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Absolute rather than relative income is a better socioeconomic predictor of chronic obstructive pulmonary disease in Swedish adults.

https://arctichealth.org/en/permalink/ahliterature292715
Source
Int J Equity Health. 2017 05 04; 16(1):70
Publication Type
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Date
05-04-2017
Author
Sten Axelsson Fisk
Juan Merlo
Author Affiliation
Unit for Social Epidemiology, Faculty of Medicine, Lund University, CRC, Jan Waldeströms gata, 35, S-205 02, Malmö, Sweden. sten.axelsson_fisk@med.lu.se.
Source
Int J Equity Health. 2017 05 04; 16(1):70
Date
05-04-2017
Language
English
Publication Type
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Keywords
Aged
Female
Humans
Incidence
Income - statistics & numerical data
Logistic Models
Male
Middle Aged
Odds Ratio
Poverty - statistics & numerical data
Prevalence
Pulmonary Disease, Chronic Obstructive - economics - epidemiology
Risk assessment
Social Class
Socioeconomic Factors
Sweden - epidemiology
Abstract
While psychosocial theory claims that socioeconomic status (SES), acting through social comparisons, has an important influence on susceptibility to disease, materialistic theory says that socioeconomic position (SEP) and related access to material resources matter more. However, the relative role of SEP versus SES in chronic obstructive pulmonary disease (COPD) risk has still not been examined.
We investigated the association between SES/SEP and COPD risk among 667 094 older adults, aged 55 to 60, residing in Sweden between 2006 and 2011. Absolute income in five groups by population quintiles depicted SEP and relative income expressed as quintile groups within each absolute income group represented SES. We performed sex-stratified logistic regression models to estimate odds ratios and the area under the receiver operator curve (AUC) to compare the discriminatory accuracy of SES and SEP in relation to COPD.
Even though both absolute (SEP) and relative income (SES) were associated with COPD risk, only absolute income (SEP) presented a clear gradient, so the poorest had a three-fold higher COPD risk than the richest individuals. While the AUC for a model including only age was 0.54 and 0.55 when including relative income (SES), it increased to 0.65 when accounting for absolute income (SEP). SEP rather than SES demonstrated a consistent association with COPD.
Our study supports the materialistic theory. Access to material resources seems more relevant to COPD risk than the consequences of low relative income.
Notes
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PubMed ID
28472960 View in PubMed
Less detail

Acculturation and celiac disease risk in second-generation immigrants: a nationwide cohort study in Sweden.

https://arctichealth.org/en/permalink/ahliterature122335
Source
Scand J Gastroenterol. 2012 Oct;47(10):1174-80
Publication Type
Article
Date
Oct-2012
Author
Carl Johan Wingren
Daniel Agardh
Juan Merlo
Author Affiliation
Unit for Social Epidemiology, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden. carl_johan.wingren@med.lu.se
Source
Scand J Gastroenterol. 2012 Oct;47(10):1174-80
Date
Oct-2012
Language
English
Publication Type
Article
Keywords
Acculturation
Celiac Disease - epidemiology
Child
Child, Preschool
Cohort Effect
Cohort Studies
Cost of Illness
Emigrants and Immigrants - statistics & numerical data
Environmental health
Female
Health Status Disparities
Humans
Incidence
Male
Mothers - statistics & numerical data
Proportional Hazards Models
Registries - statistics & numerical data
Risk assessment
Risk factors
Sweden - epidemiology
Time Factors
Young Adult
Abstract
The burden of celiac disease (CD) is increasingly recognized as a global problem. However, whether this situation depends on genetics or environmental factors is uncertain. The authors examined these aspects in Sweden, a country in which the risk of CD is generally considered to be high. If environmental factors are relevant, CD risk in second-generation immigrant children should be related to maternal length of stay in Sweden before delivery.
Linking the Swedish Medical Birth Registry to other national registries, the authors investigated all singleton children (n = 792,401) born in Sweden between 1987 and 1993. They studied the risk of CD in children before age 6 as a function of the mother's geographical region of birth and length of stay in Sweden before delivery using Cox regression models.
In children whose mothers immigrated to Sweden from a country outside of Europe, a maternal length of stay in Sweden of more than 5 years increased the hazard ratio (HR) of CD (1.73, 95% confidence interval (CI) 1.06-2.81). The authors observed a similar result among children born to mothers from a Nordic country outside of Sweden (HR 1.57, 95% CI 0.89-2.75), but a non-conclusive protective effect was observed in second-generation immigrant children from a non-Nordic European country (HR 0.65, 95% CI 0.39-1.09).
The risk of CD among second-generation immigrants seems to be conditioned by maternal length of stay in Sweden before delivery, suggesting that environmental factors contribute to the variation in CD risk observed across populations.
PubMed ID
22827636 View in PubMed
Less detail

