location, location, location: the role of experience of disadvantage in lay perceptions of area...

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Health & Place 14 (2008) 167–181

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Location, location, location: The role of experience ofdisadvantage in lay perceptions of area inequalities in health

Rosemary Davidsona, Richard Mitchellb, Kate Huntc,�

aCentre for Outcomes Research and Effectiveness, Sub-Department of Clinical Health Psychology,

University College London, 1-19 Torrington Place, London, WC1E 7HB, UKbResearch Unit for Health, Behaviour and Change, Division of Community Health Sciences,

University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UKcMRC Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZ, UK

Received 30 April 2006; received in revised form 9 February 2007; accepted 30 May 2007

Abstract

This paper examines how people see and express their experience of inequalities through place and how they understand

the impact of place on health. Drawing on focus group discussions with participants from varying socio-economic

backgrounds, we show, in contrast to a nascent received wisdom, how people from more deprived areas more readily

discuss the adverse effects on health and well-being of structural and contextual features, whereas those with least

experience of deprivation or hardship were more likely to draw on behavioural explanations of area inequalities. People

living in more deprived areas also more readily accept statistics on area inequalities in health than those based in more

affluent areas. We discuss these findings in the light of people’s constructions of differences and distance between

contiguous areas. We conclude by discussing some methodological and contextual features of our study which may explain

why our findings both support and challenge those from earlier studies.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Area and health; Inequalities; Social stigma

Introduction

Health, wealth and place

Theories of the creation and maintenance ofsocial and spatial health inequalities in westernsocieties are dominated by the role of materialadvantage and disadvantage (Black et al., 1980;Gordon et al., 1999; Shaw et al., 1999; Whitehead,

e front matter r 2007 Elsevier Ltd. All rights reserved

althplace.2007.05.008

ing author. Tel.: +44141 357 3949;

7 2389.

ess: [email protected] (K. Hunt).

1987; Wilkinson and Marmot, 1998). Whilst debatescontinue about the actual mechanisms by whichmaterial disadvantage damages health and materialadvantage protects it, epidemiological evidenceabounds that it does so (Lynch et al., 2000, 2003;Marmot et al., 1997; Subramanian and Kawachi,2003; Wilkinson, 1996; Wilkinson and Pickett,2006). The role of space, and latterly ‘place’ in thisrelationship is well established (Dorling, 1997;Mitchell et al., 2000; Pearce and Dorling, 2006;Ram, 2006; Shaw et al., 1999; Singh, 2003). Mapsand figures which contrast the mortality rates andlife expectancies of different communities have been

.

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dx.doi.org/10.1016/j.healthplace.2007.05.008

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1One further study primarily reports on young children

(Backett-Milburn et al., 2003), another focuses primarily on class

identity and health (Bolam et al., 2004), and an earlier

exploratory study presented participants with findings from the

Black Report (Calnan, 1987).

R. Davidson et al. / Health & Place 14 (2008) 167–181168

constructed and studied since at least the 17thcentury (Macintyre, 2002). Then, as now, the mapsand figures show that areas with greater proportionsof people living in poverty consistently have poorerhealth.

At one level, these spatial differences in healthoften simply reflect the socio-economic processeswhich systematically advantage or disadvantagedifferent groups (McCulloch, 2001; Mitchell et al.,2000; Pickett and Pearl, 2001; Sloggett and Joshi,1994). Relatively advantaged and disadvantaged,and therefore healthier and less healthy, popula-tions tend to cluster in space. However, place ismore than a passive crucible in which ‘healthhappens’. Geographical theory recognises that spaceand society are mutually constructive; that is,people’s identities, attitudes and behaviours areshaped by, and in turn shape, the places in whichthey live (Del Casino and Jones, 2007; Harvey,1973; Mitchell, 2001; Sayer, 2000; Soja, 1980). Sincehealth is a key component and consequence ofidentity, attitude and behaviour it follows thatspace, or more accurately place, has a role inconstructing health (Macintyre et al., 2002). If placematters in the construction of health, and thereforein the construction of health inequalities, it followsthat maps of spatial differences in health andaffluence are not simply maps of where the sickand the well are to be found, they are maps of theprocesses and relationships which produce andreproduce ‘health’. For those interested in healthinequalities, this legitimates an interest in theeveryday relationships between people and theplaces they experience. In particular, as wealth andpoverty feature so prominently in the literature onhealth inequalities, and social comparisons areproposed as one mechanism by which healthinequalities are created and maintained (Wilkinson,1996), the contrasting experiences and understand-ings of inequalities of residents of richer and poorerplaces, who simultaneously experience and createthe affluence or deprivation of their area, could beimportant to understand.

The ‘lay’ perspective

The significance of the non-professional, or ‘lay’gaze on issues has growing recognition in publichealth research (see Blaxter, 1997 for an overview),stemming from qualitative research on ideas abouthealth, illness and health services. Public under-standings of the causes of health and illness are

variously referred to as lay views, beliefs, knowl-edge, epidemiology, and theories (see, for example,Cornwell, 1984). However, whilst the perceptions,beliefs and theories of the public, and particularlypatients, are being increasingly sought in the contextof trying to understand particular health beha-viours, or responses to clinical treatments (see, forexample, Hunt et al., 2000a, b, 2001; Lawton et al.,2005; Parry et al., 2006) very few studies havedirectly explored lay understandings of the causes ofhealth inequalities more generally, as other com-mentators have noted (Blaxter, 1997; Davidsonet al., 1999; Davidson, 2003; Backett-Milburnet al., 2003; Macintyre et al., 2005). Furthermore,even fewer studies have specifically focused on therelationships between the types of place peoplereside in, and their experiences of, and attitudes to,health inequalities.

Following the advent of the Labour governmentin 1997 in the UK, policy interest and researchfunding became more available for the study ofhealth inequalities. Yet, around the same time,Blaxter challenged those researching health inequal-ities with the suggestion that there was ‘‘no evidencethat inequality in health is an issue of great concernamong the lay public in Western industrialisedsocieties y it is not an issue at the front of thepublic’s consciousness’’ (Blaxter, 1997, p. 747).

