Graham Moon

Context, composition and heterogeneity: Using multilevel models in health research

This paper considers the use of multilevel models in health research. Attention focuses on the structure and potential of such models and particular consideration is given to their use in elucidating the importance of contextual effects in relation to individual level social and demographic factors in understanding health outcomes, health-related behaviour and health service performance. Four graphical typologies are used to outline the questions that multilevel models can address and the paper illustrates their potential by drawing on published examples in a number of different research areas.

From medical to health geography: novelty, place and theory after a decade of change

In this paper, we reflect on the positioning of health geography within the wider academic landscapes of geography and health-related research. Drawing on examples from a number of countries, we consider the extent to which a ‘new geography of health’ has emerged in recent years. We structure our discussion around the themes of place, theoretical engagement and critical relevancy. Changes within the subdiscipline are placed in the context of a central question: what is new about the new geography of health?

Health-related behaviour in context: a multilevel modelling approach

Recent attempts to place individual health-related behaviour in context have been judged largely unsuccessful. This paper examines how this situation might be improved and is especially concerned with the role of quantitative methodologies. It is argued that, whilst recent developments in social theory help provide important theoretical guidelines, they can only be implemented with difficulty in empirical health-related behaviour research if traditional quantitative methodologies are used. It is suggested that the best way to implement social theory within a quantitative framework is to apply the newly developed technique of multilevel modelling. This paper offers an overview of the multilevel approach and outlines its significance for health-related behaviour research. In addition, it details a number of ways in which the multilevel framework can be extended so as to achieve further improvements in the conceptualization of health-related behaviour. To illustrate the value of the technique, the paper finishes by considering one of these extensions in detail and applying it to data recording smoking behaviour in the United Kingdom.

Smoking and deprivation: are there neighbourhood effects?

Debate has centred on whether the character of places plays an independent role in shaping individual smoking behaviour. At the small-area scale, particular attention has focused on whether measures of neighbourhood deprivation predict an individuals smoking status independent of their own personal characteristics. This study applies multilevel modelling techniques to data from the British Health and Lifestyle Survey and ward (local neighbourhood) level deprivation scores based on four variables from the national Census. Results suggest that after taking account of a large range of individual characteristics, both as main effects and interactions, together with complex structures of between-individual variation, measures of neighbourhood deprivation continue to have an independent effect on individual smoking status. In addition, significant between-ward differences in smoking behaviour remain which cannot be explained either by population composition or ward-level deprivation. The study suggests that the character of the local neighbourhood plays a role in shaping smoking behaviour.

Do places matter? A multi-level analysis of regional variations in health-related behaviour in Britain

A number of commentators have argued that there is a distinctive geography of health-related behaviour. Behaviour has to be understood not only in terms of individual characteristics, but also in relation to local cultures. Places matter, and the context in which behaviour takes place is crucial for understanding and policy. Previous empirical research has been unable to operationalize these ideas and take simultaneous account of both individual compositional and aggregate contextual factors. The present paper addresses this shortcoming through a multi-level analysis of smoking and drinking behaviours recorded in a large-scale national survey. It suggests that place, expressed as regional differences, may be less important than previously implied.

Psychiatric morbidity: a multilevel approach to regional variations in the UK.

STUDY OBJECTIVE--To establish whether regional variations in psychiatric morbidity in Britain constitute a distinctive geography of mental health arising from factors that are context-specific at area level or whether these variations are an artifact generated by sampling fluctuations and differing population compositions in areas. DESIGN--Multilevel modelling techniques were applied to data from the 1984-85 health and lifestyle survey. The outcome was the prevalence of psychiatric morbidity as recorded by the application of the general health questionnaire in this survey. SETTING--The analysis was undertaken simultaneously at the individual level, electoral ward level, and regional level for England, Wales, and Scotland. PARTICIPANTS--A total of 6572 adults were selected from the electoral register. MAIN RESULTS--Regional variations were detected in crude aggregate general health questionnaire scores but these were found to be the result of sampling fluctuations and varying regional population compositions rather than higher level contextual effects. There was certainly no evidence of a clear north-south distinction in psychiatric morbidity as was suggested by earlier work. In addition, the local neighbourhood did not seem to have any importance beyond the type of people who lived there. A number of individual characteristics was shown to be associated with mental wellbeing but a large degree of individual variation remained unexplained. CONCLUSIONS--In terms of low level psychiatric disturbance it seems that the characteristics of individuals have greater importance than the characteristics of areas, although the latter may still operate as important mediating factors. Multilevel modelling represents a robust statistical method of examining area variations in health outcomes and further work needs to be conducted, particularly on more serious psychiatric conditions.

Dietary inequalities: what is the evidence for the effect of the neighbourhood food environment?

This review summarises the evidence for inequalities in community and consumer nutrition environments from ten previous review articles, and also assesses the evidence for the effect of the community and consumer nutrition environments on dietary intake. There is evidence for inequalities in food access in the US but trends are less apparent in other developed countries. There is a trend for greater access and availability to healthy and less healthy foods relating to better and poorer dietary outcomes respectively. Trends for price show that higher prices of healthy foods are associated with better dietary outcomes. More nuanced measures of the food environment, including multidimensional and individualised approaches, would enhance the state of the evidence and help inform future interventions.

Defining localities for health planning: a GIS approach

The National Health Service in Britain is undergoing far-reaching changes. While District and Regional Health Authorities are currently merging, professionals agree that primary health care is most efficiently managed at the local level. This paper uses geographical information systems (GIS) capabilities to identify a nested hierarchy of localities for the management of primary health care in West Sussex, England. GIS coverages were developed which contained key criteria for defining local areas, including nodes or focal points of service provision, edges which act as physical or psychological barriers to movement, districts such as official administrative areas and interaction criteria such as journey to work, school and family doctor (GP) surgeries. Central to the derivation of the localities was a large matrix of patient to GP flows based on postcoded data. Once managed, these data revealed clear geographical patterns of patient to GP allegiance. A large-scale field survey obtained supporting information on the perception of areas from local residents.

Health, disease and society : an introduction to medical geography

This major textbook is a comprehensive introduction to the rapidly expanding field of medical geography, illustrating the ideas, methods and debates that inform contemporary approaches to the subject.

The neighbourhood effects of geographical access to tobacco retailers on individual smoking behaviour

Objective: To investigate whether neighbourhood measures of geographical accessibility to outlets selling tobacco (supermarkets, convenience stores and petrol stations) are associated with individual smoking behaviour in New Zealand. Methods: Using geographical information systems, travel times from the population-weighted centroid of each neighbourhood to the closest outlet selling tobacco were calculated for all 38 350 neighbourhoods across New Zealand. These measures were appended to the 2002/03 New Zealand Health Survey, a national survey of 12 529 adults. Two-level logistic regression models were fitted to examine the effects of neighbourhood locational access upon individual smoking behaviour after controlling for potential individual- and neighbourhood-level confounding factors, including deprivation and urban/rural status. Results: After controlling for individual-level demographic and socioeconomic variables, individuals living in the quartiles of neighbourhoods with the best access to supermarkets (OR 1.23, 95% CI 1.06 to 1.42) and convenience stores (OR 1.19, 95% CI 1.03 to 1.38) had a higher odds of smoking compared with individuals in the worst access quartiles. However, the association between neighbourhood accessibility to supermarkets and convenience stores was not apparent once other neighbourhood-level variables (deprivation and rurality) were included. Conclusions: At the national level, there is little evidence to suggest that, after adjustment for neighbourhood deprivation, better locational access to tobacco retail provision in New Zealand is associated with individual-level smoking behaviour.