摘要：Objectives . We sought to determine whether residential area deprivation, over and above the effect of life-course socioeconomic status or position (SEP), is associated with coronary heart disease. Methods . We conducted a cross-sectional analysis of 4286 women aged 60 to 79 years from 457 British electoral wards. Results . After adjustment for age and 10 indicators of individual life-course SEP, the odds of coronary heart disease was 27% greater among those living in wards with a deprivation score above the median compared with those living in a ward with a deprivation score equal to or below the median (odds ratio=1.27; 95% confidence interval=1.02, 1.57). Conclusions . Adverse area-level socioeconomic characteristics, over and above individual life-course SEP, are associated with increased coronary heart disease. The idea that where one lives is important for one’s health is not new. 1 However, there is debate regarding whether the characteristics of where people live (contextual effects) have an important influence on health independent of the characteristics of the people living in these areas (compositional effects). 2, 3 The relevance of this issue is that if variations in health between areas can be entirely explained by the personal characteristics of the inhabitants of these areas, policymakers need act only on improving the circumstances of individuals. Conversely, the demonstration of independent area-level effects would emphasize the need to focus interventions on features of the areas where people live, not just on the individuals living there. This is important because the widening gap between the rich and the poor appears to be mirrored by a growing divergence of their residential environments, such that affluent people are increasingly living and interacting with other affluent people in affluent areas, whereas the poor increasingly live and interact with other poor people in more economically and socially deprived areas. 4 The occurrence of coronary heart disease (CHD) varies geographically, 5– 7 and CHD is strongly influenced by individual socioeconomic status or position (SEP). 8, 9 Six studies have examined the effect of socioeconomic context on CHD by determining the effect of residential area deprivation, having adjusted for individual measures of SEP, and all 6 found moderate effects. 10– 15 However, only 3 studies 10, 14, 15 adjusted for more than 1 individual measure of SEP. In such studies, it is likely that adjustment for only 1 or 2 indicators of an individual’s SEP fails to capture the full complexity of their experience over the life course, leading to residual confounding by individual SEP rather than true contextual effects. 3, 16– 19 Among studies assessing the contextual effects of SEP on all-cause mortality, the only study to adjust for individual SEP in childhood and adulthood found little remaining area-level effect, 20 suggesting that for all-cause mortality at least there may be no contextual effect over and above individual effects. 3 None of the studies assessing the association between socioeconomic context and CHD have adjusted for individual measures of SEP from across the life course. The aims of this study were to assess the association between individual life-course SEP and adult residential area deprivation and to determine whether area socioeconomic deprivation, over and above the effect of individual life-course SEP, is associated with prevalent CHD in women.
