Elsevier

Health & Place

Volume 17, Issue 1, January 2011, Pages 361-369
Health & Place

Review Essay
Neighbourhood deprivation and regional inequalities in self-reported health among Canadians: Are we equally at risk?

https://doi.org/10.1016/j.healthplace.2010.11.016Get rights and content

Abstract

Individual-level data from the Canadian Community Health Survey was combined with area-level data from the 2001 Canada Census to explore the relationship between neighbourhood deprivation and regional inequalities in self-reported health (n=120,290). While neighbourhood deprivation was a significant predictor of fair/poor health in all geographic regions (OR=1.11; 95% CI: 1.08, 1.14), living on the Atlantic and Pacific coasts exacerbated the detrimental effects of neighbourhood deprivation on the perceived health of respondents (OR=1.21; 1.28). By failing to explore regional variations in risk, we could fail to identify areas where provincial policies may interact with neighbourhood factors to reinforce health inequalities amongst deprived communities.

Introduction

Within the past two decades there has been an explosion of interest in the public health and sociological literature regarding the importance of neighbourhoods and residential environments as key determinants of physical, mental and self-perceived health (see Diez-Roux, 2001, Kawachi and Berkman, 2003 for overview). Considerable evidence now indicates that individuals living in deprived neighbourhoods have higher rates of mortality and morbidity independent of individual-level characteristics (see Kondo et al., 2009, Pickett and Pearl, 2001, Riva et al., 2007, Wilkinson and Pickett, 2006 for overview). Yet despite our acknowledgement of the importance of including geography when understanding the patterning of health outcomes among populations, the majority of neighbourhood-level studies fail to account for regional differences in geography, assuming instead that the effects of local income inequalities operate identically across the regions under investigation. Consequently, little research to date has explored whether the neighbourhood deprivation has a differential impact on the health of men and women living in varying regions of a country.

Self-reported health status is one of the most common indicators used to assess the health of populations and is now routinely asked during public health surveys within Canada and across the globe. Self-reported health is known to be a reliable indicator of an individual's physical and mental health status (Lee, 2000, Moussavi et al., 2007). In addition, poor reported health is predictive of future adverse health events, a higher utilisation of health care services and greater mortality (Kaplan and Camacho, 1983, Kaplan et al., 1996, Segovia et al., 1989). Several multilevel studies have now demonstrated that the residents of deprived neighbourhoods are more likely to rate their health as fair or poor when compared to residents of more affluent neighbourhoods (Cummins et al., 2005, Kondo et al., 2009, Pampalon et al., 1999, Poortinga et al., 2007, Riva et al., 2007, Stafford et al., 2005). Attempts to explain the mechanisms underlying these neighbourhood effects have led researchers toward two distinct theoretical camps: the compositional and the contextual views (Macintyre et al., 1993). The compositional view tends to attribute the geographical clustering of health outcomes to the shared characteristics of residents, suggesting that similar people tend to aggregate within geographical proximity, whether purposefully to share a common culture, or out of necessity due to a lack of resources (Duncan et al., 1993, Subramanian et al., 2003). While these shared characteristics explain part of the association between health and place, geographic inequalities in health tend to persist despite extensive attempts to adjust for underlying variations in the baseline demographics of their respective populations (Kondo et al., 2009, Macintyre et al., 2002, Matheson et al., 2008, Matheson et al., 2010). In contrast, the contextual view attempts to correct for this shortcoming, arguing that spatial variations in health are attributable in part to the characteristics of the environments in which people live and work (Macintyre et al., 2002, Subramanian et al., 2003). These contextual attributes pertain to multiple aspects of both the physical and built environments and they affect the whole groups of individuals residing within them, over and above the contribution of individual characteristics. Recent literature however has recognised that these early frameworks represent an oversimplification of the way places are thought to influence health (Dunn et al., 2005, Glass and McAtee, 2006). Reflecting both chances and choices, residential decisions are increasingly thought to be shaped by the interaction between individuals' economic means and lifestyle preferences as well as neighbourhood and regional characteristics pertaining to the availability of resources and services and other socially oriented criteria such as the neighbourhoods' reputation and the presence of social connections and supports (Bernarda et al., 2007, Cummins et al., 2007, Matheson et al., 2010).

