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Background
This is a multi-disciplinary study. It will examine the factors
that shape the health, knowledge and action of individuals and groups
and explore the links between knowledge, action and the social patterning
of health and illness. Central to the research will be the relationship
between material circumstances, the place in which people live and
the historical and cultural characteristics of localities.
Aims and
Objectives
The study will address the following questions:
- What is the
nature of the relationship between health status and material
circumstances within and between differing social and geographical
spaces?
- Are there
differences in the nature of lay knowledge about health, illness
and health variations between different localities?
- What are
the processes by which such knowledge is constructed, transmitted
and used as the basis for individual or collective action?
- If there
are differences in the nature and transmission of lay knowledge,
how are these shaped by present material circumstances and the
history of local areas?
- Are there
differences in the ways in which lay and professional knowledge
about health and health variations are constructed and what implications
might this have for policy and practice?
Study Design
The study involves a number of linked levels of data collection
and analysis in four localities with contrasting socio-economic
characteristics. The levels include: a geographical analysis of
routinely available data on health experiences (e.g. mortality data,
disease diagnosis and health care utilisation) and health-related
resources at ward level; local surveys of around 250 households
in neighbourhoods within wards collecting data on health status,
health-related action, social circumstances and relationships and
health-related decision-making, and qualitative case studies of
approximately 20 individuals drawn from neighbourhood surveys and
with other significant people in their lives. In addition, pilot
work will be undertaken in one locality, focusing on local service
providers and policy makers and the historical development of the
locality.
Policy Implications
The study will illuminate the complex and diverse ways in which
material circumstances and social relationships work to shape knowledge
about health and illness through the places in which people live
and within an historical context. The study will also seek to link
this understanding to spatial and social patterns of health and
illness. As well as contributing to the explanation of health variations,
the study should help to drive forward the growing interest within
the health service of ways of combining qualitative and quantitative
research traditions and, in particular, advance the way in which
information on geographical localities is coded and constructed.
In addition,
by developing a deeper understanding of health- related behaviour
and health processes, the study will signal the ways in which policy
and professional practice can move beyond current (only partially
successful) attempts to promote health by dealing with individual
behavioural 'risk factors' or environmental pathogens. Whilst simple
solutions to the problem of health variations are unlikely to emerge,
the study's outcomes will indicate new directions for interventions
at the macro and micro level.
Project Summary
The increasing area concentration of affluence and disadvantage
in Britain has focused attention on the question of whether and
how places influence the health of those who live there. It is a
question central to the development of policies - at national, local
and neighbourhood level - to tackle health inequalities.
The project
examined the area influences on health and health inequalities through
a series of linked studies based in two northern cities. In Salford
and Lancaster, two localities were selected, one relatively advantaged
and one relatively disadvantaged in health and material terms. The
Standardised Mortality Rates in the disadvantaged areas were higher
than the population as a whole, but were substantially higher in
the disadvantaged area in Salford (151) than in the disadvantaged
area in Lancaster (110). Four levels of data collection were involved:
(a) ward level geographical analysis; (b) surveys in neighbourhoods
within wards; (c) in-depth interviews with residents in these neighbourhoods
and (d) historical research on how the areas had been perceived
in the 1950s and 1960s.
As part of the
project's focus on the influence of areas on the health of their
residents, it also explored people's understandings of health inequalities
and of what makes a neighbourhood a good place in which to live.
Key findings
- The four
levels of data collection yielded detailed cartographies of inequalities
within and between the four areas. These uncovered greater heterogeneity
in health and material circumstances within the more disadvantaged
wards compared with the advantaged localities. There were also
clear clusters of deprivation within the poor localities.
- The studies
examined how far the social composition of the areas accounted
for the health differences between them. Factors which some researchers
term 'compositional', such as the low income of residents, their
smoking behaviour and their lack of social ties, were all strongly
associated with reported poor health (having taken account of
age and limiting longstanding illness).
- Aspects of
the environment - often referred to as 'contextual' factors -
had an additional effect on health. This effect was evident for
the social dimensions of the areas, including dimensions of social
capital, like lack of involvement in community life and feeling
insecure about the area. The physical dimensions of areas were
also important: the perceived quality of the physical fabric of
the area and access to services were associated with reported
poor health. After adjustment for the effects of individual material
circumstances and behaviours, these 'contextual' measures of social
capital, environmental quality and access to services remained
associated with reported health state. For example, those who
participated less in their communities and had fewer connections
with family and friends reported poorer health.
- Whilst the
quantitative work included an analysis of the relative importance
of contextual and compositional factors, the qualitative work
highlighted the difficulty of separating people from the places
in which they live out their lives. There were marked differences
between respondents in the more disadvantaged and more advantaged
areas with respect to their perceptions and experiences of their
neighbourhoods. For example, a third of those living in the disadvantaged
areas did not think it gave them a sense of community, compared
with a sixth in the advantaged areas.
- Exploring
these attitudes to place further, it became clear that feeling
one's neighbourhood was a 'proper place to live' had an important
influence on health behaviours and perceptions of well-being:
compositional and contextual factors were intimately linked. Individuals
living in areas which were not perceived as 'proper places' acted
to protect themselves and family members against external threats.
They described how they withdrew from public spaces, and the opportunity
for walking and access to support and services that it provided,
into the security of the home and health-damaging behaviours such
as poor diet and excessive drinking. As external threats triggered
increasing privatisation of everyday life, the basis for collective
action to tackle these threats was undermined.
- In respondents'
accounts of health inequalities, multi-factorial explanations
predominated. In the neighbourhood surveys, the majority (89%)
gave explanations which included structural, environmental and
individual determinants. Explanations involving structural causes
like poverty were equally common in all areas. However, people
in disadvantaged areas were significantly more likely to explain
health inequalities in terms of environmental factors and/or area
characteristics (like housing and levels of pollution) than those
in advantaged areas. Conversely, people living in the more affluent
areas were more likely to give individualistic explanations for
health inequalities.
- The in-depth
interviews confirmed that lay understandings of health inequalities
are complex and multi-factorial. Respondents in the more disadvantaged
areas tended to reject evidence that there were marked inequalities
between the health of rich and poor; those in the more affluent
areas were more ready to accept this evidence. Rejection of inequalities
may provide a mechanism whereby people experiencing the greatest
risks to their health distance themselves from the negative prognosis
for their health and that of family members and from the inferior
social status of being on the lower rungs of the class hierarchy.
- The historical
research highlighted how the more disadvantaged localities had
been subjected to repeated urban renewal programmes. These past
programmes were seen as excluding residents from decision-making
processes and discounting lay perceptions of 'proper' places to
live, perceptions which both influenced and were confirmed by
residents' experiences of current housing renewal policies. This
in turn appeared to feed into a widespread withdrawal from collective
community life and a growing distrust of neighbours and local
agencies.
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