Linking social exclusion and health: explorations in contrasting neighbourhoods in Hamilton, Ontario.

Wilson, Kathi ; Eyles, John ; Elliott, Susan 等

Abstract

While a substantial body of literature in the UK focuses on social exclusion, attention to this complex relationship is gaining some momentum in the Canadian context. "[his paper contributes to this growing area of research by examining differences in social exclusion and its impact on health between two adjacent but socially contrasting neighbourhoods in Hamilton, Ontario Canada. Data for the study were collected through a cross-sectional household survey, which contained questions on attitudes towards the neighbourhoods in which people live, social and community networks, health status, as well as socioeconomic and demographic characteristics. In addition, in-depth interviews were conducted with residents living in both neighbourhoods. The results reveal differences in both the characteristics and level of social exclusion between the neighbourhoods. The interviews also suggest that local-level social inclusion/exclusion may have an effect on health. The findings suggest the need for more policy and research attention directed towards social exclusion at local levels.

Keywords: social exclusion, neighbourhoods, mixed methods

Resume

Tandis qu'un corps substantiel de la litterature aux Etats-Unis se concentre sur l'exclusion sociale au local-niveau (c.-a-d.,voisinages), l'attention a ce rapport complexe s'accelere certain dans le contexte canadien. Cet article contribue a ce domaine de recherche croissant en examinant l'exclusion sociale dans deux voisinages urbains a Hamilton, Ontario Canada. Des donnees pour l'etude ont ete rassemblees par une enquete de voisinage, qui a contenu des questions sur des attitudes envers les voisinages dans lesquels les gens vivent, les reseaux sociaux et de la communaute, etat de sante, comportements de sante, exposition environnementale, aussi bien que des caracteristiques socio-economiques et demographiques. En outre, des entrevues detaillees ont ete conduites dans les deux voisinages. Les resultats indiquent la complexite des les deux exclusion sociale et les liens entre l'exclusion et les voisinages. Les entrevues suggerent egalement que le voisinageniveau inclusion/exclusion social puisse avoir un effet sur la sante. Les resultats suggerent le besoin de politiques de niveau locales qui adressent l'exclusion sociale dans les voisinages.

Mots cles: exclusion sociale, quartiers, methodes mixtes

Introduction

Policies and programs related to social exclusion, while relatively recent in Canada, have a lengthier history elsewhere. Contemporary use of the term social exclusion was first employed in policy debates in France during the 1970s, amid growing concerns that certain segments of society were 'excluded' from the welfare state (Guildford 2000). In Canada more attention has perhaps been focused on social cohesion as the way to lessen the impacts of social exclusion by building a more socially inclusive society (Beauvais and Jenson 2002; Jenson 1998). It is increasingly recognized that social inclusion/exclusion represents an important social determinant of health (Galabuzi 2002; Raphael 2001). Yet, there have been few empirical investigations of this determinant within the Canadian context. Thus the purpose of this paper is to examine social exclusion and health at the local level in an industrial city in Canada. In the following section we provide an overview of the development of 'social exclusion' in policy terms and discuss its importance as a determinant of health. The third section describes the geographic setting for the research and the use of mixed-methods (i.e., quantitative household survey and qualitative in-depth interviews) for data collection. In the fourth section we present the results. This is followed by the discussion and conclusion, which provide commentary on the research findings, directions for further research and the relevance of social exclusion within the context of local level policy development.

Background

While initially grounded in issues related to income, poverty, and unemployment, since the 1970s the concept of social exclusion has been adopted and expanded to include social and political participation. The increased usage and popularity of the term social exclusion are attributed to dissatisfaction with the narrow focus of such concepts as poverty, deprivation and material welfare (Littlewood and Herkhammer 1999). While social exclusion is related to poverty and unemployment, Atkinson (1998, p.v) cautions against equating these terms: "People may be poor without being socially excluded; and others may be socially excluded without being poor." Atkinson asserts that people are excluded not only because they lack income or employment. In fact, social exclusion focuses on the processes that prevent individuals from participating in economic, social, and political dimensions of society. Of course social exclusion is related to other attempts to understand the nature of social divisions, inequalities, deprivation and the consequences for social life and the enjoyment of material and social resources. It has long been recognized that rewards and resources are systematically and unequally distributed within and between societies (see Bendix and Lipset 1966). Interest in the patterning (e.g., do all inequalities cohere?) and consequences (e.g., what effects on daily living?) have led to the almost continuous refinement of these ideas. Thus, these inequalities are not merely economic (i.e., they are more than poverty--see Sen 1982) and they involve perceptions of the difference between what one group has compared with another as well as the actual distribution of goods and services.

Davies (1962) and Runciman (1966) write of the importance of relative deprivation in understanding the responses towards and consequences of inequality and poverty. But it is perhaps in the work of Townsend (1979) that the idea of relative deprivation for conceptualizing low income and poverty as more than a lack of money came to the fore: for him poverty involved people lacking the capacity to obtain the type of resources, participate in the activities and have the living conditions and amenities that are customary or at least widely enjoyed and/or available in the society to which they belong. Since Townsend, there has been serious attention paid to 'activities and conditions' (see Wilkinson 1996), especially with respect to social relations and capital, and participation in society in general (see Wilkinson 1999). Thus a complex of issues has been identified that try to assist understanding of comparative or relative social status and its consequences for action and well-being that includes but is not limited to income inequalities (see Hou and Myles 2004). Furthermore, following Harvey (1973) and Townsend (1979) the local level is seen as key with recent investigation in a variety of Canadian cities (Chappell and Funk 2004; Roos et al., 2004; Wilson et al., 2004) attesting to this. Social exclusion/inclusion may thus be seen as an attempt to bring these issues into conceptual coherence.

