Perceived neighborhood characteristics and the health of adult Koreans

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Social Science & Medicine 60 (2005) 1285–1297 www.elsevier.com/locate/socscimed

Perceived neighborhood characteristics and the health of adult Koreans Youngtae Choa,, Gil-Sung Parkb, Samuel Echevarria-Cruzc a

School of Public Health, Seoul National University, 28 Yeongun-dong, Seoul, Korea b Department of Sociology, Korea University, Anahm-dong, Seoul, Korea c Department of Sociology, The Ohio State University, 300 Bricker Hall, 190N Oval Mall, Columbus, OH 43210, USA Available online 18 August 2004

Abstract This study examines the role of the perception of neighborhood quality with respect to its influence on adult health in Korea. Employing the Quality of Korean Life Survey 2001, we found that the extent to which respondents perceive their neighborhood quality selectively affects the health of adult Koreans. That is, how individuals are satisfied with overall neighborhood characteristics, with neighborhood safety and with relationships to neighbors is considerably and significantly associated with self-rated and emotional health status among Koreans, net of individual demographic and socioeconomic characteristics. Although not statistically significant, the same direction of effect is found for daily activity limitation status, which may have been significant if a larger sample size were considered. This study also demonstrates that most individual demographic and socioeconomic risk factors are associated with health in a pattern consistent with that generally found in most Western societies, with the exception of the effect of education on psychological aspects of health. r 2004 Elsevier Ltd. All rights reserved. Keywords: Perceived neighborhood quality; Self-rated health status; Emotional health; Activity limitations; Korea

Introduction There is a traditional saying in Korea: E-oot-sa-chon, (neighbors are the same as close relatives). As this proverb suggests, neighbors and neighborhoods have been an important part of life among Koreans throughout history. Culturally, Koreans placed a high value on neighborhood relationships. The characteristics of these relationships took many forms, some of the most common and important being emotional and material support. For instance, when moving to a new neighborhood, one of the first responsibilities a new resident of Corresponding author. Tel.: +82-2-740-8857; fax: +82-2762-9105. E-mail address: [email protected] (Y. Cho).

the community assumed was to seek out neighbors, often sharing rice cakes as a sign of friendship and goodwill. Although the last three decades of rapid industrialization and urbanization have both changed the meaning and reduced the importance of neighborhoods as traditional communities, Koreans still expect their neighborhoods to play significant roles within their everyday lives. In contrast to the importance of neighborhoods, there have been few studies focusing on the impact of neighborhood characteristics on the lives of Koreans. In particular, even fewer attempts have been made to examine the influence of neighborhoods on the health of individual Koreans. A number of studies based on Western societies have reported that neighborhood characteristics play a significant role on individual

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2004.06.054

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health (e.g., Diez–Roux, 2002; Geronimus, Bound, Waidmann, Colen, & Steffick, 2001; Jones & Duncan, 1995; Macintyre, Maciver, & Sooman, 1993). Therefore, this study attempts to examine the role of certain neighborhood characteristics with respect to their influence on various dimensions of individual health in Korea. Within this study, we attempt a line of inquiry slightly different than previous efforts in this field. Instead of focusing on the more objective or ecological attributes of neighborhoods, we have chosen to identify and explore the effect of an individual’s perception of his or her neighborhood characteristics on an individual’s health.

Perceived neighborhood characteristics In recent decades, interest in the effect of neighborhood or community characteristics on individual health has notably increased. As Yen and Syme (1999) elucidate, associations between neighborhood characteristics and various aspects of individual health (e.g., infant and adult mortality, activity limitations, chronic conditions, mental health, and even health behaviors) have been reported. Studies that apply multilevel analysis techniques have facilitated simultaneous considerations of neighborhood- and individual-level characteristics and their relationship to individual health, thereby isolating the effect of neighborhood characteristics above and beyond individual attributes. Many studies continue to report the deleterious effect of various negative neighborhood characteristics (collective or ecological) on individual health. For instance, low socioeconomic status (SES) neighborhoods are more likely to suffer in terms of both the quantity and quality of municipal and public health services. Further, low SES neighborhoods may have physical environments characterized by higher levels of air, water, and/or noise pollution. These two sets of factors are well known predictors of deleterious individual health (Robert, 1999; Macintyre et al., 1993). Recently, investigators have also emphasized the importance of perceived neighborhood characteristics on individual health. In an exploratory analysis based on neighborhoods in Glasgow City, Scotland, Sooman and Macintyre (1995) discuss how an individual’s perception of his/her neighborhood affects his/her health, independent of objective features of the neighborhood. Employing six neighborhood perception domains (amenities, problems, crime, neighborliness, area reputation, and satisfaction), they suggest ‘‘living in what one perceives to be an unpleasant or threatening environment lacking amenities might lead to poorer health (1995, p. 25).’’ A study by Chandola (2001) reports on how individual perceptions of neighborhood safety are also significantly associated with an

