Interactive and Independent Associations between the Socioeconomic and Objective Built Environment on the Neighbourhood Level and Individual Health: A Systematic Review of Multilevel Studies

The research question how contextual factors of neighbourhood environments influence individual health has gained increasing attention in public health research. Both socioeconomic neighbourhood characteristics and factors of the built environment play an important role for health and health-related behaviours. However, their reciprocal relationships have not been systematically reviewed so far. This systematic review aims to identify studies applying a multilevel modelling approach which consider both neighbourhood socioeconomic position (SEP) and factors of the objective built environment simultaneously in order to disentangle their independent and interactive effects on individual health.  The three databases PubMed, PsycINFO, and Web of Science were systematically searched with terms for title and abstract screening. Grey literature was not included. Observational studies from USA, Canada, Australia, New Zealand, and Western European countries were considered which analysed simultaneously factors of neighbourhood SEP and the objective built environment with a multilevel modelling approach. Adjustment for individual SEP was a further inclusion criterion.  Thirty-three studies were included in qualitative synthesis. Twenty-two studies showed an independent association between characteristics of neighbourhood SEP or the built environment and individual health outcomes or health-related behaviours. Twenty-one studies found cross-level or within-level interactions either between neighbourhood SEP and the built environment, or between neighbourhood SEP or the built environment and individual characteristics, such as sex, individual SEP or ethnicity. Due to the large variation of study design and heterogeneous reporting of results the identification of consistent findings was problematic and made quantitative analysis not possible.  There is a need for studies considering multiple neighbourhood dimensions and applying multilevel modelling in order to clarify their causal relationship towards individual health. Especially, more studies using comparable characteristics of neighbourhood SEP and the objective built environment and analysing interactive effects are necessary to disentangle health impacts and identify vulnerable neighbourhoods and population groups.

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A literature search was conducted using the Active Living Research (ALR) literature database, an online database that codes study characteristics and results of published papers on built/social environment and physical activity/obesity/sedentary behavior. Papers in the ALR database were identified through PubMed, Web of Science, and SPORTDiscus using systematically developed and expert-validated search protocols. For the current review, additional inclusion criteria were used to select observational, quantitative studies among youth aged 3-18 years.



Papers were categorized by design features, sample characteristics, and measurement mode. Relevant results were summarized, stratified by age (children or adolescents) and mode of measurement (objective or perceived) for environmental attributes and physical activity. Percentage of significant results was calculated.



Mode of measurement greatly influenced the consistency of associations between environmental attributes and youth physical activity. For both children and adolescents, the most consistent associations involved objectively measured environmental attributes and reported physical activity. The most supported correlates for children were walkability, traffic speed/volume, access/proximity to recreation facilities, land-use mix, and residential density. The most supported correlates for adolescents were land-use mix and residential density. These findings support several recommendations for policy and environmental change from such groups as the IOM and National Physical Activity Plan.

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title: Environmental measures of physical activity supports: perception versus reality.
abstract: Perceptions of the environment and physical activity have been associated using survey methods, yet little is known about the validity of environmental surveys. In this study, perceptions of the environment at neighborhood and community levels were assessed (1) to determine validity by comparing respondent perceptions to objective measures and (2) to determine test-retest reliability of the survey.



A telephone survey was administered to a stratified sample of Sumter County, South Carolina adults. Respondents' home addresses were mapped using a geographic information system (GIS) (n =1112). As an indicator of validity, kappa statistics were used to measure agreement between perceptions and objective measures identified at neighborhood and community levels using GIS. A second survey in an independent sample (n=408) assessed test-retest reliability.



When assessing perceptions of environmental and physical activity in a defined geographic area, validity and reliability for neighborhood survey items were kappa= -0.02 to 0.37 and rho=0.42 to 0.74, and for community survey items were kappa= -0.07 to 0.25 and rho=0.28 to 0.56.



Although causality between perception of access and safety and actual physical activity level cannot be assumed, those meeting national physical activity guidelines or reporting some physical activity demonstrated greatest agreement with access to recreation facilities, while those not meeting the guidelines demonstrated greater agreement with safety of recreation facilities. Factors such as distance and behavior may explain differences in perceptions at neighborhood and community levels. Using local environments with short distances in survey methods improves validity and reliability of results.

title: Examining methodological details of neighbourhood observations and the relationship to health: a literature review.
abstract: Neighbourhood research has been growing steadily over the past two decades across the social sciences, and, in particular in the area of public health. Despite this increase, there is currently no consensus on which measure and data source researchers should use to assess neighbourhood attributes. In the past, researchers have relied on census data and household surveys to assess neighbourhood conditions, but in recent years, neighbourhood observations have become a popular alternative method for characterizing neighbourhood environments. Rooted in sociology of crime research, observations are conducted by trained observers who use a checklist to observe and rate neighbourhoods on a number of conditions such as physical (e.g., traffic volume, housing conditions) and social (e.g., presence of people, gang activity) attributes. While this methodology has been gaining momentum in recent years, notably absent from the literature is a review to examine this methodology in detail. The purpose of the present study was to examine research that has used neighbourhood observations as a method. We do so by critically reviewing 51 English language studies published from 1990 onward paying particular attention to the areas of (1) methodological rigor (i.e. how observations are carried out in the field and how data are analyzed), (2) geographical boundaries (i.e. how neighbourhoods and areas of observation are spatially defined), and (3) the relationship between neighbourhood observations and residents' health (i.e. how studies examine and analyze the link between observed neighbourhood attributes and health). We find that little attention is given to details of neighbourhood observations as a method. Further, there is wide variability in how observations are conducted and analyzed making it impossible to confidently compare findings across studies. We see this review as a first step in developing sound observational measures of neighbourhood factors and conclude by providing recommendations for researchers undertaking neighbourhood observations in the future.