Social exclusion has been defined as "a shorthand term for what can happen when people or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime, bad health and family breakdown" (Social Exclusion Unir 2001, p. 11) and "the problem field determined by the link between low income position, bad labour market position and disadvantages concerning non-monetary aspects of life" (Eurostat 2000, p.33). Glennerster et al. (1999, p. 10) define social exclusion as the "exclusion of individuals and groups from the mainstream activities of society" and similarly, Burchardt et al. (2002a, p.31) argue that "an individual is socially excluded if he or she does not participate in key activities of the society in which he or she lives". In fact, it is in the notion of lack of participation that the differences between exclusion and other similar concepts may be seen. Social capital, for example, "refers to the institutions, relationships, and the norms that shape the quality and quantity of a society's social interactions" (World Bank 2002). Social cohesion is seen as comprising a sense of belonging (Council of Europe 1999) and the process by which a community of shared values is created for a society based on "trust, hope and reciprocity" (Jeannotte 2000). Social capital and social cohesion are therefore seen as general social processes aimed at developing a strong community. On the other hand, social exclusion emphasizes the resources and networks individuals and groups require for full participation in society. The existence of social exclusion is then a threat to both social cohesion (see Jeannotte 2000) and social capital (World Bank 2002).

Many Governments have used social exclusion to tackle the links between social, political, and economic deprivation and the impact such multiple deprivation has on individuals and communities. Based on a growing body of research about the British 'underclass' (see Burchardt et al., 1998; Murray 1990; Room 1995), Prime Minister Tony Blair created in 1997 the UK Social Exclusion Unit (SEU) the goals of which are to coordinare policy-making to prevent social exclusion, reintegrate those who are excluded, and provide basic minimum standards of living for everyone (SEU 2001). In the UK there are area-based programs to address social exclusion while many other governments are also establishing national strategies in France, the Netherlands, and Denmark. There now exists a European Union agreement to combat social exclusion (European Council 2001; Sweden 2001). These strategies are also seen as important because social exclusion has enormous costs to individuals, society and the economy.

At an individual level social exclusion is associated with poor access to services, stress, low social status and poor health. It has been linked to cardiovascular disease (see Duffy 1998), respiratory illnesses, and mental illnesses, such as, suicide and psychiatric disorders (see Stansfeld 1999; Whitley et al., 1999). Santana's (2002) research on social exclusion in Portugal demonstrates that disadvantaged people (e.g., single mothers, long-term unemployed, migrants, ex-prisoners, drug addicts and alcoholics) are at greater risk of adverse health status (musuloskeletal diseases, mental illness, respiratory illness, injuries) as compared to nondisadvantaged individuals. Research has also found that a lack of social inclusion is associated with reductions in healthy lifestyles (Seeman 1996), increased mortality in males (Eng et al., 2002), and increased risk of coronary heart disease (Raphael 2001).

Within Canada, research on the links between social exclusion and health is gaining momentum. Health Canada, in partnership with the Population and Public Health Branches of Ontario and Nunavut, is leading a series of projects to explore health, social and economic exclusion (Health Canada 2002; SEII 2003). Similarly, the Atlantic Region Population and Public Health Branch have initiated policies aimed at promoting social and economic inclusion (Colman 2000). The Social Support Research Program (University of Alberta), including researchers from the University of Alberta, University of Toronto and UBC, is conducting research that compares exclusion between low-income and middle-income individuals in Edmonton and Toronto (SSRP 2003). Furthermore, Raphael's (2001) recent review of heart disease and socioeconomic status reveals that social exclusion may be the medium through which low income is linked to cardiovascular disease in Canadians. Social inclusion/exclusion has in fact been identified by both Health Canada and Canadian researchers as an important social determinant of health (Galabuzi and Labonte 2002; Raphael 2004). Building on the policy salience of these linkages this paper contributes by examining social exclusion and its implications for health at the local level. The local level is seen as being vital with respect to social networks, common values, and social identity in the development of social cohesion and the reduction of social exclusion (Kearns and Forrest 2000). Furthermore, Haan et al. (1987) suggest, the local environments in which people live may be important for shaping health above and beyond material deprivation. Forrest and Kearns (2001) note that most research focuses only on materially deprived neighbourhoods and therefore little is known about the links between social exclusion and health in nondisadvantaged neighbourhoods. Our research begins to fill this gap by identifying some of the differences in social exclusion and its impact on health between deprived and nondeprived neighbourhoods. We use a comparative neighbourhood study to address how the characteristics of social exclusion vary within one city. This is achieved by exploring two adjacent but socially contrasting areas in Hamilton, Ontario Canada.

Data and Methods

The setting for the research is Hamilton where data for a quality of life study was collected through a cross-sectional household survey, which was administered in four areas of the city, and asks questions about health, social networks and participation in clubs and societies, and access to and use of local resources as well as sociodemographic and economic characteristics. From the mid-nineteenth century, Hamilton has been known as an industrial city, becoming and remaining Canada's centre for steel manufacture. It has many associated industries, such as metal fabrication and petro-chemicals which have attracted diverse migrant streams, Italians in the 1910s to the Vietnamese and East Europeans of today. As a regional centre, it has important educational and health care functions which in employment terms now surpass manufacturing (see Weaver 1982; Bekkering and Eyles 1998).

For this paper, we concentrate on one local area--the most diverse identified in the quality of life study (see Luginaah et al., 2002; Wilson et al., 2004 for details on the others). This area, Chedoke-Kirkendall, appeared on initial analyses to contain two distinct sub-areas--a north and south neighbourhood--differentiated by social and population characteristics. Data from the Census of Canada reveals that the population in North Chedoke-Kirkendall is characterized by lower levels of education, income and higher levels of unemployment as well a higher percentage of the population rents their dwelling (see Table 1). While both neighbourhoods contain a similar percentage of immigrant populations, there are more members of the population from visible minority groups in the north neighbourhood. A street-by-street inventory of neighbourhood characteristics was conducted in the two neighbourhoods. The infrastructure in each neighbourhood was identified (e.g., fast food restaurant, sit down restaurant, alcohol retailer, park, recreation centre, doctor's office) and a total count was tallied for each neighbourhood. The results reveal slightly higher food stores and restaurants in the north neighbourhood but more cultural (e.g., ethnic clubs, theatres), religious (e.g., churches, meeting halls) and health services (e.g., pharmacies, dental and doctor offices, walk-in clinics) in the south neighbourhood. Both have similar numbers of abandoned buildings and vacant lots. Finally, while the south neighbourhood abuts the Niagara Escarpment with access to walking trails the north neighbourhood has more parks and recreation centres. Thus in close proximity there appears to be two areas that might exhibit different types of social exclusion/inclusion. To explore this, our research was carried out in two stages.

