Rapid appraisal in an urban setting, an example from the developed world

Rapid appraisal in an urban setting, an example from the developed world

Sot. Sci. Med. Vol. 32, No. 8, pp. 909-915, 1991 Printed in Great Britain. All rights reserved Copyright 0 0277-9536/91 53.00 + 0.00 1991 Pergamon ...

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Sot. Sci. Med. Vol. 32, No. 8, pp. 909-915, 1991 Printed in Great Britain. All rights reserved

Copyright

0

0277-9536/91 53.00 + 0.00 1991 Pergamon F’rcss plc

RAPID APPRAISAL IN AN URBAN SETTING, AN EXAMPLE FROM THE DEVELOPED WORLD BYENro ONG,’ GERRYHUMPHRIS,’HUGH ANNEX-?and SUSAN RIFRIN” I Centre for Health Planning and Management, Science Park, University of Keele, Keele, ST5 BP, U.K., *South Sefton (Merseyside) Health Authority, )Department of International Community Health, Liverpool School of Tropical Medicine and ‘London School of Hygiene and Tropical Medicine Abstract-Rapid Appraisal has been used as a method to understand communities’ own perceptions of their priority needs. It can be used as a tool for formulating joint action plans between communities and service planners and managers. It can also be used to complement quantitative methods of assessing needs by more indepth qualitative understanding of socio-cultural perspectives. In the example described in this paper Rapid Appraisal is used both as action research and as a qualitative tool in order to define health and social needs of an urban, deprived community in England. Key worcis-needs

assessment, community involvement, health planning, management

The year 2000 is rapidly approaching

and progress towards Health for All 2000 needs to be evaluated across the world. The European targets [l] are far from being achieved, and many countries have to speed up their efforts if they are going to succeed. Discussions of the contribution of health services to the improvement of health are central in the U.K. context as the Government is embarking on a fundamental change in health service provision [2]. The emphasis in governmental thinking is on medical services, hospital and GP based, and far removed from a public health approach. Despite conclusive evidence that within the developed world health inequalities are persisting [3] and that these are directly related to socio-economic and cultural inequalities, dominant thinking is still based on a medical model of health. Radical Public Health approaches define the role of communities and individuals within communities as central to improving health [4]. The British Government also gives the users of health services pride of place, however, within a rather different context. The user of health services is seen as a consumer who will make choices about where he or she wants to ‘buy’ services from. They are not involved in defining need, setting priorities or in planning services. The U.K. is a signatory to the WHO Health for All 2000 declaration, yet present policy appears to be diametrically opposed to the direction of HFA2000. At the same time, there are several openings for progressive developments in health services. The most important trend has been the decentralisation of Primary Health Care Services. With the managerial revolution in the National Health Service [5] the trend towards devolving power and providing localised services was inevitable. Many Community Units, providing Primary Health Care such as nursing, paramedical, medical and dental services, created new management structures reflecting this move towards ‘going local’. One of the key questions within the process was how resources should be distributed, reflecting local needs. Traditionally, health services plan distribution SSM 3218-E

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on the basis of service use, but if needs are considered to incorporate felt, but unmet, needs, this approach falls short. A further consideration was that with decentralisation accountability to local communities would become more real as the management and planning processes were more visible. Many Community Units operate with an explicit philosophy of care based upon the principles of HFA2000. This means that health is defined as a total concept, incorporating physical, mental and social well-being, thus moving outside the narrow confines of the medical paradigm. Multi-disciplinary approaches to health are of key importance and the role of the user in evaluating and planning health care is central. These considerations formed the underpinnings of the project we are discussing here. PRIMARY HEALTH CARE SERVICES AND COMMUNITY DEVELOPMENT

South Sefton is an area in the North West of England, and the District Health Authority is providing Primary Health Care Services for a population of 180,000 people. This population consists of affluent neighbourhoods alongside the most deprived urban communities in the whole of the U.K. In the Summer of 1989 South Sefton decentralised all its community based services and created four distinct localities, each covering a population of 30,00040,000 people. The localities were formed around social groupings which were relatively coherent in terms of geography, culture and socio-economit status. However, this division was based on rather sketchy evidence such as health indicators (morbidity and mortality data, census indicators and use of services) and in no way could they constitute a sound basis for local planning. Therefore, researchers within the Health Authority, with the assistance from University staff embarked on a research programme which would help them define more precisely the nature and magnitude of felt needs, whether they were met or unmet. A variety of research instruments, both quantitative and qualitative,

