Characteristics of urban regions and all-cause mortality in working-age population

Abstract

Abstract Using Finnish register data on individuals linked to information on urban regions, this study aimed to estimate the effects of some regional characteristics on all-cause mortality among working-age population in 1995-2001, and to find out whether these effects are different among those long-term unemployed than among others. Multilevel Poisson regression models were used. The characteristics of regions included unemployment rate, level of urbanisation, voting turnout, a summary measure of family cohesion, and the geographic location of the region. Our study showed that effects of most area characteristics on mortality were clear among those who suffered from long-term unemployment in the baseline but not among others, adjusting for basic socio-demographic characteristics of the individuals. The results thus suggest that the weaker in the society are more vulnerable to the effects of social environment than those better off. 1. Introduction Many multilevel studies have found effects of characteristics of areas on health and mortality after controlling for socioeconomic and other characteristics of individuals (e.g., Anderson et al. 1997, Blomgren et al. 2004, Davey Smith et al. 1998, Haan, Kaplan, and Camacho 1987, Martikainen, Maki, and Blomgren 2004, Sloggett and Joshi 1998, Yen and Kaplan, 1999). Studies have been conducted on different area levels, with different area characteristics and adjusting for different individual variables, which complicates the comparability of the results. However, a consensus seems to prevail about the importance of community and area characteristics affecting health and mortality, but the effects are generally admitted to be modest compared to the effects of individual-level socioeconomic effects (see review of Pickett and Pearl 2001). Most above-mentioned multilevel studies have focused on the effects of socioeconomic structure, unemployment rate or deprivation of areas and have generally reached the conclusion that poor socioeconomic circumstances induce adverse effects on mortality. Areas have also been characterised by their level of social capital or social cohesion. Social capital has been measured in a variety of ways, often based on Putnam's definition of the density of memberships in associations, levels of interpersonal trust and strengths of mutual aid and reciprocity (Kawachi and Berkman 2000, Putnam 1993). Defined in the Putnam way, social capital has been found to be associated with health and mortality in many studies both at the state level in the US (Kawachi, Kennedy, and Glass 1999, Kawachi et al. 1997) as well as at the neighbourhood level (Lochner et al. 2003). Other studies have used voting turnout and strength of traditional family norms as measures of social capital or social cohesion and have found that low levels of social cohesion are associated with increased alcoholrelated and suicide mortality (Blomgren et al. 2004, Martikainen et al. 2004). Most multilevel studies have adjusted for individual-level variables since part of the observed area differences in mortality may arise from the more favourable composition of population as regards to mortality in some areas than in others (Duncan, Jones, and Moon 1998). The relationships between mortality and socio-demographic characteristics of individuals, such as age, sex, education and social class, are well established. Among the individual-level socio-demographic characteristics, our study focuses on the effects of long-term unemployment and the joint effects of long-term unemployment and regional social characteristics on mortality. The relationship between unemployment and mortality has been shown in many studies. However, it has often been difficult to conclude whether there are true causal effects of unemployment on mortality or whether the unemployed are selected in terms of their characteristics leading both to poor health and higher risk of unemployment (Bartley 1994, Bartley and Ferrie 2001, Valkonen and Martikainen 1995). …