In the first stage, we analysed the household survey data by exploring differences in neighbourhood perceptions, social and community networks, as well as other measures of exclusion/inclusion between the two areas. The telephone survey was administered to a random sample of approximately 300 selected individuals in Chedoke-Kirkendall (see Luginaah et al., 2002). Of the 300 survey participants in Chedoke-Kirkendall, 196 reside in the south area and 104 live in the north. The survey was completed by individuals aged 18 years and older and has an overall response rate of 60 percent.

In the second stage of the research, 40 in-depth interviews were conducted with 10 men and 10 women in the north and south sub-areas of the Chedoke-Kirkendall neighbourhood. Participants were selected randomly from the pool of individuals who completed the neighbourhood survey. The average age of interview respondents was the same (48 years) in both neighbourhoods and only 6 individuals in each neighbourhood have resided in their neighbourhood for less than 5 years. The purpose of the interviews was to examine residents' participation in formal and informal neighbourhood events/activities, connections with neighbours, as well as perceptions of their neighbourhood.

We analyze both the survey and interview data by drawing upon the framework of social exclusion proposed by Burchardt et al. (2002). They argue that social exclusion occurs when individuals do not participate in key societal activities. They outline four main activities from which individuals may be excluded: Consumption--the ability to purchase goods and services; Production-linked to involvement in social and economic activities; Political Engagement-involvement in local or national level decision-making; and Social Interaction-involvement with family, friends and the broader community. Since our focus is possible exclusion at the local level, we replace the category of Political Engagement with Neighbourhood Engagement, referring to an individual's participation in formal and informal neighbourhood activities and decision-making processes, as well as their overall satisfaction with their neighbourhood environment.

From the survey we use a total of nineteen variables to represent each of the four dimensions (see Table 2). While we recognize that all elements of exclusion/inclusion are interconnected and that social exclusion thus appears to be quite a nuanced construct, we separate them into consumption/production and neighbourhood engagement/social interaction for ease of interpretation. We report consumption and production together because production at the local level is measured by household income and employment status, and shapes the individual's ability to participate in local economic life whereas consumption is the actual participation in that life. Thus, consumption is measured by such variables as home ownership, use of and access to health care services. We combine neighbourhood engagement and social interaction because much engagement takes the form of social interaction. We measure neighbourhood engagement through perceptions of neighbourhood satisfaction and attachment while social interaction is measured by friendships and social support. We used the data to develop an overall index of local social exclusion. To create the index, each individual was given a score of '1' for each of the 19 aspects measured (e.g., low income, unmet health needs, little or no involvement in organizations, number of friends/relatives less than the median) for a possible total score of nineteen. Theoretically one would not expect someone to be totally excluded from society using these variables. The values for the index range from a minimum of 1 to a maximum of 13, with a mean score of 5.24. In the next section, we present the results of our analysis which combine survey and interview data to demonstrate the existence and characteristics of social exclusion and its impact on health at the local level.

Results

We first present an overall picture of social exclusion (Table 2) and the extent to which it varies between the north and south areas. Scores on the social exclusion index show significant differences between the two neighbourhoods. In the south area the index ranged from 1 to 11 with 26 percent of residents scoring a 3 or lower indicating low levels of social exclusion. In the north area the index ranged from 1 to 13 with only 12 percent of residents having a score of less than 3. Almost 50 percent of residents from the north had a score of 6 or higher (i.e., above the mean) indicating higher levels of social exclusion, as compared to only 36 percent of residents from the south. In addition, eight percent of residents from the north scored 10 or higher on the index as compared to only 2 percent of residents from the south. Thus residents in the north seem to be experiencing more aspects of social exclusion and they are also experiencing higher levels of social exclusion than those in the south. In the following sections we examine these results in the context of the interview data which provide a richer, more nuanced account of exclusion in these areas including the multiple and interconnected ways in which social exclusion and its impacts on health are manifested at the local level. These data will also demonstrate that the local level is indeed relevant in shaping social exclusion.

Consumption and Production

Differences in production and consumption activities are quite evident between the two neighbourhoods (see Table 2). Approximately twice as many residents in the north have a household income that is below $30,000 (Statistics Canada Low-Income Cut-Off (LICO)), a higher percentage are unemployed, and a lower percentage own their own home as compared to residents in the south. A higher percentage of residents in the north report that they worry every month about being able to pay their bills and that they have experienced times when they did not have enough food to eat due to a lack of money. In terms of health care use and access few respondents in both neighbourhoods report that they do not have a regular family doctor. However, almost 20 percent of individuals in the north have seen or talked to their doctor in the past two weeks as compared to only 12 percent of those in south. Interestingly, twice as many respondents in the north than in the south neighbourhood report that they did not receive health care when they needed it. In addition, a slightly higher percentage of respondents in the north neighbourhood report that they lack insurance coverage for prescription medication, dental expenses, and charges for a private or semi-private hospital room as compared with individuals in the south.

