Helena Tunstall

Places and health

This glossary aims to provide readers with some key conceptual tools with which to address the issue of place and health; it is hoped that it will provoke thought and debate on the range of ways that places are connected to health.

Is economic adversity always a killer? Disadvantaged areas with relatively low mortality rates

Objectives: To identify areas of Britain whose residents have relatively low age specific mortality, despite experiencing long-term economic adversity. Methods: Longitudinal, ecological study of all residents of Britain from 1971 to 2001. Results: 54 of Britain’s 641 parliamentary constituencies were identified as having been persistently economically disadvantaged in the period 1971–2001. Within this group, there was marked variation in age group specific mortality and in the age ranges with relatively high or low mortality. A systematic scoring process identified 18 constituencies as providing strong and consistent evidence of low mortality across a range of age groups, relative to the 54 constituencies as a whole. These 18 were labelled “resilient”. Among age groups >24 years, mortality rates in the resilient areas were significantly lower than in the other economically disadvantaged areas. For example, at ages 45–59 years, the average all cause mortality rate in the resilient constituencies was 607 per 100 000 population (95% CI 574 to 641) and 728 (670 to 787) in the non-resilient constituencies (p = 0.013). Conclusions: Areas with similar adverse economic histories do not all have similarly high mortality rates. It is unlikely that a single factor explains these results. Selective migration cannot be discounted as an explanation, but particular sociocultural features of areas (including the political, economic, ethnic and religious characteristics of their population) may also be protective.

Locating the Altruistic Voter: Context, Egocentric Voting, and Support for the Conservative Party at the 1997 General Election in England and Wales

Egocentric economic voting models are widely used in studies of voting behaviour in Great Britain: they suggest that people whose standard of living has risen recently as a perceived consequence of government policies are more likely to vote for the governments return to office than are those who blame government policies for a decline in their living standards. But many people whose living standards have increased vote against the government. Analyses reported here, using specially constructed bespoke neighbourhoods around the homes of respondents to the 1997 British Election Study, show that the latter group mainly live in areas of high local unemployment. This suggests a pattern of altruistic voting, of people who are prospering personally, but whose neighbours are not, voting against the incumbent government—a pattern confirmed by statistical analyses of both egocentric and sociotropic voting.

Factors which nurture geographical resilience in Britain: a mixed methods study

Objectives: To identify plausible mechanisms by which resilience (low mortality rates despite persistent economic adversity) was achieved in some areas in Britain between 1971 and 2001. Methods: Mixed method observational study, combining quantitative analyses of cause- and age group-specific mortality rates, and area sociodemographic and environmental characteristics, with case studies of resilient areas which included in-depth interviews. Results: The causes of death, and age groups, contributing most to resilience varied markedly between the 18 resilient areas; as disease aetiology varies, a range of protective processes must be in operation. Four area characteristics, which plausibly contributed to resilience, emerged from the in-depth interviews: population composition; retaining or attracting population; environment and housing; and social cohesion. Quantitative analyses demonstrated significant difference between resilient and non-resilient areas in retaining or attracting population only. Conclusions: While we identified plausible area characteristics through which resilience was achieved, there does not appear to be a definitive set that reliably produces resilience, and resilient and non-resilient areas did not differ significantly in their possession of most of these characteristics. If such characteristics do have a role in creating resilience, but are present in both resilient and non-resilient areas, further work is needed to explore what makes them “successful” in some areas, but not in others.

Understanding differences in access and use of healthcare between international immigrants to Chile and the Chilean-born: a repeated cross-sectional population-based study in Chile

