Place effects on health: how can we conceptualise, operationalise and measure them?
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)
- et al.
Do communities differ in health behaviours?
Journal of Clinical Epidemiology
(1993) - et al.
Do places mattera multilevel analysis of regional variations in health related behaviour in Britain
Social Science and Medicine
(1993) - et al.
Health related behaviour in context–a multi level modelling approach
Social Science and Medicine
(1996) Hidden geographiesthe changing lifeworlds of women with disabilities
Social Science and Medicine
(1995)- et al.
Small area variations in health related behaviours; do these depend on the behaviour itself, its measurement, or on personal characteristics?
Journal of Health and Place
(2000) Therapeutic landscapesmedical issues in light of the new cultural geography
Social Science and Medicine
(1992)- et al.
People, places and coronary heart disease risk factora multilevel analysis of the Scottish heart health study archive
Social Science and Medicine
(1997) - et al.
Women's status and the health of women and mena view from the States
Social Science and Medicine
(1999) Epidemiology and the web of causationhas anyone seen the spider?
Social Science and Medicine
(1994)- et al.
Social and local variations in the use of urban neighbourhoodsa case study in Glasgow
Health and Place
(1998)