Social Science & Medicine 74 (2012) 1204e1212

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Review

Do neighborhoods affect individual mortality? A systematic review and

meta-analysis of multilevel studies
Mathias Meijer a, b, *, Jeannette Röhl a, Kim Bloomfield a, c, d, Ulrike Grittner d
a
Unit for Health Promotion Research, Institute of Public Health, University of Southern Denmark, Denmark
b
Department of Cancer Prevention and Documentation, Danish Cancer Society, Denmark
c
Center for Alcohol and Drug Research, Aarhus University, Copenhagen Division, Copenhagen, Denmark
d
Institute for Biometrics and Clinical Epidemiology, Charité e University Medicine Berlin, Germany

a r t i c l e i n f o a b s t r a c t

Article history: There has been increasing interest in investigating whether inhabitants in socially or physically deprived
Available online 28 January 2012 neighborhoods have higher mortality when individual socioeconomic status is adjusted for. Results so far
appear ambiguous and the objective of this study was to conduct a systematic literature review of
Keywords: previous studies and to quantify the association between area-level socioeconomic status (ALSES) and
Small-area analysis all-cause mortality in a meta-analysis. Current guidelines for systematic reviews and meta-analyses were
Neighborhoods
followed. Articles were retrieved from Medline, Embase, Social Sciences Citation Index and PsycInfo and
Breast cancer
individually evaluated by two researchers. Only peer-reviewed multilevel studies from high-income
Risk factors
Residence characteristics
countries, which analyzed the influence of at least one area-level indicator and which controlled for
Mortality individual SES, were included. The ALSES estimates in each study were first combined into a single
Meta-analysis estimate using weighted linear regression. In the meta-analysis we calculated combined estimates with
Systematic review random effects to account for heterogeneity between studies. Out of the 40 studies found eligible for the
systematic review 18 studies were included in the meta-analysis. The systematic review suggests that
there is an association between social cohesion and mortality but found no evidence for a clear asso-
ciation for area-level income inequality or for social capital. Studies including more than one area level
suggest that characteristics on different area levels contribute to individual mortality. In the meta-
analysis we found significantly higher mortality among inhabitants living in areas with low ALSES.
Associations were stronger for men and younger age groups and in studies analyzing geographical units
with fewer inhabitants.
Ó 2012 Elsevier Ltd. All rights reserved.

Introduction
The number of studies attempting to demonstrate an associa-
tion between individual mortality and the characteristics of areas in
which individuals live has steadily increased since the mid 1990s. A
recent review (Diez Roux & Mair, 2010) has summarized the
processes through which, according to various authors, neighbor-
hoods can contribute to health inequalities. First, residential
segregation by race, ethnicity and socioeconomic position influ-
ences the inequality of resource distribution in areas. These
processes influence on the one hand the physical environment in
terms of environmental exposures, food and recreational resources,
the built environment, aesthetic quality, natural spaces, services
* Corresponding author. National Institute of Public Health, University of
Southern Denmark, Øster Farimagsgade 5 A, 2nd Floor, 1353 Copenhagen K,
Denmark. Tel.: þ45 65507765.
E-mail address: matm@niph.dk (M. Meijer).
and quality of housing. For instance, inhabitants with high SES are
more likely to attract healthy food stores or sports clubs to their
local areas because they can afford these, which means that they
have easier access to health promoting goods and activities and that
even more resourceful inhabitants are attracted to the area. On the
other hand the social environment is affected in terms of safety/
violence, social connections/cohesion, local institutions and norms.
As an example, people are probably more likely to begin exercising
if they repeatedly observe fellow inhabitants exercising or if they
are encouraged to do so by neighbors who are active in sports clubs.
Thus the hypothesis is that physical and social environments have
consequences for inhabitants’ morbidity and mortality by influ-
encing individual health behavior.
In contrast to the traditional distinction between people and
places, the current literature recognizes their mutually reinforcing
and reciprocal relationships suggesting that neighborhoods affect
people, by for example attracting certain socioeconomic groups,
and that people affect neighborhoods, as for example by attracting