Was Blaxter right? She was certainly correct tonote the lack of evidence on this issue. We know ofonly two studies published since Blaxter’s paperwhich have expressly asked about health inequal-ities and are able to compare the understandingsand responses of people from both more affluentand deprived areas.1 The research was under-taken in more- and less-advantaged areas of thesame cities, in northern England (Popay et al.,2003a, b) and the West of Scotland (Macintyreet al., 2005). Macintyre and colleagues used closedquestions in a postal survey which asked whether‘rich’ or ‘poor’ people (or neither) were more likelyto experience specific health conditions. In general,their findings support Blaxter’s earlier conclusionsthat ‘‘paradoxically’’ it was people from more-advantaged circumstances who ‘‘appear to be y

aware of the structural factors—income, work, the

ARTICLE IN PRESSR. Davidson et al. / Health & Place 14 (2008) 167–181 169

environment—which the social epidemiologicalevidence has implicated in inequalities in health’’(Blaxter, 1997, pp. 749–750). Macintyre and collea-gues concluded that:

those in y poorer areas were either less, orequally, likely than those in y richer areas toagree that poorer people experience more adversehealth outcomes. Put another way, there was notevidence that the disadvantaged were more readyto assent to statements suggesting that thedisadvantaged had worse health (Macintyreet al., 2005).

Popay et al. analysed answers to an open-endedquestion in a self-completion questionnaire thatasked respondents to give ‘‘the three most impor-tant reasons’’ for area differences in health.A purposively selected subsample of 51 respondentslater took part in in-depth ‘guided conversations’which explored their ‘‘descriptions of, and feelingsabout, their area’’ (Popay et al., 2003b, p. 57).Nineteen participants (including 12 from the rela-tively deprived study area) subsequently took partin a second interview focusing on inequalities. Inresponse to the survey question, reflecting researchon health in general, most respondents highlightedcomplex multi-dimensional pathways not easilyclassified into particular ‘types’ of explanation.Amongst the minority (20%) who did offer justone type of explanation, people living in thedisadvantaged areas were more likely to focus on‘area effects’ (that is, influences on health stemmingfrom the area of residence, rather than individualbehaviours), while those living in the more-advan-

taged areas favoured individualistic explanations.However, analysis of the in-depth interviews sug-gested that:

there was a clear reluctance amongst peopleliving in disadvantaged areas to accept the notionof inequalities in health between areas and socialgroups. The data suggest that this is stronglylinked to the moral connotations acceptancewould involve for places and the people livingin them. At the same time, however, respondentsalso gave vivid accounts of how living in difficultplaces had negative effects on their health andthat of others. Within these narratives there weretherefore two potentially contradictory themes:one in which the existence of inequalities isdenied and one in which there are degrees ofacceptance of inequality (p. 21).

Other research which has explored the linksbetween place and health through people’s experi-ences and understandings has principally beenlocated in more-disadvantaged communities andhas relied on qualitative methodologies, principallyindividual in-depth semi-structured interviews. In astudy in a relatively deprived area of Edinburgh,Scotland, 9 out of 12 of Airey’s respondentsindicated that where they lived affected their health,but most thought that this was in relation to qualityof life and well-being rather than other dimensionsof health. Indeed she remarks that ‘‘almost all of thesample rejected the notion of an interaction betweenarea of residence and physical health’’ (Airey, 2003,p. 131). Her respondents were concerned about theimpact of neighbourhood incivilities and the repu-tation of the area. She observed a ‘‘tension’’between their recognition that these incivilities hada negative impact on well-being and their keennessto demonstrate ‘‘some sort of social hierarchy ofhealth risk, in which their own neighbourhood [did]not occupy the bottom rank’’ (Airey, 2003), p. 134).Other recent studies have focused more on socialcapital and place (Cattell, 2001), or on healthbehaviour and place (Stead et al., 2001), ratherthan on the link between health and place in abroader sense.

Thus, although a few studies have begun toaddress lay understandings of the link betweenliving in particular places and dimensions of health,the findings to date are not consistent, perhaps inpart because of the different methods used. AsPopay et al. note:

the ways in which questions about health andillness are asked shape people’s responses. ...Different methodologies provide different andnot necessarily complementary understandings oflay perspectives on the causes of inequalities inhealth (Popay et al., 2003a, p. 1).

Here we present the results of a study which, likethose of Popay (Popay et al., 2003a) and Macintyre(Macintyre et al., 2005), sought to directly questionpeople’s experiences and understandings of inequal-ities in health (and society more generally). Wefocus specifically on people’s reactions to, andunderstandings of, ‘facts’ in the public domainabout place and health, and question whether thereare differences in the accounts of residents in moreand less affluent areas.

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The study: design and methods

These findings are part of a broader researchproject examining lay perceptions of societal andhealth inequalities, involving an analysis of publicrepresentations of inequalities (public health policydocuments and the subsequent press coverage ofthese documents, Davidson, 2003) and 14 focusgroup discussions with a total of 76 participants (53women, 23 men). Focus groups with pre-existinggroups were deemed most appropriate (rather thanindividual in-depth interviews) because we judgedthat this method would allow access to ‘ythenetworks in which people might normally discuss(or evade) the sorts of issues likely to be raised in theresearch session’ (Kitzinger and Barbour, 1999, pp.8–9). As the study aimed to gain an insight intosocial status and social hierarchies, focus groupsenabled participants to spontaneously explore socialcomparisons and their own position within thesocial schema within their own peer groups. Thegroup setting ensured that, whilst covering poten-tially sensitive issues, the balance of power lay withthe participants and allowed them to change andmodify their views as the discussion evolved. Wehave argued elsewhere that:

Individuals talking with an interviewer (perhapsperceived to be from a more privileged back-ground) might feel inhibited about their ex-perience of relative deprivation. By contrast,group discussion with one’s peers might havethe opposite effect, diluting the significance ofthe interviewer’s persona, promoting the discus-sion of ‘lay expertise’ rather than the ‘right’answers and encouraging people to share sto-ries about how their socio-economic contextimpacts on their health (Davidson et al., 2006,pp. 2179–2180).

All groups were facilitated by RD, and wereconducted in Scotland or northern England betweenJanuary 1999 and February 2000 in settings wherethe groups normally met. Table 1 gives more detailsabout the groups.

