Association between area-level education and the co-occurrence of behavior-related risk factors: a multilevel analysis

Boing, Antonio Fernando; Subramanian, SV; Boing, Alexandra Crispim

doi:10.1590/1980-549720190052

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ORIGINAL ARTICLE • Rev. bras. epidemiol. 22 • 2019 • https://doi.org/10.1590/1980-549720190052 copy

Association between area-level education and the co-occurrence of behavior-related risk factors: a multilevel analysis

Associação entre educação da vizinhança e a coocorrência de fatores de risco comportamentais: uma análise multinível

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT:

Introduction:

This study aimed to investigate the association of four different risk factors for chronic diseases and accumulation of these health behaviors with area-level education, regardless of individual-level characteristics in Brazil.

Methods:

A population-based cross-sectional study was carried out in Southern Brazil including 1,720 adults in 2009/2010. The simultaneous occurrence of tobacco smoking, abusive drinking, unhealthy eating habits, and physical inactivity was investigated. Using multilevel models, we tested whether area-level education was associated with each risk factor and with the co-occurrence of them after controlling sociodemographic individual-level variables.

Results:

We observed a between-group variance of 7.79, 7.11, 6.84 and 1.08% for physical inactivity, problematic use of alcohol, unhealthy eating habits, and smoking, respectively. The between-group variance for the combination of four behaviors was 14.2%. Area-level education explained a significant proportion of the variance observed in physical inactivity and unhealthy eating habits. Residents of low educational level neighborhoods showed a 2.40 (95%CI 1.58 - 3.66) times higher chance of unhealthy eating and 1.78 (95%CI 1.19 - 2.67) times higher chance of physical inactivity. The likelihood of individuals with two or three/four risk factors was simultaneously higher among residents of low educational level neighborhoods.

Conclusion:

Public policies should consider the area-level characteristics, including education to control risk factors for chronic diseases.

Keywords:
Chronic disease; Risk factors; Education; Socioeconomic factors; Multilevel analysis

Variables (n = 1,720)	Sample n (%)	Smoking % (95%CI)	Problematic use of alcohol % (95%CI)	Unhealthy eating % (95%CI)	Physical inactivity % (95%CI)
Age (years)
20-29	540 (32.7)	18.0 (14.6 - 21.4)	26.4 (20.3 - 32.4)	89.2 (86.2 - 92.3)	45.9 (40.5 - 51.2)
30-39	392 (22.9)	15.7 (11.7 - 19.8)	15.6 (11.3 - 19.9)	82.5 (78.0 - 87.0)	56.4 (50.7 - 62.0)
40-49	438 (25.0)	18.6 (15.0 - 22.2)	15.5 (11.9 - 19.1)	75.1 (70.1 - 80.0)	55.5 (49.6 - 61.4)
50-59	350 (19.4)	26.1 (21.8 - 30.4)	12.6 (8.8 - 16.3)	73.9 (68.3 - 79.6)	58.3 (50.4 - 66.1)
Gender
Male	761 (44.5)	21.3 (18.2 - 24.4)	29.6 (25.3 - 33.9)	86.5 (83.2 - 89.9)	46.3 (40.7 - 51.8)
Female	959 (55.5)	17.5 (14.8 - 20.2)	9.6 (6.9 - 12.3)	76.9 (73.6 - 80.1)	58.5 (53.8 - 63.3)
Skin color
White	1,444 (85.7)	18.4 (16.2 - 20.5)	17.3 (14.8 - 19.8)	80.6 (77.7 - 83.6)	51.9 (43.1 - 52.8)
Lighter skinned Black	147 (9.1)	24.9 (17.6 - 32.2)	28.4 (19.6 - 37.2)	87.0 (80.8 - 93.2)	55.9 (47.7 - 64.2)
Dark skinned Black	87 (5.2)	20.8 (12.6 - 29.1)	19.6 (9.2 - 30.1)	83.2 (73.9 - 92.4)	68.3 (60.2 - 76.4)
Individual educational level (years of successful studies)
≤ 4	158 (8.7)	27.0 (19.2 - 34.8)	14.3 (7.0 - 21.6)	88.1 (82.4 - 93.8)	82.6 (75.8 - 89.3)
5-8	253 (14.0)	25.9 (17.9 - 33.9)	14.6 (8.7 - 20.5)	87.6 (83.4 - 91.8)	68.8 (62.0 - 75.7)
9-11	568 (33.4)	21.4 (17.7 - 25.2)	20.5 (15.8 - 25.1)	84.9 (82.0 - 87.7)	57.3 (52.1 - 62.5)
≥ 12	737 (43.9)	13.9 (11.4 - 16.5)	19.2 (15.3 - 23.1)	74.9 (70.1 - 79.8)	38.7 (35.1 - 32.4)
Equalized household income (tertile)
Poorest	574 (33.1)	23.6 (20.3 - 27.2)	16.8 (13.5 - 20.8)	86.5 (83.2 - 89.2)	65.3 (59.0 - 71.2)
Intermediate	573 (32.6)	21.8 (17.7 - 26.5)	20.2 (15.8 - 25.4)	84.3 (81.0 - 87.1)	53.9 (49.2 - 58.6)
Richest	572 (34.3)	12.6 (9.9 - 16.1)	18.6 (14.8 - 23.2)	73.2 (67.6 - 78.1)	40.7 (36.1 - 45.5)
Area-level education (years of successful studies; 63 census tracts)
≥ 12	427 (26.9)	18.6 (14.6 - 23.5)	16.3 (12.1 - 21.7)	71.4 (64.5 - 77.4)	43.4 (39.0 - 48.0)
9-11	741 (42.2)	17.0 (14.4 - 20.1)	21.2 (16.1 - 27.6)	81.5 (77.8 - 84.7)	50.2 (44.3 - 56.2)
≤ 8	552 (30.9)	22.7 (19.2 - 26.7)	16.7 (13.0 - 21.6)	89.3 (86.0 - 91.9)	65.6 (57.8 - 72.5)
Total	1720 (100.0)	19.2 (17.1 - 21.3)	18.5 (15.5 - 21.4)	81.2 (78.3 - 84.1)	53.1 (48.8 - 57.4)