0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.11.034
 M. Meijer et al. / Social Science & Medicine 74 (2012) 1204e1212
certain workplaces or demanding goods from certain shops
(Cummins, Curtis, Diez-Roux, & Macintyre, 2007; Macintyre & Ell-
away, 2003; Macintyre, Ellaway, & Cummins, 2002). Cummins et al.
(2007) also note that place and context vary in time and space
because people engage in different contexts over a day, a week or
over the life-course and argue for the importance of considering
that contextual influences operates on different spatial scales, i.e.
that influences from national and regional levels co-exist with
influences from the neighborhood level.
Despite advances in this research, it remains unclear whether
area conditions have an effect on mortality that is distinct
from health determinants linked to individual SES. The present
paper investigates this question in two steps: by systematically
identifying and reviewing recent studies, and through a meta-
analysis estimating the association between ALSES and all-cause
mortality.
To isolate neighborhood influences from individual influences
we included only multilevel studies that controlled for individual
SES. This distinguishes our study from four existing reviews (Ellen,
Mijanovich, & Dillman, 2001; Pickett & Pearl, 2001; Riva, Gauvin, &
Barnett, 2007; Yen, Michael, & Perdue, 2009). Three of these (Ellen
et al., 2001; Pickett & Pearl, 2001; Yen et al., 2009) were not based
exclusively on studies using multilevel modeling, which is essential
if health variations associated with area conditions are to be iso-
lated from relationships with individual risk factors (Subramanian,
Jones, & Duncan, 2003; Subramanian & Kawachi, 2004). The small
number of multilevel studies available in the past might have
prevented such specific reviews from being conducted earlier.
Secondly, in contrast to the previous reviews only publications that
adjusted for at least one socioeconomic indicator at the individual
level were included. Pickett and Pearl (2001) found that studies not
adjusting for individual socioeconomic measures were more likely
to observe area effects and that those studies including socioeco-
nomic indicators on the individual level found a reduced area
effect. It has been extensively demonstrated that individual socio-
economic position is associated with mortality (Mackenbach et al.,
2003; Marmot, 2010) and since most area-effect studies use
socioeconomic indicators on the area-level, individual-level SES
should be taken into account to ensure the validity of ‘independent’
area-level factors.
Methods
Systematic review
Guidelines for conducting systematic reviews provided by
Centre for Reviews and Dissemination (NHS, 2009) were followed
through the data collection and the PRISMA principles (Liberati
et al., 2009) were used for reporting results. A pilot data collec-
tion was conducted upon which a final set of methods and inclusion
criteria was developed. We included only studies that: were written
in English; were published in peer-reviewed journals; reported
data from a primary study; were based on populations from
developed countries; were based on a random sample of an adult
population; used multilevel modeling; controlled for at least one
SES variable (income, education or occupation) at the individual
level; used at least one area-level indicator and included either
mortality or cancer incidence as the individual outcome.
Developed countries were defined as countries scoring either
high or very high on the United Nations Human Development Index
(UNDP, 2009). We excluded studies where individuals were clus-
tered in hospitals or countries because our aim was to examine
residential area effects on individual health within societies.
Similarly we excluded studies focusing on children and on area
effects influencing survival after diagnosis of diseases. In addition
1205
to mortality we included studies of cancer incidence as outcome
since this paper is part of a larger project investigating area effects
on mortality and cancer incidence.
We identified studies by searching Cochrane Library, Medline
(1966epresent), Embase (1974epresent), Social Sciences Citation
index (1956epresent) and PsycInfo (1806epresent). All searches
were performed January 15th, 2010 with no limits applied. See
electronic Appendix for full search strategy used in Medline
(Appendix). Secondly we scanned reference lists in existing
reviews, reviewed those publications and contacted authors for
unpublished results.
In the first stage Mathias Meijer and Jeannette Röhl removed
duplicates and independently reviewed titles and abstracts to
assess eligibility according to our inclusion and exclusion criteria.
When in doubt, full texts were assessed. Disagreements between
reviewers were resolved by consensus (41 cases out of 766) and by
consulting Ulrike Grittner (two cases). In a second phase Mathias
Meijer and Jeannette Röhl independently assessed full text publi-
cations and excluded studies with specific reference to inclusion
criteria. Reviewers had five cases of disagreements out of the 59 full
text assessments, which were resolved by consensus. Both
reviewers independently extracted all relevant data from studies
into a pilot tested coding scheme. Extracted data included infor-
mation on first author, publication year, outcome variable, study
