Valuing the health and wellbeing aspects of Community Empowerment (CE) in an Urban Regeneration context using economic evaluation techniques

Health Economics & Health Technology Assessment
Valuing the health and wellbeing aspects of
Community Empowerment (CE) in an Urban
Regeneration context using economic evaluation
techniques
May 2016
Camilla Baba
Supervisors: Dr. Emma McIntosh & Prof. Carol Tannahill

• Defining ‘community empowerment’ and ‘urban regeneration’?
• Urban regeneration programmes as a form of PHI
• Current UK Urban Regeneration Policy
• Identifying community empowerment as an outcome and intermediate
outcome of urban regeneration programmes
» Systematic review with narrative synthesis
» Secondary analyses of Glasgow’s GoWell programme (empowerment
question)
• Measuring and valuing community empowerment
» Economic evaluations of urban regeneration
» Discrete Choice Experiment (DCE) Methodology
» Results
• Implications for policy and practice
1
Presentation Overview

Health Economics & Health Technology Assessment 2
What is ‘community empowerment’
(CE)?
“Community empowerment is a process where
people work together to make change happen in their
communities by having more power and influence over
what matters to them” (COSLA and Scottish
Government, 2009:8).
“By Empowerment I mean our aim should be to
enhance the possibilities for people to control their
own lives” (Rappaport, 1987:119).

“Realising the potential of people and places is at the heart of
the Scottish Government's approach to regeneration.
Successful regeneration demands a combination of economic
development, housing and environmental investment, better
public services, improved workforce skills, support for
community involvement, a commitment to environmental
quality and good design; and respect for local identity and the
historic features which contribute to it”
(Scottish Government, 2009).
3
What is ‘urban regeneration’?

“Urban environments typically constructed for social and cultural reasons, can
create health inequalities within the urban landscape [...] urban regeneration is an
important public health intervention and that by changing the urban physical,
social and economic environment this can facilitate health development for
disadvantaged communities” (MacGregor, 2010:38).
4
Urban regeneration
programmes: A form of
Population Health Intervention

• Since the 1990s UK policies have sought to promote a more participatory
approach, encouraging communities to have a direct impact on the decision-
making process
» Examples are of this are evident in publications such as ‘Promoting Effective
Citizenship and Community Empowerment’ (ODPM, 2006),
» ‘An Action Plan for Community Empowerment’ (DCLG, 2007) ,
» ‘Communities in Control’ (DCLG, 2008),
» Local Government’s White Paper entitled ‘Strong and Prosperous
Communities’ (DCLG, 2006).
• June 2015 Scottish Government passed the ‘Community Empowerment
(Scotland) Act’
» A clear commitment to strengthening participation
» Promoting active citizenship , give community bodies new rights
 Key motivation for this is the health and wellbeing gains it could provide
5
Community empowerment in UK
urban regeneration policy

Laverack, G. (2006). Improving Health Outcomes through Community
Empowerment: A review of the Literature. Journal of Health, Population and
Nutrition 24, 113-120.
Woodall et al. (2010). Empowerment and Health and Well-being: Evidence
Review. Leeds: Centre for Health Promotion Research.
Wallerstein, N. (2006). What is the evidence on effectiveness of empowerment to
improve health? Copenhagen: WHO Regional Office for Europe.
6
CE linked to health and
wellbeing

How do we identify, measure and value community
empowerment in urban regeneration programmes to
inform future resource allocation decisions?
Key question

Measuring community
empowerment (1)
“I do not propose to offer a
laundry list of potential measures
applicable in all circumstances;
such an exercise is almost futile,
as good measures are likely to be
context-dependent” (Khwaja,
2005:267)
Key points:
Context specific elements and
interpretation of CE
An end OR a means to an end?

Next steps…
• Can urban regeneration lead to empowerment gains (is CE an end
outcome)?
• What are its ‘elements’ within an urban regeneration context?
• Within urban regeneration is CE a pathway to health gains (a
process)?
» Systematic review with Narrative Synthesis
» Secondary GoWell analysis
» Discrete Choice Experiment (DCE)
9
Measuring community
empowerment (2)

Review hypothesis:
Regeneration in urban city neighbourhoods can act as the
catalyst to unite individuals, create community social cohesion
and promote empowerment.
The research question:
Can urban regeneration lead to empowerment gains in affected
residents/communities?
Conducted between November 2012- March 2014
Mixed methods review (qualitative and quantitative)
10
Systematic review with narrative
synthesis

Platform (database host) Databases accessed
ProQuest ASSIA, IBSS, Sociological Abstracts, Social Services
Abstracts,
EBSCOhost Psychology and Behavioral Sciences Collection,
N/A SocIndex (accessed through EBSCOhost); Copac,
OpenGrey, Social Care Institute for Excellence
(SCIE), Scopus, Joseph Rowntree Foundation
(JRF), and Web of Science (WoS).
Databases Searched

Systematic review with
narrative synthesis results
Next Step:
Use of the Mixed-Methods
Appraisal Tool (MMAT)
developed by the Centre for
Participatory Research at
McGill University, Canada
(Pace et al., 2012).

