Socioeconomic determinants of mortality in two Canadian provinces: Multilevel modelling and neighborhood context
Introduction
The relationship between individual socioeconomic characteristics and health status has been well documented; higher socioeconomic status is generally associated with better health (Smith, Bartley, & Blane, 1990; Kaplan, 1996). This association holds true in Canada, despite national health insurance and smaller income inequalities than in the United States (Veugelers, Yip, & Kephart, 2001; Mustard, Derksen, Berthelot, Wolfson, & Roos, 1997; Wolfson & Murphy (2000), Wolfson & Murphy (1998)).
However, studies examining neighborhood-level variables and their effect on individual health status have produced diverse results (McMichael, 1999). Many believe community context independently affects the health of all residents (Yen & Kaplan, 1999; Pampalon, Duncan, Subramanian, & Jones, 1999; Mitchell, Gleave, Bartley, Wiggins, & Joshi, 2000; Malmstrom, Johannson, & Sundquist, 2001; Kolegard, Diderichsen, Reuterwall, & Hallqvist, 2002). Others have reported neighborhood-level effects to be due entirely to compositional effects, to an aggregation of the relationships between individual socioeconomic context and individual health status (Sloggett & Joshi, 1994; Duncan, Jones, & Moon, 1995; Bobak, Pikhart, Rose, Hertzman, & Marmot, 2000; Sturm & Gresenz, 2002). Several papers have shown contextual effects to vary by gender (Kolegard et al., 2002), age (Waitzman & Smith, 1998), and neighborhood type (Jessop, 1992; Haynes & Gale, 1999).
Shouls, Congdon, and Curtis (1996) and Yen and Kaplan (1999) noted greater morbidity among individuals in deprived areas (of the United Kingdom and the United States) even after taking individual characteristics into account. In Nova Scotia, Canada Veugelers et al. (2001) found no direct association with neighborhood-level factors. Contextual factors were suggested to be of less importance in Canada than in the United States because of the higher levels of social services provided in Canada. Despite differing results regarding the direct effect of neighborhood characteristics on mortality, Shouls et al. (1996), Yen and Kaplan (1999), and Veugelers et al. (2001) reported a cross-level effect of neighborhood status on the relationship between individual income and mortality.
This paper replicates and extends the Nova Scotia work of Veugelers et al. (2001) in Manitoba, another Canadian province. Using two sites alleviates risks of Type 1 error (inferring a relationship when one does not actually exist) due to conducting a number of statistical tests (implicit in multilevel modelling) with moderate statistical power. Comparing the effects of socioeconomic determinants on mortality in each province using surveys differing in administration, in time period covered, and in length of follow-up increases generalizibility. The two provinces’ substantial differences in size, ethnic mix, and history also add to the generalizability of the results.
Manitoba data permitted assessing the role of two additional variables: urban/rural residence and residential mobility. Glass and Balfour (2003) have pointed out that little research has compared the income and health associations found in urban areas to those in suburban and rural communities. Urban neighborhoods show more residential segregation by income than rural neighborhoods (Wilkins, Berthelot, & Ng, 2002); therefore, differences in health among income groups in urban areas might be expected to be greater than those in rural areas.
Residential mobility information allows for comparison of mortality among movers and non-movers. Individuals “exposed” to a neighborhood for a longer period of time may show more area-specific health effects than those recently moving to that area (Robert, 1999; Lynch, Kaplan, & Shema, 1997). Selective migration of the healthy out of disadvantaged neighborhoods may leave behind “unhealthy survivors” (predisposed toward early mortality) (Macintyre & Ellaway, 2003).
This research helps determine both the generalizability of neighborhood effects and the importance of the urban/rural and mobility variables. Manitoba and Nova Scotia provide similar universal access to basic health and social services and are representative of a distinctly Canadian approach. Such work facilitates the meaningful comparison between Canadian work on socioeconomic determinants of health and that in other countries.
Section snippets
Individual characteristics
Interviews gathered information on lifestyle and other individual characteristics from non-institutionalized residents aged 18–75 years (18 years or older and less than 75 years of age). Individual characteristics were taken from the 1990 Nova Scotia Nutrition Survey and from Manitoba respondents to the 1996–97 National Population Health Survey. Individual variables included age, gender, smoking status, diabetes, body mass index (BMI), household income, and education. Essentially complete
Individual and neighborhood characteristics
Table 1 shows individual and neighborhood characteristics and their age- and gender-adjusted ORs for respondents’ mortality. The age- and gender-adjusted mortality risk was significantly greater among smokers and diabetics in both provinces; BMI of less than 20 was also associated with higher mortality in Nova Scotia (Table 1). Mortality ORs adjusted for age, gender, smoking status, diabetic status, and BMI are presented in Table 2.
In Manitoba, individual household income was significantly
Discussion
This research has combined a multilevel approach and a comparative, longitudinal design to examine the role of individual and neighborhood socioeconomic characteristics. Well-educated, higher earning respondents live longer, even after controlling for age, gender, smoking status, BMI, and diabetes. In both provinces, after controlling for individual-level variables, no neighborhood-level socioeconomic characteristics were found to have a statistically significant direct effect on individual
Acknowledgements
This work was funded by the Canadian Population Health Initiative. Ms. Magoon benefitted by a studentship from the Western Regional Training Centre, supported by the Canadian Health Services Research Foundation. A Canadian Institutes of Health Research Career Award to Dr. Veugelers provided additional support. The results and conclusions are those of the authors, and no official endorsement by Manitoba Health or the Nova Scotia Department of Health was intended or should be implied. We are
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