In general, interview respondents from the north neighbourhood have lower rates of home ownership and education and higher rates of unemployment. The north neighbourhood also contains a lower quality housing stock. Some individuals mentioned that while they do not like living in their neighbourhood they are forced to because of the inexpensive price of housing:

"... the house is incredibly cheap ... really run down. It was a power of sale in December and I just got it for dirt cheap. It needs tons of work ... I don't make enough money to save money, bur the house is basically my savings." (Dan) (1)

Since he has invested all of his savings into his home, Dan finds it very difficult to socialize in his neighbourhood at local restaurants and pubs:

"I am a little short of money ... I have only been in town for a year. I moved to town and lost my job instantly. I have had not the money to actually find a local hangout.... Right now, it's the cash thing ... I actually don't have the money ... it is $20 a week to do it (martial arts). I don't have the cash flow."

Many other respondents indicated a strong desire to move from the north neighbourhood but remain due to financial constraints:

"I want a place that is mine. What I can afford in the city, is not worth buying because they are in areas I will not live in or a dinky little house that isn't much bigger than my apartment." (Julia)

In contrast, no one in the south stated that they disliked living there. In fact, many decided to move there because of its attractive qualities. For example, Steve has been living in the south for approximately five years. He commutes to Toronto everyday for work and perceives it to be a trade-off for cheaper housing costs and an improvement in the local physical environment:

"... I would have been stuck in a condo in Toronto which is not my thing. I need green space so that's the number one--the trails, the walking, the biking, the green space. The other thing is real estate costs. We do a lot of travelling, and if we were in a condo in downtown Toronto, we couldn't do that. We couldn't afford it. We are able to own a house but at the same rime do a lot of travelling."

Similarly, Arthur has been living in the south neighbourhood for 16 years. He moved to the area because of its good reputation:

"It is a pleasant setting to live. It is a scenic road. It is called the most attractive street in Hamilton. It is not quite rural but it is not quite central city and yet we are very close to the highway, close to downtown, close to anything you want to do. I am a member of the Royal Hamilton Yacht Club and I saddle up to the club and see my sailing buddies and my crew at least twice a week, sometimes more."

In summary, the interviews reveal quite distinct experiences with social exclusion in terms of both production and consumption. A much higher number of residents from the north neighbourhood expressed dissatisfaction with their access to affordable and adequate housing and very few described their neighbourhood as a positive place to live. In the next section, the paper examines residents' engagement both formally and informally within their neighbourhoods.

Neighbourhood Engagement and Social Interaction

Neighbourhood engagement (discussed in terms of attitudes towards the neighbourhood itself and participation in area organizations) and social interaction (i.e., friendships and social support) are interrelated constructs, although the former tends to be more formal (e.g., sports teams, church membership) and the latter more informal (e.g., day-to-day talks with neighbours). The survey data show few differences between the north and south neighbourhoods with respect to number of close friends and relatives (see Table 2). A slightly lower percentage of residents in the south report little or no involvement with groups or voluntary organizations. The data also reveal that residents in both areas are largely satisfied with their neighbourhood but a slightly higher percentage of north residents report dissatisfaction (see Table 2). While a slightly higher percentage of respondents in the south report that they have considered moving in the past 12 months, of those, only 41 percent state that they would move outside their neighbourhood as compared to 50 percent of residents in the north. Similarly, a higher percentage of individuals living in the north report that they do not like anything about their neighbourhood.

With respect to the interview data, individuals in both neighbourhoods were asked about their awareness and involvement in neighbourhood clubs and other formal activities but also more informal activities as well as the factors that prevent them from participating. Even though the street-by-street neighbourhood inventory revealed more opportunities in the north to participate in neighbourhood-level activities (i.e., the existence of parks and recreation centres), in general, more individuals from the south reported that they are involved in various clubs and activities both within and outside their neighbourhood. Individuals from the south are members of a variety of formal organizations including religious, political, cultural, athletic and environmental groups:

"Well this is quite an area. It is called Kirkendall and there is a Kirkendall Association. You get together. They have various activities through the year. There is some fund raisers we have in the park that raise money for ... we bought playground equipment at the Triple-A grounds. You know, there are some activities and we have local soccer in the park. They have put together their own soccer league and I have coached that." (Stacey)

"Well, my involvement in that, I wasn't a member of the Association but I did help with their co-operative recreation dates for the kids. It gave the kids something to do and from April through June, they ran the games. The one year they needed someone to help coach the soccer and I knew the person that was organizing it. So I said yeah, 'I'll give it a try. Put me with somebody who knows what they're doing and I'll give it a try.' It kept me going with the exercise running around chasing after the kids." (Richard)

While not all individuals in the south are involved in formal activities and organizations, few individuals in the north reported any participation in formal neighbourhoods clubs or organizations. Even more interesting is the finding that reasons for lack of participation are very different between the two areas. When asked about the factors that prevent them from participating in neighbourhood activities, respondents in the south cited a lack of time due to work commitments or a lack of interest.

"If I was around more, I would participate more. I would join the running dub." (Peter)

"I basically keep to myself. I'm very involved with my own private life, with my job. That's about it ... I've just gone into my own little world now. We've got some churches that are very active here. I know that just by what's going on any given evening of the week. So if I want to get involved with any of the five churches it's easy for me to get involved with some group there but it doesn't interest me." (Doug)

In contrast, residents from the north most often mentioned financial constraints or health problems as factors that prevent them from joining clubs--thus demonstrating how interconnected the dimensions of social exclusion are:

"There's a few Scout troops around our house. A lot but the price of the Scouting is getting so high. They looked at us last year and it was fifty dollars. It's like, that's fine. It's expensive bur we'll deal with it. Then they said it was ninety bucks September of last year. So it jumped forty bucks. Now they're telling us it's a hundred and five. The kids who are taking it around here ... the parents can't afford it around here. This isn't the richest neighbourhood in the world. So, you're looking at people who have two and three children and they want to put them in ... Scouting for two kids, three kids you're looking at three hundred bucks, just to say 'You can go', not to mention buying their uniform." (Paul)

