Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review

Abstract

Purpose-Interest in the eVects of neighbourhood or local area social characteristics on health has increased in recent years, but to date the existing evidence has not been systematically reviewed. Multilevel or contextual analyses of social factors and health represent a possible reconciliation between two divergent epidemiological paradigms-individual risk factor epidemiology and an ecological approach. Data sources-Keyword searching of Index Medicus (Medline) and additional references from retrieved articles. Study selection-All original studies of the eVect of local area social characteristics on individual health outcomes, adjusted for individual socioeconomic status, published in English before 1 June 1998 and focused on populations in developed countries. Data synthesis-The methodological challenges posed by the design and interpretation of multilevel studies of local area eVects are discussed and results summarised with reference to type of health outcome. All but two of the 25 reviewed studies reported a statistically significant association between at least one measure of social environment and a health outcome (contextual eVect), after adjusting for individual level socioeconomic status (compositional eVect). Contextual eVects were generally modest and much smaller than compositional eVects. Conclusions-The evidence for modest neighbourhood eVects on health is fairly consistent despite heterogeneity of study designs, substitution of local area measures for neighbourhood measures and probable measurement error. By drawing public health attention to the health risks associated with the social structure and ecology of neighbourhoods, innovative approaches to community level interventions may ensue. (J Epidemiol Community Health 2001;55:111-122)

Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes

“…Other mechanisms by which an unfavorable neighborhood environment may impact health behaviors have been proposed, including a lack of access to health-promoting resources, accumulated stress brought on by the presence of hazards in the neighborhood environment, and prevailing attitudes that de-emphasize the importance of health and health behaviors. 1,12,[16][17][18][19] Because the association between neighborhood safety and adherence persisted after adjustment for multiple potential barriers to accessing a pharmacy and paying for prescriptions, including income, insurance status, and access to transportation, the lower adherence observed in unsafe neighborhoods is likely attributable to factors in addition to access and finances. It has been suggested that an accumulation of exposures to multiple unhealthy contextual factors may explain the deleterious health effects of unhealthy neighborhoods.…”

“…[14][15][16][17][18][19][20] Individuals who live in neighborhoods perceived to be unsafe, for example, report lower levels of physical activity 21 , higher rates of smoking 22,23 , and greater levels of obesity 12 compared to individuals living in neighborhoods perceived to be safe, even after accounting for individual-level markers of socioeconomic status, such as household income. Such "neighborhood effects" on health may be particularly pronounced among individuals with type 2 diabetes, which requires consistent adherence to management regimens that are often challenging and complex.…”

Does location matter? A proposed methodology to evaluate neighbourhood effects on cardiac arrest survival and bystander CPR

“…The patient's home neighbourhood will be used as a surrogate for patient characteristics, because previous literature shows an association between home neighbourhood and cardiac risk factors, unhealthy behaviours, and overall health. [33][34][35][36][37][38][39][40][41][42][43][44][45] The neighbourhood factors of the arrest location (i.e., the pickup address) will be used to study the effects on bystander CPR, because the emergency response (i.e., bystanders and EMS/paramedics) is contingent on the arrest location. [10][11][12][13][46][47][48] A patient's home address is recorded as mailing address with street name, street number, and postal code, whereas the pickup address is recorded as a mailing address, with latitude and longitude coordinates and a Universal Transverse Mercator (UTM) value.…”

Community Socioeconomic Context and Its Influence on Intermediary Determinants of Child Health: Evidence From Colombia

“…Additionally, the use of multilevel statistical techniques to estimate contextual effects in health research is now widespread in the demographic literature (Rice & Jones, 1997;Duncan et al, 1998;Diez Roux, 2000;Pickett & Pearl, 2001). However, the majority of empirical studies use unweighted data even when the units present unequal selection probabilities.…”