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BackgroundAlthough socio-economic factors have been identified as one of the most important groups of neighbourhood-level risks affecting birth outcomes, uncertainties still exist concerning the pathways through which they are transferred to individual risk factors. This poses a challenge for setting priorities and developing appropriate community-oriented public health interventions and planning guidelines to reduce the level of adverse birth outcomes.MethodThis study examines potential direct and mediated pathways through which neighbourhood-level socio-economic determinants exert their impacts on adverse birth outcomes. Two hypothesized models, namely the materialist and psycho-social models, and their corresponding pathways are tested using a binary-outcome multilevel mediation analysis. Live birth data, including adverse birth outcomes and person-level exposure variables, were obtained from three public health units in the province of Ontario, Canada. Corresponding neighbourhood-level socio-economic, psycho-social and living condition variables were extracted or constructed from the 2001 Canadian Census and the first three cycles (2001, 2003, and 2005) of the Canadian Community Health Surveys.ResultsNeighbourhood-level socio-economic-related risks are found to have direct effects on low birth weight and preterm birth. In addition, 20-30% of the total effects are contributed by indirect effects mediated through person-level risks. There is evidence of four person-level pathways, namely through individual socio-economic status, psycho-social stress, maternal health, and health behaviours, with all being simultaneously at work. Psycho-social pathways and buffering social capital-related variables are found to have more impact on low birth weight than on preterm birth.ConclusionThe evidence supports both the materialist and psycho-social conceptualizations and the pathways that describe them, although the magnitude of the former is greater than the latter.

Determining whether or not the treatment or innovation under study is actually in use, and if so, how it is being used, is essential to the interpretation of any study. The concept of Levels of Use of the Innovation (Loll) permits an operational, cost-feasible description and documentation of whether or not an innovation or treatment is being implemented. Data from change research and evaluation studies indicate that there are eight different LoU's that can be reliably measured. Knowing the LoU of individuals within a research or evaluation samplecan avoid holding false assumptions and making misleading interpretations about the userlnonuser and the effects of the treatment or innovation under study.

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