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Issue 3, January 1999, pp.12-13.

How does relative deprivation affect health?
Malcolm MacLeod, Elspeth Graham, Marie Johnston, Chris Dibben and Irene Morgan

Introduction
There is now compelling evidence that poor health is not simply the outcome of poverty and absolute deprivation. If it were, then those in the poorest circumstances would have the poorest health, while everyone above the poverty line would enjoy the same level of good health. Instead there is a graded relationship between income or socio-economic status and health, with relative improvements in income and living standards associated with relative improvements in levels of health. Further, societies in which there are wide inequalities in income and living standards have lower life expectancies than societies in which income differences are smaller.

In the UK, both income differences and health inequalities have increased over the last few decades despite substantial rises in standards of living. This has led Wilkinson(1) to conclude that health is related to social relativities rather than absolute standards of living. This finding, if substantiated by detailed studies, has important implications for public policy where initiatives and resources are often targeted on particular areas defined as deprived. If health status is dependent on relative rather than absolute living standards, the effects of such policies may be limited because of their failure to take into account income disparities across society as a whole. Improving conditions for the poorest could have little or no impact if their position relative to other groups remains static or worsens.

Social Geography
Recent research has shown that the relationship between relative deprivation and health, apparent at the national scale, also exists at sub-national levels within the UK and that it can be related to local social geography. Gatrell,(2) for example, used spatial data (census wards) for one health authority in north-west England to demonstrate that a measure of relative deprivation which takes account of the location of areas in relation to each other performs well as a correlate of both all-cause mortality and mortality due to ischaemic heart disease. We have been able to demonstrate a similar relationship for our study area in Scotland using age-standardised self-reported limiting long-term illness from the 1991 census as our measure of health. However, we have also found that the direction of the relationship between relative spatial deprivation and health is reversed when the deprivation scores for the wards themselves are added to the model. This is best explained by reference to Figure 1 which illustrates the detailed patterns of deprivation in two different parts of the City of Dundee.

Figure 1: Varying patterns of deprivation in the City of Dundee


In the city as a whole, we found that deprivation scores for small areas (census output areas) are positively associated with levels of limiting long-term illness in these areas. Standardising for this relationship, we then investigated the relationship between deprivation levels in surrounding areas and levels of limiting long-term illness in given census areas. Preliminary results, which show a modest but significant relationship, are intriguing. They suggest that an area, such as area A in Figure 1, which has a lower level of deprivation than its nearest neighbours records higher levels of limiting long-term illness than might be expected from its own deprivation score alone. The opposite is true of areas, like area B, which are surrounded by less deprived neighbours. Such areas exhibit lower levels of ill-health than we are led to expect by solely considering their own levels of deprivation. Thus it seems that highly local social relativities are influencing health but in the opposite way to that suggested by other research conducted at larger spatial scales. In health terms, being surrounded by less deprived neighbours appears to confer an advantage, whereas having neighbouring areas with higher levels of deprivation seems to 'pull down' an area and result in greater ill health relative to other areas with the same level of (internal) deprivation. These findings are still preliminary but they raise a further question, 'What kind of mechanism could explain the relationship between spatial aspects of deprivation and health?'

Social Comparisons
Given that, at an individual level, what may be most important with regards to relative deprivation is whether one perceives oneself to be disadvantaged relative to other people, it would seem reasonable to suppose that psychological factors are in some way involved. We already know that psychological factors (e.g. depression) can affect health and that such factors are also associated with health-related behaviours (e.g. diet and exercise) which, in turn, are related to health. The principal question then becomes, 'Is there any mechanism that could make a plausible link between spatial aspects of deprivation and those psychological factors known to be related to health?'

The fact that contrasting social geographies seem to be related to health differentials suggests that the relative comparisons made by people living in neighbouring areas may be a vital component in explaining inequalities in health. Thus there may be a role for social comparisons in explaining the relationship between relative deprivation and health (see Figure 2).

Figure 2: Schematic representation of possible relationship between relative deprivation and health


We often engage in making social comparisons with others as a way of evaluating ourselves. The social comparisons we make have many facets but one that may prove particularly important is the direction of the comparison. Many psychological studies have indicated that making downward comparisons (i.e. with people who are worse off than you in some respect) can bolster or enhance one's self-esteem and generally tends to be associated with more positive outcomes than if we make upward comparisons (i.e. with people who are better off). In addition, there may be a life course dimension in the social comparisons we make in that the extent to which one believes one is relatively deprived may be influenced by prior life experiences (e.g. number of episodes of poverty) and/or the perception of changing levels of material affluence in society.

Our Study
Our study is currently examining the issue of how the social comparisons we make might influence recovery from illness. Does comparing oneself with people who are worse-off in economic terms facilitate recovery? In order to address such questions, our study has married the varied skills and expertise of health and social geographers with those of health and social psychologists. Specifically, we are following the pattern of recovery in 200 patients in the city of Dundee and surrounding areas who have suffered a first myocardial infarction (MI). Patients are being recruited from the Cardiac Rehabilitation Unit of Ninewells Hospital in Dundee over a 2-year period. Our data (collected via face-to-face interviews with patients) will allow us to construct a range of spatial and economic indices and provide measures of health outcome and of potential mediating variables such as depression, self-esteem and health-related behaviours. In particular, we will be concerned with the extent to which social comparison processes made at 5-6 weeks post-MI are predictive of recovery three months later.

We hope to be able to: determine how important comparison processes are for explaining the relationship between relative deprivation and health; examine whether social deprivation factors operate via psychological factors (including beliefs and emotional states) and health behaviours already shown to be linked to health outcomes; establish those indices of social inequality which are most clearly related to health; and determine the psychological and spatial conditions that are most likely to give rise to perceived relative deprivation.

Policy Implications
Through an increased understanding of such relationships, it may prove possible in the future to develop policies and interventions that will ultimately lead to improvements in the health and well-being of the general population. In particular, if we find that social comparisons are an important explanatory mechanism in the relationship between relative deprivation and health, then local and national health care strategies concerned with recovery from MI may find this research valuable in the effective targeting of resources, and the education of health care professionals.

Malcolm MacLeod, Elspeth Graham and Chris Dibben are based in the School of Geography.
Marie Johnston and Irene Morgan are based in the School of Psychology at the University of St Andrews.

References:
1. Wilkinson, R. G. (1996) Unhealthy Societies, London : Routledge.
2. Gatrell, A. (1998) 'Structures of geographical and social space and their consequences for human health' Geografiska Annaler, 79 (3) pp.141-154.