How can asset-based approaches reduce inequalities? Exploring processes of change in England and Spain

Health Promotion International, 2024, 39, 1–12 https://doi.org/10.1093/heapro/daae017 Article Article Viola Cassetti1,2,3, , Katie Powell1, , Amy Barnes1,4,*, , and Tom Sanders1,5, Sheffield Centre for Health And Related Research (ScHARR), University of Sheffield, Regent Court, S1 4DA, Sheffield, UK Present address: Independent Researcher, Spain 3 Present address: Valencian International University, Valencia, Spain 4 Present address: Public Health and Society, Department of Health Sciences, University of York, YO10 5DD, York, UK 5 Present address: Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK 1 2 Corresponding author. E-mail: * Abstract Initiatives to promote health and reduce inequalities in place-based communities have increasingly adopted asset-based approaches (ABAs). However, the processes through which such initiatives might reduce inequalities are not well understood, and evidence of their impact on health is still limited. This study aimed to understand how ABAs can impact practices, relationships and the redistribution of resources to reduce health inequalities in and between less advantaged neighbourhoods. Qualitative research was conducted in two settings (England and Spain) where similar asset-based initiatives, aimed at training community members to become health promoters, were being implemented. Data were collected using theory of change workshops, 120 hours of observations and semi-structured interviews with 44 stakeholders (trained community members, voluntary and community sector organizations’ workers and health professionals). A thematic analysis informed by systems thinking was carried out. Three main processes of change were identified: first, ‘enabling asset-based thinking’ defined as supporting people to adopt a view that values their own resources and people’s skills and expertise. Second, ‘developing asset-based capacities’, described as developing personal skills, knowledge, self-confidence and relationships underpinned by asset-based thinking. Finally, ‘changing decision-making and wider health determinants through ABAs’ referred to achieving changes in neighbourhoods through mobilizing the asset-based capacities developed. These processes were associated with changes at an individual level, with potential to contribute to reducing inequalities through supporting individual empowerment and social capital. However, contextual factors were found key to enable or hinder changes in the neighbourhoods and acted as barriers to processes of collective empowerment, thus limiting ABAs’ impact on health inequalities. Keywords: inequalities, community health promotion, empowerment, qualitative methods, capacity building, asset-based approaches BACKGROUND In recent years, initiatives to promote health in high- income countries have increasingly adopted asset-based approaches (ABAs) to address health inequalities in and between place-based communities (Martin-Kerry et al., 2023). ABAs centre on supporting people to identify and mobilize resources and relationships (assets) available within places, which can support their health and well-being (Rippon and South, 2017), and ‘make the best use of these resources’ (Cassetti et al., 2020, p. 15). Asset-based initiatives take up a variety of forms (Cassetti et al., 2020), depending on the contexts and assets available. This asset-based view of people and resources reflects one of the main theoretical paradigms underpinning ABAs, Antonovsky’s salutogenesis (1996), © The Author(s) 2024. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. How can asset-based approaches reduce inequalities? Exploring processes of change in England and Spain V. Cassetti et al. 2 Contribution to Health Promotion which encouraged a shift of focus from risk factors to looking at protective factors for health. There are still no specific guidelines on how to implement ABAs for public health, but there has been significant theoretical contribution regarding principles and practices (Morgan and Ziglio, 2007; Foot, 2012; Hopkins and Rippon, 2015), namely the importance of mapping available assets and mobilizing these to co-produce a context-specific health intervention (Martin-Kerry et al., 2023). According to a recent review of ABAs’ implementation (Cassetti et al., 2020), there are three ways to mobilize assets: (i) connecting assets already available to create new activities or partnerships, (ii) raising awareness of available assets that may be underused and/or unknown to the community and (iii) enabling assets to thrive, through supporting people and communities to gain more capacities to increase control over their health determinants. These approaches have been used separately or in combination and underpin ABAs’ implementation in place-based communities (Cassetti et al., 2020). Despite their increasing popularity as an approach to promote health and reduce inequalities (Rippon and South, 2017), evidence that effectively identifies changes attributed to ABAs and their impact on health inequalities is still limited (Van Bortel et al., 2019; de Andrade and Angelova, 2020; Peters et al., 2021). This might be due to relatively ‘recent’ introduction of ABAs in public health and due to the different paradigms that underpin ABAs, ranging from Antonovsky’s salutogenesis, to the Ottawa Charter for health promotion (WHO, 1986) and community development approaches (Labonte, • A key process in ABA centres on encouraging people to adopt asset-based thinking: valuing themselves and the skills and capabilities of other people. • This asset-based thinking underpins the development of personal capacities (skills, knowledge, self-confidence and respectful relationships), which community members can use to engage in activities and to support other community members. • Change processes associated with ABAs enhance individual empowerment and social capital, but in a non-supportive institutional context, can be disempowering. • When people involved in ABAs have dedicated time to work on community projects and have institutional support and funding, they can achieve wider changes in neighbourhoods sustained over time. 1999). Nonetheless, existing literature suggests that changes associated with asset-based initiatives can be understood as ongoing processes of empowerment leading towards improving a person’s and/or population health (Cassetti et al., 2020). While it is important to note that the concept of empowerment is complex, many definitions centre on people, individually or collectively, building skills confidence and knowledge to influence decision-making about health and its determinants (Whitehead et al (...truncated)