The impact of area deprivation on differences in health: does the choice of the geographical classification matter?

Neighbourhood characteristics and trajectories of health functioning: a multilevel prospective analysis

BACKGROUND

Prospective data from over 10 years of follow-up were used to examine neighbourhood deprivation, social fragmentation and trajectories of health.

METHODS

From the third phase (1991-93) of the Whitehall II study of British civil servants, SF-36 health functioning was measured on up to five occasions for 7834 participants living in 2046 census wards. Multilevel linear regression models assessed the Townsend deprivation index and social fragmentation index as predictors of initial health and health trajectories.

RESULTS

Independent of individual socioeconomic factors, deprivation was inversely associated with initial SF-36 physical component summary (PCS) score. Social fragmentation was not associated with PCS scores. Deprivation and social fragmentation were inversely associated with initial mental component summary (MCS) score. Neighbourhood characteristics were not associated with trajectories of PCS score or MCS score for the whole set. However, restricted analysis on longer term residents revealed that residents in deprived or socially fragmented neighbourhoods had lowest initial and smallest improvements in MCS score.

CONCLUSIONS

This longitudinal study provides evidence that residence in a deprived or fragmented neighbourhood is associated with poorer mental health and that longer exposure to such neighbourhood environments has incremental effects. Associations between physical health functioning and neighbourhood characteristics were less clear. Mindful of the importance of individual socioeconomic factors, the findings warrant more detailed examination of materially and socially deprived neighbourhoods and their consequences for health.

Evaluation of SHINE — Make Every Child Count: a school‐based community intervention programme

Many barriers to health and emotional well‐being for children are prevalent within inner‐city communities, and often result in negative consequences for education. Health promotion strategies have previously cited mentoring schemes as interventions through which targeted pastoral support can be effectively provided to children. This paper draws on detailed focus group interviews in order to evaluate SHINE ‐ Make Every Child Count, a student‐led charity operating five mentoring programmes across the London boroughs of Southwark and Lambeth. Following content analysis, this paper identifies six themes associated with mentor support: rapport; emotional well‐being and development; social behaviour; enabling; emerging ambition; and attitudinal development. Results show participant children have gained considerable enjoyment from mentor support. Successful friendships are built and emotional well‐being supported, with children actively including mentors as part of their support network. Children recognise the impact of a mentor on relationships with peers, behaviour within the classroom and social responsibility, in addition to direct educational support. Children also show an increased interest in learning, and evidence of considering ‐ often for the first time ‐ their own future aspirations. Findings demonstrate the impact of the mentoring programmes, as perceived by participant children. Evaluation can be used to inform future development of the programmes, as well as expansion to further schools, with the organisation working towards achieving long‐term sustainability.

Evaluating options for measurement of neighborhood socioeconomic context: evidence from a myocardial infarction case-control study

We hypothesized that neighborhood socioeconomic context would be most strongly associated with risk of myocardial infarction (MI) for smaller "neighborhood" definitions. We used data on 487 non-fatal, incident MI cases and 1873 controls from a case-control study in Washington State. Census data on income, home ownership, and education were used to estimate socioeconomic context across four neighborhood definitions: 1 km buffer, block group, census tract, and ZIP code. No neighborhood definition led to consistently stronger associations with MI. Although we confirmed the association between neighborhood socioeconomic measures and risk of MI, we did not find these associations sensitive to neighborhood definition.

Establishing the soundness of administrative spatial units for operationalising the active living potential of residential environments: an exemplar for designing optimal zones

Background

In health and place research, definitions of areas, area characteristics, and health outcomes should ideally be coherent with one another. Yet current approaches for delimiting areas mostly rely on spatial units "of convenience" such as census tracts. These areas may be homogeneous along socioeconomic conditions but heterogeneous along other environmental characteristics. This heterogeneity can lead to biased measurement of environment characteristics and misestimation of area effects on health. The objective of this study was to assess the soundness of census tracts as units of analysis for measuring the active living potential of environments, hypothesised to be associated with walking.

Results

Starting with data at the smallest census area level available, zones homogeneous along three indicators of active living potential, i.e. population density, land use mix, and accessibility to services were designed. Delimitation of zones ensued from statistical clustering of the smallest areas into seven clusters or "types of environment". Mapping of clusters into a GIS led to the delineation of 898 zones characterised by one of seven types of environment, corresponding to different levels of active living potential. Homogeneity of census tracts along indicators of active living potential varied. A greater proportion (83%) of variation in accessibility to services was attributable to differences between census tracts suggesting within-tract homogeneity along this variable. However, census tracts were heterogeneous with respect to population density and land use mix where a greater proportion of the variation was attributable to within-tract differences. About 55% of tracts were characterised by a combination of three or more "types of environment" suggesting substantial within-tract heterogeneity in the active living potential of environments.

Conclusion

Soundness of census tracts for measuring active living potential may be limited. Measuring active living potential with error may lead to misestimation of associations with walking, therefore limiting the correctness of inference about area effects on walking. Future studies should aim to determine homogeneity of spatial units "of convenience" along environment characteristics of interest prior to examining their association with health. Further evidence is needed to assess the extent of this methodological issue with other indicators of environment context relevant to other health indicators.

The association of neighbourhood psychosocial stressors and self-rated health in Amsterdam, The Netherlands

OBJECTIVE

To investigate associations between neighbourhood-level psychosocial stressors (i.e. experience of crime, nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with the quality of green space) and self-rated health in Amsterdam, the Netherlands.

PARTICIPANTS

A random sample of 2914 subjects aged > or = 18 years from 75 neighbourhoods in the city of Amsterdam, the Netherlands.

DESIGN

Individual data from the Social State of Amsterdam Survey 2004 were linked to data on neighbourhood-level attributes from the Amsterdam Living and Security Survey 2003. Multilevel logistic regression was used to estimate odds ratios and neighbourhood-level variance.

RESULTS

Fair to poor self-rated health was significantly associated with neighbourhood-level psychosocial stressors: nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with green space. In addition, when all the neighbourhood-level psychosocial stressors were combined, individuals from neighbourhoods with a high score of psychosocial stressors were more likely than those from neighbourhoods with a low score to report fair to poor health. These associations remained after adjustments for individual-level factors (i.e. age, sex, educational level, income and ethnicity). The neighbourhood-level variance showed significant differences in self-rated health between neighbourhoods independent of individual-level demographic and socioeconomic factors.

CONCLUSION

Our findings show that neighbourhood-level psychosocial stressors are associated with self-rated health. Strategies that target these factors might prove a promising way to improve public health.

Toward the next generation of research into small area effects on health: a synthesis of multilevel investigations published since July 1998

To map out area effects on health research, this study had the following aims: (1) to inventory multilevel investigations of area effects on self rated health, cardiovascular diseases and risk factors, and mortality among adults; (2) to describe and critically discuss methodological approaches employed and results observed; and (3) to formulate selected recommendations for advancing the study of area effects on health. Overall, 86 studies were inventoried. Although several innovative methodological approaches and analytical designs were found, small areas are most often operationalised using administrative and statistical spatial units. Most studies used indicators of area socioeconomic status derived from censuses, and few provided information on the validity and reliability of measures of exposures. A consistent finding was that a significant portion of the variation in health is associated with area context independently of individual characteristics. Area effects on health, although significant in most studies, often depend on the health outcome studied, the measure of area exposure used, and the spatial scale at which associations are examined.