Adolescents' utilisation of psychiatric care, neighbourhoods and neighbourhood socioeconomic deprivation: a multilevel analysis.

https://arctichealth.org/en/permalink/ahliterature106043
Source
PLoS One. 2013;8(11):e81127
Publication Type
Article
Date
2013
Author
Anna-Karin Ivert
Marie Torstensson Levander
Juan Merlo
Author Affiliation
Faculty of Health and Society, Malmö University, Malmö, Sweden.
Source
PLoS One. 2013;8(11):e81127
Date
2013
Language
English
Publication Type
Article
Keywords
Adolescent
Databases, Factual
Delivery of Health Care - organization & administration
Female
Hospitals, Psychiatric - utilization
Humans
Male
Mental Disorders - psychology
Mental Health - statistics & numerical data
Multilevel Analysis
Poverty Areas
Residence Characteristics
Social Adjustment
Social Environment
Socioeconomic Factors
Sweden
Abstract
Mental health problems among adolescents have become a major public health issue, and it is therefore important to increase knowledge on the contextual determinants of adolescent mental health. One such determinant is the socioeconomic structure of the neighbourhood. The present study has two central objectives, (i) to examine if neighbourhood socioeconomic deprivation is associated to individual variations in utilisation of psychiatric care in a Swedish context, and (ii) to investigate if neighbourhood boundaries are a valid construct for identifying contexts that influence individual variations in psychiatric care utilization. Data were obtained from the Longitudinal Multilevel Analysis in Scania (LOMAS) database. The study population consists of all boys and girls aged 13-18 years (N=18,417), who were living in the city of Malmö, Sweden, in 2005. Multilevel logistic regression analysis was applied to estimate the probability of psychiatric care utilisation. The results from the study indicate that the neighbourhood of residence had little influence on psychiatric care utilisation. Although we initially found a variation between neighbourhoods, this general contextual effect was very small (i.e. 1.6%). The initial conclusive association between the neighbourhood level of disadvantage and psychiatric care utilisation (specific contextual effect) disappeared following adjustment for individual and family level variables. Our results suggest the neighbourhoods in Malmö (at least measured in terms of SAMS-areas), do not provide accurate information for discriminating adolescents utilisation of psychiatric care. The SAMS-areas appears to be an inappropriate construct of the social environment that influences adolescent utilisation of psychiatric care. Therefore, public health interventions should be directed to the whole city rather than to specific neighbourhoods. However, since geographical, social or cultural contexts may be important for our understanding of adolescent mental health further research is needed to identify such contexts.
Notes
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PubMed ID
24260548 View in PubMed
Less detail

An Original Stepwise Multilevel Logistic Regression Analysis of Discriminatory Accuracy: The Case of Neighbourhoods and Health.

