Neighbourhood influences on health in Montréal, Canada
Introduction
This paper examines neighbourhood health effects in Montréal: Canada's most unequal (Ross et al., 2000) and most segregated (Ross, Nobrega, & Dunn, 2001) major city in terms of income. Geographers and urban sociologists throughout the 20th century long theorized about the importance of neighbourhoods in terms of their effects on the life chances of individuals and this fundamental perspective is enjoying somewhat of a renaissance in public health circles (Kawachi & Berkman, 2003). Widespread epidemiologic evidence has also demonstrated that social structures that undermine individual educational attainment, labour market success or social connectedness can influence individual health outcomes, above and beyond the now well-known individual socio-economic risk. The influence of community of residence on life chances, furthermore, begins early: community poverty is consistently associated with low school readiness and achievement and behaviour and emotional problems in children (see review in Leventhal & Brooks-Gunn, 2000; also Tremblay, Ross, & Berthelot, 2002a).
The study of areal effects on health is currently one of the main research focuses in the public health/health geography field. In the last decade and a half, the research in this area has drawn more attention from social epidemiologists, geographers, and criminologists, with a marked increase in the number of studies employing multilevel modeling (O’Campo, 2003). The study of place effects on health is a particularly popular research area because of the possible policy implications (Macintyre, Maciver, & Soomans, 1993). In the domain of smoking research, e.g., changing social norms and altering social environmental conditions have been overwhelmingly more effective at reducing the health burden associated with tobacco use than have individually based behaviour change strategies (USDHHS, 1989).
The balance of evidence, based mainly on studies in the US and the UK, suggests that health is a function of both the characteristics of individuals and characteristics of the environments in which they live. Underlying these types of studies is the theoretical standpoint that neighbourhood contexts both constrain and enable individual health possibilities (e.g., Giddens, 1984). A review of 25 studies considering the net effect of neighbourhood context on health while controlling for individual socio-economic status reported that 23 of these studies showed at least a moderate, independent effect of the social context on individual health status (Pickett & Pearl, 2001). These effects were fairly consistent despite a variety of study designs and variation in definitions of neighbourhood context. One of the most compelling recent studies of social contextual effects is a large prospective study by Diez Roux et al. (2001). This group showed a three-fold risk of coronary heart disease incidence among poor persons living in poor neighbourhoods compared with affluent individuals living in affluent neighbourhoods in four US study sites.
The studies in the Pickett and Pearl review, however, were dominated by studies from the US (e.g., Waitzman & Smith, 1998; Robert, 1998) and to a lesser degree, the UK (e.g., Duncan, Jones, & Moon, 1999). This is perhaps not surprising given that most of the theoretical literature linking the social organization of neighbourhoods with health outcomes in individuals has come from American social scientists (e.g., Jencks & Mayer, 1990; Massey & Denton, 1993; Wilson, 1987). There have been comparatively few studies performed in Canada, with the bulk of those showing far more modest results than have been demonstrated in other national contexts. A study by Boyle and Willms (1999) employing the 1990 Ontario Health Survey found only modest evidence for place effects on health outcomes that varied by the type of outcome as well as the definition of region. In an application of the 1992–1993 Quebec Health and Social Survey, Pampalon, Duncan, Subramanian, and Jones (1999) identified significant local area variations in self-reported health status while taking account of individual characteristics, but found no regional-level effects. In the only national-scale study to date, Tremblay, Ross, and Berthelot (2002b) found only the most modest regional contextual effects on individual self-reported health status.
Expanding the geographic scope of neighbourhood and health research reminds us that neighbourhoods themselves exist within regional, provincial/state-level and national socio-political contexts (Diez Roux, 2003). More explicitly, in the Canadian context, income transfer policies and programs and the provision of public goods and services at provincial and federal levels arguably diminish the likelihood of finding neighbourhood effects. It is indeed timely to add Canadian evidence to the growing body of literature given that one of the principal hypotheses explaining why income inequality (a contextual measure) so profoundly accounts for ecological patterns of metropolitan mortality in the United States but not in Canada (Ross et al., 2000) is that urban environments in Canada have evolved within a particular national context to be protective of the health status of their residents.