The sampling process drew on characterisationsof area level deprivation (derived from levels ofovercrowding, male unemployment, low socio-economic status (SES), and car ownership) devel-oped from small area Census data in Scotland(McCloone, 1994), as we sought to include men andwomen across a broad range of age and socio-economic circumstances. Using small area Census

data to identify existing groups within areas wasconsidered an effective strategy for recruitingresidents of similar SES, since the area of residenceof participants was not known in advance of thefocus groups. This approach applied for all but twogroups (groups 9 and 11) where detailed localknowledge of a researcher with extensive experiencein the area was used to identify appropriate areas inGreater Manchester. Once areas had been selected,community groups, clubs, and organisations wereidentified though public documents (e.g. local phonebooks), informal contacts, and local knowledge.Initial contact was made with a gatekeeper. Thefinal sample included groups from inner city areas,outer city estates, city suburbs, and a small ruralScottish town. Participants completed a briefquestionnaire at the outset of the group to provideinformation on gender, SES, and voting patterns.Descriptions of focus groups as ‘affluent’/‘deprived’,or ‘higher’/‘lower’ SES are based on the question-naires and participants’ subsequent accounts.

A topic guide was developed following pilotwork. Prior to each group, respondents were givenan information sheet explaining that the discussionwould involve talking about media coverage ofhealth issues. Using newspaper headlines fromrecent coverage of public health (‘Four goals for ahealthier Britain could save 15,000 lives’; ‘War onroot causes of ill health’), each group started with adiscussion in which participants were asked what‘four goals’ would make a healthier Britain, andwhat they thought were the ‘root causes’ of illhealth. They were then explicitly prompted to talkabout inequalities in health using images andheadlines from reporting of the 1998 Scottish andEnglish Green Papers (Department of Health, 1998;Scottish Office Department of Health, 1998), the1999 Scottish and English White Papers (ScottishOffice, 1999; Department of Health, 1999) and theAcheson Inquiry (Acheson, 1998, see Davidsonet al., 2003 for an analysis of this media coverage).These included a newspaper picture of a run-downarea, another juxtaposing men in suits drinkingchampagne with a women walking through anestate, and a close-up of an infant being held aloft.Participants were asked what they thought theimages were depicting. Finally the groups wereshown headlines from the same coverage: ‘Gapbetween rich and poor increases’; ‘Children at riskas health inequality between rich and poor in-creases’; and ‘Living in Glasgow takes 5 years offyour life’. The latter headline generated a great deal

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Table 1

Focus group sample

Grp. Level of

deprivation

of area

Socio-economic

status of

participants

Age

range

Area profile Location

1 MIXED Lower SES 20–40 60s semi-detached council housing Inner city area, Greater

Glasgow

2 HIGH Lower SES 25–45 60s & 70s tower blocks Outer city estate, Greater

Glasgow

3 HIGH Lower SES 50–85 Pre-war tenements, mix of

residential/business properties

Inner city area, Greater

Glasgow

4 HIGH Lower SES 65–85 60s estate, tower & lower rise

blocks

Outer city estate, Greater

Glasgow

5 MIXED Lower SES 25–50 Pre-war tenements, 60s/70s tower

blocks


Glasgow

6 HIGH Lower SES 20–60 60s estate, tower & lower rise

blocks


Glasgow

7 LOW Higher SES 20–40 Pre-war terraces, mix of residential/

business properties

Inner city area (workplace),

Aberdeenshire

8 LOW Higher SES 20–25 70s/80s detached housing, owner

occupied

City suburb, Lothian Region

9 HIGH Lower SES 20–70 Majority pre-war terraces Outer city estate, Greater

Manchester

10 HIGH Lower SES 30–50 Majority 60s/70s tower blocks Inner city area (workplace),

Greater Glasgow

11 LOW Higher SES 30–70 Detached pre-war houses, owner

occupied

City suburb, Greater

Manchester

12 MIXED Higher SES 20–39 Pre-war tenements, mix of

residential/business properties

Inner city area, Greater

Glasgow

13 LOW Higher SES 40–70 Majority 70s-90s detached housing,

owner occupied

Small town in rural area,

Aberdeenshire

14 LOW Higher SES 20–49 Pre-war conversions, luxury flats,

penthouses

Inner city area (workplace),

Greater Glasgow

Total participants ¼ 76 53 Women, 23 Men Av. no. per group 5–6

R. Davidson et al. / Health & Place 14 (2008) 167–181 171

of discussion on the impact of place on health. Bygradually moving the discussion from general tospecific, groups were explicitly encouraged to talkabout inequalities only in the latter stages of thediscussion if they had not themselves raised thesetopics earlier.

The discussions were recorded with participants’permission and fully transcribed. They were codedonto NUD*IST (QSR, 1997) which was used toorganise material to facilitate more-detailed ana-lyses of the transcripts. The analysis focused onexplicit and implicit references to ‘place’, bothprompted and unprompted, and a comparisonbetween people from more- and less-affluent areas.As well as noting the prominence of location and‘place’ within discussions, the analysis took accountof the context in which comments were made, thetone of exchanges and group dynamics. Quotesrepresenting a spectrum of opinion were flagged as

key themes emerged. Unusual viewpoints (‘deviantcases’) were also analysed in detail, as was anydissent within groups.

Ethical approval for the study was granted by theUniversity of Glasgow’s Ethics Committee. Con-fidentiality was protected by using pseudonyms andomitting local place and street names which couldlead to the identification of participants. As thediscussions could potentially raise difficult issues ofidentity, status and stigma, participants were invitedto approach the researcher after the group if theywished to raise issues or air any reaction provokedby the discussion. The research was approached in asensitive manner, mindful that the focus groups mayprovoke uncomfortable debate amongst establishedpeer groups with pre-existing, sometimes proble-matic, dynamics. Consideration was taken of theway in which the group discussion was shapedspecifically by media representations of poverty,


wealth, and place when analysing and interpretingthe data.

In the findings below we focus on participants’discussions of differences between areas, the impactof place on health, and reasons for area inequalitiesin health. Elsewhere we discuss people’s willingnessto make social comparisons across other socialdimensions (Davidson et al., 2006).

Findings

Witnessing, ghettoization and distancing in lay

accounts of geographical areas

As people talked about living in particular places,a strong sense of social and physical distance andalienation between areas was apparent. Participantsin more affluent groups either talked in generalterms of how people were unaware of deprivedareas, or made a direct admission of their own lackof awareness and knowledge. The same sense ofgeographical exclusion was present in the moredeprived groups, but was compounded by a senseof being hidden from the outside world and anembarrassment for the authorities. Brendan, from amore affluent group, speculated that ‘people’ arenot aware of how impoverished certain areas are:

yunless you actually live or work, sort of havesomething to do with the areas. You know, whywould, you wouldn’t. People live in sort ofbubbles from each other’ [Brendan, FG14, innercity area, higher SES, Greater Glasgow].

