In the developed world, meeting health and wider societal needs through publicly-funded institutions may have neared (or in some cases reached) its limit in improving the well-being of individuals and communities. Moreover, health is very largely socially determined, and inequalities – the unfair and avoidable differences in health status seen between countries, and between socio-economic groups within countries, have been steadily widening. The persistent and well-documented problem of health inequalities has challenged public health researchers since the relationship between income and health was first established. (Marmot et al., 2008)
At the same time, there has been a deliberate move to focus attention, particularly in public health, away from a traditional ‘deficits’ or ‘treatment’ approach to the delivery of public services. The shortcomings of focusing on deficits or treatments, coupled with impending cuts to public service provision, have given a renewed impetus to finding better ways of working. (McLean, 2011)
Social enterprises act to remedy or ameliorate social conditions: the social mission lies at the heart of every social enterprise and their raison d’être is to improve the lives of individuals and communities. Implicitly they therefore work to address what we now recognise as the “social determinants of health” and achieve the means to do so through economic activity in the market. (Roy et al., 2012) They are sustainable (or at least strive to be) in a way that grant dependent organisations are not. It is thus considered that social enterprise has the potential to be a viable and sustainable way of addressing public health problems. (Donaldson et al., 2011)
Within that context, my research has been seeking to address the following overarching question: if all social enterprises act upon the social determinants of health, then can all social enterprises be considered as providers of public health?
To clarify, I am not just simply concerning myself with those social enterprises that operate within the health arena, those that look to deliver health services perhaps on behalf of the state, or even necessarily those involved in promoting the benefits of healthy living (albeit that they are both important and interesting in their own right). Instead, I am looking at the ways in which all social enterprises impact upon the social, economic and environmental circumstances of the most vulnerable members of society, irrespective of whether or not they would necessarily frame their social mission or activities in such a way.
Such impacts could encompass a wide range: improving an individual’s control over their life circumstances; encouraging a sense of self-determination or capability; developing knowledge, skills and resources to improve their own life or work chances. Or it might be about improving a person’s ability to understand, think clearly and function socially, supporting them to improve their decision making or relationships with others. It might simply be about engendering a sense of belonging or connectedness to a community: nurturing a supportive network of friends or like minded individuals. The impacts might instead be more community focused: working to improve leisure opportunities or transport links across or within a community, or simply working to improve access to green space.
But all of these impacts (and more) have something in common: they can be framed as ‘assets’ that are critical to well-being.
Such an ‘assets-based approach’ to public health has been promoted most notably by the Chief Medical Officer for Scotland (Chief Medical Officer for Scotland, 2010, 2011) who has been calling for initiatives that promote well-being to be developed in the context of building upon the potential strengths of individuals and communities, rather than focusing on deficiencies (Kretzman and McKnight, 1993; Foot and Hopkins, 2010; Foot, 2012) with communities and outside agencies working in partnership to ‘co-produce’ solutions. (Scottish Community Development Centre, 2011)
It is considered that such assets can then subsequently be viewed through the lens of exiting theoretical frameworks, including Social Capital (Bourdieu, Putnam), Sense of Coherence (Antonovsky) or Capabilities (Sen, Nussbaum), all of which have a tradition of literature upon which to draw to explain their contribution to health and well-being.
My research will use a mix of methods including a Systematic (Integrative) review of the social enterprise/health and well-being literature, a specific review method (most commonly used in public health) that summarizes past empirical or theoretical literature to provide a comprehensive understanding of a particular phenomenon. (Whittemore and Knafl, 2005; Waddington et al., 2012) The search ‘protocol’ has been registered on an international repository and has been constructed to answer the following questions:
- Does social enterprise activity impact upon health and well-being?
- If so, how?
‘Impacts upon health and well-being’ might include such aspects as health behaviours; quality of life; use of health services; psychosocial and socio-economic outcomes; and any unintended (adverse or positive) effects of the activities. ‘How’ will include the mechanisms that are put forward to explain the effects of social enterprise-led activities on health and well-being.
After the literature review a survey of social enterprises across Scotland, funnelled via our sector intermediaries (of which there are many) will be undertaken, both to gain a picture of the breadth and scale of social enterprises across Scotland, and also how they consider they contribute to individual and/or community well-being.
A qualitative phase will then be undertaken, with in depth interviews (a purposive sample of around 30) in order to gain a more rounded perspective of the claims made in the quantitative phase on their contributions to well-being and will likely include interviews with social entrepreneurs or managers of social enterprises, employees and beneficiaries.
There is a significant gap in knowledge of how, and to what extent, social enterprise-led activity impacts upon health and well-being. It is hoped that my work will lead to a greater understanding of the mechanisms and causal pathways applied (or even assumed) in the work of social enterprises. Such work will hopefully prove beneficial, not only for our understanding of the work of social enterprises on the social determinants of health, but also in other related fields relating to ‘upstream’ community/Third Sector-led activity.
Chief Medical Officer for Scotland. (2010). Health in Scotland 2009: Time for Change. Edinburgh: Scottish Government.
Chief Medical Officer for Scotland. (2011). Health in Scotland 2010: Assets for Health. Edinburgh: Scottish Government.
Donaldson, C., Baker, R., Cheater, F., Gillespie, M., McHugh, N., & Sinclair, S. (2011). Social Business, Health and Well-Being. Social Business 1, 17–35.
Foot, J., (2012). What Makes Us Healthy? The Asset Approach in Practice: Evidence, Action, Evaluation. http://www.janefoot.co.uk.
Foot, J. & Hopkins, T. (2010). A Glass Half-Full: How an Asset Approach Can Improve Community Health and Well-Being. London: Improvement and Development Agency (Great Britain)
Kretzman, J.P. & McKnight, J.L. (1993). Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets. Evanston, IL: The Asset-Based Community Development Institute, Institute for Policy Research, Northwestern University.
Marmot, M., Friel, S., Bell, R., Houweling, T.A. & Taylor, S. (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. The Lancet 372, 1661–1669.
McLean, J. (2011). Asset Based Approaches for Health Improvement: Redressing the Balance (GCPH Briefing Paper Concepts Series 9: Glasgow). Glasgow: Glasgow Centre for Population Health.
Roy, M.J., Donaldson, C., Baker, R. & Kay, A. (2012). Social Enterprise: New Pathways to Health and Well-being? Journal of Public Health Policy, Forthcoming.
Scottish Community Development Centre (2011). Community Development and Co-Production: Issues for Policy and Practice. Glasgow: SCDC.
Waddington, H., White, H., Snilstveit, B., Hombrados, J.G., Vojtkova, M., Davies, P., Bhavsar, A., Eyers, J., Koehlmoos, T.P., Petticrew, M., Valentine, J.C., & Tugwell, P. (2012. How to Do a Good Systematic Review of Effects in International Development: A Tool Kit. Journal of Development Effectiveness 4, 359–387.
Whittemore, R. & Knafl, K. (2005). The Integrative Review: Updated Methodology. Journal of Advanced Nursing 52, 546–553.
Michael Roy is in the second year of his PhD at the Yunus Centre for Social Business and Health at Glasgow Caledonian University, Glasgow, UK, having previously gained his Masters degree in Social Research (Policy Analysis) from there. His Bachelors degree was in Sociology and Management from the Open University.
He previously started up and ran his own social enterprise in Glasgow after spending time as a freelance consultant to the Third and Public Sectors. Prior to that role he had spent more than a decade working in various policy roles within the Scottish Government, including innovation, science and technology, finance, and learning and skills. But not in health.
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