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title: Estimating Multilevel Logistic Regression Models When the Number of Clusters is Low: A Comparison of Different Statistical Software Procedures
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abstract: An important problem in multilevel modeling is what constitutes a sufficient sample size for accurate estimation. In multilevel analysis, the major restriction is often the higher-level sample size. In this paper, a simulation study is used to determine the influence of different sample sizes at the group level on the accuracy of the estimates (regression coefficients and variances) and their standard errors. In addition, the influence of other factors, such as the lowest-level sample size and different variance distributions between the levels (different intraclass correlations), is examined. The results show that only a small sample size at level two (meaning a sample of 50 or less) leads to biased estimates of the second-level standard errors. In all of the other simulated conditions the estimates of the regression coefficients, the variance components, and the standard errors are unbiased and accurate.

title: A simulation study of sample size for multilevel logistic regression models
abstract: BackgroundMany studies conducted in health and social sciences collect individual level data as outcome measures. Usually, such data have a hierarchical structure, with patients clustered within physicians, and physicians clustered within practices. Large survey data, including national surveys, have a hierarchical or clustered structure; respondents are naturally clustered in geographical units (e.g., health regions) and may be grouped into smaller units. Outcomes of interest in many fields not only reflect continuous measures, but also binary outcomes such as depression, presence or absence of a disease, and self-reported general health. In the framework of multilevel studies an important problem is calculating an adequate sample size that generates unbiased and accurate estimates.MethodsIn this paper simulation studies are used to assess the effect of varying sample size at both the individual and group level on the accuracy of the estimates of the parameters and variance components of multilevel logistic regression models. In addition, the influence of prevalence of the outcome and the intra-class correlation coefficient (ICC) is examined.ResultsThe results show that the estimates of the fixed effect parameters are unbiased for 100 groups with group size of 50 or higher. The estimates of the variance covariance components are slightly biased even with 100 groups and group size of 50. The biases for both fixed and random effects are severe for group size of 5. The standard errors for fixed effect parameters are unbiased while for variance covariance components are underestimated. Results suggest that low prevalent events require larger sample sizes with at least a minimum of 100 groups and 50 individuals per group.ConclusionWe recommend using a minimum group size of 50 with at least 50 groups to produce valid estimates for multi-level logistic regression models. Group size should be adjusted under conditions where the prevalence of events is low such that the expected number of events in each group should be greater than one.

title: Disentangling the relative influence of built and socioeconomic environments on walking: the contribution of areas homogenous along exposures of interest.
abstract: The geography of small areas has important implications for studying the contextual determinants of health because of potential errors when measuring ecologic exposures and estimating their effects on health. In this paper, we present an approach for designing homogeneous zones optimising the spatial distribution of an area-level exposure, active living potential (ALP), based on data collected in Montreal, Canada. The objectives are to (1) assess and compare variation in walking behaviours between these purposefully designed zones and between standard administrative units, census tracts; and (2) disentangle the relative influence of ALP and area-level socioeconomic conditions on walking using the alternative geographies. Zones were designed by statistically classifying smallest census areas (disseminations areas) into seven categories of exposure similar along three indicators of ALP: population density, land use mix, and geographic accessibility to services. Mapping of categories resulted in the delineation of zones characterised by one of seven levels of ALP. A sample of 2716 adults aged >/=45 years was geocoded and cross-classified in 270 zones and 112 census tracts. Individuals reported on minutes and motives of walking and provided socioeconomic information. Data were analysed using cross-classified multilevel models. Variation in utilitarian walking was larger across the purposefully defined zones than across census tracts. Total walking varied significantly between census tracts only. Greater ALP was associated with more utilitarian walking but with less recreational walking. Higher socioeconomic position in census tracts was positively associated with total, utilitarian, and recreational walking. The soundness of standard administrative units for measuring ecologic exposure and their associations with health should be considered prior to conducting analyses. The added value of different approaches for understanding how place relates to health remains to be established and should be the focus of further investigations.

title: Neighborhood walkability, physical activity, and walking behavior: the Swedish Neighborhood and Physical Activity (SNAP) study.
abstract: More knowledge concerning the association between physical activity and objectively measured attributes of the built environment is needed. Previous studies on the association between objectively measured neighborhood walkability, physical activity, and walking have been conducted in the U.S. or Australia and research findings are available from only one country in Europe - Belgium. The first aim of this Swedish study of 2269 adults was to examine the associations between neighborhood walkability and walking for active transportation or leisure, and moderate-to-vigorous physical activity (MVPA) and whether these hypothesized associations are moderated by age, gender, income, marital status and neighborhood-level socioeconomic status. The second aim was to determine how much of the total variance of the walking and physical activity outcomes can be attributed to neighborhood-level differences. Neighborhood walkability was objectively measured by GIS methods. An index consisting of residential density, street connectivity, and land use mix was constructed to define 32 highly and less walkable neighborhoods in Stockholm City. MVPA was measured objectively during 7 days with an accelerometer and walking was assessed using the validated International Physical Activity Questionnaire (IPAQ). Multilevel linear as well as logistic models (mixed-effects, mixed-distribution models) were used in the analysis. The statistically significant and "adjusted" results for individuals living in highly walkable neighborhoods, as compared to those living in less walkable neighborhoods, were: (1) 77% and 28% higher odds for walking for active transportation and walking for leisure, respectively, (2) 50 min more walking for active transportation/week, and (3) 3.1 min more MVPA/day. The proportion of the total variance at the neighborhood level was low and ranged between 0.0% and 2.1% in the adjusted models. The findings of the present study stress that future policies concerning the built environment must be based on context-specific evidence, particularly in the light of the fact that neighborhood redevelopments are time-consuming and expensive.

title: Active living neighborhoods: is neighborhood walkability a key element for Belgian adolescents?
abstract: BackgroundIn adult research, neighborhood walkability has been acknowledged as an important construct among the built environmental correlates of physical activity. Research into this association has only recently been extended to adolescents and the current empirical evidence is not consistent. This study investigated whether neighborhood walkability and neighborhood socioeconomic status (SES) are associated with physical activity among Belgian adolescents and whether the association between neighborhood walkability and physical activity is moderated by neighborhood SES and gender.MethodsIn Ghent (Belgium), 32 neighborhoods were selected based on GIS-based walkability and SES derived from census data. In total, 637 adolescents (aged 13-15 year, 49.6% male) participated in the study. Physical activity was assessed using accelerometers and the Flemish Physical Activity Questionnaire. To analyze the associations between neighborhood walkability, neighborhood SES and individual physical activity, multivariate multi-level regression analyses were conducted.ResultsOnly in low-SES neighborhoods, neighborhood walkability was positively associated with accelerometer-based moderate to vigorous physical activity and the average activity level expressed in counts/minute. For active transport to and from school, cycling for transport during leisure time and sport during leisure time no association with neighborhood walkability nor, with neighborhood SES was found. For walking for transport during leisure time a negative association with neighborhood SES was found. Gender did not moderate the associations of neighborhood walkability and SES with adolescent physical activity.ConclusionsNeighborhood walkability was related to accelerometer-based physical activity only among adolescent boys and girls living in low-SES neighborhoods. The relation of built environment to adolescent physical activity may depend on the context.

