Abstract
Research into the role of place in shaping inequalities in health has focused largely on examining individual and/or localised drivers, often using a context-composition framing. Whilst this body of work has advanced considerably our understanding of the effects of local environments on health, and re-established an awareness of the importance of place for health, it has done so at the expense of marginalising and minimising the influences of macro political and economic structures on both place and health. In this paper, we argue that: (i) we need to scale up our analysis, moving beyond merely analysing local horizontal drivers to take wider, vertical structural factors into account; and (ii) if we are serious about reducing place-based health inequalities, such analysis needs be overtly linked to appropriate policy levers. Drawing on three case studies (the US mortality disadvantage, Scotland's excess mortality, and regional health divides in England and Germany) we outline the theoretical and empirical value of taking a more political economy approach to understanding geographical inequalities in health. We conclude by outlining the implications for future research and for efforts to influence policy from ‘scaling up’ geographical research into health inequalities.
Highlights
In recent years, researchers concerned with the connections between health and place have drawn on a wide array of methodological and theoretical innovations to examine how health and illness is socially and physically shaped in place and by place (Elliott, 2018)
Taking a political economy approach emphasises the importance of vertical relationships and structural factors in how place influences health
A geographically-nuanced political economy perspective on health inequalities responds to recent calls for systems-level perspectives on population health and inequalities which considers the outcomes to emerge from a complex system and for the drivers to be many and interdependent (Rutter et al, 2017)
Summary
Researchers concerned with the connections between health and place have drawn on a wide array of methodological and theoretical innovations to examine how health and illness is socially and physically shaped in place and by place (Elliott, 2018). The relational perspective has thereby opened up the analytical space in terms of focusing on the effects of factors beyond the individual and the local environment in shaping places and their health outcomes – and on how the direct and indirect effects of local places are themselves influenced by vertical factors It has still been largely used in the literature to privilege horizontal understandings of place, (over)emphasising the role of lower level, localised, proximal contextual, horizontal effects, at the expense of marginalising and minimising the role played by larger scale vertical contextual influences, macro political and economic factors. If the aim is for research on health inequalities – including geographical inequalities in health - to make a contribution to political and policy efforts to reduce these inequalities, a fundamental dimension of these analyses should be to identify the policy levers with the most potential to reduce health inequalities, at both local and national levels
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