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What makes us healthy? The assets approach in practice


Title: Appreciative Inquiry Author: jnorwood Last modified by: Owner Created Date: 11/1/2011 2:22:52 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: What makes us healthy? The assets approach in practice

What makes us healthy?The assets approach in
  • Thursday 11th April 2013
  • Middlesbrough

  • Trevor Hopkins
  • Freelance Consultant

  • What are the deficit and asset approaches
  • A glass half-full
  • Principles, values and key themes
  • Appreciative Interviewing/Appreciative Inquiry
  • What makes us healthy?
  • Evidence
  • Action
  • Evaluation
  • Asset mapping
  • A note of caution

  • Never doubt that a small group of thoughtful,
    committed citizens can change the world. Indeed,
    it is the only thing that ever has.
  • Margaret Mead US Anthropologist 1901 - 1978

The dilemma . . .
A deficit approach
  • Much of the evidence currently available to
    describe health and address health inequalities
    is based on a deficit model
  • This is a pathogenic approach to health and
  • The deficit approach focuses on the risks,
    problems, needs and deficiencies in individuals,
    families and communities
  • Professionals then design services to fix the
  • As a result the community and individuals can
    feel disempowered or can become service
  • People become passive recipients of expensive

Features of a deficit approach
  • Policymakers see professional systems or
    institutions as the principal tool for the work
    of society
  • In Public Health practice this approach has
    focused on risky behaviours and lifestyle
  • The collective term for these behaviours is the
    subject of much debate, with professionals from
    different fields preferring different
    terminology, each having a view about what is
    pejorative and what is not. (Clustering of
    unhealthy behaviours over time Kings Fund ,
    August 2012)
  • Services are targeted at specific needs
    problems, communities and individuals become

An assets approach
  • Values the capacity, skills, knowledge,
    connections and potential in individuals,
    families and communities
  • It is a salutogenic approach which highlights
    the factors that create and support resilience
    and well-being
  • It requires a change in attitudes and values
  • Professional staff have to be willing to share
  • Organisational silos and boundaries get in the
    way of people-centred outcomes and community
  • Never do for a community what it can do for

Features of an assets approach
  • Changing from servicing peoples needs to
    facilitating their aspirations
  • Redressing the balance between needs and assets
    or strengths
  • A shift in emphasis from the causes to the
    causes of the causes of the causes
  • A move from targeted to universal approaches
  • Solutions that are developed by people and
    communities not by specialists and professionals

A glass half-full
How an asset approach can improve
community health and well-being
The Principles
  • Assets any resource, skill or knowledge which
    enhances the ability of individuals, families and
    neighbourhoods to sustain health and wellbeing.
  • Instead of starting with the problems, we start
    with what is working, and what people care about.
  • Networks, friendships, self esteem and feelings
    of personal and collective effectiveness are good
    for our wellbeing.

Focusing on the positive is a public health
intervention in its own right Professor Sarah
Stewart-Brown, Professor of Public Health at
Warwick Medical School speaking at a conference
on Measuring Well-being 19 January 2011 at
Kings College
Values for an Asset Approach
  • Identify and make visible to health-enhancing
    assets in a community
  • See citizens and communities as the co-producers
    of health and well-being rather than the
    recipients of services
  • Promote community networks, relationships and
  • Value what works well
  • Identify what has the potential to improve
    health and well-being
  • Empower communities to control their futures and
    create tangible resources

Key themes
  • The defining themes of asset based ways of
    working are
  • that they are
  • Place-based
  • Relationship-based
  • Citizen-led
  • ...and that they promote social justice and

This requires a big shift in emphasis
  • Changing from servicing peoples needs to
    facilitating their aspirations
  • A move from targeted to universal approaches
  • Redressing the balance between needs and assets
    or strengths
  • A shift in emphasis from the causes to the
    causes of the causes of the causes
  • Solutions developed by people and communities
    not by specialists and professionals

Appreciative Interviewing
Appreciative interviewing
  • Can you tell a story of a time when you made a
    positive change to improve your own health and
  • What do you believe is now the single most
    important thing that positively influences your
    own health and wellbeing?
  • Now turning to your work can you tell a story
    of how you involved others as equal partners in
    bringing about real and sustainable change?
  • Imagine your community telling stories about how
    you have worked together as equal partners to
    achieve your dreams of a healthy community.
  • What would these stories be?