Does choice of spatial unit matter for estimating small-area disparities in health and place effects in the Vancouver Census Metropolitan Area?

BACKGROUND

The purposes of this study were to determine (i) the extent to which small-area estimates of self-rated health are dependent upon the choice of areal unit and measure of socio-economic (SES) status, and (ii) the extent to which place effects on self-rated health are dependent upon the choice of areal unit and measure of SES.

METHODS

The data were obtained from a subset of respondents in the Canadian Community Health Survey 2.1 (2003) aged 18 to 74 residing in the Vancouver Census Metropolitan Area. General health status was estimated using an item assessing respondents' self-rated health. Small-area data were obtained from the Statistics Canada 2001 Census at two spatial levels: larger Census Tract (CT) (average population 2,500-8,000) and smaller Dissemination Area (DA) (average population 400-700). SES quintiles were constructed using median family income and two indices. Hierarchical non-linear modelling was used to test for place effects.

RESULTS

A gradient was found of increasing prevalence of "fair or poor" self-rated health by decreasing SES quintile at both the DA and CT level. With age category, sex, family income and education controlled for, hierarchical analysis showed that compared with living in a high SES CT or DA the odds of reporting fair or poor self-rated health increased for respondents living in the lowest quintile CT or DA.

INTERPRETATION

Aggregation using DAs or CTs produces only small differences in estimates of fair or poor self-rated health by quintiles of SES. Gradients are somewhat stronger for DAs. Place effects are somewhat stronger for deprivation indices than the measure of median income.

Mental health and quality of residential environment

BACKGROUND

There is increasing interest in the proposition that residential environment can affect mental health.

AIMS

To study the degree to which common mental disorder clusters according to postcode units and households. To investigate whether contextual measures of residential environment quality and geographical accessibility are associated with symptoms of common mental disorder.

METHOD

A total of 1058 individuals aged 16-75 years (response rate 66%) participated in a cross-sectional survey. The 12-item General Health Questionnaire measured symptoms of common mental disorder.

RESULTS

Only 2% (95% CI 0-6) of the unexplained variation in symptoms existed at postcode unit level, whereas 37% (95% CI 27-49) existed at household-level, but the postcode unit variation was reduced to zero after adjustments. There was little evidence to suggest that residential quality or accessibility were associated with symptoms.

CONCLUSIONS

There was substantial unexplained variation at the household level but we could find no evidence of postcode unit variation and no association with residential environmental quality or geographical accessibility. It is likely that the psychosocial environment is more important than the physical environment in relation to common mental disorder.

Area deprivation and its association with health in a cross-sectional study: are the results biased by recent migration?

BACKGROUND

The association between area deprivation and health has mostly been examined in cross-sectional studies or prospective studies with short follow-up. These studies have rarely taken migration into account. This is a possible source of misclassification of exposure, i.e. an unknown number of study participants are attributed an exposure of area deprivation that they may have experienced too short for it to have any influence. The aim of this article was to examine to what extent associations between area deprivation and health outcomes were biased by recent migration.

METHODS

Based on data from the Oslo Health Study, a cross-sectional study conducted in 2000 in Oslo, Norway, we used six health outcomes (self rated health, mental health, coronary heart disease, chronic obstructive pulmonary disease, smoking and exercise) and considered migration nine years prior to the study conduct. Migration into Oslo, between the areas of Oslo, and the changes in area deprivation during the period were taken into account. Associations were investigated by multilevel logistic regression analyses.

RESULTS

After adjustment for individual socio-demographic variables we found significant associations between area deprivation and all health outcomes. Accounting for migration into Oslo and between areas of Oslo did not change these associations much. However, the people who migrated into Oslo were younger and had lower prevalences of unfavourable health outcomes than those who were already living in Oslo. But since they were evenly distributed across the area deprivation quintiles, they had little influence on the associations between area deprivation and health. Evidence of selective migration within Oslo was weak, as both moving up and down in the deprivation hierarchy was associated with significantly worse health than not moving.

CONCLUSION

We have documented significant associations between area deprivation and health outcomes in Oslo after adjustment for socio-demographic variables in a cross-sectional study. These associations were weakly biased by recent migration. From our results it still appears that migration prior to study conduct may be relevant to investigate even within a relatively short period of time, whereas changes in area deprivation during such a period is of limited interest.

Community-level socio-economic status and cognitive and functional impairment in the older population

BACKGROUND

This study aimed to determine if people living in communities with higher socio-economic deprivation are at an increased risk of cognitive and functional impairment even after controlling for the effects of individual socio-economic status.

METHODS

We analysed cross-sectional data from the Medical Research Council Cognitive Function and Ageing Study which consists of a community-based sample of Cambridgeshire, Gwynedd, Newcastle, Nottingham and Oxford. The study included 13 004 men and women aged 65 years and over who were randomly selected from Family Health Services Authority computerized records after being stratified to ensure equal numbers of those aged 75 years and over and those under 75 years. The outcome measures were cognitive impairment (Mini-Mental State Exam 0-21) and functional impairment (Instrumental Activities of Daily Living and/or Activities of Daily Living disability).

RESULTS

Individuals living in more deprived areas, as measured by the Townsend deprivation score, were found to have a higher prevalence of cognitive impairment [odds ratio (OR) (most deprived versus least deprived quintile) = 2.3; 95% confidence interval (CI)1.8-3.0; P < 0.001] and functional impairment [OR (most deprived versus least) = 1.6; 95% CI 1.4-1.9; P < 0.001] after controlling for age, sex, centre effects, education and social class.

CONCLUSIONS

There is a significantly higher prevalence of cognitive impairment and functional impairment in elderly individuals living in socio-economically deprived areas regardless of their own socio-economic status. This evidence is of relevance for informing public health policy and those allocating resources for the long-term care of the elderly.

The importance of social context: neighborhood stressors, stress-buffering mechanisms, and alcohol, drug, and mental health disorders

This study examines the relationship among neighborhood stressors, stress-buffering mechanisms, and likelihood of alcohol, drug, and mental health (ADM) disorders in adults from 60 US communities (n=12,716). Research shows that larger support structures may interact with individual support factors to affect mental health, but few studies have explored buffering effects of these neighborhood characteristics. We test a conceptual model that explores effects of neighborhood stressors and stress-buffering mechanisms on ADM disorders. Using Health Care for Communities with census and other data, we found a lower likelihood of disorders in neighborhoods with a greater presence of stress-buffering mechanisms. Higher neighborhood average household occupancy and churches per capita were associated with a lower likelihood of disorders. Cross-level interactions revealed that violence-exposed individuals in high crime neighborhoods are vulnerable to depressive/anxiety disorders. Likewise, individuals with low social support in neighborhoods with high social isolation (i.e., low-average household occupancy) had a higher likelihood of disorders. If replicated by future studies using longitudinal data, our results have implications for policies and programs targeting neighborhoods to reduce ADM disorders.

Does choice of spatial unit matter for estimating small-area disparities in health and place effects in the Vancouver Census Metropolitan Area?

