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Geography 2430A/B
Michael Buzzelli

Lecture Notes 17/10/2012 00:37:00 ← LECTURE 1 ← Sir Richard Wilinson • Rungs on a ladder of SES & health • Life expectancy higher, when income per capita is higher o Higher now from better housing, exposure, health system, etc. • Health is a response to SES ← ← Melinda Meade – one of the founders of health geo. In its current form ← ← LECTURE 2 ← ← Themes of Health Geo: • Health & disease o Geographical variations in health/disease & causes of variations o Health care provision & utilization o Human Health & disease and health care (according to Curtis & Taket) ← ← Development of Health Geo. ← Traditional (both quantitative – uses info systems & stats to analyze) • 1) Spatial patterns of disease and death o relevance of space & place in understanding variationsin health, disease, death o western/biomedical model o limited by data availability/crude maps o still provided insights, w/ reference to connection b/w enviro & health (disease ecology) o ie. Cholera – John Snow  examined individuals w/ symptoms like Cholera  well pump was to blame?  Individual-level and areal data o Augustus Peterman argued stats best displaed in maps (pinpoints cause of death on a map) o Ie. Schizophrenia – areal study comparing rates of Schiz. Among neighbourhoods of the city o Ecological fallacy-caution o Disease diffusion – causes disease to spread over time  Ie. AIDS • 2) Spatial patterns of health service delivery/use o access to and use of H.C. services o emphasis on geo of health service networks & utilization o key issue = accessibility, following quantitative approach (travel time, costs, distance, catchment areas) o 3 main components:  1) structure and spatial patterning of health service facilities (hospitals, clinics) w/ diff scales  2) Patterns of inequality in supply and use of services, state of affairs and how this deviates from some norm/optimum  3) Patient utilization of health services, factors influencing this (ie. How people decide to use services) o Criticisms:  1) Notions of (ill) health taken as given; little said about meanings  2) Ideas about access determined by researchers (ie. What is optimum?)  3) Variables are limited and narrowly defined  certain aspects can’t be measured directly/modeled  4) Models/numbers can present policy-makers w/ simple solutions and they often uncritically accept, but sometimes misguided (stats are shown, but reason is not understood) ← Current (qualitative – interviews, participant observation) • 3) Humanistic. Awareness, perception agency. o Interested in what people believe/think about H.C. o Mainly studies individuals  Ethnography  In-depth interviews  Field observation o Researchers can understand people’s experiences with perceptions of health, ill-health, behavior vis a vis (counterpart) H.C. system o Scarpaci study of H.C. access in Chile  Patients’ assessment of access had no assoc. w/ actual waiting times o Driedger interviewed someone who changed doctors and described new one as only asking questions and not touching • 4) Structuralism/materialist/critical o role of broader social structure in affecting health o focus on social causes of differences in health/H.C. among individuals and/or groups o material conditions that underlie inequality o not enough to say ill health/H.C. access is caused by particular disease/condition  environment, work, housing, malnutrition, education  higher income = longer life o idea of special aetiology(cause of disease)/causation o seeing alcohol as public health problem  treating consumption as function of SES, identity, alcohol outlets, alcohol adverts, etc.  consequences of consumption lead to cost  medicalization of it requiring level of social regulation/discipline  Dorn argues all these studies are flawed b/c people are all essentially the same  Instead wants to know why consumption takes place in diff contexts (ie. Poor teens)  Talks to teachers, hangs out in pubs, studies economy  Teens leave school and drink to express independence and equality (rounds of shots for women)  Can’t understand problem, cannot treat it  Materialist model • 5) (Cultural) pluralism o meaning of health/h.c. in diff cultures o humanism usually is individualistic, but this is on broader systems of meanings o ie. Therapeutic landscapes (how life is negotiated through places/spaces) o Gesler writes that humans have a need for physical, mental and spiritual healing (ie. Romans created warm public bath) ← Not competitive, but complementary ← ← Fundamental concepts in Health Geo. • Distance b/w locations o Euclidean distance –measured on surface • Scale o Core of geo. o Golden rule of geo. o Small scale = large area = small detail (Map of Ontario) o Large scale – small area = large detail (Map of London) • Aggregation (combining into districts) o Ie. Postcode areas, enumeration districts, police zones, etc. • Modifiable Areal Unit Problem (MAUP) o Relationships b/w variables change w/ selection of different areal units, reliability is questioned o Statistical bias that can affect results of statistical hypothesis tests o Resulting summary values (totals, rates, proportions) are influenced by choice of district boundaries o Problem detected by Openshaw  Must be measured at a single point and contained w/ boundary to be meaningful  2 effects:  Scale effect – variation in numerical results due to # of zones in analysis  Zonation effect – variation in numerical results arising from grouping of small areas into larger units o Small areal units = unreliable rates bcuz pop. Used to calculate rate is smaller o Large areal units = more stable rates, but mask meaningful geographic variation in small units ← ← Theoretical approaches in health geography • 1) Logical positivism o quantitative point of view o sought statistical regularities, generalization, what’s measurable and repeatable o not concerned w/ place, but disease rates o analyzes the measurable beginning w/ a map o eg of disease diffusion or ecology  hierarchial diffusion  contagious diffusion • 2) Social Interactionist o in reaction to positivist o give voice to research subjects o sometimes humanist (address human beliefs, values, meanings & intentons) or social constructionist o lay views and perceptions of the world o Qualitative (Participatory, interviews, etc.) o Explains instead of describing o Fewer subjects • 3) Conflict theory o Structuralism or political economy o From Marxist theory on oppression, domination and class conflict o Not individual unhealthy behaviours but socioeconomic patterning that conditions social relations, including health & h.c. o Directly opposed to social interactionism, not human agency but structure  Inequalities in society  Focus on cure, not preventative treatment  Looks at political & environmental patterns o Lower SES means individual/group is less healthy or has less access to health care o Forms of conflict:  Patriarchy  Colonialism  Racism  Institutionalized inequalities • 4) Structuationism o Structure and agency o Time geography – one way of looking at structure and agency o Combines social and conflict theory • 5) Post-structuralism o “Post” signifies  Dissatisfaction w/ monolithic structuralism  Particular focus on power including way it is reproduced in language and social relations o Distribution of power defines health o “Hegemonic” discourse = power differential ← ← LECTURE 3 ← Epidemiology • Ethics of research on human subjects • Epidemiologic study designs o Observational  Exposure (status) not under control of investigator  Study subjects have other characteristics that help differentiate them  Ie. Group study has people who have asthma and those who don’t  Descriptive • Characterize health status by person, place or time • Surveillance • Clinical studies (case report) • Classical epidemiology (non-clinical)  Analytical • Exposure and outcome (dose-response) o Ecological  Exploratory  Group comparisons  Time trends  Mixed studies o Cross-sectional  Assess exposure status and outcome at roughly same period in time and assess outcome  Can test hypotheses but weak interpretation o Case-control o Cohorts  Follow-up can take a long time  Track subjects over time o Hybrid studies o Experimental  RCT  Total control over study subjects • Selection of sample, random assignment to cases and controls and test for outcomes  Community interventions  Not completely controlled and therefore ‘quasi- experimental’  Same general procedure • Individual vs. Individual = Individual risk factor epidemiology Chapter 3: Method and Technique in the Geography of Health ← Mapping the Geography of Health: Quantitative Approach ← Quantitative spatial data analysis involves 1 or more of 3 tasks: ← 1) Visualization – mapping data to spot spatial patterning, or evidence associated w
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