ARTICLE IN PRESS

Health & Place 12 (2006) 644–655

www.elsevier.com/locate/healthplace

The contextual development of healthy living centres services:

An examination of food-related initiatives
David Rankina,, Julie Trumana, Kathryn Backett-Milburna, Stephen Platta,
Mark Petticrewb
a
RUHBC, School of Clinical Sciences and Community Health, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG
b
MRC Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow G12 8RZ

Received 31 May 2005

Abstract

The Healthy Living Centre (HLC) programme was designed to address the wider determinants of health, in particular
social exclusion and socio-economic disadvantage, through targeting services at the most deprived local communities. This
paper draws on data collected during an in-depth process evaluation of six Scottish HLC case study sites. Food-related
services, which were found to cross-cut all the sites, were used to address social exclusion and to promote health. Three
types of service, each linked to a social model of health, were found to be in operation: those which enhance skills; those
which promote social inclusion; and those which influence food accessibility. The paper illustrates how food-related
services have developed in the case study HLCs to take account of the differing needs of the communities and
neighbourhoods that have been targeted. Consideration is then given to how HLCs adapt to meet the practicalities of
improving health while addressing social exclusion through targeting health inequalities.
r 2005 Elsevier Ltd. All rights reserved.

Keywords: Healthy living centres (HLCs); Inequalities in health; Food-related initiatives; Scotland

Introduction: area-based initiatives and healthy living
centres
By the 1960s an acknowledgement of the effects
of poverty and identification of distinct areas of
disadvantage led to UK government recognition of
the need for additional or ‘‘top-up’’ services to be
provided in such areas (Smith, 1999). These area-
based initiatives (ABIs) are used to address ‘‘cumu-
lative, social, economic and physical problems in
disadvantaged areas’’ (Office of the Deputy Prime
Minister, 2001). With the election of a Labour
government in 1997, the number of ABIs in
operation greatly increased. More recent ABIs have
developed through partnership working between
key local organisations and agencies, such as the
NHS, local authorities, community groups and
voluntary bodies (Smith, 1999). Although different
forms of ABI exist (see Neighbourhood Renewal
Unit, 2002), they have been collectively defined as:

Corresponding author. Tel.: +44-131-651-3053; ‘‘ypublicly funded initiatives targeted on areas

fax: +44-131-650-6902. of social or economic disadvantage, which aim to
E-mail address: a.d.rankin@ed.ac.uk (D. Rankin). improve the quality of life of residents and/or