Unease about the arbitrariness of the choice of geographic scale in neighbourhood health effects is pervasive in the published literature (e.g., Macintyre & Ellaway, 2003; Macintyre, Ellaway, & Cummins, 2002; Diez Roux (2001), Diez Roux (2003)). Since the concept of neighbourhood is routinely operationalized differently across studies, it has been argued that, for the most part, the area units used in studies do not capture the right level of areal differentiation (Diez Roux, 2001). Martikainen, Kauppinen, and Valkonen (2003) recommend using different area units, both larger and smaller, in order to capture a better understanding of the causal processes involved between neighbourhood and health. Pickett and Pearl (2001) point out that part of the problem would be solved were studies to use natural boundaries. They recommend that studies using multilevel analyses of neighbourhood-level effects use routinely collected data in neighbourhoods that are ‘ecologically meaningful’ (Pickett & Pearl, 2001, p. 121).
However, agreeing on what constitutes an ‘ecologically meaningful’ neighbourhood boundary, let alone gaining consensus on the meaning and definition of the concept of neighbourhood itself, are extremely difficult tasks. In the words of Willms (2001), “To make any progress, a researcher must specify the units of analysis, and in some way define ‘community’. But any definition of community is easily challenged.” (Willms, 2001, p. 54).
Our study attempts to tackle Pickett and Pearl's recommendation: to derive neighbourhood boundaries that are ‘ecologically meaningful’, or ‘natural’. Early on, it was recognized that no single variable effectively captured all neighbourhoods. In other words, some neighbourhoods were defined by their socio-economic status, some by their ethnic makeup, some by lifestyle and others by their architecture or housing type. It was thought that a better approach would be to investigate how local government and real estate boards understood neighbourhoods. The definition of neighbourhood that we have adopted has much in common with the category of ‘neighbourhood area’ described by Brower (1996). Quite simply, the ‘neighbourhood area’ consists of a group of home areas that share a commonly defined residential area that often has a name. We also borrow from Galster's (2001) definition of neighbourhood as a ‘bundle of spatially based attributes associated with clusters of residences, sometimes in conjunction with other land uses.” (Galster, 2001, p. 2112).
Section snippets
Study area
It followed from our work at the Canadian health region scale (Tremblay et al., 2002b) that some of the most important variations in health status occur within and not between regions, so an effort was made to look within a large urban health region. Montréal as a starting point was justifiable because it is a highly segregated city (in terms of income) within the Canadian context (Ross et al., 2001) and has the largest sample of any region in the CCHS survey (2500 respondents). Furthermore, it
Sample size
There were 1694 respondents aged 25–64 resident in the Montréal health region. Of these, 42 were considered missing if they did not have an HUI score or a valid smoking or obesity status (pregnant cases were excluded here), leaving an analytical sample size of 1652. For those missing on the stress, community belonging, and income variables, a dummy flag for missing observation was included to retain these cases. The missing dummy flag was not statistically significant for either stress or
Discussion and conclusions
This paper presents the results of an intra-urban study of neighbourhood health effects in a Canadian setting. Our findings suggest that neighbourhoods do indeed exert an effect on health status above and beyond individual socio-demographic and behavioural characteristics. The amount of variation in health status attributable to neighbourhoods, however, is small (around 3%) relative to the share attributable to the individual. In addition to the now well-known effects on health status such as
Acknowledgements
This research was funded by a Canadian Institutes of Health Research (CIHR) New Investigator Research Allowance. Dr. Nancy Ross gratefully acknowledges salary funding from the CIHR New Investigator Award program. Stephanie Coen (McGill University) provided valuable research assistance on this project.
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