• A sense of inclusion and opportunity to participate in decision-making
processes;
• Stakeholders acknowledging the time commitments expected of residents and
thus seeking flexible partnerships;
• A sense of belonging to the community and area;
• A sense of trust in stakeholders and the knowledge that there is transparency in
the decision processes and that their views, existing networks and connections
are valued;
• Stakeholders offering funding and support to help communities (capability
building);
• Information and awareness about decisions regarding the regeneration
programme.
13
Narrative Synthesis results

• Now have IDENTIFIED elements of CE within an urban
regeneration context
• Can be regarded as an outcome of urban regeneration
programmes
• However – is there a link to health and wellbeing within an urban
regeneration context?
• How can we MEASURE and VALUE CE?
14
Next Step

Baba, C., Kearns, A., McIntosh, E., Tannahill, C. & Lewsey, J. (2016). Is empowerment a route to
improving mental health and wellbeing in an urban regeneration (UR) context? Urban Studies .
“A research and learning programme that
aims to investigate the impact of investment
in housing, regeneration and neighbourhood
renewal on the health and wellbeing of
individuals, families and communities over a
ten- year period”
4270 participants
2011 GoWell Community Health and
Wellbeing Survey
Personal circumstances
Neighbourhoods perceptions
Community
State of health
Link between CE and health and
wellbeing within urban
regeneration

The empowerment question within the GoWell survey asks
respondents to consider:
How much do you agree or disagree with the following
statement: ‘On your own, or with others, you can influence
decisions affecting your local area?’
Five response categories were used: strongly disagree, disagree, no
opinion/unsure, agree and strongly agree.
16
GoWell survey measure

SF-12

Response categories:
All of the time
Often
Some of the time
Rarely
Never
Warwick Edinburgh Mental
Wellbeing Scale (WEMWBS)

Results – CE and Mental
health (1)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Disagree No opinion/unsure Agree Strongly Agree
On your own, or with others, you can influence decisions affecting the local area
MCS(coef)
Empowerment as a predictor of mental health (MCS)
Lower CI
Coef
Upper CI

0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Disagree No opinion/unsure Agree Strongly Agree
On your own, or with others, you can influence decisions affecting the local area
WEMWBSscoreincrease(coef)
Empowerment as a predictor of mental health (WEMWBS)
Lower CI
Coef
Upper CI
Results – CE and Mental
health (2)

• Increased participation in local decision-making
• Sense of trust in stakeholders
• Sense of belonging and feeling part of the local neighbourhood
• Residents’ time commitment
• Stakeholders help and support
• Information and knowledge
• CE can be both a desired outcome (end) of urban regeneration
programmes AND an intermediate outcome (process) linked to general
health and mental wellbeing
CE elements identified in an urban
regeneration context

Currently, there are two economic evaluations of regeneration which incorporated CE.
1. ‘Valuing the Benefits of Regeneration’ report conducted by Tyler et al. (2010) on behalf
of the Department of Communities and Local Government (DCLG). This study was
commissioned to explore how to value the benefits of regeneration and compare them
with their relevant costs.
» Community development activities
» Volunteering, investment in community organisations, formal participation and
community facilities.
» Bring about stronger, more active and better connected communities
2. Such challenges and limitations from a lack of available evidence were reported in
2015’s evaluation of the impact on health inequalities of approaches to community
engagement in the New Deal for Communities regeneration initiative by Popay et al.
(2015).
» Use of retrospective data led to costings based on “unwarranted assumptions about
the equivalence of information extracted from the documents at different points in time”
» Best practice examples
» Inconsistent data meant assumptions were used as information was not readily
available
22
Previous valuations of CE within
urban regeneration

