Centre for Health Economics, University of York, York YO105DD, UK.
Soc Sci Med. 2013 Sep;92:61-73. doi: 10.1016/j.socscimed.2013.05.021. Epub 2013 May 31.
Improving the health and wellbeing of citizens ranks highly on the agenda of most governments. Policy action to enhance health and wellbeing can be targeted at a range of geographical levels and in England the focus has tended to shift away from the national level to smaller areas, such as communities and neighbourhoods. Our focus is to identify the potential for targeting policy interventions at the most appropriate geographical levels in order to enhance health and wellbeing. The rationale is that where variations in health and wellbeing indicators are larger, there may be greater potential for policy intervention targeted at that geographical level to have an impact on the outcomes of interest, compared with a strategy of targeting policy at those levels where relative variations are smaller. We use a multi-level regression approach to identify the degree of variation that exists in a set of health indicators at each level, taking account of the geographical hierarchical organisation of public sector organisations. We find that for each indicator, the proportion of total residual variance is greatest at smaller geographical areas. We also explore the variations in health indicators within a hierarchical level, but across the geographical areas for which public sector organisations are responsible. We show that it is feasible to identify a sub-set of organisations for which unexplained variation in health indicators is significantly greater relative to their counterparts. We demonstrate that adopting a geographical perspective to analyse the variation in indicators of health at different levels offers a potentially powerful analytical tool to signal where public sector organisations, faced increasingly with many competing demands, should target their policy efforts. This is relevant not only to the English context but also to other countries where responsibilities for health and wellbeing are being devolved to localities and communities.
提高公民的健康和福利是大多数政府的首要任务。为增进健康和福利而采取的政策行动可以针对一系列地理层面，在英格兰，重点已经从国家层面转移到较小的区域，如社区和邻里。我们的重点是确定在最合适的地理层面上有针对性地实施政策干预的潜力，以增进健康和福利。其基本原理是，在健康和福利指标差异较大的地方，针对该地理层面的政策干预可能对相关结果产生更大的影响，而针对相对差异较小的层面实施政策的策略则不然。我们使用多层次回归方法来确定一组健康指标在每个层面上存在的差异程度，同时考虑公共部门组织的地理层次结构。我们发现，对于每个指标，在较小的地理区域中，总剩余方差的比例最大。我们还探讨了在层次结构内以及公共部门组织负责的地理区域内的健康指标变化。我们表明，可以确定一组组织，这些组织的健康指标的未解释差异相对于其对应组织明显更大。我们证明，采用地理视角分析不同层面的指标变化为公共部门组织提供了一个潜在的强大分析工具，可以表明在面临众多竞争需求的情况下，应将其政策努力的目标定位在何处。这不仅与英国的情况有关，而且与其他将健康和福利责任下放给地方和社区的国家有关。
