Local Area Variations Research Articles

A New Approach for Understanding International Hospital Bed Numbers and Application to Local Area Bed Demand and Capacity Planning.

Three models/methods are given to understand the extreme international variation in available and occupied hospital bed numbers. These models/methods all rely on readily available data. In the first, occupied beds (rather than available beds) are used to measure the expressed demand for hospital beds. The expressed occupied bed demand for three countries was in the order Australia > England > USA. Next, the age-standardized mortality rate (ASMR) has dual functions. Less developed countries/regions have low access to healthcare, which results in high ASMR, or a negative slope between ASMR versus available/occupied beds. In the more developed countries, high ASMR can also be used to measure the 'need' for healthcare (including occupied beds), a positive slope among various social (wealth/lifestyle) groups, which will include Indigenous peoples. In England, a 100-unit increase in ASMR (European Standard population) leads to a 15.3-30.7 (feasible range) unit increase in occupied beds per 1000 deaths. Higher ASMR shows why the Australian states of the Northern Territory and Tasmania have an intrinsic higher bed demand. The USA has a high relative ASMR (for a developed/wealthy country) because healthcare is not universal in the widest sense. Lastly, a method for benchmarking the whole hospital's average bed occupancy which enables them to run at optimum efficiency and safety. English hospitals operate at highly disruptive and unsafe levels of bed occupancy, manifesting as high 'turn-away'. Turn-away implies bed unavailability for the next arriving patient. In the case of occupied beds, the slope of the relationship between occupied beds per 1000 deaths and deaths per 1000 population shows a power law function. Scatter around the trend line arising from year-to-year fluctuations in occupied beds per 1000 deaths, ASMR, deaths per 1000 population, changes in the number of persons hidden in the elective, outpatient and diagnostic waiting lists, and local area variation in births affecting maternity, neonatal, and pediatric bed demand. Additional variation will arise from differences in the level of local funding for social care, especially elderly care. The problems associated with crafting effective bed planning are illustrated using the English NHS as an example.

Open Defecation, Livestock Ownership, and Child Nutritional Status in India.

South Asian children are among the most severely malnourished worldwide. One prominent hypothesis is that open defecation in the local area exposes children to human fecal pathogens that can cause diarrhea and malnutrition. Much of the existing research uses district-level measures of open defecation, which could mask important local-area variation. A second hypothesis is that animal fecal matter is a major source of exposure. This analysis tested these dual hypotheses using census data collected from 949 villages in Tamil Nadu, India, and a survey conducted in a random sample of 5,000 households in the same area. The final analytic sample consisted of 2,561 children aged 0-10 years. We estimated the association between the measures of village- and household-level open defecation, household livestock ownership, and child height-for-age Z-scores in a regression framework, controlling for potential confounders. Results revealed that village- and household-level open defecations are negatively associated with child height. There was an estimated difference of approximately 0.5 height-for-age Z-score between children living in villages with no open defecation and children in villages where all households practiced open defecation (P = 0.001) and a 0.2 Z-score difference between children living in households that practiced open defecation and those living in households that did not (P = 0.001). Livestock ownership was not associated with child height. Overall, the findings provide evidence on the centrality of open defecation in explaining persistent child malnutrition in India and the higher risk of exposure to human fecal pathogens compared with animal feces in the south Indian context.

Among Medicare beneficiaries, Affordable Care Act coverage expansions reduced utilization of ambulatory care, particularly among duals.

We leveraged local area variation in the size of the Affordable Care Act (ACA) expansions of Medicaid and nongroup coverage and measured changes in Medicare utilization and spending from 2010 through 2018 using the universe of Medicare fee-for-service claims. We found that the ACA coverage expansions led to decreases in the share of Medicare beneficiaries receiving ambulatory care and decreases in spending per beneficiary on ambulatory care. The reductions in ambulatory care were larger among beneficiaries enrolled in both Medicare and Medicaid ("duals"). Our results suggest that coverage expansions may lead to congestion and reduced access to physicians for those who are continuously insured.

Rural-Urban Differences in Breast Cancer Stage at Diagnosis.