Appreciative Inquiry
Good organisations know how to preserve the
core of what they do best. Preserving the right
thing is key. Letting go of other things is the
next step David Cooperrider
Defining Appreciative Inquiry
Appreciative Valuing, recognising the best in
people or the world around us, affirming past and
present strengths, successes and
potentials Inquiry The act of exploration or
discovery or to ask questions and be open to
seeing new potentials and possibilities.
Reflection remembering times when our culture,
values and identity made us proud. Affirmation -
inquiring into those strengths and how we can use
them to create the future Action practical
planning towards the future
Some background
  • Traditional approaches to development
  • Identify problems, barriers, gaps
  • Maybe analyse why the problems exist
  • Propose solutions
  • Create an action plan
  • Also assign blame
  • Focus attention on what is missing, and
  • Can sap energy and motivation

When to use Appreciative Inquiry
  • When there is a complex situation which needs
    some collective will to address
  • When you want to bring people together to work
    on something of mutual interest.
  • When you want to build a vision of the future as
    well as work with others to make things happen in
    the short-term.
  • When you want to deliver a shared vision,
    improved relationships and working together.

When not to use Appreciative Inquiry
  • When one person is clear about a desired
  • When there is no interest in involving others in
    a creative way or when their opinions are not
  • When there is no interest in sharing
    responsibility or decision-making.
  • When it is important to involve all key
    stakeholders and you cannot recruit a good core
  • It cannot deliver a pre-formed solution. Each
    community develops its own response to its own

The appreciative cycle
...building the path as we walk it
What makes us healthy?The assets approach in
  • Evidence
  • Action
  • Evaluation

Evidence 1.
  • There is growing evidence for the importance of
    health assets, broadly defined as the factors
    that protect health, notably in the face of
    adversity, and for the impact of assets based
  • Individuals do not exist in isolation social
    factors influence individuals health though
    cognitive, affective, and behavioural pathways.
  • The quality and quantity of individuals social
    relationships has been linked not only to mental
    health but also to both morbidity and mortality.
    It is comparable with well established risk
    factors for mortality.
  • There is an increased likelihood of survival for
    people with stronger social relationships.

Meta analysis comparative odds of decreased
The relative value of social support/ social
integration Source Holt-Lundstad et al 2010
Evidence 2.
  • Stress buffering relationships provide support
    and resources (information, emotional or
    tangible) that promote adaptive behavioural or
    neuroendocrinal responses to acute or chronic
    stressors e.g. illness, life events.
  • Social relationships may encourage or model
    healthy behaviours, thus being part of a social
    network is typically associated with conformity
    to social norms relevant to health and social
    care. In addition being part of a social network
    gives individuals meaningful roles that provide
    self esteem and purpose to life.

Action 1.
  • Assets require both whole system and whole
    community working.
  • Instead of services that target the most
    disadvantaged and reduce exposure to risk, there
    is a shift to facilitating and supporting the
    well-being of individuals, families and
  • It requires all agencies and communities to
    collaborate and invest in actions that foster
    health giving assets, prevent illness and benefit
    the whole community by reducing the steepness of
    the social gradient in health.

Action 2.
  • Asset mapping
  • Toronto framework for mapping community capacity
  • Joint Strategic Assets Assessment
  • Time-banking
  • Social prescribing
  • Peer support
  • Co-Production
  • Supporting healthy behaviours
  • Community development to tackle health
  • Network building
  • Resilient Places
  • Appreciative Inquiry
  • Asset based service re-design
  • Assets embedding it in the organisation
  • Workforce and organisational development

  • To evaluate health asset based activities
    requires a new approach. Instead of studying
    patterns of illness, we need ways of
    understanding patterns of health and the impact
    of assets and protective factors.
  • Methods that seek to understand the effects of
    context, the mechanisms which link assets to
    change and the complexities of neighbourhoods and
    networks are consistent with the asset
  • The participation of those whose assets and
    capacities are being supported will be a vital
    part of local reflective practice.