IntroductionInternational evidence indicates consistently lower rates of access and use of healthcare by international immigrants. Factors associated with this phenomenon vary significantly depending on the context. Some research into the health of immigrants has been conducted in Latin America, mostly from a qualitative perspective. This population-based study is the first quantitative study to explore healthcare provision entitlement and use of healthcare services by immigrants in Chile and compare them to the Chilean-born.MethodsData come from the nationally representative CASEN (Socioeconomic characterization of the population in Chile) surveys, conducted in 2006 and 2009. Self-reported immigrants were compared to the Chilean-born, by demographic characteristics (age, sex, urban/rural, household composition, ethnicity), socioeconomic status (SES: education, household income, contractual status), healthcare provision entitlement (public, private, other, none), and use of primary services. Weighted descriptive, stratified and adjusted regression models were used to analyse factors associated with access to and use of healthcare.ResultsThere was an increase in self-reported immigrant status and in household income inequality among immigrants between 2006 and 2009. Over time there was a decrease in the rate of immigrants reporting no healthcare provision and an increase in reporting of private healthcare provision entitlement. Compared to the Chilean-born, immigrants reported higher rates of use of antenatal and gynaecological care, lower use of well-baby care, and no difference in the use of Pap smears or the number of attentions received in the last three months. Immigrants in the bottom income quintile were four times more likely to report no healthcare provision than their equivalent Chilean-born group (with different health needs, i.e. vertical inequity). Disabled immigrants were more likely to have no healthcare provision compared to the disabled Chilean-born (with similar health needs, i.e. horizontal inequity). Factors associated with immigrants’ access to, and use of, healthcare were sex, urban/rural status, education and country of origin.ConclusionThere were significant associations between SES, and access to and use of healthcare among immigrants in Chile and a higher prevalence of no health care provision entitlement among poor and disabled immigrants compared to the Chilean-born. Changing associations between access and use of healthcare and SES among immigrants in Chile over time may reflect changes in their socio-demographic composition or in the survey methodology between 2006 and 2009.ResumenIntroducciónLa evidencia internacional indica menor acceso y uso de servicios de salud por parte de inmigrantes, pero sus factores desencadenantes varían significativamente dependiendo del contexto. Algunas investigaciones se han desarrollado en este tema en América Latina, desde una perspectiva cualitativa. Este estudio cuantitativo exploró el auto-reporte de acceso y uso de servicios de salud de inmigrantes en Chile y los comparó con la población chilena.MétodosAnálisis secundario de datos de encuesta nacional CASEN 2006 y 2009. Inmigrantes fueron comparados con chilenos en características demográficas (edad, sexo, urbano/rural, composición del hogar, etnia), estatus socioeconómico (educación, ingreso, situación contractual), tipo de previsión (pública, privada, otra, ninguna), y uso de varios servicios de atención primaria. Análisis descriptivo, estratificado, y modelos de regresión ponderados para entender factores asociados al acceso y uso de servicios de salud en STATA 11.0.ResultadosSe observó un aumento de reporte de inmigrantes y de la desigualdad en el ingreso de inmigrantes entre 2006 y 2009. Hubo una disminución en la tasa de inmigrantes sin previsión y un aumento en el acceso al sistema privado. Los inmigrantes usaron más frecuentemente la atención prenatal y ginecológica, y menos la atención del niño sano. No hubo diferencia en el uso de citología vaginal o el número total de atenciones recibidas en comparación con los chilenos. Los inmigrantes en el quintil inferior de ingresos reportaron 4 veces más la ausencia de prestación de salud que los chilenos (inequidad vertical). Similares resultados se observaron al comparar inmigrantes con discapacidad con chilenos con discapacidad (inequidad horizontal). Los factores asociados con el acceso y uso del servicio de salud por parte de los inmigrantes fueron el sexo, urbano/rural, educación y país de origen.ConclusiónSe observó una asociación significativa entre estatus socioeconomico, migración y acceso y uso de asistencia sanitaria. Los resultados de este estudio pueden deberse a verdaderos cambios en la composición de los inmigrantes y sus patrones de uso del sistema de salud chileno, pero también pueden deberse a cambios en la metodología y recolección de datos entre encuestas 2006 y 2009. Este aspecto requiere mayor análisis y debate en la región.

What are the living conditions and health status of those who don’t report their migration status? a population-based study in Chile

BackgroundUndocumented immigrants are likely to be missing from population databases, making it impossible to identify an accurate sampling frame in migration research. No population-based data has been collected in Chile regarding the living conditions and health status of undocumented immigrants. However, the CASEN survey (Caracterizacion Socio- Economica Nacional) asked about migration status in Chile for the first time in 2006 and provides an opportunity to set the base for future analysis of available migration data. We explored the living conditions and health of self-reported immigrants and respondents who preferred not to report their migration status in this survey.MethodsCross-sectional secondary analysis of CASEN survey in Chile in 2006. Outcomes: any disability, illness/accident, hospitalization/surgery, cancer/chronic condition (all binary variables); and the number of medical/emergency attentions received (count variables). Covariates: Demographics (age, sex, marital status, urban/rural, ethnicity), socioeconomic status (education level, employment status and household income), and material standard of living (overcrowding, sanitation, housing quality). Weighted regression models were estimated for each health outcome, crude and adjusted by sets of covariates, in STATA 10.0.ResultsAbout 1% of the total sample reported being immigrants and 0.7% preferred not to report their migration status (Migration Status - Missing Values; MS-MV). The MS-MV lived in more deprived conditions and reported a higher rate of health problems than immigrants. Some gender differences were observed by health status among immigrants and the MS-MV but they were not statistically significant. Regressions indicated that age, sex, SES and material factors consistently affected MS-MVs’ chance of presenting poor health and these patterns were different to those found among immigrants. Great heterogeneity in both the MS-MV and the immigrants, as indicated by wide confidence intervals, prevented the identification of other significantly associated covariates.ConclusionThis is the first study to look at the living conditions and health of those that preferred not to respond their migration status in Chile. Respondents that do not report their migration status are vulnerable to poor health and may represent undocumented immigrants. Surveys that fail to identify these people are likely to misrepresent the experiences of immigrants and further quantitative and qualitative research is urgently required.

Comparing sociodemographic factors associated with disability between immigrants and the Chilean-born: are there different stories to tell?