Niall went on to speculate on the causes ofexclusion by referring to contrasting areas inGlasgow, focusing on how problems in deprivedareas are perpetuated and magnified:

Niall: ‘I think there’s a blanket mentality, I thinkonce you’re in it, you don’t get out. It’s hard toescape. I think there’s a sense that you’re trappedwithin it. And I think what happens is that itforms its own societies within those areas, whichis why the schemes [large housing estates] ofGlasgow you have such a massive drug problembecause it contains itself within it, it doesn’timpact on the West End or on Pollockshields[affluent areas]. But within areas of Drumchapel,areas of Castlemilk, areas of Easterhouse [allmore deprived areas of Glasgow], you know, youhave drug taking of such high proportionsbecause it becomes, it creates its own society.’

[FG14, inner city area, higher SES, GreaterGlasgow].

The respondents above offer non-judgementalexplanations for the social problems they perceiveand how they are perpetuated in line with their moreliberal views. In another group Philipa, by admit-ting her own lack of awareness of deprived areas,offered two contradictory perspectives, both em-phasising her social distance from, and assumptionsof, residents in more-deprived areas. While on theone hand she said, ‘I forget that these areas exist’and that people in these disadvantaged areas are‘struggling’, she later said:

Philipa: ‘I think they’re happy with who they are,what they are. They don’t try to be somethingthey’re not, they’re happy if they live in Govan,and they come from Govan, they’re quite proudof it, or they get on with it at least.’ [FG8, citysuburb, higher SES, Lothian Region].

Participants in more-deprived areas tended toexpress themselves more forcefully, conveying apersonal sense of exclusion. In one instance,expanding on a discussion of a visit by the Queen,a distinction was made between people never seeingthe extent of degeneration within an area, andpoorer areas or housing being intentionally con-cealed by the local authorities to create a morepositive public image:

Pete: ‘You go down the road there and there washousing—flats—and they’d put quite a lot ofpeople with problems into these flats. And therewas a Royal visit to [local area]. So what do theydo? The grass embankment in front of the flats,they made it bigger.

Scott: What you’re saying is, we hide theproblem–it’s not there if you don’t see it. It’sbecause they’re embarrassed.’ [FG5, outer cityestate, lower SES, Greater Glasgow].

The landscaping was seen as a convenient way forthe government and local authorities to avoidtackling underlying problems in the area. Moredamaging was the sense of rejection and angerexpressed throughout this group’s discussion, com-pounded by their sense of being excluded from the‘acceptable’ face of the city. Sarah adds ‘‘If you’rethe Queen y and you pass by and you see a nicebuilding all freshly painted, you’d go like ‘Well,that’s nice’. But the Queen never gets to see insidethese things, and neither does a lot of other people’’


[FG5, outer city estate, lower SES, Greater Glas-gow]. Scott reinforces this view, commenting on the‘‘millions’’ spent on landscaping a nearby ‘‘defunctindustrial’’ area, saying ‘‘they [the Scottish Devel-opment Agency] believe if something looks success-ful then it is. No, maybe it might be a classlesssociety in some people’s eyes but certainly it’s notmy experience’’ [FG5, outer city estate, lower SES,Greater Glasgow].

A man in another group implied that his area’sproblems were not a priority for people in otherparts of the city as a discussion unfolded on the gulfbetween an area’s reputation and its reality forresidents. The exchange ends in laughter, withhumour being employed perhaps to deflect attentionfrom the reality of living in a poorer area:

John: ‘yyou get the reports in the newspaper-syThey always slag off Towerfields [pseudonymfor large local housing scheme] basically, the badplace Towerfields, y the tough area, but it’s no’as tough as it used to be, it’s no’ as bad as it usedto be, but they don’t acknowledge that. Theyknow it, but they don’t because it doesnae soundgood, like the really nice Towerfields doesn’tsound as good as the really bad place.

Joe: The reputation’s always bigger thany

John: Aye, the reputation’s bigger than thescheme [estate].

Andrea: What was it something was said onetimeyaye, ‘slash city’ or something.

Joe: ‘You’ve just got to think that other people inparts of the city are just getting on with their life,don’t sit and think about these things, don’t sitand think, ‘I wonder if Towerfields is getting onany better.’ [laughter] [FG6, outer city housingscheme, lower SES, Greater Glasgow].

Other participants demonstrated an acute aware-ness of the SES of areas, and even of individualstreets. In response to the newspaper picture of arun-down housing estate, the following exchangeoccurred in a group from an affluent area:

Catriona: ‘This is more Ordsall [a more deprivedarea]y

Bob: It’s illustrating deprivation wherever it is.

Alice: And Eccles actually, I mean, be perfectlyhonest, you needn’t go very far down the road tosee people living in awful conditions yy

Bob: y Ordsall is a very concentrated mass ofthat type of problem unfortunately, hemmed-inby [the] affluence of the Quays and [other] areas.’

[FG11, city suburb, higher SES, Greater Man-chester].

Ed, from an area not unlike Ordsall, alsocommented on inequalities across short distances:

Ed: ‘you get people who can’t do the things thatsomebody who lives maybe two or three milesaway might be able to afford to do eh, and so on,that sort of thingy’ [FG6, outer city estate,lower SES, Greater Glasgow].

Comparisons did not end at areas a few milesapart. Jake conveyed how two ends of the samestreet could differ:

Jake: ‘From this end, nobody likes it, okay. Butwhere me and Danny live, we’re right at the otherend, right. There’s no houses there except our’s.We’ve got an open green, everything is nice,cleany’

Danny: We’ve got ducks and foxes.

Jake: We’ve got foxes, no ducks, you shot theducks [laughter]. [FG9, outer city estate, lowerSES, Greater Manchester].

In a couple of the higher income groupsparticipants made strong connections betweensocial status and place, and used place of residenceto define a social hierarchy:

Philipa: ‘Somebody who lived in KettlestonMaines, you would call upper class. Somebodythat lived in Springhood you’d call middle class,and somebody lived in Braehead, you’d calllower class [y] My godmother y lives inMorningside and she’ll tell you it’s Morningsideand not Edinburgh.

Jill: Yeah, it’s a big thing like, if you stay inMorningside or Barnton or somewhere, ‘oh Godthey have got a lot of money’.

