System resilience and neighbourhood action on social determinants of health inequalities: an English Case Study

Main Points in Paper

Introduction

Persistent and enduring inequalities in health outcomes are found in all countries. In some, including the USA and the UK, they have been widening as increases in life expectancy have stalled and, for some groups, reversed.^1,2 Despite many national public health strategies focusing on individual behaviours, there is consistent, robust evidence that health inequalities are driven by inequalities in people’s living and working conditions, the material resources they have access to, and the degree of control they have in their lives.^3,4 The COVID-19 pandemic is occurring against this backdrop, creating what Bambra and Smith ⁵ describe as ‘a syndemic of COVID-19, inequalities in chronic disease and the social and commercial determinants of health’(p. 7).

Place-based initiatives are a prominent feature of policies aimed at tackling social inequalities, although improving health is not always an explicit aim. ⁶ These initiatives are often ‘hyper’ local being implemented in small neighbourhoods and a central feature is the involvement of people who live in the area – typically understood as the local ‘community’.^7,8 Over time, there has been an increasing adoption of strength-based approaches that seek to identify, enhance and work with the ‘assets’ and ‘competencies’ of local people – or communities – in the pursuit of positive outcomes. ⁹ Most recently, as the global recession and now the COVID pandemic have exacerbated inequalities, policy makers and practitioners in the public and third sectors have increasingly focused on how to nurture the resilience of communities bearing the brunt of social inequalities – their collective capacity to endure, adapt and generate new ways of thinking and acting in the face of these adversities. In this context, a new ‘community paradigm’ has emerged, involving approaches that devolve decision-making to people who live in particular places and opening up opportunities for community control of local services. ¹⁰ In this model, communities are to be given direct control over financial resources to implement their collective decisions, supported by the civil society sector, with a ‘soft’ enabling rather than leadership role for the local state and other actors.

Research has shown that interventions that increase the collective control communities of interest or place have over decisions and actions impacting on their lives can have positive impacts on health.^11,12 However, evaluations of neighbourhood initiatives have also shown that the type and degree of control communities are ‘given’ in these interventions vary and that the conditions and resources they need to exercise control over decisions/actions are unequally distributed. ¹³ As Baba et al. ¹³ note,

Thus, community engagement processes can be inadequately specified, producing weaknesses in the process and its aftermath, or narrowly proscribed such that they are unable to respond to variations in circumstances faced by communities living in different places. The result is that individual residents may not derive a sense of empowerment from either their participation in, or the ripple effects of, collective community engagement processes. (p. 1631)

This raises the possibility that neighbourhood initiatives aiming to enhance resilience and involve residents in local action to address social and health inequalities could be ‘imposing greater risks and responsibilities upon more disadvantaged communities in return for lower levels of power’.(p. 16). ¹⁴ There is also evidence that the individual benefits of involvement in neighbourhood initiatives may be unequally distributed and that there can be negative impacts on the health and wellbeing of residents who get involved.^15,16

Though not always explicit, co-production is an underpinning principle of many of these neighbourhood initiatives. According to the originator of the concept, the political scientist Elinor Ostrom, ¹⁷ co-production is a process that enables the knowledge and skills of citizens to be utilised to transform services and goods. By definition it can give greater control over decisions and actions to local communities but as Wilton ¹⁸ notes ‘it does not mean letting communities fend for themselves’ (p. 79). Rather it works best in the context of equal partnerships between local people, the local state and other actors. However, as Ostrom ¹⁷ noted, creating the conditions for ‘successful co-productive strategies is far more daunting than demonstrating their theoretical existence’ (p. 1080). Many writers since have identified systematic barriers, including dysfunctional leadership styles, perverse incentives, limited resources and lack of trust, that work against the development of genuine co-productive relationships. But perhaps the most important prerequisite if community members and staff in the public, civil society and private sectors are to work together as equals is for them to build a ‘credible commitment to one another’ (p. 1083). ¹⁷

