placing health in context
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ARTICLE IN PRESS
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doi:10.1016/j.so
Social Science & Medicine 65 (2007) 1821–1824
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Editorial
Placing health in context
While there is a long history of interest in placeand health in the geography of health, in the pastdecade or more a number of disciplines havewitnessed an increasing interest in the ‘effect’ thatattributes of collective social organization and thelocal built environment at neighbourhood scalehave on a variety of social outcomes, includinghealth, health behaviours, early child development,youth delinquency, crime and deviance, politicalbehaviour, employment outcomes and other eco-nomic opportunities. The argument has been thatthere are contextual processes operating at thescale of whole communities or geographicalareas, which are important for health and healthinequality (Macintyre, Maciver, & Sooman, 1993).This kind of research has sought to understandhow, why and to what extent features of thelocal social and physical environment, shape in-dividual outcomes over and above the effect ofindividual-level factors. Attention has focused forexample, on collective social organization, thelocal built environment and differences betweenareas in facilities and services (Diez-Roux, 2001).There have been significant methodological innova-tions that have had an enormous impact onempirical research on the effect of contexts onhealth, including techniques such as multi-levelmodelling and greater attention to context inqualitative studies.
This perspective on health variation is nowstarting to be subject to critical and sophisticateddebate. Several authors have enumerated many ofthe problems and challenges of neighbourhoodcontexts and health research, but researchers arenow seeking more theoretically and methodologi-cally advanced approaches to address the unan-swered questions about the importance of socialand geographical context for health variation
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(Diez-Roux, 2004). In this special issue we haveassembled a number of papers that demonstrate thelatest developments in research around this theme.It was our hope to assemble a group of papers thatpoint us in new directions for placing healthresearch in context, and I believe we have beensuccessful in doing so.
The issue begins with a critical analysis of thenotions of space and place that have been pre-dominant in this field of work. In a carefulargument, Cummins, Curtis, Diez-Roux, & Macin-tyre (2007) adopt a relational perspective to placeand health, but go well beyond previous attempts toarticulate such a perspective. Specifically, they arguefor the importance of considering place ‘on theground’ as being produced by multiple scales ofcontextual influence, thinking of places as dynamicand fluid, with different social meanings andimportance for different people and most impor-tantly, maintained by power relations at varyingspatial scales. While many of these issues are wellestablished in human geography, they have beenunderdeveloped in most of the recent flurry ofresearch on the effects of places on health. Thepaper by Bernard et al. (2007) also makes asignificant contribution to the theoretical develop-ment of place and health, again drawing on arelational notion of place, but informed by theimportance of ‘informal reciprocity’ in the provi-sion, acquisition and exchange of health-relatedresources, among people occupying common resi-dential areas.
Two empirical papers in this issue use multi-leveltechniques for the investigation of neighbourhoodeffects on health. Morenoff et al. (2007) investigateneighbourhood effects on social disparities inhypertension prevalence, awareness, treatment,and control, using data of a quality that is unusual
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in studies of context and health. They find that thereare neighbourhood effects on race/ethnic andeducational disparities in hypertension prevalenceand awareness of hypertension, but no neighbour-hood effects on hypertension control or treatment.Stockdale et al. (2007) investigate the bufferingeffects of neighbourhood environments on alcoholand drug use and mental disorders by examiningcross-level interactions between individuals andtheir neighbourhood of residence in a large USsample. This is a promising line of inquiry; fewprevious studies have examined buffering effects ofneighbourhoods. They find that individuals exposedto violence, who also live in high-crime neighbour-hoods, are vulnerable to mental disorders andindividuals who are socially isolated and live inneighbourhoods with low social support are alsovulnerable.
A shortcoming of much empirical research oncontext, place and health has been inadequatemeasures of context. The paper by Stafford et al.(2007) addresses this shortcoming head on bydeveloping a comprehensive set of measures ofneighbourhood context, and demonstrating howfeatures such as access to supermarkets and swim-ming pools are associated with lower levels ofobesity. Frank, Saelens, Powell, & Chapman (2007)are also successful in tackling the problem ofmeasuring context, in this case focusing on walk-ability in the built environment in Atlanta. Theyalso go a step further in addressing the criticismlevelled by some at research on neighbourhoods andhealth, namely that relationships between neigh-bourhoods and health are confounded by theresidential choices and preferences of households,by measuring preference for several differentneighbourhood types and including it in theiranalysis. They found a sizeable mismatch betweenthe individuals’ preference for a walkable neigh-bourhood and the actual walkability of theirneighbourhood.
One of the tantalizing features of research oncontext and health is that it may lead to moreeffective interventions to improve health and reducehealth disparities. Traditional behaviouralist per-spectives, which saw health behaviours and otherdeterminants of health as simple individual attri-butes, have now been eclipsed by a perspective thatemphasizes human behaviour and activity assignificantly influenced by contextual factors. Itfollows from this perspective that changes in contextmay produce changes in the risk profile for whole
populations, rather than just for the people whoreceive and are successful with individually-orientedinterventions. In their paper, Fong Chiu and West(2007) take a particularly inventive approach to thequestion of context-based interventions by investi-gating whether community health educators (CHEs)are effective in becoming embedded in local socialnetworks, which would be expected to make theiractivities more effective. Because their work is sooriginal and exploratory in nature, the results aretentative. Nevertheless, they strongly suggest apromising line of inquiry. Another appealing con-cept is that transformations of the built environ-ment, like that which occurs with urbanregeneration of public housing developments, canimprove the health of residents. Of course there aremultiple, complexly related causal pathways bywhich such a significant change in the builtenvironment can affect health. Durie and Wyatt(2007) explored how complexity theory may providea guide for conducting complex and multifariousinterventions in the environment. The value ofcomplexity theory, they argue, is that it directs thefocus of inquiry away from individually basedanalysis, towards the influence of context oninterventions. This focus, and their paper moregenerally, draws attention to the importance ofcontextual factors in the potential adaptation ofinterventions from one place to another.