individual’s self-rated health status, net of neighborhood, household, and individual socio-economic variables. According to the author, the fear of crime might result in a lowering of community trust and a breakdown of social networks, resulting in more negative self-ratings of health through a rise in psychosocial and physical insults to the body (e.g., physical stress and mental anxiety). In a multi-level study by Ross and Mirowsky (2001), the authors investigate the relationships between neighborhood disadvantage (objective measure), and disorder (perception measure), on an individual’s physical health (measured by self-reported health, physical functioning, and chronic medical conditions). The association between neighborhood disadvantage and individual health is significantly and substantially mediated by proxies of neighborhood disorder. They also conclude that neighborhood disorder (defined as fear of crime) decreases social control among residents, which results in chronic stress and health impairments. In another study, Hadley-Ives, Stiffman, Elze, Johnson, and Dore (2000) simultaneously assess the impacts of perceived and actual neighborhood characteristics on the mental health of adolescent individuals, finding stronger influences among the former over the latter, net of related individual risk factors. Moreover, although not specifically addressing health outcomes, perceived neighborhood characteristics (particularly neighborhood safety or fear of crime) and their association with children’s development (Bryant, 1985), various aspects of daily life (Cook, 1988), household weapon purchases (Warr, 1992), and children’s psychological distress and anxiety (Silverman, La Greca, & Wasserstein, 1996; Shumow, Vandell, & Posner, 1998) are well documented. Thus, it has been suggested that how one perceives one’s neighborhood is significantly and substantially associated with a variety of social and physical outcomes. In our estimation, one of the more important outcomes from this list is the physical and mental health and welfare of an individual, both sources and effects of widespread social stratification throughout the developed and developing world. There has been concern regarding these aforementioned associations. Some researchers have posited a reverse causation hypothesis regarding neighborhood perception and individual health (e.g., Watkins, Martin, & Stern 2000; Murray, Whitehouse, & Alloy, 1999). In contrast to the hypothesis that perception predicts health, some argue the possibility that chronic illness (mental or physical) might lead individuals to develop negative views and perceptions on a wide array of subjects, including neighborhood quality. For instance, a hypochondriac might not be willing to initiate or maintain contact or communication with neighbors, thereby negatively evaluating their relationship with neighbors. However, in a recent study, Latkin and Curry (2003) attempt to respond to this concern. Through a

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nine-month follow-up prospective study, they discover a strong association between perception of neighborhood disorder and individual symptoms of depression, even after controlling for baseline depressive conditions and selected individual characteristics. So how do perceived neighborhood characteristics affect individual health? Several studies attempt to relate the answer of this question to the actual physical characteristics of neighborhoods (e.g., Ross & Mirowsky, 2001; Hadley-Ives et al., 2000; Ross, 2000a). Neighborhood perceptions have been found to generally correspond with its ecological features. That is, one’s negative evaluation of their neighborhood is strongly associated with any disadvantaged physical features a neighborhood may possess. Additionally, low SES neighborhoods usually exhibit high levels of social disorder, which results in a decrease of social control. Once people perceive deleterious levels of social disorder and social control, these ill features can become chronic sources of psychological stress. When fear of crime (e.g., robbery, larceny, assault, abduction, etc.) and/or unsatisfactory environments (e.g., pollution, lack of recreational facilities, etc.) exist in a neighborhood, residents might be less inclined to participate in outdoor activities (e.g., exercise, pleasure walking, commuter walking) (Ross, 1993). Given the fact that these disadvantaged neighborhood features and perceptions are more often observed among low SES individuals, individuals who already suffer from the lack of resources due to ecological processes such as residential clustering and environmental racism, negative perceptions can be considerable additive stressors. Negative perceptions concerning neighborhood relationships can also be a serious stressor of health. Simply put, when one does not like his/her neighbors due to relationships characterized by negative interactions, the very fact that they live in the same neighborhood might cause psychological stress to this person. Indeed, the relationship between neighbors can be understood as a dimension of social capital, since it is related to interpersonal trust, social integration, and/or social cohesion, all of which are important elements of social capital (Lochner, Kawachi, & Kennedy, 1999). That is, when one perceives interpersonal neighborhood relationships as being pleasant and satisfactory, this person would be more likely to trust their neighbors and engage in community gatherings and activities. Recently, studies have suggested that social capital is a significant predictor of health within aggregated populations (Kawachi, Kennedy, Lochner, & Prothrow-Smith, 1997; Kawachi & Berkman, 2000; Kawachi Kennedy, & Glass, 1999) and of individuals (Sampson, Raudenbush, & Earls, 1997; Ross, 2000b; Subramanian, Kim, & Kawachi, 2002). According to Kawachi and Berkman (1997), individual health can be promoted by the quick diffusion of health-related information and salubrious

