider groups. Social capital indicators can help show, within a measurable framework, the added value that community and voluntary organisations bring to creating and building social capital, which is not captured within economic evaluation. Voluntary and community

79 organisations achieve much more than the delivery of services. Morrissey, McGinn and McDonnell (2003) suggest that the use of the social capital approach facilitates the demonstration of the way in which the sector links to and influences policy, bonds local people with each other and to local community organisations, promotes active volunteering, enhances accessibility to local services, builds capacity for participation, and creates bridges between sectors through networks and partnerships. Social Capital Indicators The Social Capital Indicators which were developed by Morrissey, McGinn and McDonnell (2003) have been organised into three domains: Bonding social capital is taken to refer to the internal cohesion or connectedness within a community Bridging refers to the levels and nature of contact and engagement between different communities Linking represents the engagement and relations between community and voluntary organisations and resource agencies and policy makers. 78

80 Tools for Action Equity in Health - Tackling Inequalities 79 The following three tables outline the indicators located under each of these domains. Table of Social Capital Outcome Indicators Bonding Evidence (suggested) Indicator Bonding Outcome Numbers participating in personal development courses. Survey of beneficiaries to assess changes in attitudes and behaviour. 1. Intended beneficiaries have increased confidence to participate in community activity. Empowerment Intended beneficiaries have confidence, skills and leadership capacity. Numbers participating in training course, Qualifications attained Survey of beneficiaries to assess levels and relevance of new skills. 2. Intended beneficiaries have skills to contribute to community activity. Evidence of participation in organising, running projects. Survey of beneficiaries. 3. Intended beneficiaries exercise leadership within the community. Numbers participating and level of engagement in organisations, projects. 4. Intended beneficiaries participate in organisations, projects within the community. Infrastructure Intended beneficiaries participate in organisations and projects, which are representative and inclusive Increased contact between intended beneficiaries and groups within the community (baseline & survey) 5. Intended beneficiaries connect and network with other people and organisations within the community. Numbers represented relative to Section 75 Categories. 6. Marginalised people are represented in organisation/project structures.

81 Table of Social Capital Outcome Indicators Bonding (continued) Increased levels of trust within community (baseline & survey) 7. Levels of trust between people and organisations in the community. Connectedness Intended beneficiaries are well connected with community trusted, sharing and working toward shared goals. Survey of organisations and projects within community. 8. Sharing of information and resources between people and organisations in the community. Survey of organisations and projects within community. 9. People and organisations in the community working together to achieve shared goals. 80

82 Tools for Action Equity in Health - Tackling Inequalities 81 Table of Social Capital Outcome Indicators Bridging Bonding Outcome Indicator Evidence (suggested) Number of contacts established with other communities/sectors. Frequency, duration and description of contacts established with other communities/sectors 10. Level of engagement by intended beneficiaries with other communities/sectors outside their own. Engagement Intended beneficiaries engage with other communities and sectors by participating in relationships and networks Presence of recognised brokers or facilitators within the community. Number and type of contacts facilitated with groups from outside the community. 11. Quality of structures to facilitate engagement between intended beneficiaries and other communities/sectors. Evidence from intended beneficiaries of their enhanced understanding (baseline & survey with intended beneficiaries). 12. Greater understanding by intended beneficiaries of the interdependence between theirs and other communities. List of measures taken by intended beneficiaries to make their community attractive to others. 13. Intended beneficiaries willingness to engage with communities outside their own. Existence of discussion, debate addressing issues of separation (self audit) Accessibility Intended beneficiaries have values and participate in structures and processes that make their community accessible to outside communities and sectors 14. Intended beneficiaries awareness and competence to deal with issues of separation between communities and sectors. Evidence of intended beneficiaries engaging in proactive cross-community and cross-sector initiatives. 15. Intended beneficiaries participate in structures and processes aimed at reducing issues of separation.

83 Table of Social Capital Outcome Indicators Bridging (continued) Evidence of ideas developed. 16. Intended beneficiaries explore new ideas to meet community needs Innovation Intended beneficiaries are open to new ideas and solutions facilitating their community to adapt to change. Evidence of solutions adopted. 17. Intended beneficiaries adopt new solutions to meet community needs. Survey of intended beneficiaries. 18. Appropriateness of new solutions to changing needs of the community, 82

84 Tools for Action Equity in Health - Tackling Inequalities 83 Table of Social Capital Outcome Indicators Linking Bonding Outcome Indicator Evidence (suggested) Contacts between community and outside resource/development agencies. 19. Formal contacts with resource/development agencies outside the community Resources Intended beneficiaries have access to people and institutions outside the community with power and resources Letters of offer from funders. Perceived value of non-financial inputs. 20. Value of additional resources leveraged for intended beneficiaries. Number of intended beneficiaries represented on public fora. 21. Participation of intended beneficiaries in public fora at local and regional levels. Influence Intended beneficiaries have representation on local and regional public fora at which their interests are articulated. Evidence of contacts, engagement between intended beneficiaries and representatives from other sectors. 22. Formation of alliances between intended beneficiaries and others participating in public fora. Intended beneficiaries recognise the interdependence between their needs and needs of others Identifiable changes in public policy positions adopted by governmental organisations that, in the opinion of governmental personnel, were significantly influenced by intended beneficiaries input. 23. Changes in public policy that better meet the needs of intended beneficiaries. Feedback from statutory agencies on effectiveness of group/organisation. Nature of discussion in public fora on community s interest. Evidence of community s issues being addressed at local policy level (interviews). 24. Perception and attitudes of public agency representatives to the participation and contribution of the organisation/project.

85 Morrissey, McGinn and McDonnell (2003) highlight the importance of both the funder and the organisation being funded agreeing a number of issues prior to using this framework. These include: Deciding what indicators to use and monitor progress on Agreeing the weighting of the indicators chosen as some may be given greater priority and importance Gaining agreement on the evidence to be collected to demonstrate performance Deciding on a plan for the evaluation answering the who, what, when, how questions This framework focuses mainly on the use of indicators as a measure of success when evaluating a programme or project. All of the other stages of evaluation outlined at the beginning of this chapter, however, are essential to ensure the planning and implementation of an evaluation is successful. 84

86 Tools for Action Equity in Health - Tackling Inequalities 4.4 Experiences of Evaluation Equity in Health Programme (2002/03) One of the activities participants on the Equity in Health Programme were asked to complete focused on the various methods used within their organisations to monitor and evaluate progress on programmes and projects.the table below highlights the responses given to this question. 85 Monitoring Methods Progress meetings and reports Quarterly monitoring meetings between commissioners and key providers Monitoring records on attendance/uptake of programmes and services Reports on business plans/strategic plans and financial returns Evaluation/feedback forms and reports Focus/reference groups; community/consumer groups Surveys and interviews Inspections Consultation with stakeholders Audit of services Internal/External Helpline calls Complaints Staff monitoring: Supervision One-to-one meetings Group/team meetings to discuss positive and negative experiences Evaluation Methods Comparison of progress against targets and baselines (quantitative/qualitative) Focus groups/questionnaires/interviews One-to-one discussions with participants in a programme Evaluation forms asking individuals to rate their experience Surveys to identify significant patterns and trends Feedback from working groups/advisory group Feedback from community groups/councils Case studies/storytelling to capture people s experiences and perceptions Benchmarking/peer review Exit polls Analysis of complaints patterns and lessons to be learnt Ongoing evaluation as well as evaluation completed at the end of a project Analysis of statistics and monitoring/evaluation reports Impact assessment External evaluation

87 Participants on the Equity in Health programme also highlighted the successes and limitations to these methods of evaluation. Successes of evaluation Creates an opportunity to get feedback from the individuals who have participated in a programme A one-to-one discussion allows individuals to speak about their personal experience whereas in a focus group discussion, only certain voices are heard Using a variety of methods can help record progress on both quantitative and qualitative targets set Qualitative methods allow the evaluator to gain a greater degree of understanding and detail that is not possible in quantitative methods. Quantitative evaluation, for example postal questionnaires, telephone interviews, allows information to be collected in such a way that it can be easily analysed to discover significant patterns Participatory evaluation gives priority to the views of lay people in the evaluation process Evaluation results can be used to implement change where necessary and can show a project s strengths and weaknesses 86 Evaluation can: Create opportunities for accessing further resources Create a sense of achievement Allow for priorities to be revisited Highlight areas of success and areas for improvement Show trends Identify risks/funding requirements Measure development of services Identify areas for new work

88 Tools for Action Equity in Health - Tackling Inequalities 87 Limitations/Difficulties experienced in evaluation Difficulties can arise when evaluation is not built in from the beginning of a project Time and money constraints can limit how thoroughly an evaluation can be performed It can be difficult to evaluate fully the outcomes of short term projects Processes that focus mainly on quantitative targets can fail to capture the depth and colour of qualitative information Evaluation of health promotion and community development projects is complex and often have uncontrolled and un-measurable variables also the time span is often too short for evidence to have fully emerged It may be difficult to always get honest answers within, for example, questionnaires or interviews It may be difficult to get a balance between positive and negative feedback i.e. to get feedback on what is working, as well as what is not working Difficulties can arise in implementing change once the lessons have been learnt through evaluation The wording of questions in questionnaires can sometimes lead a respondent to only giving a desired answer or limiting the choice of answer they can give With many projects there is a need to evaluate over a long period of time to assess the full impact this is difficult with short term funding Proper resources are necessary to evaluate properly adequate funding is not always available It is easier to reinforce positive evaluation results than to act upon negative results Evaluation needs to influence change; this does not always happen There is the danger of limiting an evaluation to only meeting funding requirements Participatory evaluation can raise expectations for more or better services when resources are limited to make the necessary changes or additions to service delivery Quality of life issues can be difficult to monitor and evaluate particularly in terms of spin-off indirect benefits

89 Difficulties that can arise with qualitative evaluation methods include: - Personal/Individual bias - Inconsistency in application - Time consuming - Expensive - Subjective - Loudest Voice Syndrome this is particularly seen in workshops and focus groups if not everybody is given a chance to have their say, only those who are more outspoken Difficulties that can arise with quantitative evaluation methods include: - Interpretation can be biased - Manipulation of figures can occur - Bureaucracy use of technical jargon can be a barrier to understanding results - Often only gives a snapshot of activity at a given time These tables highlight that there are a wide range of methods used within the statutory, voluntary and community sectors to monitor and evaluate projects and policies. However evaluation is not always straightforward or easy. Problems can arise in finding the resources to comprehensively perform evaluation. It is a challenge to evaluate complex and multi-faceted programmes and projects which can be made more difficult by short term funding. It is vital to ensure evaluation results are acted upon and stimulate change where necessary. Achieving a balance between qualitative and quantitative data collection is important as each supplements the other and it is difficult to achieve an overall picture if only one type of data is used. The methods used, however, will be influenced by the availability of resources. It is useful during the preparatory stages of evaluation to review potential limitations and difficulties (examples of which are outlined in the table above) which may be experienced during the implementation or analysis stages of evaluation, as steps can be put in place early in the process to mitigate or avoid these. 88

