How can communities participate in urban place planning for better health?

The fourth podcast episode from the TRUUD programme explores public engagement in shaping healthier urban environments. Hosted by Andrew Kelly in conversation with Dr Andy Gibson, University of the West of England and Dr Miriam Khan, GP and member of the TRUUD Public Advisory Board, they explore the importance of involving communities and listening to their lived experiences in policy creation. 

They examine methods for effective engagement, such as deliberative approaches and the use of visual aids, highlighting challenges and successes in projects like low traffic neighbourhoods. The guests also recommend books that underscore the principles of people-centred urban development and the accessibility of scientific information.

Funded by the  UK Prevention Research Partnership which aims to reduce non-communicable diseases such as cancers, type-2 diabetes, obesity, mental ill-health and respiratory illnesses, TRUUD is providing evidence and tools for policy-makers in government and industry.

Find more at the TRUUD website: https://truud.ac.uk/

Books recommended in the episode

Dr Miriam Khan

Happy Cities by Charles Montgomery

Dr Andy Gibson

Bad Science by Ben Goldacre

Andrew Kelly

The Death and Life of Great American Cities by Jane Jacobs

Music credit: New York London Tokyo by Petrenj Music

Produced by Beeston Media.

Transcript

00:00:03 Andrew Kelly

This is our 4th TRUUD podcast from the University of Bristol and Andrew Kelly. 

TRUUD looks at how we can shape places for healthier lives. We've been discussing research and action for policy now in creating healthier places and societies, governance and policy challenges, and making change stick for the long term. We're looking today at involving public and communities, which is a TRUUD priority.

I'm joined by Doctor Andy Gibson, associate professor in patient and public involvement at University of the West of England, who leads the TRUUD Public Engagement intervention Programme, and Dr. Miriam Kahn, member of TRUUD Public Advisory Group and a GP working out of Montpellier Health Clinic. Miriam is also part of a Bristol group advocating on health inequalities, called GP's at the deep end, Bristol. 

Miriam, let's start there. Tell us about the deep end movement.

00:00:58 Dr Miriam Khan

Good morning. So the GP's in the deep end network is something I got involved with about a year ago through a health inequalities fellowship that I undertook. The reason I got involved with the network in the 1st place is I've always had a lifelong sort of passion for trying to reduce health inequalities in practice and through my community work. So this fellowship was a perfect opportunity to actually try and make a difference in the practice that I work.

My practice is an inner city, Bristol, a very diverse, very engaging, amazing population. However, over 50% actually live in 20% of the most deprived areas in Bristol, so this fellowship was sort of perfect for what I wanted to do really.

00:01:40 Andrew Kelly

And it seems to me that reading about that TRUUD is beneficial for the work you're doing, but your work is also very beneficial for TRUUD. Is that why you got involved in the in the project?

00:01:51 Dr Miriam Khan

Yes, as I said, I've always had an interest in health inequalities and trying to sort of tackle sort of root causes because we know it's not just biology which is a cause for poor health. We know the urban environment has a big factor in that as well, and I see that through the patient population I work with – a lot of them, live in overcrowded houses, poorly insulated houses, areas with lots of noise pollution, air pollution. So I see the work of TRUUD in front line GP. So yeah, I think a lot of the work and what my colleagues are trying to do doesn't define with TRUUD.

00:02:24 Andrew Kelly

Thank you. Andy, public engagement can be hard and challenging. What does good public engagement mean for you?

00:02:31 Dr Andy Gibson

Well, I once had a discussion about this with some colleagues and we went around a lot of discussions around different principles like good public involvement should be about in research about the research being user-led and the agenda being set by as far as possible by members of the public, and we thought about all these things, but in the end I think the conclusion I came to is that good public involvement is thoughtful Public involvement. It’s where you actually take the time rather than just following a kind of cookbook approach. You really take the time to think about the people you want to engage with, how it's going to make it easy for them to be involved, what issues need to be addressed? What's the scope that they can be involved, what decisions are flexible and what aren't? There's no point in asking people about questions that they really cannot influence.

Thinking about how they can help set the agenda for the research, pick the outcome measures for the research. What matters to them? What does success look like for them and also when it comes to designing health interventions, what's going to work for them? 

I can remember was talking to somebody with type 2 diabetes and they were telling me all about the different things that doctors ask them to do to manage their type 2 diabetes and they say. Well, actually it's not really an intervention, is it? It's a part time job when you ask me when all these different things. 

So you got to think what's going to work in real life for people as well. What's likely to have an impact. So I think you have to take all those things into account. And so, yeah, I would say, yeah, thoughtful public involvement is, is good public involvement.

