What is the role of neighbourhoods in What is the role of neighbourhoods in understanding spatial concentrations of understanding spatial concentrations of

health and ill health? health and ill health?

Jamie PearceJamie Pearce

Centre for Research on Environment, Society and Health (CRESH)Centre for Research on Environment, Society and Health (CRESH)Institute of Geography, School of GeoSciencesInstitute of Geography, School of GeoSciences

University of EdinburghUniversity of Edinburgh

jamie.pearce@ed.ac.ukjamie.pearce@ed.ac.ukwww.cresh.org.ukwww.cresh.org.uk

OverviewOverview1.1. Is poor health Is poor health increasingly increasingly

concentratedconcentrated in socially in socially disadvantaged neighbourhoods? disadvantaged neighbourhoods?

2.2. Do socially disadvantaged Do socially disadvantaged neighbourhoods also experience neighbourhoods also experience lower quality (health-related) lower quality (health-related) physical environmentsphysical environments??

3.3. The place of The place of neighbourhood-neighbourhood-level policy interventionslevel policy interventions to to affect health affect health

Health Inequalities: Mortality

http://www.statistics.gov.uk/STATBASE/Product.asp?vlnk=6638

Life expectancy in GlasgowLife expectancy in Glasgow

LenzieLife expectancy=82

CaltonLife expectancy=54

14km apart: 28 year difference in

life expectancy

Males

0

100

200

300

400

500

600

700

800

1 2 3 4 5 6 7

DepCat

Ag

e st

and

ard

ised

mo

rtal

ity

1980–82 1991–92 2000–02 Females

0

50

100

150

200

250

300

350

400

450

1 2 3 4 5 6 7

DepCat

Ag

e st

and

ard

ised

mo

rtal

ity

1980–82 1991–92 2000–02

Age standardised mortality for area deprivation category in Scotland. Rates per 100,000 men and women aged 0–64,

1980–82, 1991–92 and 2000–02

Data taken from Leyland et al. (2007) BMC Public Health

Low

Low

High

High

Source: Pearce & Dorling. International Journal of Epidemiology 2006;35:597–603

Health selective migrationHealth selective migration

Do ‘Do ‘healthyhealthy’ or ‘’ or ‘unhealthyunhealthy’ ’ people have a greater or people have a greater or lesser propensity to move?lesser propensity to move?Implications - geographical Implications - geographical inequalities in healthinequalities in healthIf sorting occurs in which:If sorting occurs in which:– people in people in better healthbetter health are are

more likely to move to (or more likely to move to (or remain in) remain in) less deprivedless deprived areas areas

– people in people in poorer healthpoorer health are are more likely move to (or remain more likely move to (or remain in) in) more deprivedmore deprived areas areas

Geographical inequalities in Geographical inequalities in health will be exacerbatedhealth will be exacerbated

Smoking DataSmoking Data

Smoking Data

Censuses: 1981, 1996 & 2006: cigarette

smoking status age >15.

Smoking data obtained (each respondent)

classified: • smoker

• ex-smoker• never smoked

District Health Boards (DHBs): n=21

• av. pop. size of 194,000• range 31,000 to 489,000

Source: Pearce J, Dorling D, 2010. Annals of the Association of American Geographers 100(2), 393–408.

Migration effectsMigration effectsDemographic accounting - to ascertain the net movement of smokers into each area due to 1. i) internal migration 2. ii) immigration from overseas

Smoking migration balanceSmoking migration balance

Widening geographical gap in smoking behaviour (1981-2006) - only partly attributable to unequal smoking cessation rates Important component:– differential migration patterns between

regions according to their smoking status

Eg net migration balance – all DHBs (1976-1981) ranged from – 2.2 % gain in never smokers in Capital

and Coast (low deprivation)– 1.5 % gain in smokers in Wairarapa

and in Whanganui (high poverty)

Effects of International MigrationEffects of International Migration

Excluding immigrants Excluding immigrants had a significant had a significant effecteffect

E.g. 1/3 of Auckland’s E.g. 1/3 of Auckland’s ‘advantage’ due to ‘advantage’ due to selective migration of selective migration of immigrants. immigrants.

