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Space of health-related well-being
Charis Keller-Lengen, Department of Geography, University of Zurich.
Doctoral thesis within the project “Geographical milieux of health and disease in Switzerland”, funded by the program of Marie Heim-Vögtlin associated with Swiss National Science Foundation (SNF) and by the research credit of the University of Zurich, project duration : 1.10.03 — 30.9.05.
Changes in the natural and socio-cultural environment represent a challenge to societies. Economic and ecological developments, but also changes in working conditions, social relationships and life-styles, affect human health and well-being. In Switzerland, the noticeable variety of languages, cultures, identities and social capital, with their respective attitudes and "conceptions of the world", creates pronounced regional differences in health-relevant behaviour and in well-being. Switzerland therefore provides a particularly suitable context for the analysis of interactions between individual and collective factors (compositional vs. contextual effects).
The overall goal of the project is to uncover multi-causal contexts of the health-disease continuum and to analyse the reciprocal effects of collective regional factors and individual well-being. To this end, we investigate the ways in which health varies in particular socio-cultural regions and regional environments of Switzerland and the factors of influence that are responsible for these differences. The target variables are the collective risk and protective factors.
Research Design and Methods
Individual-based data from the Swiss Health Polls of 1992/93 and 1997 (Schweizerische Gesundheitsbefragung = SGB) represent the main source of information. The SGB is a micro-census based on data disclosed by individual subjects by telephone. The random sample sizes of 15,288 (1992/93) and 13,004 (1997) interviewees are sufficient to be able to make statements based on regions, because of the limited size of Switzerland. Statistical methods are two-by-two tables, chi-square statistics and correspondence analysis.
Health-related well-being is investigated in association with common social geographical approaches using structural data from census and tax statistics indicating municipality typology (Schuler, 1988) and language areas such as the German-, French- and Italian-speaking areas.
Health is recorded on a subjective level. The health variable is the subjective estimate of health-related well-being and correlates very well with mortality (Sundquist & Johansson 1997). Thus e.g. a poor health-related well-being is a strong predictor for high mortality.
Preliminary results indicate that in Switzerland the German, French and Italian regions, respectively, seem to differ. In the Italian region 8.22 percent of the people declare to have a poor health-related well-being in contrast to 3.65 percent in the German region and 4.10 percent in the French region. However, these preliminary results do not clearly show genuinely poorer health in the Italian region. Differences in culture and language use can also have an effect on the individual assessment of well-being.
Preliminary results of correspondence analysis for two-dimensional contingency tables of municipality typology and well-being suggest that large cities (MT1, Grosszentren) and middle-sized cities (MT2, Mittelzentren) as well as municipalities with industrial-tertiary working populations (MT17) and municipalities with agrarian (MT21) and agrarian-tertiary working populations (MT20) (Gemeinden mit industriell-tertiärer Erwerbsbevölkerung, mit agrarischer und agrar-tertiärer Erwerbsbevölkerung) and municipalities with a higher than average proportion of homes and sanatoriums (MT8, Heim- und Anstaltsgemeinden) and municipalities with a marked decline in population (MT21, Gemeinden mit starkem Bevölkerungsrückgang) tend to have a higher number of people who perceive their health-related well-being to be poorer than in other municipality types (Fig. 1). Periurban municipalities of large (MT11) and small (MT14) centres (periurbane Gemeinden grosszentraler und nicht-grosszentraler Regionen) as well as touristic (MT6) and semi-touristic (MT7) municipalities (touristische und semitouristische Gemeinden) are associated with a very good health-related well-being.
Fig. 1 : Municipality types, education, socio-professional categories, age, sex and health-related well-being (Keller-Lengen, in progress)
However, the eigenvalue of total inertia is low and there are not so many variations in the data. If we consider socio-demographic factors such as age, sex, education and socio-professional categories, the simple correspondence analysis shows the following results :
The first axis explains 90 percent of the total inertia. With two percent there is a slightly increased variation in the data. The first eigenvalue is = 0.0197.
By projecting the column and row variables on to the first axis it can be seen that on the left side, profiles of young men and women, profiles of well educated people in a higher socio-professional status are associated with profiles of very good health-related well-being. On the right side of the first axis, profiles of old men and women, profiles of low educated people in a lower socio-professional status are associated with profiles of poor and very poor health-related well-being.
Multivariate correspondence analysis shows an association between age and health-related well-being, but a very weak association between health-related well-being and municipality types. Only inertia of the profile “municipalities with a higher than average proportion of homes and sanatoriums” and inertia of the profile “municipalities with a marked decline in population” is higher, but their masses are very low, because the sample sizes in these types are too small.
Wilkinson (1996) shows that in developed countries health and income are very closely related, but the differences in income and health between developed countries are only very weakly related. Wilkinson asks, “why is life expectancy higher in countries like Greece, Japan, Iceland and Italy than it is in richer countries like the United States or Germany ?” There is increasing evidence that certain characteristics of the area of residence may play a significant role in mediating these individual level relationships (Macintyre 1996, Mitchell et al. 2000). Kawachi (1997) and Lochner et al. (2000) demonstrated the importance of trust and interaction with the community for maintaining high chances of good health. We originally assumed that the association between areas of different Swiss municipality typology, especially municipality types with a strong socio-economic and centre-periphery impact, and health-related well-being was much stronger than the results demonstrate. There are more reasons for our negative findings. On the one hand, it is possible that health-related well-being should not be compared with life expectancy and mortality. Then the results of Sundquist & Johansson (1997) are to be discussed. On the other hand, municipality typologies are very complex, since they were constructed on the basis of many socio-economic and socio-demographic indicators from the Swiss census data 1980, and they also considered centre-periphery aspects. In conclusion, it is to assume that this municipality typology is not perfectly suitable to characterise healthy or unhealthy areas in Switzerland.
In the next step of the project, the concepts of weltanschauung (socio-political world views) by Hermann and Leuthold (2001), and of social capital by Bourdieu (1983), Coleman (1988) and Putnam (1993), are used to derive contiguous and non-contiguous (geographical) typologies and environments, in order to identify individual and contextual risk factors (e.g. regional effects) for health and well-being. The concept of weltanschauung was developed on the basis of factor analysis from referendum voting data. Three axes of conflict (liberal/conservative, left/right, ecological/technocratic) were established. Based on these analyses, mental, cultural and social differences were represented cartographically as spatial distances and also interpreted as socio-geographical milieux.
Social capital is understood as a measure of interpersonal confidence and norms concerning mutual assistance and feeling response (Coleman 1988, Putnam 1993). The term sense of coherence coined by Antonowsky will also be taken into account with respect to social capital. In this case, we attempt to transfer the concept of sense of coherence from an individual to a regional sphere, which can give the individual a regionally toned feeling of solidarity (according to Antonowsky, 1997). Health has to be comprehended on a more objective level. For each person polled, a health status report is provided, which can then be used as a relatively objective variable.
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