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The field of arts and health, and associated academic discussion, is beset by a number of interlinked challenges which make it vulnerable to academic dismissal or, at best, poor visibility. One of these is a preoccupation with developing an evidence base of impact. This is compounded by resistance to definitions, disagreement over what constitutes appropriate evidence of success, and inadequate consideration of the mechanisms of arts and health practice, as opposed to outcomes. We argue that increased attention should be paid to the description, analysis and theorising of the practice itself as the basis upon which the findings of impact studies can be understood and accepted. A literature review identifies some important emerging themes in community arts and health practice, and some lacunae in need of further investigation. We conclude that an interdisciplinary theoretical framework for the practice could make a valuable contribution to the academic status of the field.

Use policyThe full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that:• a full bibliographic reference is made to the original source • a link is made to the metadata record in DRO • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders.Please consult the full DRO policy for further details. ABSTRACTIt is now widely accepted that context matters in evaluations of the health inequalities impact of community-based social initiatives. Systems thinking offers a lens for uncovering the dynamic relationship between such initiatives and their social contexts. However, there are very few examples that show how a systems approach can be applied in practice and what kinds of evidence are produced when this happens. In this paper, we use data from ethnographic fieldwork embedded within a multi-site mixed method evaluation to demonstrate how a systems approach can be applied in practice to evaluate the early stages of an area-based empowerment initiative -Big Local (funded by the Big Lottery Fund and delivered by Local Trust). Taking place in 150 different local areas in England and underpinned by an ethos of resident-led collective action, Big Local offers an illustration of the applicability of a systems approach to better understand the change processes that emerge as social initiatives embed and co-evolve within a series of local contexts. Findings reveal which parts of the social system are likely to be changed, by what mechanisms, and with what implications. They also raise some salient considerations for knowledge generation and methods development in public health evaluation, particularly for the evaluation of social initiatives where change does not necessarily happen in linear or predictable ways. We suggest future evaluations of such initiatives require the use of more flexible designs, encompassing qualitative approaches capable of capturing the complexity of relational systems processes, alongside more traditional quantitative methods.

There is a need for greater conceptual clarity in place-based initiatives that seek to give residents of disadvantaged neighbourhoods more control over action to address the social determinants of health inequalities at a local level. In this article, we address this issue as it relates to the concepts of participation and inclusion. We draw on qualitative data generated during the first phase of the Communities in Control Study, a longitudinal multisite independent evaluation of the impact of Big Local on the social determinants of health and health inequalities. Big Local is a resident-led area improvement initiative in England, funded by the UK Big Lottery Fund. Initiatives focused on community empowerment are increasingly prominent in public health policy and practice globally. Approaches emphasise the promotion of greater control over decisions and action among individuals, groups, and communities, particularly those living in disadvantaged circumstances. However, when it comes to participation and inclusion in taking action and making decisions, the field is characterised by conceptual confusion. This risks undermining the impact of these initiatives. While participation and inclusion are necessary conditions for empowerment and collective control, they are not necessarily sufficient. Sufficiency requires attention to the breadth of participation (i.e., to inclusion) and to the depth of participation (i.e., the extent to which it is experienced as empowering and ultimately enables the exercise of collective control over decisions and actions). In observing how different Big Local resident-led partnerships across England are tackling the day-to-day challenges of engaging with their communities, we reveal the potential for policy and practice of reframing, and therefore clarifying (to highlight the different roles they have) the concepts of participation and inclusion in terms of depth and breadth.

This research article on youth smoking in disadvantaged communities is the product of a qualitative study to understand the issues faced by young smokersand those trying not to be smokers -in such communities. Environmental factors and peer influence are widely recognised influences on adolescents' take-up and continuation of smoking but less is known about whether, what, how and why circumstances in disadvantaged communities affect young people's pathways towards and away from smoking. Focusing on a youth club in a disadvantaged neighbourhood in the North East of England, narratives about young people's relationships with tobacco provide an ethnographically rich, thick description of the experiences of a group that is too often easily ignored. We argue that young people are caught between competing domains that together exert a form of structural violence. These are, first, the economic and political structures that have overseen de-industrialisation; second, the media structures that create desire for what they cannot afford; third the structures of international organised crime that conspire to provide them with the means to consume from which 'legitimate' structures effectively exclude them. Rather than expecting young people to comply with the health imperative, interventions need to bridge issues of agency and critical consciousness, which structural violence otherwise insidiously erodes.