Placing a housing lens on neighbourhood disadvantage, socioeconomic position and mortality
Authors: Rebecca Bentley, Emma Baker
Journal: The Lancet Public Health (2022)

Designing effective health interventions requires knowledge of the interplay between context, individual circumstances and health. In this issue of The Lancet Public Health, the study by Ana Isabel Ribeiro and colleagues1Ribeiro AI Fraga S Severo M et al.Association of neighbourhood disadvantage and individual socioeconomic position with all-cause mortality: a longitudinal multicohort analysis.Lancet Public Health. 2022; 7: e447-e457Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar makes a seemingly simple and intuitive finding; that across many people and many settings, neighbourhood deprivation has a stronger effect on the mortality of people with a low educational attainment than people with a higher educational attainment. The results show, both statistically and using proxies, how context and individual opportunity work together to drive an ultimate health outcome: all-cause mortality.Ribeiro and colleagues1Ribeiro AI Fraga S Severo M et al.Association of neighbourhood disadvantage and individual socioeconomic position with all-cause mortality: a longitudinal multicohort analysis.Lancet Public Health. 2022; 7: e447-e457Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar make the following notable observations. First, that age-adjusted mortality rates can be theoretically modified by contextual and individual factors, and their interaction with each other. Second, that policies aiming to narrow health inequalities should simultaneously intervene at the individual and community levels. And third, that the amplification of inequalities by people's context (deprivation amplification), and their relative socioeconomic position within an area (relative standing), might explain the social processes underlying contextual and individual determinants of mortality.To better understand the necessity of this study for public health, and its usefulness for the design of health interventions,2WHOWHO housing and health guidelines.https://www.who.int/publications/i/item/9789241550376Date: Nov 23, 2018Date accessed: March 23, 2022Google Scholar it is important to consider that each individual's housing circumstances are different and that housing is simultaneously absolute in its negative effect on population health (eg, exposure to dampness or mould),3Knibbs LD Woldeyohannes S Marks GB Cowie CT Damp housing, gas stoves, and the burden of childhood asthma in Australia.Med J Aust. 2018; 208: 299-302Crossref PubMed Scopus (11) Google Scholar relative (eg, the negative mental health effects of housing affordability vary by tenure),4Mason K Baker E Blakely T Bentley R Housing affordability and mental health: does the relationship differ for renters and home purchasers?.Soc Sci Med. 2013; 94: 91-97Crossref PubMed Scopus (92) Google Scholar, 5Bentley RJ Pevalin D Baker E Mason K Reeves A Beer A Housing affordability, tenure and mental health in Australia and the United Kingdom: a comparative panel analysis.Housing Studies. 2016; 31: 208-222Crossref Scopus (56) Google Scholar and sits within a neighbourhood and wider housing system context that might amplify or protect against housing disadvantages. People's chances of being exposed to unhealthy housing are greater the lower their income,6Daniel L Baker E Beer A Pham NTA Cold housing: evidence, risk and vulnerability.Housing Studies. 2021; 36: 110-130Crossref Scopus (9) Google Scholar and disadvantaged neighbourhoods have more poor-quality housing.7Baker E Lester LH Bentley R Beer A Poor housing quality: prevalence and health effects.J Prev Interv Community. 2016; 44: 219-232Crossref PubMed Scopus (62) Google ScholarPoor housing conditions (ie, cold, damp, mould) can negatively affect health,8Riggs L Keall M Howden-Chapman P Baker MG Environmental burden of disease from unsafe and substandard housing, New Zealand, 2010–2017.Bull World Health Organ. 2021; 99: 259-270Crossref PubMed Scopus (2) Google Scholar compounding financial difficulties and, potentially, affecting quality of life. Also, because location is a strong driver of house prices (and rent prices), for a low-income household, home is also likely to be in a disadvantaged area. Often, health services might be less accessible or of a poorer quality—contributing to spatial inequalities,9Bentley R Kavanagh AM Subramanian SV Turrell G Area disadvantage, individual socio-economic position, and premature cancer mortality in Australia 1998 to 2000: a multilevel analysis.Cancer Causes Control. 2008; 19: 183-193Crossref PubMed Scopus (51) Google Scholar and amplifying the negative health effects of an unhealthy housing environment.In terms of the social process, identified in the study, of a household's relative standing contributing to worse health outcomes, poor condition housing might stand out in socioeconomically advantaged areas. This distinction might lead to social exclusion and discrimination, or it might lead to more community support from neighbours and health-care providers.What can be done to intervene to generate better health outcomes for people disadvantaged by their housing circumstances? This study by Ribeiro and colleagues shows the need to understand context before designing health-focused interventions. People living in poor-condition housing in a poor area might benefit most