Does the state you live in make a difference? Multilevel analysis of self-rated health in the US

This paper investigates the different sources of variation between US state s in self-rated health using multilevel statistical procedures. The differe nt sources that are considered are based on individual- and state-level fac tors. Data for the analysis comes from the 1993-94 Behavioral Risk Factor S urveillance System and the 3986-90 General Social Surveys. Results show tha t individual-level factors (such as low income, being black, smoking) are s trongly associated with self-rated poor health. Significant variation. howe ver, remain between states after allowing for individual characteristics. C rucially, between-state variation in self-rated health is different for dif ferent income groups. State-level contextual effects are found for per-capi ta median-income and 'social capital'. While not strong, there seems to be a differential impact of state income-inequality on high-income groups, suc h that the affluent report better health from living in high inequality sta tes. The paper substantiates the need to connect individual health to their macro socio-economic context. Importantly, it is argued that without adopt ing an explicitly multilevel approach, the debate: on linkages between indi vidual health and income-inequality/social capital cannot be adequately add ressed. (C) 2001 Elsevier Science Ltd. All rights reserved.