Category Archives: Inequalities

Stigma, environments and health inequalities: why should we be interested?

In recent years there has been a great deal of interest amongst health researchers in the role of social stigma in affecting health. Social stigma can be articulated as a majority view that works to spoil the identity of others on the basis of a discriminating characteristic such as race, gender or class. The social stigma associated with some minority groups has been shown to have health salience in terms of providing an obstacle to gaining access health care, housing provision, welfare, employment and other underlying factors affecting health. Groups that have been the subjects of research include disabled, homeless and itinerant populations and this body of work has revealed the multitude of interpersonal and institutional factors linking discrimination with health. Stigma has also been adopted as a deliberate strategy in health promotion initiatives, most notably in tobacco control with recent work beginning to question whether the denormalisation and stigmatisation of smoking (and the smoker) has reached its limit as a public health goal.

Given the long tradition of work on stigma and health, and the importance of stigma for establishing and perpetuating health inequalities, it is perhaps surprising that few researchers have considered the potential significance of place and the environment in establishing, perpetuating and mediating social stigma. In a recent commentary* on a Japanese paper on place-based discrimination published in the journal Social Science and Medicine, I argue that geographers (and others with interests in place, space and health) could productively consider the role of spatial stigma in affecting the health of local residents. Spatial stigma arises in places with notoriety in the public discourse, and that are constructed as ‘no-go zones’ or ‘sink estates’ that require constant policing.  Neighbourhoods such as Toxteth in Liverpool, South Central in Los Angeles or the French banlieues have for instance been prejudiced by deep-rooted geographical discrimination.  Key to the argument in the commentary is that there are a range of consequences for population health of residing in a highly stigmatised community. Yet very few empirical studies have tested the salience of spatial stigma in affecting population health.

So why should researchers with interests in the environment and spatial inequalities in health be concerned with place-based stigma? In the Social Science and Medicine commentary, I suggest that health might be compromised by spatial stigma through a series of (non-mutually exclusive) individualised and institutional pathways, which in turn can exacerbate geographical inequalities in health. These include:

1. Being ‘looked down on’ because of residing in a stigmatised community can detrimentally affect a number of life chances such as education and training opportunities, employment prospects and the prospects of developing interpersonal relationships. These factors have all been implicated in studies of health.

2. Stigma relating to particular places may act as ‘badge of dishonour’ that results in local residents taking actions such as concealing their address, avoiding receiving visitors or providing excuses to others for where they live. These feelings of shame can work to spoil, manipulate and mediate individual identities and social relations and affect health (e.g. health behaviours or mental health).

3. Place-based stigma affects the levels investment and disinvestment of public and private resources put into the local community. Progressive social policy is undermined by the lack of investment in the local infrastructure, housing and other services that provide the opportunities for healthy living.

4. Social networks, community social bonds and collective efficacy are affected by residents’ withdrawal from the public realm in response to the perceived threats associated with spatial stigma (e.g. crime). The breakdown of these community ties is detrimental to physical and mental health outcomes of local populations.

In short, there is plenty of evidence from the urban sociology and urban geography literature that through a variety of intersecting pathways place-based stigmatisation is harmful to the life chances of local residents. The population health consequences of place-based stigma are however less well established; understanding these pathways is an important challenge for researchers with an interest in the environment and health. This challenge is particularly important during a period of austerity with major reductions in state investment in a range of health related infrastructure. A likely consequence of this retrenchment is the heightened stigmatisation of many socially disadvantaged communities with potentially disastrous implications for public health and health inequalities.

Jamie Pearce, August 2012

jamie.pearce@ed.ac.uk

 *Library access required; if you are unable to get hold of the paper then I’d be please to email you a copy (jamie.pearce@ed.ac.uk). .

Financial crisis, austerity policies and geographical inequalities in health

Is austerity good for our health?

A collection of papers published in a recent issue of Social Science and Medicine considered the implications of the recent crisis in the financial sector and subsequent austerity policies for population health. The conclusions were equivocal. On the one hand the direct impact of the financial crisis (e.g. unemployment) on health is clearly detrimental to the individual concerned and their immediate family. For instance, the incidence of suicide, drug abuse and domestic violence might be expected to rise.