Purpose: To analyze the extent to which rural-urban differences in breast cancer stage at diagnosis are explained by factors including age, race, tumor grade, receptor status, and insurance status.Methods: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 18 database, analysis was performed using data from women aged 50–74 diagnosed with breast cancer between the years 2013 and 2016. Patient rurality of residence was coded according to SEER's Rural-Urban Continuum Code 2013: Large Urban (RUCC 1), Small Urban (RUCC 2,3), and Rural (RUCC 4,5,6,7,8,9). Stage at diagnosis was coded according to SEER's Combined Summary Stage 2000 (2004+) criteria: Localized (0,1), Regional (2,3,4,5), and Distant (7). Descriptive statistics were analyzed, and variations were tested for across rural-urban categories using Kruskall–Wallis and Kendall's tau-b tests. Additionally, odds ratios (ORs) and 95% confidence intervals for the three ordinal levels of rural-urban residence were calculated while adjusting for other independent variables using ordinal logistic regression.Results: The rural residence category showed the largest proportion of women diagnosed with distant stage breast cancer. Additionally, we determined that patients with residence in both large and small urban areas had statistically significantly lower odds of higher stage diagnosis compared to rural patients even after controlling for age, race, tumor grade, receptor status, and insurance status.Conclusions: Rural women with breast cancer show small but statistically significant disparities in stage-at-diagnosis. Further research is needed to understand local area variation in these disparities across a wide range of rural communities, and to identify the most effective interventions to eliminate these disparities.

Small area variation in crime effects of COVID-19 policies in England and Wales

PurposeThe aim of this study is to examine small area variation in crime trajectories during the COVID-19 pandemic in England and Wales. While we know how police-recorded crime responded to lockdown policies at the ‘macro’ level, less is known about the extent to which these trends were experienced uniformly at localized spatial scales. MethodsLongitudinal k-means clustering is used to unpick local area variation in police notifiable offences across England and Wales. We describe the clusters identified in terms of their spatial patterning, opportunity structures and crime type profile. ResultsWe find that in most small areas, crime remained fairly stable throughout the pandemic. Instead, a small number of meso-level areas contributed a disproportionately large amount to the macro-level trend. These were typically city centers with plentiful pre-pandemic crime opportunities, dominated by theft and shoplifting offences. ConclusionFindings offer support for opportunity theories of crime and for a mobility theory of crime during the pandemic. We explore potential implications for policy, theory and further research.

Local Area Variation in Morbidity Among Low-Income, Older Adults in the United States

Recent studies have reported that low-income adults living in more affluent areas of the United States have longer life expectancies. Less is known about the relationship between the affluence of a geographic area and morbidity of the low-income population. To evaluate the association between the prevalence of chronic conditions among low-income, older adults and the economic affluence of a local area. Cross-sectional association study. Medicare in 2015. 6363097 Medicare beneficiaries aged 66 to 100 years with a history of low-income support under Medicare Part D. Adjusted prevalence of 48 chronic conditions was computed for 736 commuting zones (CZs). Factor analysis was used to assess spatial covariation of condition prevalence and to construct a composite condition prevalence index for each CZ. The association between morbidity and area affluence was measured by comparing the average of condition prevalence index across deciles of median CZ house values. The mean age of study participants was 77.7 years (SD, 8.2); 67% were women, and 61% were white. The crude prevalence of 48 chronic conditions ranged from 72.5 per 100 for hypertension to 0.6 per 100 for posttraumatic stress disorder. The prevalence of these 48 chronic conditions was highly spatially correlated. Composite condition prevalence was on average substantially lower in more affluent CZs. Low-income status measured on the basis of receipt of Medicare Part D low-income subsidies and not capturing persons not enrolled in Medicare Part D. Low-income, older adults living in more affluent areas of the country are healthier, and areas with poor health in the low-income, older adult population tend to have a high prevalence of most chronic conditions. National Institute on Aging.

Understanding Cybercrime Victimisation : Modelling The Local Area Variations in Routinely Collected Cybercrime Police Data Using Latent Class Analysis

