ABSTRACT
INTRODUCTION Does where you live shape your life chances and opportunities in respect of suffering from poor health and lack of access to quality health care? Does a lack of geographical mobility condemn certain individuals to endure a higher prevalence of health problems because of the neighbourhood they reside in? A growing body of evidence in the UK indicates a distinctive geographical pattern to the distribution of social problems including poor health (see for example, McCormick and Philo 1995; Shelton et al. 2006; Dorling et al. 2007; Thomas and Dorling 2007; Shaw et al. 2009). Furthermore, once factors concerning individual characteristics, circumstances and life choices are taken into account, geographical variations in health outcomes cannot be entirely explained by simply examining the type of individuals living within different localities (see for example, Congdon et al. 1997; Curtis et al. 2004; Dibben et al. 2006). This is not to say that current policy initiatives designed to tackle ‘problematic’ individual behaviour (for example, smoking, alcohol, drugs and obesity), along with strategies that seek to address the link between household income, poverty and health deprivation (for example, minimum wage and working family tax credits) are not important. However, this present situation both highlights the extent to which ‘people’ based diagnoses still predominantly feature in policy initiatives designed to tackle health inequalities – and supports the argument by Powell et al. (2001) that there has been an over-emphasis upon people poverty conceptions of social problems at the expense of placed based factors. Why does place matter? Our own direct experience of living within specific neighbourhoods tells us that place matters in terms of the positive and negative attributes of localities. In deciding where to live, we make decisions based upon (often highly subjective) judgements about the merits of areas that are as much shaped by our view of the place as it is by our opinion concerning the individuals who live there. The extent to which place, and the complex set of circumstances, processes and interactions that operate within and around the communities we live in, really impacts upon our circumstances and life opportunities is, however, open to considerable conjecture and debate. In part this stems from arguments concerning the type of methodological approach and evidence required to demonstrate that place exerts a significant and independent impact upon our lives (see for example McCulloch 2001; Dietz 2002; Sampson et al. 2002; Diez Roux 2004). More importantly, however, disputes concerning the link between place and social problems are crucially centred around whether place or ‘area effects’ really exist at all – and if so, what aspects of place exert a causal influence on our lives? Do poor neighbourhoods make their residents poorer (Friedrichs 1998), or is it the presence of poor residents that renders neighbourhoods poorer places in which to live? Should our attempts to tackle health inequalities centre on ‘people poverty’ orientated solutions, or should we equally be concerned with addressing the structural, interpersonal, institutional context of health and health care that is embodied within the neighbourhoods in which we reside? The aim of this chapter is to explore the concepts of place, and neighbourhood effects, as a mechanism for understanding the presence of health inequalities within certain communities. The chapter seeks to develop a more holistic conception of place poverty as a theoretical framework for evaluating health inequalities, one that takes us beyond narrow conceptions of poverty that predominantly focus the attention of governments and health care organisations upon deprived individuals living within
deprived communities. Having examined the concept of place poverty, the discussion moves on to identify different types of neighbourhood effect that need to be considered in evaluating the health environment operating within specific localities, and finally introduces an analytical approach that enables the evaluation of place and health in relation to both the scale of health problems and the quality of health care operating within different areas.