BACKGROUND

The purposes of this study were to determine (i) the extent to which small-area estimates of self-rated health are dependent upon the choice of areal unit and measure of socio-economic (SES) status, and (ii) the extent to which place effects on self-rated health are dependent upon the choice of areal unit and measure of SES.

METHODS

The data were obtained from a subset of respondents in the Canadian Community Health Survey 2.1 (2003) aged 18 to 74 residing in the Vancouver Census Metropolitan Area. General health status was estimated using an item assessing respondents' self-rated health. Small-area data were obtained from the Statistics Canada 2001 Census at two spatial levels: larger Census Tract (CT) (average population 2,500-8,000) and smaller Dissemination Area (DA) (average population 400-700). SES quintiles were constructed using median family income and two indices. Hierarchical non-linear modelling was used to test for place effects.

RESULTS

A gradient was found of increasing prevalence of "fair or poor" self-rated health by decreasing SES quintile at both the DA and CT level. With age category, sex, family income and education controlled for, hierarchical analysis showed that compared with living in a high SES CT or DA the odds of reporting fair or poor self-rated health increased for respondents living in the lowest quintile CT or DA.

INTERPRETATION

Aggregation using DAs or CTs produces only small differences in estimates of fair or poor self-rated health by quintiles of SES. Gradients are somewhat stronger for DAs. Place effects are somewhat stronger for deprivation indices than the measure of median income.

Deprivation indices, population health and geography: an evaluation of the spatial effectiveness of indices at multiple scales

Area-based deprivation indices (ABDIs) have become a common tool with which to investigate the patterns and magnitude of socioeconomic inequalities in health. ABDIs are also used as a proxy for individual socioeconomic status. Despite their widespread use, comparably less attention has been focused on their geographic variability and practical concerns surrounding the Modifiable Area Unit Problem (MAUP) than on the individual attributes that make up the indices. Although scale is increasingly recognized as an important factor in interpreting mapped results among population health researchers, less attention has been paid specifically to ABDI and scale. In this paper, we highlight the effect of scale on indices by mapping ABDIs at multiple census scales in an urban area. In addition, we compare self-rated health data from the Canadian Community Health Survey with ABDIs at two census scales. The results of our analysis confirm the influence of spatial extent and scale on mapping population health-with potential implications for health policy implementation and resource distribution.

Ethnic differences in the effect of environmental stressors on blood pressure and hypertension in the Netherlands

BACKGROUND

Evidence strongly suggests that the neighbourhood in which people live influences their health. Despite this, investigations of ethnic differences in cardiovascular risk factors have focused mainly on individual-level characteristics. The main purpose of this study was to investigate associations between neighbourhood-level environmental stressors (crime, housing density, nuisance from alcohol and drug misuse, quality of green space and social participation), and blood pressure (BP) and hypertension among different ethnic groups.

METHODS

Individual data from the Amsterdam Health Survey 2004 were linked to data on neighbourhood stressors creating a multilevel design for data analysis. The study sample consisted of 517 Dutch, 404 Turkish and 365 Moroccans living in 15 neighbourhoods in Amsterdam, the Netherlands.

RESULTS

Amongst Moroccans, high density housing and nuisance from drug misuse were associated with a higher systolic BP, while high quality of green space and social participation were associated with a lower systolic BP. High level of nuisance from drug misuse was associated with a higher diastolic BP. High quality of green space was associated with lower odds of hypertension. Amongst Turkish, high level of crime and nuisance from motor traffic were associated with a higher diastolic BP. Similar associations were observed among the Dutch group but none of the differences were statistically significant.

CONCLUSION

The study findings show that neighbourhood-level stressors are associated with BP in ethnic minority groups but were less evident in the Dutch group. These findings might imply that the higher BP levels found in some ethnic minority groups might be partly due to their greater susceptibility to the adverse neighbourhood environment in which many ethnic minority people live. Primary prevention measures targeting these neighbourhood stressors may have an impact in reducing high BP related morbidity and mortality among ethnic minority groups.

Measuring the neighbourhood using UK benefits data: a multilevel analysis of mental health status

BACKGROUND

Evidence from multilevel research investigating whether the places where people live influence their mental health remains inconclusive. The objectives of this study are to derive small area-level, or contextual, measures of the local social environment using benefits data from the Department of Work and Pensions (DWP) and to investigate whether (1) the mental health status of individuals is associated with contextual measures of low income, economic inactivity, and disability, after adjusting for personal risk factors for poor mental health, (2) the associations between mental health and context vary significantly between different population sub-groups, and (3) to compare the effect of the contextual benefits measures with the Townsend area deprivation score.

METHODS

Data from the Welsh Health Survey 1998 were analysed in Normal response multilevel models of 24,975 individuals aged 17 to 74 years living within 833 wards and 22 unitary authorities in Wales. The mental health outcome measure was the Mental Health Inventory (MHI-5) of the Short Form 36 health status questionnaire. The benefits data available were the means tested Income Support and Income-based Job Seekers Allowance, and the non-means tested Incapacity Benefit, Severe Disablement Allowance, Disability Living Allowance and Attendance Allowance. Indirectly age-standardised census ward ratios were calculated to model as the contextual measures.

RESULTS

Each contextual variable was significantly associated with individual mental health after adjusting for individual risk factors, so that living in a ward with high levels of claimants was associated with worse mental health. The non-means tested benefits that were proxy measures of economic inactivity from permanent sickness or disability showed stronger associations with individual mental health than the means tested benefits and the Townsend score. All contextual effects were significantly stronger in people who were economically inactive and unavailable for work.

CONCLUSION

This study provides evidence for substantive contextual effects on mental health, and in particular the importance of small-area levels of economic inactivity and disability. DWP benefits data offer a more specific measure of local neighbourhood than generic deprivation indices and offer a starting point to hypothesise possible causal pathways to individual mental health status.

Common mental disorders and the built environment in Santiago, Chile

BACKGROUND

There is growing research interest in the influence of the built environment on mental disorders.

AIMS

To estimate the variation in the prevalence of common mental disorders attributable to individuals and the built environment of geographical sectors where they live.

METHOD

A sample of 3870 adults (response rate 90%) clustered in 248 geographical sectors participated in a household cross-sectional survey in Santiago, Chile. Independently rated contextual measures of the built environment were obtained. The Clinical Interview Schedule was used to estimate the prevalence of common mental disorders.

RESULTS

There was a significant association between the quality of the built environment of small geographical sectors and the presence of common mental disorders among its residents. The better the quality of the built environment, the lower the scores for psychiatric symptoms; however, only a small proportion of the variation in common mental disorder existed at sector level, after adjusting for individual factors.

CONCLUSIONS

Findings from our study, using a contextual assessment of the quality of the built environment and multilevel modelling in the analysis, suggest these associations may be more marked in non-Western settings with more homogeneous geographical sectors.

Does social cohesion modify the association between area income deprivation and mental health? A multilevel analysis

BACKGROUND

Despite the increasing belief that the places where people live influence their health, there is surprisingly little consistent evidence for their associations with mental health. We investigated the joint effect of community and individual-level socio-economic deprivation and social cohesion on individual mental health status.