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were applied in order to gain a multifaceted view of local needs. One of the cornerstones of the research was the development of a method capable of involving the community in diagnosing needs, and formulating action plans. Community development has been the subject of hotly contested debates. In the developing world this approach has been used in a variety of settings, and strong advocates have emerged [6]. In the developed world the approach has met with considerable opposition as it was considered to mainly deal with raising political consciousness, and incapable of delivering ‘objective’ data about the state of health of a community [7]. In the U.K. community development health projects have mainly been developed outside the mainstream NHS provision; however, in the last few years several small projects have been funded from within, e.g. attaching community development workers to Health Centres or specific client groups. Not only has there been debate about the underlying philosophy of empowering people, there is disagreement about the methods employed. Many community development projects are time-consuming, deliver intangible results, are small scale and often fail to make a significant impact on policy and planning. With health service planning being centrally controlled their influence is severely curtailed. Given the above mentioned dilemmas the researchers in South Sefton decided to look for an approach which could deal with the issue of time, the translation of findings into planning, yet involve local communities in the process. The intention was to achieve community participation in: -diagnosis; -decision-taking/priority -implementation; -benefitting; -evaluation.

setting;

RAPIDAPPRAISAL Rapid Appraisal is a research approach that has been applied in different settings. It covers a variety of methods and techniques, but all these tend to have the following characteristics in common [9]: 1. greater speed compared with conventional methods of analysis; 2. working in the ‘field’; 3. an emphasis on learning directly from the local inhabitants; 4. a semi-structured, multidisciplinary approach with room for flexibility and innovation; 5. an emphasis on producing timely insights, hypotheses or ‘best bets’ rather than final truths or fixed recommendations. This general framework was further developed for application in the health field by Rifkin and Annett [lo] firmly based on the HFA2000 philosophy. They proposed an approach to understanding the health needs of urban communities, which strengthens the principles of equity, participation and multisectoral co-operation. In terms of equity it focuses on members of urban environments that are still denied

et al.

the benefits of the residents in more affluent urban situations. In terms of participation it uses key informants (defined in a variety of ways) to both identify problems and to contribute to solutions. In terms of a multisectoral approach, it uses resource holders from various organisations to do the investigations and to make a plan of action. Consistent with health as a total concept Rapid Appraisal attempts to investigate the totality of those elements which contribute to a community’s health and individuals within those communities. Rifkin and Annett use an ‘information pyramid’ (see Fig. 1) to analyse the components of health. The diagnosis and planning processes are built upon community involvement and therefore the researchers need a firm grasp of what the composition of the community is, how it is organised and thus what its capacities to act are. The description of the next level, the socio-ecological factors which influence health, is necessary in order to examine the potential and barriers which exist for community improvements. The data on the existence, coverage, accessibility and acceptability of services will form the basis of a direct evaluation of effectiveness of present provision, and provide indicators for change. The final level is concerned with national, regional and local policies about health improvements for low income areas and information on these policies will tell whether the political leadership is committed to Primary Health Care. Rapid Appraisal, in contrast to the quantitative methods used in South Sefton, offered very specific insights. One of the most important insights is that it can tell WHAT the problems are, but NOT HOW MANY people are affected by the problems; in other words, it can tell what the strength of feeling is within a community. For example, the number of people on hard drugs can be relatively small, but the problem this creates for community living can be experienced as extremely disturbing. Rapid Appraisal is also a method of needs based community assessments as it is a tool for participatory diagnosis and planning, culminating in the formulation of action plans jointly with managers who have the resources to meet the needs identified. One of the key difficulties with using Rapid Appraisal is the problem of unrepresentative sampling, i.e. how does one determine key informants? [l 11. We will discuss the ‘solutions’ formulated within the South Sefton context, and the departures from the original methodology. Health Policy Health and Environmental Services Physical Environment

Social Services

Socio-Economic Enviranment

Disease and Disability

I Community Composition

Community Organization and Structure

Community Capacity

Fig. 1. Blocks for an information profile.