In this article, we argue that local place-based initiatives that nurture resilience can create the conditions for effective co-produced action to reduce some of the social inequalities that drive health inequalities, but we also argue that this requires a different understanding of resilience. To this end, in the first section we briefly review the literature on community resilience from a public health perspective, concluding that understanding resilience as a potential property of neighbourhood systems rather than of the people who live in a particular area offers greater analytical and practical advantages for the design of place-based initiatives. We then describe how this approach was operationalised in nine socio-economically disadvantaged neighbourhoods in North West England and present an overview of key findings from an evaluation of this Neighbourhood Resilience Programme (NRP). Finally, the implications for public health policy and practice are discussed.

Community Resilience: An Inadequate Framework For Local Action To Reduce Inequalities

The COVID-19 pandemic has reinvigorated a long-standing policy and research interest in community resilience as a potential mechanism for local action to deliver greater social and health equity.^{19 –21} Prior to the pandemic, Ziglio et al. ²² argued that ‘if we are to foster lasting and meaningful action to strengthen resilience to improve health and wellbeing … it is more vital than ever to be clear about its particular significance’ (p. 789). However, achieving clarity about the ‘community resilience paradigm’ is a formidable challenge.

First, resilience in general, and community resilience in particular, have been under-theorised. Definitions are frequently ambiguous, using the term to describe (as a metaphor), to explain (as an independent variable, a model, or a paradigm), as a normative goal for policy or combinations of these.^{23 –28} The ‘characteristics’ of resilience are typically presented as a mix of qualities such as robustness, adaptability, and transformability. Definitions rarely elaborate these qualities, which can seem inherently contradictory: never satisfactorily explaining how resilience can encompass both social stability and social transformation. ²⁹

Cutter ³⁰ argues that this definitional ‘muddiness’ makes the concept’s application to practical initiatives problematic and does little to address inequalities. Research on community resilience as a component of responses to major events such as natural disasters, terrorist attacks, or political violence illustrates this muddiness. Reviewing this literature, Patel et al. ²⁷ identified more than 50 unique definitions of community resilience to disasters, which they grouped into those focusing on resilience as: (1) a process of change and adaptation, (2) the absence of adverse effects, and/or (3) a set of traits or attributes – with some definitions including all three approaches. Where resilience properties are ‘located’ is also typically obtuse. For example, although describing community centred public health as a whole-system approach, South et al. ²¹ argue that it involves ‘the public health system supporting the least advantaged communities to become more resilient’ (p. 306) rather than focusing on action to strengthen the resilience of the ‘whole system’ in which residents and other actors are co-located.

Second, whether as a normative policy goal or the potential outcome of interventions, resilience has been criticised as a component of particular political modes of neoliberal governance.^31,32 These modes of governance are argued to legitimise the rolling back of collective state provision of goods and services, promote personal responsiblility for health and wellbeing, and prioritise interventions that aim to enhance self-reliance and self-sufficiency through local community action. These resilience-informed interventions are disproportionately targeted at communities of interest or place that are bearing the brunt of social and health inequities and as a result may be less able to benefit (p. 16). ¹⁴

Third, the design of many community resilience focused interventions in the health field compounds these limitations by adopting an ‘inward gaze’ on psychosocial dynamics within disadvantaged communities and on actions to improve health-related behaviours and proximal neighbourhood conditions. As South et al. ²¹ argue in the context of the unequal impact of the COVID pandemic, creating community resilience is ‘what public health systems can do to strengthen protective factors, such as strong social networks, which will aid people and communities to manage, adapt, and ultimately recover well’ (p. 305). Social networks are important protective factors. However, a narrow inward gaze on relationship in communities diverts attention from the arguably more important ‘outward gaze’ on collective action in the pursuit of transformative structural changes to deliver greater equity. Although currently neglected, this outward gaze was enshrined in key global consensus public health statements on community-based public health such as the Ottawa Charter.^9,33

