What are “placed-based” approaches to improving health? What is “social climate change”? And why might these concepts matter for the health and wellbeing of children and families?
The Centre for Community Child Health at the Royal Children’s Hospital in Melbourne has just released a policy brief examining these issues. I’m sorry I don’t have time to do a cut-down version for Croakey readers but the Centre has kindly agreed to let the full document be published below.
Place-based approaches to supporting children and families (it can be downloaded here)
Families are often faced with a range of different, complex health and psychosocial problems.
Place-based approaches aim to address these complex problems by focusing on the social and physical environment of a community and on better integrated and more accessible service systems, rather than focusing principally on the problems faced by individuals.
A place-based approach targets an entire community and aims to address issues that exist at the neighbourhood level, such as poor housing, social isolation, poor or fragmented service provision that leads to gaps or duplication of effort, and limited economic opportunities.
By using a community engagement approach to address complex problems, a place-based approach seeks to make families and communities more engaged, connected and resilient.
Why is this issue important?
Over the past few decades, the world has witnessed significant and rapid change. These changes have been so fast and so far-reaching, they have had a dramatic impact on the physical wellbeing of the planet in the form of climate change1,2,3,4 as well as on the physical and psychological wellbeing of societies in the form of social climate change5.
We can see the evidence of social climate change in the rapid changes that have occurred for communities, families and children. These include:
people’s sense of community has become less tied to locality, as seen in the emergence of online communities
our social relationships have taken on new forms
the structure of the family has changed (e.g. smaller families)
Australia has greater cultural and ethnic diversity
the circumstances in which families are raising young children have changed, for example, more parents work longer hours6,7,8,9,10,11.
Additionally, the circumstances in which children are growing up have changed10.
Children now have fewer models of caregiving, community environments are less child-friendly and electronic media has become a dominant feature in children’s lives12,13,14.
Social climate change is also evident in the increasing complexity of modern society15. One manifestation of this complexity is the increase in ‘wicked’ problems16 such as obesity, child abuse and social exclusion. These problems are beyond the capacity of any one organisation to understand and respond to, and there is often disagreement about their causes and the best way to tackle them.
Wicked problems “cross departmental boundaries and resist the solutions that are readily available through the action of one agency”17. However, government departments typically focus on acute problems and do so unilaterally, rather than coordinating efforts to address factors that lead to wicked problems occuring in the first place. Governments also seek to integrate services so as to improve access and thereby improve outcomes. However, while integrating services is important, it is also important to build more supportive communities. This will ensure that parents of young children have stronger social support and the interface between communities and services is improved so that service systems can be more responsive to community needs18. Both integrating services and building more supportive communities are best done through a place-based approach.
What does the research tell us?
Rationale for place-based approaches
The rationale for adopting place-based approaches is based on various factors:
Place shapes people’s wellbeing. Both social and physical environments influence health and wellbeing. Children’s daily experience of living and learning in the environment around them is a significant factor in their overall wellbeing6-8,19-23.
Feeling connected and having social networks matters for people’s wellbeing. Children’s welfare and family functioning are crucially dependent upon the social support available within local communities24, and social isolation is a risk factor for both child development and family functioning24-27.
Some communities are trapped by locational disadvantage28-32. Despite Australia’s recent strong economic growth, some communities remain caught in a spiral of disadvantage such as low school attainment, high unemployment, poor health, high imprisonment rates and child abuse31. When social disadvantage becomes entrenched in a particular locality, a disabling social environment can develop, leading to intergenerational disadvantage.
The economic collapse of certain localities30,33,34.Neighbourhoods that were reliant on the old economyhave been devastated by globalisation, economicrationalism, restructuring and closure of manufacturingindustries. Some of these neighbourhoods have becomealmost entirely dependent on welfare benefits andpublicly funded services.
Orthodox approaches fail to reduce inequalities and prevent problems35,36. The strategies that have been used so far to reduce inequalities – such as making existing services more accessible and seeking to alter the individual behaviour of vulnerable people – do not address the root cause of the problems33, and have been unable to produce sustainable change. There has been a disproportionate reliance on the deployment of strategies and programs for the treatment of existing conditions rather than on true prevention, which is defined as occurring prior to the onset of disorder36. A place-based approach addresses the broader problems that impact upon families at the community level (e.g. unsafe physical environments, non-family-friendly transport, limited social connectedness) as well as the barriers to families accessing services (e.g. fragmented service systems, lack of outreach capacity).
Local services are not able to respond effectively to the complex needs of families and communities10,37.Designed at a time when the demands on families weresimpler, many local service systems struggle to providesupport to all families who are eligible, and to meet theneeds of families facing multiple challenges in a holistic way.
It is difficult to engage and retain vulnerable families38-44. Some families make little or no use ofservices, even if they have concerns about their childrenor are experiencing family difficulties. The reasons for thislack of engagement – more common among vulnerablefamilies – include difficulties negotiating a fragmentedservice system, not knowing services exist, and anunwillingness and/or inability to access services38. With afocus on collaboration and partnership between services,a place-based approach seeks to reduce these barriersby building integrated service systems that are moreflexible and responsive to family and community needs,and have an outreach capacity to engage vulnerable andsocially isolated families.
Cumulatively, this is a formidable list of factors that provide a powerful rationale for a place-based approach. However, it is important to consider the evidence regarding the effectiveness of place-based approaches.
The effectiveness of place-based approaches
Establishing the efficacy of place-based initiatives, policy and planning is challenging. A lack of well-designed outcome evaluations of place-based initiatives limits the extent to which firm conclusions about their effectiveness can be made45,46. While some place-based initiatives have led to measurable improvements, others have not. Reviews of Australian efforts suggest that it is still too early to tell what difference these will make over the long term37,47.
