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Comparison of a spatial approach with the multilevel approach for investigating place effects on health: the example of healthcare utilisation in France
  1. Basile Chaix1,
  2. Juan Merlo2,
  3. Pierre Chauvin1
  1. 1Research Team on the Social Determinants of Health and Healthcare (INSERM U707), National Institute of Health and Medical Research, Paris, France
  2. 2Department of Community Medicine (Preventive Medicine), Malmö University Hospital, Lund University, Malmö, Sweden
  1. Correspondence to:
 Dr B Chaix
 INSERM U707, Faculté de Médecine Saint-Antoine, 27 rue Chaligny, 75571 Paris Cedex 12, France;


Study objective: Most studies of place effects on health have followed the multilevel analytical approach that investigates geographical variations of health phenomena by fragmenting space into arbitrary areas. This study examined whether analysing geographical variations across continuous space with spatial modelling techniques and contextual indicators that capture space as a continuous dimension surrounding individual residences provided more relevant information on the spatial distribution of outcomes. Healthcare utilisation in France was taken as an illustrative example in comparing the spatial approach with the multilevel approach.

Design: Multilevel and spatial analyses of cross sectional data.

Participants: 10 955 beneficiaries of the three principal national health insurance funds, surveyed in 1998 and 2000 on continental France.

Main results: Multilevel models showed significant geographical variations in healthcare utilisation. However, the Moran’s I statistic showed spatial autocorrelation unaccounted for by multilevel models. Modelling the correlation between people as a decreasing function of the spatial distance between them, spatial mixed models gave information not only on the magnitude, but also on the scale of spatial variations, and provided more accurate standard errors for risk factors effects. The socioeconomic level of the residential context and the supply of physicians were independently associated with healthcare utilisation. Place indicators better explained spatial variations in healthcare utilisation when measured across continuous space, rather than within administrative areas.

Conclusions: The kind of conceptualisation of space during analysis influences the understanding of place effects on health. In many contextual studies, viewing space as a continuum may yield more relevant information on the spatial distribution of outcomes.

  • epidemiological methods
  • logistic models
  • multilevel analysis
  • social environment
  • spatial analysis

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  • Funding: Basile Chaix carried out this work with a grant from the French Ministry of Research (TTT027) and with a grant from the French Foundation for Medical Research (FRM). The project was supported by the “Avenir 2002” programme of INSERM (the French National Institute of Health and Medical Research). Juan Merlo was supported in part by grants from FAS (Swedish Council for Working Life and Social Research) (2003–0580).

  • Conflicts of interest: none declared.

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