year(s), location of study, sample size of individuals and areas, age
range, definition of areas, individual-level variables, area-level
variables and conclusion on area effect after adjustment for indi-
vidual SES. Duplicate publications were identified by Mathias
Meijer and Ulrike Grittner by comparing authors, study locations,
sample sizes of individuals and areas, study years and outcome
variables. Based on the coding scheme, a systematic review of
studies was conducted. For each study we calculated an overall
estimate and confidence interval for the area-level effect using
weighted linear regression (Schlattman, 2009).
Quality assessment
A quality assessment of all reviewed studies was conducted
using the standardized quality assessment tool for quantitative
studies from the Effective Public Health Practice Project (EPHPP)
(EPHPP, 2007). This tool provides a systematic framework, recom-
mended by the Cochrane Collaboration, for assessing selection bias,
study design, confounders, blinding, data collection methods,
withdrawals and dropouts, intervention integrity and approaches
to analyses. Although any quantitative study can be assessed with
this tool, it was primarily developed for clinical studies. Given that
studies included in this systematic review and meta-analysis are
observational and based on registry, census and survey data we
did not assess blinding, withdrawals, dropouts or intervention
integrity.
Meta-analysis
As the number of studies did not allow for separate analyses of
area effects on cause-specific mortality or cancer incidence as the
outcome, we performed a meta-analysis of the area-level socio-
economic status on all-cause mortality. Seven out of 18 studies used
income as ALSES measure (Anderson, Sorlie, Backlund, Johnson, &
Kaplan, 1997; Blakely, Atkinson, & O’Dea, 2003; Dahl, Ivar Elstad,
Hofoss, & Martin-Mollard, 2006; Jerrett et al., 2003; Kravdal,
2007; Naess, Piro, Nafstad, Smith, & Leyland, 2007; Roos, Magoon,
Gupta, Chateau, & Veugelers, 2004). Seven studies used an index
measure of ALSES which incorporated information on e.g. income,
education, occupation, car access, house ownership or unemploy-
ment (Blakely et al., 2006; Curtis, Southall, Congdon, & Dodgeon,
1206 M. Meijer et al. / Social Science & Medicine 74 (2012) 1204e1212
2004; Jaffe, Eisenbach, Neumark, & Manor, 2005b; Jones, Gould, &
Duncan, 2000; Malmstrom, Johansson, & Sundquist, 2001;
Marinacci et al., 2004; Turrell, Kavanagh, Draper, & Subramanian,
2007). Bosma, van de Mheen, Borsboom, and Mackenbach (2001)
used the percentage of people with severe financial problems,
Lochner, Pamuk, Makuc, Kennedy, and Kawachi (2001) used the
poverty rate, Martikainen, Kauppinen, and Valkonen (2003) used
the percentage of manual workers and Naess, Leyland, Smith, and
Claussen (2005) used the percentage with primary education.
Studies estimating effects of income inequality were excluded
because they did not measure the general socioeconomic condi-
tions in areas. Most studies provided ALSES effects specified by
gender, age or ethnicity. All ALSES estimates in each study were
combined into a single estimate using weighted linear regression
(Schlattman, 2009) in order to calculate the effect of ALSES on
mortality in lower SES areas compared to higher SES areas. Studies
and their calculated single estimates are presented in Fig. 2 ranked
after the average number of inhabitants per area unit to illustrate
the effect of local areas versus larger areas. The overall estimate was
calculated by using a random effects approach, incorporating an
estimate of variation between studies (DerSimonian & Laird, 1986).
We used I2 statistics to evaluate the between-study heterogeneity
(Higgins & Thompson, 2004; Higgins, Thompson, Deeks, & Altman,
2003).
Additionally a meta-regression analysis was performed. The
outcome was estimates for mortality in lower SES areas compared
to mortality in higher SES areas. Sex, age, number of covariates
adjusted for, survey year, area-level SES, number of inhabitants in
Fig. 1. Flow diagram of identification, screening, eligibility and inclusion of studies in systematic review and meta-analysis of multilevel investigations of area effects on mortality
and cancer incidence.
areas and welfare state regimes were used as covariates. We used
an extra category for sex if no sex-specific estimates were provided
in the specific study. For age we used the midpoint of a specific age
category. The country investigated in each study was categorized as
either liberal, conservative and social democratic after Gösta
Esping-Andersen’s theory on welfare state regimes (Esping-
Andersen, 1990). ALSES was used as a quasi-metric variable
ranging from 1 (high ALSES) to 9 (low ALSES). Only significant
covariates were used in the final model. All non-categorical cova-
riates were centered before the analysis. Estimates were weighted
according to standard errors (Schlattman, 2009).
Results
Data collection and study characteristics
Fig. 1 depicts a flow diagram of identification, screening, eligi-
bility assessment and inclusion of studies in the systematic review
and in the meta-analysis. Out of 766 eligible studies we excluded
707 because they did not investigate area effects on either mortality
or cancer incidence. Another 19 were excluded for reasons given in
Fig. 1. A total of 40 publications was included in the systematic
