Social Science & Medicine 54 (2002) 65–77

Metropolitan area income inequality and self-rated health}

a multi-level study
Tony A. Blakely*, Kimberly Lochner, Ichiro Kawachi
Department of Health and Social Behavior, Harvard Center for Society and Health, Harvard School of Public Health,
Harvard University, Boston, USA

Abstract

We examined the association of income inequality measured at the metropolitan area (MA) and county levels with
individual self-rated health. Individual-level data were drawn from 259,762 respondents to the March Current
Population Survey in 1996 and 1998. Income inequality and average income were calculated from 1990 census data, the
former using Gini coefficients. Multi-level logistic regression models were used. Controlling for sex, age, race, and
individual-level household income, respondents living in high, medium–high, and medium–low income inequality MAs
had odds ratios of fair/poor self-rated health of 1.20 (95% confidence interval 1.04–1.38), 1.07 (0.95–1.21), and 1.02
(0.91–1.15), respectively, compared to people living in the MAs with the lowest income inequality. However, we found
only a small association of MA-level income inequality with fair/poor health when controlling further for average MA
household income: odds ratios were 1.10 (0.95–1.28), 1.01 (0.89–1.14), and 1.00 (0.89–1.12), respectively. Likewise, we
found only a small association of county-level income inequality with self-rated health}although only 40.7% of the
sample had an identified county on CPS data. Regarding the association of state-level income inequality with fair/poor
health, we found the association to be considerably stronger among non-metropolitan (i.e. rural) compared to
metropolitan residents. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Income inequality; Socio-economic factors; Confounding factors; Multi-level studies; Self-rated health; Health status

Introduction association of state-level income inequality, using a

Within the US, an association of income inequality
with mortality rates has been found at the state level in
ecological studies (Kaplan, Pamuk, Lynch, Cohen, &
Balfour, 1996; Kennedy, Kawachi, & Prothrow-Stith,
1996). Using a multi-level study design, Kennedy,
Kawachi, Glass, and Prothrow-Stith (1998) found that
state-level income inequality was also associated with
poor self-rated health, controlling for individual-level
demographic factors and income. Daly, Duncan, Ka-
plan, and Lynch (1998) found equivocal evidence for an
*Corresponding author. Department of Public Health,
Wellington School of Medicine, University of Otago, P.O.
Box 7343, Wellington, New Zealand. Tel.: +64-4-385-5999;
fax: +64-4-389-5319.
E-mail address: tblakely@wnmeds.ac.nz (T.A. Blakely).
multi-level study design and data from the Panel Study
of Income Dynamics. Only among middle income
earners aged 25–64 years was there a statistically
significant association of state-level income inequality
with mortality. However, there were some limitations of
the Panel Study of Income Dynamics for testing the
income inequality hypothesis: follow-up of individuals
was only 55% complete; and although the number of
deaths seem relatively large (716), when spread over
states and demographic strata they may have not
provided sufficient statistical power. Lochner, Pamuk,
Makuc, Kennedy, and Kawachi (2001) conducted a
multi-level study of the association of state-level
income inequality with mortality using the National
Health Interview Survey respondents for 1987–94
followed up for mortality to 1995. They found an
approximately 10% (but statistically significant) lower
mortality risk in the 10 lowest income inequality states