00:04:03 Andrew Kelly

And is this what makes up deliberative engagement?

00:04:06 Dr Andy Gibson

Well, deliberative engagement is and they become really interested in because I think when we ask people their opinions (sometimes we do that via surveys in a general election. We do it by asking people to vote for a political party). The problem with all those approaches is you don't really get a chance to work through and discuss the issues in a very deliberative way. 

I mean, yes, you know, in a general election you might see press releases from the other side and so on, but you rarely get the chance to actually talk and exchange different points of view. And the whole thing about deliberative approaches is to bring people together from different perspectives into a place where they can discuss the issues, bring in whatever evidence is relevant as well, and what's the rationale, What's the logic behind suggesting a particular thing that might improve things, and focusing on a particular problem. I think that's really important because people can talk in big, grand terms about political positions. But I think if you can get people to come away from that and focus on a particular problem, exchange points of views listen to some of the evidence and then try and work out a solution collectively. Then I think you've got a chance of moving forward. And there are various deliberative techniques and they've been used in different places around the world, but they've been shown to be very effective at getting people to move away from positions and cross barriers to begin to co-create solutions and that's one of the things that I I was really interested in and want to wanted to bring into this project.

00:05:38 Andrew Kelly

Miriam, one thing I've learned from this is the importance of lived experience, listening to people. And TRUUD has produced some hard hitting videos covering people living with damp and mold, overcrowding, stress, lack of play facilities, traffic noise, poor air quality. And I in fact, I recommended one in in the second podcast. I fell asleep at school. How important is material like that in in developing policy ideas?

00:06:06 Dr Miriam Khan

I think it's very, very important, because I think historically we've always just been very data-driven. So we've always presented sort of qualitative data methods, which might not always be appropriate depending on what populations you're trying to actually reach. And as like Andy said, try and you know have a conversation with about sort of creating policies. So I think visual aids are a powerful way. As we've mentioned, very powerful, very emotive as well, and really, do get people thinking. 

And I think it's a good way as well for policymakers to sort of understand sort of the real issues on the ground that people are experiencing because I think sometimes, I mean, I know from personal experience having gone to public engagement events myself and supporting communities in the past, is that policymakers very much sometimes come with their own agenda. They're very much trying to push that agenda – they're asking for opinions, but not being really listened to. So I think sometimes visual aids like this might actually get them thinking and actually make them rethink policies as well. So I think there's definitely a place for them. And also in terms of when we're trying to convince the public, I think again for people who like we said, data might not be the most appropriate method (for example, they can't speak English or you know they're illiterate, for example) then visual aids are quite powerful and getting the messages across, so yeah, that's why I think they're quite important.

00:07:34 Andrew Kelly

But you've also been involved in the practical development of those visual aids, haven't you?

00:07:38 Dr Miriam Khan

Yes, yes. And I think we're trying to make sure that they stand out and that important information is what people go to 1st and it's very important with the visual as we found as well through the public advisory group that we're not overloading people with loads and loads of information as well, but we're getting the key messages across and colors can be quite important as well, so certain colours can stand out more, grab people's attention. So there's lots of things to think about. But if it's done well, then visual aids can be very powerful tools.

00:08:08 Andrew Kelly

And just a quick question about who's on the public advisory group, who's involved in that?

00:08:13 Dr Miriam Khan

There's quite a broad group of people from various different expertise, so there's Joe White, who's an academic at UWE. We've got Andy, who's part of the group. We've got Charlie, who's, I think a local sort of news reporter. And then we've got Ian, who's from South Bristol who's very involved actively with the local community, and I think we've also had people previously involved from Manchester as well because I think they've got a similar sort of initiative up there as well. So we're a very diverse group of people and I think that's great because we all bring different views and different opinions and yeah, it works quite well.

00:08:50 Andrew Kelly

And Andy, it's not just Bristol, is it? Miriam mentioned Manchester. They have a similar involvement in the project there?

00:08:56 Dr Andy Gibson

Yeah. And we did some work with Manchester and we did have some public members of the public from Manchester that were involved in the in the project as well. And obviously I think it's important because, and it goes back to your point about the videos, it's about capturing people's lived experience, and people's lived experience and that's got a historical dimension to it in the sense that people have lived with the community. It's a place where people have got memories and attachments. And I think the history of Manchester is probably quite different to the history in Bristol – in in Manchester, you've got a history of deindustrialization and the impact of all of that. And there are probably different ethnic communities in the 22 cities. 