90 Tools for Action Equity in Health - Tackling Inequalities 89 References Cabinet Office (2003) The Magenta Book Guidance Notes for Policy Evaluation and Analysis, London ( Cabinet Office (2003) Quality in Qualitative Evaluation: A Framework for Assessing Research Evidence, compiled by Spencer L. Ritchie J, Lewis J and Dillon L ( Connell J and Kubisch A. C (2002) Applying a Theory of Change Approach to the Evaluation of Comprehensive Community Initiatives: Progress, Prospects and Problems, Volume 2: Theory, Measurement, and Analysis, Department of Finance and Personnel (2003) The Northern Ireland Practical Guide to the Green Book DFP s guide to the appraisal, evaluation, approval and management of policies, programmes and projects, Erwin B (2003) Evaluating an Integrated Approach to Health Planning, City Health Development Plan, Belfast Healthy Cities Harbison J (2001) Consultation Document on Funding for the Voluntary Sector, Report for Department of Social Development Meyrick J, and Sinkler P (1999) An Evaluation Resource for Healthy Living Centres, Health Education Authority Morrissey M, McGinn P, and McDonnell B (2003) Report on Research into Evaluating Community-Based and Voluntary Activity in Northern Ireland, Voluntary and Community Unit, Department for Social Development ( Putnam R.D (1995) in Morrissey M, McGinn P, and McDonnell B. 2003) Report on Research into Evaluating Community-Based and Voluntary Activity in Northern Ireland Final Report, Voluntary and Community Unit, Department for Social Development Tsouros A and Farrington J (2003) WHO Healthy Cities in Europe: A Compilation of Papers on Progress and Achievements, World Health Organisation Voluntary and Community Unit, Department for Social Development, (October, 2004) Investing Together - Report of the Task Force on Resourcing the Voluntary and Community Sector

91 Electronic Libraries for Policy Evaluation Campbell Collaboration aims to provide information on interventions in the social, behavioural and educational arenas ( Cochrane Collaboration produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trails and other studies of interventions ( Centre for Reviews and Dissemination (CRD) it provides researchbased information about the effects of interventions used in health and social care ( Evidence Network provides access to social science research publications relevant to policy and practice ( Policy Hub this website was developed by the Cabinet Office Strategy Unit (UK) and provides guidance on the use of research and evidence in evaluation of policy, access to projects and tools that support policy making, and links to other research resources and tools from the UK and around the world ( 90 Other Suggested Reading Building the Community Pharmacy Partnership: Evaluation (2003) this is an evaluation resource pack developed primarily for project participants to use to help set in place an effective evaluation process. This resource could be adapted to fit with a wider range of projects. The pack looks at issues which should be considered in planning an evaluation, materials for collection of data, and information concerning the analysis and reporting of evaluation findings. The pack can be found on

92 Tools for Action Equity in Health - Tackling Inequalities 5. Health Impact Assessment (HIA) 91 HIA can be defined as a combination of procedures or methods by which a policy, programme or project may be judged as to the effects it may have on the health of a population WHO (2004)

93 5.1 Introduction Health Impact Assessment (HIA) is a tool to support cross-sectoral action for promoting health and reducing inequalities. HIA provides a structured framework for mapping the health consequences of any policy, programme, or project. It can be defined as a combination of procedures or methods by which a policy, programme or project may be judged as to the effects it may have on the health of a population (WHO, 2004). HIA aims to assess the potential health impacts, both positive and negative, of projects, programmes and policies. It also aims to improve the quality of public policy decision making through recommendations to enhance predicted positive health impacts and minimise negative ones. Within this chapter the policy context for undertaking HIA is outlined as well as a description of the steps involved in HIA. Practical experience of the process of facilitating community led HIA is also highlighted. 5.2 Policy context Health Impact Assessment is a relatively new concept within Northern Ireland but is a concept which has generated a lot of interest in recent years. Investing for Health, the regional public health strategy for Northern Ireland highlights that Health Impact Assessment of nonhealth policies is increasingly seen as a key tool to facilitate cross-sectoral action, and as a means to promote health and reduce inequalities. Investing for Health encourages HIA to be used throughout all Government Departments. 92 In 2003 the Department of Health, Social Services and Public Safety (DHSSPS) in partnership with the Institute of Public Health in Ireland, on behalf of the Ministerial Group on Public Health, developed a methodology for conducting HIA. The main purpose of this is to give guidance to all Government Departments and their agencies to enable them to assess the health impact of new policies. These guidelines are easily accessible on the Investing for Health website ( and therefore only a few elements of this guidance document are outlined in this chapter. The Office of the First Minister and Deputy First Minister (OFMDFM) have developed an Integrated Impact Assessment (IIA) tool which aims to

94 Tools for Action Equity in Health - Tackling Inequalities streamline a variety of impact assessments into a single tool. Three Government Departments are currently piloting this tool Department for Regional Development on the Water Reform; Department of Health Social Services and Public Safety on the Regional Health and Social Services Strategy; and the Department of Culture Arts and Leisure on the Safety at Sports Grounds. The results of the first two of these pilot impact assessments will be published in September The integrated impact assessment tool can be found at Within the WHO Regional Office for Europe, guidelines and practical tools have been developed for Health Impact Assessment which will inform practice within the European Healthy Cities Network Tools/Frameworks There are many different tools which have been developed over the years to assist in planning and implementing HIA. For the purpose of this publication an outline only of abstracts from the latter three of these (6,7,and 8) will be presented. 1) The Merseyside model (For further information see the Liverpool University website: 2) The British Columbia model: A resource for Government Analysts (For further information see the Health Canada Website: ct.htm- For The Canadian Handbook on Health Impact Assessment (3 volumes) (English language version), see: 3) The Kirklees Metropolitan Council model (the model is briefly outlined on the following website: 4) The Swedish County Councils model (For further information see The Federation of Swedish County Councils Website: (English language version) 5) The Bielefeld model of Environmental Health Impact Assessment (For further information see: Fehr, R. (1999) Environmental Health Impact Assessment: Evaluation of a Ten-Step Model. Epidemiology 10;

95 6) NHS Executive London - Resource for Health Impact Assessment (developed by Erica Ison, 2000) (For further information see: 7) Rapid Appraisal Tool for Health Impact Assessment (Erica Ison, 2002) (For further information see: 8) Health Impact Assessment Guidance (Draft, 2003) developed by the Institute of Public Health in Ireland on behalf of the Ministerial Group on Public Health ( 5.3a: Resource for HIA - Steps involved in completing a HIA There are a number of steps outlined by Erica Ison (2002) in the process of completing a HIA. 1) Screening involves selecting policies or projects for assessment 2) Scoping involves setting the terms of reference to establish the boundaries for the appraisal of the health impacts 3) Appraisal at this stage the risk assessment is performed and the information collated and analysed 4) Influencing the decision-making process decision makers should have been an active member throughout the whole HIA process and at this stage they can consider the recommendations which have been made in the report 5) Monitoring and Evaluation this involves monitoring and evaluating the HIA process; outlining which recommendations are accepted and implemented; and the health trends and outcomes 94 When to conduct a HIA HIA can be carried out either prospectively (during developmental stage of a policy/programme, concurrently (during implementation) or retrospectively (after implementation). The ideal time to carry out a HIA is prospectively as it allows greater opportunity to influence decision-making. Table 5.1, which is taken from a HIA resource developed by Ison (2000), outlines the various steps if HIA is applied prospectively.

96 Tools for Action Equity in Health - Tackling Inequalities Table Health impact assessment applied prospectively (Ison, 2000) Policy development or strategic planning Policies/strategies Planning Screening Programme or project design Scoping Screening 95 Appraisal Scoping Appraisal Decisionmaking Decisionmaking Amended policies/ strategies Amended programmes/ projects Monitoring & Evaluation Implementation Monitoring & Evaluation Monitoring & Evaluation Outcomes Monitoring & Evaluation

97 5.3a.1: HIA Step 1 Screening Screening provides a structured way to assess if it is appropriate to complete a HIA or not. It allows practitioners to filter out proposals that do not need a HIA e.g. proposals that have a negligible impact on health; those for which the impacts and remedies are well known; and proposals which are non-negotiable. A proposal is often chosen for a HIA if it needs further investigation in relation to health impacts and or the proposal needs to be modified to minimise harmful impacts on health. The process of screening can be performed by an individual or group but is best carried out within a multi-sectoral context. In order to screen effectively a screening tool should be used. However, before using this tool it is important to have a good understanding not only of the key elements of the proposal but also be aware of the profile of the area that the proposal will affect. Sourcing HIAs completed on similar proposals is often useful, as well as sourcing evidence on the wider determinants of health. Practical decisions need to be made in terms of who will be involved in the screening process and the time frame and resources available. Two examples of screening tools are outlined below the first is a tool developed by Erica Ison commissioned by NHS Executive London, and the second tool was developed by the Institute of Public Health on behalf of the Ministerial Group on Public Health (MGPH) in Northern Ireland. 96 Example 1: Resource for HIA, Erica Ison Erica Ison developed the first screening tool in 2000 as a resource for practitioners carrying out HIA. It is made up of 4 parts: Parts 1 & 2 focus on the proposal and its potential impacts; parts 3&4 focus on the circumstances surrounding the conduct of the HIA. Part 1: Investigating the Parameters of the Proposal The following parameters are to be considered: 1. Do not conduct HIA; 2. Conduct rapid appraisal; 3. Conduct intermediate appraisal; 4. Conduct comprehensive appraisal.

98 Tools for Action Equity in Health - Tackling Inequalities 97 As HIA becomes a regular feature of decision-making within an organization, and process and outcomes are monitored and evaluated, it will be possible to develop screening guidelines relevant to and appropriate for the type of proposals an organization/partnership regularly implements. Parameters for all Types of Proposals (policies, programmes or projects) The relative importance of the proposal within the organization s priorities The extent of the population affected by the proposal The existence of vulnerable, marginalized or disadvantaged groups within the population affected Stage of development of the proposal (i.e. the potential to make changes) Parameters for proposals about programmes and projects The size of the proposal The cost of the proposal The nature and extent of the disruption to the population affected

99 Part 2: A checklist of Questions about the Nature of Potential Health Impacts Bias towards conducting HIA To your knowledge: Bias against conducting HIA Yes/don t know Are the potential health impacts likely to be serious? No Yes/don t know Are the potential health impacts likely to be disproportionately greater for vulnerable, marginalized or disadvantaged groups in the population? No Yes Are there community concerns about the potential health impacts? No 98 No/don t know No/don t know Is there a robust evidence/experience base readily available to support: Appraisal of the impacts? The recommendations that could be made to ameliorate those impacts? Yes Yes Yes/don t know Could any of the actions to ameliorate the potential negative health impacts of the proposal actually have a negative effect on health? No No/don t know If allowed to occur, could the potential negative health impacts be easily reversed through current service provision? Yes Yes Is there a need to increase social capital in the community or population affected? No

100 Tools for Action Equity in Health - Tackling Inequalities Part 3: A checklist of questions about the circumstances in which the HIA must be conducted Bias towards rapid appraisal Yes To your knowledge: Is there only a limited time in which to conduct HIA? Bias towards intermediate or comprehensive appraisal No Yes Is there only limited opportunity to influence the decision? No Yes Is the timeframe for the decisionmaking process set by external factors beyond your control? No 99 Yes Are there only very limited resources available to conduct HIA? No Part 4: A checklist of questions about the capacity within an organisation or partnership to conduct the HIA Bias towards commissioning the assessor(s) To your knowledge: Bias towards appointing internal assessor(s) No No Do personnel in the organization or partnership have the necessary skills and expertise to conduct the HIA? Do personnel in the organization or partnership have the time to conduct the HIA? Yes Yes

101 There are 3 possible decisions arising from screening: 1. Further investigation is needed because more information is needed on the health impacts identified; 2. Further investigation is not necessary because the health impacts are well known and it is possible to suggest effective ways in which beneficial effects are maximized and harmful effects are minimized; 3. Further investigation is not necessary because the potential health impacts are judged to be negligible. Source: Ison, E (2000) A Resource for Health Impact Assessment: The Main Resource, Volumes I-II. ( London: NHS Executive. Example 2: Screening Tool (Institute of Public Health in Ireland, 2003) The second screening tool was developed by the Institute of Public Health for Ireland on behalf of the Ministerial Group on Public Health for Northern Ireland. The screening tool is included within a draft guidance document which was published by the Department of Health, Social Services and Public Safety (DHSSPS) in 2003 to provide a simple framework to guide policy makers through the HIA process and assist with implementation. 100 Either of the two example tools could be used for screening purposes and are useful by providing a structured framework for choosing appropriate policies or programmes for HIA.