This study explored a range of sociodemographic factors associated with disability among international immigrants in Chile, and compared them to the Chilean-born. Secondary data analysis of the Chilean population-based survey CASEN-2006 was conducted (268,873 participants). Main health outcomes: any disability and six different types of disability: visual, hearing, learning, physical, psychiatric and speaking (binary outcomes). Sociodemographic variables: Demographic factors (age, sex, marital status, urban/rural, ethnicity), socioeconomic status (SES: income, education, employment status, and an integrated indicator combining the SES measures through cluster analysis for the immigrant population), material factors (overcrowding, sanitation, housing quality) and migration related (country of origin and length of stay). Immigrants reported a significantly lower prevalence of any disability (3.55%), visual (1.00%) and physical disability (0.38%). Factors associated with any disability among immigrants were age, low SES or over 20 years duration of residence in Chile; while a range of sociodemographic factors were associated with disability in the Chilean-born. Conditional regression models by age group varied between populations, but SES remained significantly associated with disability across immigrants and the Chilean-born. However, there are no similar patterns of factors associated to different types of disability between the populations under study. Factors associated with disability varied between populations under study, but SES showed a consistent association with any disability in immigrants and the Chilean-born. Types of disability showed different patterns of factors associated to them between populations, which suggest the great complexity of underlying mechanisms related to disability in Chile.

Where Are Socioeconomically Deprived Immigrants Located in Chile? A Spatial Analysis of Census Data Using an Index of Multiple Deprivation from the Last Three Decades (1992-2012)

Introduction and Purpose of the Study Immigrants in Chile have diverse characteristics and include socioeconomically deprived populations. The location of socioeconomically deprived immigrants is important for the development of public policy intelligence at the local and national levels but their areas of residence have not been mapped in Chile. This study explored the spatial distribution of socioeconomic deprivation among immigrants in Chile, 1992–2012, and compared it to the total population. Material and Methods Areas with socioeconomically deprived populations were identified with a deprivation index which we developed modelled upon the Index of Multiple Deprivation (IMD) for England. Our IMD was based upon the indicators of unemployment, low educational level (primary) and disability from Census data at county level for the three decades 1992, 2002 and 2012, for 332, 339 and 343 counties respectively. We developed two versions of the IMD one based on disadvantage among the total population and another focused upon the circumstances of immigrants only. We generated a spatial representation of the IMD using GIS, for the overall IMD score and for each dimension of the index, separately. We also compared the immigrants´ IMD to the total population´s IMD using Pearson´s correlation test. Results Results showed that socioeconomically deprived immigrants tended to be concentrated in counties in the northern and central area of Chile, in particular within the Metropolitan Region of Santiago. These were the same counties where there was the greatest concentration of socioeconomic deprivation for the total population during the same time periods. Since 1992 there have been significant change in the location of the socioeconomically deprived populations within the Metropolitan Region of Santiago with the highest IMD scores for both the total population and immigrants becoming increasingly concentrated in the central and eastern counties of the Region. Conclusion This is the first study analysing the spatial distribution of socioeconomic deprivation among international immigrants and the total population in a Latin American country. Findings could inform policy makers about location of areas of higher need of social protection in Chile, for both immigrants and the total resident population in the country.

Does Administrative Data Reflect Individual Experience? Comparing an Index of Poverty with Individually Collected Data on Financial Well-being in a Multi-Ethnic Community

The Income Deprivation Affecting Children Index (IDACI) uses administrative data to count children living in households in receipt of both in-work and out-of-work means-tested benefits and provides small area ranking as an indicator of child poverty in neighbourhoods. Benefit take-up rates within an area will affect its reliability. We aimed to examine benefit take-up rates and compare area ranking by the IDACI with ranking using individually reported data across areas of varying ethnic composition. Mothers living in areas with high minority ethnic density were less likely to report claiming a benefit than those in majority White or mixed areas, despite reporting lower incomes. The correlation between self-reported material difficulties and worsening IDACI rank was much lower in areas characterised by minority ethnic populations. Further investigation into the performance of area-based deprivation measures in areas with high minority ethnic density is needed.

Happiness, Social Cohesion and Income Inequalities in Britain and Japan

The above quotation is from the popular book entitled “The Spirit Level: Why More Equal Societies Almost Always Do Better”. This text describes the relationship between income distribution and well-being in affluent countries suggesting it is mediated through psychosocial pathways shaping the impacts of economic structure upon social relationships. In this model lower income inequality is seen to result in societies with more cohesion, greater trust and cooperation and lower social stress. Wilkinson and Pickett (2009) present evidence suggesting that social and economic policies affecting the income distribution of a society can make a huge difference to the psychosocial well-being of the whole populations of this society. For instance, according to the evidence used in this book if income inequality were halved in the UK then the murder rates in the country and obesity rates would also halve, mental illness could be reduced by two thirds, imprisonment could reduce by 80 %, teen births could reduce by 80 % and levels of trust could increase by 85 % (The Equality Trust 2011).