review. Two of these used the same sample but had different
outcomes (Bentley, Kavanagh, Subramanian, & Turrell, 2008;
Turrell et al., 2007), two studies had duplicate populations and
different area-level indicators (Jaffe, Eisenbach, Neumark, & Manor,
2005a; Jaffe et al., 2005b), and two studies had overlapping study
 M. Meijer et al. / Social Science & Medicine 74 (2012) 1204e1212
populations (Roos et al., 2004; Veugelers, Yip, & Kephart, 2001). All
six were included in the systematic review.
The dominant outcomes in the reviewed publications were all-
cause mortality (26 studies) and mortality from cardiovascular/
ischemic heart diseases (13 studies). Eleven studies measured all-
cancer or cause-specific cancer mortality and six studies
measured mortality from injury, suicide or accidents. Two studies
investigated alcohol-related mortality (Blomgren, Martikainen,
Makela, & Valkonen, 2004; Martikainen et al., 2003) and in
a single study the main outcome was HIV mortality (Mari-
Dell’Olmo et al., 2007). In only three studies was the outcome
cancer incidence (Robert et al., 2004; Sanderson et al., 2006;
Webster, Hoffman, Weinberg, Vieira, & Aschengrau, 2008). The
main results from our coding of individual studies appear in
Supplementary Table 1, where we also present overall estimates
and confidence intervals for all studies. Electronic Supplementary
Table 1 is available only with the online version of the paper
(Supplementary Table 1).
Twelve studies were conducted in the USA, seven in Sweden,
four were from Norway, two each from Australia, New Zealand,
Finland, Spain, United Kingdom, Israel, Italy, Canada and one study
was from the Netherlands. Thirty of the 40 studies were published
between 2003 and 2008. The sample size of individuals ranged
from 800 (Sanderson et al., 2006) to 5,995,661 (Bentley et al., 2008;
Turrell et al., 2007). The median sample size was 70,681 persons.
Out of the 40 studies in the systematic review, we excluded 22
studies in the meta-analysis for reasons stated in Fig. 1. Out of the
two studies excluded due to duplicate data, the first focused on
religious affiliation (Jaffe et al., 2005a) and not neighborhood SES
(Jaffe et al., 2005b) while the other (Veugelers et al., 2001) only
included a subset of the population used in a similar study (Roos
et al., 2004).
Quality assessment
The overall quality of the reviewed studies was high given our
strict study inclusion criteria. Only five studies received a moderate
global rating. All remaining studies were rated strong, i.e. as having
a low level of risk of bias. (For a listing of the results of the quality
assessment please see Supplementary Table 2.) Electronic Supple-
mentary Table 2 is available only with the online version of the
paper (Supplementary Table 2).
All studies used registers to obtain mortality or cancer incidence
data. Individual-level and area-level data were obtained through
either surveys (Anderson et al., 1997; Backlund et al., 2007; Bosma
et al., 2001; Jones et al., 2000; Malmstrom et al., 2001; Waitzman,
Smith, & Stroup, 1999), censuses (Bentley et al., 2008; Blakely et al.,
2003, 2006; Borrell et al., 2002; Curtis et al., 2004; Franzini &
Spears, 2003; Jaffe et al., 2005a, 2005b; Jerrett et al., 2003, 2005;
Marinacci et al., 2004; Naess, Leyland, et al., 2005; Naess et al.,
2007; Petrelli, Gnavi, Marinacci, & Costa, 2006; Turrell et al.,
2007), registers (Blomgren et al., 2004; Chaix, Rosvall, Lynch, &
Merlo, 2006; Chaix, Rosvall, & Merlo, 2007a, 2007b; Dahl et al.,
2006; Henriksson, Allebeck, Weitoft, & Thelle, 2006, 2007;
Kravdal, 2007; Martikainen et al., 2003) or through combinations
(Chaix, Lindstrom, Merlo, & Rosvall, 2008; LeClere, Rogers, & Peters,
1998; Lochner et al., 2001; Mari-Dell’Olmo et al., 2007; Robert et al.,
2004; Roos et al., 2004; Sanderson et al., 2006; Veugelers et al.,
2001; Webster et al., 2008; Yen & Kaplan, 1999).
Studies based on surveys with participation rates lower than
80% (Malmstrom et al., 2001; Roos et al., 2004; Veugelers et al.,
2001) or where certain population groups were excluded (Bentley
et al., 2008; Naess, Leyland, et al., 2005; Naess et al., 2007; Turrell
et al., 2007) were rated as having moderate selection bias. Only
one study (Sanderson et al., 2006) with a 60% response rate was
1207
rated weak. All other studies were rated strong, since they were
either based on registry data censuses or on survey data with
a participation rate higher than 80%.
We rated the data collection method strong if the area measure
was SES, income inequality, urbanization or racial composition and
that data were derived from registers or censuses. Studies using
survey data to measure ALSES were rated as having only a moderate
data collection method (Anderson et al., 1997; Backlund et al.,
2007; Jones et al., 2000; Malmstrom et al., 2001; Roos et al.,
2004; Sanderson et al., 2006; Veugelers et al., 2001; Waitzman
et al., 1999).
The most appropriate design for studies investigating area
effects on mortality and cancer incidence are longitudinal and
cohort studies. Thus, we categorized these studies strong although
EPHPP rates randomized controlled trials highest (Anderson et al.,
1997; Backlund et al., 2007; Blakely et al., 2003, 2006; Blomgren
et al., 2004; Chaix et al., 2006, 2007a, 2007b; Curtis et al., 2004;
Dahl et al., 2006; Henriksson et al., 2006, 2007; Jaffe et al., 2005a,