Numerous factors such as sociodemographic characteristics contribute to cybercrime victimisation. Previous research suggests that neighbourhood plays a role in cybercrime perpetration. However, despite the theoretical importance and particular interest to law enforcement agencies and policymakers, local area variations in cybercrime victimisation have rarely been examined. Drawing on data from recorded cybercrime incidents within one of the largest police forces in England from a three-year period with a victim dataset of 5,270 individuals enhanced by the Census data, this research untangles the relationships between demographics of cybercrime victims and their resident area characteristics. The research considers four types of cybercrime victimisation: ‘Harassment/Unwanted Contact’, ‘Fraud/Theft/Handling’, ‘Sexual/Indecent Images’ and ‘other types of cybercrime’ (classifications used by the participating police force). Latent Class Analysis (LCA) was applied to rigorously analyse the relationship among the four different types of cybercrime victimisation with victim demographics and resident area-level characteristics. This research finds that each type of cybercrime yielded statistically distinct victim profiles. Vulnerabilities to cybercrime varied among male and female of different age groups, and importantly, the types of residential areas of the victims. Specifically, it is evident that females were much more likely to become cybercrime victims than males for two types of cybercrime: ‘Harassment/Unwanted Contact’, and ‘Sexual/Indecent Images’. Vulnerabilities associated with these two types of cybercrime decreased with the increase of age. Cybercrime victims of ‘Sexual/Indecent Images’ were likely to be 5-14 year-olds living in areas with a higher number of Level 2, Level 4 qualifications and full-time students. Both males and females were vulnerable to ‘Fraud/Theft/Handling’ cybercrime and their resident areas had a higher number of full-time students, Level 4 qualifications and Asians. Finally, victims of ‘other types of cybercrime’ were most likely to be male and their resident areas had a high number of Asians and full-time students. Our work demonstrates that it is possible to apply statistical analysis to routinely collected police data to gain insight into the cybercrime victimisation that occurs across crime types in relation to demographics and area-level variations. These results provide valuable insights into policing cybercrime in England and beyond.

Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers for Geriatric Ischemic Stroke Patients: Are the Rates Right?

BackgroundOur objective is to estimate the effects associated with higher rates of renin‐angiotensin system antagonists, angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs), in secondary prevention for geriatric (aged >65 years) patients with new ischemic strokes by chronic kidney disease (CKD) status.Methods and ResultsThe effects of ACEI/ARBs on survival and renal risk were estimated by CKD status using an instrumental variable (IV) estimator. Instruments were based on local area variation in ACEI/ARB use. Data abstracted from charts were used to assess the assumptions underlying the instrumental estimator. ACEI/ARBs were used after stroke by 45.9% and 45.2% of CKD and non‐CKD patients, respectively. ACEI/ARB rate differences across local areas grouped by practice styles were nearly identical for CKD and non‐CKD patients. Higher ACEI/ARB use rates for non‐CKD patients were associated with higher 2‐year survival rates, whereas higher ACEI/ARB use rates for patients with CKD were associated with lower 2‐year survival rates. While the negative survival estimates for patients with CKD were not statistically different from zero, they were statistically lower than the estimates for non‐CKD patients. Confounders abstracted from charts were not associated with the instrumental variable used.ConclusionsHigher ACEI/ARB use rates had different survival implications for older ischemic stroke patients with and without CKD. ACEI/ARBs appear underused in ischemic stroke patients without CKD as higher use rates were associated with higher 2‐year survival rates. This conclusion is not generalizable to the ischemic stroke patients with CKD, as higher ACEI/ARBS use rates were associated with lower 2‐year survival rates that were statistically lower than the estimates for non‐CKD patients.

Factors Associated with Asthma ED Visit Rates among Medicaid-enrolled Children: A Structural Equation Modeling Approach.

BackgroundAsthma is one of the leading causes of emergency department visits and school absenteeism among school-aged children in the United States, but there is significant local-area variation in emergency department visit rates, as well as significant differences across racial-ethnic groups.AnalysisWe first calculated emergency department (ED) visit rates among Medicaid-enrolled children age 5–12 with asthma using a multi-state dataset. We then performed exploratory factor analysis using over 226 variables to assess whether they clustered around three county-level conceptual factors (socioeconomic status, healthcare capacity, and air quality) thought to be associated with variation in asthma ED visit rates. Measured variables (including ED visit rate as the outcome of interest) were then standardized and tested in a simple conceptual model through confirmatory factor analysis.ResultsCounty-level (contextual) variables did cluster around factors declared a priori in the conceptual model. Structural equation models connecting the ED visit rates to socioeconomic status, air quality, and healthcare system professional capacity factors (consistent with our conceptual framework) converged on a solution and achieved a reasonable goodness of fit on confirmatory factor analysis.ConclusionConfirmatory factor analysis offers an approach for quantitatively testing conceptual models of local-area variation and racial disparities in asthma-related emergency department use.