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behaviors and by ensuring beneficial health services and amenities through voluntarism and collective action within neighborhoods with high social capital. Thus, through these psychosocial pathways, perceptions of neighborhood quality can be a considerable risk factor of individual health and well-being. To our knowledge, no research exists testing the relationship between perceptions of neighborhood quality and health among Koreans. Given the importance of neighborhoods and neighbors in Korean society, it may be simple to conclude that what has been observed in Western society would be also apparent in Korea. However, this may not be the case. Recently Cho (2002) analyzed the association between objective characteristics of small areas and the health of adult residents in Metropolitan Seoul, Korea. Employing multilevel analysis techniques and the 1998 Korea National Health Survey data linked to annual statistical reports from each small area (a minimal administrative boundary) in Metropolitan Seoul, the author found neither significant nor substantial effects of various measures of neighborhood characteristics (e.g., aggregated SES, levels of pollutants, public expenditure for social development, provision of physicians) on adult health as measured by self-rated health status, chronic illness status, and daily activity limitation status. In contrast, individual demographic and SES characteristics played significant roles in predicting these health outcomes. The author attributes the lack of effects of objective small area characteristics to the short exposure duration of these contextual characteristics among residents. That is, where the duration of exposure should be considerably long for the contextual characteristics to be significantly associated to health (as discussed by Robert, 1999; Waitzman & Smith, 1998; Diez-Roux, 2001), the exposure to contextual concepts across small areas has been relatively short in Metropolitan Seoul. Thus, based on this study, it might also be deemed that perception of neighborhood characteristics does not have any effect on individual health, just as objective neighborhood characteristics did not. Moreover, given the importance of individual-level demographic and SES characteristics in explaining variations on health in Korean society, neighborhood perception may be highly correlated with demographic or SES characteristics as well as health. Any effect found between perceptions and health may ultimately be a data artifact. Therefore, the main purpose of this research is to explore and examine the effect of neighborhood perception on the health of adult Koreans. We also pay attention to the role of individual characteristics in predicting the health of adult Koreans, since this relationship has not been widely reported outside of Korea. We consider three individual-level neighborhood perception characteristics: neighborhood satisfaction, neighborhood safety, and satisfaction of relationship

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with neighbors. Since health is multidimensional, three different health measures are employed here as outcomes of interest: self-rated health status, emotional health, and daily activity limitations.

Materials and measures Data For this study, we employ the Quality of Korean Life Survey (QKLS). The QKLS was directed and implemented by the Asiatic Research Center, Korea University, located in Seoul, Korea to investigate the quality of life among adult Koreans (population over the age of 19). The QKLS was developed using the EUROMODULE survey as its reference, a popular instrument surveying welfare and quality of life issues in a comparative context among seventeen European countries, and includes a nationally representative sample of 1000 adult Koreans (Park, 2002). Respondents of this study were selected by the method of probabilistic, stratified, multistage cluster sampling, and they were stratified by sex, age, and region of residence. Face-toface interviews were completed by fifty trained survey interviewers from the Garam Research Corporation, with the average interview time lasting 40 minutes (Park & Kim, 2002). This survey was conducted from August 13 through 26, 2001. Questions related to a respondent’s identity (e.g., name, address, phone number, Korean social security number, etc.) were not included in the questionnaire due to confidentiality issues. As mentioned above, these data were collected in order to examine current quality of life indicators in Korea. Since health is one of the important dimensions of quality of life, the QKLS included three pertinent health questions (daily activity limitation, emotional health, and selfrated global health status) as well as questions regarding respondent’s self-assessment of various neighborhood aspects. Thus these data provide a set of relevant variables that can be readily and appropriately utilized toward our research goals. Variables and measures: outcome variables Three health measures are included in order to take the multidimensional aspects of health into consideration. Our first outcome variable is the self-rated health status of respondents. In general, it is well documented that a negative self-rating of one’s health status is a good predictor of mortality and morbidity (Idler & Benyamini, 1997; Ferraro, Farmer, & Wybraniec, 1997; Wilcox, Kasl, & Idler, 1996). In Korea, this outcome variable has recently been effectively used as an indicator of general health (e.g., Lim, Kim, Shin, Yoo, & Yang, 2003; Lee, Choi, Kang, & Kim, 1998). Further, Moon