2005b; Jerrett et al., 2003, 2005; Jones et al., 2000; Kravdal,
2007; Malmstrom et al., 2001; Marinacci et al., 2004;
Martikainen et al., 2003; Naess, Leyland, et al., 2005; Naess et al.,
2007; Petrelli et al., 2006; Roos et al., 2004; Veugelers et al.,
2001; Waitzman et al., 1999; Yen & Kaplan, 1999). Cross-sectional
studies (Bentley et al., 2008; Borrell et al., 2002; Bosma et al.,
2001; Chaix et al., 2008; Franzini & Spears, 2003; LeClere et al.,
1998; Lochner et al., 2001; Mari-Dell’Olmo et al., 2007; Turrell
et al., 2007) and case control studies (Robert et al., 2004; Sanderson
et al., 2006; Webster et al., 2008) were rated moderate.
We only included studies that controlled for at least one indi-
vidual SES factor. Since individual education, income or occupation-
based SES are often highly correlated (Geyer & Peter, 2000; Naess,
Claussen, Thelle, & Smith, 2005) and given that all included
studies control for age and sex, we rated all included studies strong
with regard to control of confounding.
All studies used appropriate analytical methods since we only
included studies using multilevel studies. However, four studies
(Chaix et al., 2006, 2007a; Jerrett et al., 2003, 2005) stood out
because they used extended Cox models, which must be considered
the gold standard in area-effect studies on survival data. These
studies were rated strong while all remaining studies were rated
moderate.
Systematic review
The characteristics and overall area-level estimate for each
study are presented in Supplementary Table 1. Electronic Supple-
mentary Table 1 is available only with the online version of the
paper (Supplementary Table 1). The overall estimate was calculated
for ALSES (Anderson et al., 1997; Blakely et al., 2003, 2006;
Blomgren et al., 2004; Borrell et al., 2002; Bosma et al., 2001;
Chaix et al., 2006, 2007a, 2007b, 2008; Curtis et al., 2004; Dahl
et al., 2006; Franzini & Spears, 2003; Jaffe et al., 2005b; Jerrett
et al., 2003; Jones et al., 2000; Kravdal, 2007; Lochner et al.,
2001; Malmstrom et al., 2001; Mari-Dell’Olmo et al., 2007; Mari-
nacci et al., 2004; Martikainen et al., 2003; Naess, Leyland, et al.,
2005; Naess et al., 2007; Petrelli et al., 2006; Robert et al., 2004;
Roos et al., 2004; Sanderson et al., 2006; Turrell et al., 2007;
Webster et al., 2008; Yen & Kaplan, 1999), for income inequality
(Backlund et al., 2007; Henriksson et al., 2006, 2007; Waitzman
et al., 1999) and for air pollution (Jerrett et al., 2005). For four
studies we did not calculate overall area effect estimates because of
duplicate data (Bentley et al., 2008; Jaffe et al., 2005a; Veugelers
et al., 2001) or insufficient information in the publication (LeClere
et al., 1998).
1208 M. Meijer et al. / Social Science & Medicine 74 (2012) 1204e1212
A significant ALSES effect was found in 24 studies (Anderson
et al., 1997; Bentley et al., 2008; Blakely et al., 2006; Blomgren
et al., 2004; Borrell et al., 2002; Chaix et al., 2006, 2007a, 2007b,
2008; Curtis et al., 2004; Franzini & Spears, 2003; Jaffe et al.,
2005a, 2005b; Jerrett et al., 2003; Malmstrom et al., 2001; Mari-
Dell’Olmo et al., 2007; Marinacci et al., 2004; Martikainen et al.,
2003; Naess et al., 2007; Robert et al., 2004; Sanderson et al., 2006;
Turrell et al., 2007; Webster et al., 2008; Yen & Kaplan, 1999), as
well as for two studies with income inequality as the outcome
(Backlund et al., 2007; Waitzman et al., 1999). Ten studies did not
find any significant effects for ALSES (Blakely et al., 2003; Bosma
et al., 2001; Dahl et al., 2006; Jones et al., 2000; Kravdal, 2007;
Lochner et al., 2001; Naess, Leyland, et al., 2005; Petrelli et al.,
2006; Roos et al., 2004; Veugelers et al., 2001), two studies found
no effect for income inequality (Henriksson et al., 2006, 2007) and
one study found no effect for air pollution (Jerrett et al., 2005).
In 22 of the 24 studies showing significant ALSES effects,
mortality or prostate cancer incidence (Sanderson et al., 2006) was
higher in lower SES areas. Only the two studies investigating breast
cancer incidence found that high ALSES was associated with an
increased risk of breast cancer (Robert et al., 2004; Webster et al.,
2008).
We found mixed results for income inequality on mortality. Four
studies (Backlund et al., 2007; Dahl et al., 2006; Lochner et al.,
2001; Waitzman et al., 1999) found that high-income inequality
was associated with increased mortality, whereas four other
studies found no effect (Blakely et al., 2003; Blomgren et al., 2004;
Franzini & Spears, 2003; Henriksson et al., 2006). One study found
that a high level of income inequality had a protective effect for
high-level non manual workers and an adverse effect for unskilled
manual workers (Henriksson et al., 2007). Further, as Backlund
et al. (2007) suggest, the mixed results could reflect that income
inequality has a stronger effect on younger age groups, which was
confirmed in a recent meta-analysis that found a moderate area
effect of income inequality on mortality (Kondo et al., 2009).
Three studies (Blomgren et al., 2004; Chaix et al., 2008;
Martikainen et al., 2003) found that low social cohesion was
associated with higher mortality while one study (Blakely et al.,
2006) found no association for social capital. Comparing these
results, however, should be done carefully, since theoretical
considerations, operationalizations and types of measurement
differ substantially.