Philipa: Or Corstorphine or Saye, you don’t sayEdinburgh, you say the area you’re from becauseit sounds better than saying Edinburgh. But ifyou’re from a worse off area you’ll just sayEdinburgh.’ [[FG8, city suburb, higher SES,Lothian Region].

These extracts demonstrate how readily peopletalked in ways which polarised (or ghettoized) moreand less affluent areas, and the importance ofpeople’s experience in shaping their views ofdifferent areas.


How do people understand the impact of place on

health?

Similar contrasts between groups living in more-deprived and more-affluent areas emerged indiscussions of the link between area and health.Participants from more-deprived areas cited factorslocated in both the social and physical environment,and their impact on people’s constitution, and theirphysical and mental health. Their descriptions oftheir own experience were often placed in sharpcontrast to their suppositions about life in moreaffluent areas. For example, in one group, discus-sion developed from exploring the direct impact ofpoor housing and behaviour on health to the toll onmental health of living in a less-desirable area:

Betty: ‘Well, I’ve got a bad chest and it’s causedthrough damp housing. Many, many years ofdamp housing. I also, I have to be honest, I didsmoke as well, but I’m convinced the damphousing’s a lot to blame.

RD: Do other people agree with that? [sounds ofagreement].

Margaret: I think if you’ve got a nice outlook onlife, I mean, if you come from, for talking’s sake,[names affluent local area], and you open yourdoor and everything’s rosy, you’ll feel rosy. But ifyou open your door and it’s full of rubbish andwhat have you, it makes you feel depressed, youknow.’ [FG3, inner city area, lower SES, GreaterGlasgow].

Betty concedes that smoking may have contrib-uted to her respiratory problems, acknowledgingthe potential impact of her behavioural choices, butreturns to the effects of dampness in her home as theprinciple explanation for her ailing health. Theemphasis placed on ‘place’ over personal agencyappears to be met with agreement from otherparticipants within the group.

With respect to the social environment, partici-pants living in disadvantaged areas spoke of abreakdown of community life, and again assump-tions were made about life in more affluent areas:

Ian: ‘So is that a reason we’re unhealthy, wedon’t bother now? Years ago mining commu-nities, my parents were from a mining commu-nity, my granny was y unwell, the other ladiesin the close would do the washing, one would[make sure] the dinner was made, one would besure my grandfather was okay or whatever.

Margaret: That’s right, exactly, we’ve lost all thatnow.

Elizabeth: They’ve got a community like thatover in [names affluent local area].

Betty: so we really lost all that now, I don’t knowwhether it’s y

Ian: the break-up of communities, so maybewe’re losing our sense of community’ [FG3, innercity area, lower SES, Greater Glasgow].

Social relations were again emphasised throughdiscussion of the strains caused by unfriendlyneighbours, the anti-social behaviour of local gangsor problems with housing. For example, the head-line ‘Living in Glasgow takes 5 years off your life’prompted the following exchange in one group:

Jake: ‘Oh that’s not a bad guess.

Sonia: Depends on the area.

Jerry: The atmosphere and that.

Sonia: Nasty neighbours and things like that.Bound to take time off your life. I think so[sounds of agreement].’ [FG9, outer city estate,lower SES, Greater Manchester].

Another group described how collective socialaction against street gangs, when a number ofmothers decided they could not ‘take it anymore’,had improved their health:

Val: ‘Cause you’re sleeping better, you’re nogetting woke up every night by a bloody fireengine zooming by your window and twenty orthirty weans [children] at the corner shouting allnighty

Sheena: We used to see people’s houses in thebloody news every week [sounds of agreement]’[FG2, outer city estate, lower SES, GreaterGlasgow].

In another discussion of the headline, a groupfrom a disadvantaged area commented on thevisible impact of area on physical constitution,based on a participant’s observations of footballteams from socio-economically contrasting areas:

Ed: That’s probably correct, about five yearsmaybe. You get people in Newton Mearns orMilngavie [affluent suburbs of Glasgow], thatsort of place, they may have more money byimplications of where they’re living, and they canafford to buy the healthy foods and live thehealthy lifestyle, go on their nice holidays. Theycan afford to go to counselors that can help them


live their life if they’ve got problems and so onyy

John: ‘The thing I’ve noticed as well through thefootball teams is y my team from [names localarea] that were twelve year-olds, and we wereplayed by a team from [names affluent neigh-bouring area], you could see the difference in thebuild of the two teamsy

Richard: Aye, aye, the height and so ony

John: Aye you could see they’d broadened outand they were taller than ours, they looked no’ illbuty

Andrea: A bit malnourished.

John: ythey did, you could see a difference atthat age group, if you go into the different areaslikes of in a sporting committee.’ [FG6, outer cityestate, lower SES, Greater Glasgow].

In a number of the less-affluent groups responsesto the headline ‘Living in Glasgow takes 5 years offyour life’ were striking in that there appeared to be acomplete acceptance of the impact of area ofresidence on health potential. Even when the basisfor this figure of 5 years was explained in moredetail (i.e. an average of mortality statistics for allareas of the city, with deprived areas faring farworse than the 5-year estimate), the reaction wasnot surprise but weary acceptance. In fact, thesegroups routinely increased the figure to between 10and 15 years, and in one case to 20 years. Alison,who lived in a deprived area of Glasgow, commen-ted (like John above) on the physical toll whichdeprivation has on appearance, the visible signs of ahard life:

Alison: ‘and you see maybe women wi’ a coupleof weans and they’re out doing crappy wee jobs,and they actually look a hell of a lot older thanwhat they actually are, or maybe about 10, 15year older. And when you find out the age, yougo ‘ooch’.

Jean: D’you think I look sixty?

Pat: No.

Jean: There you are.

Alison: You can see it in their faces.

Jean: I’ve been good to myself. I don’t go out anddrink a lot, I smoke certainly, that’s one badhabit. [FG10, lower SES, Greater Glasgow].

Lisa, from the same group, named an affluentarea in Glasgow where she suggested that residentswould live into their nineties with ‘nae worries, goodpensions’, and it was assumed that residents living

in more-affluent areas, by definition, had goodincomes. In a different group a man referred to acommonly reported statistic that someone living inGlasgow’s affluent Bearsden can expect to live 10years longer than a resident of neighbouringDrumchapel and explained it simply by saying thatBearsden has ‘amenities’, but that there is ‘this roadthat divides’ the areas [Scott, FG5, outer city estate,lower SES, Greater Glasgow].