https://arctichealth.org/en/permalink/ahliterature280453
Source
PLoS One. 2016;11(4):e0153778
Publication Type
Article
Date
2016
Author
Juan Merlo
Philippe Wagner
Nermin Ghith
George Leckie
Source
PLoS One. 2016;11(4):e0153778
Date
2016
Language
English
Publication Type
Article
Keywords
Adult
Female
General practitioners
Humans
Logistic Models
Longitudinal Studies
Male
Middle Aged
Multilevel Analysis - methods
Psychotropic Drugs - therapeutic use
Public Health - statistics & numerical data
ROC Curve
Residence Characteristics - statistics & numerical data
Socioeconomic Factors
Sweden
Abstract
Many multilevel logistic regression analyses of "neighbourhood and health" focus on interpreting measures of associations (e.g., odds ratio, OR). In contrast, multilevel analysis of variance is rarely considered. We propose an original stepwise analytical approach that distinguishes between "specific" (measures of association) and "general" (measures of variance) contextual effects. Performing two empirical examples we illustrate the methodology, interpret the results and discuss the implications of this kind of analysis in public health.
We analyse 43,291 individuals residing in 218 neighbourhoods in the city of Malmö, Sweden in 2006. We study two individual outcomes (psychotropic drug use and choice of private vs. public general practitioner, GP) for which the relative importance of neighbourhood as a source of individual variation differs substantially. In Step 1 of the analysis, we evaluate the OR and the area under the receiver operating characteristic (AUC) curve for individual-level covariates (i.e., age, sex and individual low income). In Step 2, we assess general contextual effects using the AUC. Finally, in Step 3 the OR for a specific neighbourhood characteristic (i.e., neighbourhood income) is interpreted jointly with the proportional change in variance (i.e., PCV) and the proportion of ORs in the opposite direction (POOR) statistics.
For both outcomes, information on individual characteristics (Step 1) provide a low discriminatory accuracy (AUC = 0.616 for psychotropic drugs; = 0.600 for choosing a private GP). Accounting for neighbourhood of residence (Step 2) only improved the AUC for choosing a private GP (+0.295 units). High neighbourhood income (Step 3) was strongly associated to choosing a private GP (OR = 3.50) but the PCV was only 11% and the POOR 33%.
Applying an innovative stepwise multilevel analysis, we observed that, in Malmö, the neighbourhood context per se had a negligible influence on individual use of psychotropic drugs, but appears to strongly condition individual choice of a private GP. However, the latter was only modestly explained by the socioeconomic circumstances of the neighbourhoods. Our analyses are based on real data and provide useful information for understanding neighbourhood level influences in general and on individual use of psychotropic drugs and choice of GP in particular. However, our primary aim is to illustrate how to perform and interpret a multilevel analysis of individual heterogeneity in social epidemiology and public health. Our study shows that neighbourhood "effects" are not properly quantified by reporting differences between neighbourhood averages but rather by measuring the share of the individual heterogeneity that exists at the neighbourhood level.
Notes
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PubMed ID
27120054 View in PubMed
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Anxiolytic-hypnotic drug use associated with trust, social participation, and the miniaturization of community: a multilevel analysis.

https://arctichealth.org/en/permalink/ahliterature70589
Source
Soc Sci Med. 2006 Mar;62(5):1205-14
Publication Type
Article
Date
Mar-2006
Author
Kristina Johnell
Martin Lindström
Arne Melander
Jan Sundquist
Charli Eriksson
Juan Merlo
Author Affiliation
Center for Family Medicine, Karolinska Institute, Stockholm, Sweden. Kristina.Johnell@klinvet.ki.se
Source
Soc Sci Med. 2006 Mar;62(5):1205-14
Date
Mar-2006
Language
English
Publication Type
Article
Abstract
The concept of social capital has gained wide interest in public health research in recent years. However, we suggest a concept that was introduced and developed by Fukuyama, named "miniaturization of community", as an alternative to that of social capital. The concept of miniaturization of community emphasizes that a high level of social participation can be accompanied by a low level of trust, both at the individual and at the community level, which may in turn result in social disorder and lack of social cohesion. When society becomes more disordered, people may tend to feel more insecure and anxious. Use of anxiolytic-hypnotic drugs (AHDs) could under such circumstances be a coping strategy. In this study, we first wanted to investigate whether the contextual component of the miniaturization of community concept (i.e. area high social participation and low trust) is associated with individual AHD use, over and above individual characteristics. Secondly, we aimed to study whether people living in the same municipality share a similar probability of AHD use, after adjusting for individual characteristics, and if so, how large this contextual phenomenon is. We used data on 20,319 women and 17,850 men aged 18-79 years from 58 municipalities in six regions in central Sweden, who participated in the Life & Health year 2000 postal survey. We applied multilevel logistic regression analysis with individuals at the first level and areas at the second level. Our results suggest that living in an area with a high level of miniaturization of community seems to be associated with individual AHD use, beyond people's individual characteristics including their own level of social participation and trust. The concept of miniaturization of community may be an extension of the classic concept of social capital and may increase our understanding of contextual effects on health.
PubMed ID
16115711 View in PubMed
Less detail