Only few studies investigated the influence of the physical
environment. Factors such as distance or density to shops selling
healthy food were not present in any of the reviewed articles. Air
pollution was measured in three studies and they all reported
associations with mortality (Jerrett et al., 2003, 2005; Naess et al.,
2007). One study found urban areas to be associated with higher
breast cancer incidence (Robert et al., 2004) and one Finnish study
found that a high level of urbanization had a protective effect
(Blomgren et al., 2004). Two Swedish studies found that high
population density had a negative effect on individual mortality
and that ALSES had a stronger effect in densely populated areas
(Chaix et al., 2006, 2007a).
Nearly all studies used a country-specific administrative
boundary (e.g. census tracts, counties and municipalities) as
geographical area. No studies used geographical information
systems (GIS) to delineate neighborhoods.
The most common data structure was individuals on the first
level and a single area level at the second level. Five studies allowed
for more than one area level in their analyses. After controlling for
individual SES and other area levels, three of these studies found
that all investigated area levels contributed to all-cause mortality
(Turrell et al., 2007), years-lost-to-premature-CDV mortality
(Franzini & Spears, 2003) and cancer mortality (Bentley et al.,
2008). One study found variation in all-cause mortality only at
the highest (regional) level (Jones et al., 2000) and one reported no
effect from any area levels on all-cause or cause-specific mortality
(Blakely et al., 2003). Thus, local communities as well as medium
sized contexts (e.g. municipalities or wards) and large-scale areas
such as regions, states and territories seem have independent
effects on mortality and cancer incidence.
It remains appropriate to allow for lag time between neigh-
borhood influences and health outcomes, which is also supported
by two of the reviewed studies. One study found that area-level
deprivation experienced in childhood was associated with
mortality over 40 years later (Curtis et al., 2004) while the other
found an increased effect of neighborhood context when allowing
for a 10-year latency period (Webster et al., 2008). This effect,
however, could be due to individual circumstances in this period,
since one study found that a significant area effect disappeared
when early life deprivation was controlled for at the individual
level, demonstrating the importance of incorporation of a life-
course perspective (Naess, Leyland, et al., 2005). None of the
studies investigated how length of residence affected mortality or
cancer incidence.
Meta-analysis
In Supplementary Table 3 we show the ALSES estimates and
their corresponding age range, sex category, area-level factor, SES
reference factor and the welfare regime of the respective studies.
Electronic Supplementary Table 3 is available only with the online
version of the paper (Supplementary Table 3). These estimates
were used to calculate an overall estimate and 95% confidence
interval for each study, shown in Fig. 2. As seen in Fig. 2, the overall
relative risk (95% CI) for all-cause mortality for inhabitants in lower
SES areas compared to inhabitants from higher SES areas adjusted
for individual SES was 1.07 (1.04e1.10). This demonstrates that the
ALSES has an independent effect on all-cause mortality, even after
controlling for individual SES. Fig. 2 also shows that the effect of
ALSES was stronger when the number of inhabitants in the
analyzed areas was smaller. In studies investigating area units with
few inhabitants the effect of ALSES was 1.11 (1.08e1.14) while the
effect in studies analyzing areas with many inhabitants was 1.02
(1.00e1.03). However, strong evidence of heterogeneity between
studies was observed even within the subgroups of studies
analyzing areas with few inhabitants (I2 ¼ 87.4%, P < 0.001) or area
units with many inhabitants (I2 ¼ 80.9%, P < 0.001) indicating that
there is significant variation in ALSES effects between the studies
that could be caused by differences in study designs or study
populations. We therefore conducted a meta-regression to inves-
tigate if these differences could account for the observed
heterogeneity.
Meta-regression analyses (Table 1) showed that the effect of
ALSES on mortality was higher for men than for women. For older
people the effect of ALSES on mortality was not as pronounced as
for younger people. Areas with lower SES had higher mortality than
areas with higher SES. The effect of ALSES on mortality was
stronger in studies using area units with few inhabitants than in
studies with many inhabitants per area unit.
Due to the differences in economic redistribution and access to
education and health care between welfare regimes we expected
the effect of ALSES to be stronger in liberal and conservative welfare
state models than in the social-democratic welfare state model.
Although estimates point in this direction they remained insignif-
icant (results not shown) and therefore do not explain the
heterogeneity between the studies. After adjusting for sex and age
the relative risk (95% CI) of mortality in areas with lower SES
compared to those with higher SES was 1.05 (95% CI:1.04e1.06) in
 M. Meijer et al. / Social Science & Medicine 74 (2012) 1204e1212 1209

