James Woodall

Can social prescribing provide the missing link

Background: The voluntary sector has long been recognised as making an important contribution to individual and community health. In the UK, however, the links between primary health care services and the voluntary and community sector are often underdeveloped. Social prescribing is an innovative approach, which aims to promote the use of the voluntary sector within primary health care. Social prescribing involves the creation of referral pathways that allow primary health care patients with non-clinical needs to be directed to local voluntary services and community groups. Such schemes typically use community development workers with local knowledge who are linked to primary health care settings. Social prescribing therefore has the potential to assist individual patients presenting with social needs to access health resources and social support outside of the National Health Service. Aim: The aim of this paper is to explore the concept of social prescribing and discuss its value as a public health initiative embedded within general practice. Methods: The rationale for social prescribing and existing evidence are briefly reviewed. The paper draws on a case study of a pilot social prescribing scheme based in general practice. Data collected during the development, implementation and evaluation of the scheme are used to illustrate the opportunities and limitations for development in UK primary health care. Findings: The potential for social prescribing to provide a mediating mechanism between different sectors and address social need is discussed. The paper argues that social prescribing can successfully extend the boundaries of traditional general practice through bridging the gap between primary health care and the voluntary sector. The potential for wider health gain is critically examined. The paper concludes that social prescribing not only provides a means to alternative support but also acts as a mechanism to strengthen community–professional partnerships. More research is needed on the benefits to patients and professionals.

Has empowerment lost its power

Empowerment is espoused as a flagship value ofhealth promotion. From the bold assertions in theOttawa Charter [1] and the Jakarta declaration [2]through to therecentcommitmentinNairobi[3], thediscourse of empowerment has been unwaveringthroughout. This short points of view paper intendsto stimulate critical discussion about the continuedvalue and use of empowerment in contemporaryhealth promotion. While empowerment has beenseen as a cornerstone of health promotion practiceand philosophy [4], we argue that unresolved chal-lenges associated with the concept may inhibit thecontinued primacy of empowerment within the dis-cipline. A recent evidence review of empowermentand its application to health and well-being (con-ducted by two of the authors and based primarilyon evidence published between 2000 and 2010) hasstimulated this assertion [5]. Lengthier discussionsabout these issues are currently being prepared forpublication; therefore, this short article intends tofocus on the definition of empowerment and, inthe authors’ point of view, the dilution of the con-cept from its original roots as a radical socialmovement.Empowerment,withitsoriginsinliberatorypeda-gogy, is generally viewed as an approach to enablepeople who lack power to become more powerfuland gain some degree of control over their lives andhealth [6]. This suggests that empowerment app-roaches must operate at various levels, from focuss-ing on both the individual through to organizationsand communities [7]. This perspective was capturedby Rappaport [8, p. 122] who suggested that em-powerment is:a process by which people, organzations andcommunities gain mastery over their affairs.This was further reaffirmed by Wallerstein[9, p. 198] who has referred to the concept as:...a social-action process that promotes theparticipation of people, organizations andcommunities towards the goals of increasedindividual and community control, politicalefficacy, improved quality of life and socialjustice.Labonte [10] describes empowerment as em-bodying both resistance to power structures throughadvocacy and processes such as community orga-nization, as well as community building and devel-opment. Thus, it is about giving and taking power inunison. In this respect, it is a zero–sum relationshipand power in essence is finite. For example,resources being directed at some people can causethe displacement of power (disempowerment) fromothers due to competition for the same resources[11, 12].In its widest and most radical sense, empower-ment concerns combating oppression and injusticeand is a process by which communities work to-gether to increase the control they have overevents that influence their lives and health [13].This is reflective of health promotion as it was in-tended tobe, albeit as an idealistic vision. Inthe pasttwo decades, however, the focus within publichealth and health promotion has increasingly

Improving health and well-being through community health champions: a thematic evaluation of a programme in Yorkshire and Humber