Rapid Appraisal in an urban setting THE SOUTH SEmON RAPID APPRAISAL EXERCISE

Consistent with the objectives set out by Rifkin and Annett the South Sefton project took place in one of the most deprived wards of the District. On the basis of census projections and health indicators Linacre ward in Bootle was selected for the RA exercise. The population of 11,902 people comprises of 5720 males and 6182 females. The ward is situated under the smoke of Bootle docks which, following the decline of Merseyside, has been converted into a freeport. The majority of the housing is council owned, and a considerable proportion is in need of repair. There is a growing presence of Housing Associations. As a result of unemployment in the area, which is estimated at around 20%, there is considerable male out-migration. The percentage of known one-parent families in the area is 6%, of whom the majority have children under 5. Existing evidence of service use, both from health and social services data, indicates that the ward suffers from multiple deprivation. The researchers in the Health Authority brought a team together which was capable of looking at different aspects of health, and represented resource holders from various organisations. The team consisted of the following Health Authority officers: -The Director of Nursing Services (community, elderly and mental handicap); -The Director of Nursing Services (Mental Health); -The District Health Promotion Ofhcer; -The Operational Planning Manager; -A Principal Clinical Psychologist; -The Manager of Research and Development. From other Agencies: -A Principal Housing Officer; -The Deputy Administrator of the Family Practioner Committee; -The Service Development Officer of the Social Services; -The Research Officer of the Social Services. In a two-day workshop the team formulated questions for the interview schedule, following the information pyramid structure (see Appendix 1 for the key questions asked). Available data was scrutinised, and plans were drawn up for the fieldwork. As all team members were Senior Managers they could not be released for a block period and the fieldwork was to be stretched over several weeks. The discussion over how to determine key informants in the community led to amendments to the original methodology. Key informants could be people who had knowledge about the community because of their profession, e.g. Social Workers, Health Visitors or Police. Within the community, leaders emerged OE self help groups, voluntary associations or other political groupings, e.g. playgroup leaders, chairpersons of elderly groups or Councillors. The third category of informants were people who were centrally placed because of their work or social role within a community, e.g. a comer shopkeeper, a bookie (turf accountant) or the postman. The team decided to draw up a list of names covering all three categories. The rationale behind including

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three distinct sources of information was grounded in the social science approach of ‘triangulation’, which allows the researcher to look at one issue from various perspectives, and then compare and contrast those in order to reach an intersubjective account. The Health Promotion Officer, assisted by one of the Nursing Officers, drew on her in-depth knowledge of Linacre ward in putting together a list of people to be interviewed. During the interviews new names emerged, which were then included in the fieldwork (see Appendix 2 for list). The team was divided into three sub-teams, each containing members from various agencies in order to allow for a multisectoral perspective in the interviews. Each team was allocated a diverse group of people and interviews were carried out at agreed times (distributed within the normal working week). The team met once during the fieldwork period to make an intermediate assessment of progress, and start a preliminary data analysis. Analysis of the data, i.e. written documents, interviews and observations, started after 8 weeks when the team came together for a day. Interviews and observations were the focus of analysis, because within the context of the developed world this type of qualitative data is lacking in defining priority needs. Documentary evidence is often ample, and can be used as background material, either to confhm the trends revealed in the qualitative analysis, or to querie the findings in terms of direction or depth. They can then serve as a source for further investigation. For example, the community claimed that almost 60% of their under 5s had respiratory problems which needed medical attention. This seemed an extremely high figure, and morbidity data, child surveillance records, prescription data need to be analysed to back-up or refute this claim. The interviews were done by appointment, and the sub-teams visited the participants in their own home or in their workplace. The interviews tended to be very informal, sometimes other people got drawn into the discussion, and the team members tried to divide questions between them. They always ensured that the people who were not asking questions at the time, were taking notes. The team approach allowed for discussing the same question from different angles as each team consisted of people from different professional backgrounds. The analysis of the interviews was carried out following the thematic approach, ‘filling’ in the building blocks of the planning pyramid. Each sub-team had done some pre-analysis by teasing out the main themes emerging from their interviews. When the three sub-teams came together these themes were discussed through comparing and contrasting, and intersubjective agreement was reached on the key issues that had emerged from the community. In the Linacre ward study the three ‘community planning blocks’ were merged into one category called valuable resources, while the top block, health policy, was not filled at all. The subsequent listing of priority problems was as follows: 1. Physical environment: rubbish, poor housing, air pollution, disposal of syringes, lack of recreational space;