102 Tools for Action Equity in Health - Tackling Inequalities This screening tool has 8 sections which are outlined below. 1. Title of the policy, programme or project 2. Reference code 3. Description Type 5. Health determinants - Is the initiative affecting any of the following determinants of health? 5.1 Lifestyle Positive Effect Negative Effect No Effect Diet Physical Activity Safe Sex Substance use (alcohol, tobacco, illegal substances) Other... Explanation: If there is likely to be a positive or negative effect on lifestyle factors note briefly here what those effects are..

103 5.2 Physical Environment Positive Effect Negative Effect No Effect Air Built environment and land use Noise Water Explanation: If there is likely to be a positive or negative effect on the physical environment, note briefly here what those effects might be Socio-Economic Environment 102 Positive Effect Negative Effect No Effect Crime - will the proposal have an effect on crime or the fear of crime? Education - will the proposal have an effect on educational opportunities Employment - will the proposal have an effect on: - Employment opportunities - The working environment? Family cohesion - will the proposal have an effect on levels of family contact? Housing - will the proposal affect the opportunity to live in a decent affordable home? Income - will the proposal have an effect on poverty levels? Recreation - will the proposal have an effect on recreational opportunities such as exercise, social contact, cultural activities and other areas?

104 Tools for Action Equity in Health - Tackling Inequalities Social cohesion - will the proposal have an effect on levels of community interaction? Transport - will the proposal have an effect on: Pollution levels? Exercise levels? Accident levels? Other Positive Effect Negative Effect No Effect Explanation: If there is likely to be a positive or negative effect on socioeconomic factors, note briefly here what those effects may be Health care Positive Effect Negative Effect No Effect Access to health services Explanation: If there is a likely to be a positive or negative effect on access to health services, note briefly here what those effects are..

105 7. Population affected Considering the health impacts identified above, which of the following sections of the population will be affected? (includes Section 75 groups) Positive Effect Negative Effect No Effect Whole population Yes Sub-populations Children [0-18 years] Older people Marital Status Persons with Dependants Political Opinion Religious Belief Chronically ill Economically disadvantaged people 104 Gender [specify male/female] Homeless Sexual orientation People with disabilities Racial and ethnic minority groups Rural population Unemployed (Note - there may be other population groups specific to the proposal or policy area being considered not included here (see guidance notes for an example). The exercise may also require one of the above categories to be subdivided further. Additional sub-groups can be added here.) Explanation: If there is a positive or negative effect on the whole or a section of the population, note briefly here what those effects are.. (Note - the proposal may have a positive impact on one section of the population and a negative effect on another. Specify where this occurs.)

106 Tools for Action Equity in Health - Tackling Inequalities 8. Recommendation Considering the health impacts, if any, identified above, are these significant enough to warrant a health impact assessment? Yes/No This decision will be based on a judgement of the strength of the available evidence gathered during the screening stage, and its applicability to local conditions and the strength of feeling of stakeholders and key informants. If No, what are the reasons for not carrying out a HIA? 105 (Note, possible reasons might include: health impacts not considered important enough lack of evidence to show health impacts not enough time to influence decisions on the proposal lack of resources to carry out required level of research Reasons for not carrying out a HIA:....

107 5.3a.2: HIA Step 2 Scoping The second step in the HIA process is called scoping. Scoping involves bringing together the major stakeholders of a proposal to set the boundaries or terms of reference for the HIA. Scoping requires a number of tasks to be undertaken, including: Defining the aim of the HIA - if a large proposal is to be assessed then only certain elements may be looked at within the HIA these need to be defined. Key stakeholders need to be identified as well as an assessment of the information that is needed to assist in the HIA process. Management arrangements for the HIA need to be defined. This includes developing a timetable and budget plan, arranging dates/venues for workshops, deciding how the HIA report will be disseminated, as well as allocating administrative tasks associated with running workshops and preparing information for the workshops. It is important to clarify the process by which the results of the participatory stakeholder workshop will be considered by those responsible for decision-making about the proposal. Monitoring and evaluation of the health outcomes of the proposal is also necessary within this stage a.3: Step 3 - Appraisal The central aim of appraisal is to appraise the potential impact (direct or indirect, negative or positive) that a proposal may have on the population/community when implemented. A Rapid Appraisal Tool for Health Impact Assessment was developed by Erica Ison in The tool is primarily task orientated and gives clear guidance to the exact actions that need to be considered when undertaking participatory stakeholder appraisal workshops. These tasks are categorised under seven sections: Scoping (which has already been covered in step 2) Workshop administration Information preparation Preparation for core workshop tasks Workshop tasks Reporting the results The outcomes of decision-making Within this document only a summary of the tool will be outlined.

108 Tools for Action Equity in Health - Tackling Inequalities 107 Workshop Administration this stage involves practical aspects such as booking the venue, confirming dates and times of workshops, arranging catering and childcare where necessary, developing the list of stakeholders and inviting them to workshops, agreeing workshop agenda s and preparing information which will be given out to stakeholders during workshops. Information Preparation The information pack which will be given out to stakeholders should include: A brief introduction to HIA for those who are unfamiliar with the concept, and also include an outline of the process which will be used locally. Information about the proposal itself and its implementation Evidence-based and experience-based studies relevant to the proposal. This evidence should be gathered from sources that are readily available and provide evidence of any different effects the proposal may have on a community. A profile of the area/community, giving both statistical and anecdotal information of socio-economic and environmental factors influencing health, is useful to assist stakeholders make informed decisions regarding the potential health impacts of a proposal. This profile should also consider what vulnerable, disadvantaged or marginalised groups will be affected by the proposal. It is beneficial to send this information out to stakeholders in advance of the appraisal workshop. Preparation for core workshop tasks it has been recommended that during the workshop stakeholders are divided into small groups, with each group appraising different elements of the proposal. Stakeholders will also be given a table which briefly assesses the importance of the proposal in light of current regional or local policy context this will have been agreed prior to the workshop by both the assessor and proposal developer(s).

109 An assessment of the potential impact on service delivery and the need for services should be performed either prior to or during the workshop. To assist in determining the health impacts of a proposal it is helpful to provide stakeholders with a list of the determinants of health i.e. factors that affect health. A semi-structured approach should be used during workshop tasks where stakeholders are given a series of questions to answer. To ensure each small group of stakeholders achieve the task set for them it is necessary to compile an instruction sheet for the facilitators of each group to explain how to use the supporting material as well as the importance of appointing a scribe to document the answers to each question. Workshop tasks during this section the workshop facilitator may initiate a number of tasks: The first task could involve doing a short exercise around what health means to those present at the workshop. This can help get stakeholders focused on the tasks ahead. All the responses should be visibly displayed throughout the workshop. The second workshop task involves stakeholders identifying potential barriers, threats or conflicts to the implementation of the proposal. The third task involves stakeholders identifying the potential positive and negative health impacts of the proposal. 108 Following on from this stakeholders need to explore what changes could be made to the proposal to increase the positive and reduce the negative health impacts identified (these suggestions should be recorded on flip chart paper). The small group should then feedback their responses and discuss them with the large group of stakeholders. This will then lead in to the task of gaining agreement about prioritisation of the suggestions or recommendations for change. One of the suggested methods for prioritisation is to give each stakeholder 5 sticky dots which they then use to prioritise against the full list of suggestions for change recorded on flip chart paper.

110 Tools for Action Equity in Health - Tackling Inequalities 109 Reporting the results the assessor is responsible for completing the report, and this report should include the responses to all of the tasks set within the workshop. It is suggested that all the recommendations made during the workshop are recorded. However, an additional list of the recommendations prioritised should also be included. Once the responses to the workshop have been written up it is then important for the assessor to test the recommendations to identify whether a recommendation addresses any important or influential factors in the causation of health impacts and if so does it affect one element or a number of elements of the proposal. This process will also assist the assessor highlight recommendations that the decision-makers should consider. Once the full report has been completed it is vital that the report is checked by either the steering group set up for the HIA or by independent advisors. The report should be compared with workshop records to ensure responses have been reported accurately. The content of the report should also be compared against the information prepared for the stakeholders (stage 3) to assess if they have been appropriately incorporated into the responses. The outcomes of decision-making - all stakeholders should be given details of which recommendations were accepted by the decision-makers of the proposal and of these which have been implemented. As part of the evaluation of the HIA, recommendations that were not implemented (which were accepted) need to be further investigated. For each of the stages listed above, the rapid appraisal tool guide gives a full explanation as to why, what, when, who, and how the appraisal should be carried out, as well as providing supporting material e.g. grids to use during the assessment. The full rapid appraisal tool can be found on the following website: ment.pdf

111 5.3a.4: HIA Step 4 Influencing the Decision-Makers During the scoping stage the decision-makers should have been identified and, where possible, part of the impact assessment process throughout. If this is the case recommendations made will not come as any surprise to decision-makers and they will have been given the opportunity to identify areas that were negotiable. It should be stressed to decision-makers that HIA provides valuable evidence based information to inform and support their decisions, and aims to improve the positive health impacts of the proposal and reduce the negative ones. Timing is essential to ensure that decision-makers are given HIA recommendations within the timeframe agreed. Recommendations should also be provided in a user-friendly language that they will understand. 110