0277-9536/02/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 0 0 7 - 7
66 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
compared to the remaining 38 states. The effect of
income inequality appeared to be strongest among
individuals with near-poor incomes (i.e. 100–199% of
the poverty line).
At levels of aggregation lower than the state
(metropolitan areas, counties, and census tracts) the
relationship of income inequality with health is less
secure. Lynch et al. (1998) found that mortality rates for
metropolitan areas increased with increasing income
inequality in an ecological study, independent of per
capita income. Soobader and LeClere (1999) also found
that both county-level and census tract-level income
inequality were associated with poor self-rated health,
controlling for individual-level variables in a multi-
level study. By contrast, Fiscella and Franks (1997)
reported no association of county-level income inequal-
ity with mortality after controlling for individual-level
income in a multi-level study. However, the income data
used in that study were probably based on too few
individuals to accurately calculate county-level income
inequality.
It is not unreasonable to expect the association of
income inequality with health to vary by unit of analysis.
Wilkinson (1997, p. 1505) asserts: ‘‘Inequality is
important in areas large enough to contain the salient
social heterogeneity, but in small residential neighbor-
hoods composed largely of one social stratum, mortality
is related to the average income: income differences
within such neighborhoods matter much less because the
comparisons between social strata are lost. At the other
end of the scale, between whole societies average income
does not matter, because the social comparisons are
within them rather than between them. Income distribu-
tion within societies continues to matter because it
measures the extent of relative deprivation between
social strata within the society.’’ Soobader and LeClere
(1999) provide empirical evidence that supports this
assertion. They found that after including average
income, the income inequality effect at the census tract
level was reduced more than the income inequality effect
at the county level.
Multi-level studies have the potential to control for
cross-level confounding of an association of a contextual
exposure (e.g. income inequality) with an individual-
level outcome (e.g. self-rated health) that may occur due
to omission of individual-level covariates (e.g. personal
income) that are correlated with the contextual exposure
(Blakely & Woodward, 2000; Diez-Roux, 1998). The
statistical techniques for analyzing multi-level data also
correct for intra-class correlation that would lead to
erroneously tight confidence intervals (Bryk & Raden-
bush, 1992; Burton, Gurrin, & Sly, 1998; Goldstein,
1995; Hox, 1995). In this paper, we used multi-level
methods to examine the effect of income inequality
measured at three levels of geographic aggregation in the
US}state, metropolitan area (MA), and county levels
}on individual self-rated health. The objectives of the
present study were to determine:
1. the association of MA-level income inequality with
fair/poor self-rated health;
1.1. controlling for individual-level demographics
and household income;
1.2. controlling for individual-level demographics
and household income, and MA-level average
household income;
2. whether the association of MA-level income inequal-
ity with fair/poor self-rated health was modified by
demographic factors;
3. the association of county-level income inequality
with fair/poor self-rated health, controlling for
individual-level demographics, household income,
and county-level average household income.
In meeting these objectives, we conducted analyses on
the 1996 and 1998 current population survey data. In an
unpublished paper, Mellor and Milyo (1999) have used
this data set (but for 1995–97 data) for income inequal-
ity analyses. They concluded, essentially, that there was
no association of income inequality measured at the
state or MA levels with fair/poor self-rated health.
However, we believe their analyses were flawed in many
respects. First, they used the CPS data itself to calculate
average incomes and inequality measures. Though this
procedure may be robust at the state level, the precision
of the inequality measures at the MA level is probably
low even though they excluded MAs with less than 50
observations. For MA- and county-level analyses, we
believe that census data should be used to increase
precision. (The use of 1990 census data also has the
advantage of allowing a time-lag between the measure-
ment of income inequality and self-rated health; Blakely,
Kennedy, Glass, & Kawachi, 2000.) Second, Mellor and
Milyo included ‘‘fixed year and fixed state effects to
control for unobserved characteristics that may be
spuriously correlated with the state [MA] level income
aggregates’’. While it is desirable to control for
unobserved confounding, the method used by Mellor
and Milyo is equivalent to measuring the association of
change in income inequality between adjacent years
(1995, 1996, and 1997) with any change in self-rated
health. It is highly unlikely that changes in income
inequality within one region over three years will be
substantial enough to detect any changes in self-rated
health. (We have reported elsewhere that there is more
meaningful variation in income inequality over 15 years;
Blakely et al., 2000.) There will simply be too much
‘noise’ in the fixed effects analyses of Mellor and Milyo
to pick up any change in self-rated health. Other
problems with the analyses of Mellor and Milyo include
the non-allowance for time-lags, double counting the
same individuals (each recruited household stays in the
 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
CPS for two years), and uncritically including indivi-
dual-level variables in their models that may have been
intermediaries rather than confounders (e.g. education;
Kaplan et al., 1996).
Methods
Independent variables
Individual level
The Current Population Survey (CPS) is a large
monthly survey of individuals in all 50 US states,
undertaken primarily to determine labor force status.
There are supplements to the CPS that vary by
month}we used March CPS data as the March
supplement collects detailed income data. Recruitment
to the CPS is by households, with information collected
for each individual in the household for two consecutive
years. We only used data for 1996 and 1998 to avoid
double counting, as all CPS respondents for 1997 would
already be included in either the 1996 or 1998 samples.
(Data prior to 1996 were not used, as the health question
used as the outcome in this study was only introduced in
1995.)
Individual-level socio-economic factors used as cov-
ariates in this study were sex, age, race (black, white,
other), and equivalized household income. Age was
treated as a categorical variable: 0–14, 15–24, 25–34, 35–
44, 45–54, 65–74, and 75+ years. Household income
was equivalized for the number of people in the
household by using an equivalence parameter of 0.5;
i.e. the total household income was divided by the
square root of the number of people in the household.
For most analyses, the household equivalized income
was treated as a categorical variable: 5$5000, $5000–
9999, $10,000–14,999, $15,000–19,999, $20,000–24,999,
$25,000–29,999, $30,000–39,999, $40,000–49,999, and
$50,000+.
State, MA, and county levels
Measures of income inequality and average household
income were calculated from 1990 census data (1990 US
Census Summary Tape Files STF3C and STF3A) for
three geographic levels: states, metropolitan areas, and
counties. At the state level we excluded Washington
DC, leaving 50 US states. Metropolitan areas are
established by the U.S. Office of Management and
Budget (http://www.census.gov/population/www/esti-
mates/metroarea.html) and consist of a central city (or
cities), together with adjacent communities that are
socially and economically integrated with that core.
Metropolitan areas must have at least one city with a
population of 50,000 or more, or a total metropolitan
population of at least 100,000 (75,000 in New England).
Metropolitan areas that have a population of one