title: Contextual Effects of Built and Social Environments of Urban Neighborhoods on Exercise: A Multilevel Study in Chicago
abstract: Examine the contextual effects of neighborhood built and social environments on exercise.  City of Chicago. Subjects. A probability sample of Chicago adult residents (response rate = 55%).  The exercise measures were based on two questions: “How often a week on average do you work out or exercise?” (N = 3530) and, “Did you exercise regularly in the last year?” (N = 907). Neighborhood social environment was measured by socioeconomic and social capital indicators. Neighborhood built environment was captured by pedestrian injury rate, residential density, distance to subway or parks, land use mix, and access to neighborhood amenities. Analysis. Random effects logit and multinomial models.  For weekly workout/exercise, individuals with access to restaurants and bars were more likely to report one to three times of weekly exercise (OR = 1.08; 95% CI: 0.99, 1.19) and four times or more weekly exercise (OR = 1.14; 95% CI: 1.03, 1.26) compared with those who reported no weekly exercise. For regular exercise in the past year, access to restaurants and bars (OR = 1.24; 95% CI: 1.05, 1.46) and neighborhood social environment (OR = 1.37; 95% CI: 1.11, 1.69) were significant. The social environment effects were stronger for women.  Neighborhood social and built environments are both important for exercise independent of an individual's background.

title: Neighborhood walkability and the walking behavior of Australian adults.
abstract: The physical attributes of residential neighborhoods, particularly the connectedness of streets and the proximity of destinations, can influence walking behaviors. To provide the evidence for public health advocacy on activity-friendly environments, large-scale studies in different countries are needed. Associations of neighborhood physical environments with adults' walking for transport and walking for recreation must be better understood.



Walking for transport and walking for recreation were assessed with a validated survey among 2650 adults recruited from neighborhoods in an Australian city between July 2003 and June 2004, with neighborhoods selected to have either high or low walkability, based on objective measures of connectedness and proximity derived from geographic information systems (GIS) databases. The study design was stratified by area-level socioeconomic status, while analyses controlled for participant age, gender, individual-level socioeconomic status, and reasons for neighborhood self-selection.



A strong independent positive association was found between weekly frequency of walking for transport and the objectively derived neighborhood walkability index. Preference for walkable neighborhoods moderated the relationship of walkability with weekly minutes, but not the frequency of walking for transport--walkability was related to higher frequency of transport walking, irrespective of neighborhood self-selection. There were no significant associations between environmental factors and walking for recreation.



Associations of neighborhood walkability attributes with walking for transport were confirmed in Australia. They accounted for a modest but statistically significant proportion of the total variation of the relevant walking behavior. The physical environment attributes that make up the walkability index are potentially important candidate factors for future environmental and policy initiatives designed to increase physical activity.

title: Home and work neighbourhood environments in relation to body mass index: the Multi-Ethnic Study of Atherosclerosis (MESA)
abstract: Little is known about the neighbourhood characteristics of workplaces, the extent to which they are independently and synergistically correlated with residential environments, and their impact on health.  This study investigated cross-sectional relationships between home and workplace neighbourhood environments with body mass index (BMI) in 1503 working participants of the Multi-Ethnic Study of Atherosclerosis with mean age 59.6 (SD=7.4). Neighbourhood features were socioeconomic status (SES), social environment (aesthetic quality, safety and social cohesion) and physical environment (walking environment, recreational facilities and food stores) derived from census data, locational data on businesses and survey data. Paired t tests and correlations compared environments overall and by distance between locations. Cross-classified multilevel models estimated associations with BMI.  Home neighbourhoods had more favourable social environments while workplaces had more favourable SES and physical environments. Workplace and home measures were correlated (0.39–0.70), and differences between home and workplaces were larger as distance increased. Associations between BMI and neighbourhood SES and recreational facilities were stronger for home environment (p≤0.05) but did not significantly differ for healthy food, safety or social cohesion. Healthy food availability at home and work appeared to act synergistically (interaction p=0.01).  Consideration of workplace environment may enhance our understanding of how place affects BMI.

title: Neighborhoods and obesity in later life.
abstract: We examined the influence of neighborhood environment on the weight status of adults 55 years and older.



We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability.



When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese.



The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.

title: Socioeconomic and food-related physical characteristics of the neighbourhood environment are associated with body mass index
abstract: To determine whether socioeconomic and food-related physical characteristics of the neighbourhood are associated with body mass index (BMI; kg/m2) independently of individual-level sociodemographic and behavioural characteristics.  Observational study using (1) individual-level data previously gathered in five cross-sectional surveys conducted by the Stanford Heart Disease Prevention Program between 1979 and 1990 and (2) neighbourhood-level data from (a) the census to describe socioeconomic characteristics and (b) data obtained from government and commercial sources to describe exposure to different types of retail food stores as measured by store proximity, and count of stores per square mile. Data were analysed using multilevel modelling procedures. The setting was 82 neighbourhoods in agricultural regions of California.  7595 adults, aged 25–74 years.  After adjusting for age, gender, ethnicity, individual-level socioeconomic status, smoking, physical activity and nutrition knowledge, it was found that (1) adults who lived in low socioeconomic neighbourhoods had a higher mean BMI than adults who lived in high socioeconomic neighbourhoods; (2) higher neighbourhood density of small grocery stores was associated with higher BMI among women; and (3) closer proximity to chain supermarkets was associated with higher BMI among women.  Living in low socioeconomic neighbourhoods, and in environments where healthy food is not readily available, is found to be associated with increased obesity risk. Unlike other studies which examined populations in other parts of the US, a positive association between living close to supermarkets and reduced obesity risk was not found in this study. A better understanding of the mechanisms by which neighbourhood physical characteristics influence obesity risk is needed.

title: The built environment and risk of obesity in the United States: racial-ethnic disparities.
abstract: Using data from the 2003-2008 waves of the continuous National Health Nutrition Examination Survey merged with the 2000 census and GIS-based data, this study conducted genderspecific analyses to explore whether neighborhood built environment attributes are significant correlates of obesity risk and mediators of obesity disparities by race-ethnicity. Results indicate that the built environment is a significant correlate of obesity risk but is not much of a mediator of obesity disparities by race-ethnicity. Neighborhood walkability, density, and distance to parks are significant covariates of obesity risks net of individual and neighborhood controls. Gender differences are found for some of these associations.

title: Body mass index in urban Canada: neighborhood and metropolitan area effects.
abstract: We investigated the influence of neighborhood and metropolitan area characteristics on body mass index (BMI) in urban Canada in 2001.