and Lee (2001) suggest that self-rated health status is also significantly associated with health behaviors among Koreans. It was assessed in the QKLS by the question: ‘‘How would you describe the overall state of your own health?’’. Respondents could then choose from an 11-point scale, with 0 being very poor and 10 being excellent. Although this variable is continuously measured (mean: 6.70, std: 1.80), we collapse this scale to form a dichotomous outcome of self-rated health: ‘‘good’’ and ‘‘poor’’ health, because the distribution is considerably skewed toward high scores, with a score of 4 as a pivotal point. Thus, responses 0–4 and 5–10 are collapsed into poor and good health status, respectively. Ancillary analyses that utilized the original continuous variable (logged to offset skewness) resulted in no substantial differences in conclusions as related to the main focus of this paper. Our second outcome variable is emotional health. This variable is constructed by summing the scores of five-items found within the survey: (1) Do you feel spells of complete exhaustion or fatigue?; (2) Do you usually feel unhappy or blue?; (3) Do you often shake or tremble?; (4) Do you often feel nervous or an anxious state of mind?; and (5) Do frightening thoughts continuously enter your mind?. For each question, respondents were asked to choose either yes (1) or no (0). These items have been included in popular indexes of emotional or psychological disorder such as the Center for Epidemiological Study of Depression (Radloff, 1977) or Psychiatric Symptoms Index (Ilfeld, 1976). Good internal consistency exists between these items (Cronbach Alpha=0.73), and only one factor was detected by factor analysis. Although the summed emotional health variable ranges from zero to five (mean: 0.44, std: 0.98), we collapse it into a dichotomous outcome of emotional health: ‘‘good’’ emotional health, with zero affirmative answers, and ‘‘poor’’ emotional health, with one or more affirmative answers. Since the majority of respondents answered ‘‘no’’ to all psychological/emotional distress questions (78%), and less than 10% of respondents answered affirmatively to each of the five distress questions, we feel this is a logical categorization of a seemingly rare event. As was the case in self-rated health status, ancillary analyses that utilized Poisson regression rendered results consistent with those of our present findings. Our last outcome variable is daily activity limitations. This variable has been utilized as an indicator of health status in several previous studies (e.g., Rogers, 1995; Rogers, Hummer, & Nam, 2000; Cho & Hummer, 2001). In Korea, Yoon and Kim (1996) construct disability eliminated life expectancies, examining the significance of daily activity limitation for the health of Koreans. Since neighborhood perceptions are closely related to the psychological or mental status of individuals, it is expected that daily activity limitations,