112 Tools for Action Equity in Health - Tackling Inequalities 5.3a.5: HIA Step 5 - Monitoring and Evaluation This step is crucial to help evaluate the process, the effectiveness of the HIA and the final health outcomes. The Health Development Agency have produced guidance for HIA evaluation, which is outlined below. 1. Plan your evaluation: Have clear aims and objectives which will help you in selecting an evaluation framework. 2. Identify the evaluation questions and research tools: Know what information is needed. Identify data sources so that everyone s responsibilities are clear. If other monitoring information is already collected in your city, it is useful to try and integrate that with your HIA. Choose how the data will be analysed (research tools). Core questions should be approved by all stakeholders Establish clear leadership: Make one person responsible for leading the evaluation (this could be an independent assessor or a member of the steering group). Be clear that it is possible that part of the evaluation may extend beyond the end of the HIA, so it is important to get their commitment If possible, at the early stages when proposals and options are first being formulated, convey that an evaluation can further encourage decision- makers and planners to be more conscious of health considerations. 4. Plan for dissemination: You should consider your audiences in order to best communicate with them. Have a range of objectives, and agree in advance to whom they are of interest and how you will report on them. Your objectives should be realistic so that you can show progress towards them. The questions and topics should match the explicit aims and objectives of the HIA; reflect the interests and learning needs of the HIA team; and reflect the specific interests of stakeholders and, if applicable, partners. Be clear on how you will follow up on the recommendations from the HIA, and plan a longer-term communications strategy. 5. Consider resources, costs and benefits: The costs and resources should be clear, and should include skills and experience, time and participation of stakeholders. Keep in mind that the costs can be considerable if you conduct public meetings. Despite the sources that are available to you, remember that some level of evaluation is always beneficial. (Source: Taylor L, Gowman N, & Quigley R (2003))

113 Drivers and Restraints to Using HIA It is often felt that the concept of performing HIA on new and emerging policies and programmes is beneficial. However, time, money and the other resources needed are a major constraint. HIA is not appropriate or necessary for all policies and programmes and therefore organisations should choose carefully to ensure maximum benefit from this process. Even if the full HIA is not deemed necessary it is still good practice to consciously think about the health impacts, both negative and positive, within the planning stages of the policy or programme. Ison (2000) highlights some of the drivers and restraints for the introduction and use of health impact assessment in figure 5.2. Figure 5.2 Health gain as an outcome of policy/action DRIVERS Use of evidence to inform decision making Community participation as an integral part of building social capital Resource constraints Increasing accountability of services to the public/users 112 The introduction and use of HIA Competing interests Tradition of minimal public/ community participation Overcrowded agenda for public services Lack of evidence base and expertise Resource constraints RESTRAINTS Source: Ison, E (2000) (

114 Tools for Action Equity in Health - Tackling Inequalities Experiences of Health Impact Assessment Community Led Health Impact Assessment in Practice: Belfast Healthy Cities Experience The role of the community in HIA varies significantly according to the proposal and who is carrying out the HIA. For many proposals, the integrity of an HIA without community involvement would be seriously compromised. Examples might include a local regeneration project, a housing redevelopment or plans to provide or withdraw services which directly affect a community. In 2003, Belfast Healthy Cities developed a new approach which was intended to ensure that local communities are given the opportunity to fully engage and be active decision-makers in the HIA process. Community Health Impact Assessment (CHIA) combines HIA with community development principles. It differs from HIA in three key ways: 1. The decision on what to carry out the HIA on is made by people who live or work in a specific community; in the pilots, their decision was informed by a written profile of health-related information, statistics and local views, which outlined any proposals for each area which might be suitable for HIA. 2. The decision-making throughout the process is led by an intersectoral Community Steering Group, made up of people who live or work in the community 3. The process is designed to be sustainable in the sense that it builds capacity in the community to continue involvement in decisionmaking around health after the HIA. It therefore includes a significant element of training. CHIA was piloted by Belfast Healthy Cities in in 2 communities: Ballybeen (an urban area) and four rural wards in the Ards Peninsula (Portaferry, Portavogie, Ballywalter and Kircubbin). The diagram on the following page shows the ten stages of the pilot. This approach is not without its limitations. For example, the amount of financial resources and staff time necessary to sustain the process was considerable, and might be a barrier to a community who wanted to carry out CHIA by themselves. Also, while in HIA it is

115 important to engage decision-makers from the outset, with the CHIA pilots, the community were not in a position to make a decision on the subject of the HIA until midway through the process, so only then could the decision-makers be identified and bought in. However, the two pilots were widely perceived by participants to be successful. The training was felt to be useful, as it enabled community members with limited experience of participation in decision-making to fully engage with all aspects of the CHIA process. The Profiles, which were produced by Belfast Healthy Cities and the relevant Community Steering Group, were found to be a valuable resource locally, in particular for funding applications and as a tool for lobbying for more resources to be directed into the area, as well as identifying gaps in provision. The decision-makers of the proposals selected for CHIA also considered the experience to be beneficial, as it provided an additional health element to their consultations. A number of people thought that CHIA was of great benefit in terms of bringing a diverse range of people together, and thus building stronger and more cohesive networks in the community. 114 At the time of writing, the extent to which the recommendations from the CHIA s have influenced the proposals has not been evaluated. Community Health Impact Assessment: Final Report (Belfast Healthy Cities, September 2004) gives a detailed explanation of the pilot process and explores the benefits and risks of carrying out community-led HIA.

116 Tools for Action Equity in Health - Tackling Inequalities The 10 stages in the CHIA pilot Identify and define community Establish Community Steering Group Community profile Provide training The wider determinants of health How large organisations and government departments make decisions and how you might influence them Carrying out a Health Impact Assessment Group facilitation skills 115 Identify and inform stakeholders Screening A tool is used to select a proposal on which to carry out a Health Impact Assessment. This is done at a structured workshop. Information gathering Health Impact Assessment This is done using a Rapid Appraisal Tool at a structured workshop. It can also include less formal formats, such as open events. A report is drawn up which details the recommendations agreed at the workshop. Negotiation Final Report

117 Equity in Health Programme (2002/03) Participants on the Equity in Health programme were given two days of Health Impact Assessment training. During these days participants were asked to consider the benefits of doing a HIA within their organisation and highlight the enablers and disablers that may be encountered in doing this. The results of these workshop activities are recorded in the following two tables. What is the benefit of doing a HIA within your organisation? Identifies health impacts which are not always considered Can identify unanticipated consequences Can be used as a vehicle for bringing issues to the attention of policy makers Used to assess if services provided are effective Informs planning and effective use of resources and identifies priorities May assist in attracting resources and funding The process leads to the development and production of evidence Opportunity to involve the community which will increase organisational transparency HIA provides a structured process for assessment Improves understanding of how policies/projects impact on health Helps identify problems and suggests solutions Flexible can be adapted to a wide variety of policies and projects Provides evidence of impacts to potential funders and improves organisational accountability Validates good practice and highlights areas for improvement Promotes inter-agency working/partnerships Early identification of potential negative impacts so they can be mitigated/avoided Process enables ownership and meaningful interaction with all stakeholders Can provide local meaning to national/global issues/policy Can focus on inequalities and the impacts on vulnerable groups to ensure they are not further disadvantaged Provides a wide range of perspectives looking at all the determinants of health Provides more information to decision-makers to potentially help make better decisions, leading to better outcomes 116

118 Tools for Action Equity in Health - Tackling Inequalities 117 Enablers and Disablers that May be Encountered when Performing a HIA on a Policy/Project Enablers Government Policy/Support for HIA Buy in from top level management Policy agenda supporting consultation Recognition of the added value of HIA and health gain Evidence that it works/ evidence of best practice Good stakeholder participation Active community engagement Local champions for HIA Existing networks and partnerships to work with Resources (time and money) available to complete HIA Training available to improve skills in performing HIA Assurance that recommendations made during the HIA will be considered and acted on Use of an open and transparent process Process used which can be adapted to a wide range of policies and projects Disablers Inadequate resources - time/money Limited or lack of skills/ local expertise Lack of support for the process Limited understanding of HIA Limited access to training Confusing HIA with needs assessment or evaluation Power imbalances Policy or project which has a lot of non-negotiables thereby limiting the scope for change recommended in the HIA Consultation fatigue Crowded agenda Fear of innovation/ resistance to change Organisational culture Lack of baseline information to assist in assessing impacts HIA not perceived as necessary Added value not viewed as relevant Participants had no practical experience of completing a Health Impact Assessment, which obviously had a bearing on the responses given. However, it is clear from these tables that participants felt that there was a real benefit in assessing policies and projects for their impact on health from a planning perspective and a community perspective in terms of influencing decision-making. Issues such as resources to complete HIA, knowledge and skills to perform HIA, and support for the process, were among those highlighted as being both enablers and disablers depending on their availability or provision.

119 References Belfast Healthy Cities (2004) Community Health Impact Assessment: Final Report Ison E (2000) Resource for Health Impact Assessment, NHS Executive London ( Ison E (2002) Rapid Appraisal Tool for Health Impact Assessment A Task Based Approach ( pdf) Institute of Public Health, Ireland (August 2003) Health Impact Assessment Guidance (Draft) ( Taylor L, Gowman N, & Quigley R. (2003) Evaluating Health Impact Assessment. NHS Health Development Agency (UK) ( mt.pdf) Other Suggested Reading Health Development Agency have produced 2 good documents on HIA o Introducing HIA: Informing the decision-making process ( o and Health Impact Assessment: A review of reviews ( Institute of Public Health, Ireland have produced a number of documents available at ( o HIA: An Introductory Paper (2001) o Health Impact Assessment: A baseline report for Ireland and Northern Ireland (2001) o Wraparound: The Health Impact Assessment of the All- Inclusive Wraparound Scheme (2002) London Health Commission their website contains a short guide to HIA and links to other publications ( Liverpool Public Health Observatory produced a HIA 10 minute guide ( 118

120 Tools for Action Equity in Health - Tackling Inequalities 119 Merseyside Guidelines for HIA first edition published by the Liverpool Public Health Observatory (1998), second edition by Alex Scott-Samuel, Martin Birley and Kate Arden (2001) ( HIA Gateway - a resource on HIA coordinated by the Health Development Agency in England, including toolkits and reports on HIAs carried out across England ( IMPACT Consortium - a searchable database of relevant material, as well as information on courses run by the consortium. The IMPACT Consortium is a partnership for professionals working with HIA, and is coordinated by the Department for Health at the University of Liverpool ( London Health Observatory - general resources on HIA as well as details of training courses run by the Observatory ( ent/hia.htm) University of Birmingham, Health Impact Assessment Research Unit - general resources on HIA and information on the Unit's research work ( Office of the First Minister and Deputy First Minister - a portal site to the pilot study of an Integrated Impact Assessment Tool for Northern Ireland ( Health Promotion Division (1999) Developing health impact assessment in Wales, National Assembly for Wales, Cardiff. Available at: healthimp_e.pdf WHO and International sites PHASE project - an EU-funded WHO project led by the Healthy Cities Network aiming to integrate health and sustainable development, which focuses on developing a HIA toolkit for Healthy Cities. The site provides links to WHO and other resources on HIA ( cities/urbanhealthtopics/ _2)

121 Health effects and risks of transport systems (HEARTS) - a WHO research programme aiming to develop tools that integrate HIAs in transport planning and decision making ( WHO HIA web resource - international examples of how HIA is being developed globally, alongside guidance documents and links to a selection of HIA-related sites worldwide ( WHO European Centre for Environment and Health, Rome Office - a programme addressing HIA methods and strategies. The site provides information on methods as well as the legal framework for developing HIA internationally ( Deakin University, Australia produced a HIA: A tool for policy development in Australia ( The Canadian Handbook on Health Impact Assessment: 3 volumes (English language version), see: Under heading EHIA Publications and Reports, click on HIA Handbook. 120 Integrated Impact Assessment and Other Impact Assessments International Association of Impact Assessment (IAIA) - a forum for people involved in any kind of impact assessment. The website contains a list of publications on impact assessment, and provides links to other relevant organisations and websites ( European Commission, Environment - information on Environmental Impact Assessment (EIA), which is related to HIA. The site includes studies and reports, as well as contacts and information on the legal framework of developing EIAs ( ULYSSES - an EU-funded project which focuses on public participation in support of decision-making. The site has a resource on integrated assessment, which is intended to bring together environmental, social and health impact assessments with more traditional risk assessment (

