Social capital and leisure time physical activity: a population based multilevel analysis in Malmö, Sweden

The influence of socioeconomic and environmental determinants on health and obesity: a West Virginia case study

A recursive system of ordered self assessed health together with BRFSS data were used to investigate health and obesity in the Appalachian state of West Virginia. Implications of unobserved heterogeneity and endogeneity of lifestyle outcomes on health were investigated. Obesity was found to be an endogenous lifestyle outcome associated with impaired health status. Risk of obesity is found to increase at a decreasing rate with per capita income and age. Intervention measures which stimulate human capital development, diet-disease knowledge and careful land use planning may improve health and obesity outcomes in Appalachia in particular and rural America in general.

Socioeconomic differences in lack of recreational walking among older adults: the role of neighbourhood and individual factors

BACKGROUND

People with a low socioeconomic status (SES) are more likely to be physically inactive than their higher status counterparts, however, the mechanisms underlying this socioeconomic gradient in physical inactivity remain largely unknown. Our aims were (1) to investigate socioeconomic differences in recreational walking among older adults and (2) to examine to what extent neighbourhood perceptions and individual cognitions regarding regular physical activity can explain these differences.

METHODS

Data were obtained by a large-scale postal survey among a stratified sample of older adults (age 55-75 years) (N = 1994), residing in 147 neighbourhoods of Eindhoven and surrounding areas, in the Netherlands. Multilevel logistic regression analyses assessed associations between SES (i.e. education and income), perceptions of the social and physical neighbourhood environment, measures of individual cognitions derived from the Theory of Planned Behaviour (e.g. attitude, perceived behaviour control), and recreational walking for >/=10 minutes/week (no vs. yes).

RESULTS

Participants in the lowest educational group (OR 1.67 (95% CI, 1.18-2.35)) and lowest income group (OR 1.40 (95% CI, 0.98-2.01)) were more likely to report no recreational walking than their higher status counterparts. The association between SES and recreational walking attenuated when neighbourhood aesthetics was included in the model, and largely reduced when individual cognitions were added to the model (with largest effects of attitude, and intention regarding regular physical activity). The assiation between poor neighbourhood aesthetics and no recreational walking attenuated to (borderline) insignificance when individual cognitions were taken into account.

CONCLUSION

Both neighbourhood aesthetics and individual cognitions regarding physical activity contributed to the explanation of socioeconomic differences in no recreational walking. Neighbourhood aesthetics may explain the association between SES and recreational walking largely via individual cognitions towards physical activity. Intervention and policy strategies to reduce socioeconomic differences in lack of recreational walking among older adults would be most effective if they intervene on both neighbourhood perceptions as well as individual cognitions.

Multidisciplinary research in public health: a case study of research on access to green space

OBJECTIVES

Quantitative analysis of the physical and demographic parameters of access to Thames Chase Community Forest (TCCF), and how these have changed between 1990 and 2003; and qualitative exploration of our understanding of the links between health and the natural environment (TCCF), with a focus on the issue of 'access' to green space.

STUDY DESIGN

Multimethod design involving both quantitative (analysis of physical access to green space) and qualitative (ethnography) components.

METHODS

Quantitative analysis, using geographical information systems, of physical access to the community forest; and ethnographic research including participant observation, non-participant observation, in-depth interviews and attendance at meetings and conferences.

RESULTS

The quantitative analysis showed that public access to green space improved between 1990 and 2003 as a result of the regeneration and acquisition of new areas, and the average reduction in distance to green space was 162 m. However, such improvements were distributed differentially between population groups. In both 1990 and 2003, people from deprived areas and in poorer health had better access to green space than people from less deprived areas, but the greatest improvement in access to green space over this interval occurred in areas of below average deprivation (i.e. in the more affluent areas). The ethnographic research showed different interpretations of the notion of access. Use of TCCF was determined by a variety of factors including whether a person could 'imagine themselves' using such a space, different perceptions of what is actually being accessed (e.g. a place to exercise or a place to socialise), and ideas about using the countryside 'properly'.