We conducted a multilevel analysis with data collected from a cross-sectional survey of men and women nested in neighborhoods and metropolitan areas in urban Canada during 2001.



After we controlled for individual sociodemographic characteristics and behaviors, the average BMIs of residents of neighborhoods in which a large proportion of individuals had less than a high school education were higher than those BMIs of residents in neighborhoods with small proportions of such individuals (P< .01). Living in a neighborhood with a high proportion of recent immigrants was associated with lower BMI for men (P<.01), but not for women. Neighborhood dwelling density was not associated with BMI for either gender. Metropolitan sprawl was associated with higher BMI for men (P=.02), but the effect was not significant for women (P= .09).



BMI is strongly patterned by an individual's social position in urban Canada. A neighborhood's social condition has an incremental influence on the average BMI of its residents. However, BMI is not influenced by dwelling density. Metropolitan sprawl is associated with higher BMI for Canadian men, which supports recent evidence of this same association among American men. Individuals and their environments collectively influence BMI in urban Canada.

title: Relationships Between Neighborhoods, Physical Activity, and Obesity: A Multilevel Analysis of a Large Canadian City
abstract: In Canada, there is limited research examining the associations between objectively measured neighborhood environments and physical activity (PA) and obesity. The purpose of this study was to determine the relationships between variables from built and social environments and PA and overweight/obesity across 86 Ottawa, Canada neighborhoods. Individual‐level data including self‐reported leisure‐time PA (LTPA), height, and weight were examined in a sample of 4,727 adults from four combined cycles (years 2001/03/05/07) of the Canadian Community Health Survey (CCHS). Data on neighborhood characteristics were obtained from the Ottawa Neighbourhood Study (ONS); a large study of neighborhoods and health in Ottawa, Canada. Binomial multivariate multilevel models were used to examine the relationships between environmental and individual variables with LTPA and overweight/obesity using survey weights in men and women separately. Within the sample, ∼75% of the adults were inactive (<3.0 kcal/kg/day) while half were overweight/obese. Results of the multilevel models suggested that for females greater park area was associated with increased odds of LTPA and overweight/obesity. Greater neighborhood density of convenience stores and fast food outlets were associated with increased odds of females being overweight/obese. Higher crime rates were associated with greater odds of LTPA in males, and lower odds of male and female overweight/obesity. Season was significantly associated with PA in men and women; the odds of LTPA in winter months were half that of summer months. Findings revealed that park area, crime rates, and neighborhood food outlets may have different roles with LTPA and overweight/obesity in men and women and future prospective studies are needed.

title: A Multilevel Analysis of Neighbourhood Built and Social Environments and Adult Self-Reported Physical Activity and Body Mass Index in Ottawa, Canada
abstract: Canadian research examining the combined effects of social and built environments on physical activity (PA) and obesity is limited. The purpose of this study was to determine the relationships among built and social environments and PA and overweight/obesity in 85 Ottawa neighbourhoods. Self-reported PA, height and weight were collected from 3,883 adults using the International PA Questionnaire from the 2003–2007 samples of the Rapid Risk Factor Surveillance System. Data on neighbourhood characteristics were obtained from the Ottawa Neighbourhood Study; a large study of neighbourhoods and health in Ottawa. Two-level binomial logistic regression models stratified by sex were used to examine the relationships of environmental and individual variables with PA and overweight/obesity while using survey weights. Results identified that approximately half of the adults were insufficiently active or overweight/obese. Multilevel models identified that for every additional convenience store, men were two times more likely to be physically active (OR = 2.08, 95% CI: 1.72, 2.43) and with every additional specialty food store women were almost two times more likely to be overweight or obese (OR = 1.77, 95% CI: 1.33, 2.20). Higher green space was associated with a reduced likelihood of PA (OR = 0.93, 95% CI: 0.86, 0.99) and increased odds of overweight and obesity in men (OR = 1.10, 95% CI: 1.01, 1.19), and decreased odds of overweight/obesity in women (OR = 0.66, 95% CI: 0.44, 0.89). In men, neighbourhood socioeconomic scores, voting rates and sense of community belonging were all significantly associated with overweight/obesity. Intraclass coefficients were low, but identified that the majority of neighbourhood variation in outcomes was explained by the models. Findings identified that green space, food landscapes and social cohesiveness may play different roles on PA and overweight/obesity in men and women and future prospective studies are needed.

title: Regional differences in walking frequency and BMI: what role does the built environment play for Blacks and Whites?
abstract: Studies have found that urban sprawl explains many regional differences in BMI and walking behavior. Yet, African Americans, who often live in dense, urban neighborhoods with exemplar street connectivity, suffer disproportionately from obesity. This study analyzed walking and BMI among 1124 Whites and 691 Blacks in Los Angeles County and southern Louisiana in relation to neighborhood safety, street connectivity, and walking destinations. While the built environment partly explains regional differences in walking and BMI among Whites, the magnitude of effect was modest. There were no regional differences in outcomes for African Americans; individual rather than neighborhood characteristics served as the best predictors.

title: The association between community physical activity settings and youth physical activity, obesity, and body mass index.
abstract: This study examined the association between the level of physical activity (PA) friendliness of the built environment and adolescent PA and body mass index using a national sample of youth and data collected from the communities where they reside.



Data on height, weight, and PA were taken from annual nationally representative cross-sectional Monitoring the Future surveys of 8th and 10th graders in schools, from 2001 through 2003. Measures of safety, outdoor and commercial PA settings, and urban sprawl were constructed using data collected from the communities in which the students reside. Multilevel models were run and controlled for youth and community demographic and socioeconomic characteristics.