Other lower income groups focused on specificproblems in their area which they thought reducedlife expectancy. One woman told of how the localdoctor had described the high-rise flats where afriend lived as a ‘disgrace for anybody to live. Saysshe could get dysentery out of there, in these flats’.In response another participant remarked on thedifficulty of making any individual impact on localconditions: ‘I mean that’s people keeping cleanhouses but as soon as you’re opening your frontdoor, you’re in an enclosed area and it’s stinking’[Jean, FG2, outer city estate, lower SES, GreaterGlasgow].

Jake, who lived in a very deprived area, won thesupport of his fellow participants as he related areduced life expectancy to the stresses of the localenvironment:

Jake: ‘Actually I don’t think it’s [the headline‘Living in Glasgow takes 5 years off your life’]that realistic. I think it’s wrong. I don’t thinkyou’re looking at five, I think more like fifteen.Not ten, fifteen maybe twenty years off your life.‘Cause the older you get, the more susceptibleyou are to stress. As soon as you’re getting, let’ssay ‘a problem’, let’s say a minor thing likerheumatism or something like that, which createsworry, and then next thing you start worryingabout ‘oh I’m going to have a heart attack’ andthis, that and the other. And then with the addedstress of where you’re living, is going to reduceyour, you know, lifespan.’ [FG9, outer cityestate, lower SES, Greater Manchester].

Jane explained why she thought her life span hadbeen reduced. Her account focuses on her local areaand reveals her anger and frustration at not beingable to get the relevant agencies to respond to theproblems faced by many in disadvantaged areas:

Jane: ‘Aye we’ve lost five years off our life, well Ihave.

RD: And in what way do you think you have?


Jane: One, because I’m a single parent and theage I am. Two, because of the area I’m staying in,and the fighting I’ve had to do to get what I’veneeded for the house. The amount of times I’vebeen so depressed because of the way the house ishas been unbelievable, that’s their fault. I beggedfor help, they never gave me it. I begged for helpand they shut the door in my face. I begged forhelp and the councilors werenae there. So youcome to the end of the rope eventually, andyou’ve got nowhere else to go, so you do getdepressed. But whose fault is it, and that’s theirs.So there is five years off my life, and you can’tturn the page back, you cannae go back.’ [FG1,inner city area, lower SES, Greater Glasgow].

After Jane’s impassioned response, Kay lightenedthe tone by joking: ‘‘you should just take 5 years offmy age and I’d be quite happy!’’, provokinglaughter from the group and diffusing any discom-fort felt.

Just one group from a more-disadvantaged area,a group of pensioners, rejected the ‘Living inGlasgow takes 5 years off your life’ headline outof hand. Having seen living standards rise drama-tically in their lifetimes and recalling childhoodmemories of abject poverty, they were less likely toentertain ideas of the contemporary role of povertyand inequality. Although they cited pollution as apossible cause of area disparities in mortality rates,a distrust of statistics won through: ‘Statistics isrubbish’ [Mary]; ‘Average is only a word’ [Robert],‘Averages, averages does nae apply into anythingfeasible’ [Robert] [FG4, outer city estate, lower SES,Greater Glasgow].

The lower income groups did talk about thecontribution of health behaviours to health andhealth inequalities, but these behaviours were‘bracketed off’ and were seen as part of a complexweb of contextual factors. Behaviours known to bebad for health (such as smoking, excessive drinking,drug abuse, and high-fat diets) were described inrelation to an overall experience of hardship wherepeople were seeking comfort or escape. Within thismulti-factorial model, participants from a numberof groups made a link between poverty andbehaviour, seeing the behaviour in question as a‘coping strategy’:

Cassie: ‘yI’m well aware that this [indicating hercigarette] is knocking seconds off my life everytime I take a puff, it’s doing my head in.

Sonia: But it calms you down, it keeps you, don’tit. It does.’ [FG9, outer city estate, lower SES,Greater Manchester].

Others in this and other groups made similarcomments: ‘it’s either a cigarette or a tablet’ [FG9,outer city estate, lower SES, Greater Manchester];‘people are always going to buy cakes, it’s just thepills of life. They eat cakes and biscuits and sweetsand so on, that taste nice so they make you think ofdifferent things’ [FG6, inner city estate, lower SES,Greater Glasgow].

Thus, in general, the discussions amongst parti-cipants from more-deprived areas demonstrated aready acceptance of the link between place andhealth, a willingness to discuss the issues and acceptcertain ‘facts’ about place and health, and a sense ofanger and frustration about the state’s response tothe problems and challenges that their livingcircumstances imposed.

Amongst the groups in more-affluent areas,speculation about the impact of living in a more-deprived area seemed dependent upon the extent ofthe participants’ own experience of living on lowincomes or in disadvantaged areas. More-affluentparticipants who had personal and/or professionalexperience of less-affluent lives tended to offer quitecomplex and non-judgmental explanations of thecauses of health inequalities. In contrast, more-affluent participants who revealed no such directexperience in their accounts tended to draw on adecontextualised behavioural model of health cau-sation and to assume a more-judgmental stance. Toillustrate a more-sympathetic stance, the followingquote reveals Sheena’s experiences of teaching inboth affluent and deprived schools in the north eastof Scotland:

Sheena: ‘yIf you’ve got a good quality of lifeyou’re likely to be healthy, unless you’re un-fortunate and have an accident or some geneticdisease y I can remember years ago y I wasteaching at [a] school once a week in y really avery, very poor area. And one group [laughs]came in one day and I said ‘you had a goodholiday?’. Oh, and out of, I should think half theclass, out of about twenty, had some, y eitherhad had an accident with a fire and gone tohospital, someone had a heart condition and soon. Whereas another school I was teaching at[laughs] [names school] where, I mean, everybodyhad a nice Christmas holiday. But, you seeaccidents happen if you haven’t y if you can’t


afford an electrician to fix your points [agree-ment]. And, you know, it’s the poverty thingbrings you down in every way.’ [FG13, smalltown in rural area, higher SES, Aberdeenshire].