Applying measures of discriminatory accuracy to revisit traditional risk factors for being small for gestational age in Sweden: a national cross-sectional study.

https://arctichealth.org/en/permalink/ahliterature261080
Source
BMJ Open. 2014;4(7):e005388
Publication Type
Article
Date
2014
Author
Sol Pía Juárez
Phillip Wagner
Juan Merlo
Source
BMJ Open. 2014;4(7):e005388
Date
2014
Language
English
Publication Type
Article
Keywords
Age Factors
Area Under Curve
Cross-Sectional Studies
Educational Status
Female
Fetal Growth Retardation - epidemiology - etiology
Humans
Hypertension - physiopathology
Infant
Infant, Newborn
Infant, Small for Gestational Age - physiology
Logistic Models
Male
Marital status
Pregnancy
Pregnancy Complications
Risk factors
Smoking - adverse effects
Sweden - epidemiology
Abstract
Small for gestational age (SGA) is considered as an indicator of intrauterine growth restriction, and multiple maternal and newborn characteristics have been identified as risk factors for SGA. This knowledge is mainly based on measures of average association (ie, OR) that quantify differences in average risk between exposed and unexposed groups. Nevertheless, average associations do not assess the discriminatory accuracy of the risk factors (ie, its ability to discriminate the babies who will develop SGA from those that will not). Therefore, applying measures of discriminatory accuracy rather than measures of association only, our study revisits known risk factors of SGA and discusses their role from a public health perspective.
Cross-sectional study. We measured maternal (ie, smoking, hypertension, age, marital status, education) and delivery (ie, sex, gestational age, birth order) characteristics and performed logistic regression models to estimate both ORs and measures of discriminatory accuracy, like the area under the receiver operating characteristic curve (AU-ROC) and the net reclassification improvement.
Data were obtained from the Swedish Medical Birth Registry.
Our sample included 731 989 babies born during 1987-1993.
We replicated the expected associations. For instance, smoking (OR=2.57), having had a previous SGA baby (OR=5.48) and hypertension (OR=4.02) were strongly associated with SGA. However, they show a very small discriminatory accuracy (AU-ROC╦ť0.5). The discriminatory accuracy increased, but remained unsatisfactorily low (AU-ROC=0.6), when including all variables studied in the same model.
Traditional risk factors for SGA alone or in combination have a low accuracy for discriminating babies with SGA from those without SGA. A proper understanding of these findings is of fundamental relevance to address future research and to design policymaking recommendations in a more informed way.
Notes
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PubMed ID
25079936 View in PubMed
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Appropriate assessment of ethnic differences in adolescent use of psychotropic medication: multilevel analysis of discriminatory accuracy.