In addition to financial issues, some residents identified physical mobility limitations and a lack of physical accessibility in their neighbourhood as key contributors to their lack of participation:

"The only thing I noticed around here, anything that, to make anything accessible is not possible here. Everything has stairs in it, all the stores now. There isn't even a hairdresser around here you can go to that doesn't have stairs ... I just get very angry with the fact that I want to do something and I can't get out of this chair to do it." (Judith)

Individuals in both areas interact informally with their neighbours although the degree and type of interactions are quite different between the north and south. Residents in the south interact frequently with their neighbours. Although there are fewer restaurants and coffee shops in the south than in the north neighbourhood, many residents from the south meet for daily walks or at local coffee shops each morning or evening. In addition, some women in the south have organized a book club:

"There's a number of people from the general morning coffee group that I know and any one of them keeps an eye on what's going on in their street or what's happening. If something is going on and you want to know what's happening and you were to come here to Tim Horton's in the morning for coffee, you sit and listen. It's almost like the village market place!" (Richard)

Many residents in the north also indicated that they have friendly interactions with their neighbours. Individuals can rely on one another to keep an eye on their houses while they are away and some will engage spontaneously in conversation but very few indicated that they interact on a regular basis with the neighbours. For example, Dan spends time occasionally with his next door neighbour:

"Me and [neighbour] will have a couple of beers together. He'll come over. For me, that's sort of amazing. You know in Toronto, you could live next door to someone for ten years, and all it would be is "hi". That's it. You don't care where they work. It's like being a good neighbour in Toronto. You have no idea of what they do, or where they work, or anything about them."

In contrast to circumstances in the north, it appears that the regular, often daily, interaction with neighbours has allowed residents in the south to create a sense of community:

"We certainly felt that we were part of the community ... You become part of the school, and then part of that community, part of the church community, and then you start to know other people. That's where we really started to meet people in the neighbourhood ... The women--Moms--that I met the very first year are the ones that I still know and am friends with and actually invited--two of them are in that book club--and there are two that can't. They are friends that I made long ago." (Barbara)

"It (interacting with friends at Tim Horton's) gives us a sense of community. It's not just stuck in the middle of a big city. There's this little community that keeps the pulse on what's going on ... We're very comfortable here. We feel very secure and when you walk down the street, you can say 'Hi, how are you doing?' There's a lot of people in the area that we know. There's a sense of knowing a number of people in this neighbourhood so it feels more like a community." (Richard)

This sense of community appears to allow residents in the south to work together to make changes in their neighbourhood. For example, some residents talk about their involvement in neighbourhood issues ranging from raising money to redevelop a local park to mounting an unsuccessful campaign to prevent a local ski club from closing:

"The city was putting forth money to redevelop the park and something came in the paper saying that they were putting on a presentation about what that might be. The neighbourhood association ... so I thought, well, I'll go because I live across from the park to see what's what.... I ended up becoming the Chair of the fund raiser committee, because I have a hard time saying no. But I have three kids, and it took a long time. They only needed to raise $6,500. It wasn't a huge amount. It was a lot of planning for a short amount of time. So I did that and I did stay on for about a year or so. We raised it pretty quickly, within about six months and got it all together. That's fine. It was a lot of fun." (Barbara)

Very few residents in the north mentioned that they felt a strong sense of community in their neighbourhood. Perhaps this lack of a community feeling leads some to feel like they cannot make positive changes to their neighbourhood although some change may be the responsibility of the municipality. For example, Jim has lived in the area for 9 years but feels that he cannot make a difference when it comes to solving problems in his neighbourhood:

"There are people who come at night and they will rifle through your car to find anything inside it, like open the cigarette ashtray looking for change, under the seats, if it's not locked ... it bothers me a lot, but there doesn't seem to be too much we can do about it except lock stuff up ... we reported it to the police every time, which gets us nothing."

Similar to the survey data, the interview data demonstrate that individuals in the north tend to experience various (most often multiple) dimensions of social exclusion while residents of the south enjoy social inclusion through their ability to consume goods and services, participate in both formal and informal activities and interact with other people in their neighbourhood. It does appear however that differences in social aspects of exclusion (i.e., neighbourhood engagement and social interaction) are less pronounced between both groups of residents than differences in material advantage (i.e., consumption and production). That said, what are the impacts of such exclusion on health?

Impacts on Health

Social exclusion is now recognized as an important social determinant of health (Canada 2003; Galabuzi and Labonte 2002; Raphael 2001). In this section, we explore the how social exclusion shapes health differently between the two areas. In terms of health status, a higher percentage of residents from the north report 1 or more chronic conditions and are overweight (see Table 2). In addition, more residents from the north area rate their health as 'fair or poor' and have higher levels of dissatisfaction with their health as compared to residents from the south area.

In examining the connections between social exclusion and health, some residents in the south discussed the physical health benefits associated with the physical and social environments in their neighbourhood:

"When we actually moved to this neighbourhood, well, of course, my husband graduating and starting his own clinic, and he had high blood pressure. We bought a dog and he walks him on the Bruce Trail. Now he does not need any medication for blood pressure. It is back to normal." (Maryann)

Residents from the south area also talked about the importance of involvement with their neighbours and involvement in the neighbourhood community for emotional and mental well-being:

"I think emotionally because it feels comfortable and safe. There isn't a large amount of stress about worrying about living in this particular neighbourhood." (Richard)

"If you've got lousy neighbours, your mental health is not going to be good." (Doug)

Other residents discussed the importance of socializing with neighbours on a daily basis for emotional and mental health:

"I'd like to think that because it's a nice place to live, one feels more relaxed than anything else. It gives you a good feeling about yourself. Maybe that's conducive to better health. I'm sure we breathe the same air in West Hamilton that we do in East Hamilton or near the Stelco plant or whatever. It may give you the feeling that perhaps you're a little remote from it." (Arthur)

In contrast, very few residents in the north discussed ways in which their health was affected by the lack of involvement, participation and social support or by the characteristics of the neighbourhood itself. Those who did discuss this relationship mainly perceived the physical and social environments in their neighbourhood to have negative effects on their health:

"I want to go somewhere where it is quiet and green. I see houses and houses and streets and noise, construction more than normal. Queen Street is very busy, so you hear traffic all of the time. You hear kids out yelling at three o'clock in the morning--annoying. Just the space of not having houses being three feet between each other, open air, trees. Not that they scare me, but it's like 'Go home. You are disturbing my sleep.'" (Julia)

In general, these results illustrate that those individuals who are involved with their neighbours and the broader neighbourhood community perceive where they live to have a positive impact on their health. In contrast, those individuals who lack these forms of engagement and interaction tend to perceive their neighbourhood to affect their health in a negative way.