in the long term from place-based initiatives that seek to increase housing quality for everyone (perhaps by setting minimum standards for housing construction and maintenance), whereas people living in poor-condition houses in advantaged areas might benefit from both universal minimum standards and community-focused social inclusion initiatives. Households experiencing both types of disadvantage would also benefit from direct support (either financial or instrumental) to fix and maintain their homes.The study by Ribeiro and colleagues has some notable limitations. First, the model assumes static populations without agency. However, people often move. Place-based solutions that improve housing and amenity in an area might see property prices rise and lower socioeconomically positioned households displaced elsewhere.10Baker E Bentley R Lester L Beer A Housing affordability and residential mobility as drivers of locational inequality.Applied Geography. 2016; 72: 65-75Crossref Scopus (66) Google Scholar Second, the sensitivity analyses suggest that settings with a high spatial segregation had the strongest effects of deprivation. The extent to which people who live in the same area are homogenous varies greatly across contexts. Discrepancies between an individual's social position relative to their neighbour's in an area is a determinant of how much the characteristics of places can affect the health of people within that group. Such variations need to be factored in policy responses to improve health and reduce health inequalities. Finally, it is imperative to establish the relevant geography that is meaningful to people's health: streets, houses, neighbourhoods, or boundaries defined by a person's social networks. Although postal code and other administrative areas are convenient for research, they are not necessary for people's lives.The study by Ribeiro and colleagues contributes to our conceptual knowledge, it provides a valuable demonstration of the connectedness of socioeconomic position, area disadvantage, and life expectancy across national contexts. The challenge remains how to operationalise these findings and design interventions that disrupt the contextual and individual differences of people that result in real years of life lost. Context matters, places are dynamic, deprivation is just one dimension of a place, and death rates are amenable to change. With this knowledge comes an obligation to act to reduce socioeconomic inequalities in mortality where possible. Designing effective health interventions requires knowledge of the interplay between context, individual circumstances and health. In this issue of The Lancet Public Health, the study by Ana Isabel Ribeiro and colleagues1Ribeiro AI Fraga S Severo M et al.Association of neighbourhood disadvantage and individual socioeconomic position with all-cause mortality: a longitudinal multicohort analysis.Lancet Public Health. 2022; 7: e447-e457Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar makes a seemingly simple and intuitive finding; that across many people and many settings, neighbourhood deprivation has a stronger effect on the mortality of people with a low educational attainment than people with a higher educational attainment. The results show, both statistically and using proxies, how context and individual opportunity work together to drive an ultimate health outcome: all-cause mortality. Ribeiro and colleagues1Ribeiro AI Fraga S Severo M et al.Association of neighbourhood disadvantage and individual socioeconomic position with all-cause mortality: a longitudinal multicohort analysis.Lancet Public Health. 2022; 7: e447-e457Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar make the following notable observations. First, that age-adjusted mortality rates can be theoretically modified by contextual and individual factors, and their interaction with each other. Second, that policies aiming to narrow health inequalities should simultaneously intervene at the individual and community levels. And third, that the amplification of inequalities by people's context (deprivation amplification), and their relative socioeconomic position within an area (relative standing), might explain the social processes underlying contextual and individual determinants of mortality. To better understand the necessity of this study for public health, and its usefulness for the design of health interventions,2WHOWHO housing and health guidelines.https://www.who.int/publications/i/item/9789241550376Date: Nov 23, 2018Date accessed: March 23, 2022Google Scholar it is important to consider that each individual's housing circumstances are different and that housing is simultaneously absolute in its negative effect on population health (eg, exposure to dampness or mould),3Knibbs LD Woldeyohannes S Marks GB Cowie CT Damp housing, gas stoves, and the burden of childhood asthma in Australia.Med J Aust. 2018; 208: 299-302Crossref PubMed Scopus (11) Google Scholar relative (eg, the negative mental health effects of housing affordability vary by tenure),4Mason K Baker E Blakely T Bentley R Housing affordability and mental health: does the relationship differ for renters and home purchasers?.Soc Sci Med. 2013; 94: 91-97Crossref PubMed Scopus (92) Google Scholar, 5Bentley RJ Pevalin D Baker E Mason K Reeves A Beer A Housing affordability, tenure and mental health in Australia and the United Kingdom: a comparative panel analysis.Housing Studies. 