Sheena continued to demonstrate an understand-ing of the challenges faced: she described how livingin an undesirable area, and having a ‘notorious’address, had repercussions on employment chances;and how growing up in a deprived area greatlyincreased the chances of going to a lower statusschool, leading to a domino effect on individual lifeand health chances. Marion, another higher incomeparticipant in this group, commented on the ‘lack ofshops’ other than expensive corner shops indeprived areas and limited access to cheaper goodsbecause of the location of big supermarkets. Theseparticipants were also more likely to see health-damaging behaviours as a means of escape for thosewho could not envisage an optimistic future forthemselves.

By contrast, the relatively affluent participantswith no obvious experience of deprived areas ordisadvantage rarely, if ever, drew on place-basedfactors and were more likely to be judgmental intheir descriptions of the role of health-relatedbehaviours in the generation of inequalities inhealth (Davidson et al., 2006). For example, in adiscussion emphasising the role of education inchanging health behaviours, one woman said:Denise: ‘I think it is education, I mean you knowyou’ll still find that these poor people can affordtheir cigarettes.’ [FG7, inner city area, higher SES,Aberdeenshire].

The more-affluent groups also tended to have agreater range of responses to the headline ‘Living inGlasgow takes 5 years off your life’. Some were ableto unpack the statistics and give considered,reflexive explanations. Niall related his own circum-stances to the 5-year difference:

Niall: ‘ythere is [a] huge underbelly of societywho are dying much younger because of all we’vebeen talking about, the whole social conditionsy whereas for me, cosily ensconced in [affluentGlasgow area], it doesn’t affect me particularly.You know, it doesn’t affect me particularly. Youknow, it doesn’t, it won’t take five years off mylife and I live in Glasgow. But across the averageof the city, the quality of life is so poor in largeareas, that that’s the net effect of it.’ [FG14, innercity area, higher SES, Greater Glasgow].

Discussion went on to touch upon the stigmatisedimage of areas and cities with Sian reflecting on herstatus as an ‘outsider’ and how this influenced herperceptions:

Sian: ‘Coming as an outsider em, I wanted tomove back to Scotland and I moved to Edin-burgh because Edinburgh is a place that I know.But I was saying y I’m not sure whether I wantto move through to Glasgow because none of myfriends would want to come and visit me, whichsounds terrible [laughter]. And everybody wholives in Glasgow loves it, but when anyone saysthey want to go to Scotland, they want to comethrough to Edinburgh.’ [FG14, inner city area,higher SES, Greater Glasgow].

A small number of the more-affluent groupsquestioned the ‘Living in Glasgow’ headline, believ-ing it to be misleading or false. One woman,reflecting the dismissal of the statement within hergroup, described the headline as a ‘yvery sweepingstatement’ [Philipa, FG8, city suburb, higher SES,Greater Glasgow], and favoured a view of illness asa random occurrence in the population. When thegroup did speculate about area inequalities inhealth, she attributed inequalities in mortality to‘yshootings, stabbings [and] drug overdoses’ andgetting ‘gunned down at twenty’ [Philipa, FG8, citysuburb, higher SES, Lothian Region]. A woman inanother group, disputed the statistic not because shedisbelieved that poverty had an adverse impact onhealth but because she could not see why Glasgowwas being singled out: ‘No I don’t think Glasgow’sparticularly—I know that they always say that theWest of Scotland heart rate being so bad, butcompared to London, there’s terrible poverty downthere’ [Hannah, FG12, inner city area, higher SES,Greater Glasgow].

In summary, the data presented here illustratehow participants living in deprived areas (and tosome extent more-affluent participants with directexperience of disadvantage in one form or another)gave more credit to area inequalities in health andtended to draw upon place-based explanations.Their accounts demonstrated a lack of surpriseabout area inequalities in mortality and discussionsof the reasons for diminished life chances of peoplein poorer areas and their experience of living in suchareas were often vivid and empassioned. Severalpeople spoke of the detrimental impact of feelingthat their lives and problems were actively hiddenfrom wider society rather than addressed. Although


they recognised the potentially health-damagingeffects of individual lifestyle ‘choices’, disadvanta-geous health behaviours were generally understoodas a necessary way of coping with the challenges ofdaily life. Higher income groups, by contrast, weremore likely to question rather than accept statisticson area inequalities in health, and to view theadoption of adverse health behaviours as the resultof lack of education or a reckless attitude.

Discussion and conclusions

The aim of this paper was to explore how peoplefrom different types of area understand andexperience inequalities in health, and specificallythe impact of place on health. We found thatpeople’s own (direct or indirect) experience of livingin more-advantage and disadvantaged areas, i.e. theextent to which they had directly witnessed dis-advantage and tempered their views. In apparentcontrast to the findings of some earlier studies(Blaxter, 1997; Popay et al., 2003a; Macintyre et al.,2005)) we found that it was people from more-disadvantaged areas (together with those frommore-advantaged areas with past personal orprofessional experience of deprivation) who mostreadily accepted the veracity of statements aboutarea inequalities in life expectancy. In contrast toAirey’s findings (Airey, 2003), some participantsfrom the more-deprived areas spoke not only of theimpact of a poorer neighbourhood on well-beingand quality of life, but about how deprivation waswritten in the body, physically apparent in lessdeveloped physiques or prematurely aged bodies.As in other studies, our participants from more-disadvantaged areas spoke of the negative impact ofneighbourhood incivilities (Stead et al., 2001; Airey,2003; Popay et al., 2003a), poor social relationshipsand networks (Airey, 2003; Popay et al., 2003b),and of how health behaviours such as smoking,which they recognised as being detrimental to healthbut portrayed as being a means of coping with anadverse environment (Graham, 1987; Cattell, 2001;Stead et al., 2001).

Thus, although in some ways our findings echothose of earlier studies, they differ in two crucialrespects: first, in general, we did not encounter areluctance to discuss inequalities in health; andsecondly, we did not find that it was the more-advantaged groups who were most likely to discussthe impact of social structure or place on health (seealso Davidson et al., 2006). Rather they demon-

strate a readier acceptance of area inequalities inhealth amongst those who live in more-deprivedareas, and a particularly stark contrast with theviews of people in more advantaged areas whoappear to have had no experience of poverty anddisadvantage in their personal or professional lives.This distinction within the more affluent areasechoes Bolam et al.’s finding that it was thoseengaged in public sector work who spoke ‘‘mostextensively’’ about health as ‘‘structurally deter-mined by social class’’ (Bolam et al., 2004).