I think part of that lived experience and I hope it does come out in the videos, is understanding how people are relating to their environment, the issues they're facing, the struggles that we all go through in terms of making a living, looking after our children etcetera, etcetera, but some people doing it in extremely difficult and challenging circumstances and I hope that's part of what the videos transmit to people to communicate to people and that's one of the things we wanted to get over to the politicians because when we talk about health inequalities, it can feel very statistical. It can feel very dry and actually trying to bring out the human stories and the people that are behind those statistics, I think it's really important.

00:10:21 Andrew Kelly

Andy, it seems to me that asking the right questions is critical, and I think some of the TRUUD work suggested that if you just go in with the standard, what do you like in the area? What don't you like in the area is not enough? It's got to be enhanced with questions about feelings, emotions, and meanings and values that people have associated with the place they live in.

00:10:41 Dr Andy Gibson

Yeah, and I agree. I think if you ask questions like what do you like, “what you don't like, what would you like to have improved?” It's a very open question and it can raise expectations. People will have lots of ideas about how things could be improved, but if you get a lot of ideas, and then you say, well, actually most of those things, we can't do much about because we haven't got the resources or it's outside of our control, then straight away I think you're creating cynicism. I think it's much better to think about specific issues and problems that you can work on with the Community and then involve that community in designing some solutions.

00:11:18 Andrew Kelly

Thank you. Miriam, and I'll also ask Andy this as well. One key lesson I've learned from this work is how complex it all is, how you have to think about systems. Do you think we can break through some of that complexity by the involvement of lay voices, by bringing peoples lived experience into this?

00:11:38 Dr Miriam Khan

Absolutely. I think I mentioned this before, but I think historically, I think Andy mentioned it as well, we've just kind of been presented policies and been told to sort of vote on them sort of been given a raw opinion without any understanding of how these policies have actually come into place. This kind of assumption that they know us, they know our communities know our neighborhoods, that kind of arrogance, I think really angers and frustrates communities from my experience. 

So I think with the work that should have done, for example with the videos and using lay experience, real experience, I think it's very powerful and it also, if you present this work to the public or to governing bodies, it shows that they're being listened to, and I think it's a pathway to increasing trust between the public bodies and the communities as we know historically, that's not always gone down very well with multiple policies. 

So I think the value of the lay, non-expert is invaluable because not only can they sort of contribute by producing videos through and showing us their lived experience and the issues that they face, but like these people actually know their communities as well. So if you get members of the Community, especially maybe like community leaders as well who know the communities and get their opinions, I think you will actually learn a lot about what the real issues are. 

So rather than coming in with assumptions about what's going on, especially if you're not from that community, you're hearing directly from them what the issues are and that can actually make you create policies and you know, Co-design of policies with lay members is really, really important as well. So I feel in a way that it's organic, it's fresh, and if people know that you're doing that, if they know policymakers are coming in there, actively involving the communities in the design of policies, I think that will definitely improve trust. And also in a way it improves accountability as well. 

So I find historically what happens is even though people have tried to come in and get lay members sort of opinions, they'll kind of come in and do an event and then sort of go away and then they'll get no sort of feedback. So the public are sort of fed up of these public engagement events as such because they feel like, well, we're not actually seeing any of our valuable inputs in anything. So I think there needs to be some accountability as well if you're going to go in and work in this way and make sure they know that and that sort of Fed back to them. And I think that's most more likely to make sure that they engage again more in future as well.

00:14:07 Andrew Kelly

I mean, Andy, we've all been involved in really bad public engagement or have experience of it. Do you think this model that TRUUD has developed, or models, is valuable not just for issues of Urban Development, for wider engagement on other areas?

00:14:22 Dr Andy Gibson

Yeah, I think it could be. I mean, unfortunately, we're living in a time as people are aware, where views seem to become more and more polarized, social media and so on, and you know if I had looked at the news this morning, there's probably something about immigration and something about inequality and so on and so forth. These are all controversial issues, and I think we need to find ways of bringing people together from very different perspectives in a way that they can talk to each other and exchange ideas, and make it easier for people to understand what the research and the evidence is saying, because it can feel like it's a very academic debate about health and equalities and statistics. And Miriam was saying about creating ways to make data understandable. So one of the things we've been exploring is can we use maps of pollution levels or other ways of showing what risks are that make them understandable or easier to comprehend to people.

So you've got that academic knowledge, but you're bringing that together with what we might call the lay knowledge that the understanding of the issues in the Community and the problems and so on that need to be addressed, and bring those things together – together with different people's perspectives –  to create a more, it's a more democratic way of thing doing things, but it's also a more holistic way of understanding a complex problem, and although we're looking at this in the terms of Urban Development and health, I think that kind of a methodology can have a big impact on a whole range of complex and controversial issues.