Two questions to ask
  • Does it work?
  • Is it worth it?

Does it work?
  • There is a spectrum of models for answering
    questions about impact, ranging from high level
    national data sets to methods that ask about
    local and individual impacts
  • Taking the temperature of local communities
  • The Well-being and Resilience Measure (WARM)
  • Measuring mental wellbeing
  • Mental well-being impact assessment a toolkit
  • Warwick-Edinburgh Mental Well-being Scale
  • North West Mental Well-being Survey 2009
  • Measuring community empowerment
  • The Toronto Indicators of Community Capacity
  • The Outcomes Star

Is it worth it?
  • There is a small field of methods for
    establishing cost effectiveness which in time
    will generate evidence about work that aims to
    strengthen both social and psychosocial assets
  • A business case for community development
  • The Health Empowerment Leverage Project (HELP)
  • Evidence for the economic benefits of capacity
  • The Building Community Capacity for Putting
    People First Project
  • Cost effectiveness of promoting mental
  • The All Wales Mental Health Promotion Network
  • Social Return on Investment (SROI)

Asset Mapping
Asset mapping
  • Can be done with
  • Individuals circles of friends/support
  • Communities Community asset mapping
  • Organisations using Appreciative Inquiry
  • Forming new and expanding connections to bring
    about change

Asset mapping
  • The actual and potential assets of
  • Individuals
  • Associations
  • Organisations

Creating an asset map
  • The actual and potential assets of
  • Individuals heart, head hand
  • Associations
  • Organisations

Analysing assets
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Adding more depth
  • As well as individuals, associations and
    organisations, in a community this can also
  • The physical assets
  • The economic assets
  • The cultural assets

Community asset mapping process
  • Meet the people who will become the core group
  • Contact individuals or groups who are active in
    the community
  • Collate the assets and talents of individuals in
    the community
  • Identify the resources and assets of local
    associations, clubs and volunteers
  • Map the assets of agencies, including the
    services they offer.

Asset mapping exercise
Heart Hands Head
Challenges limitations
The material basis of inequalities
  • Health inequalities are a symptom, an outcome of
    inequalities in power, money and resources
  • Achieving a more equitable distribution of
    power requires collective social action.
  • (Closing the gap in a generation health equity
    through action on the social determinants of
    health WHO - 2008)
  • Both assets approaches and the well-being debate
    are associated with a non-materialist position
  • The problem is not that assets approaches
    address psychosocial and cultural determinants
    but if they do so without emphasising the
    material basis of inequalities in life chances
  • Its perhaps a cheap point to note that income
    in the higher echelons of public health situates
    these professionals well in the top decile, where
    the feeling that life is meaningful is daily
    reinforced by material reward. And the social and
    emotional distance between those who design
    interventions and those who experience them
  • (Reasons to be Cheerful the count your assets
    approach to public health Lynne Friedli (2011)

Reasons to be cheerful?
  • Asset approaches speak to the resistance of
    deprived communities to being pathologised,
    criminalised ostracised. Being described in
    public health reports in terms of multiple
    deficits, disorders and needs.
  • Concepts like co-production challenge the
    professional gifted model, empower citizens and
    involve recognition of their knowledge, skills
    and potential
  • There are conversations to be had about
    reclaiming the language of assets, perhaps as
    part of struggles to regain community
  • The problem is not dependency, dependency is a
    fact of the human condition, not a moral failing.
    The problem is responding to peoples needs in
    ways that do not undermine choice and
  • In its heart public health knows this. The move
    into the political world of local government is
    an ideal opportunity to insist on a fairer
    distribution of material wealth as this remains
    the key determinant of poor health

Questions and discussion
The asset approach is a set of values and
principles and a way of thinking about the world.
It takes everyone to build a healthy, strong and
safe community.
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