https://arctichealth.org/en/permalink/ahliterature289566
Source
Ethn Health. 2016 12; 21(6):578-95
Publication Type
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Date
12-2016
Author
Anna-Karin Ivert
Shai Mulinari
Willemijn van Leeuwen
Philippe Wagner
Juan Merlo
Author Affiliation
a Faculty of Medicine, Unit for Social Epidemiology , CRC, Skåne University Hospital, Lund University , Malmö , Sweden.
Source
Ethn Health. 2016 12; 21(6):578-95
Date
12-2016
Language
English
Geographic Location
Sweden
Publication Type
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Keywords
Adolescent
Adult
Developing Countries
Drug Utilization - statistics & numerical data
Female
Humans
Male
Mothers - statistics & numerical data
Multilevel Analysis
Psychotropic Drugs - economics - therapeutic use
ROC Curve
Registries
Risk factors
Socioeconomic Factors
Sweden - epidemiology
Young Adult
Abstract
In the present study, we used a multilevel approach to investigate the role of maternal country of birth (MCOB) in predicting adolescent use of psychotropic medication in Sweden.
Using the Swedish Medical Birth Register we identified all 428,314 adolescents born between 1987 and 1990 and who were residing in Sweden in the year they turned 18. We applied multilevel logistic regression analysis with adolescents (level 1) nested within MCOBs (level 2). Measures of association (odds ratio) and measures of variance (intra-class correlation (ICC)) were calculated, as well as the discriminatory accuracy by calculating the area under the Receiver Operator Characteristic (AU-ROC) curve.
In comparison with adolescents with Swedish-born mothers, adolescents with mothers born in upper-middle, lower-middle and low-income countries were less likely to use psychotropic medication. However, the variance between MCOBs was small (ICC = 2.5 in the final model) relative to the variation within MCOBs. This was confirmed by an AU-ROC value of 0.598.
Even though we found associations between MCOB and adolescent use of psychotropic medication, the small ICC and AU-ROC indicate that MCOB appears to be an inaccurate context for discriminating adolescent use of psychotropic medication in Sweden.
Notes
ErratumIn: Ethn Health. 2016 Dec;21(6):i PMID 26965376
PubMed ID
26884047 View in PubMed
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Appropriate assessment of ethnic differences in adolescent use of psychotropic medication: multilevel analysis of discriminatory accuracy.

https://arctichealth.org/en/permalink/ahliterature289724
Source
Ethn Health. 2016 12; 21(6):578-95
Publication Type
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Date
12-2016
Author
Anna-Karin Ivert
Shai Mulinari
Willemijn van Leeuwen
Philippe Wagner
Juan Merlo
Author Affiliation
a Faculty of Medicine, Unit for Social Epidemiology , CRC, Skåne University Hospital, Lund University , Malmö , Sweden.
Source
Ethn Health. 2016 12; 21(6):578-95
Date
12-2016
Language
English
Publication Type
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Keywords
Adolescent
Adult
Developing Countries
Drug Utilization - statistics & numerical data
Female
Humans
Male
Mothers - statistics & numerical data
Multilevel Analysis
Psychotropic Drugs - economics - therapeutic use
ROC Curve
Registries
Risk factors
Socioeconomic Factors
Sweden - epidemiology
Young Adult
Abstract
In the present study, we used a multilevel approach to investigate the role of maternal country of birth (MCOB) in predicting adolescent use of psychotropic medication in Sweden.
Using the Swedish Medical Birth Register we identified all 428,314 adolescents born between 1987 and 1990 and who were residing in Sweden in the year they turned 18. We applied multilevel logistic regression analysis with adolescents (level 1) nested within MCOBs (level 2). Measures of association (odds ratio) and measures of variance (intra-class correlation (ICC)) were calculated, as well as the discriminatory accuracy by calculating the area under the Receiver Operator Characteristic (AU-ROC) curve.
In comparison with adolescents with Swedish-born mothers, adolescents with mothers born in upper-middle, lower-middle and low-income countries were less likely to use psychotropic medication. However, the variance between MCOBs was small (ICC = 2.5 in the final model) relative to the variation within MCOBs. This was confirmed by an AU-ROC value of 0.598.
Even though we found associations between MCOB and adolescent use of psychotropic medication, the small ICC and AU-ROC indicate that MCOB appears to be an inaccurate context for discriminating adolescent use of psychotropic medication in Sweden.
Notes
ErratumIn: Ethn Health. 2016 Dec;21(6):i PMID 26965376
PubMed ID
26884047 View in PubMed
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Appropriate assessment of neighborhood effects on individual health: integrating random and fixed effects in multilevel logistic regression.