In response to these and other criticisms, Welsh ³⁴ highlights a growing stream of work rehabilitating resilience as ‘an analytical framework for examining [and as a means of mobilising] change’ (p. 22) towards more equitable and ecologically sustainable social and economic systems. Similarly, Hart et al. ³⁵ have developed a formulation of resilience in the context of psychological services for children and young people that integrates with social justice approaches. Alternative framings have also been proposed that move away from understanding resilience as a property of a ‘community’ defined as the people who live in a particular place. The Canadian Centre for Community Renewal, ³⁶ for example, proposes a place-based system perspective defining: ‘[r]esilient neighbourhoods [as] those that take action to enhance the personal and collective capacity of citizens and institutions to respond to and influence the course of social, economic and environmental change’ (p. 5).

These attempts to reconceptualise resilience through the prism of equity and systems-thinking go some way to deliver a potentially more useful framework for local action to address structural drivers of health inequalities. Building on this foundation, we designed a place-based intervention around the concept of neighbourhood system resilience and implemented and evaluated this in nine neighbourhoods in North West England. In the rest of this article, we describe the concept, the action research programme in which it was embedded, and key findings from an evaluation of this programme.

Neighbourhood System Resilience: A Public Health Concept Fit For Purpose

The concept of Neighbourhood system Resilience (NR) directs attention away from a narrow focus on the resilience of people living in disadvantaged places and on a ‘supporting’ role of external agencies and professionals. Instead, resilience is understood to be the collective capacity of all individuals and agencies, living, working, and operating within a neighbourhood to adapt positively to change and adversity. This collective capacity emerges primarily from social connections and governance processes that engage everyone with a stake in a neighbourhood. In turn, these connections and processes enable adaptive capacities and resources to be activated, shared, and used to co-produce action for greater social and health equity. The term ‘adaptive capacities’ refers to the tangible and intangible resources available to be modified or transformed by the actions of system players. ²⁶

More equitable and inclusive social connectivities and governance processes can only emerge, if traditional power dynamics are challenged and changed. In particular, imbalances in the power local communities and civil society have compared to other players in the public and private sectors need to change. Governance processes need to include and value all system players, building trust between them. Key to this is the harnessing and sharing of all forms of knowledge, particularly the knowledge emerging from lived experience, to co-produce a holistic picture of the drivers of social and health disadvantage locally, and effective action to address these.

Hyper-local places, such as neighbourhoods, have a unique combination of factors including local histories, contemporary economic, social and environmental conditions, cultural norms, and participatory structures and processes. These combine to shape local patterns of inequalities, the actions that are possible, and the impacts these actions will have. Every neighbourhood also has a unique group of system players that live, work, and operate there. At this granular geographical level, all system players can in principle debate, agree, and own a common goal of tackling specific structural determinants of health inequalities that are amenable to local action.

The Neighbourhood Resilience Programme

The NRP sought to operationalise the concept of neighbourhood system resilience and evaluate the impacts.^{37 –39} The NRP was developed by partners in the Collaboration for Leadership in Applied Health Research and Care in the North West Coast region of England (CLAHRC NWC) between 2014 and 2019. It was funded by the English National Institute for Health Research and CLAHRC NWC partners and implemented in nine Neighbourhoods For Learning (NFLs). Populations in the NFLs ranged from 5000 to 10,000. The neighbourhoods were all in the bottom 15% on the index of multiple deprivation, had relatively poor health indicators, and no previous experience of a major place-based initiative.

Local design and implementation

Within the framework described above, and following a common albeit non-linear process, local programmes were designed and implemented in nine Neighbourhoods for Learning (NFLs). Key elements of the implementation included establishing a space for inclusive collective governance; working with the COREN to recruit and support resident advisers and other system players; getting started by bringing the ‘whole system’ together to discuss and decide on a local priority for action; undertaking local enquires; and acting for change.

