Tackling health inequalities: Evaluating a local integrated community-based approach and strengthening that approach using participatory action research

Reducing socioeconomic health inequalities is a challenge for health policy-makers and civil society. In many parts of the world, people with a relatively low socioeconomic position (SEP) in their society have a shorter life expectancy compared with people with a high SEP. In the Netherlands, people with a low education level live six years shorter on average compared with people with a high education level. When examining healthy life expectancy, this difference is even greater: people with a low SEP live fifteen years shorter in good health on average compared with people with a high SEP. Zwolle Healthy City is an integrated community-based approach aimed at reducing local health inequalities. The aim of this thesis is twofold. The first aim is to show what key elements, according to involved professionals and policy-makers, contributed to the success of Zwolle Healthy City, and identify related mechanisms and contextual factors. The second aim is to show how people with a low SEP can participate in all phases of PAR and what, according to the participants and involved professionals, affected this process. In addition to these two aims, a third question arose during the course of this project: ‘Why are we not able to reduce health inequalities so far, despite local integrated approaches such as Zwolle Healthy City and the increasing attention for applying PAR in such approaches?’ For this reason, we conducted an additional study to increase insight into why socioeconomic health inequalities are so persistent and build a way forward for developing, implementing and evaluating improved approaches from a theoretical perspective.