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an indicator of physical health, may not be associated with how individuals perceive their neighborhood. However, as suggested above, negatively perceiving one’s own neighborhood may result in daily activity limitations by preventing one from outside physical activities such as regular walking or exercising. For instance, if one thinks that their neighborhood is dangerous due to crimes, this person might reduce their time outside, or if no place exists to exercise or walk for pleasure in the neighborhood (e.g., parks), minimal levels physical activity that are crucial to maintaining one’s health may be negatively impacted. Insufficient physical activity may result in daily activity limitations. This health outcome is assessed in the QKLS by asking, ‘‘Are your daily activities limited by chronic conditions, illnesses, or disabilities?’’ Although there are three response categories (severely limited, moderately limited, and not limited), we combine the responses ‘‘severely limited’’ and ‘‘moderately limited’’, since the proportion of responses for ‘‘severely limited’’ is considerably low (2.4%). Thus, daily activity limitation status is dichotomously utilized here: not limited, and limited. Variables and measures: independent variables Variables of main interest in this study include three neighborhood characteristics perceived by individuals: overall neighborhood satisfaction, neighborhood safety, and satisfaction of relationship with neighbors. They are assessed in the QKLS by asking: ‘‘How satisfied are you with your neighborhood?’’, ‘‘How satisfied are you with the security of your neighborhood?’’, and ‘‘How satisfied are you with your relationships toward your neighbors?’’, respectively. Each question includes an 11-point scale: from 0 being totally unsatisfied to 10 being totally satisfied. Although it is true that overall neighborhood satisfaction is inclusive of fear of crime and relationship to neighbors, the correlation coefficients range from 0.45 to 0.56, indicating that they do not measure the same aspect of perceived neighborhood features. However, to avoid the possible problem of multicollinearity between these variables, we run separate models that include three perceived neighborhood characteristics one at a time. The associations of interest are adjusted by various individual demographic and SES characteristics, viz., age, sex, marital status, residence (rural/small to medium size city/large city), family income, and educational attainment. Each variable has been demonstrated to significantly impact individual health or to be useful as a control when estimating the effects of other variables on health. As evident in the tables that follow, measurements of the control variables are conventional and straightforward. For family income, we include a category for missing values to offset the reduction in

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viable cases due to missing data on family income (18.6%).

Findings Descriptive analysis Table 1 documents the unadjusted patterns of association between each health measure and perceived neighborhood characteristics as well as demographic and SES characteristics of adult Koreans. We invert the scales of these three neighborhood perception variables so as to capture the unidirectional relationship between negative perception and negative health within our corresponding models as discussed below. Negative perceptions of our three neighborhood characteristics included in this study are positively associated with poor self-rated health status, one or more reported distress symptom(s), and one or more daily activity limitation(s) among adult Koreans, while this direct pattern is most pronounced in the case of self-rated health status. For daily activity limitation status, only neighborhood safety shows statistical significance. However, just from the pattern of association, it is deemed that the less individuals are satisfied with neighborhood quality, the worse their health is as measured by three different health indicators in Korea. Of interest is daily activity limitation status in that, despite being an indicator of physical conditions, it is slightly related with how individuals perceive their neighborhoods, a psychological condition. In terms of the individual’s demographic and SES characteristics, all three health indicators are consistently associated in the generally expected directions. Being female, older, divorced/separated/widowed, a rural resident, low educated, and of low family income are considerably related with an elevated risk of poor self-rated health, poor emotional health, and daily activity limitations among Koreans. Note that since findings from Table 1 are unadjusted, interpretations on the relationships between independent variables and each health indicator are tenuous, pending results from our multivariate models. Multivariate analysis: self-rated health status Table 2 presents parameter estimate results of logistic regression analyses, in the form of odds ratios, for the effect of perceived neighborhood characteristics along with demographic and SES characteristics on self-rated health status among adult Koreans. Again, we remind our readers that we have inverted our perceptions scales so that the direct associations found in the descriptive findings from Table 1 can be more easily interpreted by the resulting positive logistic regression parameter estimates and corresponding odds ratios greater than

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Table 1 Distributions of perceived neighborhood characteristics and demographic and socioeconomic status characteristics of adult (20-year old and +) Koreans, by indicators of health status Characteristics

Neighborhood perception (mean) a Neighborhood dissatisfaction Dissatisfaction of neighborhood safety Dissatisfaction of relationship with neighbors Sex (%) b Male Female Age (mean, years)

