Health in Hard Times Austerity and Health Inequalities Edited by Clare Bambra First published in Great Britain in 2019 by Policy Press North America office: University of Bristol Policy Press 1-9 Old Park Hill c/o The University of Chicago Press Bristol 1427 East 60th Street BS2 8BB Chicago, IL 60637, USA UK t: +1 773 702 7700 t: +44 (0)117 954 5940 f: +1 773-702-9756 [email protected] [email protected] www.policypress.co.uk www.press.uchicago.edu © Policy Press 2019 The digital PDF version of this title is available Open Access and distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 license (http://creativecommons. org/licenses/by-nc/4.0/) which permits adaptation, alteration, reproduction and distribution for non-commercial use, without further permission provided the original work is attributed. The derivative works do not need to be licensed on the same terms. 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Cover design by Hayes Design Front cover image: ‘Industrial landscape’, © Connor Guy 2019 Printed and bound in Great Britain by CPI Group (UK) Ltd, Croydon, CR0 4YY Policy Press uses environmentally responsible print partners Contents List of tables, figures and boxes iv About the authors vii Acknowledgements xi Foreword by Jamie Pearce xiii Preface xvii one Introduction: Local Health Inequalities in an 1 Age of Austerity Clare Bambra two Austerity Then and Now 35 Mike Langthorne three Placing Health in Austerity 77 Ramjee Bhandari four How the Other Half Live 109 Kayleigh Garthwaite five Divided Lives 141 Kate Mattheys six Minding the Gap 171 Nasima Akhter, Kate Mattheys, Jon Warren and Adetayo Kasim seven Mothers in Austerity 201 Amy Greer Murphy eight Conclusion: Health in Hard Times 233 Clare Bambra Index 255 iii List of tables, figures and boxes Tables 1.1 Welfare reform in the UK, 2010–15 14 2.1 Unemployment Benefit before and after the cuts 39 3.1 Total number of survey participants before and after data 85 cleaning 3.2 Sociodemographic characteristics of the baseline sample 87 3.3 Characteristics of the baseline sample: compositional 88 characteristics 3.4 Characteristics of the baseline sample: contextual factors 89 3.5 Trend of health inequalities in Stockton-on-Tees: 90 estimates of fixed effects 3.6 Association between health outcome measures and the 92 explanatory variables (shaded blocks indicate the presence of significant association) 3.7 Relative contribution of different categories standardised 94 to the total explained percentage of the full model for the gap in general and physical health measures 6.1 Summary statistics (mean, standard deviation or %, n/N) 183 for outcome and demographic indicators for least and most deprived areas in Stockton-on-Tees across waves 6.2 Summary statistics (%, n/N and median) for material 184 socioeconomic indicators across waves for most deprived and least deprived areas of Stockton-on-Tees 6.3 Summary statistics (%, n/N) for material physical 185 environmental indicators among households from most deprived and least deprived areas in Stockton-on-Tees across waves 6.4 Profile of psychosocial indicators (%, n/N or mean, 186 standard deviation) for households in most and least deprived areas of Stockton-on-Tees across waves 6.5 Summary statistics for behavioural factors 187 (%, n/mean, SD) among most and least deprived areas of Stockton-on-Tees 6.6 Percentage contribution of direct and indirect effects 188 SF8-MCS and WEMWBS iv List of tables, figures and boxes Figures 1.1 Map of per-head welfare reductions for local authorities, 16 England, 2010–15 1.2 Map of per-head reductions in local authority budgets, 17 England, 2010–15 1.3 Location of Stockton-on-Tees 22 2.1 UK unemployment 1929–39, yearly average 38 2.2 Unemployment in Stockton, 1929–38 40 2.3 Constables Yard, Stockton, circa 1925 42 2.4 1930s Stockton – approximate locations of old housing 43 (King Street; Queen Street; Bay Street) and new housing (Manor House Terrace; Brisbane Grove) 2.5 Overcrowding by ward, private housing only, 1935 47 2.6 Stockton, 1936 – slum clearance areas; doctors; 49 midwives; health care facilities 2.7 Overall death rate, 1929–39 (per 1,000 population) 54 2.8 Infant mortality rate, 1929–38 (per 1,000 births) 55 2.9 Overall death rate by ward, 1936 56 2.10 Infant mortality by ward, 1935 56 2.11 Combined infant mortality and stillbirth rates, 1935 57 2.12 Stockton 1930s – ‘slum’ wards (circled area) 60 2.13 