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2. Disease and disability: depression and anxiety, drug abuse, chest problems, poor diet; 3. Health services: lack of prevention services for children, too ‘busy’ GPs, lack of home-care support, lack of well women services, lack of chiropody; 4. Social services: information on social services not readily available, lack of pre-school facilities, fear of the power of social services (to take children away), home helps not free of charge; 5. Socio-economic environment: unemployment, debts, unsafe environment; 6. Valuable resources: strong family support, community action groups, ‘Bootle identity’, Councillors, support from churches, Community Health Council. Each item was placed on an index card and the categories were kept together. With these cards the team members returned to the community to ask them to place the items in priority order. This started a two-way discussion about the opportunities for change. The research team learned more about the main concerns of the community, but the informants also came to understand the limitations of statutory services, and the need to prioritise problems. Before talking to the community about priorities the team first ranked the items themselves, in order to provide a comparison of their opinions with those of the community. Furthermore, the team tried to

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rank order on the basis of what they understood the community felt. The three sets of rankings were analysed separately to assess the extent of agreements amongst the ‘judges’ by utilising Kendall’s coefficient of concordance. The mean rankings and the coefficients are presented in Table 1. As to be expected there was considerable difference between professionals and community. For example, the rank order given by the community of problems in the physical environment were (from most to least important); rubbish, bad housing, air pollution, syringes, lack of recreational space. The team’s rank order was: housing, air pollution, lack of recreational space, rubbish and syringes. Confirmation of the disparity of rank ordering in this section was found formally by computing the Mann-Whitney U-test. Both rubbish and recreational space had sufficiently different ranks assigned between the professionals and the community to render the statistics significant beyond the 5% level. The additional major statistical difference in the rankings between the team and community perspectives was their perception of the drugs problem. The professionals regarded the implications for ill-health of drugs usage as significantly (P < 0.02) less important relative to other problems than the community. However, a consistent rank ordering between the professionals and the community was clearly found in the area of how the community could draw on its

Table 1. Priorities Team professional view N=lO

Team view of community N = 10

Community N = 32

1. Physical environmenr I. Rubbish 2. Housing 3. Air pollution 4. Syringes 5. Lack of recreational space

(0.28)’

(0.17)

3.40 2.00 2.70 4.20 2.70

3.20 2.00 2.90 3.80 3.10

2. Disease and disability 1. Depression 2. Drugs 3. Chest problems 4. Poor diet

(0.20)

2.40 3.20 1.80 2.60

2.30 2.90 I .40 3.40

2.19 2.34 2.50 2.97

3. Health services I. Children’s prevention services 2. Too ‘busy’ GPs 3. No care support at home 4. No well women services 5. Lack of chiropody

(0.33)**

(0.57)*-

(0.27)**

2.40 2.55 2.15 3.60 4.30

2.30 1.90 2.11 4.20 4.40

2.34 2.58 2.59 3.09 4.39

4. Social services 1. Info on social services lacking 2. Lack of pre-school facil’s 3. Fear of social services 4. Home helps

(0.20) 2.50 1.70 3.00 2.80

(0.16) 2.70 2.30 1.90 3.10

%Z*** 2.13 2.72 3.16

5. Socio-economic environment 1. Unemployment 2. Debts 3. Unsafe environ.

(0.16) 1.60 2.40 2.00

(0.49)** I .30 2.70 2.00

(0.34)*” 1.34 2.19 2.47

6. 1. Valuable Strong resources family

(0.62)*** 1.40

(0.59)*** 1.70

w;)-

2.60 3.10 3.60 5.00 5.30

2.90 2.50 3.60 4.70 5.60

2. 3. 4. 5. 6.

Commun. action Bootle identity Councillors Churches CHC

Figures in brackets are Kendall’s Codhcient of Concordance, ‘judges’ ranks. lP < 0.05; l*P < 0.01; l**P -z 0.0001 (significance levels).

(0.44)**

(0.12)**

2.19 2.69 3.19 3.38 3.56 (0.07)