Yet at the same time economic downturns may lead to an improvement in the overall health of populations.  But what explains this apparent contradiction? One possibility is that population health may be enhanced during periods of economic downturn because of a reduction in unhealthy ‘affluent behaviours’ such as the over consumption of food and alcohol or a fall in road traffic accidents. What is clear is that the longer term implications of the recent financial crisis are difficult to predict.

Geography matters

An important omission from this discussion of the health implications of the financial crisis is a consideration of geography.  This seems surprising as the health consequences of economic retrenchment are unlikely to be evenly shared across all parts of the country. In the UK for example, the financial crisis and subsequent austerity are likely to affect people living in Glasgow rather differently to folks from London. The health impacts will be most detrimental for people in the least socially advantaged places. It is feasible that in the most prosperous regions of the country, health will be unaffected…..or even enhanced. In short, geographical inequalities in health in the UK could rise substantially in response to the ‘austerity agenda’.

Financial crisis & geographical inequalities in health

So what are the processes linked to the deficit reduction strategies that are likely to affect geographical inequalities in health in the UK? In this CRESH blog we outline four (non-exhaustive and inter-related) reasons for why we might expect health to become geographically polarised.

  1. Perhaps most obviously, the ‘social geography’ of the UK is likely to be heavily affected by the current and forthcoming austerity strategies which in turn can be expected to undermine some key social determinants of health. Austerity measures could well widen the geographical discrepancy in social markers at various different scales, particularly between regions of the country. For example, places with a larger proportion of workers employed in the public sector will be particularly vulnerable to unemployment and job insecurity.  Similarly income disparities between regions are likely to grow. Unemployment, job insecurity and income inequality are causally related to health. One response to the changing socio-economic map of the UK is likely to be heightened regional inequalities in health.
  1. Job insecurity, unemployment and changes to welfare including a cap on housing benefits are likely to ‘disrupt’ patterns of mobility and lead to new forms of migration and mobility streams that are health selective. As job markets stagnate or contract, it is feasible that migration from north to south may lessen and/or become increasingly socially selective. There is also the worrying prospect of low income (and less ‘healthy’) families being displaced from their homes by the cap on housing benefits. This policy change is likely to see a movement of low income (and less ‘healthy’) individuals away from more prosperous suburbs into more ‘affordable’ neighbourhoods, as well as the entrapment of others in less healthy places.
  1. Austerity measures are already leading to a reprioritisation of public services provided by local authorities and other organisations. Which services will continue to receive resources and where there will be disinvestment is starting to become clear. As a recent blog argues, the middle classes are skilled in resisting cuts in services and new (unwanted) developments, an advantage that may lead to further disinvestment in disadvantaged communities during periods of fiscal tightening. At the same time, the Westminster government is looking to deregulate various environmental regulations that were often implemented to protect vulnerable communities from the health effects of various types if disamenities. The re-prioritisation of investment in public services and changes to environmental legislation is likely to lead to greater environmental disparities across regions in the UK. Environments that support health and well-being may well become just as disparate, raising environmental justice concerns and negatively affecting area-level health inequalities.
  1. Much academic research and policy initiatives have been concerned with ‘place-based’ determinants of health. The premise here is that factors relating to geographical (often local) context are fundamental to understanding social and geographical differences in health outcomes and behaviours. Place-based factors such as neighbourhood social capital, local norms, access to shops and services, social networks, concentration of poverty and a whole host of other factors have been implicated.  Austerity measures are likely to undermine efforts to improve local infrastructure (see above) as well as disrupt local community networks. Similarly, earlier CRESH work suggests that ‘problem’ health behaviours such as smoking, drinking and gambling may be reinforced in disadvantaged settings during tightened financial times.

We would be delighted to hear your comments and suggestions. What are other mechanisms that might affect geographical inequalities in health?  What are the key concerns outside the UK?

Jamie Pearce. April 2012.