122 Tools for Action Equity in Health - Tackling Inequalities 6. Health Indicators 121 A measurement giving evidence of meeting a goal as well as a visible sign that demonstrates that outcomes have been achieved

123 6.1 Introduction The primary aims of collecting data and setting indicators are to facilitate more evidence-based, rational decision making and priority setting in relation to health planning; to create visibility of health problems; to provide a baseline of information to make comparisons over time; and to assist in monitoring and evaluation of activities/programmes to assess their success. This chapter will focus on indicators of inequalities, community profiling, sources of information for collection of indicators as well as highlighting some of the challenges faced in gathering statistics and data. Definition of an Indicator An indicator is a measurement giving evidence of meeting a goal. Indicators are visible signs that demonstrate that the outcomes are achieved. Indicators can be of a qualitative (descriptive) or quantitative (can be counted) nature. It has become more widely accepted that qualitative indicators are as important as quantitative indicators. In chapter 4 a number of qualitative social capital indicators are outlined which have been developed by Morrissey, McGinn and McDonnell (2003) on behalf of the Voluntary and Community Unit in Northern Ireland, and therefore are not repeated in this chapter. 122 Indicators are often set to measure success and activity within a project/programme. Community Evaluation Northern Ireland (2001) suggest that any model for measuring community-based activity should be: Robust capable of making rigorous judgements on what has been done, with what effect and at what cost, including a comparative element with similar activities Sensitive to the complexities of context including a recognition of the constantly changing environment in which community organisations operate Comprehensible capable of being easily understood by both evaluators and the organisations being evaluated

124 Tools for Action Equity in Health - Tackling Inequalities 123 Ease of use can be employed by a wide range of non-specialists Transparent so that community organisations know what is expected of them Equitable treat all the organisations in the environment with equal fairness. 6.2 Policy Context Within the Investing for Health strategy (2002) a number of objectives and targets have been set and baseline information provided to assist in measuring if targets have been achieved. The strategy indicates that it is not possible to monitor annual progress in relation to a number of these targets as data for these targets is not collected on an annual basis. This highlights the real dilemma that organizations face in general when trying to measure progress and compare trends over a period of time and over a wide geographical area. The choice of indicators which can be set to monitor progress on factors outside the control of an individual organisation is often restricted to data which is currently routinely collected. Northern Ireland Statistics and Research Agency (NISRA) have begun to address this problem through the launch of a Neighbourhood Information Service (NINAS), which provides viewers of this website with a wide range of statistics and information, on both a small and large geographical scale. Data collated on this website is outlined later in this chapter. More work however is needed on setting a wide range of both process/outcome and qualitative/quantitative indicators which are applicable to organizations working in Northern Ireland and are collectable on at least an annual basis. The Office of the First Minister and Deputy First Minister (OFMDFM) in 2002 developed a number of socio-economic indicators which are outlined later in the chapter. Work is currently underway to develop a broader range of indicators to monitor progress in reducing poverty and disadvantage in Northern Ireland. In 2003, OFMDFM and the Department of Finance and Personnel funded research into Poverty and Social Exclusion in Northern Ireland.

125 This study, called Bare Necessities, was published in October 2003, and involved over three thousand people participating in a survey. Hillyard et al (2003) suggests it is the first ever large-scale quantitative study of poverty and social exclusion in Northern Ireland, and it confirms the existence of high levels of these in Northern Ireland. The research provides baseline measurement which can be updated in the future and provides data in relation to section 75 elements of the Northern Ireland Act which may be used as a benchmark against which public authorities can assess the extent to which they have carried out their statutory duties to promote equality. One fact highlighted in the report shows that 37.4% (over a third) of all children in Northern Ireland are being brought up in poverty. Hillyard et al (2003) states that the challenge for Northern Ireland as a whole and the local politicians, is how to reduce these deep fractures of inequality. The full report can be found on the following website: Tools/Frameworks 6.3a Local Basket of Inequalities Indicators In October 2003 Fitzpatrick and Jacobson (London Health Observatory) developed a Local Basket of Inequalities Indicators. The indicators were chosen from a wide range of indicators used by organisations throughout the UK. They were included in the basket of indicators if they meet the following criteria which were agreed: 124 Is the indicator routinely published at local authority or trust level? Is the indicator updateable at at least 3-yearly intervals? Is the indicator robust enough to detect changes over time? Can the indicator be interpreted? If not routinely published, are the data to calculate this indicator routinely collected at trust/local authority level?

126 Tools for Action Equity in Health - Tackling Inequalities 125 Indicators selected for the basket also needed to cover the wider determinants of health; cover the four overarching themes of the UK Programme for Action on health inequalities and national health inequalities targets; cover process as well as outcome indicators; be relevant to all localities; be able to track long and short term drivers of health inequalities and address the measurable dimensions of inequality. All indicators chosen also needed to incorporate 3 basic concepts: 1) Be measurable (e.g. mortality rate, low birth weight rate, unemployment rate) 2) Have an inequality dimension (e.g. social class, ethnicity, geographical area) 3) Be comparable (e.g. rate ratio, range, relative or absolute differences) Within the Basket of Inequalities Indicators document, indicators were listed and information was provided as to who collects this data and at what level, the frequency of collection and whether the data is published or not, and the dimensions of inequality collected (e.g. gender, age, disability etc). In the following 13 tables the indicators chosen for the basket of indicators are listed, and instead of documenting the source of data for the UK, for the purposes of this publication information has been collected providing the source of data within the Eastern Health and Social Services Board Area, and the area/level they are collected.

127 Basket of Indicators 1) Employment, poverty and deprivation addressing the underlying determinant of health Indicator definition Where to source information Area/level collected Contact DETI Statistics Branch Netherleigh, Massey Avenue Belfast BT4 2JP District Council Northern Ireland Department of Enterprise, Trade and Industry (DETI) Census also provides ward level data Those unemployed (International Labour Organisation definition) as % of the economically active population in the area statistics@detini.gov.uk Statistics are collected within the quarterly Labour Force Survey. On request, breakdowns per electoral ward can be made. Northern Ireland Research and Statistics Agency (NISRA) Census Office McAuley House 2-14 Castle Street Belfast BT1 1SA As above As above DETI The proportion of unemployed people claiming benefits who have been out of work for more than a year As above As above DETI The proportion of people of working age in employment 126

128 Tools for Action Equity in Health - Tackling Inequalities 127 Basket of Indicators 1) Employment, poverty and deprivation addressing the underlying determinant of health (continued) DETI as above District Council Northern Ireland DETI DEL DELNI Statistics Department/Tertiary Education Analytical Services Branch Adelaide House 39/49 Adelaide Street Belfast BT2 8FD The proportion of young people (18-24 year olds) in full time education or employment DSD Statistics Branch Room 3, Block 4 The Village Stormont Belfast BT4 3SJ Electoral ward; District Council Northern Ireland Department of Social Development (DSD) The percentage of population of working age who are claiming key benefits (JSA, IB, DLA) NISRA McAuley House 2-14 Castle Street Belfast BT1 1SA deprivation/ default.asp Enumeration district (small area based on postcode); Electoral ward (1984 boundaries); District Council Northern Ireland Index of multiple deprivation Northern Ireland Statistics and Research Agency (NISRA) Last survey was published in 2001 and a review is due in Statistics Branch/Family Resources Survey Room 3, Block 4 The Village Stormont Belfast BT4 3SJ Northern Ireland DSD Family Resources Survey Proportion of children under 16 living in low income households On request, breakdown into Health and Social Services Board level can be made. DSD hopes to produce statistics on Local Government District level from DSD

129 Area/level collected 128 Basket of Indicators 2) Housing and Homelessness Indicator definition Housing District; District Council Northern Ireland Where to source information Number of homeless families with children living in temporary accommodation Northern Ireland Housing Executive (NIHE) Number of unfit homes per 1,000 dwellings (or proportion living in non-decent housing) NIHE DSD (for general housing statistics) Contact District Council Northern Ireland NIHE Housing and Regeneration Department Housing Centre 2 Adelaide Street Belfast BT or local NIHE District Office - NIHE Resources Department Housing Centre 2 Adelaide Street Belfast BT (or local NIHE District Office) - DSD Statistics Branch Room 3, Block 4 The Village Stormont Belfast BT4 3SJ Data on occupied and vacant stock is also available at ward level

130 Tools for Action Equity in Health - Tackling Inequalities 129 Basket of Indicators 3) Education Indicator definition Where to source information Area/level collected Contact DENI Statistics Department Rathgael House 43 Balloo Road Bangor BT19 7PR Individual school; Education and Library Board Northern Ireland Department of Education (DENI) (for all levels) % of 11 year olds achieving expected Level 4 or above in Maths and English at Key Stage 2 Local Education and Library Board (for school and Board level) or local Education and Library Board On request, breakdowns by ward etc can also be made. As above As above As above % of 14 year olds at or above Level 5 in literacy, numeracy, science and ICT at Key Stage 3 As above As above As above % of unauthorised half days missed from primary/secondary schools As above As above As above % of 15 year olds gaining 5 or more GCSEs at A*-C DEL Tertiary Education Analytical Services Branch Adelaide House 39/49 Adelaide Street Belfast BT2 8FD Individual Colleges Northern Ireland Department for Employment and Learning (DEL) Number of enrolments on all adult education courses per 1,000 adult population Statistics are broken down per course and type of study as well as mode of study (full/part time). Local Institutes of Further and Higher Education (for college level) or local Institute of Further and Higher Education

131 Basket of Indicators 4) Crime Engaging Communities and Individuals Indicator definition Where to source information Area/level collected Contact PSNI Statistics Branch Lisnasharragh 42 Montgomery Road Belfast BT6 9LD (Police Exchange) ranch.htm District Command Unit (DCU) Northern Ireland Police Service of Northern Ireland (PSNI) Number of robberies recorded (per 1000 population) On request, breakdowns into ward level can be made. or local DCU As above As above PSNI Vehicle crimes recorded (per 1000 population) As above As above PSNI Violent offences recorded (per 1000 population) PSNI As above As above Domestic burglaries recorded (per 1000 households) 130

132 Tools for Action Equity in Health - Tackling Inequalities 131 Basket of Indicators 5) Pollution and the Physical Environment Area/level collected Where to source information Indicator definition Measuring station District Council area Northern Ireland Contact DoE (NI) Air and Environmental Quality Team 1st Floor, Commonwealth House 35 Castle Street Belfast BT1 1GU EP@doeni.gov.uk r.shtml or local District Council Envir. Department Environment and Heritage Service, Department of the Environment Northern Ireland (DoE) (for measuring station and NI level) local District Council Air pollution a) Number of days per year when air pollution is moderate or higher for PM10 b) Annual average nitrogen dioxide concentration c) For rural sites, number of days per year when air pollution is moderate or higher for ozone