Aims: The contribution that lay people can make to the public health agenda is being increasingly recognised in research and policy literature. This paper examines the role of lay workers (referred to as ‘community health champions’) involved in community projects delivered by Altogether Better across Yorkshire and Humber. The aim of the paper is to describe key features of the community health champion approach and to examine the evidence that this type of intervention can have an impact on health. Methods: A qualitative approach was taken to the evaluation, with two strands to gathering evidence: interviews conducted with different stakeholder groups including project leads, key partners from community and statutory sectors and community workers, plus two participatory workshops to gather the views of community health champions. Seven projects (from a possible 12) were identified to be involved in the evaluation. Those projects that allowed the evaluation team to explore fully the champion role (training, infrastructure, etc.) and how that works in practice as a mechanism for empowerment were selected. In total, 29 semi-structured interviews were conducted with project staff and partners, and 30 champions, varying in terms of age, gender, ethnicity and disability, took part in the workshops. Results: Becoming a community health champion has health benefits such as increased self-esteem and confidence and improved well-being. For some champions, this was the start of a journey to other opportunities such as education or paid employment. There were many examples of the influence of champions extending to the wider community of family, friends and neighbours, including helping to support people to take part in community life. Champions recognised the value of connecting people through social networks, group activities, and linking people into services and the impact that that had on health and well-being. Project staff and partners also recognised that champions were promoting social cohesiveness and helping to integrate people into their community. Conclusions: The recent public health White Paper suggested that the Altogether Better programme is improving individual and community health as well as increasing social capital, voluntary activity and wider civic participation. This evaluation supports this statement and suggests that the community health champion role can be a catalyst for change for both individuals and communities.

Barriers to Positive Mental Health in a Young Offenders Institution: A Qualitative Study.

Objective To explore the barriers to positive mental health in a group of young offenders. Design A qualitative approach was used to provide insight into the ways in which mental health for young offenders is experienced and managed. Setting A Young Offenders Institute (YOI) accommodating males aged between 18 and 21 years. Method Participants were recruited voluntarily using posters. Twelve offenders participated in focus groups and an additional three interviews were carried out with individuals who felt uncomfortable in the focus group situation. Results Participants stressed that feelings in a YOI could not be shared due to the masculine ethos that had been created on the wings. Listener services were reported to be ineffective for support because using them would show weakness and vulnerability to other prisoners. Visiting time was the main highlight in the routine for most young offenders; however, leaving family and friends was difficult. In dealing with these emotions young offenders would use coping mechanisms, including acts of aggression to vent built-up frustrations. The issue of prison staff and their effect on mental health was raised by all offenders involved in the research. Unanimously, it was suggested that there are both excellent prison officers who engage with the prisoners, and staff who abuse their power and treat prisoners disrespectfully. Conclusion Promoting mental health is not the principle business of a YOI. However, this research has generated some issues for consideration for governors and those working within this setting.

A systematic review of the effectiveness and cost-effectiveness of peer education and peer support in prisons

BackgroundPrisoners experience significantly worse health than the general population. This review examines the effectiveness and cost-effectiveness of peer interventions in prison settings.MethodsA mixed methods systematic review of effectiveness and cost-effectiveness studies, including qualitative and quantitative synthesis was conducted. In addition to grey literature identified and searches of websites, nineteen electronic databases were searched from 1985 to 2012.Study selection criteria were:Population: Prisoners resident in adult prisons and children resident in Young Offender Institutions (YOIs).Intervention: Peer-based interventions.Comparators: Review questions 3 and 4 compared peer and professionally led approaches.Outcomes: Prisoner health or determinants of health; organisational/process outcomes; views of prison populations.Study designs: Quantitative, qualitative and mixed method evaluations.ResultsFifty-seven studies were included in the effectiveness review and one study in the cost-effectiveness review; most were of poor methodological quality. Evidence suggested that peer education interventions are effective at reducing risky behaviours, and that peer support services are acceptable within the prison environment and have a positive effect on recipients, practically or emotionally. Consistent evidence from many, predominantly qualitative, studies, suggested that being a peer deliverer was associated with positive effects. There was little evidence on cost-effectiveness of peer-based interventions.ConclusionsThere is consistent evidence from a large number of studies that being a peer worker is associated with positive health; peer support services are also an acceptable source of help within the prison environment and can have a positive effect on recipients. Research into cost-effectiveness is sparse.Systematic review registrationPROSPERO ref: CRD42012002349.

