Area-level Effects Research Articles

Pattern of Hepatitis A Incidence According to Area Characteristics Using National Health Insurance Data

ObjectivesOver the past several years, the incidence of hepatitis A infection has been increasing rapidly in the young-adult population in Korea. We examined the effects of area-level socioeconomic status and environmental hygiene on the incidence of hepatitis A.MethodsThis study is based on the registered national population of Korea and the national health insurance data from 2004 to 2008. A total of 73 459 individuals were confirmed to have had hepatitis A. The standardized incidences of hepatitis A in 232 districts adjusted for sex and age of people were calculated for each year, and the rate ratios of the incidence rates were estimated according to area-level socioeconomic status and environmental hygiene using multiple Poisson regression models.ResultsThe incidence rates of hepatitis A infection were 15.6 (per 100 000) in 2004, 19.0 (per 100 000) in 2005, 27.2 (per 100 000) in 2006, 25.1 (per 100 000) in 2007, and 61.7 (per 100 000) in 2008. The analysis of the area-level effects showed that residential areas of the less deprived than other regions, areas with higher levels of education, and heavily populated areas were significantly associated with increased risk.ConclusionsThere is a very strong possibility that both area-level socioeconomic status and environmental hygiene play a role in increasing the risk of hepatitis A infection in Korea. Therefore, to reduce hepatitis A infection, we need a nationwide strategy that considers these area-level characteristics.

Spatial Context and Poverty: Area-Level Effects and Micro-Level Effects on Household Poverty in the Texas Borderland & Lower Mississippi Delta: United States, 2006

This paper uses microdata from the 2006 American Community Survey for households in the Texas Borderland and Mississippi Delta to examine the effects of spatial location context on the odds of households being in poverty. We examine the micro-level and area-level effects of poverty among households located in the two regions. We estimate a series of multilevel regression models predicting the log odds of a household being in poverty. Our major contribution is the demonstration that areal context characteristics have statistically significant effects on the likelihood of households being in poverty. Spatial context matters when it comes to predicting poverty of the households in the Delta and Borderland.

Abstract B9: Geographic disparity in HPV vaccination among girls in six U.S. states

Abstract Introduction: The human papillomavirus (HPV) vaccine was approved by the Food and Drug Administration in 2006. Since that time, limited research has examined HPV vaccine uptake among adolescent females and no studies have examined the role of disparities in HPV vaccination. The purpose of this study is to examine geographic disparity in the prevalence of HPV vaccination and to examine individual-, county-, and state-level correlates of vaccination. Methods: Three-level random intercept logistic regression models were fitted to data from 1,709 girls aged 13–17 living in 6 U.S. states using 2008 Behavioral Risk Factor Surveillance System and 2000 U.S. Census data. Results: Overall, 34.4% of girls were vaccinated. Significant geographical disparity across states (Var: 0.134 SE: 0.065) and counties (Var: 0.146 SE: 0.063) was present, which was partially explained by state- and county-level poverty rates. Independent of individual-level factors, poverty had differing effects at the state- and county-level: girls in higher poverty states were less likely while girls in higher poverty counties were more likely to be vaccinated. Household income demonstrated a similar pattern to that of county-level poverty: compared to girls in the highest income families, girls in the lowest income families were more likely to be vaccinated. Conclusions: The results of this study suggest geographic disparity in HPV vaccination and area-level effects of poverty that have not previously been studied. The higher odds of vaccination among girls living in higher poverty counties and low income families may indicate the success of publicly-funded vaccination efforts targeting the underserved or a bias against vaccination among higher income groups. Overall vaccination rates continue to be sub-optimal however, and future research is needed to examine the impact of state- and local-area policies and to increase vaccination among eligible girls. Citation Information: Cancer Prev Res 2010;3(1 Suppl):B9.

Climate and Atopic Disease in Children in Temperate Countries in Europe and North America

ISEE-0563 Background: Although atopic diseases exhibit strong seasonal patterns, there is only weak evidence that climate per se is a determinant of the variation in prevalence of wheeze between populations. Previous studies that reported an association between climate factors and wheeze did not take into account other environmental hazards or potential confounding factors. We investigated the impact of climate factors (temperature and humidity) on the prevalence of symptoms of atopy-related diseases such as asthma and eczema in children. Methods: We used the PATY combined cross-sectional dataset of respiratory health in children in 10 countries in Europe and North America to investigate the effect of long term climate factors (temperature, relative humidity) on three outcomes: wheeze, woken by wheeze and itchy rash. Study-specific odds ratios for associations with climate factors were estimated using logistic regressions with area-level random effects, controlling for ambient air pollutant exposures and individual risk factors. Mean effects were estimated using meta-analysis. Results: Climate exposure had no effect on the prevalence of wheeze or itchy rash. Controlling for NO2 or PM10 did not strongly confound the overall associations between symptoms and climate variables. Climate factors did not modify observed associations between air pollution and children’s health. Conclusions: The prevalence of wheeze or itchy rash is unlikely to be determined by the outdoor climate within mid to high latitude countries in North America and Europe.