67
million or more may be subdivided into ‘primary
metropolitan statistical areas’ (PMSA) if population
and commuting criteria are met. If no PMSAs are
recognized, the entire area is designated as a
‘metropolitan statistical area’ (MSA). In this paper, we
use PMSAs and MSAs as the units of analysis, and refer
to them collectively as MAs. Counties are the primary
administrative division of states. There are over 3000 US
counties.
We used the Gini coefficient as the measure of income
inequality. The Gini coefficient is highly correlated with
other measures of income inequality (Kawachi &
Kennedy, 1997), is a measure of inequality right across
the income range, and is the most commonly used
measure of income inequality. The Gini ranges theore-
tically from zero (absolute equality) to 1.0 (absolute
inequality in the distribution of income); see Kawachi
and Kennedy (1997), and Ryscavage (1999) for details
on calculation. Census data of 1990 provides annual
household income data for 25 income intervals. Counts
of the number of households that fall into each income
bin along with the total aggregate income and the
average household income were obtained for each
county, MA, and state. The Gini was calculated using
the income distribution software developed by Ed
Welniak (1988, personal communication) at the US
Census Bureau. The census household income is available
for 25 income categories, with the top category being a
(1989) household income of greater than $150,000.
Categorical variables for state-, MA-, and county-
level income inequality and average household income
were used in analyses to avoid assumptions of linearity.
The mean and the mean  1 SD of the Gini coefficient
were used to assign areas to one of four categories of
income inequality: high (i.e. areas with Gini greater than
[mean+1 SD]), medium–high (i.e. areas with Gini
between [mean] and [mean+1 SD), medium–low (i.e.
areas with Gini between [mean 1 SD] and [mean]) and
low (i.e. areas with Gini less than [mean 1 SD]).
Average household income was categorized as quartiles
for MAs and counties, and as quintiles for states (50
states divided conveniently into five quintiles). American
Chamber of Commerce Research Association (ACCRA,
1997) cost of living index data for the third quarter of
1996 was used in sensitivity analyses of the association
of MA-level average income with self-rated health.
The above calculated average incomes and Ginis for
each state, MA, and county were then linked to the CPS
data}both the census and CPS data used geographic
codes based on the Office of Management and Budget’s
June 30, 1993 definitions (U.S. Dept. of Commerce, 1998).
Dependent variable
Since 1995, the March supplement of the CPS has
collected information on self-rated health in five
68 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
categories (excellent, very good, good, fair, and poor) by
direct questioning of each adult in the household and by
parental proxy for children. We dichotomized this self-
rated health variable as poor and fair versus the three
other responses, and used this variable as the dependent
variable in all analyses. This choice of dichotomy for
self-rated health is the most commonly used in health
research (Kawachi, Kennedy, & Glass, 1999; Marmot
et al., 1998; Power, Hertzman, Matthews, & Manor,
1997; Power, Matthews, & Manor, 1996; Soobader &
LeClere, 1999). A review of 27 studies has shown that
this simple measure of self-rated health has strong
predictive validity for mortality, independent of other
physiological, behavioral, and psychosocial factors
(Idler & Kasl, 1995).
Data analysis
Multi-level logistic regression models were conducted
using Proc Glimmix in SAS (SAS Institute Inc., 1998).
Three sets of multi-level analyses were conducted. First,
two-level models were fitted for MA- and individual-
level data, to investigate the independent effect of MA-
level income inequality on self-rated health. A random
intercept was included at the MA level in addition to the
usual random error term at the individual level, to allow
for intra-class correlation of observations within MAs
(Burton et al., 1998; Goldstein, 1995). Put another way,
a ‘random intercept’ model requires that the regression
coefficients for the individual-level variables are the
same across all MAs (fixed effects), but the intercept is
allowed to vary randomly between MAs (random
effect). We did not extend the analyses to allow
randomly varying slopes (random regression coefficients
for individual-level variables) between MAs. Sex, race,
age, and household income were treated as confounders
at the individual level, while average household income
was treated as a confounder at the MA level. In a second
set of analyses, two-level models were fitted for county-
and individual-level data. Finally, two-level models were
fitted with a state-level random intercept to test whether
the association of state-level income inequality with self-
rated health varied by metropolitan and non-metropo-
litan status.
We conducted multi-level logistic regression analyses
both with and without the CPS weights. This weight is a
product of several adjustments (e.g. selection probability
and non-interview adjustment) (U.S. Dept. of Com-
merce, 1998), and allows accurate point estimates of
various population characteristics such as the unem-
ployment rate. Historically, the weights were calculated
to ensure accuracy of point estimates at the national and
regional level, but in the 1990s has been altered to
improve accuracy at the state level (U.S. Dept. of
Commerce, 1998, p. 14, Appendix G). Use of the CPS
final weights in our analyses should result in greater
accuracy for state-level coefficients, probably greater
accuracy for MA-level coefficients, but it is uncertain
whether the accuracy of county-level coefficients would
be improved. Analyses with and without the weights
were not substantially different. Unless stated otherwise,
we report only the weighted analyses for state and MA
levels and unweighted analyses for the county-level
analyses.
Finally, the CPS is a large complex survey, with
clustered sampling methods (U.S. Dept. of Commerce,
1998). Whilst we were able to use weights in our
analyses, we were unable to use full design-based
analyses as the sampling unit for each individual is not
disclosed on the CPS data. Moreover, we had a
theoretical priority to consider individuals clustered
within units of particular interest}state, MAs, and
counties}and therefore included random effects at these
levels of interest. Lemeshow et al. (1998) has shown that
results from simple regression modeling of complex-
design survey data are likely to be little different from
more thorough analyses that do allow for the complex
design, particularly if the survey weights are used.
Results
There was a total of 259,762 respondents in the March
CPS sample for 1996 and 1998, excluding Washington
DC. Of these respondents, 189,431 had an identified MA
(72.9%; n=242 MAs) and 105,645 had an identified
county (40.7%; n=216 counties). Ten of the 242 MAs
had no match on the 1990 census data (STF3C): five
were coded as counties on census data, and five were
listed in census data dictionaries as MAs but did not
have disclosed data on the STF3C file. Thus, the final
CPS sample with MA-level variables was 185,479
(71.4% of the full CPS sample, or 93.0% of the CPS
sample living in a metropolitan area; n=232 MAs).
MA-level analyses
The average number of households in the 232 MAs
was 279,809 (191,113 for the 180 MSAs and 586,833 for
the 52 PMSAs). The mean Gini coefficient was 0.417
(SD 0.025), and using the mean and mean  SD as cut-
points, 34, 71, 95, and 32 MAs were assigned to high
(Gini >0.442), medium–high (Gini 0.417–0.442), med-
ium–low (Gini 0.392–0.417), and low (Gini 50.392)
categories of income inequality. The average household
income by MAs was distributed with mean $37,713 (SD
$7890) and median $36,627 (inter-quartile range
$32,725–40,404). The Pearson correlation coefficient
between the Gini and mean income among the 232
MAs was 0.29 (p50.0001), but increased to 0.41
when the outlier Stamford CT (average household
income $96,804 and Gini 0.467) was discarded.
 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77 69