The final three papers in this issue address aspectsof the geography of relative inequality and health.Each takes a very different approach, but alladdress questions of scale and proximity in examin-ing the relationship between relative inequality andhealth. Using exploratory data analysis (ESDA),Sridharan, Tunstall, Lawder, & Mitchell (2007)investigate the relationship between spatial cluster-ing of deprivation and elevated mortality in Scottishpostcode sectors. The issue at stake in their analysisis not only whether there is a relationship betweendeprivation and mortality in individual postcodesectors, but also whether the spatial patterning ofdeprivation affects mortality. Their findings suggestthat it does, and that there may be a fundamentaldifference between ‘islands’ of deprived areas,surrounded by wealthier communities,and thosethat are metaphorically ‘land-locked’ by neighbour-ing deprived areas. Their work offers an importantnew direction for research in this area, which has, todate, been relatively silent on the importance ofcontiguity and spatial patterning of deprivation forhealth disparities.
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Cox, Boyle, Davey, Feng, & Morris (2007), take aslightly different approach to investigating a similarphenomenon of geographical clustering of smallareas with similar population risk factors. One ofthe important aspects of the literature on relativeinequality and health has been the debate surround-ing the relative importance of psychosocial and neo-material factors. The former refer to ill effects of themeanings that individuals and groups attribute totheir relative socio-economic position, while thelatter refers to the difference in access to materialresources that are experienced by people at differentlevels of relative socio-economic position. Cox et al.(2007) test two opposing hypotheses about therelationship between deprivation, the disparity indeprivation between neighbouring small areas, andthe incidence of Type 2 diabetes in Scotland. First,the ‘psycho-social hypothesis’ suggests that negativecomparisons made by individuals in relation tothose who surround them may lead to chronic low-level stress via psycho-social pathways, the physio-logical effects of which may promote diabetes. Theyfind that deprivation is associated with Type 2diabetes, but deprived areas surrounded by lessdeprived areas had lower diabetes incidence thanexpected, while less deprived areas surrounded byrelatively more deprived areas had higher diabetesincidence. Their results are consistent with whatCox, et al call a ‘pull-up/pull-down model’ but donot support their formulation of a ‘psycho-social’hypothesis at the level of very small geographicareas. Their results, in other words, are consistentwith those of Sridharan et al. (2007).
The final paper in this Special Issue by Wilkinsonand Pickett (2007) also investigates the psycho-social aspects of relative inequality. Their perspec-tive on the geography of relative inequality andhealth is quite different, though no less compelling,than that of Cox and colleagues. Working at thelevel of whole societies (operationally defined asnation-states), Wilkinson and Pickett (2007) reviewthe evidence on the relationship between incomedistribution and health, and appeal to evidence onother health and social indicators to make anargument for the importance of societal levelpsycho-social factors in the production of popula-tion health. Specifically, they present new evidenceof how between-country differences in processes ofsocial differentiation are associated with differencesin health and a variety of other social problems. ForWilkinson and Pickett, the geography of relativeinequality must consider societal-level processes of
social differentiation because the processes obser-vable at small area levels are only partial views ofsuch processes. They demonstrate that largerincome differences appear to make social mobilityless likely and processes of social differentiation lesstractable and this translates into consistent effectson population-level rates of mortality, morbidity,crime, educational performance and a host of othersocial indicators. Finally, without discountingthe potential importance of local status hierarchieson health, they make a strong argument for theimportance of national-level structural factorsin producing societal-level status hierarchiesand health differences both within and betweencountries.
The collection of papers presented here that sowthe seeds of debate, for example, on the role ofneighbourhood preference in understanding asso-ciations between context and health, is a potentiallightning rod. Similarly, the use of complexitytheory, given its novelty and its dissimilarity to theconventional ‘black box’ approach of investigatingthe effects of interventions should also sparkresponses in the literature. All of the papers in thisSpecial Issue point us in compelling new directionsfor research that places health in context. We hopethat this special issue sparks debate and new lines ofinquiry and look forward to its future repercussions.To close this brief overview of the Issue, we wouldlike to thank all of the authors for their patiencewith the review process and their willingness toconstructively engage with the comments providedby reviewers and the editors, and the anonymousreviewers who provided very constructive andthoughtful comments to help refine the papersincluded here. We would also like to thankthose authors (more than 140) who sent usproposals for papers to be included. If we couldhave accepted them all, it would have filled thepages of half a year’s Issues of Social Science &
Medicine. The response to our invitation for paperproposals only underscores the importance and thelevel of interest in this compelling area of research.Finally, we would also like to thank Sarah Curtis,the Senior Editor for Medical Geography at Social
Science and Medicine, Ellen Annandale, the Editor-in-Chief, and Ryan Mowat, the Managing Editor,for their oversight of the review process andSarah Deedat, the Editorial Assistant, for managingthe submissions and reviews. We believe that thefinal product was well worth the efforts of allinvolved.
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James R. DunnSt. Michael’s Hospital Toronto, Ont., Canada
E-mail address: [email protected]
Steven CumminsQueen Mary University, London
E-mail address: [email protected]