00:15:58 Andrew Kelly

Let's talk about one controversial issue, which is in some places called low traffic neighborhoods in in Bristol, for example livable neighborhoods, this has been a difficult process. It's led to protests. Andy, what's gone right and wrong there, do you think?

00:16:15 Dr Andy Gibson

I think it's worth just taking a step back and looking at the historical context to this. By definition, you bring those schemes into areas where there are high levels of pollution, so they're also going to be the communities with where the with higher levels of deprivation and so on and so forth. And many of those communities have been experiencing that for several decades now, going back to say perhaps in some communities, the impact of deindustrialisation and so on through, the 80s and 90s to the present, and accompanied with that feeling that none of the political parties or the mechanisms for views from the community to be represented are working. They're being ignored.

So you go into that conversation already with quite high levels of distrust. Then as I said mentioned earlier, if you go in and ask questions like well, “what would you like to be improved about your community” create a lot of expectations and then say well actually we can't really do all that you're already going in a very difficult direction to get out of.

And then when you say we want to improve your health by basically making it harder for you to use your car as one person. Put it to me in a workshop where a community that's already carrying a lot of burdens, why do you want to add more burdens to our community? And I think particularly if you don't then listen to what those extra burdens are and how you might mitigate them, that's really problematic. 

So if we did a comparison with somewhere like London, that's got a low emission zone, that seems to work, but it also works because you've got a very good public transport alternative in terms of buses and a tube system. If you tried that in some parts of Bristol it wouldn't work because people would quite rightly say to you there isn't a good bus system. There isn't a good public transport system, and even if you say to people and I think it has been said locally in Bristol, we will give you some money to offset the cost of public transport or things like that. That's no good if the public transport just isn't there. So I think that's one of the key problems is understanding that this communities have high levels of distrust, feeling that they've been very much ignored and then you're adding extra burdens and then you're not actually listening to them when they say these are the things that need to be addressed to make this work for us.

00:18:42 Andrew Kelly

Do you think we need a new approach? Miriam, on the way, we look at low traffic neighborhoods?

00:18:49 Dr Miriam Khan

Yeah, I agree with everything. So Vandy said and I would just like to add sort of in terms of when we are consulting the Community. It's usually the ones when we're talking about health and qualities here, the ones who are the most affected are the ones whose voices don't get heard. So of course, everyone's opinions are important, but I find when you do go to these public engagement events, you'll get a certain cohort of people coming and giving their opinion, which isn't representative of the whole communities. For example, people like business owners. They are obviously quite sceptical. I find from things like low traffic neighborhoods because of the worry of the effects can have on their business with the lack of influx of customers coming in, people not wanting to travel through these kind of zones. 

Also we talked about before, usually people from low income backgrounds I find are the ones who need to use their cars the most. So obviously post COVID, the world has changed and people with higher incomes have the opportunity of flexible working hybrid working so they don't need to travel, but people from lower income communities do. So I think it's really, really important going forward and I think through and the programs have already been introduced, the problem is that these communities are the ones who haven't been consulted and these are the ones who are angry, who are frustrated, who are protesting and backlashing. So going forward, it's really important to make sure that their voice are involved and we have diverse sort of representation. 

And sort of leading with Andy saying right from the start rather than I feel like as later on sort of introducing these sort of initiatives to get people on board because people are now suddenly angry is when you're doing the initial public engagement and you're starting it at the beginning, making sure you've got some real sort of viable alternatives at the start, so: this is the problem, this is why we want to change things, this is how it's going to get better, this is how we're going to make things better for you. So we need to come up with some real life initiatives first before saying that we need to, like you said, change your life suddenly make it more difficult.

00:20:45 Andrew Kelly

And one of the practical outcomes, Andy of this work is a toolkit for based on I'll call it low traffic neighborhoods but it will have wider opportunities for use, won't it?

00:20:55 Dr Andy Gibson

Yeah. And we kind of thought and I'm not sure that this was a wise decision we kind of thought let's go for something where there is some controversy if we can build something that can be helpful in that context, everything else will be relatively easy. 

I'm not sure that's a wise strategy, but that's what we decided to do. So yeah, the idea is, is that we will create some resources. So part of it will be about ways to visualise data, to make it more understandable to people. It will be advice about saying that is really important to share the data with local people, and to be very explicit about your reasoning explicitly enough to allow other people to challenge your reasoning if they don't think it, it holds water.