Risk factors	Smoking	Drinking	Unhealthy diet	Physical inactivity	Prevalence (95%CI)
0	-	-	-	-	8.2 (6.9 - 9.5)
1	-	-	-	+	1.3 (0.8 - 1.8)
	-	-	+	-	1.2 (0.7 - 1.7)
	-	+	-	-	24.0 (22.0 - 26.0)
	+	-	-	-	5.7 (4.6 - 6.8)
2	+	+	-	-	30.6 (28.4 - 32.8)
	+	-	+	-	0.5 (0.1 - 0.7)
	+	-	-	+	6.2 (5.1 - 7.3)
	-	+	+	-	1.3 (0.8 - 1.8)
	-	+	-	+	3.2 (2.3 - 4.0)
	-	-	+	+	0.2 (0.0 - 0.4)
3	+	+	+	-	4.0 (3.0 - 4.9)
	+	+	-	+	7.2 (5.9 - 8.4)
	+	-	+	+	0.4 (0.1 - 0.6)
	-	+	+	+	2.6 (1.9 - 3.3)
4	+	+	+	+	3.4 (2.6 - 4.3)

Area-level education (mean years of schooling)	Logistic regression			Variance estimates
Area-level education (mean years of schooling)	Crude model OR (95%CI)	Model 1 OR (95%CI)	Model 2 OR (95%CI)	VPC (%) Empty model	VPC (%)*	VPC (%)**
Smoking
≥ 12	Reference	Reference	Reference	1.08	0.54	0.00
9-11	0.89 (0.65 - 1.23)	0.89 (0.65 - 1.22)	0.66 (0.46 - 0.92)
≤ 8	1.22 (0.86 - 1.73)	1.18 (0.83 - 1.69)	0.70 (0.47 - 1.03)
AIC	11,837.7	11,366.1	10,915.7
Problematic use of alcohol
≥ 12	Reference	Reference	Reference	7.11	6.61	3.80
9-11	1.25 (0.80 - 1.96)	1.08 (0.69 - 1.68)	1.18 (0.73 - 1.90)
≤ 8	0.97 (0.63 - 1.47)	0.86 (0.56 - 1.33)	0.97 (0.61 - 1.55)
AIC	11,385.2	10,149.7	9,896.7
Unhealthy eating
≥ 12	Reference	Reference	Reference	6.84	1.73	0.84
9-11	1.71 (1.22 - 2.41)	1.58 (1.09 - 2.29)	1.34 (0.95 - 1.89)
≤ 8	3.25 (2.17 - 4.87)	3.17 (2.06 - 4.88)	2.40 (1.58 - 3.66)
AIC	11,293.3	10,469.2	10,095.1
Physical inactivity
≥ 12	Reference	Reference	Reference	7.79	4.58	5.19
9-11	1.29 (0.96 - 1.74)	1.34 (0.98 - 1.84)	1.07 (0.76 - 1.51)
≤ 8	2.41 (1.65 - 3.50)	2.47 (1.67 - 3.64)	1.78 (1.19 - 2.67)
AIC	16,210.0	15,542.4	14,674.5

Number of risk factors	Area-level education (mean years of schooling)			VPC (%)	AIC
Number of risk factors	≥ 12 years OR (95%CI)	9-11 years OR (95%CI)	≤ 8 years OR (95%CI)	VPC (%)	AIC
Crude analysis
1 risk factor	Reference	1.40 (0.81 - 2.40)	2.69 (1.32 - 5.46)	14.2	29,237.1
2 risk factors	Reference	1.86 (1.06 - 3.24)	5.48 (2.83 - 10.6)
3 to 4 risk factors	Reference	1.87 (1.01 - 3.44)	5.90 (2.92 - 11.89)
Model 1
1 risk factor	Reference	1.31 (0.76 - 2.28)	2.68 (1.33 - 5.40)	14.1	27,959.6
2 risk factors	Reference	1.75 (0.99 - 3.10)	5.53 (2.88 - 10.62)
3 to 4 risk factors	Reference	1.65 (0.87 - 3.11)	5.42 (2.68 - 10.97)
Model 2
1 risk factor	Reference	1.30 (0.74 - 2.28)	2.63 (1.28 - 5.39)	13.8	26,741.2
2 risk factors	Reference	1.43 (0.82 - 2.48)	4.03 (2.14 - 7.60)
3 to 4 risk factors	Reference	1.08 (0.56 - 2.07)	2.61 (1.22 - 5.62)

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[1] Corresponding author: Antonio Fernando Boing. Department of Public Health, Universidade Federal de Santa Catarina. Campus Universitário Trindade, CEP: 88040-900, Florianópolis, SC, Brazil. E-mail: antonio.boing@ufsc.br