133 Basket of Indicators 6) Community development Engaging Communities and Individuals Indicator definition Where to source information Area/level collected Contact PSNI Statistics Branch Lisnasharragh 42 Montgomery Road Belfast BT6 9LD (Police Exchange) ranch.htm District Command Unit (DCU) Northern Ireland PSNI Number of recorded racial/ sectarian incidents Statistics are broken down per type of incident and target ethnic group. or local DCU 132

134 Tools for Action Equity in Health - Tackling Inequalities 133 Basket of Indicators - 7) Lifestyle Including Diet, Smoking and Physical Activity Area/level collected Where to source information Indicator definition Health and Social Services Board area Northern Ireland Department of Health, Social Services and Public Safety (DHSSPS) (for NI level) Contact DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD &research/ Health and Social Services Board Smoking Cessation Co-ordinators Proportion of people who have set a quit date and remain quit at 4 weeks On request, more detailed statistics from community pharmacies and community groups cessation services can be provided by the Boards. Local Health and Social Services Board (for Board and local level) Electoral Ward; Health and Social Services Trust area; Health and Social Services Board area Northern Ireland Child Health System (managed by Eastern Health and Social Services Board) (for all levels) Child Health System secretariat Eastern Health and Social Services Board Champion House Linenhall Street Belfast BT2 8BS Health and Care Northern Ireland, a portal to all Trusts and Boards in Northern Ireland Proportion of women continuing to smoke throughout pregnancy (those who smoke at delivery as a proportion of total maternities) Local Health and Social Services Trust Local Health and Social Services Board

135 Basket of Indicators - 8) Access to Local Health and Other Services Area/level collected Where to source information Indicator definition Health and Social Services Board area Northern Ireland Local Health and Social Services Board (for Board level) Number of primary care professionals per 100,000 population Central Services Agency (CSA) Medical Directorate (for NI level) As above As above Percentage of patients able to be offered an appointment to see a GP within two working days Contact Central Services Agency Medical Directorate 25 Adelaide Street Belfast BT2 8FH agency.n-i.nhs.uk or local Health and Social Services Board As above As above As above As above Percentage of patients able to be offered an appointment to see a Primary Care Professional within one working day Local Health and Social Services/Hospital Trust Hospitals Northern Ireland Local Health and Social Services/Hospital Trust Proportion of patients admitted, transferred or discharged from A&E within 4 hours 134

136 Tools for Action Equity in Health - Tackling Inequalities 135 Basket of Indicators - 8) Access to Local Health and Other Services (continued) DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD www.dhsspsni.gov.uk/stats &research/ DHSSPS Hospitals; Health and Social Services Board area Northern Ireland Proportion of patients on waiting list that have been waiting more than 6 months for treatment DHSSPS As Above As Above Proportion of patients on waiting list that have been waiting more than 3 months for treatment DHSSPS DAIRU Annex 2, Castle Buildings Stormont Belfast BT4 3SQ dairu@dhsspsni. gov.uk Health and Social Services Board area Northern Ireland DHSSPS Drug and Alcohol Information and Research Unit (DAIRU) % of drug users enrolling on treatment programme Local Drug and Alcohol Co- Ordination Teams

137 136 Basket of Indicators - 9) Accidents and injury services Indicator definition Where to source information Percentage of primary school pupils aged five and over receiving road safety advice during the year Department of the Environment NI (DoE) Local Road Safety Education Branch The number of nursery and primary pupils aged five and over in local education authority schools which have an adopted school travel plan, as a percentage of the total number of nursery and primary pupils aged five and over in local education authority schools Department for Regional Development (DRD) Roads Transportation Branch Contact Road Safety Education Branch BELB area 40 Academy Street Belfast BT1 2NQ Area/level collected Education and Library Board area Northern Ireland Road Safety Education Branch SEELB area Hydebank 4 Hospital Road Belfast BT8 8JL DRD Transportation Unit Avenue House Rosemary Street Belfast BT1 1QE roads.transportation@drdni.gov.uk Northern Ireland (currently only six schools with travel plan)

138 Tools for Action Equity in Health - Tackling Inequalities 137 Basket of Indicators - 9) Accidents and injury services. (continued) PSNI Statistics Branch Lisnasharragh 42 Montgomery Road Belfast BT6 9LD (Police Exchange) ranch.htm or local DCU PSNI Policing sector District Command Unit (DCU) Northern Ireland Number of pedestrian casualties per 100,000 population PSNI As Above As Above Number of road traffic casualties per 1000 resident population DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD &research/ or local Health and Social Services Board Hospitals Northern Ireland DHSSPS Local Health and Social Services Board Directly age-standardised hospital episode rates for serious accidental injury requiring a stay exceeding 3 days per 100,000 population These statistics are not collected routinely, but can be provided on specific request

139 Basket of Indicators - 9) Accidents and injury services. (continued) As Above As Above As Above Number of people killed or seriously injured in Road Traffic Accidents per 100,000 population NISRA General Register Office Oxford House Chichester Street Belfast BT1 4HL census.nisra@dfpni.gov.uk District Councils; Local Health and Social Services Board area Northern Ireland Northern Ireland Research and Statistics Agency (NISRA) Registrar General Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) for accidents Statistics are also broken down by age and sex of victim. 138

140 Tools for Action Equity in Health - Tackling Inequalities 139 Basket of Indicators - 10) Mental health preventing illness and providing effective treatment and care Indicator definition Where to source information Area/level collected Contact DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD Hospitals Northern Ireland DHSSPS Age standardised hospital episode rates for neuroses per 100,000 population Local Health and Social Services Board These statistics are not collected routinely but can be provided on specific request or local Health and Social Services Board Local Health and Social Services Board Local Health and Social Services Board area Local Health and Social Services Board Age-standardised hospital episode rates for schizophrenia per 100,000 population NISRA General Register Office Oxford House Chichester Street Belfast BT1 4HL census.nisra@dfpni.gov.uk District Councils; Local Health and Social Services Board area Northern Ireland NISRA Registrar General Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) from suicide and undetermined injury Statistics are also broken down by method of suicide and available by age group.

141 Basket of Indicators - 11) Maternal, infant and child health Supporting families, mothers and children Indicator definition Where to source information Area/level collected Contact Child Health System secretariat EHSSB Linenhall Street Belfast BT2 8BS Electoral Ward; Local Health and Social Services Trust area; Local Health and Social Services Board area Northern Ireland Child Health System (managed by Eastern Health and Social Services Board) (for all levels) Number of conceptions to girls under 18 per 1000 population aged NISRA (NI level) NISRA General Register Office Oxford House Chichester Street Belfast BT1 4HL census.nisra@dfpni.gov.uk Local Health and Social Services Trusts (ward and Trust level) Local Health and Social Services Boards Health and Care Northern Ireland, a portal to all Trusts and Boards Child Health System secretariat EHSSB Linenhall Street Belfast BT2 8BS As above Child Health System (managed by Eastern Health and Social Services Board) Proportion of total births with a birth weight less than 2500 grams Local Health and Social Services Trusts Health and Care Northern Ireland, a portal to all Trusts and Boards Local Health and Social Services Boards 140

142 Tools for Action Equity in Health - Tackling Inequalities 141 Basket of Indicators - 11) Maternal, infant and child health Supporting families, mothers and children (continued) Child Health System secretariat EHSSB Linenhall Street Belfast BT2 8BS Place of birth (hospital) for neonatal deaths; District Councils; Health and Social Services Board area Northern Ireland Child Health System (for neonatal deaths) Infant mortality rate (three year rate) NISRA Registrar General (for LGD, Board and NI level) NISRA General Register Office Oxford House Chichester Street Belfast BT1 4HL census.nisra@dfpni.gov.uk Health and Care Northern Ireland, a portal to all Trusts and Boards Local Health and Social Services Trust Local Health and Social Services Board DENI Statistics Department Rathgael House 43 Balloo Road Bangor BT19 7PR Education and Library Board Northern Ireland Local Education and Library Board DENI (for NI level) Percentage of teenage mothers participating in education and obtaining qualification at NVQ Level 1 or above Statistics are only available for school age mothers or local Education and Library Board

143 Basket of Indicators - 11) Maternal, infant and child health Supporting families, mothers and children (continued) DHSSPS Social Services Analysis Branch Room C3.23, Castle Buildings Stormont Belfast BT4 3SX p Health and Social Services Trust area; Health and Social Services Board area Northern Ireland Local Health and Social Services Trust The number of childcare places available per 1,000 population Local Area Childcare Partnership at Health and Social Services Board DHSSPS Social Services Inspectorate Or Local Health and Social Services Trust Childcare Team Or Local Area Childcare Partnership DHSSPS Regional Sure Start Co-Ordinator Room C4.8 Castle Buildings Stormont Estate Belfast BT4 3SX DHSSPS Northern Ireland DHSSPS Number of local Sure Start programmes (currently 15 Sure Start programmes across Northern Ireland) 142

144 Tools for Action Equity in Health - Tackling Inequalities 143 Basket of Indicators - 11) Maternal, infant and child health Supporting families, mothers and children (continued) DHSSPS Social Services Analysis Branch Room C3.23, Castle Buildings Stormont Belfast BT4 3SX Electoral Ward; Health and Social Services Trust area; Health and Social Services Board area Northern Ireland DHSSPS Social Services Analysis Branch Local Health and Social Services Trust Percentage of children registered during the year on the Child Protection Register who had been previously registered Local Health and Social Services Board or local Health and Social Services Trust Child Protection Team or local Health and Social Services Board Child Protection Committee Community Dental Service in local Health and Social Services Trust Schools; Health and Social Services Trust area; Health and Social Services Board area Local Health and Social Services Trust (school and Trust level) Percentage of children with active dental decay Dental Health Director in local Health and Social Services Board Local Health and Social Services Board DHSSPS are working on a system for standardising data collection across Northern Ireland, and hope to be able to collate regional level statistics in the future. A UK wide report on child health is published in autumn 2004.

