Social capital and administrative contextual determinants of lack of access to a regular doctor: a multilevel analysis in southern Sweden

BACKGROUND: The aim of this study was to investigate the influence of contextual (social capital and administrative/neo-materialist) and individual factors on lack of access to a regular doctor. METHODS: The 2000 public health survey in Scania is a cross-sectional study. A total of 13,715 persons answered a postal questionnaire, which is 59% of the random sample. A multilevel logistic regression model, with individuals at the first level and municipalities at the second, was performed. The effect (intra-class correlations, cross-level modification and odds ratios) of individual and municipality (social capital and health care district) factors on lack of access to a regular doctor was analysed using simulation method. The Deviance Information Criterion (DIC) was used as information criterion for the models. RESULTS: The second level municipality variance in lack of access to a regular doctor is substantial even in the final models with all individual and contextual variables included. The model that results in the largest reduction in DIC is the model including age, sex and individual social participation (which is a network aspect of social capital), but the models which include administrative and social capital second level factors also reduced the DIC values. CONCLUSIONS: This study suggests that both administrative health care district and social capital may partly explain the individual's self reported lack of access to a regular doctor.     

Social capital and sense of insecurity in the neighbourhood: a population-based multilevel analysis in Malmö, Sweden

The aim of this study was to investigate the influence of social capital on self-reported sense of insecurity in the neighbourhood. The public health survey in Malm?, Sweden in 1994 was a cross-sectional study. A total of 5600 individuals aged 20-80 years were asked to answer a postal questionnaire. The participation rate was 71%. A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second, was performed. We analysed the effect (intra-area correlation, cross-level modification and odds ratios) of individual (social participation) and neighbourhood social capital (electoral participation in the 1994 municipal election) on sense of insecurity after adjustment for compositional factors. Neighbourhood factors accounted for 7.2% of the total variance in individual insecurity. This effect was marginally reduced when the individual factors were included in the model. In contrast, it was reduced by 70% by the introduction of the contextual variable. This study suggests that social capital, measured as electoral participation, may partly explain the individual's sense of insecurity in the neighbourhood.     

Individual and contextual determinants of self-reported poor psychological health: a population-based multilevel analysis in southern Sweden

OBJECTIVE: To investigate the influence of contextual and individual factors on self-reported psychological health. DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS: The 2000 public health survey in Scania is a cross-sectional postal questionnaire study with a 59% participation rate. A total of 13,715 persons aged 18-80 answered the questionnaire. A multilevel logistic regression model, with individuals at the first level and municipalities/city quarters at the second, was performed. The effect (intra-class correlation, cross-level modification, and odds ratios) of individual and municipality/city quarter factors on self-reported psychological health was analysed. RESULTS: The crude variance between municipalities/city quarters was small but significant. It was particularly affected and lowered by individual civil status, country of origin, economic stress, and social participation. The inclusion of all individual factors age, sex, civil status, country of origin, education, economic stress, and social participation lowered the between municipality variance to not-significant levels, which is the reason why no contextual variables were included in the calculations. CONCLUSIONS: The results of this study suggest that poor self-reported psychological health is affected mainly by individual characteristics of the population and not by contextual factors at the municipality/city quarter level.     

Social capital and leisure time physical activity: a population based multilevel analysis in Malmö, Sweden

Objective: To investigate the influence of social capital and individual factors on the level of leisure time physical inactivity in the neighbourhoods. Methods: The public health survey in Malmö 1994 is a cross sectional study. A total of 5600 people aged 20–80 years were invited to answer a postal questionnaire. The participation rate was 71%. A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second, was performed. The effect (intra-area correlation, cross level modification, and odds ratios) was analysed of individual and neighbourhood (the 1993 migration out of an area as a proxy for social capital) factors on leisure time physical inactivity after adjustment for individual factors. Results: Neighbourhood factors accounted for 5.0% of the crude total variance in physical inactivity. This effect was significantly reduced when the individual factors, especially country of origin, education, and social participation, were included in the model. In contrast, it was not reduced by the introduction of the contextual social capital variable. Conclusion: This study suggests that in the neighbourhoods of Malmö leisure time physical inactivity is mainly affected by individual factors.     

Individual self-reported health, social participation and neighbourhood: a multilevel analysis in Malmö, Sweden

BACKGROUND: The influence of neighbourhood and individual factors on self-reported health was investigated. METHODS: The public health survey in Malm? 1994 is a cross-sectional study. A total of 3,602 individuals aged 20-80 living in 75 neighbourhoods answered a postal questionnaire. The participation rate was 71%. A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second, was performed. We analysed the effect (intra-area correlation, cross-level modification and odds ratios) of neighbourhood on self-reported health after adjustment for individual factors. RESULTS: The neighbourhoods accounted for 2.8% of the crude total variance in self-reported health status. This effect was significantly reduced when individual factors such as country of origin, education and social participation were included in the model. In fact, no significant variance in self-reported health remained after the introduction of the individual factors in the model. CONCLUSIONS: In Malm?, the neighbourhood variance in self-reported health is mainly affected by individual factors, especially country of origin, socioeconomic status measured as level of education and individual social participation.     

Perceptions of social capital and the built environment and mental health

There has been much speculation about a possible association between the social and built environment and health, but the empirical evidence is still elusive. The social and built environments are best seen as contextual concepts but they are usually estimated as an aggregation of individual compositional measures, such as perceptions on trust or the desirability to live in an area. If these aggregated compositional measures were valid measures, one would expect that they would evince correlations at higher levels of data collection (e.g., neighbourhood). The aims of this paper are: (1) to investigate the factor structure of a self-administered questionnaire measuring individual perceptions of trust, social participation, social cohesion, social control, and the built environment; (2) to investigate variation in these factors at higher than the individual level (households and postcodes) in order to assess if these constructs reflect some contextual effect; and (3) to study the association between mental health, as measured by the General Health Questionnaire-12 (GHQ-12), and these derived factors. A cross-sectional household survey was undertaken during May-August 2001 in a district of South Wales with a population of 140,000. We found that factor analysis grouped our questions in factors similar to the theoretical ones we had previously envisaged. We also found that approximately one-third of the variance for neighbourhood quality and 10% for social control was explained at postcode (neighbourhood) level after adjusting for individual variables, thus suggesting that some of our compositional measures capture contextual characteristics of the built and social environment. After adjusting for individual variables, trust and social cohesion, two key social capital components were the only factors to show statistically significant associations with GHQ-12 scores. However, these factors also showed little variation at postcode levels, suggesting a stronger individual determination. We conclude that our results provide some evidence in support of an association between mental health (GHQ-12 scores) and perceptions of social capital, but less support for the contextual nature of social capital.     

Association between perceived security of the neighbourhood and small-for-gestational-age birth

Evidence points to an association between a mother's place of residence and her newborn's health, independent of individual characteristics. Neighbourhood constructs such as immigrant density, deprivation and crime have all been separately associated with birth outcomes. Little research has considered the joint influence of variables representing a spectrum of neighbourhood constructs. Subjective vs. objective measures of neighbourhood constructs (e.g. reported vs. perceived crime) are often not considered. We sought to evaluate the relationship between neighbourhood measures of reported crime, neighbourhood perceived security, immigrant density, material/social deprivation, residential stability and the odds of small-for-gestational-age (SGA) birth in an urban setting in Canada. Neighbourhood was defined as police districts ( n  = 49). We linked Montreal livebirths 1997–2001 ( n  = 98 330) to police district crime measures, survey data on perceived security, and 2001 census data. We used multi-level analysis to calculate odds ratios (OR) for neighbourhood effects on SGA birth accounting for individual characteristics.
Mothers residing in neighbourhoods with the most favourable perception had a lower odds of SGA birth than neighbourhoods with the least favourable perception [OR 0.87, 95% CI 0.77, 0.97]. Mothers in neighbourhoods with lower proportions of immigrants had lower odds of SGA birth relative to neighbourhoods with the highest proportion of immigrants. Reported crime, residential stability and material/social deprivation (accounting for neighbourhood perception) were not associated with SGA birth. Immigrant density and subjective perceptions of neighbourhood security are associated with SGA birth. Public health strategies to improve fetal growth should target neighbourhoods with low perceived security and high immigrant density.     

Individual and neighbourhood determinants of social participation and social capital: a multilevel analysis of the city of Malmö, Sweden

The aim of this study was to analyse the impact of neighbourhood on individual social capital (measured as social participation). The study population consisted of 14,390 individuals aged 45–73 that participated in the Malmö diet and cancer study in 1992–1994, residing in 90 neighbourhoods of Malmö, Sweden (population 250,000). A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second level, was performed. The study analysed the effect (intra-area correlation and cross-level modification) of the neighbourhood on individual social capital after adjustment for compositional factors (e.g. age, sex, educational level, occupational status, disability pension, living alone, sick leave, unemployment) and, finally, one contextual migration factor. The prevalence of low social participation varied from 23.0% to 39.7% in the first and third neighbourhood quartiles, respectively. Neighbourhood factors accounted for 6.3% of the total variance in social participation, and this effect was reduced but not eliminated when adjusting for all studied variables (−73%), especially the occupational composition of the neighbourhoods (−58%). The contextual migration variable further reduced the variance in social participation at the neighbourhood level to some extent. Our study supports Putnam's notion that social capital, which is suggested to be an important factor for population health and possibly for health equity, is an aspect that is partly contextual in its nature.     

Income inequality and psychological distress at neighbourhood and municipality level: An analysis in the Netherlands

This study examines the associations between income inequality at neighbourhood and municipality level and psychological distress in a country with a relatively low income inequality, the Netherlands. Multilevel linear regression analyses were used to investigate associations between income inequality and mean income at the neighbourhood (n = 7803) and municipality (n = 406) level and psychological distress (scale range 10–50), in a country-wide sample of 343,327 individuals, adjusted for gender, age, ethnicity, marital status, education and household income. No significant association was found between neighbourhood income inequality and psychological distress after adjustment for individual and neighbourhood level confounding. However, a higher neighbourhood income inequality in neighbourhoods with the middle to highest mean neighbourhood incomes was associated with more psychological distress. Individuals living in municipalities with the highest income inequality reported 2.5% higher psychological distress compared to those living in municipalities with the lowest income inequality. Income inequality seems to matter more for mental health at the municipality than neighbourhood level.     

Under-reporting of live births in Ontario: 1991-1997

OBJECTIVE: To examine unregistered births in Ontario and consider related factors, including adoption of administrative fees for birth registration. METHODS: Documents from both the parents and the attending physician are required for births to be entered into Ontario's live birth database. Our study used data from the Ontario Registrar General to look at the prevalence and characteristics of unregistered births, and a survey of municipal clerks to identify municipalities charging fees for parental documentation. RESULTS: The percentage of births going unrecorded increased threefold from 1991 to 1997. The odds of an unregistered birth were higher for teenage mothers, low birthweight babies, and mothers residing in a municipality that charged birth registration fees. CONCLUSION: The introduction of registration fees by some municipalities appears to account for an increase in unregistered births. It is recommended that the Ontario Registrar General work to remove financial and administrative barriers that compromise birth statistics.     

Low linking social capital as a predictor of coronary heart disease in Sweden: a cohort study of 2.8 million people

This study investigated the association between the recently minted concept of linking social capital and incidence of coronary heart disease (CHD). A follow-up study of 1,358,932 men and 1,446,747 women in Sweden aged 45-74 years was conducted between 1 January 1998 and 31 December 1999. Neighbourhood linking social capital was conceptualised as proportions of individuals voting in local government elections at neighbourhood level. The neighbourhood- and individual-level factors were analysed within a multilevel framework. Linking social capital was associated with CHD in both men and women beyond individual-level factors: in neighbourhoods with low linking social capital the odds ratios were 1.19 (CI = 1.14-1.24) and 1.29 (CI = 1.21-1.38) for men and women, respectively, after adjustment for age, country of birth, education, marital status, and housing tenure. The significant between-neighbourhood variance (i.e. the random intercept) showed significant differences in CHD incidence between neighbourhoods. Even in a relatively egalitarian society, as exemplified by the Swedish Welfare State, individual health is affected by differences between neighbourhoods in linking social capital. The use of linking social capital represents a novel conceptual advance in research on the association between CHD, one of the major causes of death in Western countries, and the multidimensional aspects of social capital.     

The effect of neighbourhood social capital on child injuries: A gender-stratified analysis

We designed a longitudinal retrospective cohort study to analyse the associations between neighbourhood social capital and child injures. Register data from the Umeå Simsam Lab in Sweden was used to measure child injuries and demographic and socioeconomic factors at individual, household and neighbourhood level. A social capital score from a previous survey was used to measure neighbourhood social capital. We conducted a three-level multilevel negative binomial regression analysis, with children (level 1, N = 77,193) nested within households (level 2, N = 10,465), and households nested within neighbourhoods (level 3, N = 49). The incidence rate of child injuries was lower in high social capital neighbourhoods. When controlling for factors at individual, household and neighbourhood levels, living in a high social capital neighbourhood was protective of injuries among girls, but not among boys. Promoting social capital in local neighbourhoods could be seen as a prevention strategy for injuries among girls.     

The importance of social characteristics of communities for the medically based disability pension

BACKGROUND: The aim of this study was to look for any possible contextual effect of deprivation at municipality level on the risk of being granted the medically based disability pension, controlled for compositional effects due to spatial concentration of people with a high risk of disability. METHODS: The material consists of the residentiary part of a total Norwegian county population aged 20-54 years without disability pension at baseline, n=40,083. This study was performed as a 10-year follow-up study. The relative risk of being granted a disability pension was estimated by logistic regression analyses as odds ratios (OR) between people living in different municipalities according to a municipality deprivation index at three levels, adjusted for individual factors. RESULTS: The OR of disability pension was 1.36 (1.22, 1.51) for people residing in intermediate deprived municipalities and 1.48 (1.31, 1.67) for people residing in the most deprived municipalities compared to the most affluent municipalities, adjusted for gender and age. After adjustment for individual risk factors the OR was 1.26 (1.12, 1.41) and 1.18 (1.04, 1.35) respectively. Analyses stratified by gender showed that the increased risk of receiving a disability pension for men in the most deprived municipalities was explained by individual factors alone. CONCLUSION: Relative municipality deprivation seems to account for an increase in the incidence of disability pension. This effect contributes to marginalization of people living in less affluent areas out of employment and thus to widening socioeconomic inequalities in the population.     

Neighbourhood characteristics,social capital and self-rated health - A population-based survey in Sweden

Background

In previous public health surveys large differences in health have been shown between citizens living in different neighbourhoods in the Örebro municipality, which has about 125000 inhabitants. The aim of this study was to investigate the determinants of health with an emphasis on the importance of neighbourhood characteristics such as the influence of neighbourhood social cohesion and social capital. The point of departure in this study was a conceptual model inspired by the work of Carpiano, where different factors related to the neighbourhood have been used to find associations to individual self-rated health.

Methods

We used data from the survey 'Life &; Health 2004' sent to inhabitants aged 18-84 years in Örebro municipality, Sweden. The respondents (n = 2346) answered a postal questionnaire about living conditions, housing conditions, health risk factors and individual health. The outcome variable was self-rated health. In the analysis we applied logistic regression modelling in various model steps following a conceptual model.

Results

The results show that poor self-rated health was associated with social capital, such as lack of personal support and no experience of being made proud even after controlling for strong factors related to health, such as age, disability pension, ethnicity and economic stress. Also the neighbourhood factors, housing area and residential stability were associated with self-rated health. Poor self-rated health was more common among people living in areas with predominately large blocks of flats or areas outside the city centre. Moreover, people who had lived in the same area 1-5 years reported poor health more frequently than those who had lived there longer.

Conclusions

The importance of the neighbourhood and social capital for individual health is confirmed in this study. The neighbourhoods could be emphasized as settings for health promotion. They can be constructed to promote social interaction which in turn supports the development of social networks, social support and social capital - all important determinants of health.