Prisoners’ perspectives on the transition from the prison to the community: implications for settings-based health promotion

Through qualitative exploration with soon-to-be released men in three prisons in England, this article examines the difficulties that prisoners envisage on returning back to community settings, entering other settings such as workplaces, and the implications the transition may have for their health. Interviews and focus groups were conducted with 36 prisoners, some of whom were convicted of sexual offences and based on a vulnerable prisoner unit. While not all prisoners offered the information, approximately two-thirds of the sample had offended previously. The transition that individuals make from the prison setting to the community can be potentially complex and often detrimental to health. Accommodation issues were forecast as a major concern for those men without family ties. Temporarily residing with friends or living in hostel residences were viable options for many prisoners, but both had drawbacks which could increase the probability of engaging in substance misuse. Resettlement issues were perceived to be more difficult for sex-offenders; their ‘identity’ provided an additional burden which created further reintegration difficulties. Employment opportunities, for example, were predicted to be drastically reduced as the men had signed the sex-offenders’ register. This article suggests that opportunities for successful transition could be enhanced by a more ‘joined-up’ settings perspective and proposes that a settings-based approach to health promotion, which emphasises the synergy between social settings and addressing wider determinants of health, should be applied to prisons to reduce, rather than exacerbate, inequalities.

A critical examination of the health promoting prison two decades on

Abstract Two decades since the WHO Regional Office for Europe outlined and published a report on health promotion in prison, which stimulated further debate on the concept of the ‘health promoting prison’, this paper discusses the extent to which the concept has translated into practice and the extent to which success has been achieved. This paper primarily focuses on why there has been a gap between the strategic philosophy of health promotion in prison and practical implementation, suggesting that factors such as ‘lifestyle drift’ and public and political opinion have played a part. A further argument is made in relation to the overall commitment of European countries and more broadly WHO in their support of settings-based health promotion in this context. It is proposed that there has been a weakening of commitment over time with a worrying ‘negative trajectory’ of support for health promoting prisons. The paper argues that despite these challenges, the opportunities and potential to address the needs of those who are often most vulnerable and excluded is colossal and acting to tackle this should be a greater priority.

Moving prison health promotion along: towards an integrative framework for action to develop health promotion and tackle the social determinants of health

The majority of prisoners are drawn from deprived circumstances with a range of health and social needs. The current focus within ‘prison health’ does not, and cannot, given its predominant medical model, adequately address the current health and well-being needs of offenders. Adopting a social model of health is more likely to address the wide range of health issues faced by offenders and thus lead to better rehabilitation outcomes. At the same time, broader action at governmental level is required to address the social determinants of health (poverty, unemployment and educational attainment) that marginalise populations and increase the likelihood of criminal activities. Within prison, there is more that can be done to promote prisoners’ health if a move away from a solely curative, medical model is facilitated, towards a preventive perspective designed to promote positive health. Here, we use the Ottawa Charter for health promotion to frame public health and health promotion within prisons and to set out a challenging agenda that would make health a priority for everyone, not just ‘health’ staff, within the prison setting. A series of outcomes under each of the five action areas of the Charter offers a plan of action, showing how each can improve health. We also go further than the Ottawa Charter, to comment on how the values of emancipatory health promotion need to permeate prison health discourse, along with the concept of salutogenesis.

Women’s perspectives on the value of a father’s initiative in shifting gendered practices within families

Abstract This paper explores the qualitative perspectives of women about a community embedded fathers’ initiative in Northern England. Projects to improve the well-being of men and their children are less common within the landscape of parent and child support, with mothers more often being the target recipients. Asking women about their perceptions of an initiative for fathers then offers original insights from women who are positioned as ‘related outsiders’, in that they were ‘outside’ the project but ‘inside’ the family and community. Findings suggest that women are able to see the positive impact of such a project, identifying that it offers a shared space for men and children, time for mothers without their children and can help with shifting roles and attitudes around childcare and emotional labour in the home. The initiative was also seen by the women as offering men more healthy means of coping, including men moving away from traditional hegemonic practices, which in turn shifted some women’s long held gendered beliefs about men as fathers. This research then offers a relational gendered backstory to a father’s initiative, demonstrating how such initiatives can potentially ‘undo’ gender and the positive implications this could have for families.

Advancing the health-promoting prison: a call for global action.

The global prison population has grown exponentially in all five continents and consistent analysis shows that many diseases, illnesses and long-term conditions are over-represented in the prison population. Despite the myriad of health challenges in the population, the concept and practice of health promotion is both contested and underdeveloped with significant variation in its application in prison systems globally. The purpose of this commentary paper is twofold. The first is to provide a short overview of the health-promoting prison concept which we argue, at present, is a largely Eurocentric idea which has not been adopted on a global scale. Second, the paper makes a case for more global action on prison health promotion and invites further dialogue and discussion amongst the health promotion community.