I think there's a lot of we're doing this because it's going to be good for you, without really explaining why it's going to be good, good for you. I think other things that we've learned is it's one thing to talk about traffic and pollution in generalities. But what about our particular community? What's the evidence for the impact of various environmental factors in our community, with its unique set of circumstances and so on, and can people be involved in how that data is collected?

Certainly how the data is collected is made transparent so that they can feel confident that it does actually represent what they experience and what they're going through. So, with that scientific knowledge or that scientific evidence, but what we also then, as we've said previously, is we need that lived experience. We need to treat that as a form of evidence, as equally valid as the more traditional scientific evidence that we bring into that decision making process. And crucially, yeah, Co-producing the solutions as far as we possibly can.

The toolkit will have resources and some examples of how we've done that and some guidance about how to create some of those things to be used, not just as you say in low traffic neighborhoods, but in a whole range of decisions about urban design. It could be about housing, it could be about green spaces, where do you want your green spaces? How big do you want your green spaces? You want lots of little pocket parks. Do you want? But there's a whole range of issues that we could be discussing with different people.

00:23:08 Andrew Kelly

Finally, we ask all our guests to tell us about a book to join our other guests, books on the TRUUD bookshelf. Miriam, what book would you suggest we add to that bookshelf?

00:23:18 Dr Miriam Khan

I really like Happy Cities by Charles Montgomery. It's quite a recent publication, but it's very witty and why I think I really, really like it and it sort of sparked my interest was this whole notion of the healthy and happy citizen and what is a happy citizen and how that's linked to creating a happy city. Charles Montgomery talks about the whole notion of a happy city being, one which promotes health and not sickness. It's sort of support of cohesion between family members, friends, communities. It's all about social connection. That's helps us thrive as communities and the importance of equal work opportunities, access to open spaces, so a lot of it links in with TRUUD work as well, and he uses real life examples from different countries around the world which are trying to create this notion of a happy city. 

So for example in Columbia, I think the previous Prime Minister for many months ago he was very keen on this whole notion of a happy city and basically made it law that once a year car transport was banned and everyone has to travel by public transport or walk to work or do their day-to-day activities. And actually he found that by doing that commuting times to work commuting times to do the school run, actually didn't increase at all. People were happier as well because they were meeting each other, talking with each other. So there's a lot of positive benefit to it. So I just really like that initiative and other initiatives in the books, I highly recommend it.

00:24:49 Andrew Kelly

I mean, it's a terrific book because it has a bit of theory, but it has lots of practical ideas as well. I find. Yeah, yeah, Andy.

00:24:54 Dr Miriam Khan

Yes, and very witty as well.

00:24:58 Dr Andy Gibson

Yeah. So my books, Ben Gold Acres, Bad Science. Why I picked that is because I first read it in about 2009, which is when I was first, I had my first full time job doing public involvement in research.

I just a little bit of a story. When I left school at 16 having not done that well academically and spent a first few years of my life as a as a diesel fitter and now I'm an associate professor. So it's been a, and there's been various other careers along the way. But one of the things that really struck me when I left the cowboy that someone said to me, you'll forget about us. You'll go off to your new career and you'll forget about people like us. And I've always felt I don't ever want to forget those communities. And one of the things about that book is it makes the science so understandable and it starts off very nicely with some important but relatively light things like the science behind things like creams that allegedly prevent aging and works its way up to really, really, really important issues. And it does it in a really understandable way. And there's a few jokes in there which is, you know, unusual in a book about science, but that approach to saying everybody can understand this, everybody can get involved in this debate. Everybody can be part of the discussion if it's done well and that book very much influenced me and as it's happened, I think you've probably heard that it's informed some of the discussions we've had today.

00:26:28 Andrew Kelly

Well, thank you. My recommendation is Jane Jacobs, The Death and Life of Great American Cities. Jacobs was a writer, thinker, and activist, and one key take away from me from this book for me is about engaging with people and communities affected. Her book is from 1961, but still has a lot to teach us today about the subjects we've been talking about and about Cities generally.

Generally, other takeaways from me today, public engagement is challenging and time consuming, but working with people is critical. Listen to the lived experience of people and involve them in finding and designing solutions, provide understandable evidence based information and or we seek out new ways of engaging. 

Our final podcast looks at the future of Urban Development, the TRUUD website TRUUD.ac.uk has links to all podcasts, background research, and issues and recommendations discussed today. 

Thank you, Andy Gibson and Miriam McCann for joining me today.

00:27:26 Andrew Kelly

Thank you.

00:27:27 Dr Andy Gibson

Thank you.