@CRESHnews @jamie0pearce

CRESH call for papers – RGS-IBG: Environment, justice & health inequalities

CRESH are organising a conference session at the RGS-IBG and look forward to receiving abstracts.
The conference runs from 3-5 July 2012 and is being held at the University of Edinburgh

Environment, justice & health inequalities
In recent years the dominant discourse in environmental justice research has been concerned with notions of distributive justice. Studies adopting this utilitarian perspective have tended to consider the socio-spatial distribution of environmental ‘goods’ and ‘bads’. A common conclusion is that low socio-economic, ethnic minority and other vulnerable groups and places are often disadvantaged in terms of the availability of environmental resources or contact with environmental burdens. More recently, environmental justice scholars have challenged the dominance of the distributional approach. They have called for a reorientation that includes a consideration of (i) the processes underlying the maldistribution of resources and (ii) how the distribution of resources affects health and well-being. To date, despite its obvious potential, there has been little geographical work at the intersection of the fields of environmental justice and health inequalities.

The aim of this session is to bring together papers from an interdisciplinary group of researchers concerned with issues of environmental justice and health. This session, organised by the Centre for Research on Environment Society and Health (CRESH), seeks papers which address the following non exhaustive list of possible topics including climate change, health behaviours, salutogenic environments and vulnerability.

Deadline for submitting abstracts is Friday 2nd of December.
Please send abstracts up to a maximum of 250 words, proposed titles and 5 keywords (clearly stating name, institution, and contact details) to Niamh Shortt (niamh.shortt@ed.ac.uk), Jamie Pearce (Jamie.pearce@ed.ac.uk), Richard Mitchell (Richard.Mitchell@glasgow.ac.uk) and Elizabeth Richardson (e.richardson@ed.ac.uk)

Measuring the Big Society: stakeholder consultation

We’ve produced a draft proposal for measuring the baseline and future progress of Big Society at a local level.  We would value thoughts and comments from interested parties on:

  • our approach,
  • our selection of variables with which to measure the Big Society and
  • the methods we propose to use to develop the measure.

Please download the document here and comment by Friday April 22nd.  Many thanks for your involvement.

How do you measure Big Society?

The CRESH team and colleagues from Portsmouth and Liverpool are currently collaborating to produce a ‘blueprint’ for measuring Big Society.  You can read more about the work and funders on the project page.

To design a measure of Big Society begs a question… what is Big Society? Actually defining it is not easy. Although the general idea has been quite clearly articulated by David Cameron, a huge range of supporters, detractors and commentators have been writing and blogging about what it means since the coalition government took power. Opinions vary about what Big Society is and is not. There are also strong views about whether it’s a good thing or not. The government is also now encountering the realities of putting an idea developed in opposition into practice. Tony Blair has some interesting things to say about the difference between having an idea in opposition, and delivering change in government…

Although debates continue about what a Big Society should look like  and what policies the coalition need to build it, its key principle is clear; it represents a desire for a society in which citizens and communities take a vastly increased role in managing, shaping and delivering social and physical infrastructure. As Number 10 wrote in May 2010, their aim is “to create a climate that empowers local people and communities…[to] ‘take power away from politicians and give it to people’” .

We have a sense that some in government believe their job will be done once they change the law to empower people to run local services or to have a say on how their neighbourhood will be developed. The ‘offer’ to participate in a Big Society will have been made and it doesn’t matter who, or if anyone, takes up the offer. Others, however, want to see evidence of changes wrought. Will it alter how much people like you and I are aware of, care about, and get involved in, what’s happening in our local areas? Which communities will do well from it, and which will not?  The fact that Big Society has the potential to affect everyone makes it an important thing to monitor and measure.

At the start of the project, we focused on designing a framework for understanding ‘Big Society’ and identifying the set and sequence of changes which expect to see if it’s ‘successful’. Then, we looked for datasets and indicators to measure each of these things. It’s remarkable how many surveys which would have been useful to monitor and measure the progress of Big Society, have been cut. On Friday, we will visit the Department for Communities and Local Government to present our work so far and hear what they have to say about it. Sometime after that, we will post information about our ‘model’ of Big Society and how it might be measured.