%
study area_size ES (95% CI) Weight

smaller areas
Naess 2005 248 1.35 (0.96, 1.89) 0.56
Naess 2007 1010 1.14 (1.11, 1.18) 6.27
Roos 2004 1120 1.07 (0.92, 1.23) 2.19
Malmström 2001 1500 1.03 (1.01, 1.05) 6.55
Blakely 2006 2034 1.09 (1.08, 1.11) 6.71
Bosma 2001 2221 1.06 (0.97, 1.15) 4.02
Jerrett 2003 3642 1.11 (1.03, 1.20) 4.41
Anderson 1997 4500 1.10 (1.07, 1.13) 6.33
Turrell 2007 4500 1.12 (1.11, 1.13) 6.71
Jaffe 2005 5000 1.22 (1.15, 1.29) 5.17
Curtis 2004 5000 1.15 (1.11, 1.19) 6.06
Subtotal (I-squared = 87.4%, p = 0.000) 1.11 (1.08, 1.14) 54.98
.
larger areas
Kravdal 2007 7000 0.99 (0.97, 1.02) 6.33
Dahl 2006 11250 1.01 (0.99, 1.02) 6.68
Martikainen 2003 14635 1.06 (1.03, 1.08) 6.50
Jones 2000 22375 1.03 (0.98, 1.07) 5.67
Marinacci 2004 41139 1.03 (1.02, 1.05) 6.64
Blakely 2003 164474 1.00 (0.97, 1.02) 6.45
Lochner 2001 6000000 1.00 (0.99, 1.01) 6.74
Subtotal (I-squared = 80.9%, p = 0.000) 1.02 (1.00, 1.03) 45.02
.
Overall (I-squared = 96.1%, p = 0.000) 1.07 (1.04, 1.10) 100.00

NOTE: Weights are from random effects analysis

.9 1 1.25

Fig. 2. Results of meta-analysis: relative risks for mortality in low-SES areas compared to high-SES areas and between-study heterogeneity, studies grouped according to number of
inhabitants per area unit analyzed (<7000 or 7000).

studies analyzing larger area units and 1.10 (95% CI: 1.06e1.15) in
studies using smaller area units. There was still significant variance
between studies after adjusting for the covariates. We found no
evidence of publication bias (P ¼ 0.363 in Begg-Test).
Discussion
Principal findings
municipalities or regions have effects on individual mortality and
breast cancer incidence. The meta-analysis and meta-regression
found evidence that people living in areas with low socioeco-
nomic status have higher mortality than people living in higher
socioeconomic areas, even after accounting for individual SES. This
is in accordance with the conclusions in previous systematic
reviews (Pickett & Pearl, 2001; Riva et al., 2007) and generally
extends the well-documented effect of individual SES on indi-
vidual health outcomes to also encompass ALSES.