1353-8292/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.healthplace.2005.08.013
 ARTICLE IN PRESS
D. Rankin et al. / Health & Place 12 (2006) 644–655
their future life chances and those of their
children’’ (Regional Co-ordination Unit, 2002).
While debate regarding the nature of the associa-
tion between place of residence and health continues
(see Macintyre and Ellaway, 2003; Diez-Roux,
2003), it is evident that lower socio-economic
groups and poorer communities often live within
deprived areas and experience poorer health stem-
ming from poverty, poor housing, unemployment
and low pay (Department of Health, 2001). Graham
(2004) contends that health inequalities are the poor
health consequences of poverty, such that health
disadvantages result from social disadvantage.
Linking social and health disadvantage in this way
‘‘y provides a bridge between the public health and
social exclusion agenda’’ and allows a combined
approach to be taken to tackle health inequality and
social exclusion (Graham, 2004). ABIs may there-
fore be a useful way of targeting health interven-
tions and reducing social inclusion for particular
groups living in deprived areas. Since 1997, a
number of health-oriented ABIs have been operat-
ing across the UK, including Health Action Zones,
New Deal for Communities and Sure Start (Re-
gional Co-ordination Unit, 2003; Wanless, 2004).
One of the more recent health-related ABIs to be
established is the Healthy Living Centre (HLC)
programme, which seeks to address health and
social exclusion as both primary and secondary
outcomes (New Opportunities Fund, 2001).
An early example on which the HLC programme is
based is the Pioneer Health Centre in Peckham which
opened in 1935 and closed in 1950 after operating for
8 years either side of the Second World War (see
Ashton, 1976). The current programme was devel-
oped following the establishment of a £300 million
fund distributed by the Big Lottery Fund (BLF)
(previously known as the New Opportunities Fund).
At the outset, the government stipulated that it
sought innovative proposals from HLC bidders to
tackle public health issues. Tessa Jowell, then
Minister of State for Public Health, envisaged that
successful HLCs would not adopt a standardised
format but should link with emerging government
policies that targeted health, such as the English
White Paper ‘Saving Lives: Our Healthier Nation’
(Department of Health, 1999) and the Scottish
equivalent White Paper ‘Towards a Healthier Scot-
land’ (Scottish Executive, 1999) (Jowell, 1998, cited in
Hogg, 1998). A central feature of the establishment of
each HLC was the commitment of partnerships of
645
local and national agencies to work with commu-
nities, which experienced inequalities in health service
provision, in order to address the wider social,
economic and environmental influences on health
(Hogg, 1998). Across the UK, BLF funding has
supported the establishment of 350 HLCs.
The BLF gave a wide remit to bidders which has
led to the creation of a broad spectrum of HLCs.
Sites have been established at a number of geogra-
phical locations, including urban, inner city areas,
semi-urban/rural areas and in rural, sometimes
island-based locations. HLCs differ in the number,
type and composition of target groups. Some HLCs
have chosen to concentrate on single target groups
(e.g. socially excluded young people), while others
adopt a multi-focus approach, targeting a number of
groups within a community (e.g. elderly, disabled,
youths, breast feeding women, school-age children,
etc.), or, in some instances, all groups living within a
particular community. Groups targeted by HLCs are
not necessarily geographically restricted to particular
neighbourhoods and can be located across cities or
even whole counties. To address the range of needs
of these diverse target groups, HLC bidders specified
their intention to develop both as centre-based
initiatives with publicly accessible premises, and as
virtual operations that implement and support out-
reach activities at a number of locations. Activities
provided by HLCs were initially specified on funding
applications, usually following a period of consulta-
tion with potential service users. Consultation or
needs analysis took a variety of forms, including lay
interviews, roadshows and taster events. Subse-
quently, following discussion with the funders, some
HLC services were adapted when operations began
in order to reflect the changing needs of the target
population and newly developed forms of service
provision. Examples of HLC activities listed on bid
documentation and identified during fieldwork in-
clude: smoking cessation clinics, mental health
support services, such as stress management and
counselling, parenting support classes, exercise
groups in leisure centres and GP referral schemes,
led walks, and health education drop-ins.
Food-related projects have been chosen
to illustrate service development following preli-
minary analysis of data gathered in evaluations
of HLCs conducted in Scotland1 and across the
1
Evaluation of the Scottish Healthy Living Centre Programme.
Platt S, Petticrew M, Backett-Milburn K. Funding: Chief
Scientist Office, Scottish Executive Health Department.
 ARTICLE IN PRESS
646 D. Rankin et al. / Health & Place 12 (2006) 644–655
UK2. The development of food-related projects
across HLC sites reflects the widespread prolifera-
tion of food projects to have emerged across the UK
since the 1997 general election (Lang and Rayner,
2003). Findings from the evaluation are presented
which illustrate three different aims of food-related
services in HLCs: to enhance skills; to promote
social inclusion; and to influence food accessibility.
Food and the ways in which it is used in HLCs are
clearly seen as an important determinant of health
and health inequalities. Following the elaboration of
findings, the discussion examines how the develop-
ment of food-related services in HLCs takes into
account the differing needs of the identified com-
munities and neighbourhoods. Further considera-
tion is given to how food-related services developed
by HLCs attempt to meet the practicalities of
improving health while seeking to address social
exclusion through targeting health inequalities.
Food poverty, area and health impacts
Access to, and affordability of, good food is used
as an indicator of wider social exclusion (Dowler
and Caraher, 2003). Many deprived groups experi-
ence ‘‘food poverty’’ (Dowler et al., 2001), defined
as the ‘‘inability to acquire or consume an adequate
or sufficient quantity of food in socially acceptable
ways, or the uncertainty that one will be able to do
so’’ (Riches, 1997).3 Within socially excluded
groups, food choices are primarily affected by levels
of income: the lower the income, the worse the diet,
at least in terms of nutritional content (Dowler
et al., 2001; see also findings from the National Diet
and Nutrition Survey; Gregory et al., 1990, 1995,
2000; Henderson et al., 2002).
Within urban areas, Cummins and Macintyre
(2002) have conducted work on ‘food deserts’ (see
Department of Health, 1996), defined as areas
where cheap, nutritious food is hard to obtain.
These findings indicated that food prices in shops
did not vary to a great extent by area deprivation.
However, lower quality, often high-fat, high-sugar
foods were cheaper in poorer socio-economic
locations. Inequalities in access to nutritious food
are also evident between urban and rural areas
2
The Bridge Consortium evaluation of NOF Healthy Living
Centre Programme. Funding: New Opportunities Fund. Ref:
FCSP/TEN/02/24.
3
It should be noted that food poverty in the UK is considered
to consist mainly of a nutritional rather than calorific inadequacy
(Hitchman et al., 2002).
(Newby, 1983), with higher costs and poorer quality
found in isolated locations (Skerratt, 1999). This is
mainly due to the more limited choice of shops and
constraints imposed by inadequate public transport,
suggesting that ‘food deserts’ are best conceptua-
lised as ‘‘areas of vulnerability to food poverty’’
(Hitchman et al., 2002), rather than as particular
geographical neighbourhoods. Such areas of vulner-
ability are to be found in the diverse communities,
neighbourhoods and populations targeted by
HLCs.
Further evidence indicates that poorer socio-
economic groups derive cheap energy from meat
products, fats, sugars, preserves, and cereals but
have a reduced intake of vegetables, fruits, and
wholemeal bread, which are known to have health
benefits (James et al., 1997; Gillman, 1996; Key
et al., 1996). More recently, findings indicate that
the intake of fruit and vegetables among poorer
adults and children is still lower than advisory limits
and that, while saturated fat consumption is
declining, consumption remains higher than recom-
mended (Wanless, 2003, 2004). These types of food
have been found to lead to a diet that is high in
saturated fatty acids, excess salt and unrefined
sugar, and which contributes to an increased risk
of cardiovascular disease, obesity, non-insulin
dependent diabetes, some cancers and dental caries
(Robertson et al., 1999; Wanless, 2004). Other
evidence (Wanless, 2004) suggests that low income
groups experience higher mortality, which is prob-
ably causally linked to nutritional factors and food
intake (James et al., 1997; Dowler et al., 2001).
Policy context: food
The food policy context on which the UK-wide
HLC programme is based is derived in part from
conclusions reached by the Acheson Report (1998),
which drew on global research findings examining
diet (e.g. World Health Organisation, 1990). The
Acheson report emphasised the following food/
nutrition measures that could be used by ABIs to
promote health and reduce social exclusion in lower
socio-economic groups:4