METHODS

Multilevel analysis of population survey data on 10,653 adults aged 18-74 years nested within the 325 census enumeration districts in Caerphilly county borough, Wales, UK. The outcome measure was the Mental Health Inventory (MHI-5) subscale of the SF-36 instrument. A social cohesion subscale was derived from a factor analysis of responses to the Neighbourhood Cohesion scale and was modelled at individual and area level. Area income deprivation was measured by the percentage of low income households.

RESULTS

Poor mental health was significantly associated with area-level income deprivation and low social cohesion after adjusting for individual risk factors. High social cohesion significantly modified the association between income deprivation and mental health: the difference between the predicted mean area mental health scores at the 10th and 90th centiles of the low income distribution was 3.7 in the low cohesion group and 0.9 in the high cohesion group (difference of the difference in means = 2.8, 95% CI: 0.2, 5.4).

CONCLUSIONS

Income deprivation and social cohesion measured at community level are potentially important joint determinants of mental health. Further research on the impact of the social environment on mental health should investigate causal pathways in a longitudinal study.

Exceptions to the rule: Healthy deprived areas and unhealthy wealthy areas

In general, inhabitants of low socio-economic areas are unhealthier than inhabitants of high socio-economic areas, but some areas are an exception to this rule. These exceptions imply that other factors besides the socio-economic level of an area contribute to the health of the inhabitants of an area, e.g. environmental factors. In our study we concentrate on areas within the Netherlands that are healthier or unhealthier than could be expected based on their socio-economic level. This study first identifies these areas and secondly determines which area characteristics distinguish these areas from those areas where the level of health is in agreement with their socio-economic level. We used nation-wide data on neighbourhood differences in population composition (gender, age, marital status and ethnicity), urbanisation and two health indicators: mortality and hospitalisation rates. In the Netherlands, many areas are healthier or unhealthier than could be expected based on their income level alone. Areas with higher mortality rates than expected are mainly urban areas with high percentages of elderly people and persons living alone. Similar but opposite associations are observed for areas with lower mortality rates than expected, which are further characterised by a low percentage of non-western immigrants. Areas with lower hospitalisation rates than expected are mainly rural areas with few non-western immigrants. From these results, we conclude that urbanisation and residential segregation based on age, ethnicity and marital status might be important contributors to geographical health inequalities.

Time and place: putting individual health into context. A multilevel analysis of the British household panel survey, 1991–2001

Examination of the extent to which time and place affect people's health has been constrained by the resources available to answer this question. A British longitudinal, nationally representative survey of 8301 adults aged 16 years and older living in private households was used to consider the influence of household membership, area of residence and time using multilevel logistic regression. Self-rated health was assessed by general health and limiting illness during periods characterized by economic decline (1992), economic improvement (1996) and prosperity (2000). There was modest evidence of clustering of poor general health within areas and stronger support for within household similarities in general health which increased over time. Individual, household and area level deprivation accounted for almost all the area-level variability but had little effect on household variance. There was greater evidence of clustering of limiting illness within areas: deprivation did not account for this to any great extent. Area differences in general health reduced as the economy improved but time trends in differences in limiting illness lagged behind the timing of economic recovery. Both time and place are shown to affect self-rated health although the processes may differ depending on the health outcome.

Perceived environmental determinants of physical activity and fruit and vegetable consumption among high and low socioeconomic groups in the Netherlands

A focus group study was conducted to explore how perceptions of environmental influences on health behaviours pattern across socioeconomic groups in the Netherlands. Participants perceived their spouse's and friend's health behaviour and support as highly important. People from lower socioeconomic backgrounds reported poor neighbourhood aesthetics, safety concerns and poor access to facilities as barriers for being physically active, while easy accessibility to sports facilities was mentioned by high socioeconomic participants. The availability of fruits and vegetables at home was perceived as good by all particpants. Overall, lower socioeconomic groups expressed more price concerns. Possible pathways between socioeconomic status, environmental factors and health behaviours are represented in a framework, and they should be investigated further in longitudinal research.

A comparison of methods for calculating general practice level socioeconomic deprivation

Background

A measure of the socioeconomic deprivation experienced by the registered patient population of a general practice is of interest because it can be used to explore the association between deprivation and a wide range of other variables measured at practice level. If patient level geographical data are available a population weighted mean area-based deprivation score can be calculated for each practice. In the absence of these data, an area-based deprivation score linked to the practice postcode can be used as an estimate of the socioeconomic deprivation of the practice population. This study explores the correlation between Index of Multiple Deprivation 2004 (IMD) scores linked to general practice postcodes (main surgery address alone and main surgery plus any branch surgeries), practice population weighted mean IMD scores, and practice level mortality (aged 1 to 75 years, all causes) for 38 practices in Rotherham UK.

Results

Population weighted deprivation scores correlated with practice postcode based scores (main surgery only, Pearson r = 0.74, 95% CI 0.54 to 0.85; main plus branch surgeries, r = 0.79, 95% CI 0.63 to 0.89). All cause mortality aged 1 to 75 correlated with deprivation (main surgery postcode based measure, r = 0.50, 95% CI 0.22 to 0.71; main plus branch surgery based score, r = 0.55, 95% CI 0.28 to 0.74); population weighted measure, r = 0.66, 95% CI 0.43 to 0.81).

Conclusion

Practice postcode linked IMD scores provide a valid proxy for a population weighted measure in the absence of patient level data. However, by using them, the strength of association between mortality and deprivation may be underestimated.

Mental health, places and people: a multilevel analysis of economic inactivity and social deprivation

Using data on 24,975 respondents to the Welsh Health Survey 1998 aged 17-74 years, we investigated associations between individual mental health status measured using the SF-36 instrument, social class, economic inactivity and the electoral division Townsend deprivation score. In a multilevel modelling analysis, we found mental health was significantly associated with the Townsend score after adjusting for composition, and this effect was strongest in respondents who were economically inactive. Further contextual effects were shown by significant random variability in the slopes of the relation between mental health and economic inactivity at the electoral division level. Our results suggest that the places in which people live affect their mental health, supporting NHS policy that multi-agency planning to reduce inequalities in mental health status should address the wider determinants of health, as well as services for individual patients.

Community socioeconomic status and prehospital times in acute stroke and transient ischemic attack: do poorer patients have longer delays from 911 call to the emergency department?

BACKGROUND AND PURPOSE

Timely access to medical treatment is critical for patients with acute stroke because acute therapies must be given very quickly after symptom onset. We examined the effect of socioeconomic status on prehospital delays in stroke and transient ischemic attack (TIA) patients within a large, biracial population.

METHODS

By screening all local hospital ICD-9 codes 430 to 436, all stroke and TIA patients were identified during the calendar year of 1999. Cases must have used emergency medical services (EMS), lived at home, had their stroke at home, and had documented times of the 911 call and arrival to the emergency department. Socioeconomic status was estimated using economic data regarding the geocoded home residence census tract.

RESULTS

Only 38% of stroke and TIA patients used EMS. There were 978 cases of stroke and TIA included in this analysis. The mean times were call to arrival on scene 6.5 minutes, on-scene time 14.1 minutes, and transport time 13.1 minutes. Lower community socioeconomic status was associated with all 3 EMS time intervals; however, all time differences were small: the largest difference was 5 minutes.

