title: Estimating the Impact of Health-related Behaviors on Geographic Variation in Cardiovascular Mortality: A New Approach Based on the Synthesis of Ecological and Individual-level Data.
abstract: BACKGROUND
  Incidence of and mortality from cardiovascular disease (CVD) exhibit a strong geographical pattern, with inhabitants of more affluent neighborhoods showing a substantially lower risk of CVD mortality than inhabitants of deprived neighborhoods. Thus far, there is insufficient evidence as to what extent these differences can be attributed to differences in health-related behaviors.
  
  
  METHODS
  Using a Hierarchical Related Regression approach, we combined individual and aggregate (ecological) data to investigate the extent to which small-area variation in CVD mortality in Dutch neighborhoods can be explained by several behavioral risk factors (i.e., smoking, drinking, overweight, and physical inactivity). The proposed approach combines the benefits of both an ecological analysis (in terms of data availability and statistical power) and an individual-level analysis (in terms of identification of the parameters and interpretation of the results).
  
  
  RESULTS
  After correcting for differences in age and sex, accounting for differences in the behavioral risk factors reduces income-related inequalities in CVD mortality by approximately 30%.
  
  
  CONCLUSIONS
  Direct targeting of the excess prevalence of unhealthy behaviors in deprived neighborhoods is identified as a relevant strategy to reduce inequalities in CVD mortality. Our results also show that the proposed Hierarchical Related Regression approach provides a powerful method for the investigation of small-area variation in health outcomes.
authors.affiliation: From the aDepartment of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands; bDepartment of Business Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands; cInserm, Paris, France; and dFaculté de Médecine Saint-Antoine, Université Pierre et Marie Curie, Paris, France.
authors.forename: Marcel F
authors.initials: MF
authors.lastname: Jonker
authors.forename: Bas
authors.initials: B
authors.lastname: Donkers
authors.forename: Basile
authors.initials: B
authors.lastname: Chaix
authors.forename: Frank J
authors.initials: FJ
authors.lastname: van Lenthe
authors.forename: A
authors.initials: A
authors.lastname: Burdorf
authors.forename: Johan P
authors.initials: JP
authors.lastname: Mackenbach
mesh_terms: D000328:Adult; D000368:Aged; D000428:Alcohol Drinking / Q000453:epidemiology*; D001499:Bayes Theorem; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000401:mortality*; D005260:Female; D015438:Health Behavior; D054624:Health Status Disparities; D006801:Humans; D015994:Incidence; D007182:Income / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D050177:Overweight / Q000453:epidemiology*; D012044:Regression Analysis; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012307:Risk Factors; D057185:Sedentary Behavior; D017062:Small-Area Analysis; D012907:Smoking / Q000453:epidemiology*