Summary of published studies of area level socioeconomic factors and health outcomes
| Reference | Outcome | Sample | Neighbourhood definition (average or stated size) | Neighbourhood SES measures | Individual SES measures | Cofactors | Type of model | Significant area level effects after controlling for individual SES and cofactors | ||||||||
| 1 Mortality studies | ||||||||||||||||
| Andersonet al, 199755 | All cause mortality | 233 600 black or white adults over age 25 from US National Longitudinal Mortality Study | Census tract (4000) | Median family income | Annual family income | Sex, age, race | Cox proportional hazards model using robust covariance matrix | Among whites: RR of lowv high income = 1.26 for men, 1.16 for women | ||||||||
| Among blacks: RR = 1.49 for men, no effect in black women or in either ethnic group over age 65 | ||||||||||||||||
| Davey Smith et al, 199748 | All cause mortality | 5766 men aged 35–64 recruited from 27 workplaces in West Scotland | Postcode sector (4660) | Carstair's index of deprivation | Cumulative lifetime social class, based on current, early adulthood and father's occupation | Age | Cox proportional hazards | None, with cumulative lifetime socioeconomic status in the model | ||||||||
| Davey Smithet al, 199856 1-150 | All cause mortality | 14 952 adult residents of West Scotland, aged 45–64 | Postcode sector (4660) | Carstair's index of deprivation | Occupational class | Sex, age | Cox proportional hazards | For most deprived v least deprived areas: in men RR = 1.34 for all cause mortality, 1.26 for CVD mortality; in women RR = 1.29 for all cause mortality, 1.33 for CVD mortality | ||||||||
| Haan et al, 198757 | All cause mortality | 1811 residents of Alameda County, California, over age 35 | Federal poverty area (151 000) | Residence within poverty areav not | Income, education, employment, health insurance | Sex, age, race, health | Logistic regression | RRs from 1.46–1.53 for residence in poverty area, adjusting for age, sex, race, health, and single measures of individual SES | ||||||||
| Kaplan, 199658 | As for: Haan, 1987 | As for: Haan, 1987 | Census tract (4000) | 4 scales of neighbourhood type, based on factor analysis | Income | Sex, age | Cox proportional hazards | Relative hazards from 1.3–2.0 for highv low quartile in all 4 scales | ||||||||
| LeClereet al, 199759 | All cause mortality | 346 917 white, black or Hispanic men and women over age 18 from US National Health Interview Survey | Census tract (4000) | Proportion black and Hispanic, median income, education, female headed households, poor female headed households | Education, income-to-needs ratio | Sex, age, race, marital status | Cox proportional hazards | Multiple models, eg: for men, RR for high proportion African-American tracts v low proportion = 1.13 to 1.18. For women, RR for high proportion female headed households v low proportion = 1.16, for high v low education = 0.84–0.86 | ||||||||
| LeClere et al, 199860 | Heart disease mortality | 199 221 white, black or Hispanic women over age 18 from US National Health Interview Survey | Census tract (4000) | Female headed household (female headship), black race, public assistance, poverty, poor female headed households, unemployment, median income | Per capita household income, education, employment status | Age, race, marital status, BMI, pre-existing heart conditions or hypertension, limiting activity | Cox proportional hazards | Multiple models, eg: in women under 65, effects of all other tract level variables become non-significant when tract level % of female headship included in models. RR from 1.47–1.85 for highest quartile of female headship | ||||||||
| Effect of % female headship weaker in older women | ||||||||||||||||
| Sloggett and Joshi, 199461 | All cause mortality before age 70 | Population-based, longitudinal sample of 292 860 adult residents of England and Wales, ages 16–65 | Electoral ward (5500) | Index based on unemployment, access to car, rental housing, social class | Occupational social class, housing tenure, access to car | Sex, age, region, marital status, presence of spouse, time period | Logistic regression | No significant area level effects in men, RR = 1.02 in women | ||||||||
| Sloggett and Joshi, 199862 1-150 | All cause mortality before age 70 | Population-based, longitudinal sample of over 300 000 residents of England and Wales, ages 10–64 | Electoral ward (5500) | Index based on unemployment, access to car, rental housing, social class | Occupational social class, unemployment, housewife status, housing tenure, access to car | Sex, age, region, time period | Logistic regression | Comparing most deprived to least deprived areas: for men RR = 1.02, for women, RR = 1.04 | ||||||||
| Waitzman and Smith, 199863 | All cause mortality, and cardiovascular, cancer, external, and other cause mortality | 10 161 black or white adults from US National Health and Nutrition Examination Study I | Federal poverty area (not given) | Residence within poverty area v not | Education, income | Sex, age, race, marital status, alcohol use, BMI, smoking, exercise, health status, hypertension, cholesterol | Cox proportional hazards | No significant effect in adults aged 55–74. In adults, 25–54 years, RR = 1.78 for all cause mortality, 1.9 for cardiovascular mortality, 1.95 for cancer mortality | ||||||||