CONCLUSIONS

The health benefits of using a green space, such as TCCF, for walking or exercising are well recognized. However, whether people choose to use local green space may be determined by a variety of factors. These are likely to include physical distance to access of green space, as well as perceptions and understandings of what is being accessed and how it should be used. This study has also illustrated the ways in which multiple methods can be integrated in public health research, and the merits of different approaches to undertaking multidisciplinary work of this type.

Psychosocial work conditions, unemployment and health locus of control: a population-based study

AIMS

To investigate the association between psychosocial work conditions, unemployment and lack of belief in the possibility of influencing one's own health.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS

The 2000 public health survey in Scania is a cross-sectional postal questionnaire study with a 59% participation rate. In total, 5180 persons aged 18-64 years who belonged to the workforce and the unemployed were included in this study. Logistic regression models were used to investigate the associations between psychosocial factors at work and unemployment, and lack of belief in the possibility of influencing one's own health (external locus of control). Psychosocial conditions at work were defined according to the Karasek-Theorell demand-control/decision latitudes into relaxed, active, passive, and job strain categories. The multivariate analyses included age, country of birth, education, economic stress, and social participation.

RESULTS

In total, 26.6% of all men and 26.9% of all women lack an internal locus of control. The passive, job strain and unemployed categories have significantly higher odds ratios of lack of internal locus of control, as compared to the relaxed reference category. No such significant differences are observed for the active category. These patterns remain in the multivariate models, with the exception of the passive and unemployed categories among men, in which the significant differences disappear.

CONCLUSIONS

Psychosocial work conditions and unemployment may affect health locus of control. The control dimension in the Karasek-Theorell model seems to be of greatest importance.

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.

Perceptions of the environment, physical activity, and obesity

Obesity rates are rising rapidly across the developed and developing world. Until recently obesity research has mainly focused on biological, psychological and behavioural factors. But there is growing agreement that environmental factors play an important role as well. In this study data from the 2003 Health Survey for England (n = 14,836) were analysed from a multilevel perspective to examine (1) the associations of the perceptions of the local environment with obesity, self-rated health, and physical activity, and (2) whether physical activity mediates the association between the perceptions of the environment, and obesity and self-rated health. This study found that perceptions of the friendliness of the local environment were mainly associated with self-rated health; perceived access to leisure facilities with sports activities; perceived access to a post office with walking; and the presence of social nuisances with obesity and poor self-rated health. In addition, positive perceptions of the social environment (i.e., social support and social capital) were associated with higher levels of physical activity, and lower levels of poor self-rated health and obesity. Only limited support was found for the idea that health behaviours mediate the associations between the perceptions of the environment, obesity, and self-rated health. Controlling for the three physical activity measures only rendered a small number of associations with self-rated health non-significant, and did not affect the associations with obesity. Overall, the results show that certain aspects of the environment may contribute to the risk of obesity and poor health. More research is needed to examine the specific mechanisms that link (the perceptions of) the environment to obesity and health.

Social capital, socio-economic status and psychological distress among Australian adults

High levels of social capital may be associated with positive mental health in adults. However, quantifying the various dimensions of social capital has presented a challenge due in part to the diverse definitions and measures used. Data from a representative, population-wide survey of Australian adults aged 16 years and older were used to investigate the links between dimensions of social capital and mental health morbidity. Social capital comprised three constructs and was measured at the individual level: feelings of trust and safety, community participation and neighbourhood connections and reciprocity. Mental health was measured by the 10-item Kessler (K10) instrument and assessed symptoms of psychological distress (i.e., depression and anxiety) over the previous month. Community participation showed a weak, and neighbourhood connections and reciprocity a moderate association with distress. Having higher levels of trust and feeling safe were consistently associated with low levels of psychological distress, after adjusting for socio-demographic characteristics and health conditions. The results clearly demonstrate that having trust in people, feeling safe in the community and having social reciprocity are associated with lower risk of mental health distress. The implications for conceptualising and measuring the individual and collective (contextual) dimensions of social capital are discussed. The findings also suggest the importance of examining the interrelationships between socio-economic status, social capital and mental health for community-dwelling adults.