CONCLUSIONS

Within our population, living in a poorer area does not appear to delay access to acute care for stroke in a clinically significant way. We did find small, statistically significant delays in prehospital times that were associated with poorer communities, black race, and increasing age. However, delays related to public recognition of stroke symptoms, and limited use of 911, are likely much more important than these small delays that occur with EMS systems.

Race disparities in childhood asthma: does where you live matter?

OBJECTIVE

This study investigates whether racial/ethnic disparities in childhood asthma prevalence can be explained by differences in family and neighborhood socioeconomic position (SEP).

METHODS

Data were from the 2001 Rhode Island Health Interview Survey (RI HIS), a statewide representative sample of 2,600 Rhode Island households, and the 2000 U.S. Census. A series of weighted multivariate models were fitted using generalized estimating equations (GEE) for the logistic case to analyze the independent and joint effects of race/ethnicity and SEP on doctor-diagnosed asthma among 1,769 white, black and Hispanic children <18 years old.

RESULTS

Compared with white children, black children were at increased odds for asthma and this effect persisted when measures of family and neighborhood SEP were included in multivariate models (AOR: 2.49; 95% Cl: 1.30-4.77). Black children living in poverty neighborhoods had substantially higher odds of asthma than Hispanic and white children in poverty areas and children in moderate- and high-income neighborhoods (AOR: 3.20: 95% Cl: 1.62-6.29).

CONCLUSION

The high prevalence of asthma among black children in poor neighborhoods is consistent with previous research on higher-than-average prevalence of childhood asthma in poor urban minority communities. Changing neighborhood social structures that contribute to racial disparities in asthma prevalence remains a challenge.

Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses

BACKGROUND

Social disorganisation, fragmentation and isolation have long been posited as influencing the rate of psychoses at area level. Measuring such societal constructs is difficult. A census-based index measuring social fragmentation has been proposed.

AIMS

To investigate the association between first-admission rates for psychosis and area-based measures of social fragmentation, deprivation and urban/rural index.

METHOD

We used indirect standardisation methods and logistic regression models to examine associations of social fragmentation, deprivation and urban/rural categories with first admissions for psychoses in Scotland for the 5-year period 1989-1993.

RESULTS

Areas characterised by high social fragmentation had higher first-ever admission rates for psychosis independent of deprivation and urban/rural status. There was a dose-response relationship between social fragmentation category and first-ever admission rates for psychosis. There was no statistically significant interaction between social fragmentation, deprivation and urban/rural index.

CONCLUSIONS

First-admission rates are strongly associated with measures of social fragmentation, independent of material deprivation and urban/rural category.

Geographical variation in rates of common mental disorders in Britain: prospective cohort study

BACKGROUND

There is little geographical variation in the prevalence of the common mental disorders. However, there is little longitudinal research.

AIMS

To estimate variance in rates of common mental disorders at individual, household and electoral ward levels prospectively.

METHOD

A 12-month cohort study of 7659 adults aged 16-74 years in 4338 private households, in 626 electoral wards. Data were collected as part of the British Household Panel Survey. Common mental disorders were assessed using the 12-item General Health Questionnaire (GHQ). Ward-level socio-economic deprivation was measured using the Carstairs index.

RESULTS

Less than 1% of total variance, in onset and maintenance of common mental disorders and change in GHQ score between waves, occurred at ward level. However, 12% of variance, which is a statistically significant difference, was found at household level (a much smaller geographical unit) and this difference remained after further analyses.

CONCLUSIONS

Ward level socio-economic deprivation does not influence the onset and maintenance of common mental disorders in Britain but local factors at the household level do. Reasons for this remain unclear.

Neighbourhood unemployment and all cause mortality: a comparison of six countries

STUDY OBJECTIVE

Studies have shown that living in more deprived neighbourhoods is related to higher mortality rates, independent of individual socioeconomic characteristics. One approach that contributes to understanding the processes underlying this association is to examine whether the relation is modified by the country context. In this study, the size of the association between neighbourhood unemployment rates and all cause mortality was compared across samples from six countries (United States, Netherlands, England, Finland, Italy, and Spain).

DESIGN

Data from three prospective cohort studies (ARIC (US), GLOBE (Netherlands), and Whitehall II (England)) and three population based register studies (Helsinki, Turin, Madrid) were analysed. In each study, neighbourhood unemployment rates were derived from census, register based data. Cox proportional hazard models, taking into account the possible correlation of outcomes among people of the same neighbourhood, were used to assess the associations between neighbourhood unemployment and all cause mortality, adjusted for education and occupation at the individual level.

RESULTS

In men, after adjustment for age, education, and occupation, living in the quartile of neighbourhoods with the highest compared with the lowest unemployment rates was associated with increased hazards of mortality (14%-46%), although for the Whitehall II study associations were not statistically significant. Similar patterns were found in women, but associations were not statistically significant in two of the five studies that included women.

CONCLUSIONS

Living in more deprived neighbourhoods is associated with increased all cause mortality in the US and five European countries, independent of individual socioeconomic characteristics. There is no evidence that country substantially modified this association.

Choice of geographic unit influences socioeconomic inequalities in breast cancer survival

Socioeconomic differences in age-standardised crude survival for women diagnosed with breast cancer during 1991–1999 in England were influenced by the population of the geographic area used to assign the deprivation index, but not by the choice of index.

Municipal socioeconomic status and mortality in Japan: sex and age differences, and trends in 1973-1998

The purpose of this study was to examine the sex and age differences and the time trends in the association between municipal socioeconomic status (SES) and all-cause mortality across Japan from 1973 to 1998. Sex-specific mortality of municipalities (N=3319 in 1995) by age groups (total, under 75-year, and over 75-year populations) was linked to municipal SES indicators related to income, education, unemployment and living space, and two SES composite indices formulated by principle component analysis (Index 1 related to lower income and education, and Index 2 related to unemployment and overcrowding). The relation was assessed using mortality gradients by SES quintiles and Bayesian hierarchical Poisson regression. The results showed that a lower SES was related to higher mortality for all SES indicators and composite indices. The mortality gradient was steeper for the under 75-year population than the total and over 75-year populations, and the relation between mortality and income- and education-related indicators/index was stronger for males than for females. The time trend showed an increase in the relation for Index 2, while a decrease for Index 1. This study demonstrated that lower municipal SES had an adverse influence on population health, and the influence was marked for males and premature death. Although a substantial health disadvantage still remained in lower SES areas, the impact of SES factors on geographical health variation changed over time; the association with mortality has weakened for income and education, while it has strengthened for unemployment and living space.

The influence of neighborhood environment on the incidence of childhood asthma: a multilevel approach

Some ecological analyses suggest an influence of neighborhood environment on asthma outcomes. However, no previous study has applied a multilevel approach to assess an ecological effect of neighborhood environment on the incidence of childhood asthma accounting for individual risk factors. This study assessed the influence of neighborhood and individual-level factors on the incidence of childhood asthma among all children born in Rochester, Minnesota, between 1976 and 1979. We identified asthmatics among all children born in Rochester, between 1976 and 1983. We applied a multilevel survival model with the frailty term to assess the effects of neighborhood characteristics, such as mean family income per census tract (n = 16) from the 1980 census report and the status of whether a census tract faces intersections with major highways or railroads, on asthma incidence. The relative risks (RR) of neighborhood socioeconomic status (SES), the status of whether census tracts face intersections with highways or railroads and the variance of random effect of census tracts were calculated adjusting individual-level covariates for asthma, including gender, birth weight, mother's age at birth and parental educational level at birth. We found that the RR of developing asthma among children living in census tracts facing intersections with highways or railroads was 1.6 (95% CI: 1.1-2.2) compared to those who lived in census tracts not facing intersections, adjusting individual- and neighborhood-level covariates. The variance of the frailty term attributable to census tracts was small (0.0085) and was modified (from 0.004 to 0.0085, 112% change) by adding neighborhood covariates. The overall effects of individual-level factors on asthma incidence were independent of neighborhood environment. The influence of neighborhood environment on childhood asthma in a non-inner-city setting, like Rochester, Minnesota, was small to modest. Incorporating pertinent neighborhood-level covariates into multilevel models needs to be considered in assessing the random effect of clusters.

Area deprivation and child psychosocial problems--a national cross-sectional study among school-aged children

BACKGROUND

We examined the association of area deprivation with the occurrence of psychosocial problems among children aged 4-16 in a representative national sample of children based on standardised measures of parent-reported problems and diagnoses made by doctors and nurses working in child healthcare (child health professionals, CHPs).

METHODS

The study comprised 4480 children aged 4-16 years, eligible for a routine health assessment (response: 90.1 %), in 19 Child Healthcare Services across the Netherlands that routinely provided preventive child healthcare to nearly all school-aged children. Parents completed the Child Behaviour Checklist (CBCL). CHPs examined the child and interviewed parents and child during their routine health assessments. Main outcome measures concerned psychosocial problems as reported by parents (i. e. a clinical score on the CBCL) and as identified by CHPs.

RESULTS

Prevalence rates of psychosocial problems were 8.6% for parent-reported problems and 10.1 % for CHP-identified problems. They were much higher in the most deprived third of the areas. Odds ratios (95 % confidence intervals) compared with the least deprived third were 1.93 (1.41-2.64) regarding parent-reported problems and 1.76 (1.30-2.38) regarding CHP-identified problems. Regarding parent reports, associations were slightly stronger for behavioural problems than for emotional problems. Less than a quarter of the area differences could be explained by individual and family characteristics.

CONCLUSIONS

Child psychosocial problems occur more frequently in deprived areas. Both preventive and curative health services should be better equipped for this concentration of child and adolescent morbidity in deprived areas.

Income inequality and pregnancy spacing

We examined the relationship between county-level income inequality and pregnancy spacing in a welfare-recipient cohort in Washington State. We identified 20,028 welfare-recipient women who had at least one birth between July 1, 1992, and December 31, 1999, and followed this cohort from the date of that first in-study birth until the occurrence of a subsequent pregnancy or the end of the study period. Income inequality was measured as the proportion of total county income earned by the wealthiest 10% of households in that county compared to that earned by the poorest 10%. To measure the relationship between income inequality and the time-dependent risk (hazard) of a subsequent pregnancy, we used Cox proportional hazards methods and adjusted for individual- and county-level covariates. Among women aged 25 and younger at the time of the index birth, the hazard ratio (HR) of subsequent pregnancy associated with income inequality was 1.24 (95% CI: 0.85, 1.80), controlling for individual-level (age, marital status, education at index birth; race, parity) and community-level variables. Among women aged 26 or older at the time of the index birth, the adjusted HR was 2.14 (95% CI: 1.09, 4.18). While income inequality is not the only community-level feature that may affect health, among women aged 26 or older at the index birth it appears to be associated with hazard of a subsequent pregnancy, even after controlling for other factors. These results support previous findings that income inequality may impact health, perhaps by influencing health-related behaviors.

Assessment of a national health interview survey-based method of measuring community socioeconomic status

PURPOSE

Increasingly researchers are interested in assessing the role of community socioeconomic status (SES) in poor health outcomes, above and beyond the influence of low individual SES. However, the feasibility of conducting these multi-level studies is often limited by restrictions on release of confidential identifiers for linkage to census data, resources for the linkage, and the availability of data sources with individual SES measures. This study assessed a new method of measuring community socioeconomic status (SES) that can be used with the publicly available National Health Interview Survey (NHIS) and preserves confidentiality and can be used with individual SES measures from the NHIS.

METHODS

The associations between community SES and mortality from all causes and breast cancer in women were assessed in two samples: 1) deaths in 1987-1993 NHIS respondents linked to community SES measures developed with the new method; and 2) deaths in 1991 from the National Multiple Cause of Death Files linked to 1990 county-level census SES measures. The magnitude of crude mortality rates, direction of trend, and age-adjusted relative risk of mortality for low vs. high SES were compared in the two samples.

RESULTS

Crude all-cause mortality and breast cancer mortality rates were similar in both samples in terms of magnitude and direction of trend. In both samples, as SES decreased, rates of all-cause mortality increased, whereas breast cancer mortality rates tended to decrease. Age-adjusted relative risks of mortality from all causes and breast cancer for low vs. high SES were similar in the two samples.

CONCLUSIONS

Similarity of associations between community SES and mortality from all causes and breast cancer in the two samples provides support for the validity of a new NHIS-based method of measuring community SES. Since the NHIS is a large, nationally representative survey with high response rates and low loss to mortality follow-up, this method represents an important resource for multi-level studies.

Colorectal cancer, screening and survival: the influence of socio-economic deprivation

OBJECTIVES

To determine the extent to which socio-economic deprivation explains colorectal cancer prevalence, subject participation in screening, and postoperative survival and life expectancy.

METHODS

Regression analyses of clinical data from a large randomized controlled trial, augmented by geographical-based indices of deprivation.

RESULTS

Deprivation appears to exert no significant impact on colorectal cancer prevalence but is a major factor explaining subject participation in screening. Cancer detection at later stages reduces life expectancy at time of treatment. Females from more-deprived areas have poorer post-treatment life expectancies and survival prospects, independently of their screening behaviour.

CONCLUSIONS

Screening increases the chances of having a cancer treated at an earlier stage, and treatment at an earlier stage is associated with longer subsequent life expectancy. However, those from more-deprived areas are less likely to accept an invitation to be screened.

Distribución de recursos del Plan de Atención Básico con criterio de equidad, Bogotá 2002

OBJETIVO: Aplicar una técnica que oriente la distribución de recursos financieros del Plan de Atención Básico para acciones colectivas, según las condiciones de salud diferenciales. MÉTODOS: Se parte de la estimación previa de un índice global de salud mediante análisis de componentes principales, que jerarquiza las localidades de Bogotá, Colombia, en grupos según su estado de salud: "peor" estado, "intermedio" y "mejor" que los anteriores. Se aplica una técnica de mínimos cuadrados que minimice la diferencia entre el índice global de salud observado y un índice esperado con la inversión de tales recursos. RESULTADOS: Se obtiene la distribución de los recursos del Plan de Atención Básico para las veinte Localidades, destinando una cifra superior a la mediana Distrital en las Localidades con "peor" estado de salud. Además, se identifican las Localidades con déficit para el cubrimiento universal de la población de acuerdo con la destinación per cápita de dichos recursos. CONCLUSIÓN: La técnica utilizada pone en evidencia la diferencia en las condiciones de salud entre las localidades con "peor" estado de salud, con respecto a las localidades con "mejor" estado, a pesar de la incremento en la asignación del Plan de Atención Básico, indicando la necesidad de inversión social a nivel intersectorial en dichas localidades.

