Title: What are the health and health inequalities impacts of the Big Local community empowerment initiative in England?
Funder: Department of Health and Social Care

Abstract: We propose to investigate health and social outcomes at the population level and amongst engaged residents of the community engagement approach adopted in an area-based empowerment initiative. The initiative, Big Local (BL), being implemented in 150 relatively disadvantaged areas across England, is funded by the Big Lottery Fund. It is noteworthy in its attempt to create empowering conditions, rather than engaging communities for health promotion purposes. In theory, such an initiative has potential to improve health via several pathways. First collective action by communities may improve local social determinants of health e.g. by improving transport, quality of green spaces, and reducing place-based stigma.. Second, collective action by residents may reduce social isolation and improve mental health. Third, feeling more in control over decisions that affect your life may have direct health benefits. An evaluation of BL offers a unique opportunity to generate much needed evidence on how best to design and implement community empowerment initiatives to maximize positive impacts on health and health inequalities. The proposal builds on our current research on BL funded by the NIHR School for Public Health Research (SPHR. We developed a novel systems approach for this evaluation and collected base-line data for the longer term follow up that we now propose the objectives of which are to: (1) Investigate longer-term health and social outcomes of BL's approach to community engagement at population health level; (2) Investigate impact of active involvement in BL on health and well-being of engaged residents (3) Assess changes in collective control amongst BL residents and identify any resulting improvements/deteriorations in social determinants of health. (4) Illuminate pathways to changes in collective control by BL residents and to health and social impacts, including dampening/amplifying processes (5) Conduct an economic evaluation of BL (6) Draw out policy/practice and research implications for future community engagement strategies. We propose four work packages (WPs). WP1 uses a difference-in-differences design to investigate the impact of BL on population outcomes in all 150 BL areas compared to matched comparator areas (created by propensity score matching). The primary outcome is mental health measured by self reported anxiety from the ONS Annual Population Survey. The secondary outcomes include antidepressant prescribing, rates of hospital presentation for self harm and rates of recorded crime. WP2 assesses impacts of active engagement in BL on health and social outcomes. The primary outcomes are mental wellbeing, plus changes in perceived control using secondary data from a biannual longitudinal survey conducted by Local Trust of all BL partnership board members in all 150 BL areas. WP3 will conduct qualitative research in 15 BL neighbourhoods to understand pathways to impact using a systems change framework. A central focus of this fieldwork will be investigation of 15 Critical Collective Control episodes exploring how residents act together to improve their neighbourhoods and identifying positive and negative impacts. WP4 assesses economic impact of Big Local, comprising assessment of: costs of changes in mental wellbeing amongst BL residents compared to matched comparitors; any spill over effects areas; cost-benefit analysis in15 fieldwork neighbourhoods ; and any costs savings to the NHS.

Lay abstract: This proposal is answering the NIHR call for commissioned research on health-related impacts of community engagement initiatives. We propose an evaluation of a large initiative in England seeking to increase the control communities have over improvements in their neighbourhoods. The initiative is called the Big Local. Funded by the Big Lottery, Big Local is taking place in 150 areas. In each area residents are given £1 million over ten years to use as they see fit to make their area “an even better place to live”. The idea is that residents will have complete control over decisions about how the money is spent, with support from an independent organisation, Local Trust - set up to be supportive, not controlling. In theory, when residents of disadvantaged communities join together to take action for mutual benefit, this could lead to health benefits. Direct effects could include deflecting health hazards or attracting greater resources to the area to create a healthier environment. Indirect effects could include reduction in social isolation and improvement in mental health as people participate in various activities together. Feeling more in control of decisions that impact on your life can also have health benefits. Our research aims to investigate health and social impacts of Big Local approaches to community empowerment and to draw out lessons for the development of future community engagement interventions. We will build on findings from two preliminary studies we have conducted funded by NIHR School for Public Health Research, which provide a baseline for our proposed study. This will investigate longer-term outcome and processes that lead to these in 4 main work packages: WP1 will analyse existing surveys to measure changes in anxiety and mental health among the population of Big Local areas over time compared with changes in comparison areas. WP2 will analyse 3 waves of a survey of engaged residents of all 150 Big Local areas, carried out by Local Trust. We will follow a panel of residents over 4 years to identify what, if any, impacts Big Local had on residents who have participated directly in the initiative. WP3 will conduct in-depth qualitative work with residents and other participants in 15 Big Local areas to understand the processes and pathways leading from greater collective control by residents over resources to positive or negative health effects. We will investigate some of the diverse ways in which residents act together to improve their neighbourhoods and identify the factors that help or hinder these processes. WP4 will conduct an economic evaluation of Big Local. We will then draw out learning for future community empowerment interventions. Public involvement has been integral to all stages of our earlier BL research. This will continue in the proposed study. The fifteen members of our existing BL Resident Network will take part in face-to-face and telephone meetings over the life of the project to help shape the research and outputs. we will also have regular meetings with Local Trust which oversees the programme nationally. Our team includes academic staff from 5 universities: Lancaster, Liverpool, Newcastle, Durham and LSHTM. We have all worked together in the past on community engagement initiatives and form a multi-disciplinary team with complementary expertise working in collaboration with our resident advisers and with input from Public Health Professionals.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH