Neighbourhood level versus individual level correlates of women's body dissatisfaction: toward a multilevel understanding of the role of affluence

STUDY OBJECTIVE: This study examined the prevalence of body dissatisfaction as a function of individual level and neighbourhood level indicators of affluence. PARTICIPANTS AND SETTING: A subset of data from a larger random digit dialling telephone survey was used to obtain individual level data on body dissatisfaction, body weight and height, and income from a group of 895 adult women (age 24-56, 61% English speaking) living in 52 neighbourhoods (census tract areas) within the provinces of Alberta, Ontario, and Quebec, Canada who were selected for their heterogeneity in social class. DESIGN: Aggregated census tract data from 1996 were used to develop neighbourhood indicators of affluence. Using hierarchical linear modelling, body dissatisfaction (dichotomous) was examined as a function of individual body mass index, individual level affluence and neighbourhood level affluence. MAIN RESULTS: The impact of body mass index on body dissatisfaction depended on the level of neighbourhood affluence: an average body mass index was associated with higher likelihood of reporting body dissatisfaction in a neighbourhood of above average affluence (71% probability) than in a neighbourhood of average affluence (58% probability), independent of a woman's individual affluence (whether she was low income or not). CONCLUSION: It is concluded that a clearer understanding of the role of affluence on body dissatisfaction can be achieved by a joint examination of individual and neighbourhood level influences.     

Poverty,affluence, and income inequality: neighborhood economic structure and its implications for health

In this paper, we attempt to verify that neighborhood economic structure influences individual health over and above other individual characteristics, and to comparatively evaluate the effects of neighborhood concentrated affluence, concentrated poverty and income inequality in relation to individual health in the USA. We also explore physical environment, health-enhancing services, social hazards (crime) and social resources as mechanisms operating at the neighborhood level that may help to explain the influence of structural economic conditions on health. We use Hierarchical Ordinal Logit Models to examine a rich multi-level data set. Results indicate that affluence exerts significant contextual effects on self-rated health while poverty and income inequality at the neighborhood level are not important structural factors. Moreover, we find that a composite measure of social resources distinguishes itself in both explaining the impact of concentrated affluence and exerting an independent contextual effect on individual health. Physical environment, or the level of physical disorder in the neighborhood, also mediates the effect of affluence on self-rated health, although to a lesser degree than social resources. Our empirical findings suggest that different dimensions of economic structure do not in fact have unique and additive contributions to individual health; the presence of affluent residents is essential to sustain neighborhood social organization which in turn positively affect health.     

Going upstream: Social inequality and children's health

This study explores the impact of income inequality on the health of children. We examine the direct effects of income inequality and the mediating effects of income inequality via poverty concentration at local levels. We use a multilevel study design incorporating individual level data from the 1988 Child Health Supplement to the National Health Interview Survey supplemented with aggregate data from the 1990 Census of Population STF3A economic/ demographic files. Measures of income inequality are constructed at the county level and poverty concentration at the county and neighbourhood level. Multiple indicators are used to examine child health including physiologic, functional status, and psychological measures and behavior and school problems. The association between income inequality and child health was examined using logistic regression models. Direct effects of income inequality were observed for school suspension and indirect effects for chronic conditions, learning disabilities, emotional and behavior problems, school suspension, health status and seeing a counsellor/psychiatrist. To assess whether income inequality works through challenging the integrity of local economic institutions, we also examine whether inequality and poverty concentration at the neighbourhood level or the larger administrative unit influence children's access to health insurance. Income inequality was found to exert both a direct and an indirect effect on children's health insurance status. These findings specifically provide evidence of the effects of income inequality on children's health, and more generally demonstrate that higher level contextual factors need to be incorporated into research in order to enhance our understanding of the determinants of children's health.     

Exploring the generalisability of the association between income inequality and self-assessed health

A growing between- and within-country literature suggests that the association between income inequality and health reflects individual- or area-level characteristics with which income inequality is associated, rather than the effects of income inequality per se. These studies also suggest that the association between income inequality and health is country-specific. Unresolved methodological issues include the geographical level at which to model the effects of income inequality, and the appropriate statistical methods to use. This study compares the results of single-level and multi-level logistic regression models estimating the association between income inequality and self-assessed health in local authorities in Scotland. The results suggest that there is a significant positive association between income inequality and health across local authorities in Scotland, even after adjusting for individual-level socio-economic status. They also suggest that there is significant local authority-level variation in self-assessed health, but this is small compared to the variation at the individual level. Income and other measures of individuals' socio-economic status are more strongly associated with self-assessed health than income inequality. This study provides further evidence that the income inequality:health association is place-specific. It also suggests that methodological choices regarding the ways of estimating the association between self-assessed health, individual-level socio-economic status and area-level income inequality may not make a substantive difference to the results when contextual effects are small. Further work is required to test the sensitivity of these conclusions to alternative levels of geographical aggregation.     

A multilevel analysis of the effects of neighbourhood income inequality on individual self-rated health in Hong Kong

We examined the effect on self-rated health of neighbourhood-level income inequality in Hong Kong, which has a high and growing Gini coefficient. Data were derived from two population household surveys in 2002 and 2005 of 25,623 and 24,610 non-institutional residents aged 15 or over. We estimated neighbourhood-level Gini coefficients in each of 287 Government Planning Department Tertiary Planning Units. We used multilevel regression analysis to assess the association of neighbourhood income inequality with individual self-perceived health status. After adjustment for both individual- and household-level predictors, there was no association between neighbourhood income inequality, median household income or household-level income and self-rated health. We tested for but did not find any statistical interaction between these three income-related exposures. These findings suggest that neighbourhood income inequality is not an important predictor of individual health status in Hong Kong.     

An investigation of the longitudinal relationship between neighbourhood income inequality and individual self-rated health in England

There are mixed findings on whether neighbourhood income inequality leads to better self-rated health (SRH) or not. This study considers two hypotheses: individuals living in more unequal neighbourhoods have better SRH and the level of neighbourhood income inequality and its impact on SRH is moderated by household and neighbourhood level income related variables. Data from Waves 8–10 of the UK Household Longitudinal Study for respondents living in England at wave 8 were used. Neighbourhood income inequality was measured using Gini coefficients of household income from the Pay As You Earn and benefits systems for Lower Super Output Areas. Longitudinal ordinal multilevel models predicted self-rated health in 2016–18, 2017–19 and 2019-20 by income inequality and its interaction with household income, neighbourhood median income and neighbourhood deprivation, conditional on individual educational attainment, age, sex, ethnic group, years lived in current residence, region of residence and study wave. There were 24,889 respondents analysed over three waves. SRH was worse for those living in more income equal neighbourhoods. There was no indication that neighbourhood inequality was moderated by household income, neighbourhood median income or neighbourhood deprivation. These findings are in line with the balance of existing evidence and support policy interventions that aim to create mixed communities for the purpose of improving population health.     

Social inequality and ethnic differences in smoking in New Zealand

This study tests a generalisation of the 'Wilkinson' thesis that the greater a nation's income inequality, the poorer the average national health status. We consider the effect of socio-economic inequality upon ethnic variations in smoking in New Zealand. Analysis of Maori and Pakeha (New Zealanders of European descent) smoking rates from the 1996 Census is conducted for 73 Territorial Local Authority areas in New Zealand, disaggregated by gender and rural-urban location. Partial correlation is used to control for absolute levels of deprivation and examine the independent effect of ethnic social inequality upon smoking rates. The level of social inequality between Maori and Pakeha has an independent effect on Maori smoking rates. Pakeha smoking rates by contrast are more sensitive to variations in absolute rather than relative deprivation. The effect of inequality is greatest for Maori women, especially among urban residents. By contrast, among Maori men the effects are greatest in rural areas. The results provide some qualified support for the Wilkinson thesis and suggest that policies which address fundamental issues of social inequality will play a small, but significant, role in helping to reduce high smoking rates amongst Maori.     

Income inequality and alcohol use: a multilevel analysis of drinking and drunkenness in adolescents in 34 countries

BACKGROUND: Economic inequality has been hypothesized to be a health determinant, independent of poverty and household income. The goal of this study was to explore the contextual influences of income inequality on alcohol use and frequency of drunkenness in adolescents. METHODS: The Health Behaviour in School-aged Children study surveyed 162 305 adolescents (ages 11, 13 and 15 years) in 34 countries, providing self-report data on family affluence, alcohol consumption and episodes of drunkenness. Country-level data on income inequality and overall wealth were retrieved from the United Nations Development Program. RESULTS: Multilevel logistic regression revealed that 11- and 13-year-olds in countries of high income inequality consumed more alcohol than their counterparts in countries of low income inequality (after adjustment for sex, family affluence and country wealth). No such effect on alcohol consumption was found in 15-year-olds. Eleven-year-olds in countries of high income inequality reported more episodes of drunkenness than their counterparts in countries of low income inequality. No such effect of income inequality on drunkenness was found in 13- or 15-year-olds. CONCLUSIONS: Income inequality may have a contextual influence on the use of alcohol among younger adolescents. Findings suggest that economic policies that affect the distribution of wealth within societies may indirectly influence the use of alcohol during early and mid-adolescence.     

Explaining the differences in income-related health inequalities across European countries

This paper provides new evidence on the sources of differences in the degree of income-related inequalities in self-assessed health in 13 European Union member states. It goes beyond earlier work by measuring health using an interval regression approach to compute concentration indices and by decomposing inequality into its determining factors. New and more comparable data were used, taken from the 1996 wave of the European Community Household Panel. Significant inequalities in health (utility) favouring the higher income groups emerge in all countries, but are particularly high in Portugal and - to a lesser extent - in the UK and in Denmark. By contrast, relatively low health inequality is observed in the Netherlands and Germany, and also in Italy, Belgium, Spain Austria and Ireland. There is a positive correlation with income inequality per se but the relationship is weaker than in previous research. Health inequality is not merely a reflection of income inequality. A decomposition analysis shows that the (partial) income elasticities of the explanatory variables are generally more important than their unequal distribution by income in explaining the cross-country differences in income-related health inequality. Especially the relative health and income position of non-working Europeans like the retired and disabled explains a great deal of 'excess inequality'. We also find a substantial contribution of regional health disparities to socio-economic inequalities, primarily in the Southern European countries.     

What is the relationship between income inequality and health? Evidence from the BHPS

Income inequality hypotheses propose that income differentials and/or income distributions have a detrimental effect on health. This previously well accepted relationship between inequality and health has recently come under scrutiny; some claim that it is a statistical artefact, arguing that aggregate level data are not sophisticated enough to adequately test for (and discriminate between) their existence. Supporters argue that it is a question of estimating the relationship using, amongst other things, an appropriate geographical scale. This paper adds to the debate by estimating the relationship between income inequality and health using individual panel data, exploring the relationship at the regional as well as the national level, while attempting to discriminate between the competing hypotheses. Pooled, random and fixed effects ordered probit models are exploited to estimate the relationship between self-reported health and household income, income inequality and relative income. While the estimating regressions find support for the absolute income hypothesis, there is no support for the income inequality hypothesis or relative income hypothesis, and as such we argue that there is limited evidence of an effect of income inequality on health within Britain.     

Concentrated affluence,concentrated disadvantage,and children's readiness for school: A population-based,multi-level investigation

A number of studies demonstrates a relationship between neighbourhood concentration of affluence and disadvantage and the health and development of its residents. We contribute to this literature by testing hypotheses about the relationship between neighbourhood-level concentrated affluence/disadvantage and child-level developmental outcomes in a study population of 37,798 Kindergarten children residing in 433 neighbourhoods throughout the province of British Columbia, Canada. We utilise a previously-validated measure of neighbourhood socioeconomic composition—the Index of Concentration at the Extremes (ICE)—which not only allows for more precise estimation of the competing influences of concentrated affluence and disadvantage, but also facilitates examination of the potential impact of neighbourhood-level income inequality. Our findings show that increases in neighbourhood affluence are associated with increases in children's scores on the Early Development Instrument (EDI), a holistic measure of Kindergarteners' readiness for school. Particularly noteworthy is that, for four of the five EDI scales (physical, social, emotional, and communication) and the total score, results indicate a significant curvilinear relationship – whereby the highest average child-level outcomes are not found in locations with the highest concentrations of affluence, but rather in locations with relatively equal proportions of affluent and disadvantaged families. This finding suggests, first, that concentrated affluence may have diminishing rates of return on contributing to enhanced child development, and, second, that children residing in mixed-income neighbourhoods may benefit both from the presence of affluent residents and from the presence of services and institutions aimed at assisting lower-income residents. Implications and future directions are discussed.     

Shifting dollars, saving lives: what might happen to mortality rates, and socio-economic inequalities in mortality rates, if income was redistributed?

Personal or household income predicts mortality risk, with each additional dollar of income conferring a slightly smaller decrease in the mortality risk. Regardless of whether levels of income inequality in a society impact on mortality rates over and above this individual-level association (i.e., the 'income inequality hypothesis'), the current consensus is that narrowing income distributions will probably improve overall health status and reduce socio-economic inequalities in health. Our objective was to quantify this impact in a national population using 1.3 million 25-59-year-old respondents to the New Zealand 1996 census followed-up for mortality over 3 years. We modelled 10-40% shifts of everyone's income to the mean income (equivalent to 10-40% reductions in the Gini coefficient). The strength of the income-mortality association was modelled using rate ratios from Poisson regression of mortality on the logarithm of equivalised household income, adjusted for confounders of age, marital status, education, car access, and neighbourhood socio-economic deprivation. Overall mortality reduced by 4-13% following 10-40% shifts in everyone's income, respectively. Inequalities in mortality reduced by 12-38% following 10-40% shifts in everyone's income. Sensitivity analyses suggested that halving the strength of the income-mortality association (i.e., assuming our multivariable estimate still overestimated the causal income-mortality association) would result in 2-6% reductions in overall mortality and 6-19% reductions in inequalities in mortality in this New Zealand setting. Many commentators have noted the non-linear association of income with mortality predicts that narrowing the income distribution will both reduce overall mortality rates and reduce inequalities in mortality. Quantifying such reductions can only be done with considerable uncertainty. Nevertheless, we tentatively suggest that the gains in overall mortality will be modest (although still potentially worthwhile from a policy perspective) and the reductions in inequalities in mortality will be more substantial.     

