Health inequalities and place: A theoretical conception of neighbourhood
Introduction
Investigators in various countries have reported that area of residence is associated with health above and beyond individual level risk factors (Diez-Roux, Link, & Northridge, 2000; Jones & Duncan, 1995; Kaplan, 1996; Kawachi & Berkman, 2003; Macintyre, MacIver, & Sooman, 1993; Pickett & Pearl, 2001). Such associations have been observed for a variety of health outcomes including tobacco consumption (Duncan, Jones, & Moon (1996), Duncan, Jones, & Moon (1999)) and smoking initiation (Frohlich, Potvin, Chabot, & Corin, 2002), adolescent risk behaviours (Ennet, Flewelling, Lindrooth, & Norton, 1997; Karnoven & Rimpala (1996), Karnoven & Rimpala (1997)), general mortality (Yen & Kaplan, 1999), perceived health (Blaxter, 1990; Soobader & LeClere, 1999), and cardiovascular diseases risk factors (Diez-Roux et al., 2000; Sundquist, Malmstrom, & Johansson, 1999), thus suggesting that some neighbourhoods are healthier than others (Diez-Roux et al., 2001; Kaplan, Everson, & Lynch, 2000; Macintyre & Ellaway, 2000).
Attempts to understand the reasons for this spatial patterning of health have led to distinguishing compositional from contextual explanations (Macintyre et al., 1993; Shouls, Congdon, & Curtis, 1996). The compositional explanation attributes the geographical clustering of health outcomes to the shared characteristics of residents. Similar people (e.g., similar in terms of socioeconomic status, or educational level) tend to aggregate within geographical proximity, whether purposefully to share a common culture, or because they are driven to certain areas because of lack of personal resources, money and others (De Koninck & Pampalon, in press; Harvey, 1973). These shared characteristics explain in part the health and place association. The contextual explanation attributes spatial variations in health outcomes in part to characteristics of the environment proper (Macintyre & Ellaway, 2000). The contextual explanation states that there exist ecological attributes of spatially defined areas that affect whole groups. These contextual attributes pertain to various aspects of the environment, and they affect health over and above the contribution of aggregate individual characteristics (Macintyre, Ellaway, & Cummins, 2002).
This distinction between compositional and contextual effects has fuelled heated debates in the public health literature. Recent commentaries, however, have suggested that this framing of effects constitutes an oversimplification. Disentangling compositional and contextual effects cannot be done from a strictly empirical perspective (Macintyre & Ellaway, 2003). Indeed, people's distribution across areas of residence is neither random nor totally intentional. As a reflection of both chances and choices, residential decisions (or the absence thereof) are shaped by the correspondence between individuals’ economic means and lifestyle preferences, and neighbourhood characteristics pertaining to the availability of resources and services, the quality of the physical and built environments such as housing, and other socially oriented criteria such as reputation, history or the presence of social connections (De Koninck & Pampalon, in press).
Conversely, neighbourhoods are not static, as their contextual and compositional characteristics change over time in a related, and sometimes almost synergistic manner (Soja, 2000). Galster (2001) identified four key neighbourhood users (and producers) whose decisions influence the flow of neighbourhood resources: households, businesses, property owners and local government. Through their consumption, service use, political processes and social connection patterns, these neighbourhood actors reproduce and transform their context, while the lifestyle and health of individuals are affected by the goods consumed, the services used, and the social relationships built. The collective lifestyle heuristic is an attempt to capture this dialectical relationship between individuals and places (Frohlich, Corin, & Potvin, 2001; Williams, 2003). It justifies “the need to link individual life histories with social factors” (Dunn, Frohlich, Ross, Curtis, & Sanmartin, 2005) such as those encompassed in the social entities of places (Curtis & Jones, 1998).
Our team has taken up the task of putting together a data infrastructure that will facilitate empirical studies of the evolution and associations between selected health outcomes, individual factors, and contextual characteristics of neighbourhoods. The first step in this endeavour was to elaborate a conceptual framework of neighbourhoods that would account for the local production of health. The main lens through which the framework, and this paper, views the neighbourhood association with health is through differences in the distribution of resources. We see this distribution as governed by four types of rules associated with five domains of social regulation. The spatial patterning of health inequalities is thus related to the variable configurations of those domains across neighbourhoods rather than simply the sheer number of resources available to residents within neighbourhoods. These configurations are in turn shaped by social interactions between neighbourhood users/producers and by patterns of geographic mobility through which people move away from, or into, areas according to their choices and to their personal economic and other resources.
This paper thus presents our conceptualisation of neighbourhood as a configuration of five domains through which residents acquire (or do not acquire) resources necessary for the production of health in every day life. A presentation of the specific mechanisms or pathways by which those resources are transformed into health remains, however, outside the scope of the present paper.
Section snippets
Resources and opportunity structures as sources of inequalities
Underlying our conception of neighbourhoods is the notion of place as a unique system of health-relevant resources and social relationships embedded within geographical borders (Curtis & Jones, 1998). This notion was expanded by Macintyre and colleagues into the concept of opportunity structure in the study of four socially differentiated areas in Glasgow, Scotland (Macintyre & Ellaway (2000), Macintyre & Ellaway (2003)). They consider five aspects of neighbourhoods as forming the opportunity
Neighbourhoods as environments for accessing resources
Health inequalities, we argue, are determined to a significant extent by the resources to which individuals have access. Neighbourhoods do offer such resources, some with a positive valence (such as parks, wholesome food stores, quality schools, and active neighbourhood organisations), and others with a negative one (such as pollution, liquor stores, violence and inferior law enforcement, and low level of interpersonal trust). The resources offered in neighbourhoods are not equally relevant for
The complex relationship between resources and rules of access
How, then, are neighbourhoods shaping the health of their residents? Basically, they do so, as illustrated in Fig. 1, because they offer different and unequal resources arising from: (1) the physical domain, where rules of proximity regulate access; (2) the economic domain, ruled by markets and price; (3) the institutional domain, where citizen rights prevail; and in two domains in which informal reciprocity is the primary rule, (4) the local sociability domain and (5) the community
Conclusion
In this paper, we have offered a conceptualisation of neighbourhoods as providers of resources related to population health and to the production of health inequalities. A framework that would explain how those resources, accessed by individuals through these various domains, are transformed into health and health inequalities remains beyond the scope of this paper. Despite this obvious limitation, we propose that our conception of neighbourhoods, as configurations of domains with distinct
Acknowledgements
This work was funded through a grant to the Lea-Roback Centre on Social Inequalities of Health in Montreal from the Institute of Public and Population Health of the Canadian Institutes of Health Research. Rana Charafeddine holds a post-doctoral fellowship from the Canadian Health Services Research Foundation. Mark Daniel holds the Canada Research Chair on Biopsychosocial Pathways in Population Health. Louise Potvin holds a CHSRF-CIHR Chair on Community Approaches and Health Inequality (CHSRF
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