Increased levels of physical disorder were associated with decreased PA and higher weight. A greater number of commercial PA facilities was associated with increased PA. More compact communities were associated with lower weight and less sports participation.



It is important to explore these associations to help guide future development patterns and land use policies to create more active neighborhoods.

title: Neighborhood built environment and income: examining multiple health outcomes.
abstract: There is growing interest in the relation of built environments to physical activity, obesity, and other health outcomes. The purpose of the present study was to test associations of neighborhood built environment and median income to multiple health outcomes and examine whether associations are similar for low- and high-income groups. This was a cross-sectional study of 32 neighborhoods in Seattle, WA and Baltimore, MD regions, stratified by income and walkability, and conducted between 2001 and 2005. Participants were adults aged 20-65years (n=2199; 26% ethnic minority). The main outcomes were daily minutes of moderate-to-vigorous physical activity (MVPA) from accelerometer monitoring, body mass index (BMI) based on self-report, and mental and physical quality of life (QoL) assessed with the SF-12. We found that MVPA was higher in high- vs. low-walkability neighborhoods but did not differ by neighborhood income. Overweight/obesity (BMI > or = 25) was lower in high-walkability neighborhoods. Physical QoL was higher in high-income neighborhoods but unrelated to walkability. Adjustment for neighborhood self-selection produced minor changes. We concluded that living in walkable neighborhoods was associated with more physical activity and lower overweight/obesity but not with other benefits. Lower- and higher-income groups benefited similarly from living in high-walkability neighborhoods. Adults in higher-income neighborhoods had lower BMI and higher physical QoL.

title: Assessing the impact of the local environment on birth outcomes: a case for HLM
abstract: Hierarchical linear Models (HLM) is a useful way to analyze the relationships between community level environmental data, individual risk factors, and birth outcomes. With HLM we can determine the effects of potentially remediable environmental conditions (e.g., air pollution) after controlling for individual characteristics such as health factors and socioeconomic factors. Methodological limitations of ecological studies of birth outcomes and a detailed analysis of the varying models that predict birth weight will be discussed. Ambient concentrations of criterion air pollutants (e.g., lead and sulfur dioxide) demonstrated a sizeable negative effect on birth weight; while the economic characteristics of the mother's residential census tract (ex. poverty level) also negatively influenced birth weight.

title: The effects of socioeconomic status and indices of physical environment on reduced birth weight and preterm births in Eastern Massachusetts
abstract: BackgroundAir pollution and social characteristics have been shown to affect indicators of health. While use of spatial methods to estimate exposure to air pollution has increased the power to detect effects, questions have been raised about potential for confounding by social factors.MethodsA study of singleton births in Eastern Massachusetts was conducted between 1996 and 2002 to examine the association between indicators of traffic, land use, individual and area-based socioeconomic measures (SEM), and birth outcomes (birth weight, small for gestational age and preterm births), in a two-level hierarchical model.ResultsWe found effects of both individual (education, race, prenatal care index) and area-based (median household income) SEM with all birth outcomes. The associations for traffic and land use variables were mainly seen with birth weight, with an exception for an effect of cumulative traffic density on small for gestational age. Race/ethnicity of mother was an important predictor of birth outcomes and a strong confounder for both area-based SEM and indices of physical environment. The effects of traffic and land use differed by level of education and median household income.ConclusionOverall, the findings of the study suggested greater likelihood of reduced birth weight and preterm birth s among the more socially disadvantaged, and a greater risk of reduced birth weight associated with traffic exposures. Results revealed the importance of controlling simultaneously for SEM and environmental exposures as the way to better understand determinants of health.

title: Neighbourhood socioeconomic status, maternal education and adverse birth outcomes among mothers living near highways
abstract: Residential proximity to highways is a potential proxy for exposure to traffic-related pollution that has been linked to adverse birth outcomes. We evaluated whether proximity to highway interacts with individual and neighbourhood socioeconomic status (SES) to influence birth outcomes.  The study population consisted of all live singleton births in Montréal, Canada, from 1997 to 2001 (n = 99 819). Proximity was defined as residing within 200 m of a highway. Neighbourhood SES was measured for census tracts as the proportion of families below the low-income threshold. Individual SES was represented by maternal education. Using multilevel logistic regression, the odds of preterm birth (PTB), low birthweight (LBW) and small-for-gestational-age (SGA) birth were calculated for mothers residing in proximity to highways, accounting for individual and neighbourhood SES. Effect modification between SES and proximity to highway was tested for each outcome.  In wealthy neighbourhoods, proximity to highway was associated with an elevated odds of PTB (OR 1.58, 95% CI 1.23 to 2.04), LBW (OR 1.81, 95% CI 1.36 to 2.41) and SGA birth (OR 1.32, 95% CI 1.05 to 1.66). For highly educated mothers, proximity to highway was associated with PTB (OR 1.25, 95% CI 1.07 to 1.46) and LBW (OR 1.24, 95% CI 1.03 to 1.49), but the association was borderline for SGA birth (OR 1.15, 95% CI 1.00 to 1.32). Proximity to highway was not associated with birth outcomes in other maternal and neighbourhood SES categories.  Counterintuitively, high SES mothers may be more likely than low SES mothers to experience adverse births associated with residential proximity to highway.

title: Preterm birth: the interaction of traffic-related air pollution with economic hardship in Los Angeles neighborhoods.
abstract: Preterm birth may be affected by the interaction of residential air pollution with neighborhood economic hardship. The authors examined variations in traffic-related pollution exposure--measured by distance-weighted traffic density--using a framework reflecting the social and physical environments. An adverse social environment was conceptualized as low socioeconomic status (SES) neighborhoods--census tracts with concentrated poverty, unemployment, and dependence on public assistance. An adverse physical environment was depicted by the winter season, when thermal inversions trap motor vehicle pollutants, thereby increasing traffic-related air pollution.  The authors fit multivariate logistic models of preterm birth, stratified by neighborhood SES and third pregnancy trimester season. Traffic-related air pollution exposure disproportionately affected low SES neighborhoods in the winter. Further, in these poorer neighborhoods, the winter season evidenced increased susceptibility among women with known risk factors. Health insurance was most beneficial to women residing in neighborhoods exposed to economic hardship and an adverse physical environment. Reducing preterm births warrants a concerted effort of social, economic, and environmental policies, focused on not only individual risk factors but also the reduction of localized air pollution, expansion of health-care coverage, and improvement of neighborhood resources.