Aggregation and the measurement of income inequality: effects on morbidity

This is a cross-sectional study using records from the National Health Interview Survey linked to Census geography. The sample is restricted to white males ages 25-64 in the United States from three years (1989-1991) of the National Health Interview Survey. Perceived health is used to measure morbidity. Individual covariates include income-to-needs ratio, education and occupation. Contextual level measures of income inequality, median household income and percent in poverty are constructed at the US census county and tract level. The association between inequality and morbidity is examined using logistic regression models. Income inequality is found to exert an independent adverse effect on self-rated health at the county level, controlling for individual socioeconomic status and median income or percent poverty in the county. This corresponding effect at the tract level is reduced. Median income or percent poverty and individual socioeconomic status are the dominant correlates of perceived health status at the tract level. These results suggest that the level of geographic aggregation influences the pathways through which income inequality is actualized into an individuals' morbidity risk. At higher levels of aggregation there are independent effects of income inequality, while at lower levels of aggregation, income inequality is mediated by the neighborhood consequences of income inequality and individual processes.     

Income, income inequality and health: what can we learn from aggregate data?

It has been suggested that, especially in countries with high per capita income, there is an independent effect of income distribution on the health of individuals. One source of evidence in support of this relative income hypothesis is the analysis of aggregate cross-section data on population health, per capita income and income inequality. We examine the empirical robustness of cross-section analyses by using a new data set to replicate and extend the methodology in a frequently cited paper. The estimated relationship between income inequality and population health is not significant in any of our estimated models. We also argue there are serious conceptual difficulties in using aggregate cross-sections as a means of testing hypotheses about the effect of income, and its distribution, on the health of individuals.     

Policy implications of neighbourhood effects on health research: towards an alternative to poverty deconcentration

While researchers build an evidence that where one lives has an independent effect on their health, the work of translating this research into effective policies is impeded by problematic assumptions about urban poverty. In light of new experimental studies on the health effects of neighbourhoods using housing mobility programs, this paper addresses the politics of poverty deconcentration that implicitly undergirds much of this new research. By raising critiques of these programs that are rarely considered in the health literature, this paper challenges the central treatment of poverty dispersal in the new experimental literature. Poverty dispersal policies, without addressing the competitive urban structure, simply react to symptoms of poverty and ignore the underlying factors that shape the neighbourhood resources that structure health outcomes. These factors include municipal fragmentation, exclusionary land use planning, and municipal competition. Effective social policies aimed at improving neighbourhood influence on health must address the competitive and fragmented municipal structure that produces a patchwork of affluence and deprivation in today’s urban America.     

Income inequality and health in Ontario: a multilevel analysis

OBJECTIVE: To examine the association of income inequality at the public health unit level with individual health status in Ontario. METHODS: Cross-sectional multilevel study carried out among subjects aged 25 years or older residing in 42 public health units in Ontario. Individual-level data drawn from 30,939 respondents in 1996-97 Ontario Health Survey. Median area income and income inequality (Gini coefficient) calculated from 1996 census. Self-rated health status (SRH) and Health Utilities Index (HUI-3) scores were used as main outcomes. RESULTS: Controlling for individual-level factors including income, respondents living in public health units in the highest tercile of income inequality had odds ratios of 1.20 (95% CI 1.04 - 1.38) for fair/poor self-rated health, and 1.11 (95% CI 1.01 - 1.22) for HUI score below the median, compared with people living in public health units in the lowest tercile. Controlling further for median area income had little effect on the association. CONCLUSION: Income inequality was significantly associated with individual self-reported health status at public health unit level in Ontario, independent of individual income.     