Measures to improve the nutrition provided at
school, including: the promotion of school food
policies; the development of budgeting and
4
Adapted from Wanless, 2004, p31: Acheson recommendations
concerning key dietary health related behaviours.
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D. Rankin et al. / Health & Place 12 (2006) 644–655
cooking skills; the preservation of free school
meals entitlement; the provision of free school
fruit; and the restriction of less healthy food.

Policies which will increase the availability and
accessibility of foodstuffs to supply an adequate
and affordable diet.

Further development of policies which will
ensure adequate retail provision of food to those
who are disadvantaged.

Policies which improve the health and nutrition
of women of child-bearing age and their children
with priority given to the elimination of food
poverty and the prevention and reduction of
obesity.

Policies which increase the prevalence of breast-
feeding.
Following the Acheson Report the UK govern-
ment published the Public Health White Paper,
‘Saving Lives: Our Healthier Nation’ (Department
of Health, 1999), while the Scottish Executive
published the White Paper ‘Towards a Healthier
Scotland’ (Scottish Executive, 1999). These White
Papers highlighted the importance of adequate
access to healthy foods for lower socio-economic
groups and recognised the structural barriers faced
by many people in accessing retailers selling
affordable, quality and healthy foodstuffs (Watson,
2001). However, the policies contained in the White
Papers have been criticised for failing to respond
adequately to Acheson’s recommendations regard-
ing structural barriers to accessing and affording a
healthy diet, such as trade, taxation, benefits,
planning and retailing (Dowler et al., 2001; Watson,
2001). Instead, measures taken to address problems
associated with nutritional conditions in low-in-
come groups remain an ‘‘individualist affair’’,
relying on community-based activities to effect
change (Dowler, 2002). While the numbers of
food-related projects have increased over recent
decades (Caraher and Cowburn, 2004), government
policies have further promoted the development of
food initiatives to target disadvantaged groups, e.g.
breakfast clubs, food co-ops and community cafes,
within ABIs (Dowler et al., 2001), including (as will
be shown) HLCs.
The current evaluation
This paper presents analytical findings from data
gathered in the course of the Scottish Executive-
funded process evaluation of six purposively
647
selected HLC case study sites. In-depth case studies
permitted intensive description and analysis of HLC
activities, with a view to improving understanding,
contributing to learning and informing best prac-
tice, in the implementation of health-focused ABIs.
The purposive selection and recruitment of Scottish
HLCs took into account the following criteria:
geographical location; management structures;
community development orientation; size of part-
nership; and the type of target group addressed. The
resulting sample was intended to represent a mix of
HLCs with respect to these criteria, thereby max-
imising the empirical (as well as theoretical)
generalisability of the study findings. All six HLCs
that were approached agreed to participate. They
are described (in anonymised format) in Table 1.
Methods and analysis
To allow adequate time for fieldwork, HLCs were
recruited at intervals spaced over a 9-month period.
Data collection began with the gathering and
assimilating of background documentation, fol-
lowed by two rounds of (largely residential) field-
work, separated in time by an interval of
approximately one year. Fieldwork consisted of
semi-structured, individual and group interviews
with key staff and stakeholders, including project
managers, project workers, partners, volunteers and
service users. Formal and informal observations of
selected activities, services, meetings and daily
interactions also took place. Telephone contact
was maintained with key contacts (usually the
manager) within each HLC prior to the second
round of fieldwork, which enabled the recording of
developments between fieldwork episodes.
For each HLC case study, researchers who were
familiar with the diversity of the data selected a
sample of transcripts and fieldnotes to include key
ideas and recurrent themes (Ritchie and Spencer,
1994). A sub-group team (comprising research
fellows and a senior qualitative researcher), who
had visited each HLC fieldsite, met in analytical
workshops to examine data from each site. These
workshops entailed prior reading of selected tran-
scripts, detailed qualitative analysis and interpreta-
tive discussion. The team developed a situated
understanding of emergent themes by taking into
account HLC-specific contextual elements based on
first-hand experience (Green and Hart, 1999). In-
depth discussion of individual themes resulted in the
identification and crosschecking of further themes
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648 D. Rankin et al. / Health & Place 12 (2006) 644–655

