Abstract
BackgroundMost of the research investigating the effect of social context on individual health outcomes has interpreted context in terms of the residential environment. In these studies, individuals are nested within their neighbourhoods or communities, disregarding the intermediate household level that lies between individuals and their residential environment. Households are an important determinant of health yet they are rarely included at the contextual level in research examining association between body mass index (BMI) and the social determinants of health. In this study, our main aim was to provide a methodological demonstration of multilevel analysis, which disentangles the simultaneous effects of households and districts as well as their associated predictors on BMI over time.MethodsUsing both two- and three-level multilevel analysis, we utilized data from all four cross-sections of the Indonesian Family life Survey (IFLS) 1993 to 2007-8.ResultsWe found that: (i) the variation in BMI attributable to districts decreased from 4.3 % in 1993 to 1.5 % in 1997-98, and remained constant until 2007–08, while there was an alarming increase in the variation of BMI attributable to households, from 10 % in 2000 to 15 % in 2007–08; (ii) ignoring the household level did not change the relative variance contribution of districts on BMI, but ignoring the district level resulted in overestimation of household effects, and (iii) households’ characteristics (socioeconomic status, size, and place of residence) did not attenuate the variation of BMI at the household-level.ConclusionsEstimating the relative importance of multiple social settings allows us to better understand and unpack the variation in clustered or hieratical data in order to make valid and robust inferences. Our findings will help direct investment of limited public health resources to the appropriate context in order to reduce health risk (variation in BMI) and promote population health.
Highlights
Most of the research investigating the effect of social context on individual health outcomes has interpreted context in terms of the residential environment
Households or families as a major determinant of health [9, 10] can be considered in terms of an omitted contextual level, which has by and large been ignored in many empirical researches on social determinants of health
The specific objectives of our study are: (i) to assess the extent to which variation in body mass index (BMI) is attributed to the individual level, household level and district level, and how it is changing over time; (ii) whether ignoring the household level results in over- or under-estimation of the relative variance contribution of the district; and (iii) to examine how much of the variation in BMI is explained by the characteristics of each level and how it is changing over time
Summary
Most of the research investigating the effect of social context on individual health outcomes has interpreted context in terms of the residential environment. In these studies, individuals are nested within their neighbourhoods or communities, disregarding the intermediate household level that lies between individuals and their residential environment. Few studies have examined the empirical implications or discussed the substantive eminence of this omitted level in empirical research [11,12,13,14] The focus of these studies was mainly on methodological applications by using simulated data for analysis. Examine the application of omitted level on health related outcomes – i.e. BMI – to better guide the limited public health resources to the right setting which has a greater impact on reducing variations in health among individual
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