Tight-binding approach to strain and curvature in monolayer transition-metal dichalcogenides

We present a model of the electronic properties of monolayer transition-metal dichalcogenides based on a tight binding approach which includes the effects of strain and curvature of the crystal lattice. Mechanical deformations of the lattice offer a powerful route for tuning the electronic structure of the transition-metal dichalcogenides, as changes to bond lengths lead directly to corrections in the electronic Hamiltonian while curvature of the crystal lattice mixes the orbital structure of the electronic Bloch bands. We first present an effective low energy Hamiltonian describing the electronic properties near the K point in the Brillouin zone, then present the corrections to this Hamiltonian due to arbitrary mechanical deformations and curvature in a way which treats both effects on an equal footing. This analysis finds that local area variations of the lattice allow for tuning of the band gap and effective masses, while the application of uniaxial strain decreases the magnitude of the direct band gap at the K point. Additionally, strain induced bond length modifications create a fictitious gauge field with a coupling strength that is smaller than that seen in related materials like graphene. We also find that curvature of the lattice leads to the appearance of both an effective in-plane magnetic field which couples to spin degrees of freedom and a Rashba-like spin-orbit coupling due to broken mirror inversion symmetry.

The need for leadership training in long-term care settings.

Purpose Globally, in 1980, approximately 5.8 per cent of the world population was 65 years old and older. By 2050, this number will more than triple to 16 per cent. From a leadership perspective, there is at least one challenge (among many others challenges) to consider. This paper (viewpoint) aims to provide support for the growing need for academically prepared managers. Design/methodology/approach This paper is a viewpoint which presents several characteristics of the long-term care (LTC) field that support the need for academically trained leaders. Findings LTC leaders in all countries must be sufficiently versed in numerous management areas to provide leadership when called on by those assigned to their care. Given local area variations in population needs present across all countries, it may be unwise to advocate for national, countrywide standardization of requirements. Yet, older adults accessing LTC services should expect a minimum level of knowledge from all of their providers - not just those who provide direct, hands-on care. However, similar to those who provide direct care, leaders should receive competency-based education with specific attention to effective communication skills, team-based approaches to care delivery, information technologies and population health. Originality/value Although much of the extant literature focuses on the delivery of care to older persons, there is a dearth of literature addressing the role of LTC leaders in light of global aging. Establishing a minimum level of academic training and increasing transparency focused on the positive experiences of elders residing in LTC facilities should help dispel the notion that placement in an LTC facility reflects filial failure.

Measuring regional and district variations in the incidence of pregnancy-induced hypertension in Ghana: challenges, opportunities and implications for maternal and newborn health policy and programmes.

ObjectivesThe objectives were to assess the quality of health management information system (HMIS) data needed for assessment of local area variation in pregnancy‐induced hypertension (PIH) incidence and to describe district and regional variations in PIH incidence.MethodsA retrospective review of antenatal and delivery records of 2682 pregnant women in 10 district hospitals in the Greater Accra and Upper West regions of Ghana was conducted in 2013. Quality of HMIS data was assessed by completeness of reporting. The incidence of PIH was estimated for each district.ResultsKey variables for routine assessment of PIH such as blood pressure (BP) at antenatal visits, weight and height were 95–100% complete. Fundal height, gestational age and BP at delivery were not consistently reported. The incidence of PIH differed significantly between Greater Accra region (6.1%) and Upper West region (3.2%). Prevalence of obesity among pregnant women in Greater Accra region (13.9%) was significantly higher than that of women in Upper West region (2.2%).ConclusionsMore attention needs to be given to understanding local area variations in PIH and possible relationships with urbanisation and lifestyle changes that promote obesity, to inform maternal and newborn health policy. This can be done with good quality routine HMIS data.

Paths to health equity: Local area variation in progress toward eliminating breast cancer mortality disparities, 1990-2009.