Table 1
Description of case study HLCs

HLC Description of HLC Site

Site 1 Multi-site, multi-focus, geographically diverse HLC, incorporating predominantly rural locations with some urban locations
also targeted
Site 2 Single-focus, urban HLC incorporating a geographically disparate target group living across a large city

Site 3 Multi-focus, urban-based HLC with tightly defined boundaries

Site 4 Multi-focus, urban-based HLC operating peripatetically within defined areas
Site 5 Multi-focus, semi-urban HLC, operating mainly peripatetically across a large geographic area
Site 6 Multi-focus, rural, island-based HLC

Table 2
HLCs specification of food/diet elements in bid documentation

Reference to food/diet England Northern Ireland Scotland Wales (n ¼ 28) All countries
(n ¼ 257) (n ¼ 19) (n ¼ 46) (n ¼ 350)

NHS priority—Diet/Nutrition 114 (44.4%) 5 (26.3%) 37 (80.4%) 11 (39.3%) 167 (47.7%)

Address inequalities—low cost 63 (24.5%) 1 (5.3%) 13 (28.3%) 8 (28.6%) 85 (24.3%)
food buying
Activity—Café 102 (39.7%) 4 (21.1%) 11 (23.9%) 7 (25.0%) 124 (35.4%)

Activity—Food co-op 63 (24.5%) 1 (5.3%) 15 (32.6%) 4 (14.3%) 83 (23.7%)