title: Individual factors explain neighbourhood variations in accidents to children under 5 years of age.
abstract: Previous studies have identified possible neighbourhood-level influences on the risk of injuries to preschool children, but none have had sufficient data at both household and area level to explain these neighbourhood effects. We used data from the Avon Longitudinal Study of Parents and Children, which recruited over 14,062 children at birth in the former county of Avon, UK, and collected information about accidents, as well as extensive social, health and developmental data throughout the first 5 years of life. This information was combined with census and geographical data in order to identify neighbourhood influences on accident risks and then attempt to explain these using multilevel regression modelling. A small but statistically significant amount of between-neighbourhood variance in accident risk was found, with neighbourhood intraclass correlation coefficients of 0.82% for any accident, and 0.84% for accidents resulting in injury requiring medical attention. This was entirely accounted for by a variety of child, parental and household level variables. Independent risk factors for both outcomes were children who were developmentally more advanced or displayed greater conduct and behavioural problems, mothers who were of younger age, who were without work, who were smokers, whose partners were unemployed or drank alcohol excessively, and households in which there had recently been adverse life events, or which were under financial stress. The mother's perceptions of neighbourhood quality also explained some of the risks for any accident, but not for medically attended accidents, and this was a variable that operated at the level of individual households rather than at the level of neighbourhoods. The implications of this study are that differences in accident risk between neighbourhoods are explained by geographical clustering of similar types of children, families and households. Interventions should focus more on parental factors and household social circumstances than on the physical environment or community based risks. However, many of these factors are those most resistant to modification without broader societal change.

title: Neighbourhood environment and its association with self rated health: evidence from Scotland and England
abstract: To investigate associations between measures of neighbourhood social and material environment and self rated health.  New contextual measures added to cross sectional study of a sample of people from the Health Survey for England and the Scottish Health Survey to provide multilevel data.  13 899 men and women aged 16 or over for whom data on self rated health were available from the Health Survey for England (years 1994–99) and the Scottish Health Survey (years 1995 and 1998).  Fair to very bad self rated health was significantly associated with six neighbourhood attributes: poor physical quality residential environment, left wing political climate, low political engagement, high unemployment, lower access to private transport, and lower transport wealth. Associations were independent of sex, age, social class, and economic activity. Odds ratios were larger for non-employed residents than for employed residents. Self rated health was not significantly associated with five other neighbourhood measures: public recreation facilities, crime, health service provision, access to food shops, or access to banks and buildings societies.  Some, but not all, features of the neighbourhood environment are associated with self rated health and may be indicators of important causal pathways that could provide a focus for public health intervention strategies. Associations were more pronounced for non-employed residents, perhaps because of greater exposure to the local environment compared with employed people. Operationalising specific measures of the characteristics of local areas hypothesised to be important for living a healthy life provides a more focused approach than general measures of deprivation in the search for area effects.

title: Exploring the Role of the Built and Social Neighborhood Environment in Moderating Stress and Health
abstract: BackgroundHealth researchers have explored how different aspects of neighborhood characteristics contribute to health and well-being, but current understanding of built environment factors is limited.PurposeThis study explores whether the association between stress and health varies by residential neighborhood, and if yes, whether built and social neighborhood environment characteristics act as moderators.MethodsThis study uses multilevel modeling and variables derived from geospatial data to explore the role of neighborhood environment in moderating the association of stress with health. Individual-level data (N = 4,093) were drawn from residents of 45 neighborhoods within Philadelphia County, PA, collected as part of the 2006 Philadelphia Health Management Corporation's Household Health Survey.ResultsWe find that the negative influence of high stress varied by neighborhood, that residential stability and affluence (social characteristics) attenuated the association of high stress with health, and that the presence of hazardous waste facilities (built environment characteristics) moderated health by enhancing the association with stress.ConclusionsOur findings suggest that neighborhood environment has both direct and moderating associations with health, after adjusting for individual characteristics. The use of geospatial data could broaden the scope of stress–health research and advance knowledge by untangling the intertwined relationship between built and social environments, stress, and health. In particular, future studies should integrate built environment characteristics in health-related research; these characteristics are modifiable and can facilitate health promotion policies.

title: Neighborhoods and chronic disease onset in later life.
abstract: To strengthen existing evidence on the role of neighborhoods in chronic disease onset in later life, we investigated associations between multiple neighborhood features and 2-year onset of 6 common conditions using a national sample of older adults.



Neighborhood features for adults aged 55 years or older in the 2002 Health and Retirement Study were measured by use of previously validated scales reflecting the built, social, and economic environment. Two-level random-intercept logistic models predicting the onset of heart problems, hypertension, stroke, diabetes, cancer, and arthritis by 2004 were estimated.



In adjusted models, living in more economically disadvantaged areas predicted the onset of heart problems for women (odds ratio [OR] = 1.20; P < .05). Living in more highly segregated, higher-crime areas was associated with greater chances of developing cancer for men (OR = 1.31; P < .05) and women (OR = 1.25; P < .05).



The neighborhood economic environment is associated with heart disease onset for women, and neighborhood-level social stressors are associated with cancer onset for men and women. The social and biological mechanisms that underlie these associations require further investigation.

title: Neighborhoods and disability in later life.
abstract: This paper uses the US Health and Retirement Study to explore linkages between neighborhood conditions and stages of the disablement process among adults aged 55 years and older in the United States. We consider multiple dimensions of the neighborhood including the built environment as well as social and economic conditions. In doing so, we use factor analysis to reduce indicators into eight neighborhood scales, which we incorporate into two-level logistic regression models along with controls for individual-level factors. We find evidence that economic conditions and the built environment, but not social conditions, matter. Neighborhood economic advantage is associated with a reduced risk of lower body limitations for both men and women. We also find for men that neighborhood economic disadvantage is linked to increased chances of reporting personal care limitations, particularly for those aged 55-64 years, and that high connectivity of the built environment is associated with reduced risk of limitations in instrumental activities. Our findings highlight the distinctive benefits of neighborhood economic advantage early in the disablement process. In addition, findings underscore the need for attention in the design and evaluation of disability-prevention efforts to the benefits that accrue from more physically connected communities and to the potential harm that may arise in later life from living in economically disadvantaged areas.