Previous studies conducted both in Canada and elsewhere have acknowledged regional variations in the self-reported health status of their respective populations (Au et al., 2001, Canadian Institute for Health Information, 2008b, Evans, 2007, Matthews et al., 2006). In addition, several Canadian studies have showed progressive deterioration in both health (i.e. lower life expectancies, higher morbidity) and lifestyle-related determinants (i.e. greater rates of smoking and inactivity) with decreasing area-level income (Canadian Institute for Health Information, 2008a, Canadian Institute for Health Information, 2008b, Chow et al., 2005, Voeks et al., 2008). These regional variations in health indicators and outcomes are often attributed to the following four mechanisms: (i) underlying variations in the baseline health status of respective populations (Duncan et al., 1993); (ii) differences in the physical and/or environmental characteristics of the place(s) in question (Langford and Bentham, 1996, Yiannakoulias et al., 2009); (iii) regional cultural structures and their influence on individual health behaviour (Macintyre et al., 2002, Osypuk and Acevedo-Garcia, 2010) and physician practice styles (Sirovich et al., 2008, Yiannakoulias et al., 2009) and (iv) government and private investments in health and social infrastructure (Braveman et al., 2000, Evans, 2007). While mechanisms one through three are generally captured within the compositional and contextual views outlined above, present day practices and policies of public and private institutions which can affect the equitable distribution of resources and services are generally not explored in neighbourhood-level investigations of health (Cohen et al., 2009).

By expanding the scope of neighbourhood-level research to examine regional differences in health, we are reminded that neighbourhoods themselves exist within the larger regional, provincial/state and national socio-cultural and political contexts, which can result in varying attitudes and priorities toward the distribution of collective resources that subsequently act to reinforce and/or exacerbate health behaviours and illness/disease already present among their respective populations. The present multilevel investigation expands on previous research by examining the relationship between place of residence and the self-reported health status of men and women living in 3668 urban neighbourhoods in Canada. Using hierarchical modelling, we seek to understand how neighbourhood deprivation affects the self-reported health of Canadians after adjusting for known individual-level risk factors. Furthermore, we examined whether the impact of neighbourhood deprivation differed across the regions of Canada after allowing for variation at the individual and neighbourhood levels.

Hypotheses:

  • (i)

    Higher levels of neighbourhood deprivation will be associated with an increased risk of reporting fair/poor health after adjusting for demographic, socioeconomic and lifestyle characteristics at the individual-level.

  • (ii)

    The magnitude of the association between neighbourhood deprivation and fair/poor health will differ by region such that living in certain regions of Canada will exacerbate health inequalities already present for residents of deprived communities.

Section snippets

Methods

Data used to investigate the association between neighbourhood deprivation, regional inequalities and self-reported health came from two sources, both of which are collected and maintained by Statistics Canada. Individual-level data was obtained from the Canadian Community Health Survey (CCHS), a nationally representative cross-sectional survey designed to collect detailed information on health determinants, outcomes and service utilisation among non-institutionalized Canadian adults (see

Results

Descriptive statistics describing the sample population are presented in Table 1. To account for unequal probabilities of selection and non-response, and to reflect age and gender distributions of the Canadian population at the time of the survey, descriptive statistics are presented as unweighted sample frequencies with weighted population proportions. The sample was roughly split by gender, comprised of 56,018 men (50.2%) and 64,272 women (49.8%) living in 3668 urban neighbourhoods. Overall,

Discussion

Neighbourhood deprivation was a significant predictor of fair/poor reported health for respondents residing in all six geographic regions of Canada; however, our findings suggested that living in neighbourhoods marked by higher levels of deprivation may be more influential on the pathways leading to a disease for populations residing in the coastal regions of Canada. This study provides a unique perspective on the relationship between neighbourhood deprivation and health by highlighting that

Conclusion

Our findings suggest that living in neighbourhoods marked by high levels of deprivation may be more influential on the pathways leading to a disease for populations residing in the coastal regions of Canada. When we assume that neighbourhood contextual effects operate identically across geographic levels under investigation, we may fail to identify regional disparities which are exacerbated by neighbourhood disadvantage. Future research is needed to determine whether interventions at the

Acknowledgements

The authors gratefully acknowledge the support of the Ontario Ministry of Health and Long-Term Care. The views expressed in this publication are the views of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care.