through an iterative interrogation of the data as
further fieldwork was conducted (Bryman and
Burgess, 1994). Following anonymisation, coding
of data was conducted using QSR-N6 (QSR
International Pty Ltd, 2002) to enable storage and
systematic retrieval.
The study was also able to draw on information
concerning each HLC, contained in the Bridge
Consortium database and derived from grant
application forms submitted to the BLF. With
regard to food-related services, bid documents were
coded to indicate the following: whether an HLC
reflected NHS health priorities concerning diet and
nutrition; whether an HLC sought to use food to
tackle health inequalities; and the types of activities
that would be established.
Findings
Food related services in UK HLCs
Multiple overlapping and site-specific themes
emerged from the analytic workshop discussions.
One cross-cutting and salient theme concerned food
and food-related work and the ways in which food
was used in HLC services to address inequalities
and improve health. In contextualising this theme,
the Tavistock Institute database was searched with
a view to comparing Scottish HLC intentions with
those of HLCs across the whole of the UK. Table 2
indicates the numbers (and percentages) of HLC by
country that recorded such information in bid
documents.
It is noteworthy that 80% of the Scottish HLC
bids for BLF funding report targeting diet and
nutrition as a NHS priority, compared with 48%
of all UK HLCs. Although the scope of the
present study did not cover all HLC sites or each
project operated or supported by the selected
sites, the in-depth design did permit the research
team to become familiar with a comprehensive
sample of food-related services within the six case
study sites.
Use of food in case study HLCs in Scotland
Each HLC case study sought to devise or support
a form of food initiative according to the needs of
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D. Rankin et al. / Health & Place 12 (2006) 644–655
local areas and users. Preliminary analyses of the
first round of fieldwork data suggested, however,
that the aims, objectives and ethos of food
initiatives were qualitatively different. Further
analysis led to the development of three food-
related sub-themes, which address ways in which
HLCs use food within their programmes: use of
food as a tool to promote social inclusion; influen-
cing the accessibility of quality food choices; and
using food as a method to enhance knowledge and
develop skills. There are some similarities between
these themes and findings from the examination of
other community food initiatives (e.g. Dowler and
Caraher, 2003). The examples found within the
HLC sample are discussed in more detail below.
1. Using food as a tool to promote social inclusion.
HLCs are expected to work with people or groups
who are socially excluded or who are at risk of
becoming so. The relationship between food and
social exclusion is such that people on lower
incomes often have to pay more while having
limited access to a poorer quality range of foods
(Dowler and Caraher, 2003). Many HLCs address
this objective through developing food-related
activities, both as elements within other services
and as specific services.
One indirect, cross-cutting method used by
several sites involved the preparation and distribu-
tion of food at HLC launch or promotion events, or
within weekly services, e.g. parenting classes, in
order to attract service users and enhance service
uptake. In site 2, the manager indicated that food
was provided during each activity or service and
acted as an inherent attraction to encourage and
increase attendance among service users who sub-
sequently took part in organised events.
‘‘The key attraction or one of the key attractions
is food and the fact that youy you know, and I
mean if the young folk show up this afternoon
and you ask them why they come here, they’ll say
‘‘Because there’s free scran’’, right, and I think
that again is a bit of learning.’’ (Project
Manager—Site 2)
As well as providing food to encourage users to
attend activities, a social drop-in service run by site
2 advertised the free provision of bacon rolls to
attract new or potential users. While staff did not
consider this to be a ‘healthy’ food choice, they
suggested that this type of food was beneficial to a
target population who may not eat much elsewhere
649
and that it would assist in breaking down barriers to
access of other HLC services.
‘‘So I came along and came in and they had the
decks and everything set up and I went through
and there was bacon, sausage rolls everything
and egg and all that there and I was like, ‘tasty’.
So I came back the next again Saturday and after
coming here for about three Saturdays, I started
finding out a bit more about it and I started
finding out there was more things going on
during the week. So I was just coming down for
more free food but I’ve been coming down for
more things as well. The other week there they
asked me to help at the interviewsy’’ (Service
User—Site 2)
In the example above, food is used to promote
social inclusion as a prime aim, but also assisted in
increasing uptake of non-food oriented services
(‘more things’ in the quotation above). In this
instance, the service user became involved in
assisting with interviews for a new staff member
and attended a course of relaxation therapies. In
addition, two sites, 3 and 5, run joint programmes
to deliver food services together with other health
messages. Combining food with other services is
considered useful by staff in appealing to excluded
users who might not otherwise attend services. As
well as promoting social inclusion, staff provided
healthy eating messages and instruction in how to
cook meals using recipe cards. (More information
on this particular use of food can be found in the
third sub-theme, discussed below.)
‘‘Clara5 makes the food and in the actual main
hall area there’ll be an activity. Say, for example,
it would be the line dancing and people in that
area doing the line dancing. What would happen
was, at half past seven to half past eight the line
dancing will take place. Half past eight, every-
body would stop, put the tables up, Clara would
bring her food out, and everybody would sit
down and eat the food. Nice kind of healthy food
on that day and meanwhile, people were getting
wee taster sessions in aromatherapyy at the
same time.’’ (Volunteer—Site 3)
In other examples, staff encouraged local people
using food co-operatives (in sites 3, 4 and 5) to have
a cup of tea and socialise after completing their
shopping, thereby promoting inclusion as a second-
5
Names have been changed to ensure confidentiality.
 ARTICLE IN PRESS
650 D. Rankin et al. / Health & Place 12 (2006) 644–655
ary aim through providing a focal meeting point for
local people. Project workers indicated that food
stocks were tailored according to each particular
community’s needs and the local infrastructure,