US breast cancer deaths have been declining since 1989, but African American women are still more likely than white women to die of breast cancer. Black/white disparities in breast cancer mortality rate ratios have actually been increasing. Across 762 US counties with enough deaths to generate reliable rates, county-level, age-adjusted breast cancer mortality rates were examined for women who were 35 to 74 years old during the period of 1989-2010. Twenty-two years of mortality data generated twenty 3-year rolling average data points, each centered on a specific year from 1990 to 2009. Mixed linear models were used to group each county into 1 of 4 mutually exclusive trend patterns. The most recent 3-year average black breast cancer mortality rate for each county was also categorized as being worse or not worse than the breast cancer mortality rate for the total US population. More than half of the counties (54%) showed persistent, unchanging disparities. Roughly 1 in 4 (24%) had a divergent pattern of worsening black/white disparities. However, 10.5% of the counties sustained racial equality over the 20-year period, and 11.7% of the counties actually showed a converging pattern from high disparities to greater equality. Twenty-three counties had 2008-2010 black mortality rates better than the US average mortality rate. Disparities are not inevitable. Four US counties have sustained both optimal and equitable black outcomes as measured by both absolute (better than the US average) and relative benchmarks (equality in the local black/white rate ratio) for decades, and 6 counties have shown a path from disparities to health equity.

Geographic and racial variation in asthma prevalence and emergency department use among Medicaid-enrolled children in 14 southern states

Background: Despite evidence-based prevention and practice guidelines, asthma prevalence, treatment, and outcomes vary widely at individual and community levels. Asthma disproportionate/ly affects low-income and minority children, who comprise a large segment of the Medicaid population. Methods: 2007 Medicaid claims data from 14 southern states was mapped for 556 counties to describe the local area variation in 1-year asthma prevalence rates, emergency department (ED) visit rates, and racial disparity rate ratios. Results: One-year period prevalence of asthma ranged from 2.8% in Florida to 6.4% in Alabama, with a median prevalence rate of 4.1%. At the county level, the prevalence was higher for Black children and ranged from 1.03% in Manatee County, FL, to 21.0% in Hockley County, TX. Black–White rate ratios of prevalence ranged from 0.49 in LeFlore County, MS, to 3.87 in Flagler County, FL. Adjusted asthma ED visit rates ranged from 2.2 per 1000 children in Maryland to 16.5 in Alabama, with a median Black–White ED-visit rate ratio of 2.4. Rates were higher for Black children, ranging from 0.80 per 1000 in Wicomico County, MD, to 70 per 1000 in DeSoto County, FL. Rate ratios of ED visits ranged from 0.25 in Vernon Parish, LA, to 25.28 in Nelson County, KY. Conclusions and relevance: Low-income children with Medicaid coverage still experience substantial variation in asthma prevalence and outcomes from one community to another. The pattern of worse outcomes for Black children also varies widely across counties. Eliminating this variation could substantially improve overall outcomes and eliminate asthma disparities.

Geographic Variation in Statin Use for Complex Acute Myocardial Infarction Patients

Despite strong evidence to designate statin use for secondary prevention of cardiovascular disease (CVD) as "effective care," observational studies show that many patients with CVD do not receive statins. This suggests that statin prescribing decisions for complex CVD patients are preference sensitive. The aim of this study was to evaluate local area variation in statin prescribing for subsets of complex patients after acute myocardial infarction (AMI) to assess whether current statin prescribing patterns fit profiles of either "effective care" or "preference-sensitive care." This was a retrospective cohort study of 124,618 Medicare patients with fee-for-service parts A, B, and D benefits who were hospitalized with AMI in 2008 or 2009 with no evidence of AMI in the past 12 months. Patient complexity was defined by the presence of diabetes, heart failure, and chronic kidney disease in the year before AMI admission. Local area practice styles for "no statin," "lower-intensity statins," and "high-intensity statins" were measured using the driving area for clinical care method. Statin prescribing rates for complex patient subsets were contrasted across patients grouped by local areas practice styles. Lower statin treatment rates were observed for patients with complex conditions, especially among those with heart failure. However, substantial local area variation in statin prescribing is observed across all complex patient groups. Despite guidelines promoting the use of statins for secondary prevention for CVD patients, substantial local area variation suggests that patient and provider beliefs and preferences weigh heavily in statin prescribing decisions.