145 Basket of Indicators - 11) Maternal, infant and child health Supporting families, mothers and children (continued) Child Health System secretariat EHSSB Linenhall Street Belfast BT2 8BS Electoral Ward; Health and Social Services Trust area; Health and Social Services Board area Northern Ireland Child Health System Local Health and Social Services Trust % of children reaching their second birthday who were vaccinated against MMR Local Health and Social Services Board Health Protection Agency Communicable Disease Surveillance Centre (NI) McBrien Building, Belfast City Hospital Lisburn Road Belfast BT9 7AB Health Protection Agency (NI level) or local Health and Social Services Trust/Board 144

146 Tools for Action Equity in Health - Tackling Inequalities 145 Basket of Indicators - 12) Older People Area/level collected Where to source information Indicator definition Health and Social Services Board area Northern Ireland Communicable Disease Surveillance Centre (NI) % uptake of influenza immunisation in people aged over 65 Hospitals Northern Ireland Contact Health Protection Agency Communicable Disease Surveillance Centre (NI) McBrien Building, Belfast City Hospital Lisburn Road Belfast BT9 7AB DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD or local Health and Social Services Board DHSSPS Local Health and Social Services Board Admissions to hospital of people aged 75 or over due to hypothermia or injury caused by a fall per 1,000 head of population aged 75 and over Local Health and Social Services Trust These statistics are not collected routinely but can be provided on specific request Local Health and Social Services Trust Health and Social Services Trust area Statistics are available at Health and Social Services Board level as well as regional level, but these will be less exact as they record individuals and each type of care separately. Number of households receiving intensive home help/care as a percentage of all adults and older people in residential and nursing care and households receiving intensive home help/care

147 Basket of Indicators - 12) Older People (continued) DHSSPS Regional Information Branch Annex 2, Castle Buildings Stormont Belfast BT4 3UD Health and Social Services Trust area; Health and Social Services Board area Northern Ireland Local Health and Social Services Trust Proportion of assessments of older people completed by social services within 2 weeks Local Health and Social Services Board DHSSPS Regional Information Branch or local Health and Social Services/Hospital Trust Local Health and Social Services Trust Health and Social Services Trust area Local Health and Social Services Trust Number of carers receiving a formal break from caring To confirm As above As above Local Health and Social Services Trust Local Health and Social Services Board Older people aged 65 or over helped to live at home (per 1,000-65s or over) Statistics available are for care managed persons receiving a care package. Other statistics are also available but less exact as each Trust will record them differently. DHSSPS Social Services Inspectorate 146

148 Tools for Action Equity in Health - Tackling Inequalities 147 Basket of Indicators - 13) Tackling the Major Killers Indicator definition Where to source information Proportion of women aged who have been successfully screened for breast cancer Local Health and Social Services Board Tuberculosis notification rate per 100,000 population (directly standardised rates) Communicable Disease Surveillance Centre (NI) Proportion of those treated waiting more than 3 months for revascularisation DHSSPS Local Health and Social Services Board These statistics are not collected routinely but can be provided on specific request Contact Area/level collected Health and Social Services Board Northern Ireland Northern Ireland Breast Screening Unit in local Health and Social Services Board Health Protection Agency Communicable Disease Surveillance Centre (NI) McBrien Building, Belfast City Hospital Lisburn Road Belfast BT9 7AB Northern Ireland level statistics are also fed into UK and Europe wide reports. DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD or local Health and Social Services Board Hospitals Northern Ireland

149 Hospitals Northern Ireland DHSSPS Proportion of those treated waiting more than 3 months for angiography Local Health and Social Services Board DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD or local Health and Social Services Board These statistics are not collected routinely but can be provided on specific request Local Health and Social Services Board area Local Health and Social Services Board Local Health and Social Services Board Proportion of cancer patients waiting more than one month between diagnosis and treatment Hospitals Northern Ireland DHSSPS Local Health and Social Services Board Number of emergency admissions of children aged under 16 with lower respiratory infections, per 100,000 resident children (age sex standardised) DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD or local Health and Social Services Board These statistics are not collected routinely but can be provided on specific request Hospitals Northern Ireland DHSSPS Emergency admissions to hospital for people of all ages per 1000 people Local Health and Social Services Board DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD or local Health and Social Services Board Basket of Indicators - 13) Tackling the Major Killers (continued) These statistics are not collected routinely but can be provided on specific request 148

150 Tools for Action Equity in Health - Tackling Inequalities 149 Hospitals Northern Ireland DHSSPS Local Health and Social Services Board DHSSPS Regional Information Branch Annex 2, Castle Buildings Belfast BT4 3UD or local Health and Social Services Board Proportion of people admitted for stroke, admitted to a hospital with a specialised stroke service These statistics are not collected routinely but can be provided on specific request District Councils; Local Health and Social Services Board area Northern Ireland NISRA General Register Office Oxford House Chichester Street Belfast BT1 4HL census.nisra@dfpni.gov.uk NISRA Registrar General Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) from circulatory disease for those aged under 75 Electoral Ward; District Councils; Local Health and Social Services Board area Northern Ireland Northern Ireland Cancer Registry Northern Ireland Cancer Registry Department of Epidemiology and Public Health Queen s University of Belfast Mulhouse Building Grosvenor Road Belfast BT12 6BJ nicr@qub.ac.uk Basket of Indicators - 13) Tackling the Major Killers (continued) NISRA Registrar General Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) from cancer for those aged under 75

151 Basket of Indicators - 13) Tackling the Major Killers (continued) NISRA General Register Office Oxford House Chichester Street Belfast BT1 4HL census.nisra@dfpni.gov.uk As above As above NISRA Registrar General Age-standardised mortality rate from lung cancer for those aged under 75 Northern Ireland As above Life expectancy at birth NISRA Registrar General 150

152 Tools for Action Equity in Health - Tackling Inequalities Experiences of Sourcing Indicators Equity in Health (2002/03) - Setting Indicators Workshop activity during the Equity in Health training days provided the following responses from participants on the programme in relation to criteria which they felt they could use to select indicators relevant to health inequalities. Data collected for indicators should be: Routinely available Available on a community/geographical level Useful for policy/decision makers Allowing for comparison over time Simple everyone can understand Pick up statistically significant changes at national and local level Valid Non-discriminatory (equity audit) Agreed by all partners Credible Provide a range of indicators qualitative/quantitative Quantifiable measurable also qualitative Reliable, robust, readable, reusable, reflects trends, retrievable, recent This set of criteria could be applied to any programme or project to assist in choosing appropriate indicators.

153 Community Profiling: Belfast Healthy Cities Experience In March 2004 Belfast Healthy Cities produced 2 community profiles as part of the process for a Community Health Impact Assessment project that was being implemented at that time within a rural and urban setting. The purpose of the profiles was to provide information on the many factors which contribute to good health in the community. Experience in preparing these profiles highlighted the problems faced in obtaining information at a local level. Apart from data collected by Northern Ireland Statistics and Research Agency (NISRA) there was a lack of consistency in the collection of information available at a ward level by other organisations. Outlined in the following section are a number of indicators which may impact directly or indirectly on health. These indicators are listed under 9 categories: demography, health and health behaviour, housing, transport, employment, environment, essential services, education, and voluntary, community and private provision. 152 Gathering information on all of the wider determinants of health goes beyond what is normally brought together in statistical publications in Northern Ireland, for example statutory organisations often only produce statistics and indicators for their area of work alone.

154 Tools for Action Equity in Health - Tackling Inequalities 153 Challenges of Gathering Statistics/Data The task of gathering statistics and information for local community profiles is not always an easy one. Some of the challenges faced during the process of compiling community profiles for the Community Health Impact Assessment project included: Difficulty in obtaining information at ward level a number of statistics are only available at either a health or education board level, district council or Northern Ireland level and are therefore not directly applicable to a small locality The process of accessing the appropriate person within an organisation who could provide the appropriate information or statistics was not always straightforward. Large organisations which have a research branch/department were more accessible On a few occasions there were conflicting messages regarding information which was collected depending on the person(s) spoken to In some cases the unavailability of relevant data at a local level severely limited the range of information which could be provided within the profile Inconsistencies were found between statistics which were collected between branches of the same organisation Difficulties arose over sourcing statistics over a time period to make comparisons Sourcing anecdotal information to assist in interpreting information collected as well as providing local insights into the area was essential but required skill and time In some cases figures at ward level were too small to give out publicly to protect anonymity e.g. education statistics To obtain information at a local/ward level often required making a special request to the appropriate agencies to source this information it was not readily available on agencies websites or in their publications The following tables have been included in this chapter only as an example of the type of statistics that can easily be collected for a small geographical area.

155 Community Profiling - 1) Demography Where to source this information Indicator Definition NISRA (Census Output age structure table) Census2001Output/KeyStatistics/ keystatrep.html Area/level collected/available Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency (as census data is only collected every 10 years this is a limitation to its relevance over time) Age of the population NISRA (Census Output usually resident population table) Census2001Output/KeyStatistics/ keystatrep.html Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency Population density (number of persons per area in hectares) 154

156 Tools for Action Equity in Health - Tackling Inequalities 155 Community Profiling - 2) Health and Health Behaviour Area/level collected/available Where to source this information Indicator Definition Collected by male/female/age ranges per electoral ward level. Social Security Agency/ DSD website Persons claiming Disability Living Allowance (DLA) Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency Population by long-term illness NISRA (Census Output households with dependent children and households with limiting long-term illness table) Census2001Output/KeyStatistics/ keystatrep.html District council and health board level Registrar General, NISRA (general register office) Standardised death rates (listed per condition/disease) Incidence of cancers NI cancer registry Electoral ward level, district council level, and board level Individual schools, HSS Trusts and Boards Individual schools, HSS Trust level and board level Dental health recorded as dmf rates (decayed, missing and filled teeth) Electoral ward level, health and social services trust level and board level Child Health System -information can be obtained via the health boards Immunisation uptake rates of: Diphtheria, Tetanus and Polio at 2nd birthday (as a proxy for all primary vaccinations)

157 Community Profiling - 2) Health and Health Behaviour (continued) Electoral ward level, trust level and board level Child Health System -information can be obtained via the health boards Immunisation uptake of measles, mumps and rubella at 2nd birthday Electoral ward level, trust level and board level Child Health System -information can be obtained via the health boards Low birth weight incidence in singleton term births Electoral ward level, trust level and board level Teenage pregnancies Child Health System -information can be obtained via the health boards Electoral ward level, trust level and board level (Breast feeding rates at 7 months are also collected although inconsistencies currently arise in accuracy between areas) Breast feeding (rates at discharge from hospital) Child Health System -information can be obtained via the health boards Many more statistics on health and health behaviour are available at a Northern Ireland level. These are not outlined in the above table as they were not available at local level and therefore deemed not as applicable to the purpose of the profiles developed by Belfast Healthy Cities i.e. to create a local picture and profile of a small geographical area. 156

158 Tools for Action Equity in Health - Tackling Inequalities 157 Community Profiling - 3) Housing Where to source this information Indicator Definition Electoral ward level (based on 1984 ward boundaries) (figures up to 2001 only) Noble Deprivation Indicators found on NISRA website Housing stress as an indicator of social disadvantage Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency NISRA (Census Output rooms, amenities, central heating and lowest floor level table) Census2001Output/KeyStatistics/ keystatrep.html Area/level collected/available District housing areas; District council area Percentage of households without central heating as a proxy for fuel poverty Homelessness District Housing Plans/ Housing Executive Community Profiling - 4) Transport Where to source this information Indicator Definition Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency NISRA (Census Output Cars or Vans table) Census2001Output/KeyStatistics/ keystatrep.html Area/level collected/available Electoral ward level (based on 1984 ward boundaries) (figures up to 2001 only) Car ownership (which has an impact on access to services) Access to essential services Noble Deprivation Indicators found on NISRA website

159 Community Profiling - 5) Employment Area/level collected/available Where to source this information Indicator Definition Electoral ward level, information published on website twice a year DSD website Persons claiming job seekers allowance Electoral ward level (based on 1984 ward boundaries) (figures up to 2001 only) Noble Deprivation Indicators found on NISRA website Deprivation score by income (score constructed using counts of adults in families in receipt of means tested benefits) Community Profiling - 6) Environment Area/level collected/available Where to source this information Indicator Definition Monitoring stations spread throughout the country District councils Air quality Results recorded at district council level Radiation (ionising; radon and non-ionising Department of the Environment (DOE) website Environment and heritage service - radiation/radiation.shtml. Information also provided by district councils. River quality DOE Water Management Unit Assessments completed on all rivers and results provided on request 27 sites are monitored throughout NI water quality is tested on 20 occasions between June and mid-september - results are provided on request Bathing water quality DOE website Environment and heritage service environment.shtml 158