2.66 2.95 3.73 4.44 5.09

i.e. measure of agreement amongst

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Rapid Appraisal in an urban setting own internal valuable resources, with strong family support coming top, followed by community action groups, Bootle identity, councillors, support from churches and Community Health Council. The results show that, despite intensive dialogue between community and professionals, the understanding of professionals is mediated by their disciplinary and organisational worldview. The possibilities for ‘empathy’ are bounded by this perception of reality. This is not to dismiss professional judgement, rather to illustrate the very complex issue of sharing diagnoses. At the same time, we do not advocate taking the community’s word as gospel. There are issues that need further debate with the community, and we cannot always accept their priorities at face value. To give just one example, the community never mentioned the vaccination and immunisation of children as an important problem. Yet, we know from scientific evidence that childhood immunisation has important benefits for child health. It would be impossible (both from a professional and governmental point of view) to drop this as a key priority. Therefore, ongoing debate with the community is an absolute necessity. All the participants received a short paper reporting back on the priorities described from the research. Following the distribution of the paper a meeting was held with the participants and any other interested member of the community. Almost all the team members were present at the meeting (or were represented by their staff). The Locality Manager of the Primary Health Care Services in Bootle was invited to attend, as she would be a key figure in taking action on some of the findings. The priorities set by the community were taken as point of departure and each was discussed in-depth with the view to formulate action. This is the crucial part of Rapid Appraisal, because so many projects stop at the point of diagnosis. It is important to build on the community’s capacity, and on the collaboration that has started in the research phase, to jointly formulate plans to improve the situation. If one is serious about local planning, community involvement and continuing evaluation of the contribution of services, this phase is essential and needs careful handling. In the meeting each problem area was analysed, and points of action identified. The professionals often had to explain the limitations of their influence, or the budgetary constraints upon them. This was not meant to frustrate change, rather to allow better insight into the reasons of why statutory services cannot act in certain cases. An example was the problems with Social Services. The organisation and budget allocation is controlled by the local Council, and the people capable of altering this are the elected Councillors, not the Social Services Officers themselves. The community needed to understand the structure and decision-making process of the organisation in order to gauge where action would be most effective. It was agreed that the community would put pressure on local Councillors, and Officers would provide more and better information to the community. This example illustrates the dual approach to problem-solving: we tried to define the action that could be taken by the community itself (or groups

and individuals within it), and action that statutory services could undertake to support the community. The role of professionals therefore shifted into enabling, rather than determining priorities and strategies. The role of the Locality Manager was defined as the central person in harnessing local efforts, as she was one of the Managers who would be most accessible and ‘in touch’ with the community. She arranged to meet several people to formulate intermediate steps, to support new ideas, and to act as a link with statutory services. Liaison between health, social services, housing and voluntary organisations was strengthened, both at field level and at managerial level. The contact between the team and the community was to continue, but on a more infrequent basis i.e. through meetings where progress would be assessed. CONCLUSION

Rapid Appraisal aims to understand the strength of feeling in a community through identifying priority problems. It tries to translate those priorities into action by making a strong link between the community and planners (resource holders) who are capable of instigating organisational changes which will harness community capacity. The example of the excercise in Linacre ward, Bootle, has demonstrated that the aims of Rapid Appraisal can be achieved. Within the context of a developed country Rapid Appraisal is not only seen as a method of involving communities in the planning of services, but very much as a method of gathering information. Access to sophisticated data sources such as epidemiological information, local studies, age-sex registers, service utilisation data etc. needs the addition of more qualitative data concerned with communities’ views on health needs. Together, these form a very powerful baseline for assessing the impact of services on the improvement of the life and health of populations. In Linacre, where health and social services management is largely local&d the input from the community in planning and evaluating services can be even more focused through using Rapid Appraisal alongside conventional quantitative methods. The attraction of Rapid Appraisal is the flexibility of the methodology. In the Linacre ward amendments were made in terms of length of study period (less rapid than originally envisaged, yet the 5 months period was rapid in comparison with other research and community development projects), the analysis of the rank order data employing non-parametric statistical techniques (SPSSX) available at the local University computing laboratory and the longer term contacts with the community through local structures. It is intended to carry out a Rapid Appraisal exercise in a more affluent locality. In order to assess its suitability for a different population, and to provide comparisons within one district in terms of the nature of community involvement. The intersectoral approach to health was essential in the dialogue with the community, as it was obvious that they did not define health as a separate category, and many problems that were identified fell outside the traditional medical remit, yet were firmly at the centre

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of a multi-disciplinary and multi-agency public health approach. The Linacre ward exercise shows that the potential of using Rapid Appraisal in the process of achieving HFA2000 targets is tremendous. would like to thank everyone in Linacre ward who participated, and our colleagues Beryl Griffiths, John Hotchkiss, Barbara Hotchkiss, David Quinn, Catherine Theis, Mary Alpert, Caroline Wilson, Morag Day. Acknowledgements-We

