What is known about this topic dCommunity engagement is central to many health improvement programmes. dCommunity engagement involves a range of strategies from simple consultation to community control. Evidence of the impact of community engagement on 'engaged' individuals is limited. What this paper adds dThe majority of individuals perceive benefits from community engagement -for physical and psychological health, self-confidence and esteem, personal empowerment and social relationships. For some individuals there are unintended adverse consequences of community engagement, such as exhaustion and stress, which may pose a risk to well-being. Potential adverse consequences need to be considered by those planning community engagement initiatives. AbstractCommunity engagement is central to strategies to promote health and well-being and reduce health inequalities in many countries, particularly interventions which focus on improving health in disadvantaged populations. Despite the widespread use of community engagement approaches, however, there have been relatively few attempts to review the evidence on the impact that participation has on the lives of individuals involved. Drawing on a wider review of evidence carried out on behalf of the National Institute for Health and Clinical Excellence (NICE), this article reports on a rapid review of evidence of the effectiveness of initiatives which seek to engage communities in action to address the wider social determinants of health, to explore individuals' subjective experiences of engagement. The rapid review process was guided by NICE's public health methods manual, adapted to suit the diversity of the evidence. A total of 22 studies were identified containing empirical data on subjective experiences of community engagement for individuals. The findings of the rapid review suggest that the majority of 'engaged' individuals perceived benefits for their physical and psychological health, self-confidence, selfesteem, sense of personal empowerment and social relationships. Set against these positive outcomes, however, the evidence suggests that there are unintended negative consequences of community engagement for some individuals, which may pose a risk to well-being. These consequences included exhaustion and stress, as involvement drained participants' energy levels as well as time and financial resources. The physical demands of engagement were reported as particularly onerous by individuals with disabilities. Consultation fatigue and disappointment were negative consequences for some participants who had experienced successive waves of engagement initiatives. For some individuals, engagement may involve a process of negotiation between gains and losses. This complexity needs to be more widely recognised among those who seek to engage communities.

The World Health Organization's Commission on Social Determinants of Health has called for 'health equity impact assessments' of all economic agreements, market regulation and public policies. We carried out an international study to clarify if existing health impact assessment (HIA) methods are adequate for the task of global health equity assessments. We triangulated data from a scoping review of the international literature, in-depth interviews with health equity and HIA experts and an international stakeholder workshop. We found that equity is not addressed adequately in HIAs for a variety of reasons, including inadequate guidance, absence of definitions, poor data and evidence, perceived lack of methods and tools and practitioner unwillingness or inability to address values like fairness and social justice. Current methods can address immediate, 'downstream' factors, but not the root causes of inequity. Extending HIAs to cover macro policy and global equity issues will require new tools to address macroeconomic policies, historical roots of inequities and upstream causes like power imbalances. More sensitive, participatory methods are also required. There is, however, no need for the development of a completely new methodology.

The social determinants of health are increasingly receiving international attention since the publication of the World Health Organization's Commission on the Social Determinants of Health in 2008. How different determinants affect health is much debated. Contrasting suggestions include, for example, a major link with socio-economic inequalities, lack of social status and psychosocial stress or the extent of the welfare state. Others emphasise the need to understand the socio-cultural contexts of specific situations. Diet-related health is a good example of the relationship between poor health outcomes and deprivation. The aim of this paper is to explore the specific conditions and contexts that might reduce or exacerbate the provision of a healthy diet to children under 5 years in a range of nurseries supported by the Sure Start Local Programmes initiative in Liverpool. An ethnographic approach was taken to gather data from six nurseries, combining observation at the nurseries with interviews with owners and or managers (10), cooks (6), staff (12) and parents (2). The findings reveal the complex way different issues work together to support or hinder a nursery to develop a healthy eating culture and how relative inequalities, in general, are outworked. While recognising the importance of social status leading to poor health due to psychosocial stress, the findings tend to emphasise the importance of a strong welfare state and taking an early years of life-course approach in reducing health inequalities.