Reframing “participation” and “inclusion” in public health policy and practice to address health inequalities: Evidence from a major resident‐led neighbourhood improvement initiative

Abstract

There is a need for greater conceptual clarity in place-based initiatives that seek to give residents of disadvantaged neighbourhoods more control over action to address the social determinants of health inequalities at a local level. In this article, we address this issue as it relates to the concepts of participation and inclusion. We draw on qualitative data generated during the first phase of the Communities in Control Study, a longitudinal multisite independent evaluation of the impact of Big Local on the social determinants of health and health inequalities. Big Local is a resident-led area improvement initiative in England, funded by the UK Big Lottery Fund. Initiatives focused on community empowerment are increasingly prominent in public health policy and practice globally. Approaches emphasise the promotion of greater control over decisions and action among individuals, groups, and communities, particularly those living in disadvantaged circumstances. However, when it comes to participation and inclusion in taking action and making decisions, the field is characterised by conceptual confusion. This risks undermining the impact of these initiatives. While participation and inclusion are necessary conditions for empowerment and collective control, they are not necessarily sufficient. Sufficiency requires attention to the breadth of participation (i.e., to inclusion) and to the depth of participation (i.e., the extent to which it is experienced as empowering and ultimately enables the exercise of collective control over decisions and actions). In observing how different Big Local resident-led partnerships across England are tackling the day-to-day challenges of engaging with their communities, we reveal the potential for policy and practice of reframing, and therefore clarifying (to highlight the different roles they have) the concepts of participation and inclusion in terms of depth and breadth.

Increasing Public Participation and Influence in Local Decision-making to Address Social Determinants of Health During Times of Resource Constraint: A Systematic Review Examining Initiatives and Theories

“…Speci c activities recommended to support participation and in uence included: the use of threedimensional graphics (33), use of virtual tools to help visualise a local area, social media, geographical information systems and decision support systems (30), newsletters and establishment of a communication plan (34). Paying attention to mechanisms for sharing information with the wider community was reported to be key (35), with clear feedback and demonstration of commitment required (36).…”

“…Theoretical papers therefore highlighted that approaches should involve a set of activities functioning together to support public participation and in uence (rather than just "one" intervention). Empirical papers similarly emphasised that differing forms of activity may be required to be in uential within decision-making (39-41), and that activities will differ depending on context (42) and the breadth, depth and reach intended (34). While much of public involvement tends to be "top down" (30,32,43,44), the literature emphasised the importance of moving towards a "bottom up" approach; starting from the communities' agendas and not the organisations' (39, 40).…”

“…The need for formal and organised involvement strategies was emphasised (41), together with having an organisation policy in place to drive change (47). There should be strengthening of people's perception of the possibilities (51), and effective governance to support and drive through initiatives (34).…”

“…A sizeable volume of studies highlighted challenges in involving a wide cross-section of any community in involvement initiatives (34,35,41,(45)(46)(47)(56)(57)(58). Authors noted the often small number of individuals participating, and that increased involvement/in uence often did not extend beyond "the few", with a particular need to empower those who are typically excluded.…”

“…The literature emphasised that the concept of "communities" is often unclear and uid, creating challenges to increasing community involvement. Authors described how some residents may not identify with a geographical area, that changes in the demographic of the local area can adversely in uence the cohesiveness of a community, and how there can be shifting concepts of community boundaries (34,40,45,46,57,59,60). Cultural variance was noted as important to recognise, with language and literacy affecting whether and how some members of a community participate (39).…”