a

Self-rated health status

Emotional health

Daily activity limitation

Poor

Good

Poor

Yes

4.3* 4.7* 4.2*

3.5 3.5 3.6

3.8* 3.9* 3.8*

3.5 3.5 3.6

6.9 11.6*

93.1 88.4*

18.5 25.7*

81.5 74.3*

47.2*

38.9

44.6*

3.5* 9.9 36.0*

96.5* 90.1 64.0*

7.6 10.0 13.8

Good

3.7 4.0* 3.7

Total

No

3.5 3.5 3.6

1000 1000 1000

14.9 16.5

85.1 83.5

491 509

38.3

44.8*

38.3

1000

10.0* 24.3 56.0*

90.0* 75.7 44.0*

7.5* 16.4 60.0*

92.5* 83.6 40.0*

200 775 25

92.4 90.0 86.2

20.2 22.5 29.3*

79.8 77.5 70.7*

11.7 18.7* 22.0*

88.3 81.3* 78.0*

486 391 123

26.0* 6.2 6.2

74.1* 93.8 93.9

46.2* 18.2 17.0

53.8* 81.8 83.0

40.5* 13.0* 8.4

59.5* 87.0* 91.6

158 484 358

17.6* 6.3 3.0 12.9* 93

82.4* 93.7 97.0 87.1* 907

31.0* 18.7 15.8 26.3* 222

69.0* 81.3 84.2 73.7* 778

26.9* 12.2 8.4 18.3* 157

73.2* 87.9 91.6 81.7* 843

216 395 203 186 1000

b

Marital status (%) Never married Married Divorced/separated/widowed Residence by size of city (%) Large city Small to medium size city Rural towns Educational attainment (%) Less than high school High school graduate College or more Family income (%) Low Middle High Missing All persons

b

b

b

Source: Quality of Korean Life Survey, 2001. Note: Except for rounding error, percentages sum to 100.0%.
po0:05. Italic indicates reference category. a Statistical test of difference between two categories of each dependent variable. b Statistical test of difference to the reference category in each independent variable.

one. Model 1 contains all individual demographic and SES characteristics only. This model shows that age, sex, and family income are significantly associated with ‘‘poor’’ self-rated health status among Korean adults. Interestingly, females are significantly and substantially more likely to self assess their own health as being poor than males (odds ratio: 1.69), and this finding does not change even when additional perceived neighborhood characteristics are considered in subsequent models. As far as the effect of family income is considered, individuals of low family income and whose family income information is missing are at a substantially higher risk of poor self-rated health than their counterparts of high family income (odds ratio: 5.42 and 5.04, respectively), an effect that decreases in magnitude but remains still significant in the models that add perceived

neighborhood characteristics. Although not significant, the odds ratio of high school graduates are less than the unity (0.60), indicating the possibility that Korean adults whose terminal educational attainment are high school graduation have more favorable health, defined by self-rated health status, than their college or more educated counterparts, net of other individual characteristics included in this study. In the subsequent models, this pattern does not change, and indeed in Model 3, where perceived neighborhood safety is controlled, the odds ratio of high school graduates becomes statistically significant. This is a puzzling and inconsistent finding in regard to the general extant relationship between health and education. We defer our explanation until the analyses of all three outcome variables are considered. Model 2 through 4 successively adds each of the three

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Table 2 The effect of perceived neighborhood characteristics and individual demographic and socioeconomic status characteristics on ‘‘Poor’’ self-rated health status for adult (20-year old and +) Koreans, in odds ratios Model 1

Model 2

Perceived neighborhood characteristics Neighborhood dissatisfaction Dissatisfaction of neighborhood safety Dissatisfaction of relationship with neighbors Individual characteristics Age (years) Sex [male] Female

1.33*

Model 3

Model 4

(1.18, 1.58) 1.43**

(1.26, 1.63) 1.54**

(1.31, 1.82)

1.05**

(1.02, 1.08)

1.05**

(1.02, 1.08)

1.05**

(1.02, 1.09)

1.06**

(1.03, 1.09)

1.69*

(1.04, 2.74)

1.77*

(1.08, 2.90)

1.88*

(1.14, 3.10)

1.95*

(1.18, 3.22)

0.94 1.54

(0.36, 2.48) (0.61, 3.91)

0.91 1.41

(0.34, 2.43) (0.54, 3.66)

0.81 1.45

(0.30, 2.18) (0.56, 3.74)

0.80 1.34

(0.30, 2.13) (0.51, 3.52)

Residence by size of city [large city] Small to medium size city 1.04 Rural towns 1.00

(0.63, 1.73) (0.49, 2.01)

1.13 1.02

(0.68, 1.89) (0.50, 2.09)

1.11 1.15

(0.66, 1.87) (0.56, 2.36)

1.02 1.20

(0.61, 1.71) (0.58, 2.47)

Educational attainment [college or more] Less than high school 1.31 High school graduate 0.60

(0.61, 2.80) (0.32, 1.11)

1.32 0.52

(0.61, 2.85) (0.27, 0.98)