The distribution by sex, age, race, and equivalized
household income of the 185,479 individuals in the CPS
sample with an identified MA Gini coefficient is shown
in Table 1. Also shown is the crude (i.e. unweighted)
percentage of respondents in each demographic category
reporting fair/poor self-rated health. The final column of
Table 1 shows the odds ratios of fair/poor health by
category of sex, age, race, income, and MA-level income
inequality. These odds ratios are from a logistic
regression model that included all the variables shown,
fitted a random intercept at the MA level, and used the
CPS weights. As expected, strong associations were
found between age and income and fair/poor self-rated
health at the individual level, and a moderately strong
association with race. A dose response pattern was
present for the association of MA-level income inequal-
ity with fair/poor self-rated health. Respondents living
in the MAs with the highest income inequality had an
odds ratio of 1.20 (95% confidence interval 1.04–1.38)
for fair/poor self-rated health, compared to people living
in the MAs with the lowest income inequality. Respon-
dents living in MAs with medium–high and medium–
low income inequality had odds ratios of 1.07 (0.95–
1.21) and 1.02 (0.91–1.15), respectively.
We repeated the analysis in Table 1 with adjustment
for MA level confounding by average household income

Table 1
March CPS (1996 and 1998) sample with MA-level Gini assigned (n=185,479): distribution by demographic factors, equivalized
household income, and MA-level category of income inequality, and the associated odds ratios of fair/poor health for all variables
modeled simultaneouslya

Variable Number Fair/poor health Odds ratios

(n=185,479) (non-weighted) (%) (95% CI)

Sex
Maleb 88,835 9.4 1.00
Female 96,644 12.0 1.02 (0.99–1.06)

Age
0–14 43,588 2.7 0.39 (0.36–0.43)
15–24 24,598 3.4 0.54 (0.49–0.59)
25–34b 28,349 5.4 1.00
35–44 30,277 8.3 1.78 (1.66–1.91)
45–54 22,819 13.3 3.61 (3.37–3.87)
55–64 14,667 21.4 5.75 (5.36–6.17)
65–74 12,035 31.3 7.90 (7.37–8.47)
75+ 9146 42.9 11.5 (10.7–12.4)

Race
Whiteb 155,540 10.3 1.00
Black 20,653 14.9 1.41 (1.35–1.48)
Other 9286 9.5 1.15 (1.06–1.25)

Equivalized household income

5$5000 11,399 16.7 7.63 (7.01–8.31)
$5000–9999 19,741 22.1 7.32 (6.80–7.88)
$10,000–14,999 21,986 16.7 4.43 (4.12–4.77)
$15,000–19,999 21,463 12.8 3.31 (3.07–3.56)
$20,000–24,999 20,351 10.0 2.66 (2.46–2.87)
$25,000–29,999 18,023 7.6 2.04 (1.88–2.22)
$30,000–39,999 27,595 6.1 1.58 (1.46–1.71)
$40,000–49,999 16,787 5.2 1.21 (1.11–1.33)
5$50,000b 28,134 4.7 1.00

Income inequality (MAs)

High (n=34) 36,672 12.7 1.20 (1.04–1.38)
Medium–high (n=71) 66,259 11.1 1.07 (0.95–1.21)
Medium–low (n=95) 60,732 9.9 1.02 (0.91–1.15)
Lowb (n=32) 21,816 8.8 1.00
a
The odds ratios are from a weighted logistic regression model with a random intercept at the MA level.
b
Reference category.
70 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
Table 2
Odds ratios of fair/poor health by MA-level income inequality and average household income, for CPS sample with MA Gini assigned
(n=185,479)a
MA-level variable Gini only
Income inequality (MAs)
High (n=34) 1.20 (1.04–1.38)
Medium–high (n=71) 1.07 (0.95–1.21)
Medium–low (n=95) 1.02 (0.91–1.15)
Lowb (n=32) 1.00
Average household income
(quartiles of n=58 MAs)
Low
Medium–low
Medium–high
Highb
a
The odds ratios are from a weighted logistic regression model for fair/poor self-rated health that included the variables in each
column, and individual-level sex, age, race, and equivalized household income. A random intercept was specified at the MA level in
each model.
b
Reference category.
(Table 2). The first column in Table 2 simply reproduces
the odds ratios from Table 1. The second column
demonstrates the effect of controlling for confounding
by MA-level average household income, where average
income was categorized into quartiles. Compared to the
model in the first column, the odds ratios for the highest
quartile of MA-level income inequality is halved (1.10),
and reduced to the null for the middle two quartiles.
Further models (not presented) with a log-transformed
continuous variable of MA average household income
(rather than categorical quartiles) did not substantially
alter the effect sizes for MA-level income inequality
shown in the second column in Table 2.
The model represented in the final column of Table 2
drops the individual-level household income variable.
The association of income inequality with fair/poor self-
rated health increases notably, e.g. respondents living in
the highest income inequality MAs had an odds ratio of
1.26 (1.06–1.49) for fair/poor self-rated health compared
to respondents living in the lowest income inequality
MAs. A model using a log-transformed continuous
variable of MA average household income (rather than
categorical quartiles), but otherwise the same as in the
final column of Table 2, resulted in a modest reduction
in the income inequality odds ratios: 1.24, 1.07, and
0.99.
Cross-level effect modification
To test for any cross-level effect modification of MA-
level income inequality with sex, age group, and race, we
ran models stratified by these demographic variables.
Within each demographic strata (males, females; 0–14,
15–24, 25–44, 45–60, and 65+ year olds; black, white)
Gini and average income Without individual-level income
1.10 (0.95–1.28) 1.26 (1.06–1.49)
1.01 (0.89–1.14) 1.10 (0.95–1.26)
1.00 (0.89–1.12) 1.04 (0.91–1.19)
1.00 1.00
1.18 (1.05–1.32) 1.43 (1.26–1.62)
1.16 (1.04–1.28) 1.26 (1.12–1.41)
1.06 (0.96–1.17) 1.12 (1.01–1.25)
1.00 1.00
the model was essentially that in the second column of
Table 2. We found no significant effect modification by
sex or race. For individuals older than 25 years (25–44,
45–64, and 65+ strata) there was little apparent
association of MA-level income inequality with health.
Among 0–14 year olds (n=43,588), the odds ratios of
fair/poor self-rated health were elevated for the higher
categories of MA-level income inequality, but with wide
95% confidence intervals: 1.45 (0.88–2.37), 1.02 (0.67–
1.57), and 1.22 (0.82–1.81) for high, medium–high, and
medium–low MA income inequality, respectively. Con-
versely, among 15–24 year olds (n=24,598), there was
an apparent protective association for people living in
high income inequality MAs (odds ratio 0.74), but the
95% confidence intervals were, again, wide (0.49–1.14).
Sensitivity analyses: MA size and cost of living index
(COLI)
The model represented in the second column of Table
2 was run separately for the MAs with greater than a
million households (n=51) and for the MAs with less
than a million households (n=181). Among the larger
MAs there was no association of income inequality with
fair/poor self-rated health, with odds ratios 1.00, 0.97,
and 0.98 for the high, medium–high, and medium–low
income inequality MAs compared to the low income
inequality MAs, respectively. Among the smaller MAs
the odds ratios were 1.14, 1.02, and 1.00, respectively,
but all 95% confidence intervals include 1.00 (e.g. 0.94–
1.38 for the 1.14 odds ratio).
American Chamber of Commerce Research Associa-
tion (ACCRA) cost of living index (COLI) data was
obtained for 151 of the 232 MAs (65.1%). The baseline
 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
model including the Gini and average MA income
variables (without adjustment for the COLI) is shown in
the first column of Table 3. The odds ratios from this
model are similar to those for the same model in Table 2
(column 2), suggesting that the subset of 129,684 CPS
respondents living in MAs with COLI data are
representative of the 185,479 respondents living in the
242 MAs shown in Tables 1 and 2. The reason for
adjusting for the COLI was to assess whether the
apparent contextual association of MA average income
might be, in part at least, due to varying purchasing
power across MAs in the US. We ran two models to
explore this possibility. First, we only adjusted the
individual-level household income data by the COLI.
That is, we attempted to better specify the individual-
level income so as to be comparable across MAs, but left
the average household income unadjusted so that it still
reflected the actual MA level (i.e. contextual or
ecological) economic prosperity. Doing so, the income
inequality odds ratios were unchanged but the average
household income odds ratios increased further (column
2 of Table 3). For example, people living in the lowest
average income MAs now had a 31% greater odds of
fair/poor self-rated health than people living in the
richest MAs did. Second, we additionally adjusted the
MA-level average income by the COLI (column 3 of
Table 3)}the association of income inequality with fair/
poor self-rated health strengthened (although all 95%
confidence intervals still included 1.00) and the associa-
tion of average income with fair/poor self-rated health
weakened. The odds ratios for income inequality in this
third model were essentially the same as those when
average income was excluded from model (results not
Table 3
Odds ratios of fair/poor health by MA-level income inequality and average household income}sensitivity analyses of the effect of
using cost of living index (COLI) adjusted income data for 129,684 CPS respondents living in 151 MAsa
MA-level variable No COLI adjustment
Income inequality
High 1.10 (0.90–1.34)
Medium–high 1.06 (0.89–1.26)
Medium–low 1.02 (0.87–1.20)
Lowb 1.00
Average household income
Low 1.17 (1.01–1.35)
Medium–low 1.12 (0.98–1.27)
Medium–high 1.04 (0.91–1.18)
Highb 1.00
a
The odds ratios are from a weighted logistic regression model for fair/poor self-rated health that included the variables in each
column, and individual-level sex, age, race, and equivalized household income. A random intercept was specified at the MA level in
each model.
b
Reference category.
71
shown). That is, controlling for a COLI adjusted
average MA income did not alter (i.e. was not
confounding) the association of income inequality with
self-rated health, whereas adjusting for the non-COLI
adjusted average income did reduce the income inequal-
ity association.
County-level analyses
The average number of households for the 216
counties was 173,120}considerably larger than the
29,288 average number of households for all 3141
counties at the 1990 census. Thus, because of sampling
characteristics of the CPS and the non-disclosure of
county for many CPS respondents, our county-level
analyses are confined to counties with larger than
average population size.
The sex, age, race, and household income distribution
for the county sample (n=105,645) were similar to the
larger MA sample in Table 1. Table 4 shows odds ratios
of fair/poor self-rated health for county-level income
inequality. Controlling for county-level average house-
hold income and county population size reduced the
association of county-level income inequality with self-
rated health for both unweighted and weighted analyses.
Most of this reduction was due to county average
income, but population size further reduced the income
inequality odds ratios to the null. Overall, the results in
Table 4 for counties are comparable to those in Table 2
for MAs.
Soobader and LeClere (1999) report odds ratios of
1.35 (p50.01) and 1.51 (p50.001) for fair/poor self-
rated health for people living in the third and fourth
COLI adjustment, COLI adjustment, both house-
household income only hold- and MA-level income
1.10 (0.90–1.35) 1.20 (0.97–1.48)
1.07 (0.90–1.28) 1.14 (0.95–1.36)
1.03 (0.87–1.22) 1.06 (0.88–1.26)
1.00 1.00
1.31 1.12–1.53) 1.12 (0.97–1.31)
1.24 (1.08–1.42) 1.06 (0.93–1.22)
1.13 (0.99–1.30) 1.09 (0.95–1.24)
1.00 1.00
72 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
Table 4
Odds ratios of fair/poor health by county-level income inequality and average household income, for CPS sample with county Gini
assigned (n=105,645)a
County-level variable
(number of counties)
Income inequality
High (n=29)
Medium–high (n=81)
Medium–low (n=74)
Lowb (n=32)
County size (households)
5200,000 (n=54)
100,000–199,999 (n=51)
50,000–99,999 (n=68)
550,000b (n=43)
Average household income
(quartiles of n=54 counties)
Low
Medium–low
Medium–high
Highb
a
The odds ratios are from a weighted logistic regression model for fair/poor self-rated health that included the variables in each
column, and individual-level sex, age, race, and equivalized household income. A random intercept was specified at the county level in
each model.
b
Reference category.
quartiles, respectively, of counties by income inequality
compared to people living in the lowest income inequal-
ity quartile of counties. Their analyses were restricted to
white males aged 25–64 years from the National Health
Interview Survey for the years 1989–91, and controlled
for county median income, and the individual-level
covariates of income to needs ratio, age, education, and
occupation. In an attempt to replicate the findings of
Soobader and LeClere (1999), we conducted analyses
restricted to white males and females, aged 25–64 years.
We included the same variables as in the models in the
last column of Table 4, and did not use the CPS weights.
For males, there was no association of county-level
income inequality and self-rated health (odds ratios of
1.06 (95% confidence interval 0.82–1.38), 0.98 (0.77–
1.24), and 0.91 (0.73–1.14) for high, medium–high, and
medium–low income inequality counties, respectively).
This conclusion for males was robust to sensitivity
analyses using CPS weights and dropping the county
population size variable. For females, results suggested
that living in a high income inequality county may be
associated with poorer self-rated health. The odds ratios
were 1.29 (1.00–1.67), 1.14 (0.90–1.44), and 1.06 (0.85–
1.33) for high, medium–high, and medium–low income
inequality counties, respectively. These odds ratios were
reduced by about 20% toward the null when the CPS
weights were used, and increased by about a third away
Gini only Gini, population size,
and average income
1.25 (1.04–1.49) 1.11 (0.91–1.36)
1.06 (0.90–1.24) 0.95 (0.79–1.13)
0.99 (0.84–1.16) 0.93 (0.79–1.10)
1.00 1.00
1.05 (0.89–1.24)
1.08 (0.92–1.27)
0.96 (0.82–1.11)
1.00
1.24 (1.05–1.47)
1.12 (0.97–1.30)
1.01 (0.88–1.15)
1.00
from the null if the county population size variable was
excluded from the model.
State-level analyses
The final finding of this study was that the association
of state-level income inequality with fair/poor self-rated
health was stronger for those living in non-metropolitan
areas (i.e. largely rural) than in metropolitan areas.
Table 5 shows the results for a multi-level logistic
regression model of the 259,065 respondents (99.7% of
the full CPS sample) with non-missing data on
metropolitan area status. The model included variables
for individual-level sex, age, race, and household income
(as per Table 1), state-level average household income
(quintiles), and a cross-classified variable combining
state-level income inequality with metropolitan area
status. The upper panel in Table 5 shows the odds ratios
for state-level average income: individuals living in the
10 poorest states had a moderately elevated odds ratio
of 1.21 (95% confidence interval 1.05–1.40), with only
small differences between the four other quintiles. The
lower panel shows the odds ratios for CPS respondents
in each of the eight cells formed by cross-classifying
state-level income inequality by metropolitan area
status, where respondents living in metropolitan areas
within low income inequality states were treated as the
 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77 73