while staff described how co-ops had a wider remit
in combating social exclusion.
‘‘It’s not only about healthier food options,
health in the widest sense. But obviously those
people also come to us and talk about housing
problems or health problems in the wider sense
so it’s good to be able to connect and say, ah well
I know someone that you can go and speak to
about that or someone to get some advice about
that, that I can’t give you. So, rather than being
almost closed off in the food area we are now
connected into a wider picture of benefit in [the
area].’’ (Project Worker—Site 4)
The emphasis given to social wellbeing in this site
was linked to the provision of affordable produce
and the additional benefits that might thereby be
produced.
‘‘My basic view is that it’s more, it’s healthier for
people to eat than not eat [y]. You know, first of
all, they are eating. Secondly, if they are eating
and eating cheaper through using the food co-ops
then they will have more money to spend on all
the other things they buy which might in itself
improve their quality of life. It might also mean
their bill paying for amenities, you know, electric
and so on is easily managed which is also a
mental health benefit. It might mean that their
kids are happier or, you know, which again is a
huge pressure in terms of single parents in these
areas.’’ (Project Worker—Site 4)
The wider messages from food services in
promoting social inclusion and social wellbeing
described above were also noted in several other
sites. Two rural sites (1 and 6) and one urban site (3)
were seeking to establish community partnerships to
operate market gardens with a view to improving
access to a range of healthy food choices for local
people as well as providing a social focal point for
local people.
‘‘[Local] people will then be able to access fresh
fruit and vegetables weekly and participate on
the land as well.’’ (Project Co-ordinator—Site 1)
HLCs also provided assistance to existing or
newly developing projects. For example, site 5
provided lay health worker and volunteer support
to several local school breakfast clubs. Teachers
considered that these clubs offered parents an
alternative form of pre-school childcare, in addition
to providing breakfast. Food choices were varied
(although not all were low in sugar); children were
able to choose from a number of cereals, fruits, and
yoghurts and could prepare toast. Similarly, site 6
provided support to a lunch club, operated by a
partner organisation, which sought to draw in
elderly, often housebound, people. Social isolation,
a key characteristic of the location, was addressed
through the provision of pre-arranged transport to
the venue, while staff indicated that the food
provided was wholesome and filling as opposed to
overtly ‘healthy’.
2. Influencing the accessibility of quality food
choices
Food is both a private commodity, stored and
consumed in the home, and also a social or
communal good (bought and/or eaten in company)
(Dowler, 2002). However, target users in HLC areas
often have limited access to a range of shops and
‘healthy’ foods can be overly expensive. Limited
food choices within both urban and rural areas are
countered by services that seek to improve food
retailing and food provision options for individuals
through developing ‘‘yfood activities that impact
on peoples povertyy’’ (Partner—Site 5), and also,
on occasion, through targeting local retailing
structures.
In targeting individuals, several HLC services
seek to enhance access to ‘healthy’ food choices,
bringing together ‘‘yhealthy food and affordable
costs in an accessible wayy’’ (Project Worker—Site
4). These include traditional facility-based food co-
ops in sites 3 and 4, and the development of a
partnership in site 5 to develop virtual food co-ops
where products would be made available for sale
on-line and delivered to pre-determined locations
across a large geographical area. The enhanced
purchasing power of the HLC organisations was
also used to develop ‘‘fruit barras’’6 in sites 3 and 5,
which enabled projects to reduce the costs of
supplying quality food choices.
‘‘We’re doing that and subsidising that so we’re
selling five pieces of fruit for, is it fifty pence,
sixty pence. We’ve got a good deal as the fruit is
delivered to us, we take it out, we’re charged and
6
Scottish form of barrow.
 ARTICLE IN PRESS
D. Rankin et al. / Health & Place 12 (2006) 644–655
the money we charge all goes back into the pot,
so it all goes back into the HLC. So it’s not as
though we’re making a profit. What we’ve got is
three fruit barras, what we’ve also got is what we
call, I think it can only be described as fruit and
veg drop-offsy ywe’ve got about 7–8 organisa-
tions where we get the fruit, order it for them and
drop it off and we invoice them for the fruit and
then they then hand it out to their groups. And
again because we get the subsidised rate, they get
subsidised and get it relatively cheaply, and then
they hand it out to their organisations.’’ (Project
Co-ordinator—Site 5)
While enhancing uptake of quality food through
the provision of cheap fruit, HLCs also sought to
improve access through the development of local
growing initiatives in both rural and urban loca-
tions. Such initiatives were being established in rural
market gardens in sites 1 and 6 and in urban
allotments in site 3. These sought to engage local
people in awareness of the origins of food ‘‘yto try
and reconnect the growing of food and eating of
food y’’ (Project Worker—Site 3), while encoura-
ging informed ‘healthy’ choices to be made in homes
and local shops.
‘‘I think what we’re trying to get over is like eat
‘food’ rather than all the convenience [items]
that’s in there [local supermarkets]. And that’s
what we’re looking at, the whole market garden
thing about locally grown produce.’’ (Project Co-
ordinator—Site 6)
As well as seeking to influence both cooking and
purchasing patterns, services in two further sites (2
and 4) sought to enhance access through the direct
provision of free food. Site 4 supported an urban
initiative where large businesses are encouraged to
donate unused and date-limited food to charities, to
be distributed to groups on low incomes, while site 2
provided users with free, unprepared food along
with cooking facilities (e.g. cooker, oven and
utensils) to aid preparation.
In contrast to direct provision of services
operated or supported by HLCs, two sites (1 and
3) have sought to influence the accessibility of
quality food choices through their involvement with
local retail structures. In site 1 a project co-
ordinator had established good relations with local
businesses, independent shops, suppliers and restau-
rateurs. Meetings had been held to attempt to
influence the supply of healthier food choices within
651
local shops, which would then be promoted at food
tasters run by the HLC.
‘‘I’m hoping to be able to provide y this food
thing, once a month, do a food taster or food