Contextual risk factors for the common mental disorders in Britain: a multilevel investigation of the effects of place

STUDY OBJECTIVE

To test hypotheses about associations between area level exposures and the prevalence of the most common mental disorders (CMD) in Britain. A statistically significant urban-rural gradient was predicted, but not a socioeconomic gradient, in the prevalence of CMD after adjusting for characteristics of individual respondents. The study tested the hypothesis that the effects of area level exposures would be greatest among those not in paid employment.

DESIGN

Cross sectional survey, analysed using multilevel logistic and linear regression. CMD were assessed using the General Health Questionnaire (GHQ). Electoral wards were characterised using the Carstairs index, the Office of National Statistics (ONS) Classification of Wards, and population density.

SETTING

England, Wales, and Scotland.

PARTICIPANTS

Nearly 9000 adults aged 16-74 living in 4904 private households, nested in 642 electoral wards.

MAIN RESULTS

Little evidence was found of statistically significant variance in the prevalence of CMD between wards, which ranged from 18.8% to 29.5% (variance 0.035, SE 0.026) (p=0.11). Associations between CMD and characteristics of wards, such as the Carstairs index, only reached statistical significance among those who were economically inactive (adjusted odds ratio for top v bottom Carstairs score quintile 1.58, 95% CI 1.08 to 2.31) (p<0.05).

CONCLUSIONS

There may be multiple pathways linking socioeconomic inequalities and ill health. The effects of place of residence on mental health are greatest among those who are economically inactive and hence more likely to spend the time at home.

Community income and surgical rates in the Netherlands

BACKGROUND

The study describes variations in use of surgical procedures by community income in the Netherlands. From the literature it is known that surgical rates have a socioeconomic gradient. Both positive and negative associations of socioeconomic factors of patients (for example, income, education) with surgical rates have been reported. The question raised here is: how do (possible) socioeconomic variations in surgery in the Netherlands compare with variations observed elsewhere?

DATA AND METHODS

The data comprised Dutch hospital discharges and population estimates for 1999. Socioeconomic status was indicated by a patient's income and based on the average family income of the postcode area of residence. Poisson regression was used to compute relative incidence (odds ratios) for 10 common surgical procedures. The model included age, gender, degree of urbanisation, and province of residence.

RESULTS

The association between surgical rates and community level income is rather weak. For half of the surgical rates the authors observed higher utilisation rates in communities with low income levels, but the differences are small. The range of odds ratios in the lowest income quintile group (compared with the group with the highest income) observed is: 0.87 to 1.18. Men from a low income community received more appendicectomies (1.18), cholecystectomies (1.12), knee replacements (1.06), and prostatectomies (1.14) and less tonsillectomies (0.90). Women from a low income community received more appendicectomies (1.12), caesarean sections (1.18), hip and knee replacements (1.05,1.17), and hysterectomies (1.14). Whereas they received less coronary artery bypass grafts (0.92), cholecystectomies (0.87), and tonsillectomies (0.92).

CONCLUSIONS

Compared with findings reported in the international literature, this study indicates that variations in use of surgical procedures by community income in the Netherlands are comparatively small. Because of lack of data the authors could not study the influence of variations in need for surgical care by community income, but as the incidence of conditions requiring surgical interventions generally is higher in lower income groups, it is suspected some degree of underutilisation exists in these groups.

Choosing area based socioeconomic measures to monitor social inequalities in low birth weight and childhood lead poisoning: The Public Health Disparities Geocoding Project (US)

STUDY OBJECTIVES

: To determine which area based socioeconomic measures can meaningfully be used, at which level of geography, to monitor socioeconomic inequalities in childhood health in the US.

DESIGN

Cross sectional analysis of birth certificate and childhood lead poisoning registry data, geocoded and linked to diverse area based socioeconomic measures that were generated at three geographical levels: census tract, block group, and ZIP code.

SETTING

Two US states: Massachusetts (1990 population=6,016,425) and Rhode Island (1990 population=1,003,464).

PARTICIPANTS

All births born to mothers ages 15 to 55 years old who were residents of either Massachusetts (1989-1991; n=267,311) or Rhode Island (1987-1993; n=96 138), and all children ages 1 to 5 years residing in Rhode Island who were screened for lead levels between 1994 and 1996 (n=62,514 children, restricted to first test during the study period).

MAIN RESULTS

Analyses of both the birth weight and lead data indicated that: (a) block group and tract socioeconomic measures performed similarly within and across both states, while ZIP code level measures tended to detect smaller effects; (b) measures pertaining to economic poverty detected stronger gradients than measures of education, occupation, and wealth; (c) results were similar for categories generated by quintiles and by a priori categorical cut off points; and (d) the area based socioeconomic measures yielded estimates of effect equal to or augmenting those detected, respectively, by individual level educational data for birth outcomes and by the area based housing measure recommended by the US government for monitoring childhood lead poisoning.

CONCLUSIONS

Census tract or block group area based socioeconomic measures of economic deprivation could be meaningfully used in conjunction with US public health surveillance systems to enable or enhance monitoring of social inequalities in health in the United States.

Monitoring socioeconomic inequalities in sexually transmitted infections, tuberculosis, and violence: geocoding and choice of area-based socioeconomic measures--the public health disparities geocoding project (US)

OBJECTIVES

To determine which area-based socioeconomic measures, at which level of geography, are suitable for monitoring socioeconomic inequalities in sexually transmitted infections (STIs), tuberculosis (TB), and violence in the United States.

METHODS

Cross-sectional analysis of public health surveillance data, geocoded and linked to area-based socioeconomic measures generated from 1990 census tract, block group, and ZIP Code data. We included all incident cases among residents of either Massachusetts (MA; 1990 population = 6016425) or Rhode Island (RI; 1990 population = 1003464) for: STIs (MA: 1994-1998, n = 26535 chlamydia, 7464 gonorrhea, 2619 syphilis; RI: 1994-1996, n = 4473 chlamydia, 1256 gonorrhea, 305 syphilis); TB (MA: 1993-1998, n = 1793; RI: 1985-1994, n = 576), and non-fatal weapons related injuries (MA: 1995-1997, n = 6628).

RESULTS

Analyses indicated that: (a). block group and tract socioeconomic measures performed similarly within and across both states, with results more variable for the ZIP Code level measures; (b). measures of economic deprivation consistently detected the steepest socioeconomic gradients, considered across all outcomes (incidence rate ratios on the order of 10 or higher for syphilis, gonorrhea, and non-fatal intentional weapons-related injuries, and 7 or higher for chlamydia and TB); and (c). results were similar for categories generated by quintiles and by a priori categorical cut-points.

CONCLUSIONS

Supplementing U.S. public health surveillance systems with census tract or block group area-based socioeconomic measures of economic deprivation could greatly enhance monitoring and analysis of social inequalities in health in the United States.

