c y eventualmente llegar a ser una calle muy congestionada en una ciudad.

communities about appropriate peers and used communities to recruit appeared to identify appropriate and acceptable PSs. Conversely, organisations that did not use community-based approaches to recruiting identified PSs who were not known to local communities, leading to less successful participation, which may have been due to the lack of credibility of the PSs.

During the design and delivery of training, some organisations and HPs did not capitalise upon experiential knowledge or engage in coproduction. Where organisations maintained ownership and control over the content and delivery of health education, PSs were uncomfortable delivering some of the health messages. Conversely, in contexts where training materials and content were coproduced, PSs felt valued with a greater sense of ownership over the intervention and confidence to deliver health messages.

During implementation, when organisations allowed PSs to use their tacit knowledge of social norms and social approaches to well-being, PSs reported feelings of self-esteem, confidence and satisfaction with the programme. Conversely, when organisations monitored and controlled social networking activities, PSs felt unwelcome and lacked confidence in their role.

Supportive organisational contexts recognised the worth of the experiential knowledge that PS held about marginalised groups. This recognition led to a relinquishing of control, giving PSs the autonomy to tap into social networks to develop relationships with participants, use their judgement about appropriate times and places to deliver health messages, use a process of social learning and reflection, and tailor health messages to local norms and values. Recognition transformed interventions from those that merely targeted groups to receive health education messages, to interventions where PSs were empowered to tailor messages based on their knowledge and understanding of the individual’s situation within the community and the broader society. When PSs were empowered to mediate, they were able to facilitate a social process through which participants were able to construct meaningful knowledge from health information and support each other in overcoming social barriers to changing HB.

Relating theories of change to theories of action and

engagement

The fit between empowerment education and successful peer support led us to revisit the different theories of change and theories of action in our respective peer-support programmes, and compare them to current models for CE. CBPS was situated at different points on Popay’s model40_{of CE. The more}

controlling stance taken by some implementing organisations reflected a consultation approach, through which professionals exercised power in terms of shaping meaning and value, setting agendas and priorities, and decision-making. This approach represents a public health process of shaping issues so that particular ideas are considered, discussed and valued at the expense of others. The knock-on effect from unequal representation at the design stage is an agenda and priorities that may not reflect experiences of socially vulnerable groups. Decisions may be made about appropriate interventions that are based on insufficient recognition of identity. Furthermore, when relationships have not been established, a lack of dialogue may further perpetuate mis-recognition of ethnic, cultural, religious or geographical identities.155_{The end result,}

in terms of increasing HL and reducing health inequalities, is an antagonism in terms of health goals rather than an alignment of goals with recipients’perceptions of what is relevant to their everyday lives. Figure 27compares the stages of designing and researching health inequalities interventions that were

concern is triggered as a result of differentials in population health. We describe the alternative perspective as a community-based social perspective, in which concern is triggered by perceived unfairness in living conditions (in dark green).

The epidemiological perspective is triggered by morbidity and mortality statistics produced by health systems, which represent health inequality as an inequality in the mathematical sense.156_{In some cases,}

the focus remains on the problem of unequal numbers, for example greater proportions of poor glucose control and subsequent diabetic complications; low rates of colorectal cancer screening; low rates of HIV counselling and testing; and low rates of breastfeeding. The solution becomes provision of health information, with the assumption that using a peer to deliver messages will persuade people to comply. The valued outcomes focus on balancing the numbers, for example decreasing the proportion of people with poor glucose control, and increasing the rates of screening or breastfeeding.

Tones157_{characterises this as an authoritarian approach, through which ideological perspectives of HPs and}

researchers are used to select the theory of change and the methods for taking action to address the problem. When the authoritarian approach is used to design the intervention, PSs are seen as a vehicle to transmit the messages that have been deemed important by professionals. This theory of change was predominant in the review of experimental studies assessing effectiveness of CE to reduce inequalities in health [the CERI (Community Engagement to Reduce Inequalities)] review9_{(Figure 28).}

Community-based social perspective

Epidemiological health system perspective Documented via experiences of people in communities Meaning and values shaped by community experiences Reflect theories of causation articulated by communities Designed by those with experiences of the issue Potential alignment of goals Outcomes of interest reflect community values Outcome of programme Design of intervention programme Theories about

how and why interventions might work to bring about change Policy goals to address causes Perceived causes of problem Observed problem of health inequality Documented by morbidity and mortality statistics Meaning and values shaped by public health professionals Potential misalignment of goals Reflect theories of causation articulated by public health Designed by professionals Outcomes of interest reflect health system values

FIGURE 27 Epidemiological and social approaches to designing health inequality interventions.