Social capital, the miniaturisation of community, traditionalism and first time acute myocardial infarction: A prospective cohort study in southern Sweden

This longitudinal study investigates the impact of social participation, trust and the combinations of social participation and trust on the incidence of first time acute myocardial infarction (AMI) in the population of Scania, southern Sweden. It is based on the cross-sectional 2000 public-health survey in Scania with a 59% participation rate and 13,604 participants, and prospective morbidity/mortality data collected for three years (January 2000-December 2002). The study cohort was followed prospectively to examine first ever AMI. Hazard rate ratios (HRR) for first time AMI in the social participation, trust and social participation/trust combinations were calculated in a Cox regression model with adjustments for age, sex, education, economic stress, daily smoking, leisure time physical activity, body mass index (BMI), and self-reported health. The prevalence of low social participation was 32.8% among men and 31.5% among women. The prevalence of low trust was 40.0% among men and 44.2% among women. The three-year first time AMI rate was significantly higher among people with higher age, low education, daily smoking, poor self-reported health (among men), low social participation, and the combinations of low social participation/high trust and low social participation/low trust. The results show that low social participation but not trust was significantly associated with first time AMI after adjustment for age and sex. The positive association between low social participation and myocardial infarction remained significant after further adjustments for education, economic stress, daily smoking, physical activity and BMI, and became not significant only after additional adjustment for self-reported health, HRR 1.3 (0.9-2.0). High trust in combination with low social participation as well as low social capital (low trust/low social participation) were significantly associated with AMI, but after multiple adjustments only the low social participation/high trust category remained significant, HRR 1.6 (1.0-2.6).

Capital social e a agenda de pesquisa em epidemiologia

Capital social é definido como as características da organização social, tais como confiança interpessoal, normas de reciprocidade e redes solidárias, que capacitam os participantes a agir coletivamente e mais eficientemente, na busca de objetivos e metas comuns. Um número crescente de pesquisas, em sua maioria produzidas em países industrializados, sugere que sociedades com altos níveis de capital social possuem taxas mais baixas de mortalidade, maior expectativa de vida, são menos violentas e avaliam melhor a sua saúde. O principal objetivo deste artigo é revisar a relação entre capital social e saúde. Primeiramente, capital social é conceituado e as críticas que têm sido feitas quanto ao seu uso são discutidas. Em seguida, são apresentados os principais instrumentos de aferição adotados. Logo após é descrito o relacionamento entre capital social e saúde e, por último, considerações são feitas quanto ao seu uso na realidade brasileira. Capital social, se utilizado com maior rigor e atenção às dificuldades teórico-metodológicas que apresenta, pode ampliar a agenda de pesquisa em epidemiologia, contribuindo para um melhor entendimento de como enfrentar efetivamente as desigualdades em saúde.

US state- and county-level social capital in relation to obesity and physical inactivity: a multilevel, multivariable analysis

Although social capital has been linked to a variety of health outcomes, its association with obesity has yet to be elucidated. This study explored the relations between social capital measured at the US state and county levels and individual obesity and leisure-time physical inactivity. Individual-level data were drawn from the 2001 Behavioral Risk Factor Surveillance System survey, while data from other surveys and administrative sources were used to construct contextual measures. Two state-level social capital scales were derived from 10 indicators and two county-level scales from five indicators. In 2-level analyses of over 167,000 adults nested within 48 states plus the District of Columbia, residence in a state above the median on one or both state social capital scales (vs. neither scale) was associated with lower relative odds of obesity and physical inactivity, controlling for individual-level covariables and state-level estimates of mean household income, the Gini coefficient, and the percentage of Black residents. In 3-level analyses, the adjusted odds ratio (OR) for physical inactivity associated with residence in a county above the median on one or both county social capital scales was significantly below 1, while the association with obesity was not significant. Significantly weaker inverse ORs for the relations between state- and county-level social capital and obesity were observed among American Indians/Alaska Natives compared to Whites. Meanwhile, little support was found for mediation by social capital of the associations of urban sprawl and income inequality with obesity or physical inactivity. Overall, this study provides some evidence for the promotion of social capital as a potential strategy for addressing the burgeoning obesity epidemic.