Spaces for collective governance

In each NFL, programme governance rested with a Local Oversight Group (LOG) with members from across the ‘neighbourhood system’ including local residents. The LOG was responsible for designing, implementing, and overseeing action to address a local issue that was negatively impacting on population health in the area. Drawing inspiration from the Habermassian ‘ideal speech situation’, ⁴¹ LOGs sought to create the conditions in which diverse knowledges and voices were treated as equal. In addition to formal governance, they were spaces in which all system players could be engaged in collective sense making, consensus building, learning, and improvisation. In addition, the LOGs convened and facilitated transient spaces for collaborative deliberation and problem-solving. These typically took the form of public events in which diverse system players were invited to voice their perspectives, hear those of others, attempt to find common ground, and make shared decisions.

Recruiting resident advisers and working with the COREN

In each area, a civil society organisation was funded to employ a COREN facilitator. They were in post as local implementation began and their first task was to recruit local people as Resident Advisers (RAs). Together with the COREN organisation and supported by the COREN facilitator, RAs participated in the LOG and other discussions, contributing knowledge about the neighbourhood including previous and existing community-based initiatives, the community’s strengths, and the social, economic, and environmental risks to health locally. The COREN facilitators and RAs were key players in the collation of evidence about local issues and in the design and delivery of action for change.

Getting started and deciding the focus

Work in all the NFLs started with a public event that sought to bring people across the neighbourhood system together to discuss the aims of the NRP. Participants also began to consider which of the social determinants of health inequalities amenable to local action should be prioritised as a focus for change within the lifetime of the NRP. The NRP framework served to focus local programmes on the five domains – social, economic, environmental, cultural, and governance – in which resilience capabilities needed to be enhanced and structural adversities needed to be addressed. These early phases of implementation embodied a commitment to shifting power dynamics: residents and other system players were engaged in participative governance spaces in which discussion and debate were supported, different voices were heard, and diverse evidence was valued.

Typically, the final decision on the issues to be prioritised for local action was taken by a small number of system players including residents, but subsequently, involvement in evidence collection and action was widened. A list of the focus for action in the nine NFLs is provided in Table 1. They included the experience of social isolation and cohesion; local employment prospects: air pollution; the quality of local streets and the neighbourhood environment; the availability of debt advice and awareness of gambling and debt in schools; and local transport.

OPEN IN VIEWER

Table 1

Focus of action in the neighbourhoods for learning

Blackpool	Improving privately rented accommodation
Liverpool	Rethinking the role of the High Street and taking action on air pollution
Knowsley	Community cohesion & environmental quality
Cumbria	Job searching and barriers to employment
Preston	Healthy streets and play places
Haslingden	Social cohesion and reduced social isolation
Ellesmere Port	Improving the quality of public spaces and increasing safety
Blackburn with Darwen	Housing and living environment
Sefton	Improving access to debt advice and support, increasing financial knowledge amongst young people

Resident-led enquiries and acting for change

Once a priority for action had been identified, rapid reviews of research sources and resident-led, participatory enquiries provided evidence on the current ‘state’ of the issue and potential action for change. The resident-led enquiries involved residents working as ‘peer researchers’ alongside the NFL Academic Leads and sometimes the COREN facilitator. Enquiry methods were diverse. They included working with a graphic artist to produce illustrated booklets and commissioning drama workshops, alongside more traditional methods, such as surveys, face-to-face, and group interviews. Findings fed directly into the design of local actions for change which were typically small scale and involved modest additional financial resources, often depending primarily on people’s commitment of time. On some occasions, enquiry findings were a key component of local action for change. For example, in one neighbourhood, the information collected was produced as a local exhibition and shared with several large local employers to inform and strengthen their social impact policies and to address some of the practical problems experienced by employed and unemployed people in the area.

