Geographies of Health References

• Context and composition are not mutually exclusive but places encompass both the people within them and the wider environment

• People of higher socioeconomic status often have better access to resources, money, knowledge, power and networks that promote better health

• Place is an ecosystem made up of people, systems and structures so to separate context and composition is to oversimplify

• Health varies with age, ethnicity, occupation, physical environments and social/spatial inequalities

• Historical events such as C19th industrialisation or Thatcherism can also impact health

Bambra, 2016

• The second Marmot Review highlighted that people can now expect to spend more of their lives in poor health

• Improvements to life expectancy have stalled and health inequalities grow

Marmot et al., 2020

• Income inequality and health have been linked in the US, UK and Brazil; often interpretations of this ignore contextual determinants

• Income inequality can impact health through perceptions of place in a social hierarchy leading to antisocial behaviour, reduce participation and low community cohesion

• There is a clustering of conditions impacting population health interacting with hierarchy impacts

• Social capital in terms of trust, belonging and volunteering could be more important than economic GDP

Lynch et al., 2000

• ‘People make places, and places make people’ shows the interconnectedness of context and composition

• To separate context and composition is to oversimplify the relationship between place and health where it acts like an ecosystem

Macintyre & Ellaway, 2003

• Clustering can see unemployed people living near other unemployed people

• On small scales, places can create conditions such as pollution but also perceptions on health and healing

• Places where fewer people are ill would be expected to have higher levels of social capital and community showing the connection

• On smaller scales, differences in health are often seen as a product of the individual but internationally area affects are often seen as more important

• The history of a place is important in the life course of the place as well as genetic inheritance

Tunstall et al., 2004

• Greenspace creates a venue for exercising to improve physical and mental health

• It can also be sen to improve cognitive functioning and sleep quality

• Those with greater greenspace deprivation levels have been shown to have shorter life expectancies that those less deprived

The Health Foundation, 2024

• Wellbeing is a network of reinforced individual, community and place impacts that are often associated with use of green space, civic agency and neighbourhood cohesion

• The individual and context of a place are in a reciprocal relationship as one’s health will be based on the resources available as well as other factors

• Individual factors have been seen to be the strongest predictors of well-being as financial difficulties and physical health have strong connections to poorer wellbeing

• Individuals often do not have control over place based conditions such as COVID limiting access to greenspace

• Joint decision making is important in increasing feelings of civic agency, neighbourhood purpose and optimism

• Hearth is important as it informs on wider policy, future work should unpack more complex relationships

McElroy et al., 2021

• Place is often underestimated in its contribution to disease risk, this should be understood better to inform policy interventions

• Context of place is importance as it constitutes social relations and physical resources

• Relational perspectives are important in understanding how context impacts health through feedback loops and dynamic natures of place

• Power relations are important as actors control and maintain health influencing factors, there can be places of prescription or negotiation and exogenous processes can also impact local places

• Access to resources is not necessarily the same as geographical proximity, relative position is important

Cummins et al., 2007

• Multilevel modelling allows for better separation of individual and contextual factors seeing how there can be direct and indirect impacts of the two

• There should be better frameworks and comparisons used for understanding health outcomes as well as the dynamic nature of places subject to processes such as migration

• There is a focus on context which may take the blame away from the individual and onto the government

• It is time for more interconnected and humanistic theories of health variation, it is not isolated but policy should strive for greater depth

Smyth, 2008

• The Dahlgren-Whitehead rainbow model broadens horizons to allow people to think beyond the health sector into local environments, it escapes the idea that health is determined by formal health services

• It allows people to work together on a common goal with each sector taking responsibility, it is easy to understand and includes more than just risk

• It consists of layers and focuses on health as a whole rather than specific diseases

• The model is not about inequality and is not an analytical tool but simply a visual representation

• In the future it aims for better illustrations of links, focus on commercial determinants and the idea of racism as a driving force