1.25 0.51*

(0.57, 2.74) (0.26, 0.96)

1.64 0.58

(0.75, 3.59) (0.30, 1.09)

Family income [high] Low Middle Missing

(2.14, 13.71) 4.70** (0.97, 6.14) 2.39 (1.95, 13.02) 4.30**

Marital status [married] Never married Divorced/separated/ widowed

Intercept (SE) -2LL -2LL(Delta to Model 1)

5.42** 2.43 5.04** 5.26**

(0.77) 529.77

3.37**

(1.85, 11.97) 3.92** (0.94, 6.07) 2.16 (1.65, 11.21) 4.43** (0.86) 509.95 19.82**

2.89**

(1.52, 10.08) 4.64** (0.85, 5.48) 2.14 (1.70, 11.56) 4.61** (0.87) 498.47 31.30**

2.65**

(1.81, 11.90) (0.84, 5.47) (1.76, 12.06) (0.91) 501.39 28.38**


po0:05;

o0:01. Reference category for self-rated health status is Good. See text for more information. All other reference categories are in [ ]. 95% confidence intervals are in ( ). For all models, n ¼ 1000. Source: Quality of Korean Life Survey.

specific perceived neighborhood characteristics. Odds ratios for perceived neighborhood characteristics in these models are all statistically significant and greater than the unity, indicating that a negative perception of one’s own neighborhood characteristics significantly raises the risk of poor self-rated health status among Koreans. Particularly, individual’s level of satisfaction of relationship with neighbors exerts substantially protective influence on his/her self-assessment of health status. In these models (Model 2 through 4), odds ratios of individual demographic and SES characteristics remain almost unchanged in their magnitude and significance, compared to Model 1, except for the odds ratios for high school graduates and low family incomes. The odds ratio for low family income decreases when

perceived neighborhood characteristics are considered by 13% to 28%, which suggests that a considerable portion of the health disadvantage among individuals of low income families is attributable to their negative perception or dissatisfaction of neighborhood profiles. Test of model fit also indicates relative advantage of these models compared to a model with individual characteristics only (Model 1). Multivariate analysis: emotional health Table 3 presents an analogous set of models focusing on predicting poor emotional health utilizing logistic regression with resulting parameter estimates expressed as odds ratios. As described above, we treat individuals

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Table 3 The effect of perceived neighborhood characteristics and individual demographic and socioeconomic status characteristics on emotional health conditions for adult (20-year old and +) Koreans, in odds ratios Model 1

Model 2

Perceived neighborhood characteristics Neighborhood dissatisfaction Dissatisfaction of neighborhood safety Dissatisfaction of relationship with neighbors Individual characteristics Age (years) Sex [male] Female

Model 3

Model 4

1.12* (1.02, 1.23) 1.12* (1.02, 1.22) 1.23** (1.11, 1.37) 1.03** (1.01, 1.05)

1.03** (1.01, 1.05)

1.03** (1.01, 1.05)

1.03** (1.01, 1.05)

1.40* (1.01, 1.95)

1.42* (1.02, 1.98)

1.42* (1.02, 1.98)

1.47* (1.05, 2.06)

Marital status [married] Never married Divorced/separated/widowed

0.67 1.67

(0.36, 1.21) (0.70, 3.97)

0.66 1.59

(0.36, 1.20) (0.67, 3.78)

0.64 1.60

(0.35, 1.18) (0.67, 3.79)

0.61 1.57

(0.33, 1.12) (0.65, 3.77)

Residence by size of city [large city] Small to medium size city Rural towns

1.04 1.11

(0.73, 1.46) (0.67, 1.82)

1.08 1.13

(0.76, 1.52) (0.68, 1.87)

1.06 1.15

(0.75, 1.50) (0.70, 1.91)

1.04 1.22

(0.74, 1.47) (0.74, 2.04)

Educational attainment [college or more] Less than high school High school graduate

1.57 0.74

(0.90, 2.73) (0.50, 1.10)

1.56 0.70

(0.89, 2.72) (0.47, 1.05)

1.54 0.70

(0.88, 2.69) (0.47, 1.05)

1.74 0.72

(0.99, 3.06) (0.49, 1.08)

Family income [high] Low Middle Missing

1.87* (1.11, 3.13) 1.26 (0.79, 2.03) 1.96* (1.16, 3.31)

Intercept (SE) -2LL -2LL(Delta to Model 1)

