American Journal of Epidemiology Vol. 154, No. 8 : 725-732
Copyright © 2001 by The Johns Hopkins University School of Hygiene and Public Health
ORIGINAL CONTRIBUTIONS |
Proximate and Contextual Socioeconomic Determinants of Mortality: Multilevel Approaches in a Setting with Universal Health Care Coverage
From the Dalhousie University Department of Community Health and Epidemiology, Faculty of Medicine, 5849 University Avenue, Halifax, Nova Scotia, B3H 4H7 Canada.
Investigations of contextual factors (income inequality, cultural disruption, access to health and social services, safety and crime rate, and others) have received little emphasis by epidemiologists, although a few have demonstrated the importance of such factors for mortality, particularly in the United States. To expand current understanding of the importance of contextual factors, the authors evaluated mortality in a longitudinal study in Nova Scotia, Canada, where all residents have greater access to health and social services and where income inequalities are smaller than in the United States. A total of 2,116 participants were followed from 1990 through December 1999, linked to the 1991 Canada Census as a source of neighborhood characteristics, and analyzed using individual-level and multilevel logistic regression. Well-educated and high-earning persons fared better. Neighborhood socioeconomic characteristics (neighborhood income, educational level, unemployment rate), in contrast, were not significantly associated with mortality. However, within advantaged neighborhoods, the importance of individual income and education for mortality was increased relative to disadvantaged neighborhoods. The latter findings may direct health policy aimed at reducing health inequalities.
health status; income; mortality; socioeconomic factors
Abbreviations: BMI, body mass index; CI, confidence interval
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