Stockton-on-Tees, 2015, with 1930s ‘slum’ areas circled 61 2.14 Unemployment in Stockton, 2008–17 62 3.1 Sampling strategy for the survey 84 3.2 Trend of estimated inequality gap in EQ5D-VAS and 91 SF8PCS scores between most and least deprived areas with 95% confidence interval 3.3 Understanding geographical inequalities in health 94 6.1 Maps of Stockton-on-Tees including most and least 178 deprived survey neighbourhoods 6.2 Sampling strategy for the survey 179 6.3 Mean Warwick Edinburgh Mental Wellbeing Score 188 (WEMWBS) and SF8 Mental Component Summary (SF8MCS) for study participants in most and least deprived areas across waves 6.4 Longitudinal analysis of association between psychosocial 189 factors and mental health outcomes, estimates from multilevel models 6.5 Unemployment prevalence in Stockton-on-Tees 2004–17 192 in comparison to North East England and Britain 7.1 Home baking from women’s group 207 v Health in Hard Times 7.2 Row of terraced housing in Town Centre ward 221 7.3 Town centre on market day 224 Boxes 6.1 Mental health 173 vi About the authors Nasima Akhter is Assistant Professor (Research) in the Wolfson Research Institute for Health and Wellbeing and the Department of Anthropology, Durham University. She has a PhD in child health from University College London. Her research focuses on health inequalities, particularly in terms of ethnicity and nutrition in the UK and in the global south (particularly Bangladesh). She has over 15 years’ experience in evaluation, monitoring and data analysis. She works across many projects in applied health research, including evaluation of interventions and advanced data analysis. Clare Bambra is Professor of Public Health at the Institute of Health and Society, Newcastle University. Her research focuses on understanding and reducing health inequalities. She has published extensively including Work, Worklessness and the Political Economy of Health (Oxford University Press, 2011), How Politics Makes Us Sick: Neoliberal Epidemics (Palgrave, 2015), Health Inequalities: Critical Perspectives (Oxford University Press, 2016) and Health Divides: Where You Live Can Kill You (Policy Press, 2016). She was previously Executive Director of the Wolfson Research Institute for Health and Wellbeing, Durham University. Ramjee Bhandari is a Postdoctoral Research Fellow in the GCRF Centre for Sustainable, Healthy and Learning Cities and Neighbourhoods at University of Glasgow. His research examines the relationship between health and place in the UK and in the global south. He holds an MA and PhD in geography (Durham University) and a Master in public health (Tribhuvan University, Nepal). He was previously a Postgraduate Fellow of the Wolfson Research Institute for Health and Wellbeing, Durham University. Kayleigh Garthwaite is a Birmingham Fellow in the Department of Social Policy, Sociology and Criminology, University of Birmingham. She has a PhD in human geography from Durham University. Her research interests focus on poverty and inequality, foodbank use and welfare reform, with a particular focus on stigma. She has published extensively in these fields includingHunger Pains: Life inside Foodbank Britain (Policy Press, 2016). She was previously a Research Associate in the Institute of Health and Society, Newcastle University, and a vii Health in Hard Times Fellow of the Wolfson Research Institute for Health and Wellbeing, Durham University. Amy Greer Murphy is an independent researcher in Ireland. She has a PhD from the Department of Geography and School of Applied Social Sciences, Durham University. Her research focuses on qualitative methods, formal and informal care, health inequalities and gender equity. She was previously a Postgraduate Fellow at the Wolfson Research Institute for Health and Wellbeing, Durham University. Adetayo Kasim is Associate Professor (Research) in the Wolfson Research Institute for Health and Wellbeing, Durham University. He holds a Master’s degree and PhD in biostatistics from Hasselt University, Belgium. He leads statistical input into large educational evaluations, epidemiological surveys and clinical trials. His research interests include generalised linear models, longitudinal data analysis and Bayesian modelling framework. He has published extensively on the development of statistical methods including Applied Biclustering Methods for Big and High-Dimensional Data Using R (CRC Press, 2016).