Psychosocial work conditions, unemployment, and leisure-time physical activity: a population-based study

OBJECTIVE

To investigate the association between psychosocial work conditions and unemployment, and low leisure-time physical activity.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS

The 2000 public health survey in Scania is a cross-sectional postal questionnaire study with a 59% participation rate. A total of 5,180 persons aged 18-64 years who belonged to the workforce and the unemployed were included in this study. Logistic regression models were used to investigate the associations between psychosocial factors at work and unemployment, and low leisure-time physical activity. Psychosocial conditions at work were defined according to the Karasek-Theorell demand-control/decision latitudes into relaxed, active, passive, and job strain categories. The multivariate analyses included age, country of birth, education, economic stress, and social participation.

RESULTS

In total, 16.1% of men and 14.8% of women had low leisure-time physical activity. The job strain (high demands/low control) and unemployed categories had significantly higher odds ratios of low leisure-time physical activity among both men and women compared with the relaxed (low demands/high control) reference category. However, the significant differences between the job strain, the unemployed, and the relaxed categories disappeared in the multivariate models.

CONCLUSIONS

Respondents with job strain or unemployment have significantly higher odds ratios of low leisure-time physical activity than the relaxed category. However, after adjustments for education in particular the differences disappear. Nevertheless, the results suggest that the association between psychosocial work conditions, which are often dependent on education, and leisure-time physical activity may be interesting to study in more detail.

Social capital and health: does egalitarianism matter? A literature review

The aim of the paper is to critically review the notion of social capital and review empirical literature on the association between social capital and health across countries. The methodology used for the review includes a systematic search on electronic databases for peer-reviewed published literature. We categorize studies according to level of analysis (single and multilevel) and examine whether studies reveal a significant health impact of individual and area level social capital. We compare the study conclusions according to the country's degrees of economic egalitarianism. Regardless of study design, our findings indicate that a positive association (fixed effect) exists between social capital and better health irrespective of countries degree of egalitarianism. However, we find that the between-area variance (random effect) in health tends to be lower in more egalitarian countries than in less egalitarian countries. Our tentative conclusion is that an association between social capital and health at the individual level is robust with respect to the degree of egalitarianism within a country. Area level or contextual social capital may be less salient in egalitarian countries in explaining health differences across places.

Measuring and modeling the social and geographic context of trauma: a multilevel modeling approach

Increasingly it is recognized that health and illness are products of individual level risk and protective factors, as well as forces operating at contextual levels. In this article, we present the motivation and rationale for understanding trauma within its context. We use the example of the concept of social capital to illustrate the relevance of the contextual approach for trauma research and outline a multilevel modeling approach to examining contextual influences on trauma outcomes.

Individual characteristics, area social participation, and primary non-concordance with medication: a multilevel analysis

Background

Non-concordance with medication remains a major public health problem that imposes a considerable financial burden on the health care system, and there is still a need for studies on correlates of non-concordance. Our first aim is to analyse whether any of the individual characteristics age, educational level, financial strain, self-rated health, social participation, and trust in the health care system are associated with primary non-concordance with medication. Our second aim is to investigate whether people living in the same area have similar probability of primary non-concordance with medication, that relates to area social participation.

Methods

We analysed cross sectional data from 9 070 women and 6 795 men aged 18 to 79 years, living in 78 areas in central Sweden, who participated in the Life & Health year 2000 survey, with multilevel logistic regression (individuals at the first level and areas at the second level).

Results

Younger age, financial strain, low self-rated health, and low trust in the health care system were associated with primary non-concordance with medication. However, area social participation was not related to primary non-concordance, and the variation in primary non-concordance between the areas was small.