delivery into each food shop and there’ll be, you
know, food recipe card kind of things and
working with the suppliers that they’ll make that
food on special offer. The whole idea being that
we’re trying to get more people to spend money
in their local shops on healthy optionsy’’
(Project Co-ordinator—Site 1)
Site 3, perhaps aided by its location in a large
conurbation, had gone further, successfully nego-
tiating access to a local major retailer. This had led
to the promotion of healthy choices with HLC
support.
‘‘Over the last five weeks we’ve been in Kwik
Save two hours a week and we’ve had five
hundred people, a hundred people a week sort of
coming and chatting to us. We’ve got money
from the Scottish Executive to do a promotional
leaflet for eachy so we’ve done one fory like
one week we did wholemeal breads, so we did a
wholemeal bread leaflet, advertising that with the
healthy living telephone number and the logo on
the back. And then we did oily fish, we did pure
fruit juice, next week we’re doing pasta, carbo-
hydrates as a basis for your meal.’’ (Project
Worker—Site 3)
These attempts to influence local retail structures,
although innovative in terms of HLC remit, were
notable for the length of negotiations required to
gain access. Project workers indicated that a series
of meetings had taken place between the HLCs and
retailers in order to establish these projects, more so
than was required to develop food-related initiatives
with other partner organisations. In site 3, the
project worker indicated that more needed to be
done on a continuing basis further to influence food
provision structures. Overall, HLC services concen-
trated on improving access through providing
support to existing projects and by delivering their
own services. These services mainly relied upon
individual uptake by service users to effect changes
in health.
Several barriers to improving the accessibility of
quality food choices (and HLC activities in general)
were found. Staff across several sites indicated that
negative associations were sometimes drawn by
local people between the work of the HLCs and the
 ARTICLE IN PRESS
652 D. Rankin et al. / Health & Place 12 (2006) 644–655
government’s ‘Healthy Living’ campaign.7 Some
service users regarded this campaign as unwanted
interference in their private lives. Confusion arose
over the name of some HLCs, especially those using
a ‘Healthy Livingy’ designation in their project
title, with users initially assuming a connection
between the HLC, the promotion of healthy food
choices and the ‘Healthy Living’ campaign. HLC
staff also found that new users were surprised to
learn that HLCs offered a wider range of services
than healthy eating programmes. In another exam-
ple, staff in one site had been criticised by local
people in the local supermarket over their own
personal food choices even though they had yet to
deliver any food-related programmes: potential
users had assumed that the HLC was targeting
healthy eating.
3. Using food as a method to enhance knowledge
and develop skills
Food is also used to provide education about how
to source food and prepare a healthy meal, and on
topics such as nutrition and obesity. Furthermore,
food is used to train users in food hygiene and food
handling techniques to address a number of aims
outlined below.
To counter a lack of knowledge of basic nutri-
tional information and cooking skills, several sites
have established courses to educate client groups,
including youths, young parents, adults and elderly
groups. Courses in rural and urban sites (2, 4, 5 and
6) were established to deliver instruction on buying
affordable, healthy foods and provided recipe
booklets and directions to other sources of informa-
tion such as the government’s healthy living website.
‘‘ywe funded a Life Skills shopping, it’s quite
difficult to describe. It was a Life Skills shopping
course, aimed at parents on low income, to show
them how to get the healthiest food they can and
how to cook with it. You know, what to beware
in the supermarkets and how to read labelsy’’
(Community Worker—Site 4)
Workers felt that such courses might influence
wider attitudes to food within the home or in
extended family environments.
‘‘yperhaps they will take it back into their home
now or perhaps at a later date they will be able to
reflect back and think well that was really quite a
7
See http://www.healthyliving.gov.uk
good thing that we took part in and perhaps take
it back to brothers and sisters and even mum and
dad or whoever the guardians are and maybe
extend into home.’’ (Lay Health Worker—Site 5)
While it was hoped that food messages might
filter down to friends and families, the attraction of
food to a wide range of potential users led to its
incorporation within other HLC activities, such as
taster events and exercise sessions. As noted above,
some sites combined activities which allowed food
to be used to promote social inclusion. In addition,
these holistic activities educated users in healthy
eating.
‘‘[The provision of] healthy eating and the fact
that that’s somethingy well this is my experi-
ence, that’s something that people can readily
access in a way that’s non-threatening, plus
they’re getting something back, they’re getting
information. They’re actually getting fed.’’ (Pro-
ject Worker 2—Site 3)
Food has also been used to educate HLC service
users in new skills. Food hygiene training has been
delivered or supported by several sites (1, 2, 3 and
5). Targeted users include first-time parents and
carers who prepare food for young children, groups
seeking pre-employment training, volunteers who
cater for HLC users, and staff members who handle
food.
‘‘ythe training they’re getting is actually trans-
latable into a real job. So if you’re staffing a
coffee kiosk and you’ve got your Food Hygiene
Certificate, you’ve handled cash, you’re dealing
with the public, those skills are a job basically
and there’s loads of jobsy’’ (Project Manager—
Site 2)
These basic skills had proved effective in enabling
several users to gain employment and further
training, while in other sites users reported being
increasingly aware of the importance of food
handling in caring roles.
Discussion and conclusion
The paper illustrates how food-related services
have been developed in the case study HLC sample
to take account of the differing needs of the
communities and neighbourhoods that have been
targeted. HLCs have devised a range of food-
related, culturally appropriate services to tackle
 ARTICLE IN PRESS
D. Rankin et al. / Health & Place 12 (2006) 644–655
socio-economic inequalities, social exclusion and
health improvement in a variety of areas and
settings. The analysis suggests that food is used to
appeal to and attract individuals in non-geographi-
cal communities of interest, while dedicated services
such as co-ops have been designed to meet the
specific needs of neighbourhood-based communities
living within tightly defined boundaries.
