Is Region of Country a Useful Variable for Child Health Studies?

Abstract

In their article “The Health Status of Southern Children: A Neglected Regional Disparity” (in this month's Pediatrics electronic pages ), Goldhagen et al1 have raised the intriguing question of whether US region is a significant factor for child health outcomes. Although much attention has been given to contextual influences on health,2–4 most studies have considered local contextual effects such as neighborhood characteristics.5 Few have considered region as a contextual level.2,6 Therefore, Goldhagen et al's conclusion that region is a stronger predictor of poor outcomes than other variables commonly used is quite remarkable. A careful examination of their methods is in order before their recommended research agenda is undertaken. We have 2 levels of concern: the general approach to the definition of health regions and a specific concern about the geographic unit of analysis. The definition of geographic regions for health studies can be achieved either by an impartial exploration of the geographic distribution of health statistics or through historical, sociocultural, or policy-relevant considerations. Goldhagen et al frame their article as an examination of the South, which suggests a preference for the latter approach. This focus might stem from an interest in the legacies of slavery or in current-day clustering of state policies and funding for public health and health care. Yet their methods are primarily an exploration of health statistics. They mapped the child health index (CHI) and identified the Deep South based on the revealed geographic distribution. Their methods for selecting member states are not precisely explained, but it seems that state selection was influenced somewhat by a desire to achieve a contiguous Deep South. Nevertheless, the CHI and its components were the variables used to define regions. To confirm the validity of the CHI-defined Deep South, they contrasted it with other … Address correspondence to Mark F. Guagliardo, PhD, Center for Health Services and Community Research, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010. E-mail: mguaglia{at}cnmc.org