Conclusion

Our results indicate that people in central Sweden with younger age, financial difficulties, low self-rated health, and low trust in the health care system may have a higher probability of primary non-concordance with medication. However, the area of residence – as defined by administrative boundaries – seems to play a minor role for primary non-concordance.

Reduced likelihood of cancer screening among women in urban areas and with low socio-economic status: a multilevel analysis in Japan

OBJECTIVES

To elucidate socio-economic predictors of participation in cancer screening in Japanese women, paying attention to regional variations.

METHODS

In a nationally representative sample of women aged 40--64 years (n=15,224) in Japan, the relationships of self-reported attendance at screening for stomach, colon, uterine and breast cancers with individual characteristics (marital status, occupation and household income) and regional variables (living in a metropolitan area or not, and per capita income) were examined using multilevel analysis.

RESULTS

The participation rate ranged from 21.6% for colon cancer to 32.5% for uterine cancer. Being married, employed and having a higher household income were significantly associated with a higher likelihood of cancer screening for all types of cancer: the adjusted odds ratio in the lowest income quintile ranged from 0.45 for uterine cancer to 0.53 for colon cancer compared with the highest income quintile. There was significant regional variance, and living in a metropolitan area and per capita income were associated with a reduced likelihood of cancer screening.

CONCLUSIONS

Women with lower socio-economic status and living in urban areas are less likely to participate in cancer screening in Japan. Cancer screening should be encouraged in urban areas, taking account of the socio-economic inequalities.

Social capital and neo-materialist contextual determinants of sense of insecurity in the neighbourhood: a multilevel analysis in Southern Sweden

BACKGROUND

The aim of this study was to investigate the influence of contextual (social capital and neo-materialist) and individual factors on sense of insecurity in the neighbourhood.

METHODS

The 2000 public health survey in Scania is a cross-sectional study. A total of 13,715 persons answered a postal questionnaire, which is 59% of the random sample. A multilevel logistic regression model, with individuals at the first level and municipalities at the second, was performed. The effect (median odds ratios, intra-class correlation, cross-level modification and odds ratios) of individual and municipality/city quarter (social capital and police district) factors on sense of insecurity was analysed.

RESULTS

The crude variance between municipalities/city quarters was not affected by individual factors. The introduction of administrative police district in the model reduced the municipality variance, although some of the significant variance between municipalities remained. The introduction of social capital did not affect the municipality variance.

CONCLUSIONS

This study suggests that the neo-materialist factor administrative police district may partly explain the individual's sense of insecurity in the neighbourhood.

Accumulation of health risk behaviours is associated with lower socioeconomic status and women's urban residence: a multilevel analysis in Japan

Background

Little is known about the socioeconomic differences in health-related behaviours in Japan. The present study was performed to elucidate the effects of individual and regional socioeconomic factors on selected health risk behaviours among Japanese adults, with a particular focus on regional variations.

Methods

In a nationally representative sample aged 25 to 59 years old (20,030 men and 21,076 women), the relationships between six risk behaviours (i.e., current smoking, excessive alcohol consumption, poor dietary habits, physical inactivity, stress and non-attendance of health check-ups), individual characteristics (i.e., age, marital status, occupation and household income) and regional (N = 60) indicators (per capita income and unemployment rate) were examined by multilevel analysis.

Results

Divorce, employment in women, lower occupational class and lower household income were generally associated with a higher likelihood of risk behaviour. The degrees of regional variation in risk behaviour and the influence of regional indicators were greater in women than in men: higher per capita income was significantly associated with current smoking, excessive alcohol consumption, stress and non-attendance of health check-ups in women.

Conclusion

Individual lower socioeconomic status was a substantial predictor of risk behaviour in both sexes, while a marked regional influence was observed only in women. The accumulation of risk behaviours in individuals with lower socioeconomic status and in women in areas with higher income, reflecting an urban context, may contribute to their higher mortality rates.