Table 5
Odds ratios of fair/poor health by state-level average household income and the interaction of state-level income inequality with
metropolitan area status, for CPS sample with identified metropolitan area status (n=259,065)a

Average state-level household

income (no. of states and
individuals)
OR (95% CI)
Low (n=10 and 33,756) 1.21 (1.05–1.40)
Medium–low (n=10 and 36,352) 1.07 (0.94–1.23)
Medium (n=10 and 61,682) 1.08 (0.94–1.23)
Medium–high (n=10 and 54,171) 1.04 (0.91–1.19)
Highb (n=10 and 73,104) 1.00

State-level income inequality Living in metropolitan Living in non-metropolitan Percentage of fair/poor self-
(number of states and individuals) area n=199,381) area (n=59,684) rated health in non-metropolitan
areas attributable to interactionc
OR (95% CI) OR (95% CI)
High (n=9 and 65,203) 1.36 (1.13–1.64) 1.60 (1.32–1.94) 20
Medium–high (n=16 and 108,199) 1.24 (1.03–1.48) 1.38 (1.15–1.65) 16
Medium–low (n=18 and 63,404) 1.15 (0.96–1.38) 1.05 (0.88–1.27) 1
Lowb (n=7 and 22,259) 1.00 0.92 (0.78–1.08) }
a
The odds ratios are from a weighted logistic regression model for fair/poor self-rated health that included sex, age group, race, and
household income at the individual level. A random intercept was specified at the state level.
b
Reference group.
c
The percentage of fair/poor health in non-metropolitan areas attributable to the interaction of income inequality and metropolitan
area status, assuming an additive model for interaction (Rothman & Greenland, 1998, p. 341), calculated as (OR(-
AB) OR(aB) OR(Ab)+1)/OR(AB), where OR(AB) is the odds ratio for people exposed to both higher income inequality and
non-metropolitan status (i.e. 1.60, 1.38, or 1.05); OR(aB) is for people exposed to low income inequality and non-metropolitan status
(i.e. 0.92); OR(Ab) is for people exposed to higher income inequality and metropolitan status (i.e. 1.36, 1.24, or 1.15). For example, the
percentage of people with fair/poor self-rated in high income inequality states and non-metropolitan areas attributable to the
interaction of income inequality and metropolitan status is (1.60 1.36 0.92+1)/1.60=20%.

