The importance of protecting time: Considering positionality in research programmes into health inequalities
Dr Maev Conneely reflects on her experience working on the “Acceptability of perinatal mental health services for women from Ethnic minorities (PAAM) study”. She highlights the importance of positionality (developing an understanding of your own identities, particularly ethnic and racial identities, and how these exist in relation to systems of power and oppression).
“It’s no longer a question of knowing the world, but of transforming it.”
– Franz Fanon
Researchers concerned with understanding and redressing health inequalities generally have good intentions when it comes to improving mental health and removing the (often dramatic) health inequalities that exist between racially minoritised1 groups and the White British majority. However, through insufficient (or total lack of) devotion of resources into delving into the large bodies of knowledge on positionality, intersectionality and anti-racism, there is a risk of researchers entrenching the very inequalities that are trying to reduce.
All research addressing health inequalities needs to have an investment of time and effort, as standard, so that each researcher on the team can read, learn and engage in reflexive practice to consider their own positionality.
I will use the example of my experience working as a researcher on an NIHR-funded project to explain why this investment is vital.
The project I work on ultimately aims to improve the care provided to women from ethnic minority backgrounds 2 who experience mental health problems in the perinatal period 3. The PAAM project investigated the experiences of South Asian and Black women who received help and did not receive help from services, after finding that women from South Asian, Black and White Other ethnic groups were more likely to be admitted involuntarily, and less likely to access routine mental health appointments in the perinatal period 4.
Positionality here is understood as developing an understanding of your own identities, particularly ethnic and racial identities, and how these exist in relation to systems of power and oppression. Positionality includes consideration of experiences that a researcher might not have. For example, as a childless White woman, there are experiences I do not have access to that are relevant to the project. I cannot fully know what existing as a racially minoritised woman in the UK is like. Despite being able to learn facts about pregnancy, childbirth and parenting, I cannot truly understand what having a baby is like. Academics pride themselves on knowledge and learning – we are experts in the field of research we have chosen. Acknowledging a lack of knowledge that cannot be remedied is likely to feel uncomfortable.
Willingness to read, learn and acknowledge the limits of our understanding as White researchers working in this field is essential, as is taking steps to mitigate the risks resulting from these limitations, e.g. involving people in the decision-making processes who have relevant experiences.
Engaging with relevant literature on reflexive practices, positionality and antiracism may – perhaps should – make the researcher feel uncomfortable.
There is a significant difference between being anti-racist as opposed to non-racist.
The starting point, or assumptions, for research investigating health inequalities related to ethnicity (and indeed all healthcare research) cannot be that the world is bias-, stereotype- and racism-free 5. Aiming to be non-racist, and approaching work with purported “objective distance” and the projection of neutrality (i.e., without any specific backgrounds), risks missing biases, stereotypes and assumptions, and may thus lead to perpetuating and reinforcing inequalities.
The findings of the PAAM study are important, and its prioritisation of implementation gives hope that we will start to see a change so that all women access the perinatal mental health support they need. Throughout the project, the research team, which was made up of people from different ethnic backgrounds and with first-hand experience of perinatal mental illness, learned and educated themselves, taught each other, and attended anti-racism groups. They invested their own time to understand the topic. This resource-intensive work was not a required part of the research but the programme facilitated its evolution. An investment was needed from the research staff to delve into, examine and consider their positionality, and reading into anti-racist literature was a key element in this work. In the future, this effort should not be left to chance, but should be embedded in each stage of work from the very start of a research project.
One of the findings to come out of the PAAM study is that much is already known about how to improve access to care, and that despite this, change in practice appears to be slow. The same sentiment could be applied to the conduct of health research. There is a wealth of knowledge and literature on anti-racism, the importance of reflective and reflexive practices (in qualitative research especially), and the positioning of researchers and research projects. But there is a gap when it comes to translating this into practical, day-to-day work on a research project.
Practical steps need to be taken so that time is protected for research staff to engage with the knowledge we already have – some of which may be uncomfortable for us with our “scientific” training.
Research into health inequalities should embed in each phase, a space for researchers to reflect on their positionality, biases, and assumptions. This could be linked with deliverables to funders to ensure it is not left by the wayside when projects inevitably overrun, and targets need to be met.
1 Language advocated for in the Lancet Public Health to reflect the understanding that people are “actively minoritised by others rather than naturally existing as a minority, as the terms racial minorities or ethnic minorities imply” from Milner, A., & Jumbe, S. (2020). Using the right words to address racial disparities in COVID-19. The Lancet. Public Health, 5(8), e419. 2 Wording from the application. 3 The perinatal period is pregnancy and the first year after birth. 4 Jankovic, J., Parsons, J., Jovanović, N., Berrisford, G., Copello, A., Fazil, Q., & Priebe, S. (2020). Differences in access and utilisation of mental health services in the perinatal period for women from ethnic minorities—a population-based study. BMC medicine, 18(1), 1-12. 5 As is the case with the project I work on, when we are dealing with different intersecting marginalised groups of women and people who experience mental illness.