Associations between disability prevalence and local-area characteristics in a general community-living population

BackgroundDisability is understood to arise from person-environment interactions. Hence, heterogeneity in local-area characteristics should be associated with local-area variation in disability prevalence. This study evaluated the associations of disability prevalence with local-area socioeconomic status and contextual features. MethodsDisability prevalence was obtained from the Canada census of 2001 for the entire province of Québec at the level of dissemination areas (617 individuals on average) based on responses from 20% of the population. Data on local-area characteristics were urban-rural denomination, social and material deprivation, active and collective commuting, residential stability, and housing quality. Associations between local-area characteristics and disability prevalence were assessed using multilevel logistic regressions. ResultsDisability was associated with local-area socioeconomic status and contextual characteristics, and heterogeneity in these factors accounted for urban-rural differences in disability prevalence. Associations between contextual features and disability prevalence were confounded by local-area socioeconomic status. Some associations between local-area socioeconomic status and disability prevalence were moderated by contextual characteristics. The importance of this effect modification is greater when expressed in terms of the absolute magnitude of disability than in the relative likelihood of disability. ConclusionExplanation of rural-urban differences by the contribution of other local-area characteristics is consistent with the conceptualization of urban-rural categories as the reflection of spatially varying ensembles of compositional and contextual factors. Although local-area socioeconomic status explains most variability in disability prevalence, this study shows that contextual characteristics are relevant to analyses of the spatial patterning of disability as they predict spatial variations of disability, sometimes in interaction with socioeconomic status. This study demonstrates that absolute and relative perspectives on effect modification may lead to differing conclusions.

Immigration Enforcement Policies, the Economic Recession, and the Size of Local Mexican Immigrant Populations

This article relies on local area variation in immigration policies, specifically the local implementation of the 287(g) program, and economic conditions to estimate their impact on changes in the size of local Mexican immigrant populations between 2007 and 2009. The author also investigates the impact of the 287(g) program on the employment prospects of low-skilled native black and white workers. The study finds that outside of four influential outliers (Dallas, Los Angeles, Riverside, and Phoenix), there is no evidence that the 287(g) program impacted the size of the Mexican immigrant population. In addition, there is no evidence that immigration enforcement policies mitigated the negative impact of the economic recession on the native population, even in the four outliers where the program was strongly enforced. The author highlights the limited efficacy of immigration enforcement as a way to resolve the issue of the undocumented immigrant population and for altering the employment opportunities of native workers.

The relationship between fading and bandwidth for multipath channels

A signal transmitted over a multipath channel experiences fading, the variability of which is a function of: 1) signal bandwidth; and 2) power delay profiles of the channel's specular and diffuse components. We analyze this general relationship and, for several important classes of multipath channel, we derive simple, closed-form approximations for what we call the stability bandwidth, W/sub 0/. For signal bandwidths greater than W/sub 0/, the local area variation in the received signal power is acceptably small, e.g., less than 1 dB standard deviation of decibel power. We demonstrate the accuracy of our W/sub 0/ approximations for some representative cases. Moreover, we show that the root mean square delay spread-a statistic commonly used to characterize multipath channels-has limited utility in estimating W/sub 0/.

Stature and adiposity among children in contrasting neighborhoods in the city of Hamilton, Ontario, Canada

It is hypothesized in this study that body size and shape vary by local area within the North American urban environment. This study tests that hypothesis by comparing stature and adiposity among children (of age 6-10 years) attending elementary schools in three neighborhoods that contrast by socioeconomic status and recent immigrant status. While the whole sample of children (n = 266) has 27.4% of children that can be classified as overweight/obese (> or =85th percentile for body mass index), analysis by socioeconomic status (SES) reveals that there are approximately twice as many children in the overweight/obese category in the two low-SES schools compared to the high-SES school. Further analysis by individual school indicates that the school in the poorest neighborhood has a statistically significantly lower mean height-for-age Z score relative to the most affluent school. It is concluded that the influence of socioeconomic, demographic, and environmental factors on stature and adiposity can be investigated through studies such as this one that consider local area variation.

Geographies of health perception in Québec: a multilevel perspective

Self perceived health is a widely used measure and, in Québec, it has been shown to vary significantly between geographical areas. In the present study, these geographical variations are examined in a multilevel analysis in order to disentangle compositional (individual characteristics) and contextual (place) effects. The analysis recognizes four levels of variation: individual, household, local and regional. Similar analyses carried out in Britain, have considered only two levels: individual and local. Data come from the 1992–1993 Québec Health and Social Survey, a general household survey using a stratified two-stage sampling design. Health perception (the response variable) is considered with a set of individual predictor characteristics reflecting gender, lifestyle, socio-economic conditions, marital status and social support. Results show the existence of significant local area variations in health perception after having allowed for individual characteristics and variations at the household level. At the regional level, however, no systematic and significant variations remain although some individual regions are found to have a significant impact on health perception.