reference group. Considering just the 199,381 respon-
dents living in metropolitan areas, the odds ratios of
fair/poor self-rated health are 1.36, 1.24, and 1.15 for
high, medium–high, and medium–low income inequality
states, respectively.1 However, the income inequality
association was stronger among the 59,684 respondents
living in non-metropolitan areas, with odds ratios
ranging from 1.60 for high income inequality states to
0.92 for low income inequality states. Among residents
of non-metropolitan areas, the odds ratio for living in
the highest versus the lowest income inequality states
was 1.75 (1.60/0.92), approximately twice the compar-
able odds ratio of 1.36 for those living in metropolitan
areas. Over and above the independent effect of living in
a metropolitan area (first column) and living in a low
income inequality state (bottom row), people living in
non-metropolitan areas within high income inequality
states had a 20% greater prevalence of fair/poor self-
rated health than expected (last column of Table 5).
1
13,902 respondents with a stated metropolitan area status
did not also have an identified MA; hence, the 199,381
respondents in Table 4 exceed the 185,479 respondents in
Tables 1 and 2.
That is, income inequality and metropolitan status
appear to interact in their association with self-rated
health.
Discussion
An association of income inequality with mortality
has been shown at the state level (Kaplan et al., 1996;
Kennedy et al., 1996) and MA level (Lynch et al., 1998)
in ecological analyses. More recently, income inequality
has been found to be associated with self-rated health at
the state level (Kennedy et al., 1998), and the county and
census tract levels (Soobader & LeClere, 1999) in studies
that also include individual-level income data}the so-
called multi-level studies. However, Fiscella and Franks
(1997) failed to find an association of county-level
income inequality with mortality. What does our multi-
level study add to existing knowledge?
First, we found an approximately 20% excess odds of
fair/poor self-rated health among people living in high
income inequality MAs compared to low income
inequality areas after controlling for individual-level
sex, age, race, and equivalized household income (Table
74 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
1). This association was halved after controlling for
average MA household income (OR=1.10, Table 2), the
95% confidence intervals included one (0.95–1.28), and
there was no apparent effect among medium–high and
medium–low income inequality MAs compared to low
income inequality MAs (ORs 1.01 and 1.00). The
corollary, though, was that there was an independent
contextual effect of MA-level average income on self-
rated health}particularly for people living in the
poorest MAs (Table 2).
A contextual effect for average MA (and county)
income is plausible. For example, whilst the association
of GDP with life expectancy weakens above US$5000 in
cross-national comparison studies, there is still a small
gradient of increasing life-expectancy with further
increasing GDP (Lynch, Davey Smith, & Kaplan,
2000). Likewise, increasing GDP is still associated with
further decreases in infant mortality rates (Hales,
Howden-Chapman, Salmond, Woodward, & Macken-
bach, 1999). Within the US, Anderson et al. have found
an independent contextual effect for census tract median
income on mortality in the National Longitudinal
Mortality Study (Anderson, Sorlie, Backlund, Johnson,
& Kaplan, 1997). Such contextual effects are likely to
reflect access to material resources that, even in an
affluent country like the US, still contribute some
additional marginal health benefit. For example, perso-
nal wealth (as opposed to just income) and educational
levels may mediate some of the contextual association.
The association of average income with health may also
be due, in part at least, to community-level variables
(e.g. provision of higher quality health and welfare
services) that have ecological effects over and above that
explained by individual-level variables (Blakely &
Woodward, 2000). We conducted sensitivity analyses
of the association of MA average income with self-rated
health by adjusting for cost of living (COLI; Table 3).
These analyses must be treated with caution, as the
number of MAs with COLI data was limited and we
cannot guarantee that the boundaries used to calculate
the ACCRA COLI were always identical with the CPS
MA boundaries. However, adjusting just the individual-
level household income strengthened the association of
MA average income with self-rated health, and did not
change the income inequality association. This house-
hold income-only adjustment is our preferred model as it
should improve the comparability of household income
across MAs (i.e. improve the specification of the
household income variable), yet leave the unadjusted
MA average income variable to reflect actual variations
between MAs in their economic prosperity. Thus, we
interpret this COLI adjustment as confirming that
something about MA average income (and by proxy
MA wealth and economic prosperity) is predictive of
health, and confounds the association of MA income
inequality with self-rated health. We also presented a
model adjusting the MA average income by the COLI in
the last column of Table 3. However, we believe this
model is not particularly informative as adjusting the
MA-level average income by the COLI simply removes
the variation of interest}the variation between MAs in
economic prosperity. Not surprisingly, therefore, this
extra COLI adjustment generates income inequality
odds ratios similar to models that do not include any
MA average income variable (e.g. model in Table 1).
Returning to income inequality, our results suggest
little (if any) association of MA-level income inequality
with fair/poor self-rated health after controlling for
MA- and individual-level income. However, the appro-
priateness of adjusting for individual-level income is a
matter of debate (Diez-Roux, Link, & Northridge,
2000). Gravelle (1998) and others have argued that it
is necessary to adjust for individual income in order to
overcome the ‘artefactual’ association between income
inequality and poor health produced by the concave,
non-linear relationship between personal income and
health. While it is necessary to adjust for individual
income to get rid of this first-order effect, it could be
equally argued that there is nothing artefactual about
this first-order relationship between income inequality
and health. That is, a society with a narrower income
distribution of income yields a higher average level of
health because of the non-linear relationship between
individual income and health (whereby the curve is
steeper at lower levels of income). According to this
view, adjusting for individual income underestimates the
real impact of income inequality by over-controlling for
the consequences of income inequality that works
through the non-linear association of individual income
with poor health. The last column in Table 2 demon-
strates the overall effect of income inequality on fair/
poor self-rated health by removing the statistical control
for individual income}the odds ratio of fair/poor self-
rated health among people in the highest income
inequality MAs, compared to lowest income inequality
MAs, increased to 1.26. Further, the 95% confidence
interval for this odds ratio now excluded one (1.06–
1.49), and there was an apparent dose response with
medium–high (1.10) and medium–low (1.04) income
inequality MAs having intermediary odds ratios. Which
of these two models}column 2 or 3 of Table 2}is more
correct depends on one’s theoretical perspective. Ascrib-
ing to the model reflected in column 3, the total income
inequality effect was a 26% excess odds of fair/poor self-
rated health among high (compared to low) income
inequality MAs. Of this 26% excess odds, 72%
([1.26 1.10]/[1.26 1.00]) was attributable to the non-
linear association of individual-level income with health,
or what Gravelle (1998) termed ‘statistical artefact’.
However, we believe it is better to refer to this
component as the ‘first order effect’ of income inequality
on health, or, using a framework of different types of
 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
ecological effects proposed by Blakely and Woodward
(2000), as one type of ‘indirect cross-level effect’. The
residual 28% ([1.10 1.00]/[1.26 1.00]) of the total
income inequality effect is due to a shift in the whole
association of individual-level income with self-rated