Neighbourhood socioeconomic context and self reported health and smoking: a secondary analysis of data on seven cities

OBJECTIVE

Many studies have shown that poor health status and harmful health behaviour occur more frequently in deprived neighbourhoods. Most studies show modest associations between area level socioeconomic factors, the neighbourhood context, and health outcomes. However, estimates for the contextual effects vary. It is unclear if this variation is attributable to differences in methodology. This study examines whether contextual neighbourhood differences in health outcomes really vary between cities or that differences in methodology may account for these differences.

DESIGN

Secondary analysis of data from health interview surveys in seven large Dutch cities in the 1990s comprising 23 269 residents of 484 neighbourhoods, using multilevel logistic models.

SETTING

General population aged 16 and over.

MAIN OUTCOME MEASURES

Self reported health, smoking of cigarettes.

MAIN RESULTS

The socioeconomic context of neighbourhoods is associated with health outcomes in all large Dutch cities. The strength of the association varies between cities, but variation is much smaller in the age group 25-64. Furthermore, neighbourhood differences vary in size between native and other residents. Contextual neighbourhood differences are about two times larger for self reported health than for the smoking of cigarettes, but for native Dutch people they are of similar size.

CONCLUSIONS

A comparatively large improvement in health may be gained in deprived neighbourhoods, because of the poorer health status to which the context of these neighbourhoods also contributes. Health promoting interventions should be aimed at the residents and at the context of deprived neighbourhoods, taking differences between ethnic groups and age groups into account.

Socioeconomic status of very small areas and stroke incidence in the Netherlands

OBJECTIVE

To examine whether characteristics of very small living areas can be used to predict disease incidence and to use these characteristics to assess socioeconomic differences in stroke incidence in the Netherlands.

DESIGN

Characteristics of postcode areas of stroke patients are compared with characteristics of postcode areas of all individual people in the study region, using Poisson regression analysis.

SETTING

Six provinces of the Netherlands, covering about half of the country.

PATIENTS

760 patients who in 1991 or 1992 were consecutively admitted because of stroke to 23 Dutch hospitals.

MAIN RESULTS

Stroke incidence is significantly higher among people living in postcode areas with below average socioeconomic status (relative risk=1.27; 95% confidence intervals 1.08 to 1.51) and among people living in postcode areas with predominantly older inhabitants (RR=3.17; 95% CI=2.29 to 4.39). It is also significantly increased in more urbanised areas compared with the countryside, the highest incidence being found in the large cities (RR=1.78; 95% CI=1.31 to 2.44).

CONCLUSIONS

A clear socioeconomic gradient in stroke incidence in the Netherlands is observed, with people living in detailed postcode areas with below average socioeconomic status experiencing a significantly higher risk of stroke. The analysis also confirms that characteristics of detailed postcode areas can effectively be used to differentiate between areas with and areas without stroke patients.

Income inequality and self rated health in Britain

STUDY OBJECTIVE

Several studies have reported an association between income inequality and increased mortality, but few have used net income data, controlled for individual income, or evaluated sensitivity to the choice of inequality measure. The study tested the hypotheses that people in regions of Britain with the greatest income inequality would report worse health than those in other regions, after adjusting for individual socioeconomic circumstances.

DESIGN

Cross sectional survey.

SETTING

England, Wales, and Scotland.

PARTICIPANTS

8366 people living in private households.

MAIN RESULTS

Regional income inequality, measured using the Gini index, was associated with worse self rated health, especially among those with the lowest incomes (adjusted OR 1.55, 95% CI 1.24 to 1.92) (p<0.001). This association was not robust to the choice of income inequality measure, being maximal for the Gini coefficient and weakest when using indices that are more sensitive to income differences among those at the top or bottom of the income distribution.

CONCLUSIONS

The study found limited evidence of an association between income inequality and worse self rated health in Britain, which was greatest among those with the lowest individual income levels. As regions with the highest income inequality were also the most urban, these findings may be attributable to characteristics of cities rather than income inequality. The variation in this association with the choice of income inequality measure also highlights the difficulty of studying income distributions using summary measures of income inequality.

Teen births, income inequality, and social capital: developing an understanding of the causal pathway

Many studies have demonstrated a relationship between income inequality and poor health, but how does income inequality impact health? One possible explanation is that greater income inequality undermines social capital (social cohesion, civic engagement, and mutual trust in a community). We conducted path analyses of the relationship between income inequality, poverty, and teen birth rate, testing for the mediating effect of social capital in 39 US states. Birth rate was affected by both poverty and income inequality, though income inequality appeared to affect teen birth rate primarily through its impact on social capital.

Socioeconomic context in area of living and risk of myocardial infarction: results from Stockholm Heart Epidemiology Program (SHEEP)

STUDY OBJECTIVE

To analyse if socioeconomic characteristics in area of living affect the risk of myocardial infarction in a Swedish urban population, and to evaluate to what extent the contextual effect is confounded by the individual exposures.

DESIGN

A population based case-referent study (SHEEP).

SETTING

Cases (n=1631) were all incident first events of myocardial infarction during 1992-1994. The study base included all Swedish citizens aged 45-70 years, living in Stockholm metropolitan area during these years. The social context of all metropolitan parishes (n=89) was determined by routine statistics on 21 socioeconomic indicators. A factor analysis of the socioeconomic indicators resulted in three dimensions of socioeconomic deprivation, which were analysed separately as three different contextual exposures.

MAIN RESULTS

The main characteristics of the extracted factors were; class structure, social exclusion and poverty. Among men, there were increased relative risks of similar magnitudes (1.28 to 1.33) in the more deprived areas according to all three dimensions of the socioeconomic context. However, when adjusting for individual exposures, the poverty factor had the strongest contextual impact. The contextual effects among women showed a different pattern. In comparison with women living the most affluent areas according to the class structure index, women in the rest of Stockholm metropolitan area had nearly 70% higher risk of myocardial infarction after adjustment for individual social exposures.

CONCLUSIONS

The results suggest that the socioeconomic context in area of living increases the risk of myocardial infarction. The increased risk in only partially explained by individual social factors (the compositional effect).

The validity of self-reported use of health care across socioeconomic strata: a comparison of survey and registration data

BACKGROUND

Socioeconomic differences in health and in use of health care are well known. Most data on socioeconomic differences in health care utilization are based on retrospective self-report in community surveys, but the evidence on the validity of self-reported utilization of health care across socioeconomic groups is limited. The aim of this study was to assess the validity of self-reported utilization of health care across socioeconomic groups in the general population.

METHODS

We compared the concordance of self-reported and registered hospitalization (one year, n = 1277), and utilization of physiotherapy (one year, n = 1302) and use of prescription drugs (3 months, n = 899), by socioeconomic group (educational level, income, occupational status). Data came from a face-to-face health interview survey in Amsterdam and a health insurance register, and were limited to native Dutch and lower and middle income groups.

RESULTS

Concordance between reported and registered utilization was generally good to excellent; kappas (agreement adjusted for chance agreement) and percentage accurately reporting ranged from 0.60 and 80% (drugs) to 0.80 and 96% (hospitalization). They differed little, and without statistical significance, between people of low socioeconomic status and others. Assessment of socioeconomic groups in more detail yields somewhat more variation, but no systematic trend in concordance by higher socioeconomic status.

CONCLUSION

Self-report offers a reasonably valid estimate of differences in utilization of health care between socioeconomic groups in the general population, at least for lower and middle income groups.