Dahlgren & Whitehead, 2021

• Minority ethnic groups have been disproportionately impacted by COVID-19 through multiple pathways as a result of social processes and hidden structural racism

• Ethnicity is a socially constructed idea tat causes inequalities to rise through broader social mechanisms

• There are impacts of differential expose, vulnerability, disease consequences, social consequences, effectiveness or control measures and adverse consequences of control measures all leading to unequal health outcomes

• Ethnicity must be better understood in order for action to be more meaningful

Katikireddi et al., 2021

• The Preston curve states a strong positive relationship between national incomes and life expectancy in poorer countries and also sees that this relationship is changing with life expectancy increasing at all levels

• There is a dispute over which mechanisms is the most important

• The relationship is also true for individuals speaking of their relative income and how it places them in the social hierarchy

• Arguments for redistribution lack evidence from the curve but there is clear importance of technological innovation and resource allocation

• There may be a reverse link between health and wealth that would have important implications for economic development and poverty reduction

Bloom & Canning, 2007

• We are affected differently by income differences within our own society than between one society and another

• It is not your actual income level that matters, but instead how you compare yourself with others from the same society shown as poor health and violence are more common in more unequal societies

• Inequality causes created anxiety and defensive self esteem resulting from increasing social evaluative threat causing higher levels of stress, this is now amplified by a more mobile population seeing familiar faces often replaced by constant fluxes of strangers

• Greater inequality increases status competition and increases status anxiety, this can lead to greater self-promotion with the idea of more inequality produced as a result

• In order to create a better society we must prioritise liberty, equality and fraternity

Wilkinson & Pickett, 2010

• Jen et al. refutes the inequality hypothesis yet this is based on self-rated health data which is inappropriate for international comparison 

• There are high political stakes of understanding if the effect is due to context or composition as it effects support for redistribution policies from the rich

• In more unequal rich countries although health is worse, people are less likely to kill themselves than in more equal societies

• In more equal societies it is harder to blame others or the system for your woes meaning concerns become internalised; people are also less likely to pretend that they are well and judge their situations better 

• In more equal societies, you have a health service to fall back on so you do not have to convince yourself you are fit and healthy, therefore self-rated health would be lower

Dorling & Barford, 2009

• Wilkinson presents a contextual argument for relating inter-country variations in mortality rates to income inequalities, Gravelle counters this by stating a compositional approach is sufficient 

• This study uses multilevel modelling to sustain the case that is is compositional rather than contextual variable that account for inter-country variations in health status

Jen et al., 2008

• Analysis of Wilkinson’s hypothesis that individuals will be less healthy the greater the lack of social cohesion in a country, this was shown in self-rated health data and provides insight into countries such as former Soviet Bloc regions and Scandinavia

• Wilkinson claims that in advances societies, it is not material disadvantage that is the most important determinant but instead psychosocial feelings associated with relative deprivation

• This was shown as there was a correlation between lower social cohesion and worse health, this also extended Wilkinson’s hypothesis to non-Western countries

• Income inequality may be linked to this by worsening social cohesion, but this requires more research 

• By living in a trustful society stress levels are reduced and therefore associated physiological stresses reduced, this was not found on the individual level probably due to altered contextual factors

Jen et al., 2010

• Proposes a framework based on the premise that all social and economic determinants of child mortality operate through a common set of biological mechanisms (proximate determinants) to impact mortality 

• This bridges the gap between traditional social and medical methodologies to create a more coherent framework that can advance research on social policy and medical interventions to improve child survival in developing countries

• The key advantage of the model lies in its organisation of seemingly disparate factors that interlink to determine child health, it highlights the need to understand the multifactorial origins of child mortality 

• More research and intervention will help to determine which factors are of key importance and should be changed in order to increase child survival

Mosely & Chen, 1984

• Preston saw that national income levels were positively related to increasing life expectancy but also that the relationship shifts upwards overtime due to medical developments; but there are problems with this as income may act as a proxy for wider socioeconomic developments 

