Diastolic blood pressure and area of residence: multilevel versus ecological analysis of social inequity

Juan Merlo · Martin Lindström · Arne Melander

74 citations0/0 files storedJournal of Epidemiology & Community Health

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Health disparities and outcomes Blood Pressure and Hypertension Studies Public Health and Social Inequalities

Abstract

STUDY OBJECTIVES: To study geographical differences in diastolic blood pressure and the influence of the social environment (census percentage of people with low educational achievement) on individual diastolic blood pressure level, after controlling for individual age and educational achievement. To compare the results of multilevel and ecological analyses. DESIGN: Cross sectional analysis performed by multilevel linear regression modelling, with women at the first level and urban areas at the second level, and by single level ecological regression using areas as the unit of analysis. SETTING: Malmö, Sweden (population 250 000). PARTICIPANTS: 15 569 women aged 45 to 73, residing in 17 urban areas, who took part in the Malmö Diet and Cancer Study (1991-1996). MAIN RESULTS: In the "fixed effects" multilevel analysis, low educational achievement at both individual (beta=1.093, SE=0.167) and area levels (beta=2.966, SE=1.250) were independently associated with blood pressure, although in the "random effects" multilevel analysis almost none of the total variability in blood pressure across persons was attributable to areas (intraclass correlation=0.3%). The ecological analysis also found an association between the area educational variable and mean diastolic blood pressure (beta=4.058, SE=1.345). CONCLUSIONS: The small intraclass correlation found indicated very marginal geographical differences and almost no influence of the urban area on individual blood pressure. However, these slight differences were enough to detect an effect of the social environment on blood pressure. The ecological study overestimated the associations found in the "fixed" effects multilevel analysis, and neither distinguished individual from area levels nor provided information on the intraclass correlation. Ecological analyses are inadequate to evaluate geographical differences in health.

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References

2001Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review: Table 1 1998Bringing context back into epidemiology: variables and fallacies in multilevel analysis.1997Neighborhood Environments and Coronary Heart Disease: A Multilevel Analysis 2000Ecological effects in multi-level studies 2000A multilevel analysis of income inequality and cardiovascular disease risk factors 1999Cardiovascular risk factors and the neighbourhood environment: a multilevel analysis 1998The impact of individual and area characteristics on urban socioeconomic differences in health and smoking 1999Place Effects for Areas Defined by Administrative Boundaries

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