2016; 31: 208-222Crossref Scopus (56) Google Scholar and sits within a neighbourhood and wider housing system context that might amplify or protect against housing disadvantages. People's chances of being exposed to unhealthy housing are greater the lower their income,6Daniel L Baker E Beer A Pham NTA Cold housing: evidence, risk and vulnerability.Housing Studies. 2021; 36: 110-130Crossref Scopus (9) Google Scholar and disadvantaged neighbourhoods have more poor-quality housing.7Baker E Lester LH Bentley R Beer A Poor housing quality: prevalence and health effects.J Prev Interv Community. 2016; 44: 219-232Crossref PubMed Scopus (62) Google Scholar Poor housing conditions (ie, cold, damp, mould) can negatively affect health,8Riggs L Keall M Howden-Chapman P Baker MG Environmental burden of disease from unsafe and substandard housing, New Zealand, 2010–2017.Bull World Health Organ. 2021; 99: 259-270Crossref PubMed Scopus (2) Google Scholar compounding financial difficulties and, potentially, affecting quality of life. Also, because location is a strong driver of house prices (and rent prices), for a low-income household, home is also likely to be in a disadvantaged area. Often, health services might be less accessible or of a poorer quality—contributing to spatial inequalities,9Bentley R Kavanagh AM Subramanian SV Turrell G Area disadvantage, individual socio-economic position, and premature cancer mortality in Australia 1998 to 2000: a multilevel analysis.Cancer Causes Control. 2008; 19: 183-193Crossref PubMed Scopus (51) Google Scholar and amplifying the negative health effects of an unhealthy housing environment. In terms of the social process, identified in the study, of a household's relative standing contributing to worse health outcomes, poor condition housing might stand out in socioeconomically advantaged areas. This distinction might lead to social exclusion and discrimination, or it might lead to more community support from neighbours and health-care providers. What can be done to intervene to generate better health outcomes for people disadvantaged by their housing circumstances? This study by Ribeiro and colleagues shows the need to understand context before designing health-focused interventions. People living in poor-condition housing in a poor area might benefit most in the long term from place-based initiatives that seek to increase housing quality for everyone (perhaps by setting minimum standards for housing construction and maintenance), whereas people living in poor-condition houses in advantaged areas might benefit from both universal minimum standards and community-focused social inclusion initiatives. Households experiencing both types of disadvantage would also benefit from direct support (either financial or instrumental) to fix and maintain their homes. The study by Ribeiro and colleagues has some notable limitations. First, the model assumes static populations without agency. However, people often move. Place-based solutions that improve housing and amenity in an area might see property prices rise and lower socioeconomically positioned households displaced elsewhere.10Baker E Bentley R Lester L Beer A Housing affordability and residential mobility as drivers of locational inequality.Applied Geography. 2016; 72: 65-75Crossref Scopus (66) Google Scholar Second, the sensitivity analyses suggest that settings with a high spatial segregation had the strongest effects of deprivation. The extent to which people who live in the same area are homogenous varies greatly across contexts. Discrepancies between an individual's social position relative to their neighbour's in an area is a determinant of how much the characteristics of places can affect the health of people within that group. Such variations need to be factored in policy responses to improve health and reduce health inequalities. Finally, it is imperative to establish the relevant geography that is meaningful to people's health: streets, houses, neighbourhoods, or boundaries defined by a person's social networks. Although postal code and other administrative areas are convenient for research, they are not necessary for people's lives. The study by Ribeiro and colleagues contributes to our conceptual knowledge, it provides a valuable demonstration of the connectedness of socioeconomic position, area disadvantage, and life expectancy across national contexts. The challenge remains how to operationalise these findings and design interventions that disrupt the contextual and individual differences of people that result in real years of life lost. Context matters, places are dynamic, deprivation is just one dimension of a place, and death rates are amenable to change. With this knowledge comes an obligation to act to reduce socioeconomic inequalities in mortality where possible. We declare no competing interests. Association of neighbourhood disadvantage and individual socioeconomic position with all-cause mortality: a longitudinal multicohort analysisOur study suggests that the detrimental health effect of living in disadvantaged neighbourhoods is more pronounced among individuals with low education attainment, amplifying social inequalities in health. This finding is relevant to policies aimed at reducing health inequalities, suggesting that these issues should be addressed at both the individual level and the community level. Full-Text PDF Open Access