Despite this cautious conclusion, there is some evidence as to what successful place-based interventions involve.
Characteristics of successful place-based interventions
Communities participate, lead and own the intervention. At the heart of all successful place-based partnerships are communities that provide maximum practicable input in all decision making. This is the key to community strengthening32 and extensive community engagement, as well as engagement with public and private sector stakeholders37,48. Knowledge of the local community decreases the amount of time required to identify needs and develop plans and programs, thereby leading to greater efficiency.
Investment in capacity building. This investment includes time and resources for communities as well as long-term capacity building of staff48.
Adequate time. Problems that have been decades in the making will not be reversed in a few short years32. Similarly, service transformation through behaviour change takes a long time50,51.
Adequate funding.Governments can help to support community-strengthening outcomes by investing in core public infrastructure48 and facilitating investment from other sources (e.g. private sector funding) to support initiatives and ideas that flow from the project37, and fund pilot and demonstration projects48.
Strong leadership and support from governments. Wiseman (2006) notes that governments can support community-strengthening outcomes by articulating and demonstrating their commitment.
Effective relationships between stakeholder groups.Effective coalitions or partnerships between keycommunity stakeholders increase the likelihood that aprevention effort will be successful52. Key factors thatcontribute to effective relationships between stakeholders include high levels of trust and communication, and the establishment of shared vision and values between service providers. Governance structures need to be established through which the various stakeholders and service providers can effectively engage with users of the service system to develop planning mechanisms that respond to community need, and through which services can be jointly planned and delivered.
Evaluation. Processes to rigorously measure and evaluate outcomes need to be built into the project from the start37.
A ‘good fit’.The scale of the project needs to be appropriate to the policy challenges it addresses. The community needs to be prepared to implement a prevention program37 and any programs or interventions need to meet the identified needs of the community and be appropriate for the targeted cultural groups52.
The evidence also suggests that a place-based approach is only one feature of a comprehensive community-based service framework that can respond more effectively to the wicked problems that affect communities, families and children53. Other features include:
a strong universal service system backed by a tiered set of additional supports for families experiencing particular stresses
an integrated service system providing holistic support to families
multi-level interventions to address all factors that directly or indirectly shape the development of young children and the functioning of their families
a partnership-based approach based on partnerships between families and service providers; between different service providers; and between government and service providers
a robust governance structure that allows different levels of government, different government departments, non-government services and communities to collaborate in developing and implementing comprehensive place-based action plans.
Although there are no place-based initiatives that have all of these features, there are some valuable local and overseas examples that demonstrate many of these characteristics. Australian initiatives include Neighbourhood Renewal in Victoria and the federal Communities for Children program. Overseas examples include Sure Start in the UK and Choice Neighbourhoods in the US.
Place-based approaches are typically delivered within disadvantaged areas. However, we know that disadvantage is not necessarily confined to such areas – family problems and poor child outcomes are widespread and not limited by geography. For this reason, place based approaches can be validly applied within any community.
Place-based approaches represent a significant advance on the traditional service system. However, place-based approaches are not sufficient on their own to ensure a sustainable improvement in child and family outcomes. Two other complementary approaches are needed: person-based and national approaches.
A person-based approach focuses on direct help to the individual person or family with the problem, regardless of their circumstances or where they live35. A place-based approach addresses the collective problems of families and communities at a local level, usually involving a focus on community-strengthening. These approaches have usually been deployed separately but there are good grounds for combining them30. Such a strategy would be consistent with calls for multi-level approaches to social and behavioural change49. Significantly disadvantaged communities require programs targeted at individuals as well as renewal and development programs that address social infrastructure and the environment (e.g. public spaces, housing etc.)37.
Although place-based approaches seek to address the conditions under which families are raising young children, they can only address those factors that can be modified at a community level (e.g. social networks, integrated services). There are other factors that can have a major impact on families and communities that are beyond the control of place based initiatives. These include national and global economic policies and market forces that can contribute to disparities in housing, employment, education and health. National approaches are needed to minimise the impact of these factors on families of young children.
What are the implications of the research?
Rapid, sweeping social changes have had widespread impacts on communities, families and children. The current service system is not equipped to deal with the fallout from these social changes and struggles to meet the needs of all families effectively. As an alternative to this current system, place-based approaches:
are an efficient way of addressing place-based disadvantages
address the conditions under which families are raising young children as well as the presenting problems
involve the community in the development of initiatives and interventions, and provide services and facilities that are more responsive to community needs and more acceptable to families
build the capacity of communities to take responsibility for their own issues over time
create integrated service systems that are able to reach out to and engage families more successfully and respond to their needs in a holistic fashion.
This analysis suggests that meeting the needs of vulnerable families and communities requires a three-pronged approach – a combination of person-based, place-based and national approaches.
Considerations for policy and programs
Implementing a comprehensive approach – including place-based strategies – to effectively meet the needs of today’s young children and their families is a formidable undertaking that requires a sustained commitment by many stakeholders.
Community involvement should be viewed as a long term goal of any place-based initiative as it takes time to build community capacity.
Close monitoring of and continuous learning and research from a comprehensive community-based approach will be important to ensure that the future roll-out of the model is fully effective.
More work is needed on developing a full program logic model of the framework for place-based approaches, showing how it leads to improved outcomes for children, families and communities.
Place-based approaches should be seen as just one feature of a broader framework; a combined approach (person, place and national) is required to more efficiently and effectively respond to wicked problems that affect communities, families and children.
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