     

Who you know, where you live: social capital, neighbourhood and health

This article examines the degree to which relationships between social capital and health are embedded in local geographical contexts and influenced by demographic factors, socio-economic status, health behaviours and coping skills. Using data from a telephone survey of a random sample of adults (N=1504 respondents, response rate=60%), the article determines if relationships between involvement in voluntary associations and various measures of individual health are associated with neighbourhood of residence in the mid-sized city of Hamilton, Canada. Associational involvement and overweight status (assessed by body-mass score) were weakly but significantly related after controlling for the other variables; involvement had relationships with self-rated health and emotional distress before but not after controlling for socio-economic status, health behaviours and coping skills. Relationships between neighbourhood of residence and two health outcomes, self-rated health and overweight status, were statistically significant before and after controlling for the other characteristics of respondents; neighbourhood of residence was not a significant predictor of number of chronic conditions and emotional distress in multivariate models. The neighbourhood and associational involvement relationships with health were not dependent upon one another, suggesting that neighbourhood of residence did not help to explain the positive health effects of this particular measure of social capital.     

Urban-rural difference in stroke mortality from a 19-year cohort study of the Japanese general population: NIPPON DATA80

In Japan, cohort studies on stroke have been mainly conducted in rural areas, with few studies comparing stroke mortality between urban and rural areas. We aimed to explore urban-rural difference in stroke mortality throughout Japan using a representative sample of the general Japanese population, the NIPPON DATA80. This study included 9309 subjects (4080 men and 5229 women) aged 30 years or older who were residents of 294 areas in 211 municipalities of Japan in 1980 and followed-up until 1999. Population size of the municipality in which the aforementioned areas were located was used to distinguish between urban and rural areas, because municipalities in Japan are classified as village, town or city principally by population size. We applied a multilevel logistic regression model to take into account the hierarchical data structure of individuals (subjects) (level 1) nested within areas (level 2), and then calculated odds ratios and 95% confidence intervals (CIs) of deaths from total stroke. Statistically significant variance between areas was not observed in men but was in women. Age-adjusted odds ratios of the areas in the medium (population > or = 30,000 and <300,000) and small municipalities (<30,000) compared with the areas in the large municipalities (> or = 300,000) were 1.31 and 1.40 in men, and 1.32 and 1.62 in women, respectively. Multivariate-adjusted odds ratios (adjusted for age, body mass index, total cholesterol, diabetes, hypertension, current smoking, and daily alcohol consumption) of the areas in the medium and small municipalities compared with the areas in the large municipalities were 1.29 and 1.36 in men, and 1.34 and 1.68 in women, respectively. In conclusion, stroke mortality tended to be higher in rural areas than in urban areas in Japan, especially among women.     

Social capital,collective efficacy and the provision of social support services and amenities by municipalities in the Netherlands

Differential provision of local services and amenities has been proposed as a mechanism behind the relationship between social capital and health. The aim of this study was to investigate whether social capital and collective efficacy are related to the provision of social support services and amenities in Dutch municipalities, against a background of decentralisation of long‐term care to municipalities. We used data on neighbourhood social capital, collective efficacy (the extent to which people are willing to work for the common good), and the provision of services and amenities in 2012. We included the services municipalities provide to support informal caregivers (e.g. respite care), individual services and support (e.g. domiciliary help), and general and collective services and amenities (e.g. lending point for wheelchairs). Data for social capital were collected between May 2011 and September 2012. Social capital was measured by focusing on contacts between neighbours. A social capital measure was estimated for 414 municipalities with ecometric measurements. A measure of collective efficacy was constructed based on information about the experienced responsibility for the liveability of the neighbourhood by residents in 2012, average charity collection returns in municipalities in 2012, voter turnout at the municipal elections in 2010 and the percentage of blood donors in 2012. We conducted Poisson regression and negative binomial regression to test our hypotheses. We found no relationship between social capital and the provision of services and amenities in municipalities. We found an interaction effect (coefficient = 3.11, 95% CI = 0.72–5.51, P = 0.011) of social capital and collective efficacy on the provision of support services for informal caregivers in rural municipalities. To gain more insight in the relationship between social capital and health, it will be important to study the relationship between social capital and differential provision of services and amenities more extensively and in different contexts.     