The influence of contextual features is also shown
in the different concepts of health inequalities
employed by the case study sites and how these
inform the development of activities to tackle health
and wellbeing issues. In the majority of food-related
services, HLCs have adopted a social model of
health whereby improvements in health and well-
being are sought through addressing social and
environmental determinants (see Dahlgren and
Whitehead, 1991). Social inclusion is promoted
through the provision of opportunities for indivi-
duals across communities to meet in social settings.
These include breakfast clubs, lunch clubs, and
drop-in services. Within these settings, foods that
might not necessarily be considered ‘healthy’ (e.g.
high-sugar and high-fat products) were often avail-
able and appealed to a range of service users
including homeless young people, school children
and the elderly.
There was both explicit and implicit understand-
ing amongst HLC staff and some stakeholders of
how food could be used to address social exclusion
through improving uptake and maintaining atten-
dance at health improving activities. HLC staff were
aware of the concerns felt by some users when
encouraged to eat ‘healthy’ foods. While some of
the foods provided were high in sugar and high in
fat, overall it was evident from staff that the
provision of any type of meal was beneficial for
some socially excluded groups who would not
ordinarily eat well (or at all) elsewhere. What
constitutes ‘healthy’ food choices would appear to
be contingent upon the needs of the target group
being addressed. Greater acknowledgement is
needed of the practicalities of targeting hard-to-
reach groups and the dilemma faced by HLCs with
regard to the provision of healthy foods versus
using food as a social tool in community food
initiatives.
The use of food initiatives in HLCs targeting
disadvantaged groups reflects the critical role that
food and nutrition is thought to play in enduring
health inequalities (Davey-Smith and Brunner,
1997; Dowler et al., 2001). However, the focus on
653
targeting disadvantaged groups to address inequal-
ities brings to the fore wider criticism of the
construction of the HLC programme. Graham’s
(2004) critique of the UK Labour government’s
conceptualisation of health inequalities suggests
that the attribution of success to the work of the
HLCs in addressing health issues faced by deprived
groups should be treated with caution. In her
analysis, Graham contends that government policy
references to health inequalities can be placed along
a continuum, ranging from ‘health disadvantages’,
through ‘health gaps’ to ‘health gradients’. In the
two former conceptualisations, targeting is directed
towards the poorest sub-groups whereas, in the
latter conceptualisation, efforts are made to equalise
health opportunities across the population
(Graham, 2004). With regard to the HLC pro-
gramme, the BLF sought to ‘‘improve the health of
the most disadvantaged sections of the popula-
tion’’,8 while also ensuring that projects were
‘‘designed to reduce the health gap between richer
and poorer groups and improve health overall’’
(New Opportunities Fund, 2003). It can be argued
that ABIs such as HLCs, which conceptualise health
inequalities as disadvantages or gaps, also confine
their benefits to poorer sub-groups without being
able to address health differentials across the wider
population.
This criticism relates to the inability of short-term
funded food initiatives (such as those within HLCs)
to change wider economic structures, such as income
and retailing. However, the two examples discussed
above illustrate how both rural and urban case study
sites had attempted to change local food provision
structures to improve accessibility. These projects,
although at different stages of development and
delivery, stand out as exceptions to the norm,
inasmuch as they target structural issues relating to
supply and affordability rather than concentrating
solely on individual level behavioural change. It is of
note that these one-off initiatives have been limited
to two HLC locations. Access to shops and work
with retailers have necessitated lengthy discussions
and much effort, and appear to have come about as a
result of the enthusiasm of one or two key, informed
individuals. The main focus of HLCs therefore seems
to be directed towards individual-level behavioural
change, ignoring earlier recommendations to con-
centrate on changing structural factors (Black
8
See http://www.nof.org.uk/default.aspx?tc=76&tct=2&fc=
8&fct=18
 ARTICLE IN PRESS
654 D. Rankin et al. / Health & Place 12 (2006) 644–655
Report, Department of Health and Social Security,
1980; Acheson, 1998). As a result, material depriva-
tion runs the risk of becoming a matter of ‘personal
responsibility’ (Scambler, 2002: 108). Calls to imple-
ment structural solutions have been made in the past
(Watson, 2001). However, HLC attempts to imple-
ment structural change and overcome the ‘individua-
lisation’ of responsibility have themselves been
limited by the willingness and ability of HLC staff
to develop and deliver programmes which can be
time-consuming and often beyond the boundary of
their original job remits.
Several structural changes to augment opportu-
nities to purchase food have been suggested, including
using re-distributive income measures (Dowler et al.,
2001) and through improving access to quality food
retailing (Dowler and Caraher, 2003), so that access
to adequate food intake becomes a basic right
(Holden et al., 2002). However, the food-related
services developed by HLCs reflect the policies of the
time (e.g. Department of Health, 1999) which
emphasise the role of the individual over national
structural reforms (Dowler et al., 2001) and which
contrast with Acheson’s recommendations to address
structural and planning issues in retailing in order to
improve food access (Acheson, 1998). This construc-
tion of the HLC programme therefore limits sites’
opportunities to instigate wider reforms beyond the
limited measures undertaken at local levels. As in
other ABIs, individual HLCs must focus on their own
short-term funding agendas (Neighbourhood Renew-
al Unit, 2002), delivering projects on short-term
money on the basis of competition and not as a right
(Barling and Lang, 2003). The search for future
funding may have to be undertaken by project
managers, thereby curbing the time they have
available to perform operational and strategic roles,
as has been found in other studies (e.g. Audit
Commission, 2002; The Cornerstone Consulting
Group, 2002). It is probable that HLC-devised
projects with measurable local impacts (such as
food-related projects which target individuals, or
which use food to attract target numbers) will assist in
the acquisition of continuing funding, but do little to
address problems that are often generated at a
national level.
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