title: Gender differences in the associations between health and neighbourhood environment.
abstract: Multiple deprivation indicators are frequently used to capture the characteristics of an area. This is a useful approach for identifying the most deprived areas, and summary indices are good predictors of mortality and morbidity, but it remains unclear which aspects of the residential environment are most salient for health. A further question is whether the most important aspects vary for different types of residents. This paper focuses on whether associations with neighbourhood characteristics are different for men and women. The sociopolitical and physical environment, amenities, and indicators of economic deprivation and affluence were measured in neighbourhoods in the UK, and their relationship with self-rated health was investigated using multilevel regression models. Each of these contextual domains was associated with self-rated health over and above individual socioeconomic characteristics. The magnitude of the association was larger for women in each case. Statistically significant interactions between gender and residential environment were found for trust, integration into wider society, left-wing political climate, physical quality of the residential environment, and unemployment rate. These findings add to the literature indicating greater effects of non-work-based stressors for women and highlight the influence of the residential environment on women's health.

title: The role of social and built environments in predicting self-rated stress: A multilevel analysis in Philadelphia.
abstract: Most studies of the predictors of stress focus on individual characteristics. Linking multiple contextual data sources to an individual-level health survey, we explore the associations of both built and social environment determinants with self-rated stress. At the individual level few social factors were significant predictors, although neighborhood trust and food insecurity have independent effects on stress. At the neighborhood level, the presence of hazardous waste sites and traffic volume were determinants of self-rated stress even after controlling for other individual characteristics. The latter two factors are of relevance to public health policy as they are potentially modifiable.

title: Effects of neighbourhood socioeconomic status and convenience store concentration on individual level smoking
abstract: To assess the effects of neighbourhood level socioeconomic status (SES) and convenience store concentration on individual level smoking, after consideration of individual level characteristics.  Individual sociodemographic characteristics and smoking were obtained from five cross sectional surveys (1979–1990). Participants’ addresses were geocoded and linked with census data for measuring neighbourhood SES and with telephone yellow page listings for measuring convenience store concentration (density in a neighbourhood, distance between a participant’s home and the nearest convenience store, and number of convenience stores within a one mile radius of a participant’s home). The data were analysed with multilevel Poisson regression models.  82 neighbourhoods in four northern California cities.  8121 women and men aged 25–74 from the Stanford heart disease prevention programme.  Lower neighbourhood SES and higher convenience store concentration, measured by density and distance, were both significantly associated with higher level of individual smoking after taking individual characteristics into account. The association between convenience store density and individual smoking was modified by individual SES and neighbourhood SES.  These findings are consistent with a growing body of literature suggesting that the socioeconomic and physical environments of neighbourhoods are associated with individual level smoking.

title: Neighbourhood deprivation and alcohol consumption: does the availability of alcohol play a role?
abstract: Previous studies suggest that the physical availability of alcohol may mediate the association between neighbourhood-level material deprivation and alcohol consumption. This study tests the relationships between neighbourhood-level deprivation, alcohol availability, and individual-level alcohol consumption using a multilevel analysis.



Data are from cross-sectional surveys conducted between 1979 and 1990 as part of the Stanford Heart Disease Prevention Program (SHDPP). Women and men (n = 8197) living in four northern/central California cities and 82 neighbourhoods were linked to neighbourhood deprivation variables derived from the US census (e.g. unemployment, crowded housing) and to measures of alcohol availability (density of outlets in the respondent's neighbourhood, nearest distance to an outlet from the respondent's home, and number of outlets within a half mile radius of the respondent's home). Separate analyses were conducted for on- and off-sale outlets.



The most deprived neighbourhoods had substantially higher levels of alcohol outlet density than the least deprived neighbourhoods (45.5% vs 14.8%, respectively). However, multilevel analyses showed that the least deprived neighbourhoods were associated with the heaviest alcohol consumption, even after adjusting for individual-level sociodemographic characteristics (OR 1.30, CI 1.08-1.56). Alcohol availability was not associated with heavy drinking and thus did not mediate the relationship between neighbourhood deprivation and heavy alcohol consumption.



Although alcohol availability is concentrated in the most deprived neighbourhoods, women and men in least deprived neighbourhoods are most likely to be heavy drinkers. This mismatch between supply and demand may cause people in the most deprived neighbourhoods to disproportionately suffer the negative health consequences of living near alcohol outlets.

title: Traffic exposure and subclinical cardiovascular disease: is the association modified by socioeconomic characteristics of individuals and neighbourhoods? Results from a multilevel study in an urban region
abstract: Traffic-related pollution is associated with cardiovascular disease in general, but previous studies suggested that low socioeconomic status (SES) groups might be more susceptible towards a negative impact. We examined whether the association between long-term exposure to high traffic and early signs of coronary artery disease is modified by SES.  Individual-level medical and social data from a population-based study were linked with census information on neighbourhood socioeconomic characteristics. Residential exposure to traffic was defined as proximity to major roads using a geographical information system. We studied associations between high traffic and coronary artery calcification (CAC) within strata of SES to examine effect modification. Data stem from an epidemiological study in Germany including 2264 women and 2037 men (45–75 years).  High traffic and low SES were both associated with higher amounts of calcification (⩾75th age-specific percentile). More participants with low SES lived close to major roads while stratified analyses did not indicate higher susceptibility in low SES groups. Participants with low SES and simultaneous exposure to high traffic had highest levels of CAC. For example, the prevalence of high calcification was 23.9% in better-educated men with low traffic exposure but 37.7% in lower-educated men with high traffic exposure (women: 22.0% vs 28.1%).  High traffic exposure was associated with coronary calcification in all social groups, but as low SES individuals had higher calcification in general and were also more often exposed to traffic, existing inequalities could be further shaped by traffic exposure.