160 Tools for Action Equity in Health - Tackling Inequalities 159 Community Profiling - 7) Essential Services Area/level collected/available Where to source this information Indicator Definition Results recorded per district command unit provided on request Police Service for Northern Ireland (PSNI) statistics branch (see also Number of domestic violence offences PSNI statistics branch District command unit area, ward level, and area covered by each police station Notifiable offences (e.g. burglary, criminal damage, sexual offences, fraud etc) Recorded per fire station each month available on request Northern Ireland Fire Brigade HQ Statistics Branch Number and type of incidences attended by the fire brigade Community Profiling - 8) Education Area/level collected/available Where to source this information Indicator Definition Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency NISRA (Census Output qualifications and students table) Census2001Output/KeyStatistics/ keystatrep.html Population by range of qualifications Electoral ward level, school available on request Department of Education (DENI) Destination of school leavers (into higher, further education, or employment/ unemployment)

161 Community Profiling - 9) Voluntary, Community and Private Provision Area/level collected/available Where to source this information Indicator Definition Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency NISRA (Census Output health and provision of unpaid care table) Census2001Output/KeyStatistics/ keystatrep.html Provision of unpaid health care Electoral Ward level; output level; local District Council, Health and Social Service Boards, Education and Library Boards, Parliamentary Constituency Lone parents in employment NISRA (Census Output lone parent households with dependent children table) Census2001Output/KeyStatistics/ HSS trusts Electoral ward level, trust and board level Number of childminders versus the child population The 9 tables above only scratch the surface on the type of information that is collected on factors which have an impact on the health of the population either directly or indirectly. As mentioned earlier a lot more information is collected either at a health board, district council or Northern Ireland level. However, difficulties arise in sourcing information at a smaller geographical area. 160

162 Tools for Action Equity in Health - Tackling Inequalities New TSN Evaluation Socio-Economic Indicators In December 2002 OFMDFM produced a document outlining Socio- Economic Indicators for Northern Ireland. These indicators focused on what they saw as the key stages of the life cycle: children, young adults, adults and older people, a selection of macro socio-economic indicators were also produced. These indicators and their source are recorded in the following table. In the development of the indicators it was highlighted that the main limiting factor was the absence of robust and reliable income information and therefore a number of indicators were chosen to act as a proxy for this data. The report also highlighted that some sources of data are only collected every 5 years (e.g. Northern Ireland House Conditions Survey) as opposed to yearly, which in itself has limitations in terms of how up to date they are. Socio-Economic Indicators 161 Group Children Indicator 1.1 Incidence of low birth weight babies 1.2 The proportion of children living in workless households 1.3 The number of children living in families claiming a key benefit 1.4 The proportion of school leavers achieving no qualifications 1.5 The proportion of children achieving no GCSE s 1.6 The proportion of children not achieving 5+ GCSE s (A* - G) 1.7 The proportion of children not achieving 5+ GCSE s (A* - C) 1.8 The number of births to mothers aged under The proportion of households with at least one child that live in homes that are unfit 1.10 The proportion of children that live in homes that are below bedroom standard Source 1.1 DHSSPS 1.2 DETI: Labour Force Survey 1.3 DSD 1.4 DE 1.5 DE 1.11 The number of children aged under 16 in residential care 1.6 DE 1.7 DE 1.8 DHSSPS 1.9 NIHE: House Conditions Survey 1.10 NISRA: Continuous Household Survey 1.11 DHSSPS

163 Socio-Economic Indicators Young Adults 2.1 The proportion of young adults aged between who are unemployed 2.2 The proportion of young adults aged between who do not have a basic education (NVQ level 2 or equivalent) DETI: Labour Force Survey Adults 3.1 The proportion of working age adults who are in employment 3.2 The proportion of working age adults who are unemployed 3.3 The proportion of working age adults living in workless households 3.4 The proportion of working age adults with disabilities in employment 3.5 The proportion of working age lone parents in employment 3.6 The proportion of those aged over 50 in employment 3.7 The proportion of working age people without a qualification 3.8 The proportion of working age people who would like paid work but do not have it 3.9 The proportion of workless households where the head of household is long-term unemployed DETI: Labour Force Survey 162 Older People 4.1 The proportion of pensioners with no income other than state retirement pension and state benefits 4.2 Pensioners household weekly spend on necessities NISRA: Family Expenditure Survey 4.3 The proportion of households where the head of the household is aged 60 or over that live in homes that are unfit 4.3 NIHE: House Conditions Survey

164 Tools for Action Equity in Health - Tackling Inequalities 163 Socio-Economic Indicators Macro Indicators 5.1 The sources of household income by quartile or gross weekly household income 5.2 The number of working age people in receipt of a key benefit 5.3 The number of individuals claiming Job Seekers Allowance or Income Support for a period of 2 years or more 5.4 The proportion of households which are workless 5.5 The proportion of households that live in homes that are unfit 5.6 The proportion of households that live in homes below the bedroom standard 5.7 The proportion of economically active working age people who are long-term unemployed 5.8 Life expectancy at birth 5.9 Self perceived general health status 5.10 The proportion of work rich households 5.11 The proportion of lone parent households 5.1 NISRA: Family Expenditure Survey DSD 5.4 DETI: Labour Force Survey 5.5 NIHE: House Conditions Survey 5.6 NISRA: Continuous Household survey 5.7 DETI: Labour Force Survey 5.8 NISRA: GRO 5.9 Continuous Household Survey DETI: Labour Force Survey (OFMDFM, 2002) Within the consultation document New TSN the Way Forward (OFMDFM, April 2004) mention is given to the development of a broader range of statistical indicators to monitor more generally progress in reducing poverty and disadvantage in Northern Ireland. These indicators will be developed and available by the end of the year (2004) and will be published at a Northern Ireland level presenting statistics based on various groups of people (e.g. older people etc) as opposed to a geographical level (Research Branch, OFMDFM, 2004).

165 Local Sources of Statistical Information - NISRA In June 2003 a Neighbourhood Information Service was launched ( which allows free access to information and statistics on a wide range of issues and can be searched for on a small geographical area basis. The table below outlines the datasets that are currently available on this website. Datasets Available on the NINIS Website Theme Agriculture, Fishing and Forestry Dataset available DARD Farm Census results Lowest level of detail Electoral Ward and above Education & Training Free School Meals Ward and above School Leavers Data Higher Education Data Further Education Data Ward and above Ward and above Ward and above 164 Health & Care Hospital Episodes (FCEs) Ward and above Population and Migration GP Registrations Dental Registrations Vital Statistics (Births/Deaths) 2001 Census Key Statistics Population Estimates Ward and above Ward and above Ward and above OA and above District council Social and Welfare Income Support Ward and above Disability Living Allowance Attendance Allowance Incapacity Benefit Severe Disablement Allowance Ward and above Ward and above Ward and above Ward and above

166 Tools for Action Equity in Health - Tackling Inequalities Datasets Available on the NINIS Website Housing Benefit Child Benefit Jobseeker s Allowance Retirement Pension Widow s Benefit Ward and above Ward and above Ward and above Ward and above Ward and above Transport, Travel & Tourism Crime & Justice Commerce, Energy & Industry Car Registrations Notifiable Offences Recorded Registered Companies Ward and above Ward and above District council 165 Natural & Built Environment New Dwelling Starts District council Labour Market New Earnings Survey District council Other Housing Labour Force Survey Employment Data Location of Social Security Offices Location of Post Offices Location of Pharmacists Location of Opticians Location of Dentists Location of GPs Results of the Northern Ireland Housing Executive House Conditions Survey (2001) District council District council Northern Ireland Northern Ireland Northern Ireland Northern Ireland Northern Ireland Northern Ireland Full survey report available at: HCS/

167 Datasets Available on the NINIS Website Employment Census of Employment statistics (2001) this provides survey information on the nature and Local District council level; Assembly Area and, Electoral Ward level characteristics of nonagricultural businesses. This census is conducted every two years in NI. Domestic properties (from Rate Collection Agency s database) Counts of property with a rateable value of 20 or over Local District council level; Assembly Area and Electoral Ward level Domestic Property information (compiled from the Valuation and Lands Agency s (VLA) Valuation List Counts of property by type Local District council level; Assembly Area and Electoral Ward level 166 Births and deaths Births, deaths, stillbirths and infant deaths, and the major causes of deaths collected by quarter year and gender District council Mid Year Population Estimates (2002) Breakdown of the population by age and gender Local District Council, Health and Social Services Board, Education and Library Board, Parliamentary Constituency and Northern Ireland levels (source:

168 Tools for Action Equity in Health - Tackling Inequalities NISRA have also developed a new website for the Social Survey function The Central Survey Unit (CSU) manages the Northern Ireland fieldwork on a number of regular national and European surveys, such as: Labour Force Survey National Food Survey Family Expenditure Survey Expenditure and Food Survey. The Unit conducts a number of Northern Ireland specific surveys including the Continuous Household Survey (which is the NI equivalent of the GB General Household Survey) and the Northern Ireland Travel Survey on behalf of Government Departments in Northern Ireland. The Unit also conducts large scale commissioned surveys for Departments and non-departmental bodies e.g. 167 Health and Social Well Being Survey International Adult Literacy Survey Health Behaviour of School Children Survey Northern Ireland Crime Survey The methodology, questionnaire and results of the following surveys can be found on the central survey unit site: Adult Literacy Survey Child of the New Century Survey Continuous Household Survey Crime and Justice Survey Expenditure and Food Survey Family Resources Survey Health and Social Wellbeing Survey Labour Force Survey Northern Ireland Household Panel Survey Northern Ireland Quarterly Construction Enquiry Omnibus Survey Poverty and Social Exclusion Programme for International Student Assessment Social survey of Farmers Travel Survey Young Persons Behaviour and Attitudes survey

169 References DHSSPS (2004) Equality and Inequalities in Health and Social Care in Northern Ireland A Statistical Overview Fitzpatrick J, and Jacobson B (October 2003) Local Basket of Inequalities Indicators, London Health Observatory, Association of Public Health Observatories and Health Development Agency ( asket.htm) Hillyard P, Kelly g, McLaughlin E, Patsios D and Tomlinson M (2003) Bare Necessities Poverty and Social Exclusion in Northern Ireland, Key Findings, Democratic Dialogue (document available at: OFMDFM (April 2004) New TSN the Way Forward: Towards an Anti-Poverty Strategy OFMDFM (December 2002) Evaluation of New TSN Socio- Economic Indicators for Northern Ireland, WHO (2001) Analysis of Baseline Healthy Cities Indicators, National Institute of Public Health in Denmark, WHO Regional Office for Europe, Centre for Urban Health 168 Other Suggested Reading Public Health Institute of Scotland (PHIS) have developed 15 community profiles across Scotland providing information on 49 indicators these profiles can be accessed on Vermont Communities Count: Using Results to Strengthen Services for Families and Children (1999) Vermont have developed 51 social well-being indicators categorised under 8 health outcomes with the aim of tracking these outcomes. This document can be accessed on

170 Tools for Action Equity in Health - Tackling Inequalities Notes 169

171

172