Place effects on health: how can we conceptualise, operationalise and measure them?

https://doi.org/10.1016/S0277-9536(01)00214-3Get rights and content

Abstract

In this paper we highlight what we consider to be a lack of adequate conceptualisation, operationalisation and measurement of “place effects”. We briefly review recent historical trends in the study of the effects of place on health in industrial countries, and argue that “place effects” often appear to have the status of a residual category, an unspecified black box of somewhat mystical influences on health which remain after investigators have controlled for a range of individual and place characteristics. We note that the distinction between “composition” and “context” may be more apparent than real, and that features of both material infrastructure and collective social functioning may influence health. We suggest using a framework of universal human needs as a basis for thinking about how places may influence health, and recommend the testing of hypotheses about specific chains of causation that might link place of residence with health outcomes.

Introduction

In this paper we highlight what we consider to be a lack of adequate conceptualisation, operationalisation and measurement of “place effects”. We briefly review recent historical trends in the study of the effects of place on health in industrial countries, and argue that “place effects” often appear to have the status of a residual category, an unspecified black box of somewhat mystical influences on health which remain after investigators have controlled for a range of individual and place characteristics. We note that the distinction between “composition” and “context” may be more apparent than real, and that features of both material infrastructure and collective social functioning may influence health. We suggest using a framework of universal human needs as a basis for thinking about how places may influence health, and recommend the testing of hypotheses about specific chains of causation that might link place of residence with health outcomes.

Section snippets

Recent history of ecological analysis

During a period roughly dating from the end of the Second World War to the early 1990s, neither epidemiology, medical geography, nor medical sociology tended directly to study the impact of the local social or physical environment on human health (Macintyre & Ellaway, 2000a), despite the abundance of community studies exploring life in particular localities (Gans, 1962; Suttles, 1972; Young & Willmott, 1957). Below we summarise what we believe to be the main reasons for this absence of

Places and people

Since the early 1990s there has been a resurgence of interest in the role of place in shaping people's health experiences, and a new debate has developed about the relative importance of people or place characteristics. In 1993 two of the present authors collaborated in publishing a paper which pointed out that area level data were commonly used as surrogates for missing individual level data (for example, exposure to specific pathogens, or poverty). Much information supposedly about areas was

Composition and context: a useful distinction?

Most of the research described in the previous section aimed to establish the relative importance of compositional and contextual explanations for the geographical patterning of health. Just as much research on socioeconomic inequalities in health was based on debates between what were seen as mutually exclusive competing explanations (for example, selection vs. causation, or material vs. psychosocial (Macintyre, 1997a)), compositional and contextual explanations have tended to be seen as

The collective dimension

In a previous paper, we suggested three types of explanation for geographical variations in health: compositional, contextual, and collective (Macintyre, 1997b). Compositional explanations draw our attention to the characteristics of individuals concentrated in particular places; contextual explanations draw our attention to opportunity structures in the local physical and social environment collective explanations draw our attention to socio-cultural and historical features of communities.

The black box of places

In the remainder of this paper we try to shed light on the interior of the “black box of places” and to suggest a conceptual framework and set of measures which might be used to test specific hypotheses about the role of place, taking into account the ideas described above about specific contextual aspects of the local physical and social environments which might influence health or health-related behaviours in particular population groups.

What constitutes a healthy neighbourhood?

In our own work in the West of Scotland, we have been trying to look directly at features of local areas that might be health promoting or health damaging. We have been using as an organising framework the following five types of features of local areas which might influence health:

1. Physical features of the environment shared by all residents in a locality. These include the quality of air and water, latitude, climate, etc. and are likely to be shared by neighbourhoods across a wide area. In

Methodological issues

In trying to collect data on local material infrastructure and the social context in areas, three major methodological issues are what spatial scales are appropriate for meeting different needs, at what spatial scale or level of aggregation information is actually available, and what might be the appropriate time interval between environmental exposures and any effects on health.

Although much epidemiology and medical geography uses administrative or postal delivery areas such as census tracts,

Conclusion

The recently renewed interest in place or community effects on health has been largely data driven and has rarely been underpinned by explicit, testable, hypotheses about the mechanisms by which place might influence specific aspects of health in specific population groups, and the appropriate time scale over which these operate. Conflicting evidence about the extent and magnitude of area effects on health may be due to differing conceptualisations and operationalisations of area effects, and

Acknowledgements

All authors are employed by the UK Medical Research Council. The new study to which we will be applying the framework developed in the latter half of this paper is funded by the MRC (grant number G9900620). We are grateful to Fiona McDonald for help with the references, and to Anne Kavanagh and an anonymous referee for helpful comments on earlier drafts.

References (112)

  • J.B. McKinlay

    The promotion of health through planned sociopolitical change; challenges for research and policy

    Social Science and Medicine

    (1993)
  • D. Mechanic

    Social research in health and the American sociopolitical contextthe changing fortunes of medical sociology

    Social Science and Medicine

    (1993)
  • V. Pinfold

    Building up safe havens…all around the world; users’ experience of living in the community with mental health problems

    Health and Place

    (2000)
  • L. Pucci et al.