| 2 Morbidity studies | ||||||||||||||||
| (a) Infant and child health (See also RR for low birth weight in Sloggett and Joshi, 1998) | ||||||||||||||||
| Morgan and Chinn, 198364 | Asthma in last year, bronchitis in last year, respiratory illness, hospital stay in last year, physician consult in last 2 weeks | 4902 children aged 5–11 years resident in England and Scotland from National Study of Health and Growth | Enumeration district (500) | ACORN group: classification of area based on factor analysis of 6 SES variables | Father or male guardian's occupational social class | Sex, age | Logistic regression | Effect of ACORN on bronchitis but not other outcomes. | ||||||||
| O'Campo et al, 199747 | Low birth weight | 50 757 births in Baltimore, Maryland | Census tract (4000) | Home ownership, number of community groups, unemployment, housing violations, crime rate, wealth, income | Education, insurance status | Maternal age, prenatal care, education, health insurance status | Hierarchical logistic regression | RR = 1.11 for low per capita income, interaction effects of unemployment and maternal age, crime rate and maternal education, wealth and prenatal care, unemployment and prenatal care, per capita income and health insurance status | ||||||||
| Roberts, 199725 | Low birth weight | 112 327 births in the Chicago Statistical Metropolitan Area | Community area | SES index, hardship, demography, residential stability, median rent, overcrowding, % black, % Hispanic | Education | Age, race, marital status, prenatal care, parity, smoking, alcohol use | Logistic regression | Economic hardship and median rent positively associated with low birth weight, area level SES, overcrowding, proportion of young residents and proportion of black residents negatively associated with low birth weight | ||||||||
| (b) Chronic disease among adults | ||||||||||||||||
| Davey Smith et al, 199856 1-150 | Diastolic blood pressure, cholesterol, height, BMI, FEV, bronchitis, angina, ECG ischaemia | Cross referenced above | Trend test of age adjusted means and proportions | In women, all outcomes except blood pressure and cholesterol were related to deprivation at p<0.05. Among men, BMI and ECG ischaemia were also not significant. | ||||||||||||
| Diez-Roux, 199769 1-150 | Coronary heart disease, serum cholesterol, systolic blood pressure | 12 601 black or white adults aged 45–64 years from 4 US communities in North Carolina, Minnesota, Mississippi, Maryland | Census block group (1000) | Education, median income, occupation, housing value | Income or education or occupation (each modelled only with area level analogue) | Age, field centre | Hierarchical linear and logistic regression | Multiple models: significant effects of area level SES on blood pressure (mean differences (MD) from 1.8–3.2) and cholesterol (MD from 4.4–5.2). CHD (RR for area level variables from 1.61–2.82) was only significant in women living in white communities but not in predominantly black communities or in men | ||||||||
| Humphreys and Carr-Hill, 199165 | Self assessed health, long term illness, respiratory function, symptom scores | 4352 British adults aged over 18 from Health and Lifestyle Survey | Electoral ward (5500) | Clusters based on factor analysis of birthplace, unemployment, housing tenure, overcrowding, access to car, social class | Education, overcrowding | Sex, age, ethnicity, alcohol use, smoking, exercise, access to garden | Hierarchical linear regression | Multiple models: significant negative effects of unemployment, rental housing, no access to car, low social class on self assessed health, symptoms score; effect only of lack of access to car on respiratory function. No effects found for long term illness. | ||||||||
| Jones and Duncan, 19954 | Self reported health, symptoms of heart disease, respiratory function | 9003 British adults, aged over 18 from Health and Lifestyle Survey | Electoral ward (5500) and constituency | Urban environment, index of deprivation based on employment, social class, housing tenure and access to car, average household income | Social class, employment status, housing class, income | Sex, age, height, smoking, alcohol use, eating, exercising | Hierarchical logistic regression | Significant effect of ward deprivation on all outcomes. For respiratory function, a significant interaction between smoking and urban environment, for self rated health, an interaction between deprivation index and social class, for heart disease symptoms interaction between individual income and deprivation index | ||||||||
| Krieger, 199231 1-150 | Hypertension, height | 14 240 black or white members of Northern California Kaiser Permanente Medical Care Program | Census tract (4000) and block group (1000) | Proportion working class, impoverished and undereducated | Working class occupation | Sex, age, race, BMI (for hypertension only) | Multiple linear and logistic regression | Results shown for block group level only: coefficient for non-working class people in non-working class block groupv working class block group = −0.9 for height in centimetres, RR = 1.2 for hypertension | ||||||||