The role of behavioural factors in explaining socio-economic differences in adolescent health: A multilevel study in 33 countries

Attempts to describe and explain socio-economic differences in health have mainly focused on adults. Little is known about the mechanisms of the relationship between socio-economic status (SES) and health in adolescence including inconsistent findings between SES and health among young people. Data were derived from representative samples of 13 and 15-year-old students in 33 European and North American countries (n = 97,721) as part of the Health Behaviour in School-aged Children (HBSC) study 2001/2002. Multilevel logistic regression models were used to investigate socio-economic differences in self-rated health among adolescents and the contribution of health-related behaviours to the explanation of such differences. Odds ratios of self-rated health by family affluence were calculated before and after adjustment for behavioural factors (tobacco smoking, physical activity, television use, breakfast intake, consumption of fruits and vegetables). On average, adolescents from low affluent families had an odds ratio for low self-rated health of 1.84 for boys and 1.80 for girls, compared to those from high affluent families. The majority of behavioural factors were significantly associated with family affluence in all countries and explained part of the relationship between self-rated health and family affluence. Smoking, physical activity and breakfast consumption showed the largest independent effect on health. The present study suggests that behavioural factors in early adolescence partly account for the association between self-rated health and socio-economic status. Prevention programmes should target unhealthy behaviours of adolescents from lower socio-economic groups to help prevent future life-course disadvantages in terms of health and social inequalities.     

Letting the Gini out of the bottle? Challenges facing the relative income hypothesis

The relative income hypothesis interprets statistical associations between income inequality and average health status at the population level, as evidence that income inequality has a deleterious psychosocial effect on individual health. An alternative explanation is that these, population-level associations, are statistical artefacts of curvilinear, individual-level relationships between income and health. Indeed, provided the cost-benefit ratio of health-enhancing goods and services vary, the law of diminishing returns should produce curvilinear, asymptotic relationships between income and health at the individual level, which create ('artefactual') associations between income inequality and health at the population level. However, proponents of the relative income hypothesis have argued that these relationships are unlikely to be responsible for the associations observed between income inequality and average health status amongst high-income populations. In these populations, the individual-level relationships between income and health would be nearer their asymptotes, where a shallower slope should ensure that income inequality has little (if any) 'artefactual' effect on average health status. Yet this argument was based on analyses of population-level data which underestimated the slope and curvilinearity of underlying, individual-level relationships between income and health. It is therefore likely that (at least some part of) the population-level associations between income inequality and average health status (amongst low-, middle- and high-income populations) are 'artefacts' of curvilinear, individual-level relationships between income and health. Nevertheless, it is also possible that income inequality is somehow (partly or wholly) responsible for the curvilinear nature of individual-level relationships between income and health. Likewise, it is possible that income inequality alters the height, slope and/or curvilinearity of these relationships in such a way that income inequality has an independent effect on individual health. In either instance, the 'artefactual' effect of curvilinear relationships between income and health at the individual level would simply reflect the mechanism underlying the relative income hypothesis.     

Income inequality and mortality: time series evidence from Canada

In this paper, we apply the standard model used in the income strand of the socio-economic status (SES)-population health literature to explain the relationship between mortality and income to pooled cross-section time-series data for Canada. The use of time-series data increases the available degrees of freedom and allows for the possibility that the effects of inequality take time to translate into poorer health outcomes. In light of recent criticisms of aggregate level studies, we do not attempt to differentiate between the absolute and relative inequality hypotheses, but test for the existence of a relationship between mortality and a measure of income inequality. We find that whether an exogenous trend is incorporated or an auto-regressive distributed lag form is used, the coefficients on mean income and the Gini are not significantly different from zero, which contradicts the findings in other parts of the literature, but which is consistent with earlier cross-section evidence for Canada. The results suggest that models that focus exclusively on income as a measure of the impact of SES on mortality are not complete and that health spending and unemployment may be even more important than income growth and dispersion.     

Income and health: what is the nature of the relationship?

The aim of this article is to examine the relationship between income and morbidity, both before and after controlling for other socio-economic variables. We use data from the Health and Lifestyle Survey (first wave), a national sample survey of adults, aged 18 upwards, in England, Wales and Scotland, conducted in 1984-1985. In total, 9003 interviews were achieved. We examine the shape of the relationship between household equivalised income and height, waist-hip ratio, respiratory function (FEV1), malaise, limiting longterm illness. These indices of morbidity, both self-reported and measured, are approximately linearly related to the logarithm of income, in all except very high and low incomes (this means that increasing income is associated with better health, but that there are diminishing returns at higher levels of income). A doubling of income is associated with a similar effect on health, regardless of the point at which this occurs, providing this is within the central portion (10-90%) of the income distribution. The effect of income on the health measures is comparable to that of the other socio-economic variables in combination. The shape of the relationship found between income and health is compatible with worse health in countries with greater income inequality, without the need to postulate any direct effect of income inequality itself.