“Discrete choice experiments are an attribute based measure of benefit that is based
on the assumptions that firstly, healthcare interventions, services, or policies can be
described by their characteristics (or attributes) and secondly, an individual’s
valuation depends on the levels of these characteristics” (Ryan, 2004:360).
• DCE’s are an attribute-based stated preference method to establish measure of value
 Attributes, levels & scenarios are identified using:
- systematic review methods, statistical design software, online survey company
• The DCE approach is rooted in economic theory and can be used to measure the
strength of preference for attributes & levels as well as quantify the trade-offs between
attributes
• The inclusion of a ‘payment vehicle’ such as money or time allows the trade-offs between
attributes to be measured on common scale thus facilitating direct comparisons of ‘value’
between attributes
Methodology: Discrete Choice
Experiment (DCE)

 Qualitative methods often used for this stage
 Systematic review with narrative synthesis results
 Specialist opinions and guidance sought
» ID 1: An ex-housing officer who had previously worked in
neighbourhoods undergoing regeneration in Glasgow and
continues to volunteer with local community groups;
» ID 2:A librarian for NHS Scotland who works with communities in
Scotland and arranges local consultation meetings they provided
invaluable preliminary insight;
» ID 3: The NHS Greater Glasgow and Clyde Community
Engagement Advisory group and patient panels;
» ID 4: A Network Development Officer for the West and Central
Voluntary Sector Network (WCVNS) and community group leader
committee.
 Face validity testing
24
Identifying ‘attributes’

Community Empowerment features Levels
Inclusion
The extent to which you are included in
community decision making processes
(e.g. through local meetings, regular
email/telephone contact).
 You never have the opportunity participate
 You have the opportunity to participate sometimes
 You have the opportunity to participate regularly
Trust in Stakeholders
The extent to which community
decision making processes are
explained and transparent and
whether your views are included in
local decisions.
 Decision making processes are not explained and no
consideration of your views is evident
 Some decision making is explained and some consideration
of your views is evident
 Decision making processes are fully explained; you can see
consideration of your views in local decisions
Sense of belonging
How well you know your neighbours
and how valued you feel as a member
of the local community.
 You do not know your neighbours and do not feel a valued
member of the community
 You know some of your neighbours and feel a valued
member in the community
 You know all your neighbours well and feel a valued member
of the community
CE elements (1)

Residents time commitment
Amount of your own time you have to
give up to ensure your views are
heard.
 0 hours every month
Resources/funding
The level of stakeholder provided
opportunities and resources for
communities to develop
skills/expertise and gain new
community assets.
 None - there is no help or support of any kind
 Some – limited help and support is available
 Yes - help and support is available
Information/knowledge
Your level of knowledge of issues and
developments in the urban
regeneration programme.
 You are not informed about the regeneration programme
 You are somewhat informed about the regeneration
programme
 You are fully informed about the regeneration programme
CE elements (2)

• Convenience sample pilot
» Validity testing
» UK representative sample (n=20)
• Phased approach to main survey
» Phase 1 (n = 34)
» Phase 2 (n = 302)
» Reliable prior estimates from which to create a D-efficient design
» Use of actual preference knowledge i.e. ‘priors’ as the basis of the design
results in more accurate preference information which in turn means the
design is suited to a smaller sample size and/or fewer questions.
» The lower the D-error scores the more efficient the design. The most D-
efficient designs are built on informative priors rather than assuming that
parameters are uniform and all equal to zero (how orthogonal designs are
created), are considered to be statistically more efficient
27
DCE: Methods

• Conducted November 2014 – January 2015
• advice gained from attendance on the ‘Design and analysis of discrete
choice experiments’ course run by London School of Hygiene and
Tropical Medicine (LSHTM) August 2014
• Based on the 2011 census results, the pilot respondents were
representative of the UK population (based on age and gender). That is,
11 participants were female (51%) whilst 9 were male (49%).
• Likelihood of choosing CE where they are able to participate in
decision-making, trust stakeholders, have access to information, have to
dedicate less time and stakeholders provide funding and resources.
• In theory it is expected that, all else equal, people would prefer to pay
less for a good or service. The same assumption can be made about
time.
28
Convenience sample results

Main survey example choice-
set

• ‘Cheap-talk’
• In order to reduce this bias and to make the choice task as realistic as possible, clearly describing
the choice context is paramount. This is also known as ‘cheap-talk’. This contextual information
helps respondents familiarise themselves with the good or service in question, and its
characteristics and which can reduce the occurrence of random errors in the task due to
misinterpretation or lack of understanding.
• Validity testing
• Reliability check refers to repeating a choice-set later in a choice task by presenting the same
scenarios yet reversing scenarios.
• Consistency checks are choice-sets where one scenario is constructed to be theoretically more
attractive to respondents than the other.
30
DCE additional features