Discussion

To date, there are few empirical studies of social exclusion or cohesion in Canada. Jaffe and Quark (2006) have examined the diminution of social cohesion in rural Saskatchewan. Duhaime et al. (2004) investigated social cohesion and living conditions in the Canadian Arctic. This research represents one of the first empirical studies of an industrial city (but see Tallon et al., 2005). Thus, we recognize that this exploratory study in Hamilton awaits confirmation or rejection by others examining in generalizable ways the links between health and social exclusion at the local level.

In summary, this exploratory study shows that the characteristics of social exclusion and its impacts on health vary between north and south Chedoke-Kirkendall. In general, overall levels of social exclusion are higher in the north than the south and residents from the north appear to experience multiple dimensions of exclusion, with respect to neighbourhood engagement and social interaction as well as consumption and production. Further, the neighbourhoods appear quite different with respect to material dimensions of exclusion and less dissimilar with respect to the social dimensions of exclusion. We recognize however that there are some limitations to this study. First, the neighbourhoods are materially different in terms of income, housing tenure and lower socioeconomic status in general. Yet, the interview data does suggest that social exclusion is more than material deprivation. Thus our research confirms that social exclusion involves the interconnection of a lack of economic productivity, consumption of necessary goods and services, neighbourhood engagement and social interaction.

Second, our findings do not permit an assessment of the relative importance of each of the dimensions in contributing to overall levels of social exclusion. Nor can we identify which of the dimensions has greater impact on health in these neighbourhoods.

Finally social exclusion is a complex, nuanced idea that defies the easy creation of a common standard by which it can be measured. If anything, our results suggest that exclusion may or may not involve the combination of any of the four dimensions. For example, there are individuals in the north who do not feel socially excluded and conversely those in the south who do not feel socially included. Further, there are individuals in the north who are economically productive yet do not feel a part of their neighbourhood. In contrast, there are those who are not economically productive, do not have the means to acquire many of life's basic necessities but feel like they are an important part of their neighbourhood. Perhaps then, as Burchardt et al. (2002a) suggest, exclusion/inclusion is part of a continuum, with individuals potentially falling below some threshold level on some items and above on others. As this research demonstrates, Burchardt et al.'s dimensions are useful with some modification at the local level. Production is not normally a local level activity and we have modified it to mean the ability to consume goods and services at the local level. Furthermore, there is little political activity at the neighbourhood level in Canadian cities. We have therefore modified political engagement to capture local-level participation in formal activities such as clubs and associations. Yet, we are convinced that the local level is important for the manifestation of exclusion.

Conclusion

European governments have not only addressed social exclusion but also recognize its devastating effects on their citizens and have implemented policies to minimize the effects. In Canada, the intellectual engagement as a political precursor of policy development appears to be beginning. Furthermore, Raphael (2003) argues that social exclusion is a key social determinant of health yet government policymakers are only beginning to apply existing knowledge of social exclusion to promote the health of Canadians (Canada 2004). We agree with Raphael's (2003) claim and extend it to the local level. If we are to build policies aimed at improving the health of Canadians, then we have to acknowledge the role of local areas in shaping quality of life, including health. In other jurisdictions the importance of local organizational capacity and the potential for individual mobilization have been identified as important mechanisms for improving local social cohesion (Brioschi et al., 2002; Jacobi 2006). In a Canadian context the ability of municipalities to develop such strategies is limited. Working with the provinces however municipalities may be able to target job creation, community development and social infrastructure as ways of reducing and preventing social exclusion.

Economic security, participation in local affairs and feelings of worth in local environments are key elements for a strong, vibrant local democratic society. As Evans and Advokaat (2001) note for the Law Commission of Canada, inclusion and the struggle against exclusion are necessary elements for strong public life and vitality. It is also recognized as an important part of the Canadian social model (Boychuk 2004). Furthermore, the Federation of Canadian Municipalities also notes the importance of an inclusive quality of life for a democratic community: it is recognized as a vital element of their quality of life reports (FCM 2004). But for health in particular, municipalities have few policy levers. They can help develop health service infrastructure and ensure good public health through their healthy lifestyles and healthy child programs (Hamilton 2005) but their ability to address the broad social determinants of health such as social exclusion depends upon the investments of the provincial and federal governments. Such concerted and integrated efforts are necessary to build strong, healthy neighbourhoods for a strong, healthy democracy. Any 'cities agenda' whereby the provincial or federal governments invest more in urban communities is not only about transit and sewers but about citizens and providing the conditions for healthful lives. For cities themselves then social inclusion becomes a key dimension in a sustainable, inclusive and democratic future.

Acknowledgements

This paper gratefully acknowledges the helpful suggestions of two anonymous reviewers. Funding for this research was provided by the Social Sciences and Humanities Research Council of Canada.

References

Atkinson, A.B. 1998. Preface. In Exclusion, Employment and Opportunities, eds. A.B. Atkinson and J. Hills 1998. v-vii. London: Centre for Analysis of Social Exclusion, London School of Economics.

Beauvais, C., and J. Jenson. 2002. Social Cohesion: Updating the State of the Research. Ottawa: Canadian Policy Research Networks.