title: Subclinical coronary atherosclerosis and neighbourhood deprivation in an urban region
abstract: Inhabitants of deprived neighbourhoods are at higher risk of coronary heart disease. In this study we investigate the hypothesis that social inequalities at neighbourhood level become already manifest in subclinical coronary atherosclerosis, as defined by electron-beam computed tomography derived measures. Coronary artery calcification was assessed as a marker of atherosclerosis in a population based sample of 4301 men and women (45–75 years) without a history of coronary heart disease. Participants lived in three adjacent cities in Germany and were examined between 2000 and 2003 as part of the Heinz Nixdorf Recall Study. Individual level data was combined with neighbourhood level information about unemployment, welfare and living space per inhabitant. This dataset was analysed with descriptive and multilevel regression methods. An association between neighbourhood deprivation and subclinical coronary calcification was observed. After adjustment for age and individual socioeconomic status male inhabitants of high unemployment neighbourhoods had an odds ratio of 1.45 (1.11, 1.96) of exhibiting a high calcification score (>75th percentile) compared to men living in low unemployment areas. The respective odds for women was 1.29 (0.97, 1.70). Additional explorative analyses suggest that clustering of unhealthy lifestyles in deprived neighbourhoods contributes to the observed association. In conclusion, findings suggest that certain neighbourhood characteristics promote the emergence of coronary atherosclerosis. This might point to a pathway from neighbourhood deprivation to manifest coronary heart disease.

title: Vulnerability as a Function of Individual and Group Resources in Cumulative Risk Assessment
abstract: The field of risk assessment has focused on protecting the health of individual people or populations of wildlife from single risks, mostly from chemical exposure. The U.S. Environmental Protection Agency recently began to address multiple risks to communities in the “Framework for Cumulative Risk Assessment” [EPA/630/P02/001F. Washington DC:Risk Assessment Forum, U.S. Environmental Protection Agency (2003)]. Simultaneously, several reports concluded that some individuals and groups are more vulnerable to environmental risks than the general population. However, vulnerability has received little specific attention in the risk assessment literature.  Our objective is to examine the issue of vulnerability in cumulative risk assessment and present a conceptual framework rather than a comprehensive review of the literature. In this article we consider similarities between ecologic and human communities and the factors that make communities vulnerable to environmental risks.  The literature provides substantial evidence on single environmental factors and simple conditions that increase vulnerability or reduce resilience for humans and ecologic systems. This observation is especially true for individual people and populations of wildlife. Little research directly addresses the topic of vulnerability in cumulative risk situations, especially at the community level. The community level of organization has not been adequately considered as an end point in either human or ecologic risk assessment. Furthermore, current information on human risk does not completely explain the level of response in cumulative risk conditions. Ecologic risk situations are similarly more complex and unpredictable for cases of cumulative risk.  Psychosocial conditions and responses are the principal missing element for humans. We propose a model for including psychologic and social factors as an integral component of cumulative risk assessment.

title: Is epidemiology the key to cumulative risk assessment?
abstract: Although cumulative risk assessment by definition evaluates the joint effects of chemical and nonchemical stressors, studies to date have not considered both dimensions, in part because toxicological studies cannot capture many stressors of interest. Epidemiology can potentially include all relevant stressors, but developing and extracting the necessary information is challenging given some of the inherent limitations of epidemiology. In this article, I propose a conceptual framework within which epidemiological studies could be evaluated for their inclusion into cumulative risk assessment, including a problem formulation/planning and scoping step that focuses on stressors meaningful for risk management decisions, extension of the chemical mixtures framework to include nonchemical stressors, and formal consideration of vulnerability characteristics of the population. In the long term, broadening the applicability and informativeness of cumulative risk assessment will require enhanced communication and collaboration between epidemiologists and risk assessors, in which the structure of social and environmental epidemiological analyses may be informed in part by the needs of cumulative risk assessment.

title: A brief conceptual tutorial on multilevel analysis in social epidemiology: interpreting neighbourhood differences and the effect of neighbourhood characteristics on individual health
abstract: Using a conceptual rather than a mathematical approach, this article proposed a link between multilevel regression analysis (MLRA) and social epidemiological concepts. It has been previously explained that the concept of clustering of individual health status within neighbourhoods is useful for operationalising contextual phenomena in social epidemiology. It has been shown that MLRA permits investigating neighbourhood disparities in health without considering any particular neighbourhood characteristic but only information on the neighbourhood to which each person belongs. This article illustrates how to analyse cross level (neighbourhood–individual) interactions, how to investigate associations between neighbourhood characteristics and individual health, and how to use the concept of clustering when interpreting those associations and geographical differences in health.  A MLRA was performed using hypothetical data pertaining to systolic blood pressure (SBP) from 25 000 subjects living in the 39 neighbourhoods of an imaginary city. Associations between individual characteristics (age, body mass index (BMI), use of antihypertensive drug, income) or neighbourhood characteristic (neighbourhood income) and SBP were analysed.  About 8% of the individual differences in SBP were located at the neighbourhood level. SBP disparities and clustering of individual SBP within neighbourhoods increased along individual BMI. Neighbourhood low income was associated with increased SBP over and above the effect of individual characteristics, and explained 22% of the neighbourhood differences in SBP among people of normal BMI. This neighbourhood income effect was more intense in overweight people.  Measures of variance are relevant to understanding geographical and individual disparities in health, and complement the information conveyed by measures of association between neighbourhood characteristics and health.

title: A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena
abstract: In social epidemiology, it is easy to compute and interpret measures of variation in multilevel linear regression, but technical difficulties exist in the case of logistic regression. The aim of this study was to present measures of variation appropriate for the logistic case in a didactic rather than a mathematical way.  Data were used from the health survey conducted in 2000 in the county of Scania, Sweden, that comprised 10 723 persons aged 18–80 years living in 60 areas. Conducting multilevel logistic regression different techniques were applied to investigate whether the individual propensity to consult private physicians was statistically dependent on the area of residence (that is, intraclass correlation (ICC), median odds ratio (MOR)), the 80% interval odds ratio (IOR-80), and the sorting out index).  The MOR provided more interpretable information than the ICC on the relevance of the residential area for understanding the individual propensity of consulting private physicians. The MOR showed that the unexplained heterogeneity between areas was of greater relevance than the individual variables considered in the analysis (age, sex, and education) for understanding the individual propensity of visiting private physicians. Residing in a high education area increased the probability of visiting a private physician. However, the IOR showed that the unexplained variability between areas did not allow to clearly distinguishing low from high propensity areas with the area educational level. The sorting out index was equal to 82%.  Measures of variation in logistic regression should be promoted in social epidemiological and public health research as efficient means of quantifying the importance of the context of residence for understanding disparities in health and health related behaviour.