Observed problem

Health service designs intervention to tackle the problem

Peers deliver the intervention

Outcomes (higher than they would have been because

of peer delivery)

FIGURE 28 Theory of change for peer-delivered interventions. Reproduced with permission of the National Institute for Health Research Journals from O_’Mara-Eves A, Brunton G, McDaid D, Olicer S, Kavanagh J, Jamal F,

et al.Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic

When engagement with the community is the issue, experimental study design using authoritarian approaches risk missing the perspectives of those who need to be involved in the intervention. Incorrect assumptions lead to theories of change and action that do not reflect the reality of vulnerable groups, thereby producing equivocal or ineffective results (Figure 29). This was noted by our Advisory Network members:

My analogy of it is that it’s almost that you’ve got a group of academics if you like sort of sat in one place building this brilliant mansion. But they’re not talking to the people who it’s there for, who are the concrete. So they’ve put their mansion on some sand and it sinks.

Advisory Network #11

In trials using CE, the views of stakeholders were primarily sought after HPs and health services had defined the problem. This contrasts with a community-based social perspective to designing interventions (Figure 30, in dark green). The involvement of communities is assumed to make the proposed intervention more appropriate and relevant.

This may be the case, but the point at which communities are involved may have a marked effect on whether the people receiving the intervention are seen as passive recipients or actors in the cocreation of the intervention. Implementing organisations who have adopted a community-based social perspective factor in experiential and cultural knowledge when defining the problem. This produces an intervention that is cocreated or controlled rather than just being altered, which may influence the outcomes. For example, some of our programmes included stakeholders in intervention design. One of our smoking cessation programmes was entirely community based and did not include any health service participation when designing their intervention, whereas our healthy nutrition and older people initiatives had

community health service partnership at the design stage. Earlier involvement provides opportunities to look at the root causes of epidemiological disparity from the perspective of those with the condition, taking the surrounding context into account. The PS takes on the role of helping people to explore social barriers to managing health and well-being, including issues that may not fall within a traditional‘health’ remit, such as social isolation or financial and housing issues. The solutions are social: facilitating

participation in groups that will help people to make sense of their situation, building relationships that support people with a range of problems beyond immediate issues, such as breastfeeding or learning to cook healthy meals. Tones157_{describes this as a negotiated approach to theory-based health promotion.}

grounded understanding of the problem and generate solutions that include empowerment to take action. This approach was illustrated in the Smoking Fag Ends programme (Box 5).

The opposing perspectives are reproduced in research paradigms representing two different

epistemological views. The epistemological difference between the models emerging from both the CERI review9_{and our realist synthesis is worthy of examination, because the different stances help to explain}

the challenges in determining effectiveness of CBPS interventions. When health services define the problem and largely design the intervention, the theories of change neglect the interaction between social structure and individual agency, presuming that behaviour can be bounded within causal chains that

Health service defines the problem Implement intervention (which has been altered by stakeholders) Outcomes dependent on amount of engagement Implement intervention (cocreated or controlled by stakeholders) Appropriateness of intervention dependent on process of engagement The views of stakeholders are sought Community defines the problem Observed problem of health inequality Codefinition of problem with community

FIGURE 30 Theory of change for patient/consumer involvement (adapted from O_’Mara-Eveset al.9_).

BOX 5 Fag Ends case study

The Smoking Fag Ends cluster, which involved the community from the beginning in creating the peer-support programme, made the decision early on to avoid the use of health education materials that were branded by the NHS, as it was felt that they gave negative messages about smoking. By developing an own-branded programme,_‘Fag Ends_’was able to give users a sense of clear ownership, and the feeling that it was a service run‘by people like them’and not by HPs. It has not been unusual for individuals to turn up to sessions and ask for an exact match of support to that which helped a friend or relation stop:_‘You helped our Julie give up. I don’t want messages or lectures. I just want the same stuff you gave her and the same plan’. In terms of non-material gain, one of the key benefits of the programme is the community cohesion and ownership it creates. Groups choose the venues where sessions are held; make new friends; get to know new people; and end up coming because the sessions offer social interaction. To bolster this social element, the programme offers a‘recommend a friend’card, which encourages individuals to spread the word and bring their friends or family along. In some cases, people who have quit smoking continue to attend the sessions because of the company and social element that they offer. Such attendance is encouraged, as it provides groups with positive, relevant role models from within their own community. Advice, support and treatment from a layperson may remove existing social barriers in the community and increase the chance of a successful period of abstinence. Having the services based in the community has also encouraged many members to attend through word-of-mouth recommendations from their friends. The strong social networks have been used to the programme_’s advantage, for if one person stops smoking it can have a domino effect through their immediate community.

‘enclose human actions in a set of actions that appear determined, predictable and modifiable’.158_{This sort}

of design produced programmes that were unable to engage or that triggered negative mechanisms in both PSs and participants. Conversely, those that used interactive and engaged processes for intervention design coproduced causal chains and triggered positive mechanisms in stakeholders that extended through recruitment and training to implementers. In this intervention design, PSs were empowered to reconfigure ‘existing social networks’by creating or supporting forums through which people can discuss and act upon conditions that shape their health.158