DCE UK-wide survey
Conducted May 2015
Online survey panel provider and host
ResearchNow
(http://www.researchnow.com/) was
used to collect responses from UK adult
respondents aged 16 years or older.
49% men
51% women
Three-quarters of respondents (75%)
had not lived in an area undergoing
urban regeneration whilst 25% had
previously experienced urban
regeneration.
17 Non-demanders
None failed the validity tests

32
Attributes β (SE) P-value 95% CI
Inclusion
You never have the opportunity participate - - -
You have the opportunity to participate sometimes 0.63 (0.34) 0.05 -0.03, 1.29
You have the opportunity to participate regularly 0.6 (0.1) 0.001 0.41, 0.79
Trust in Stakeholders
Decision making processes are not explained and no consideration of your views is evident - - -
Some decision making is explained and some consideration of your views is evident 0.31 (0.23) 0.17 -0.14, 0.76
Decision making processes are fully explained; you can see consideration of your views in local
decisions
0.66 (0.15) 0.001 0.37, 0.95
Sense of belonging
You do not know your neighbours and do not feel a valued member of the community - - -
You know some of your neighbours and feel a valued member in the community 0.99 (0.6) 0.05 -0.18, 2.16
You know all your neighbours well and feel a valued member of the community 0.67 (0.12) 0.001 0.44, 0.89
Resources/funding
None – there is no help or support of any kind - - -
Some – limited help and support is available 0.08 (0.16) 0.63 -0.24, 0.40
Yes – help and support is available 0.32 (0.09) 0.001 0.14, 0.50
Information/knowledge
You are not informed about the regeneration programme - - -
You are somewhat informed about the regeneration programme 0.56 (0.23) 0.02 0.10, 1.02
You are fully informed about the regeneration programme 0.78 (0.09) 0.001 0.60, 0.95
Residents’ time commitment
Amount of your own time you have to give up to ensure your views are heard. -0.05 (0.01) 0.001 -0.29, -0.1
Likelihood ratio 165.70
Pseudo R2 0.3
Prob > chi2 0.00
Number of observations 658
ResultsDCE Results (1)

• Respondents more likely to chose a scenario:
» Give up less time,
» Have the opportunity to participate,
» Decision making processes are explained (with
their views being considered),
» Know their neighbours,
» Have help and support from stakeholders,
» Are informed about the regeneration programme
» Stronger preferences for attributes ‘Inclusion’ and
‘Sense of belonging’ first level of ‘improvement’
(from the lowest (worst) level).
33
DCE Results (2)

0
5
10
15
20
25
30
35
Inclusion Trust in Stakeholders Sense of Belonging Resources/ funding Information/ knowledge
Preference(%)
CE Attributes
Relative importance of each CE attribute (%)
DCE Results (3)

0 5 10 15 20
You know some of your neighbours and feel a valued member in
the community
You are fully informed about the regeneration programme
You know all your neighbours well and feel a valued member of
the community
Decision making processes are fully explained; you can see
consideration of your views in local decisions
You have the opportunity to participate sometimes
You have the opportunity to participate regularly
You are somewhat informed about the regeneration programme
Yes – help and support is available
Hrs/month
Respondents willingness to give up time for changes in levels of CE attributes
from the reference level
Ranked willingness to give up
time

• It is possible to ‘identify, measure and value’ attributes of community empowerment within
an urban regeneration context
• The DCE survey results provide initial recommendations for future allocation of resources for
CE promotion within urban regeneration
» HOWEVER, the results also highlight the importance of stakeholders
understanding the communities current ‘baseline’ levels of CE.
Results indicated that it may not always be ‘worthwhile’ investing in the
‘best’ level of the CE elements i.e. attainment of moderate levels is
highly valued in relation to the additional value to achieve the highest
levels
» Through a detailed understanding of the affected communities and
residents it will be possible use these results to tailor the optimal
configuration of attributes to generate CE and resulting health gains
36
Conclusions (1)

 These results demonstrate the opportunities DCEs provide when trying to ‘distill’ complex
concepts such as CE into clear recommendations when there currently is a lack of
available evidence to draw from.
 This research provides the first value set for attributes of CE specifically for inclusion in
economic evaluations of urban regeneration programmes
 Combining these ‘values of time’ with monetary values of time these results can be
combined with the cost of CE generating activity within a cost-benefit analysis framework
37
Conclusions (2)

Thank you!
Camilla.Baba@glasgow.ac.uk
@CamillaBaba
38

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