7. Health and environmental

-views -views -what

services: of prevention of services services do you use

8. Social services: -views of social services -what social services do you use. APPENDIX

2

List of People from Linacre Ward Who Took Parr in the Project

REFERENCES 1. World Health Organisation. Targers for Healrh for AN 2000. WHO Regional Office for Europe, Copenhagen, 1985. 2. Department of Health and Social Security. Workingfor Patients. Her Majesty’s Stationary Office, London, 1989. 3. Townsend P. and Davidson. N Inequalities in Health, The Black Reoorf. Penauin. Harmondsworth. 1982. 7. . Whitehead hi. The Hialth Divide. Health Education Authority, London, 1987. 4. Research Unit in Health and Behavioural Change. Changing the Public Health. Wiley, Chichester, 1989. 5. Griffiths R. Report of NHS Managemenf Inquiry. 6 October 1983. 6. Freire P. Pedagogy of the Oppressed. Herder and Herder, New York, 1971. 7. Stewart-Brown S. and Prothero D. Evaluation in Community Development. Hlth Education J. 47, 156262, 1988. 8. Nichter M. Project community diagnosis: participatory research as a first step toward community involvement in Primary Health Care. Sot. Sci. Med. -19, 3, 1984. 9. Conwav G.. Editorial. RRA Notes. International Institutute for ‘Environment and Development, 1, June, 1988. 10. Annett H. and Rifkin S. Improving Urban Health. W.H.O., Geneva, 1988. 11. Chambers R. Purring the Lust First. Longman, London, 1983.

Coordinator-Family Centre Community Assistant-Family Centre Social worker-church Corner shop proprietor Postman-Royal Mail Community Liaison-police Pre-school advisor Community worker-church Senior Citizens Group Women’s group Bookie (Turf accountant) Lolly-pop person Chairman of Support group Social worker-drugs outreach Community Psychiatric Nurse-drugs outreach Social workers-Local Authority Home Help organiser General Medical Practitioners District Nurses Community Nurses-Mental Handicap/Mental Health Health Visitors Chairman of local Elderly Residents’ Group Youth workers Chairman of Widows and Widowers group Director of drop-in centre Coordinator of community centre Assistant of community centre. APPENDIX Example

APPENDIX

1

The Key Questions

These questions were formulated at the first workshop, following an intensive brainstorming session. They represent the core of the in-depth interviews. 1. Community composition: -who doesn’t belong to organisations. 2. Community organisation and structure: -what are the community organisations? 0 group names 0 purpose l who is represented l what are their resources 3. Community capacity:

-commitment -mobilisation

capacity

4. Physical environment: -assess housing, security, open spaces, transport 5. Socio-economic

environment: -assess socio-economic levels 0 employment . type of housing l literacy and education

6. Disease and disability profile: -major health problems

3

of Responses from Discussions

with Community

The problems that the elderly face were mentioned by people such as Home Help Organ&r, shopkeepers, postman and community centre workers. The common themes were that many older people are becoming isolated because they consider the environment as increasingly unsafe, and are afraid to go out. For those elderly whose children have moved away (prompted by the economic decline of the city) contacts with the outside world are decreasing. As a result many elderly are lonely and depressed, often without being noticed. The environment was discussed as a major topic of concern for residents and people who provide services in the area. One of the residents explained the fact that there were pests such as rodents and cockroaches as follows: “Because this area is poor with the unemployment etc. there is more drug abuse which also means more crime like burglaries. Lots of people have dogs to protect their homes, but often those dogs roam the streets. When the binbags are outside and are not collected (some people miss the binman who comes very early) the dogs break the bags open and all the stuff spills out and is left. Of course rats are attracted-and there you are.” Industrial pollution was a key issue and one of the Residents’ Associations was very active in campaigning to curb the companies who dump coaldust on the dockside. However, there is a long history of other industrial substances polluting the area. One of the mothers of the children in the playgroup explained- that she .could pinpoint . . -. very clearly which streets were aliected and by what. She

Rapid Appraisal in an urban setting blamed a woodyard as well as the heavy lorry traffic in one part of the ward for creating unclean air, and told us that her own children suffered from respiratory problems ever since she moved into the area five years ago. Her story was repeated by other parents and child care workers. In one of the nurseries it was claimed that 60% of the children under five who attended were suffering from ‘asthma-type problems’ and were on some form of medication. The use of drugs within the area was regarded by the large majority of respondents ‘as a way of life’. Alcohol and

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nicotine were also used heavily. Typically according to the local drugs counsehors alcohol was extensively employed by men to dampen anxieties associated with the lack of work and reduced leisure choices. Women with young children faced extensive problems of meeting the family bills and having to take the primary responsibility for child care and household management. The drugs counsellors “could not think of a family where the mother was not taking tranquillizers”. Many respondents quoted ‘helplessness’ as a term to explain the views of residents towards their situation and their inability to escape the area.