While the systematic review found no clear associations

between mortality and income inequality or social capital on the
neighborhood level, there was evidence for associations for ALSES, Interpretation of findings
social coherence and population density/urbanization. Both local
communities as well as higher-level contexts such as Economic capital and cultural capital (such as income and
education) are good health predictors on the individual level
Table 1 because they form opportunity structures and frameworks that
Meta-regression results (random effects model) of the effect of area SES on mortality enable and promote positive health behavior. We contend that, in
(outcome: estimate of mortality in relative lower SES areas in comparison to highest a similar way, ALSES has an effect on individual mortality because
SES area). inhabitants in neighborhoods affect each other’s’ health behavior
Beta (SE) RR (95% CI) through exchanges of norms, values and social sanctions. ALSES can
Sex (reference: women) also affect the physical environment. As others have argued, the
Men 0.021 (0.008) 1.02 (1.004e1.04) composition of individuals can influence the presence of health
Botha 0.044 (0.024) 0.96 (0.91e1.00) promoting businesses, services and activities in the neighborhood
Age (in decades) 0.021 (0.004) 0.98 (0.97e0.99)
(Diez Roux & Mair, 2010; Macintyre & Ellaway, 2003).
Area SES 0.046 (0.005) 1.05 (1.04e1.06)
Age  area SES 0.014 (0.005) 0.99 (0.98e0.99) The meta-regression showed that younger age groups are more
Smaller area units analyzed 0.096 (0.022) 1.10 (1.06e1.15) susceptible to the effect of ALSES on mortality and we interpret this
(<7000 inhabitants per area) as a result of elderly persons dying mainly because of age, whereas
Variance between studies 0.001 (0.0007) younger persons’ mortality more often is related to negative socio-
a
No sex-specific estimates were provided. environmental influences, accidents etc.
1210 M. Meijer et al. / Social Science & Medicine 74 (2012) 1204e1212
We could not explain the heterogeneity between studies by
their representation of different welfare state regimes. This
resembles research at the individual level, demonstrating that,
despite efforts to reduce socioeconomic inequalities in social-
democratic welfare regimes, health inequalities continue to exist
(Mackenbach, Kunst, Cavelaars, Groenhof, & Geurts, 1997). It
implies that all countries and all welfare state models could reduce
all-cause mortality by initiating prevention efforts on the area level.
The meta-regression further showed that the effect of ALSES is
greater when analyzing units with fewer inhabitants. Overall this
suggests that it is the environment close to peoples’ homes that has
the greatest effect on individuals whereas larger geographical units
are less important. However, this may vary between urban and
rural settings. In urban settings with higher population density it
might be appropriate to analyze area units with more inhabitants,
whereas this might not be the case in rural areas with lower pop-
ulation density. In the meta-analysis two studies found a signifi-
cantly stronger effect of ALSES when analyzing larger area units in
urban areas (Marinacci et al., 2004; Martikainen et al., 2003).
The systematic review showed also that larger geographical
areas affect individual mortality after taking into account the small-
scale local neighborhood. This may be a result of differing political
and administrative regulations as well as cultural differences
existing across regions.
Limitations
A drawback of our study pertains to the number of searched
databases and search terms used in our retrieval. We believe,
however, that by conducting a pilot and having searched four
databases have contributed to a solid data collection. Also, a quali-
tative analysis is always subject to possible subjective interpreta-
tions, but by having two researchers individually code the
individual studies we have attempted to reduce this bias. In our
assessment of risk of bias we showed that the reviewed studies are
of very high overall quality. However, it is a limitation that we have
used studies that vary as to cause of mortality, controlling of indi-
vidual SES, age range, geographical scale and statistical method.
Therefore the results should be treated with caution. This is also
evident in the high level of heterogeneity between studies as
assessed by the meta-analysis and meta-regression. One particular
weakness is that studies in the meta-analysis used different ALSES
measures, which also might contribute to the heterogeneity. On the
other hand these measures are correlated (Geyer & Peter, 2000;
Naess, Claussen, et al., 2005) and are often used interchangeably
in the literature. To account for the study differences in sex, age,
welfare regime, geographical scale we performed a meta-
regression.
Implications
Returning to Diez Roux and Mair’s (2010) review of neighbor-
hood influences on health inequalities, our results confirm that
ALSES affects individual mortality, especially on a small-scale level.
With respect to national health policy this implies that in all
western countries, no matter what welfare regime, it would be
beneficial to identify low-SES areas and to invest in these, by for
example creating more job opportunities, better housing and better
infrastructure. Thus, policy areas traditionally thought of as unre-
lated to public health could contribute to reducing morbidity and
mortality (Schoeni, House, Kaplan, & Pollack, 2008). Shifting focus
from concentrating on individual health behavior to also investing
in low-SES areas would have several advantages. First, the infra-
structural circumstances for inhabitants would improve, which in
itself would reduce morbidity and mortality. Secondly, it would
attract higher socioeconomic groups to these areas, which on the
one hand would increase the positive social influences gained
through social interaction and on the other hand would increase
the attractiveness for more private enterprises, including stores
promoting a healthy behavior to settle there. Some researchers
have suggested looking at housing policy (Diez Roux & Mair, 2010;
Van Lenthe, 2006). Similarly we suggest avoiding large-scale public
housing complexes and also situating public housing in more
affluent areas. This could reduce high concentrations of low-SES
groups and thereby improve public health conditions through the
mentioned mechanisms.
Our results suggest that more research into the impact of social
cohesion, social capital and the contributions of the physical
environments should be pursued. A particular task is to disentangle
the relative contributions of the social and the physical environ-
ments on individual health and to identify mediating processes
between ALSES and mortality. Both qualitative and quantitative
investigations could contribute to an understanding of how
neighborhoods and larger scale areas influence the health behavior
of inhabitants on different area levels. Previous studies have
investigated how inhabitants’ health behavior in terms of diet
(Moore, Diez Roux, Nettleton, Jacobs, & Franco, 2009), alcohol
consumption (Treno, Johnson, Remer, & Gruenewald, 2007;
Weitzman, Folkman, Folkman, & Wechsler, 2003) and smoking
(Chuang, Cubbin, Ahn, & Winkleby, 2005) are affected by the
distance and the density fast-food restaurants, super markets, bars,
alcohol outlets and stores selling cigarettes. Given the ambiguous
results in these studies and the structural prevention potential
linked to such factors we particularly encourage more investiga-
tions into how physical factors affect not only health behavior but
also morbidity and mortality.
Finally, we encourage researchers to include multiple area levels
in future investigations. People engage daily in different contexts
all contributing to their health (e.g. a family, a small-scale neigh-
borhood, a municipality, a region and a workplace). The inclusion of
these levels would provide more precise estimates of both indi-
vidual effects and area-level effects on health.
Competing interests
None.
Acknowledgment
The research reported here was supported by grants from the
Forskningsrådet (project number 271-06-0549) and Sygekassernes
Helsefond (journal numbers 2007B048 and 2009B077).
Appendix. Supplementary data
Supplementary data associated with this article can be found, in
the online, version at doi:10.1016/j.socscimed.2011.11.034.
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