Bendix, R., and S.M. Lipset. 1966. Class, Status and Power: Social Stratification in Comparative Perspective. New York: Free Press.

Bekkering, M., and J. Eyles. 1998. Making a region sustainable: governments and communities in action in Greater Hamilton. In Sustainable Communities, ed. M. Hoff, 1998, 157-179. Boca Raton: Lewis Publishers.

Boychuk, G. 2004. The Canadian Social Model: The Logics of Policy Development. Ottawa: Canadian Policy Council Network.

Brioschi, F., M.S. Brioschi, and G. Cainelli. 2002. From the industrial district to the district group: An insight into the evolution of local capitalism in Italy. Regional Studies 36(9): 1037-1052.

Burchardt, T., J. Le Grand, and D. Piachaud. 2002a. Degrees of social exclusion: Developing a dynamic, multidimensional measure. In Understanding Social Exclusion, eds. J. Hills, J. Le Grand and D. Piachaud 2002, 30-43. Toronto: Oxford University Press.

Burchardt, T., J. Le Grand, and D. Piachaud. 2002b. Introduction. In Understanding Social Exclusion, eds. J. Hills, J. Le Grand, and D. Piachaud 2002, 1-12. Toronto: Oxford University Press.

Canada. 2004. An Integrated Pan-Canadian Healthy Living Strategy. A Discussion Document for the Healthy Living Symposium June 2003. Toronto: Ontario, Canada. http://www.phac-aspc.gc.ca/hl-vs-strat/(accessed April 5, 2006).

Canada. 2003. Population Health: What Determines Health. Ottawa: Health Canada. http://www.phac-aspc.gc.ca/ph-spphdd/determinants/index.html (accessed April 5, 2006).

Chappell, N., and L. Funk. 2004. Lay perceptions of neighbourhood health. Health and Social Care in the Community 12(3):243-253.

Colman, R. 2000. Women's Health in Atlantic Canada: A Statistical Portrait. Halifax: Genuine Progress Index for Atlantic Canada.

Davies, J. 1962. Towards a theory of revolution. American Sociological Review 27(5):5-19.

Duffy, K. 1998. Final Report: Social Cohesion and Quality of Life. The Human Dignity and Social Exclusion Project. Strasbourg Cedex: Council of Europe.

Duhaime, G., E. Searles, P. Usher, H. Myers, and P. Frechette. 2004. Social cohesion and living conditions in the Canadian Arctic: From theory to measurement. Social Indicators Research 66:295-317.

Eng, P.M., E.B. Rimm, G. Fitzmaurice, and I. Kawachi. 2002. Social ties and change in social ties in relation to subsequent total and cause-specific mortality and coronary heart disease incidence in men. American Journal of Epidemiology 155(8):700-709.

European Council. 2001. Treaty of Nice: Amending the Treaty on European Union, The Treaties Establishing The European Communities and Certain Related Acts (2001/C80/01). Nice: European Union.

Eurostat. 2000. European Social Statistics: Income, Poverty and Social Exclusion. Luxembourg: Eurostat.

Evans, H., and E. Advokaat. 2001. The Language of Communicating in Canada. Ottawa: Law Commission of Canada.

Federation of Canadian Municipalities (FCM). 2004. Quality of Life Report 2004. http://www.fcm.ca/english/qol/reports.html. (Last accessed March 22, 2006).

Forrest, R., and A. Kearns. 2001. Social cohesion, social capital and the neighbourhood. Urban Studies 38 (12): 2125-2143.

Galabuzi, G., and R. Labonte. 2002. Social Inclusion as a Determinant of Health. Ottawa: Health Canada. http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/ overview_implications/03_inclusion_e.pdf (accessed April 5 2007).

Glennerster, H., R. Lupton, P. Noden, and A. Power. 1999. Poverty, Social Exclusion and Neighbourhood: Studying the Area Bases of Social Exclusion. London: Centre for Analysis of Social Exclusion, London School of Economics.

Guildford, J. 2000. Making the Case for Social and Economic Inclusion. Halifax: Atlantic Regional Health Office Population and Public Health Branch, Health Canada.

Haan, N., G.A. Kaplan, and T. Camacho. 1987. Poverty and health: Prospective evidence from the Alameda County study. American Journal of Epidemiology 125:989-998.

Hamilton. 2005. Social and Health Issues Report. City of Hamilton: Public Health and Community Services Department.

Harvey, D. 1973. Social Justice and the City. London: Blackwell.

Health Canada. 2002. Poverty as Social and Economic Exclusion. Ottawa: Population and Public Health Branch, Health Canada. http://www.hc-sc.gc. ca/hppb/regions/atlantic/work/e_c_1.html. (accessed March 5, 2004).

Hou, F., and J. Myles. 2004. Neighbourhood Inequality, Relative Deprivation and Self-perceived Health Status. Ottawa: Statistics Canada.

Jacobi, P. 2006. Public and private responses to social exclusion among youth in Sao Paulo. ANNALS of the American Academy of Political and Social Science. 606(1): 261-230.

Jaffe, J., and A. Quark. 2006. Social cohesion, neoliberalism and the entrepreneurial community in rural Saskatchewan. American Behavioral Scientist 50:206-225.

Jeannotte, S. 2000. Social Cohesion Around the World: An International Comparison of Definitions and Issues. Ottawa: Department of Canadian Heritage, Strategic Research and Analysis Directorate.

Jenson, J. 1998. Mapping Social Cohesion: The State of Canadian Research. Ottawa: Canadian Policy Research Networks.

Kearns, A., and R. Forrest. 2000. Social cohesion and multilevel urban governance. Urban Studies 37(5/6): 995-1017.

Littlewood, P., and S. Herkammer. 1999. Identifying social exclusion: Some problems of meaning. In Social Exclusion in Europe: Problems and Paradigms, ed. P. Littlewood 1999. Aldershot: Ashgate Publishing Ltd.