The smoking migration balance of men and women combined by DBH 1976-1981, 1991-1996 and 2001-2006, and standard deviation

Excluding immigrants Including immigrants

Smoking migration balance and life Smoking migration balance and life expectancyexpectancy

What are effects of the selective migration patterns of smokers and non-smokers on the spatial pattern of health inequalities ?– Clear relationship: DHB smoking

migration balance and life expectancy for males in 2001

More smokers that tend to leave each area compared to the net number of non-smokers that arrive, the higher the DHB-level life expectancy. Correlation - life expectancy in 2001 & net smoking migration balance (1976-1981)– stronger for males (-0.67) than for

females (-0.50), – maybe because lower proportion of

females smoked (particularly 1981).

Concepts of Environmental

Justice

Distribution

Environmental JusticeEnvironmental Justice

Recognition

Participation Capabilities

after Schlosberg (2007)

Pearce, Witten, Hiscock & Blakely. International Journal of Epidemiology 2007;36:348–355

Source: Pearce, Day & Witten. Urban Policy & Research 26: 2008; 213–27

Source: Pearce, Blakely, Witten & Bartie. American Journal of Preventive Medicine 2007;32:375–382

Fast food outletsFast food outlets

Source: Day & Pearce. American Journal of Preventive Medicine 2011;40(2):113–121

K Function Clustering

High degree clustering around schools

Up to 5.5 times more than expected

Particularly socially deprived schools

Source: Pearce et al. Journal of Epidemiology and Community Health 2009; 63, 69-77.

Tobacco outlets and smokingTobacco outlets and smoking

But….But….

Source: Witten, Pearce & Day. Environment & Planning A 43: 2011; 205-23

Neighbourhood Destination Accessibility Index (NDAI): infrastructure support for neighbourhood physical activity

Median travel time to 16 sub-domains of community resources in deprivation quintiles across New Zealand

Source: Pearce et al. International Journal of Epidemiology 2007;36:348–355

Health/ behaviour effectsHealth/ behaviour effects

Associations between community resource access and Associations between community resource access and health in NZ neighbourhoods:health in NZ neighbourhoods:

Access to fast food outlets

•No association with BMI

•No association with diet

(Pearce et al. Health and Place 2009; 15, 193-197)

Access to supermarkets & convenience stores

•No association with fruit consumption

•No association with vegetable consumption

(Pearce et al. Journal of Epidemiology and Community Health 2008; 62, 198-200)

Access to green space

•No association with CVD

(Richardson, Pearce et al. BMC Public Health 2010; 10(1):240.)

Measure of Multiple Measure of Multiple Physical Environmental Deprivation?Physical Environmental Deprivation?

Multiple Environmental Deprivation Multiple Environmental Deprivation

Consider the social dimensions of Consider the social dimensions of multiple environmental risk factors:multiple environmental risk factors:1.1. Assess socio-spatial distribution of multiple dimensions of the physical Assess socio-spatial distribution of multiple dimensions of the physical

environment (related to health)environment (related to health)2.2. Test the tool to assess implications for Test the tool to assess implications for healthhealth and and health inequalitieshealth inequalities

MEDIx score

-2

-1

0

+1

+2

+3

0 150 30075km

Multiple Environmental Multiple Environmental Deprivation Index Deprivation Index

(MEDIx)(MEDIx)

MEDIx score -2 =

Least environmentally deprived wards (‘healthiest’ places, theoretically)

MEDIx score +3 =

Most environmentally deprived wards (‘unhealthiest’ places)

All cause mortality

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dise

d m

orta

lity

ratio

Unadjusted Adjusted

Cardiovascular disease

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintileSt

anda

rdis

ed m

orta

lity

ratio

Unadjusted Adjusted

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Respiratory disease

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Stan

dard

ised

mor

talit

y ra

tio

Unadjusted Adjusted

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Colorectal cancer

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dise

d m

orta

lity

ratio

Unadjusted Adjusted

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Oesophageal cancer

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dise

d m

orta

lity

ratio

Unadjusted Adjusted

Standardised Mortality Ratios and confidence intervals across quintiles of socio-economic deprivation, unadjusted and adjusted for physical environmental deprivation