Neighborhood influences on physical activity in middle-aged and older adults: a multilevel perspective

Over the past few years, attention has been drawn to the importance of neighborhood influences on physical activity behavior and the need to consider a multilevel analysis involving not only individual-level variables but also social- and physical-environment variables at the neighborhood level in explaining individual differences in physical activity outcomes. This new paradigm raises a series of issues concerning systems of influence observed at different hierarchical levels (e.g., individuals, neighborhoods) and variables that can be defined at each level. This article reviews research literature and discusses substantive, operational, and statistical issues in studies involving multilevel influences on middle-aged and older adults' physical activity. To encourage multilevel research, the authors propose a model that focuses attention on multiple levels of influence and the interaction among variables characterizing individuals, among variables characterizing neighborhoods, and across both levels. They conclude that a multilevel perspective is needed to increase understanding of the multiple influences on physical activity.

Environmental correlates of physical activity among individuals with diabetes in the rural midwest

OBJECTIVE

To determine the relationship between physical and social environment attributes and levels of physical activity in a population-based sample of diabetic individuals living in rural areas.

RESEARCH DESIGN AND METHODS

Cross-sectional telephone survey data from rural communities of southeastern Missouri, Tennessee, and Arkansas were used. Logistic regression was used to calculate crude and adjusted prevalence odds ratios (PORs) and 95% CIs.

RESULTS

A total of 278 (11%) individuals with diabetes were identified. Almost 37% of this group reported no leisure-time physical activity. Individuals with diabetes who reported regular physical activity were more likely to report better general health status, normal BMI, and no physical impairment. After adjustment, regular activity was positively associated with use of three or more facilities (POR 14.3, 95% CI 3.0-67.3) in the past 30 days, the availability of many nearby places to walk (2.3, 1.1-4.8), the availability of shoulders on streets (2.4, 1.3-4.5), often walking to nearby places (4.1, 2.0-8.3), and rating the community for physical activity as generally pleasant (2.3, 1.1-4.8). Additionally, the regular activity group was more likely to report their physician had helped make a plan to increase physical activity (2.8, 1.3-5.8) and followed up on their plan (2.2, 1.1-4.4). Social environment variables were not associated with physical activity after adjustment.

CONCLUSIONS

Physical inactivity is a significant problem in rural diabetic populations. We have identified aspects of the social and physical environment that are positively associated with physical activity. Understanding the role of the environment may result in increased physical activity for individuals with diabetes.

Social capital and health among the aged: comparisons between the United States and Germany

Through a cross-national investigation of the United States and Germany, this study examines how individual level social capital relates to the health of the elderly. Data from two national telephone surveys conducted in Germany (N=682) and the United States (N=608) with probability samples of non-institutionalized persons aged 60 and older was used. Indicators of social capital including both norms (reciprocity and civic trust) and behaviors (participation) were tested with three self-reported health indicators-overall health, depression (CES-D) and functional limitations. Housing variables and social support were controlled for in the study. Lack of reciprocity was associated with poorer self-rated health in both countries. Civic mistrust was associated with poorer self-rated health in both countries as well as with depression and functional limitations in America. Lack of participation was, in Germany, associated with poorer self-rated health and depression. The cross-national results indicate that individual-level analysis of social capital along with marco-level determinants are important for understanding the health of the elderly.

Individual self-reported health, social participation and neighbourhood: a multilevel analysis in Malmö, Sweden

BACKGROUND

The influence of neighbourhood and individual factors on self-reported health was investigated.

METHODS

The public health survey in Malmö 1994 is a cross-sectional study. A total of 3,602 individuals aged 20-80 living in 75 neighbourhoods answered a postal questionnaire. The participation rate was 71%. A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second, was performed. We analysed the effect (intra-area correlation, cross-level modification and odds ratios) of neighbourhood on self-reported health after adjustment for individual factors.

RESULTS

The neighbourhoods accounted for 2.8% of the crude total variance in self-reported health status. This effect was significantly reduced when individual factors such as country of origin, education and social participation were included in the model. In fact, no significant variance in self-reported health remained after the introduction of the individual factors in the model.

CONCLUSIONS

In Malmö, the neighbourhood variance in self-reported health is mainly affected by individual factors, especially country of origin, socioeconomic status measured as level of education and individual social participation.