health. That is, regardless of whether you are rich or
poor, living in a high income inequality MA compared
to a low income inequality MA confers a 10% increased
odds of fair/poor self-rated health. This residual effect
may be thought of as a ‘pollution effect’ of income
inequality on health, or, again using Blakely and
Woodwards’ (2000) framework, a ‘direct cross-level
effect’.
Lynch et al. (1998) reported that income inequality
was associated with increased mortality at the MA level
in an ecological study. Although the association of
income inequality with mortality may be different from
that for self-rated health, given that self-rated health has
been found to be strongly predictive of mortality (Idler
& Kasl, 1995) the results in column 2 of Table 2 suggest
that Lynch et al.’s finding may be ‘explained’ by cross-
level confounding by individual-level income.2 Lynch
et al. (1998, p. 1078), however, opt for treating
individual-level income as ‘‘one of the mechanisms that
link income inequality to individual mortality’’, thus
making it inappropriate to ‘control’ for individual-level
income (in which case column 3 of Table 2 becomes the
appropriate analysis). It is not clear to us whether it is
appropriate to control for individual-level income when
determining the total income inequality effect; our
purpose here is to highlight the issue for debate. For
the remainder of this paper, we revert to considering
only the direct cross-level effect of income inequality as
the measure of interest (i.e. controlling for individual-
level household income).
The second major finding of this paper was that we
found little apparent overall association of county-level
income inequality with self-rated health (Table 4).
Soobader and LeClere (1999, Table 7, p. 740) found
an independent association of county-level income
inequality for white males aged 25–64 from the National
Health Interview Survey (1989–91), controlling for
county-level median income and individual-level educa-
tion, occupation and income. Males in the fourth, third,
2
Using the Gini coefficient they found an excess age-
standardized mortality rate of 64.3 per 100,000 between the
lowest and highest quartile of MAs. Using the average age-
standardized mortality rate of 849.6 per 100,000 (stated by
Lynch et al. in their methods) this excess mortality rate
corresponds to a standardized rate ratio of approximately
1.08 for the lowest quartile compared to the highest income
inequality quartile. The difference in odds ratios between
columns 2 and 3 of Table 2 in this paper suggests that the
state ratio of 1.08 found by Lynch et al. would have been
reduced to the null had individual-level income been included.
75
and second quartiles of counties by income inequality
had odds ratios of 1.51, 1.35, and 1.00, respectively,
compared to males in the lowest quartile. (Interestingly,
these odds ratios were greater than those uncontrolled
for personal socio-economic status; Soobader & Le-
Clere, 1999, Table 6, p. 739.) When we conducted
analyses specifically among 25–64 year old male CPS
respondents, we found no association of county-level
income inequality with self-rated health, thus failing to
reproduce the findings of Soobader and LeClere.
However, we did find a suggestion of an adverse
association of increasing county-level income inequality
with fair/poor self-rated health for females aged 25–64
years, with odds ratios of 1.32, 1.14, and 1.08 for high,
medium–high, and medium–low income inequality
counties (compared to low income inequality counties),
respectively. The 95% confidence intervals all included
1.0, however.
Whilst not a specific objective of this study, we also
made an interesting observation about the nature of the
state-level association of income inequality with self-
rated health}it was stronger among people living in
non-metropolitan areas compared to people living in
metropolitan areas (columns of bottom panel of Table
5). Put another way, there was a notable excess in the
odds of fair/poor self-rated health for people living in
non-metropolitan compared to metropolitan areas,
within higher income inequality states. This may be a
chance finding}replication by other researchers is
required (e.g. different data sets, years, and health
outcomes). If the finding is replicated, then features of
rural US that may modify or explain the stronger
income inequality association warrant scrutiny (e.g.
provision of resources, access to services).
There are possible limitations to the analyses in this
paper. First, self-rated health is a strong predictor of
mortality within groups (Idler & Benyamini, 1997).
However, between groups the tendency for individuals
to rate their health as fair or poor may vary. For
example, Hispanics have been reported as twice as likely
to rate their health as fair or poor compared to non-
Hispanics, even after controlling for reported illness,
medications, hospitalizations, demographics, socioeco-
nomic status, health behaviors, and negative feelings
(Shetterly, Baxter, Mason, & Hamman, 1996). It was
only among the acculturated quartile of Hispanics that
self-rated health was similar to non-Hispanics. Could it
be that there was enough variation (‘cultural’ or
otherwise) between MAs by propensity to self-rate
health as fair/poor to have confounded our analyses?
If there truly was an association of MA income
inequality with self-rated health after controlling for
individual-level income, then for our analysis to have
found essentially no association would mean that people
similar by race, age, sex, and household income would
have to respond differently depending on whether they
76 T.A. Blakely et al. / Social Science & Medicine 54 (2002) 65–77
lived in high or low income inequality MAs. Whilst this
scenario is possible, we believe it unlikely.
A second limitation was that our analyses were
limited to the available CPS data. The CPS tends to
over-represent larger MAs, both due to the probability
of being sampled and the need to suppress MA identity
on occasions when respondent privacy may be breached.
The actual identity of the MA identity was suppressed
for 7% of people that lived in an MA on the CPS data
set. Thus our results may be subject to selection biases if
the association of income inequality with self-rated
health varied for people living in the excluded and non-
sampled MAs. Whilst we are unable to test specifically
for selection biases in our MA- and county-level
analyses, we were able to compare the association of
state-level income inequality with fair/poor self-rated
health for the 199,381 CPS respondents living in
metropolitan areas (Table 5) with that for the subset
of 185,479 CPS respondents who also had the identity
of their MA disclosed}there was no substantive
difference.
Conclusion
This study found that the association of income
inequality with fair/poor self-rated health MA level may
be largely attributable to confounding by MA-level
average income and individual-level household income.
MA-level average income itself was more strongly
associated with self-rated health than MA-level income
inequality. On the other hand, some researchers may
view income inequality and low individual income as
being causally linked, in which case adjustment for
individual-level income may seem somewhat artificial
(Diez-Roux et al., 2000). Indeed, in analyses not
adjusted for individual-level income the association of
income inequality with self-rated health is more sub-
stantial. What may be definitely concluded from this
study is that, for CPS respondents in 1996 and 1998 at
least, there is little association of MA-level income
inequality with fair/poor health: (a) after controlling for
confounding by MA average income, and (b) by pathways
other than income itself at the individual level.
Acknowledgements
We thank Dr. Bruce Kennedy for comments and
suggestions during the conceptualization of this paper.
We also thank Roberta Glass for assistance with data
extraction.
Dr. Tony Blakely was a recipient of a New Zealand
Health Research Council Training Fellowship during
1999 when the work presented in this paper was carried
out whilst he was a visiting Research Fellow at the
Harvard Centre for Society and Health. Dr. Ichiro
Kawachi is a recipient of a Robert Wood Johnson
Foundation Investigator Awards in Health Policy
Research. Ichiro Kawachi is also supported in part by
the MacArthur network on Socio-Economic Status and
Health. Dr. Kim Lochner is supported by a Society and
Health Postdoctoral Fellowship of the Harvard Centre
for Society and Health.
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