https://arctichealth.org/en/permalink/ahliterature53232
Source
Am J Epidemiol. 2005 Jan 1;161(1):81-8
Publication Type
Article
Date
Jan-1-2005
Author
Klaus Larsen
Juan Merlo
Author Affiliation
Clinical Research Unit, Hvidovre University Hospital, University of Copenhagen, DK-2650 Hvidovre, Denmark. klaus.larsen@hh.hops.dk
Source
Am J Epidemiol. 2005 Jan 1;161(1):81-8
Date
Jan-1-2005
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Hospitalization - statistics & numerical data
Humans
Logistic Models
Male
Middle Aged
Myocardial Ischemia - epidemiology
Physicians, Family - utilization
Research Support, Non-U.S. Gov't
Residence Characteristics
Urban Population
Abstract
The logistic regression model is frequently used in epidemiologic studies, yielding odds ratio or relative risk interpretations. Inspired by the theory of linear normal models, the logistic regression model has been extended to allow for correlated responses by introducing random effects. However, the model does not inherit the interpretational features of the normal model. In this paper, the authors argue that the existing measures are unsatisfactory (and some of them are even improper) when quantifying results from multilevel logistic regression analyses. The authors suggest a measure of heterogeneity, the median odds ratio, that quantifies cluster heterogeneity and facilitates a direct comparison between covariate effects and the magnitude of heterogeneity in terms of well-known odds ratios. Quantifying cluster-level covariates in a meaningful way is a challenge in multilevel logistic regression. For this purpose, the authors propose an odds ratio measure, the interval odds ratio, that takes these difficulties into account. The authors demonstrate the two measures by investigating heterogeneity between neighborhoods and effects of neighborhood-level covariates in two examples--public physician visits and ischemic heart disease hospitalizations--using 1999 data on 11,312 men aged 45-85 years in Malmo, Sweden.
Notes
Comment In: Am J Epidemiol. 2005 Sep 15;162(6):602-3; author reply 60316093285
PubMed ID
15615918 View in PubMed
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Area-aggregated assessments of perceived environmental attributes may overcome single-source bias in studies of green environments and health: results from a cross-sectional survey in southern Sweden.

https://arctichealth.org/en/permalink/ahliterature137891
Source
Environ Health. 2011;10(1):4
Publication Type
Article
Date
2011
Author
Kim de Jong
Maria Albin
Erik Skärbäck
Patrik Grahn
John Wadbro
Juan Merlo
Jonas Björk
Author Affiliation
Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.
Source
Environ Health. 2011;10(1):4
Date
2011
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Bias (epidemiology)
Cross-Sectional Studies
Environment
Female
Geographic Information Systems
Health Surveys
Humans
Male
Middle Aged
Models, Econometric
Public Health
Public Opinion
Residence Characteristics
Sweden
Young Adult
Abstract
Most studies assessing health effects of neighborhood characteristics either use self-reports or objective assessments of the environment, the latter often based on Geographical Information Systems (GIS). While objective measures require detailed landscape data, self-assessments may yield confounded results. In this study we demonstrate how self-assessments of green neighborhood environments aggregated to narrow area units may serve as an appealing compromise between objective measures and individual self-assessments.
The study uses cross-sectional data (N = 24,847) from a public health survey conducted in the county of Scania, southern Sweden, in 2008 and validates the Scania Green Score (SGS), a new index comprising five self-reported green neighborhood qualities (Culture, Lush, Serene, Spacious and Wild). The same qualities were also assessed objectively using landscape data and GIS. A multilevel (ecometric) model was used to aggregate individual self-reports to assessments of perceived green environmental attributes for areas of 1,000 square meters. We assessed convergent and concurrent validity for self-assessments of the five items separately and for the sum score, individually and area-aggregated.
Correlations between the index scores based on self-assessments and the corresponding objective assessments were clearly present, indicating convergent validity, but the agreement was low. The correlation was even more evident for the area-aggregated SGS. All three scores (individual SGS, area-aggregated SGS and GIS index score) were associated with neighborhood satisfaction, indicating concurrent validity. However, while individual SGS was associated with vitality, this association was not present for aggregated SGS and the GIS-index score, suggesting confounding (single-source bias) when individual SGS was used.
Perceived and objectively assessed qualities of the green neighborhood environment correlate but do not agree. An index score based on self-reports but aggregated to narrow area units can be a valid approach to assess perceived green neighborhood qualities in settings where objective assessments are not possible or feasible.
Notes
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PubMed ID
21235826 View in PubMed
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