Valuing the health and wellbeing aspects of community empowerment in an urban regeneration context using economic evaluation techniques

[摘要] Background and Rationale:Urban regeneration programmes are well placed to address social inequalities, and improve residents' quality of life and thus, are increasingly regarded a form of population health intervention. Within such programmes, the central role of communities is becoming increasingly recognised as important, with policy makers highlighting the need for activities that foster community empowerment and community involvement in programmes’ delivery. A motivating factor for this emphasis on community empowerment is the envisaged health gains it can produce. Existing literature has demonstrated that community empowerment is linked to positive health (specifically mental health) however, little is known about this link within an urban regeneration context and the value of allocating resources to foster community empowerment as an outcome of urban regeneration programmes. Previous attempts to value community empowerment as an outcome of urban regenerations have failed to fully capture and measure this complex, multi-faceted outcome or its theorised links to health. This thesis crosses disciplines, addressing issues of public health, urban planning and health economics. However, as outlined in Chapter 1, its leading discipline is health economics, drawing on methodology from the field to make a contribution to the evolving focus of public health economic evaluation. Specifically, the thesis demonstrates how health economic methodology can be adapted or expanded upon to aid the challenges researchers face when trying to identify, measure and value complex, non-health outcomes (such as community empowerment) for inclusion in economic evaluations of population health interventions (such as urban regeneration), which, as discussed at length in Chapter 5,present numerous challenges for techniques previously used solely within the health sector, and commonly in controlled settings (randomised controlled trials). Methods:The thesis initially outlines the policy context of the study (community empowerment in urban regeneration), defines what is meant by community empowerment and the study’s overall health economics focus in Chapter 1. Chapter 2 continues this introduction to the study’s context by highlighting how community empowerment relates to other concepts, whether it is viewed as an outcome or a process and how this impacts on efforts of measuring the concept and through a rapid scoping review, summarises what is known in the current evidence base on community empowerment and its links to health. It clearly highlights that community empowerment is a context specific concept and that in order to identify, measure and value it within an urban regeneration context, investigation of its specific, quantifiable ‘elements’ within this context must be identified. This is presented in Chapters 3 and 4. Firstly, a systematic review with narrative synthesis was then conducted (Chapter 3) to identify whether urban regeneration interventions can lead to a sense of empowerment and key community empowerment elements within this context. Then in Chapter 4, analyses of cross-sectional data from Glasgow’s GoWell neighbourhoods regeneration study (n=4254) was used to further test the causal relationship between community empowerment and self-reported health. The final part of the thesis (Chapters 5-8), firmly centres these initial findings into the health economics focus of the thesis to demonstrate how discrete choice experiments could be used to value a non-health outcome such as community empowerment for future inclusion in economic evaluations of population health interventions. It outlines the challenges of conducting economic evaluations of population health interventions and the importance of health economics as a discipline for decision-makers (Chapter 5). Then in Chapters 6-8 it presents the conceptualisation, design and results of a UK representative population discrete choice experiment survey (n=311) and how its results can value community empowerment as a potential outcome (using the payment vehicle ‘time’) for use in economic evaluation of population health interventions within urban regeneration.Results:The thesisidentifies that community empowerment can result from urban regeneration interventions and that there are specific community empowerment ‘elements’ within this context which can be used to start conceptualising how to measure and value this concept and its links to health. The thesis also demonstrated that this was not always a positive relationship between urban regeneration and community empowerment and that a sense of disempowerment could be felt by the affected communities. These elements were sense of inclusion, sense of belonging, residents’ time commitment, a sense of trust in stakeholders, availability of stakeholder help and support and, availability of information about the regeneration programme (Chapters 2-3). Regression analysis of the GoWell data (Chapter 4) highlighted significant associations between community empowerment and improved general health and mental wellbeing. The discrete choice experiment’s (shown in Chapters 6-8) mixed logit model analyses demonstrated that there is an overall value for community empowerment activities within urban regeneration. The general populations respondents strongest preferences were shown for the delivery of community empowerment activities which require less time commitment, offer opportunities to participate, fully explain decision making processes, increase social interactions with their neighbours, have help and support from stakeholders and, keep them informed of the regeneration programme. Respondents’ strongest preferences were for delivery of community empowerment attributes that increase sense of belonging and feeling informed about the regeneration programme. Conclusions:The thesis provides valuations for attributes of community empowerment which can be used to inform future resource allocation decisions related to the cost-effectiveness of community empowerment generating activities as part of the delivery of urban regeneration programmes. Progress on the application of economic evaluation methodology to public health has been challenging, thwarted by complexities due to broad ranging costs and outcomes that are not readily suited to established economic evaluation techniques. The thesis contributes to the growing field of public health economic evaluation by highlighting the use of stated preference techniques, specifically discrete choice experiment methodology as a tool for measuring and eliciting values for the non-health outcomes of population health interventions for inclusion in economic evaluations. Failure to capture and include all benefits or costs of these multi-sector interventions which seek to look beyond health gains could lead to under or over estimation of their value and total effectiveness. This could ultimately result in poor investment decisions. To conclude, this study has contributed to current evidence by providing a means for identifying, measuring and valuing community empowerment both as an outcome in its own right and as an interim surrogate outcome linked to health. Thus, it has begun to address and tackle the research gaps identified in previous studies (outlined in Section 1.2.2). It has valued individual elements of CE within urban regeneration programmes which can be used by policy makers for decisions regarding future investment in CE and has further evidenced claims that community empowerment is linked to health within this context. Therefore, the thesis is able to recommend investment for community empowerment promoting activities in the delivery of urban regeneration programmes as a pathway to mental health gains.

[发布机构] University:University of Glasgow;Department:Institute of Health and Wellbeing

[关键词] community empowerment, urban regeneration, discrete choice experiment, Population health interventions, health economics.