Localism in the UKLocalism in the UK

May 2010 – May 2010 – Coalition GovernmentCoalition Government (Conservative/Liberal Democrats)(Conservative/Liberal Democrats)Implementing radical agendaImplementing radical agenda– Budget cutsBudget cuts– Central government spendCentral government spend– Local government spendLocal government spend– Greatest cuts – most disadvantaged groups/ placesGreatest cuts – most disadvantaged groups/ places

Implications include:Implications include:– Increase Value Added Tax (VAT)Increase Value Added Tax (VAT)– Removing ‘Education Maintenance Allowance’Removing ‘Education Maintenance Allowance’– Tripling student feesTripling student fees– WelfareWelfare– National Health Service restructuringNational Health Service restructuring

Wholesale redefinition of the relationship Wholesale redefinition of the relationship between the individual and the state…?between the individual and the state…?

Localism AgendaLocalism Agenda‘‘Big Society’:Big Society’:– transfer of power & rights from transfer of power & rights from centrecentre to to locallocal– Increase role for community groups and third Increase role for community groups and third

sector organisations – delivery of servicessector organisations – delivery of services– do things for yourself rather than the statedo things for yourself rather than the state

Localism Bill:Localism Bill:– Placing power at the heart of local communities?Placing power at the heart of local communities?– Reinforce local democracy?Reinforce local democracy?– Devolving responsibility?Devolving responsibility?

Implications include:Implications include:– return funds from business rates to councils that return funds from business rates to councils that

earn themearn themrather than distribute according to needrather than distribute according to need

– removal of national housing targetsremoval of national housing targets

Localism the shield for a sizeable Localism the shield for a sizeable redistributionredistribution from poor to rich? from poor to rich?

Deficit reduction & localismDeficit reduction & localism

Socio-ecological perspective:Socio-ecological perspective:– Social distribution in health - underlain by Social distribution in health - underlain by

unequal distribution of resources fundamental unequal distribution of resources fundamental to a healthful lifeto a healthful life

– Wealth, education, employment, access to Wealth, education, employment, access to health care, health care, environment (physical, social, environment (physical, social, built etc)built etc) in which people live….in which people live….

Fundamental implications for SDOH?Fundamental implications for SDOH?– rise in social & economic inequalitiesrise in social & economic inequalities– welfare supportwelfare support– food securityfood security– housinghousing– migrationmigration– etcetc

Local environment (neighbourhoods) Local environment (neighbourhoods) – increasingly pertinent – public health/ health increasingly pertinent – public health/ health

inequalities?inequalities?

ConclusionConclusionIncreasing concentration of poor health in more Increasing concentration of poor health in more disadvantaged neighbourhoodsdisadvantaged neighbourhoods– Selective migration/mobility part of the storySelective migration/mobility part of the story

Socially disadvantaged neighbourhoods also experience Socially disadvantaged neighbourhoods also experience lower quality (health-related) physical environments?lower quality (health-related) physical environments?– Triple jeopardy?Triple jeopardy?– UK evidence supportiveUK evidence supportive

Mixed evidence from neighbourhoods in NZMixed evidence from neighbourhoods in NZ– Questions some aspects of the neo-material understanding of Questions some aspects of the neo-material understanding of

health inequalitieshealth inequalities

Public health perspective on ‘Big Society’Public health perspective on ‘Big Society’– Localism agenda Localism agenda – Building community resilience and devolving local services?– Or putting a sticking plaster over the wound caused by macro-

structural inequalities in power and resources?– Challenge to efforts to reduce health inequalities?Challenge to efforts to reduce health inequalities?

AcknowledgementsAcknowledgements

New Zealand work funded by the NZ Health New Zealand work funded by the NZ Health Research CouncilResearch Council– Tony Blakely (University of Otago)Tony Blakely (University of Otago)– Karen Witten (Massey University)Karen Witten (Massey University)

MEDIx work funded by the NERC-led Environment MEDIx work funded by the NERC-led Environment & Human Health Program& Human Health Program– Richard Mitchell (University of Glasgow)Richard Mitchell (University of Glasgow)– Niamh Shortt (University of Edinburgh)Niamh Shortt (University of Edinburgh)– Elizabeth Richardson (University of Edinburgh)Elizabeth Richardson (University of Edinburgh)