We focus on four complex health issues more prevalent in urban areas
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Urban health • COVID-19
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Rowena Estwick talks about the need for an equitable research approach to create policies with impact and amplify underrepresented voices.
For the last 18 months, we have lived through a period of almost constant uncertainty. As an organisation, it’s our mission to understand how inner-city areas, particularly our local boroughs of Lambeth and Southwark, are going to fare as a result of big, long-term changes to things like business, immigration, and the built space around us.
We recently published a report – Future Scenarios for Lambeth and Southwark – developed with the London School of Economics (LSE) and Centric, a group of Community Researchers from the boroughs, to map some of the future scenarios London might find itself in post-pandemic.
As well as teaching us valuable lessons about the next 10 years of health and social care in our place, and potentially cities across the world, our approach to this report was an important example of the realities of combining academic research and research centred on the experiences of those living in urban neighbourhoods.
The development of these future scenarios gave important insight into the different but equally valuable roles each methodology plays. Using London and our boroughs as a focus, LSE took trends from past recessions and insights from our programmes on urban health to develop a set of future scenarios of what London might look like if we prioritise health equity, and the fallout if we do not.
Centric, a Community Researcher team we work with on other projects, reviewed the scenarios through their experience as residents of Lambeth and Southwark, providing contextual knowledge of what each scenario would really mean for people living in the boroughs.
As the pandemic unfolded it became clear that inequalities would continue to widen. To understand how this might impact our communities, those most affected by the pandemic needed to be integral to the process of developing these scenarios. Combining both community and academic research brought invaluable insights and credibility to the work and gave us an opportunity to see what the future of London might really look like for people living in our place. Equally as valuable was the understanding gained about the barriers faced when trying to do this well and authentically.
Due to the exceptional circumstances of the pandemic, our collaboration with the Community Researchers was more transactional than is ideal. They were asked to share their insights on a set of scenarios that had been partially formed, and under different circumstances co-design of the research methodology and co-production of each scenario from the outset would be the minimum requirement to ensure the fullest story was told. Even so, the Community Researchers’ collaboration with LSE helped to further shape the scenarios and add nuance, deep understanding, and context to each potential future.
Though this does not lessen the joint effort, it does point to a wider issue: If academic research – that traditionally does not include the experiences of communities as an equal and valid form of data – is used as the basis for policy and decision making, then the risk of excluding these perspectives is increasing the very inequalities such research aims to address.
Understanding this gave us two key learning points about research aimed at influencing change: when and how you involve different voices matters, and underrepresented voices need to be in a position to be heard.
“ If academic research – that traditionally does not include the experiences of communities as an equal and valid form of data – is used as the basis for policy and decision making, then the risk of excluding these perspectives is increasing the very inequalities such research aims to address.
If academic research – that traditionally does not include the experiences of communities as an equal and valid form of data – is used as the basis for policy and decision making, then the risk of excluding these perspectives is increasing the very inequalities such research aims to address.
Often, the inclusion of underrepresented voices from communities most affected by an issue can – whether perceived or real – be an afterthought. Lack of time or need to be ‘reactive’ is used as a reason for limiting involvement or excluding a diversity of voices.
Our report on health equity in cities around the world found that it is the lack of value placed on community insights, and the experiences and perspectives of people from affected communities, rather than available time or resources, that drives lack of inclusion. This means that, more often than not, insights gained from communities most impacted by inequality are used more to validate already formed ideas or theories rather than to inform or shape them.
It’s crucial that researchers and funders see those with lived experience of inequalities as the subject matter experts they are.
We’re working with the Wellcome Trust to improve health outcomes by transforming public engagement in health research, both in terms of how the public contributes to the production of research and how they can use it. This means supporting projects that challenge existing methods; exploring new models and building evidence; and giving power to communities.
Notwithstanding the issue of time, the Community Researchers we worked with had limited capacity to support this project as they were working across several of our other programmes, as well as with other clients. This highlighted to us how few research organisations there are built and run by people from underrepresented communities.
A historical lack of investment into such organisations and a perception that they are unsustainable or high risk by funders and commissioners limits their ability to be involved in research that meaningfully shapes policy. As a result, their rich insights and the contextual knowledge they bring are lost. And so the research aimed at addressing systemic issues is built on an incomplete picture of the current social landscape.
Organisations like ours are at risk of contributing to this inequity if we do not take intentional action to understand the full picture. This means not only focusing on what we do to reduce inequalities through the projects we fund, but also how we do it and who we work with.
We’ve started to actively engage and invest in organisations rooted in our communities, built and run by those who are most impacted by the inequalities we are aiming to understand. In this way, we are not only gaining the insights we need for our projects but supporting the sector to build its own profile and capacity. And the greater their capacity, the easier it will be for policymakers to engage with underrepresented voices in a meaningful way (and the fewer excuses they will have not to).
“ Organisations like ours are at risk of contributing to this inequity if we do not take intentional action to understand the full picture. This means not only focusing on what we do to reduce inequalities through the projects we fund, but also how we do it and who we work with.
Place-based organisations like ours hold a unique space in driving change but cannot do it alone. Building a fairer future for London and the UK as we emerge from the pandemic will need sustained effort and political will.
Our scenarios look 10 years into the future; this covers three political cycles in the UK, which means potentially three different political agendas and sets of priorities. If sustained political will is a requirement of tackling systemic inequality, then an environment that enables elected governments to engage in a long-term agenda is the challenge – but not an insurmountable one.
In thinking about what an equitable recovery would look like, there is the opportunity for us and others working in this space to act as catalytic conveners – creating the right conditions and bringing the right people together to create change.
By being able to commit to long-term strategic objectives we can support the leaders, policymakers, and those who own the environments that contribute to health outcomes (housing, business, commerce, etc) to drive towards a fairer future.
We understand that we too sit within systems of inequity and risk supporting or increasing these inequities if we are not mindful about our ways of working. Who and how we fund and how we engage with the communities in our place forms part of our work on building an equitable future for those living in inner cities and for our organisation.
You can find out more about how we aim to address some of these imbalances through our diversity, equity and inclusion work, as part of Guy’s & St Thomas’ Foundation.
Research and development • COVID-19
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