Funding

This research was supported by the Social Sciences and Humanities Research Council of Canada [Standard Research Grant no. 410-2005-2306].

Competing interests

None.

References (72)

  • R. Pampalon et al.

    Geographies of health perception in Quebec: a multilevel perspective

    Social Science and Medicine

    (1999)
  • B.M. Popkin et al.

    Environmental influences on food choice, physical activity and energy balance

    Physiology & Behavior

    (2005)
  • N. Ross et al.

    Neighbourhood influences on health in Montréal

    Canada Social Science & Medicine

    (2004)
  • J. Segovia et al.

    An empirical analysis of the dimensions of health status measures

    Social Science and Medicine

    (1989)
  • M. Stafford et al.

    Gender differences in the associations between health and neighbourhood environment

    Social Science and Medicine

    (2005)
  • S.V. Subramanian et al.

    Neighborhood differences in social capital: a compositional artifact or a contextual construct?

    Health & Place

    (2003)
  • R.G. Wilkinson et al.

    Income inequality and population health: a review and explanation of the evidence

    Social Science and Medicine

    (2006)
  • M. Winkleby et al.

    Inequalities in CHD incidence and case fatality by neighbourhood deprivation

    American Journal of Preventive Medicine

    (2007)
  • D.H. Au et al.

    Regional variations in health status

    Medical Care

    (2001)
  • A. Baum et al.

    Socioeconomic status and chronic stress: does stress account for SES effects on health?

    Annals of the New York Academy of Sciences

    (1999)
  • Y. Beland

    Canadian community health survey—methodological overview

    Health Reports

    (2002)
  • P. Bernarda et al.

    Health inequalities and place: a theoretical conception of neighbourhood

    Social Science and Medicine

    (2007)
  • P. Braveman et al.

    Health inequalities and social inequalities in health

    Bulletin of the World Health Organization

    (2000)
  • J.E. Callinan et al.

    Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption

    Cochrane Database of Systematic Reviews

    (2010)
  • Canadian Institute for Health Information, 2008a. Health Indicators. In: CIHI, S.C. (Ed.). CIHI,...
  • Canadian Institute for Health Information, 2008b. Reducing gaps in health: a focus on socio-economic status in urban...
  • T. Chandola et al.

    Validating self-rated health in different ethnic groups

    Ethnicity & Health

    (2000)
  • C.-M. Chow et al.

    Regional variation in self-reported heart disease prevalence in Canada

    Canadian Journal of Cardiology

    (2005)
  • L. Cohen et al.

    A Time of Opportunity: Local Solutions to Reduce Inequities in Health and Safety

    (2009)
  • S. Cummins et al.

    Neighbourhood environment and its association with self rated health: evidence from Scotland and England

    Journal of Epidemiology and Community Health

    (2005)
  • A.V. Diez-Roux

    Investigating neighbourhood and area effects on health

    American Journal of Public Health

    (2001)
  • G.J. Duncan et al.

    Assessing the effects of context in studies of child and youth development

    Educational Psychologist

    (1999)
  • J. Dunn et al.

    Role of geography in inequalities in health and human development

  • R.G. Evans

    Mr. Harringon, self-rated health and the Canadian chicken

    Health Care Policy

    (2007)
  • Hamilton, C., 2006. Healthy provinces, healthy Canadians: a provincial benchmarking report. The Conference Board of...
  • Health Statistics Division and Special Surveys Divison, S.C., 2003. Canadian community health survey (CCHS) cycle 1.1...
  • Cited by (0)

    View full text