Luginaah, I., M. Jerrett, S. Elliott, J. Eyles, K. Parizeau, S. Birch, T. Abernathy, G. Veenstra, B. Hutchison, C. Giovis. 2002. Health profiles of Hamilton: Spatial characterisation of neighbourhoods for health investigations. GeoJournal 53:135-147.

Murray, C. 1990. The British underclass. The Public Interest 99:4-28.

Raphael, D. 2004. Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholars Press.

Raphael, D. 2003. Recognizing the Political Barriers to a Healthy Inclusive Society: The Case of the Social Determinants of Health. Paper presented at Social Inclusion Research Conference March 27-28, Ottawa, Ontario.

Raphael, D. 2001. Inequality is Bad for Our Hearts: Why Low Income and Social Exclusion are Major Causes of Heart Disease in Canada. Toronto: North York Heart Health Network.

Room, G. 1995. Beyond the Threshold: The Measurement and Analysis of Social Exclusion. Bristol: The Policy Press.

Roos, L., J. Magoon, S. Gupta, D. Chateau, and P. Veugelers. 2004. Socioeconomic determinants of mortality in two Canadian provinces: Multilevel modelling and neighborhood context. Social Science and Medicine 59 (7): 1435-144.

Runciman, W.G. 1966. Relative Deprivation and Social Justice. London: Routledge.

Santanna, P. 2002. Poverty, social exclusion and health in Portugal. Social Science and Medicine 55(1):33-45.

Seeman, T.E. 1996. Social ties and health: The benefits of social integration. Annals of Epidemiology 6(5):442-451.

Sen, A. 1982. Poverty and Famine: An Essay on Entitlement and Deprivation Choice. Oxford: Oxford University Press.

Social and Economic Inclusion Initiative (SEII). 2003. Closing the Distance. Toronto: Social Planning Network of Ontario http://www.closingthedistance. ca/(accessed March 22, 2006).

Social Exclusion Unit (SEU). 2001. Preventing Social Exclusion: Report by the Social Exclusion Unit. London: Cabinet Office

Social Support Research Team (SSRP). 2003. 'Left Out': Perspectives on Social Exclusion and Social Isolation in Low-Income Populations. http://www.ssrp. ualberta.ca/projects_left_out.html (accessed April 5, 2006).

Stansfeld, S., R. Fuher, V. Cattell, and W. Head. 1999. Psychosocial factors and the explanation of socioeconomic gradients in common mental disorders. Health Variations 4:4-5.

Sweden. 2001. Sweden's Action Plan Against Poverty and Social Exclusion. Stockholm.

Tallon, A.R., R. Bromley, and C. Thomas. 2005. Swansea. Cities 22(1):65-76.

Townsend, P. 1979. Poverty in the United Kingdom. Harmondsworth: Penguin.

Weaver, J. 1982. Hamilton--An Illustrated History. Toronto: James Lorimer and Company.

Whitley, E., D. Gunnell, D. Dorling, and G. Davey Smith. 1999. Ecological study of social fragmentation, poverty and suicide. BMJ 319:1034-1037.

Wilkinson, R. 1996. Unhealthy Societies. London: Routledge.

Wilkinson, R. 1999. Income, inequality, social cohesion and health. International Journal of Health Services 29: 535-543.

Wilson, K., S. Elliott, M. Law, J. Eyles, M. Jerrett, and S. Keller-Olaman. 2004. Linking perceptions of neighbourhood to health in Hamilton, Canada. Journal of Epidemiology and Community Health 58:192-198.

World Bank. 2002. Social Capital and the World Bank. Washington: The World Bank. http://www1.worldbank.org/prem/poverty/scapital/bankl.htm (accessed April 5, 2007).

Kathi Wilson (1,3), John Eyles (2,3), Susan Elliott (2,3), Sue Keller-Olaman (3), Diane Devcic (3)

(1) Department of Geography University of Toronto Mississauga

(2) School of Geography and Geology McMaster University

(3) McMaster Institute of Environment and Health McMaster University

Notes

(1) Pseudonyms are used to protect the identity of all respondents.

Table 1: North and South Chedoke-Kirkendall, Census Characteristics

Characteristics South (%) North (%)

High school or more 85 53
Below LICO ($30,000) 33 56
Unemployed 11 12
Housing Tenure (Rent) 22 33
Visible Minorities 5 8
Recent Immigrants 2.5 2
Foreign Born 21 19

Single Source: Census of Canada 67 60

Table 2: Aspects of Social Exclusion in North and South
Chedoke-Kirkendall

Dimension of Exclusion South (%) North (%)

Consumption /Production
Below LICO ($30,000) 14 28
Unemployed 22 36
Does not own home 14 23
Worry monthly about bills 9 22
Not enough food due to lack of money 1 5
Does not have a regular family doctor 5 4
Seen/talked with doctor in past 2 weeks 12 18
Unmet health care needs 6 12
No Insurance for prescription medication 24 30
No Insurance for dental expenses 24 29
No Insurance for private/semi-private hospital 27 34
 room

Neighbourhood Engagement / Social Interaction
< median number of close friends (6) 39 42
< median number of close relatives (5) 43 41
Little or no involvement in organizations 68 73
Dissatisfied with neighbourhood 1 6
Considered moving in past 12 months 30 28
Want to move outside neighbourhood 41 51
Does not like anything about their 47
 neighbourhood
Dislikes at least one thing about their 64 64
 neighbourhood

Social Exclusion Scores
Min, Max 1, 11 l, 13
1-3 26 12
4-5 38 39
6-9 34 41
10 or higher 2 8
Health Status
Fair or poor self-assessed health status 9 12
1 or more chronic conditions 39 54
Dissatisfaction with health status 10 17

Source: Hamilton, Ontario Neighbourhood Health Survey, 2001-2002