Blaxter has suggested that ‘‘accounts of healthand illness are accounts of social identity, and it isunreasonable to expect people to devalue thatidentity by labelling their own ‘inequality’’’ (Blaxter,1997, p. 747). In the accounts of our participantsfrom more-deprived areas their awareness of theperceived identity of their area, if not themselves,was all too obvious. There has been much discus-sion about social constructions of physical spaces.Bush and colleagues extend Goffman’s (1963)notion of stigma beyond the individual to spaceand place, and illustrate how an area can gain a‘‘spoiled’ identity’’, or be ‘‘discredited’’ with refer-ence to several sources of stigma, including techno-logical stigma, air pollution or ‘dirt’ stigma, healthstigma, and social stigma. (Bush et al., 2001, p. 53).Furthermore, they argue that people living within a‘‘stigmatised place’’ can be discredited with the‘‘same characteristics as those attributed to theplace where they live’’ (p. 52). Cattell has alsoobserved that stigma appeared to have beeninternalised by some residents on one of thedeprived estates that she studied (Cattell, 2001)and Airey has argued that neighbourhood reputa-tion can lead to psychosocial stress through theexperience of shame, despite attempts to resist being‘tarred with the same brush’ (Airey, 2003).

Concerns about the reputation of an area havebeen commonly raised by participants in this, andother, studies, (Stead et al., 2001); Popay et al.,2003b). In our study, the more-advantaged groups,whilst clearly articulating the importance of place ofresidence in signifying social hierarchies, were ableto distance themselves from (‘other’) socially pro-blematic areas with relative ease. Popay et al. alsocomment on how area inequalities are generally lesspersonally challenging for the more advantaged(Popay et al., 2003a).

For respondents living in less-advantaged ormore-stigmatised areas, life was less straightfor-ward. Popay et al. have noted how respondents


distance themselves from ‘improper’ people withintheir localities, a common approach being todevelop ‘‘subtly differentiated cartographies ofplace’’ (Popay et al., 2003b, p. 65). Similarly, Airey(2003), quotes Sibley’s (1995) observation that‘‘Spatial boundaries are in part moral boundaries’’,and notes how the women in the deprived neigh-bourhood which she studied constituted ‘their’neighbourhood at a ‘‘very small’’ spatial scale, beit their street, their block of flats or ‘‘even their frontdoor’’ (Airey, 2003, p. 134). The same process wasapparent in all our groups, fuelling a sense ofghettoization and the separated worlds of theadvantaged and relatively disadvantaged. In thissense, although people from more-disadvantagedareas readily acknowledged the existence of spatialinequalities in health, this did not inevitably leadthem to ‘‘admit an inferior moral status’’ forthemselves and their peers, as suggested by Blaxter(1997, p. 754). Some were able to resist such aconnection through ‘distancing’ and other means.However, for a minority the actions of externalagents foisted a ‘spoiled’ identity onto their area,and hence irresistibly onto them: the message toresidents whose houses and lives were renderedphysically and socially invisible by the building upof grass embankments in anticipation of a visit tothe area by a royal dignitary was clear.

Whilst this paper supports some earlier findingsof lay conceptualisations of the link between placeand health, it is significant in that it directlychallenges the view that social inequalities and theinfluence of the social structure on health are morelikely to be invoked by those from more-advantagedcircumstances or locales. Like others (Blaxter, 1997;Popay et al., 2003a; Macintyre et al., 2005), we havereflected elsewhere (Davidson et al., 2006) on howthe methods used in social research may shape thefindings they generate; we summarise and developthis discussion here. There are several ways in whichour methodological approach may have influencedour findings. First, our decision to recruit pre-existing groups may have lead to greater participa-tion from people who are socially networked in theirlocal communities and increase the likelihood thatthey share opinions. Secondly, the use of focusgroups, perhaps especially with pre-existing groupswhere people already have well-established relation-ships and are interviewed on ‘home’ territory, mayencourage people to be more confident in sharingtheir stories and diminish the influence of theinterviewer’s presence. In this context, it is interest-

ing to speculate whether this kind of focus groupencourages more ‘private’ or more ‘public’ accountsof people’s experiences (Cornwell, 1984). Thirdly, itis important to be aware of the specific material thatwe used to encourage discussion. All of the head-lines and photographs used as prompts were takenfrom material in the public domain which had beenlinked to images or metaphors for inequality; thuswe deliberately chose newspaper headlines andphotographs chosen by newspaper editors toillustrate a public discussion of inequality throughthe coverage of the UK’s New Labour Green andWhite papers on public health which outlined thegovernment’s stance in relation to inequalities, orthe coverage of the Acheson Report which theycommissioned on health inequalities. Speculationover any bias introduced by these prompts shouldbe weighed against the capacity of the images toprovoke debate amongst people over the issues andsituations which they purport to portray.

At the most-fundamental level, contrasts havebeen highlighted between the results of in-depthsemi-structured interviews (in which ‘poorer’ peopleare said to be more likely to reject notions ofinequality) and more highly structured surveymethods. Attention has also been drawn to theinfluence of the exact wording of questions (Popayet al., 2003a). Undoubtedly the specific prompts thatwe use in research to focus discussion in particularareas will have an impact on the exact form ofpeople’s responses. It is difficult to ascertain whetherthe readiness with which people entered into discus-sions about inequalities in health and place weregenerated by the specific prompts we used, orwhether characteristics of the group interaction orsetting were important. Other factors, such as theparticular historical context, could also account forsome of the differences observed; our data werecollected relatively soon after a ‘New Labour’ admi-nistration was elected after a longstanding period ofConservative government which had placed heavyemphasis on the importance of individual responsi-bility for health (Davidson et al., 2003). ‘Lay’accounts may well be different if people feel that adifferent political administration has failed todiminish inequalities in health and society morebroadly. Public support for the reduction of societaland health inequalities is more likely if negativestereotypes of disenfranchised and excluded commu-nities are challenged and there is a wider awarenessthat social mobility has declined rather thanincreased in recent years (Blanden et al., 2005).


Acknowledgements

The authors would like to thank all the partici-pants for their time and contributions. We areparticularly grateful to Jenny Kitzinger for all herinput and comments, and Sally Macintyre forcomments on an earlier draft. RD was funded viaan MRC Ph.D. Research Studentship. RM isfunded by the Chief Scientist’s Office of the ScottishExecutive Health Department. KH is employed bythe MRC. All opinions are those of the authors andnot their funding bodies.

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