Investigating perceptions of antisocial behaviour and neighbourhood ethnic heterogeneity in the British Crime Survey

There is much concern in the UK about the effects on community cohesion of anti-social behaviour (ASB) but to date relatively little is known about the geography of such behaviour: for what sort of people, and in what sort of places, are high levels of ASB a problem? What are the links, if any, between such behaviour and local socio-economic conditions, and how do such perceptions relate to local crime rates? Using data from the British Crime Survey and other secondary datasets, we develop and extend previous work which has investigated links between individual socio-economic characteristics, neighbourhood characteristics and individual perceptions of ASB. A multilevel modelling approach is used to ensure that individual and area level effects are not conflated. Secondly we extend the substantive knowledge surrounding the relationship between neighbourhood ethnic heterogeneity and individual perceptions of ASB. In so doing we challenge recent contentions that heterogeneity is associated with declining social cohesion and trust. We conclude that at a small-area scale for England, the primary area-level determinants of high levels of ASB lie in material circumstances, and that ethnic heterogeneity has no discernible effect on perceptions of ASB.

Examining evidence for neighbourhood variation in the duration of untreated psychosis

BackgroundFamily involvement in help-seeking is associated with a shorter duration of untreated psychoses [DUP], but it is unknown whether neighbourhood-level factors are also important. MethodsDUP was estimated for all cases of first-episode psychoses identified over 2 years in 33 Southeast London neighbourhoods (n=329). DUP was positively skewed and transformed to the natural logarithm scale. We fitted various hierarchical models, adopting different assumptions with regard to spatial variability of DUP, to assess whether there was evidence of neighbourhood heterogeneity in DUP, having accounted for a priori individual-level confounders. ResultsNeighbourhood-level variation in DUP was negligible compared to overall variability. A non-hierarchical model with age, sex and ethnicity covariates, but without area-level random effects, provided the best fit to the data. DiscussionNeighbourhood factors do not appear to be associated with DUP, suggesting its predictors lie at individual and family levels. Our results inform mental healthcare planning, suggesting that in one urbanised area of Southeast London, where you live does not affect duration of untreated psychosis.

Geographic variation and effect of area-level poverty rate on colorectal cancer screening

BackgroundWith a secular trend of increasing colorectal cancer (CRC) screening, concerns about disparities in CRC screening also have been rising. It is unclear if CRC screening varies geographically, if area-level poverty rate affects CRC screening, and if individual-level characteristics mediate the area-level effects on CRC screening.MethodsUsing 2006 Missouri Behavioral Risk Factor Surveillance System (BRFSS) data, a multilevel study was conducted to examine geographic variation and the effect of area-level poverty rate on CRC screening use among persons age 50 or older. Individuals were nested within ZIP codes (ZIP5 areas), which in turn, were nested within aggregations of ZIP codes (ZIP3 areas). Six groups of individual-level covariates were considered as potential mediators.ResultsAn estimated 51.8% of Missourians aged 50 or older adhered to CRC screening recommendations. Nearly 15% of the total variation in CRC screening lay between ZIP5 areas. Persons residing in ZIP5 areas with ≥ 10% of poverty rate had lower odds of CRC screening use than those residing in ZIP5 areas with <10% poverty rate (unadjusted odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.58–0.81; adjusted OR, 0.81; 95% CI, 0.67–0.98). Persons who resided in ZIP3 areas with ≥ 20% poverty rate also had lower odds of following CRC screening guidelines than those residing in ZIP3 areas with <20% poverty rate (unadjusted OR, 0.66; 95% CI, 0.52–0.83; adjusted OR, 0.64; 95% CI, 0.50–0.83). Obesity, history of depression/anxiety and access to care were associated with CRC screening, but did not mediate the effect of area-level poverty on CRC screening.ConclusionLarge geographic variation of CRC screening exists in Missouri. Area-level poverty rate, independent of individual-level characteristics, is a significant predictor of CRC screening, but it only explains a small portion of the geographic heterogeneity of CRC screening. Individual-level factors we examined do not mediate the effect of the area-level poverty rate on CRC screening. Future studies should identify other area- and individual-level characteristics associated with CRC screening in Missouri.

NO2 and children’s respiratory symptoms in the PATY study

Objectives: NO2 is a major urban air pollutant. Previously reported associations between ambient NO2 and children’s respiratory health have been inconsistent, and independent effects of correlated pollutants hard to assess....

Area-level determinants of specialty care utilization in France: a multilevel analysis

Objectives. We investigated the effects of the density of specialists and of the area-level percentage of highly educated individuals on the odds of consulting a specialist, and examined whether these variables could explain the observed urban/rural contrast in utilization of specialty care. Study design. The study sample, representative of the French population aged 18–75 years in 1999, comprised 12,435 individuals. Methods. Multilevel logistic models allowed us to investigate predictors of the odds of consulting a specialist occasionally, regularly and frequently over the previous 12 months. Results. We observed a modest but significant clustering within areas of the utilization of specialty care, with higher levels of clustering for behaviours representing heavy consumption of care. After adjustment for individual factors, the odds of consulting a specialist were higher in larger cities compared with rural areas, but most of this effect was attributable to other area-level variables. These area-level effects were different in magnitude and nature among males and females. Among males, the odds of consulting a specialist increased with the area-level density of specialists. Among females, such an effect was not significant, but the odds of consulting a specialist increased with the area-level percentage of highly educated individuals. Conclusions. Further investigation is required to better understand the processes operating at the area level that were shown to affect healthcare utilization in a different way for males and females. Policies may be needed to address problems of geographical access to specialty care, as well as situations of overuse of specialty care without regular recourse to primary care.