    Outdoor tobacco advertising in six Boston neighborhoods—evaluating youth exposure

    American Journal of Preventive Medicine

    (1998)
  • N.B. Anderson et al.

    Toward understanding the association of socioeconomic status and healtha new challenge for the biopsychosocial approach

    Psychosomatic Medicine

    (1995)
  • D.J.P. Barker

    The foetal and infant origins of inequalities in health in Britain

    Journal of Public Health Medicine

    (1991)
  • D. Barker et al.

    Inequalities in health in Britainspecific explanations in three Lancashire towns

    British Medical Journal

    (1987)
  • F. Baum

    The new public healthan Australian perspective

    (1998)
  • T. Blakely et al.

    Ecological effects in multi-level studies

    Journal of Epidemiology and Community Health

    (2000)
  • S. Brower

    Good neighborhoodsa study of in-town and suburban residential environments

    (1996)
  • V. Carstairs et al.

    Deprivation and health in Scotland

    (1991)
  • S. Cummins et al.

    The location of food stores in urban areasa case study in Glasgow

    British Food Journal

    (1999)
  • S. Curtis et al.

    Is there a place for geography in the analysis of health inequality?

    Sociology of Health & Illness

    (1998)
  • G. Davey Smith et al.

    Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortalitythe Renfrew and Paisley study

    Journal of Epidemiology and Community Health

    (1998)
  • G. Davey Smith et al.

    Explaining male mortality differentials between the west of Scotland and the south of England (abstract)

    Journal of Epidemiology and Community Health

    (1995)
  • J. Davidson

    ‘…the world was getting smaller’women, agoraphobia and body boundaries

    Area

    (2000)
  • A. Diez-Roux

    Bringing context back into epidemiologyvariables and fallacies in multilevel analysis

    American Journal of Public Health

    (1998)
  • A.V. Diez-Roux et al.

    Neighborhood environments and coronary heart diseasea multilevel analysis

    American Journal of Epidemiology

    (1997)
  • P.G. Donnelly et al.

    Change, cohesion, and commitment in a diverse urban neighborhood

    Journal of Urban Affairs

    (1996)
  • D. Dorling

    Death in Britain. How local mortality rates have changed 1950s–1990s

    (1997)
  • W. Dressler et al.

    Culture, skin color, and arterial blood pressure in Brazil

    American Journal of Human Biology

    (1999)
  • Drever, F., Whitehead, M. (Eds.), (1997). Health Inequalities. London: The Stationery...
  • C. Duncan et al.

    Psychiatric morbidity; a multi level approach to regional variations in the UK

    Journal of Epidemiology and Community Health

    (1995)
  • Ellaway, A., Hiscock, R., Macintyre, S., & Kearns, A. In the driving seat? Mode of transport and considerations of...
  • A. Ellaway et al.

    Women in their placegender and perceptions of neighbourhoods and health in the west of scotland

  • R. Forrest et al.

    Joined-up places? Social cohesion and neighbourhood regeneration

    (1999)
  • Fox, J., & Goldblatt, P. (1982). Longitudinal Study 1971–1975; England and Wales. Office of Population Censuses and...
  • Frohlich, K. (2000). The collective lifestyles framework: A contextual analysis of social practices, social structure...
  • Frohlich, K., Potvin, L., Chabot, P., & Corin, E. A theoretical and empirical analysis of neighbourhoods, smoking and...
  • Frohlich, K., Potvin, L., Gauvin, L., & Chabot, P. Disentangling contextual from compositional effects? Insights into...
  • H. Gans

    The urban villagersgroup and class in the life of Italian–Americans

    (1962)
  • A.C. Gattrell et al.

    Spatial point pattern analysis and its application in geographical epidemiology

    Transactions of the Institute of British Geographers

    (1996)
  • A. Giddens

    The constitution of societyoutline of the theory of structuration

    (1984)
  • B. Glesson

    Geographies of Disability

    (1999)
  • E. Graham et al.

    Individual deprivation, neighbourhood and recovery from illness

  • M. Greenberg

    Improving neighborhood qualitya hierarchy of needs

    Housing Policy Debate

    (1999)
  • M. Haan et al.

    Poverty and health; prospective evidence from the Alameda county study

    American Journal of Epidemiology

    (1987)
  • D. Hackbarth et al.

    Tobacco and alcohol billboards in 50 Chicago neighbourhoodsmarket segmentation to sell dangerous products to the poor

    Journal of Public Health Policy

    (1995)
  • E. Hall

    Blood, brain & bonestaking the body seriously in the geography of health & impairment

    Area

    (2000)
  • M.V. Hayes

    Man, disease and environmental associationsfrom medical geography to health inequalities

    Progress in Human Geography

    (1999)
  • Cited by (0)

    View full text