• Educational attainment is seen to be a better predictor than income as it does not diminish at higher levels and does not leave an unexplained shift over time explained by other factors, this was validated in studies on 174 countries from 1970-2015

• This is due to education  leading to cognitive changes affecting risk perception, planning and access to information promoting health-related behaviours and use of healthcare facilities

• This means education levels should be promoted in policy

Lutz & Kebede, 2018

• Ethiopia is an example of a high achieving gaining 3.03 years on its expected life expectancy due to positive efforts in education, gender, health systems, employment, food security, affordable housing and civil organisations

• The US is a low achieve losing 2.87 years on its expected life expectancy due to neoliberalism creating inequality, high rates of poverty and unemployment 

• There is low gender equality, a complex health system combined with bad health behaviours, high levels of income inequality, a lack of affordable housing and low participation rates

• These inequalities also lead to worse social outcomes outside of health

Freeman et al., 2020

• The epidemiologic transition focuses on changes in patterns of health and disease and the interactions between these patterns and their demographic, economic and sociological determinants and consequences 

• The model has three stages: the age of pestilence and famine, age of receding pandemics and the age of degenerative and man-made diseases 

• At each stage mortality declines and life expectancy increases

• There is a gradual shift seeing a decline in infectious diseases and an increase in cancer and cardiovascular diseases, this is down to ecobiological, socioeconomic and medical factors with medical factors having a greater influence on more recent mortality declines in the Global South

• The most profound changes in health and disease during the transition occur among children and young women; the model also interacts with changing demographic and socioeconomic factors

• There are three variations of the model to represent changes in pace, pattern, determinants and consequences of population change; these are the classical Western model, the accelerated model and the contemporary/delayed model

Omran, 2005

• The Age of Degenerative and Man-made Diseases was a plateau in epidemiologic history, the major causes of death were degenerative diseases and life expectancy reached 70 which was seen to the around the biological limit to life

• In the US around the mid-1960s mortality from degenerative diseases began to rapidly decrease forming a new stage of the transition

• This was caused by a new older section of the population being formed, a focus on degenerative diseases in healthcare through new drugs, treatments, diagnosis etc. to postpone deaths by degenerative diseases; also reductions in major risk factors and inequalities in access to healthcare for the elderly and poor

• This formed a new era in epidemiologic history were there were rapid declines in deaths from major degenerative diseases and life expectancy rises to around 80 in the ‘Age of Delayed Degenerative Diseases’

Olshansky & Ault, 1986

• In recent years there has been a dramatic increase in infectious diseases such as Ebola, malaria, Hepatitis C, HIV etc. such of which can be attributed to the resistance of vectors to insecticides and microbes to antibiotics

• Aging populations, globalisation, environmental factors and changing transmission also play a part in this re-emergence

• This sees a Fifth stage arise associated with a re-emergence of IPDs and a shift towards affecting older ages; these aging groups have weaker immune systems and are often clustered in healthcare facilities promoting spread

• This could be seen as a re-emergence of the First stage but recognising the risks is more important than a definitive label

Olshansky et al., 1998

• Public health policy in industrialised societies is being reconfigured to improve population health and address inequalities in the social distribution of health

• There is a need to tackle not the social determinants of health, but the social process underpinning unequal distribution

• Often even as absolute inequalities reduce, relative inequalities between socio-economic groups remain which has negative consequences for health overall

Graham, 2004

• Health is defined as a state of ‘complete physical, mental and social well-being’ and crucially ‘not merely the absence of disease or infirmity’ 

• This understands the multifaceted dimensions of health, but simply physical or mental but a holistic measure of wellbeing

World Health Organisation, 2024

• The original Marmot review showed that there was a 7 year difference in life expectancy between rich and poor areas in the UK

• This can be viewed as a compositional effect of the population living in these areas respectively

Marmot, 2010