Study of the factors associated with the inability to perform household tasks among aged persons on the Ile-de-France. Application to the sub-regional planning of home-help services

The aim of this paper is to present the preliminary results of a planning project in the area of health and social services for the elderly, which makes it possible to estimate the number of persons likely to seek help from such services at the administrative area levels with decisional powers. This involves identifying predictors of disability from raw data routinely available in the census and at various administrative area levels, the municipality being the preferred level. From the epidemiological data collected at the regional level, an indicator of disability has been constructed. Initially, those factors possibly associated with disabilities were identified by regrouping the variables in four dimensions (discriminant analysis): socio-economic, physical environment, human environment, local administrative area environment (district data from census, medical-social services offered in the area, ect.). Subsequently, a logistic regression made it feasible to calculate the coefficients attached to these predictors of disability. In our sample, sex, age and level of housing amenities in the dwelling place appear to be predictors of disability. The application of the coefficients obtained at the region level--by means of an epidemiological approach to distributions by sex, age and dwelling amenities characterizing a municipality or group of municipalities (territorial approach)--enabled us to estimate the number of persons 65 and over likely to seek help from home-assistance services at whatever administrative area level chosen. In certain of its quantitative aspects, this mixed approach (individual and area) helps in determining need, the first step in the planning process.     

Bringing the individual back to small-area variation studies: A multilevel analysis of all-cause mortality in Andalusia, Spain

We performed a multilevel analysis (including individuals, households, census tracts, municipalities and provinces) on a 10% sample (N=230,978) from the Longitudinal Database of the Andalusian Population (LDAP). We aimed to investigate place effects on 8-year individual mortality risk. Moreover, besides calculating association (yielding odds ratios, ORs) between area socio-economic circumstances and individual risk, we wanted to estimate variance and clustering using the variance partition coefficient (VPC). We explicitly proclaim the relevance of considering general contextual effects (i.e. the degree to which the context, as a whole, affects individual variance in mortality risk) under at least two circumstances. The first of these concerns the interpretation of specific contextual effects (i.e. the association between a particular area characteristic and individual risk) obtained from multilevel regression analyses. The second involves the interpretation of geographical variance obtained from classic ecological spatial analyses. The so-called "ecological fallacy" apart, the lack of individual-level information renders geographical variance unrelated to the total individual variation and, therefore, difficult to interpret. Finally, we stress the importance of considering the familial household in multilevel analyses. We observed an association between percentage of people with a low educational level in the census tract and individual mortality risk (OR, highest v. lowest quintile=1.14; 95% confidence interval, CI 1.08-1.20). However, only a minor proportion of the total individual variance in the probability of dying was at the municipality (M) and census tract (CT) levels (VPC(M)=0.2% and VPC(CT)=0.3%). Conversely, the household (H) level appeared much more relevant (VPC(H)=18.6%) than the administrative geographical areas. Without considering general contextual effects, both multilevel analyses of specific contextual effects and ecological studies of small-area variation may provide a misleading picture that overstates the role of administrative areas as contextual determinants of individual differences in mortality.     

Development and validation of an instrument to measure perceived neighbourhood quality in Taiwan

STUDY OBJECTIVE:s: Social epidemiologists have hypothesised that neighbourhood quality may exert an important contextual influence on mental and physical health. However, validated instruments do not exist for measuring neighbourhood quality in Taiwan. A self reported instrument to measure perceived neighbourhood quality in Taiwan was developed and tested. DESIGN: Community survey. SETTING: Southern Taiwan, including the metropolitan Kaohsiung area and eight surrounding communities, representing urban, suburban, and rural districts. PARTICIPANTS: A total of 1084 residents, aged 18 to 75, were surveyed during 1999 to 2000. MAIN RESULTS: Using factor analysis with varimax rotation, three subscales explained 54.8% of the variance in our 15 item Neighbourhood Quality Index: perceived social capital (Cronbach alpha=0.84), perceived security (alpha=0.78), and adequacy of services and facilities (alpha=0.67). Lower perceived neighbourhood social capital (odds ratio, OR, 1.26; 95% CI: 1.21 to 1.32), lower neighbourhood security (OR 1.37; 95% CI: 1.26 to 1.48), and inadequate neighbourhood services and facilities (OR 1.17; 95% CI: 1.06 to 1.28) were all related to higher residential dissatisfaction. CONCLUSIONS: A Neighbourhood Quality Index was developed for use in Taiwan with good internal consistency and test-retest reliability, as well as convergent validity. Future studies will examine the association between this index and measures of individual mental and physical health.