Original Article
Pathways from deprivation to health differed between individual and neighborhood-based indices

https://doi.org/10.1016/j.jclinepi.2006.10.005Get rights and content

Abstract

Objective

To explore the role of behavioral and psychosocial factors in explaining the social gradient in self-rated health as defined either by an individual or a neighborhood deprivation index.

Study Design and Setting

Data were from the baseline survey of the UK Flexible Sigmoidoscopy trial. Recruitment through general practices was stratified to generate a socioeconomically diverse sample (N = 5,253, aged 55–64). Assessments included an individual and neighborhood deprivation index, each of which were categorized in four levels; three behavioral and three psychosocial factors; and self-rated health.

Results

Neighborhood deprivation was more strongly related to behavioral than to psychosocial factors, whereas individual deprivation was strongly related to both. The social gradient in poor self-rated health (odds in most compared to least deprived group) was 6.5 for individual and 4.2 for the neighborhood deprivation index. Behavioral and psychosocial variables explained, respectively, 7% and 11% of the individual deprivation gradient and 11% and 4% of the neighborhood gradient. The psychosocial pathway did not significantly mediate the neighborhood deprivation effect on self-rated health.

Conclusion

Intermediary pathways of the social gradient in self-rated health differed between individual and neighborhood-based deprivation indices, suggesting at least partly independent influences on poor health of individual and neighborhood-level deprivation.

Introduction

The association between low socioeconomic status (SES) and poor health is well established. Both individual-level indicators (income, occupation, educational level) and neighborhood-level characteristics show a graded relationship to health outcomes [1], [2], [3]. There is continuing debate in the literature over whether the neighborhood effect is independent of individual SES [4], [5]. In general, successive adjustment for individual-level markers of SES progressively reduces the magnitude of the association between neighborhood-level SES and health [6], [7], [8]. It is therefore unclear whether there is a real independent neighborhood effect or if incomplete adjustment for individual SES explains the residual modest differences in health between residential areas. If it could be shown that there were different pathways explaining individual and neighborhood SES effects, this would contribute evidence for genuinely different mechanisms at work.

A number of different etiological pathways for the social gradient in health have been shown to be important. Suggested intermediary factors include unequal distribution of health risk behaviors (e.g., smoking, exercise) and differences in psychosocial vulnerability (e.g., perceived stress, personal control, social support) (see Model). The SES gradient in health behaviors and psychosocial vulnerability is described in many studies, showing disadvantageous characteristics in lower socioeconomic groups [1], [9], [10], [11]. The association between these factors and health has also been repeatedly described [11], [12]. Strong evidence that both of these pathways contribute to translating social position into ill health comes from Whitehall studies [1], [13] and the GLOBE study [14]. However, conclusions about the relative importance of the two pathways are inconsistent, which might be related to different measures of socioeconomic status [11], [15].

The present analyses compared an individual-level deprivation index with a neighborhood-based deprivation index of SES, and examined two pathways through which health might be affected: i) health related behaviors and ii) psychosocial factors such as stress and a lack of social support. Evidence for differential pathways for individual and neighborhood measures of deprivation may add information to our understanding of the social gradient in health. This is important because inequalities in health between rich and poor areas in Britain continue to increase and are particularly large in Scotland [4], [16], [17].

Section snippets

Study sample

Data were collected as part of the UK Flexible Sigmoidoscopy (FS) Trial [18], which was set up to assess the efficacy of FS screening in preventing bowel cancer in adults aged 55–64. It also incorporated extensive assessment of behavioral and psychosocial characteristics as part of the baseline assessment [18], [19]. In the Scottish center of the FS trial, 53 general practices were identified from records held by the Greater Glasgow Health Board and all adults aged 55–64 were contacted.

Results

The characteristics of the sample (N = 5,253) are shown in Table 1. More than a third (39%) of respondents reported poor self-rated health. Male gender and being unmarried were significantly related to poor self-rated health. In this sample with a small age range (55–64 years), age was unrelated to self-rated health. There were significant associations between older age and higher individual deprivation, and between being unmarried and higher deprivation (both indices) (data not shown). The two

Discussion

Our results indicated, in line with many other studies, graded associations between deprivation and self-rated health. The effects were strong whether deprivation was indexed by individual circumstances or neighborhood characteristics. Each deprivation index had independent effects, with greater neighborhood deprivation increasing the risk of poor self-rated health moderately even after adjustment for individual deprivation and vice versa. Both behavioral and psychosocial pathways appeared to

Acknowledgments

The authors wish to thank DR Boniface for statistical advice. Support from Cancer Research UK is gratefully acknowledged.

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