What Was Achieved: Evaluating The NRP

Findings

Discussion

We have argued that place-based initiatives in the health field need to replace the dominant focus on nurturing and/or building resilience among local residents as a mechanism for local action on social and health inequalities with a focus on system resilience. Understanding resilience as the property of a neighbourhood system rather than a resident community isn’t just a language change. It is a mindset change that can transform local action on social and health inequalities. It requires place-based initiatives to activate, share, and use the collective adaptive capacities of all individuals and agencies, living, working, and operating within a neighbourhood working in equal partnerships towards achieving a common goal. A prerequisite for this form of co-production is that all players in a system have a ‘credible commitment to one another’ (p. 1083), ¹⁷ which in turn requires significant shifts in the power dynamics usually operating between resident communities and other players in neighbourhood systems. It also requires the active participation of, rather than support from, workers in the public and third sector.

We have described the NRP implemented in NW England that sought to ‘test’ a system resilience approach to co-producing action on social determinants of health in nine relatively disadvantaged neighbourhoods. In assessing the impact of the NRP, it is important to remember that the programme was implemented during a period of significant cuts in public spending on services, tightened eligibility for welfare benefits and increasing economic insecurity. All of which would have been felt more sharply in the disadvantaged areas in which the NRP was implemented. In addition, the programme involved relatively modest new resources in cash and kind: on average around £50,000 p.a. per neighbourhood excluding the evaluation costs, plus around ½ day a week in-kind contribution from local agencies.

A key aim of the NRP was to establish and nurture more inclusive governance spaces and greater social connectivity to engage everyone with a stake in the neighbourhood and enable their adaptive capacities and resources to be activated, shared, and used for the common good. These spaces needed to enable residents to have real influence over actions that impacted on their lives and to work in equal partnerships with other neighbourhood system players. Quantitative findings show that the programme was effective at increasing levels of perceived influence among residents in the programme neighbourhoods compared to comparator areas, and it may have contributed to a reduction in anxiety at a population level.

The qualitative findings illuminate the pathways through which the quantitative impacts were likely to have been achieved and also suggest that the people involved in the programme perceived the impacts to have been more pervasive than the survey findings suggest. The programme was reported to have enabled diverse system players in these relatively disadvantaged neighbourhoods to craft a new shared identity as an intentional, purposeful, and self-defined collectivity, to increase the breadth and depth of connections between them, to utilise and integrate diverse types of knowledge (ranging from research evidence to stories of lived experience), and to deliver improvements (albeit modest) in economic and environmental conditions.

The most significant influence on the capacity for effective, co-produced action in the NRP neighbourhoods was the increased social connectivity that was created (see Townsend et al. ⁴⁵ for a similar finding in the evaluation of a large, place-based, community initiative). The structures and processes put in place to support the delivery of the NRP facilitated the creation and development of these new connections and the repair of ruptured connections. These included the LOGs, local meetings and events, and the range of activities (including the resident-led enquiries) that brought people together. The expansion of social connectedness relied on intensive ‘relational work’ ⁴⁶ performed by a range of players involved in the NRP: the Resident Advisers, the COREN facilitators, the COREN Manager, Academic Leads, and the Local Authority Leads.

A key implication of a system resilience approach to place-based programme design is the strong focus on supporting the development of collaborative and equitable relationships between all system players with the shared aim of addressing local problems. Such relationships are supported by investing time and resources in facilitating and sustaining formal and informal opportunities for dialogue across the system; building trust; developing a shared understanding of the issues to be addressed and a vision for future collective action; exploring ways to align goals, resources, priorities, and actions; supporting the active involvement of local people working as equals alongside other system players; integrating different types of knowledge whether professional, experiential, or research-based; and finally, recognising that key players with power in the system may be located outside the neighbourhood.

The COVID-19 pandemic has made visible in the most pressing way that public health is a collective ‘commons’ whereby the disadvantages burdening some sections of the population ultimately impact negatively on the health and wellbeing of the entire population.^{47 –49} In contrast to ‘community resilience’, the concept of neighbourhood system resilience explicitly recognises and foregrounds this fundamental interdependence of everyone with a stake in a particular place. Initiatives informed by this concept would seek to create the practical framework required to support inclusive equitable collaborative efforts to address the social determinants of health inequalities that are amenable to local action.