| Reijneveld, 199866 | Self rated health, physical complaints, longterm disability, BMI | Random sample of 5121 adults over 16 years resident in Amsterdam | Borough (not given) | Mean income, household income below minimum, unemployment | Income, education, occupation | Sex, age, standardised mortality ratio of borough | Hierarchical logistic regression | RR = 1.2 for most deprived household incomev least deprived and obese BMI, RR = 1.3 for intermediate mean income v least deprived mean income for longterm disability | ||||||||
| Robert, 199867 | Number of chronic conditions, functional limitations, self rated health | 3617 adults, over 25 years from Americans' Changing Lives study | Census tract | Households receiving public assistance, unemployment, family income <$30 000, economic disadvantage index | Education, family income, family assets | Sex, age, race | Multiple linear regression | When all individual level SES variables in model: economic disadvantage index is a significant predictor of number of chronic conditions, households receiving public assistance is a significant predictor of self rated health | ||||||||
| Shouls et al, 199668 | Limiting long term illness | 10% random subsample of adults over age 16 years, from Sample of Anonymised Records from British census | Local government district | Factors and clusters of census socioeconomic variables | Social class, deprivation score | Sex, age, ethnicity, marital status | Hierarchical logistic regression | Multiple models: health inequalities most pronounced in affluent areas, deprivation most important area level variable, interaction with sex—stronger area level effects in men | ||||||||
| Sloggett and Joshi, 199862 1-150 | Long term limiting illness, low birth weight | Cross referenced above | Gender, age, region | Logistic regression | For long term limiting illness, RR = 1.08 for women and RR = 1.09 for men. For low birth weight, RR = 1.04. All RRs are <1.1 but are statistically significant, although much smaller than RR for individual level variables. | |||||||||||
| (c) Mental health | ||||||||||||||||
| Reijneveld and Schene, 199870 | Mental disorders | As for Reijneveld, 1998 above | Sex, age, standardised mortality ratio of borough, plus family type, chronic physical limitation | Hierarchical logistic regression | None, with all individual level SES variables in model | |||||||||||
| 3 Health behaviour studies | ||||||||||||||||
| Curryet al, 199324 | Attitudes towards smoking, alcohol use and dietary fat intake | Random survey of 8849 adults, aged over 18 in 15 communities in Western USA | Self defined geographical communities | Residence, education, unemployment, residential stability | Education, employment, household income, residential stability | Sex, age, race, marital status, community attitudes towards health behaviours, health behaviours | Multiple linear regression | Significant effects of community attitudes and education on attitude to smoking and of residential stability on attitude to fat consumption | ||||||||
| Diez-Roux et al, 199769 1-150 | Smoking | Cross referenced above | In mostly white communities: for men RR for smoking = 1.44 for low education, 1.6 for low household income, 1.68 for low housing value, 1.61 for low occupation; for women, RR for smoking = 1.42 for low occupation. In mostly black communities, significant effects in women for all area level effects but not in men, except for low occupation (RR = 1.54) | |||||||||||||
| Karvonen and Rimpela, 199636 | Smoking, alcohol use, physical activity, consumption of full fat milk | Population-based sample of 9121 Finnish teenagers aged 16 and 18 years | Municipality | Occupational structure, self sufficiency of employment, level of services | Occupation of head of household, type of school, type of family | Age, sex | Logistic regression | RR for high level of neighbourhood services and full fat milk use = 0.59, RR for low self sufficiency of employment and full fat milk use = 0.59 in boys, girls in areas of high occupational structure more likely to consume full fat milk, RR = 2.36. In boys, effect of education on alcohol use, modified by level of services, RR for alcohol use = 1.35 in areas with low self sufficiency of employment, RR for alcohol use = 1.47 for girls in highly educated areas | ||||||||
| Kleinschmidtet al, 199546 | Smoking | Random sample of 7866 adults from England's North West Thames regional health survey | Electoral ward | Carstair's Index, based on unemployment, overcrowding, access to car, social class | SES measured by a 17-level categorical composite | Sex, age | Hierarchical logistic regression | RR for smoking in most v least deprived areas = 1.52 | ||||||||
| Krieger, 199231 1-150 | Smoking | Cross referenced above | RR of smoking = 1.4 for non-working class women in non-working class block groupv working class block group | |||||||||||||
| O'Campoet al, 199537 | Partner perpetrated violence in childbearing year | 157 low income women from Baltimore, Maryland | Census tract | Income, home ownership, unemployment, per capita crime rate | Employment, education, income | Age, race, marital status, social support, parity, partner drug use | Logistic regression and hierarchical logistic regression | RR for violence: unemployment = 3.4, low income = 4.4 | ||||||||
| Reijneveld, 199866 1-150 | Smoking | Cross referenced above | RR for smoking: 1.19 for low average area level income, 1.23 for high % of household poverty, no effect of neighbourhood unemployment rate | |||||||||||||
↵1-150 Study is also cross referenced under another outcome.