J Epidemiol Community Health 61:853-861 doi:10.1136/jech.2006.050740
  • Review
    • Continuing professional development

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

  1. Mylène Riva,
  2. Lise Gauvin,
  3. Tracie A Barnett
  1. Département de médecine sociale et préventive, Université de Montréal, Groupe de recherche interdisciplinaire en santé, Université de Montréal, and Centre de recherche Léa-Roback sur les inégalités sociales de santé de Montréal, Canada
  1. Mylène Riva, Department of Social and Preventive Medicine, University of Montreal, PO Box 6128, Downtown Station, Montreal, Quebec, Canada, H3C 3J7; mylene.riva{at}
  • Accepted 17 December 2006


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.


  • Abbreviations:
    medical subject heading
    socioeconomic status
    self rated health