2.68** (0.47) 968.68

1.75* (1.04, 2.95) 1.26 (0.79, 2.02) 1.86* (1.09, 3.15) 1.92** (0.56) 962.72 5.96*

1.70* (1.00, 2.86) 1.22 (0.76, 1.96) 1.88* (1.11, 3.19) 1.92** (0.57) 963.23 5.63*

1.69 (1.00, 2.84) 1.20 (0.75, 1.93) 1.85* (1.09, 3.15) 1.34* (0.59) 954.36 14.32**


po0:05;

o0:01. Reference category for emotional health condition is No Distress Symptom. See text for more information. All other reference categories are in [ ]. 95% confidence intervals are in ( ). For all models, n ¼ 1000. Source: Quality of Korean Life Survey.

who respond as experiencing at least one psychological distress symptom out of a possible five as having poor emotional health. Odds ratios in Model 1 indicate that individual demographic and SES characteristics are associated with 1+emotional health conditions in the pattern similar to what was observed for self-rated health status. That is, age, sex, and family income have significant influence on emotional conditions for Koreans. Particularly, females and individuals who have low family income or whose income information is missing are at a greater risk of poor emotional health than males and high family income individuals, respectively. Of interest is the effect of educational attainment. As observed in the case of self-rated health status (Table 2), the odds ratio for high school graduates is less than the unity, indicating Koreans of this level of education are less likely to have or report psychological distress symptoms than their college attended counterparts, albeit not statistically significant. This pattern

does not change in the subsequent models that additionally consider perceived neighborhood characteristics. Again, this is puzzling and not consistent with general expectations. Our explanation of this will be discussed after all three health outcome variables have been analyzed. Models 2 through 4 consider specific perceived neighborhood characteristics, one at a time, in addition to controls for individual demographic and SES characteristics. Odds ratios in these models illustrate that neighborhood dissatisfaction, perceiving poor neighborhood safety, and dissatisfaction of relationship with neighbors are all significantly associated with poor emotional health among Koreans. Chi-square tests of model fit indicate relative advantage of considering perception variables. Similar to the case of self-rated health status, almost no changes are observed among the odds ratios for individual characteristics, compared to Model 1. Only exception is the odds ratios for family income. Six to ten percent of the reduction in

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the gap between low and high family income individuals is attributable to the inclusion of perceived neighborhood characteristics in the model. Multivariate analysis: daily activity limitations Table 4 displays findings of multivariate analysis focusing on daily activity limitation status, presenting logistic regression parameter estimates as odds ratios. Odds ratios in Model 1 show the pattern of association between individual characteristics and daily activity limitations somewhat different from what was observed in the previous two tables for self-rated health status and emotional health. Unlike the previous two tables, where males showed advantages in both health indicators over females, the current odds ratio is not significant and its magnitude is small but less than one. Adult Koreans who have been divorced, separated, or widowed are over twice as likely to experience daily activity limitations compared to their married counterparts, net of other

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risk factors including age. Individuals living in small to medium size urban areas are at a significantly greater risk of daily activity limitations than are large-city residents. It may be attributable to the fact that many work sites or factories of secondary industry that require severe physical or manual labor are located in the small to medium size cities in Korea. As a result, the visibility of those individuals with minor disabilities is higher in the small to medium size cities, as compared to large cities. Of interest is the effect of educational attainment, and particularly that of high school graduates. Although not significant and of small magnitude, the odds ratio of high school graduates is greater than one, an opposite result to the previous two health indicators, where the odds ratios of the same category were less than unity. Our explanation for this effect is explored in our subsequent discussion section. Individuals whose terminal educational attainment is less than high school graduation are significantly more likely to suffer from daily activity limitations than their college or more

Table 4 The effect of perceived neighborhood characteristics and individual demographic and socioeconomic status characteristics on daily activity limitations for adult (20-year old and +) Koreans, in odds ratios Model 1

Model 2

Perceived neighborhood characteristics Neighborhood dissatisfaction Dissatisfaction of neighborhood safety Dissatisfaction of relationship with neighbors

1.06

Model 3

Model 4

(0.96, 1.19) 1.13* (1.01, 1.25) 1.12

(0.99, 1.28)

Individual characteristics Age (years) Sex [male] Female Marital status [married] Never married Divorced/separated/widowed

1.25 (0.62, 2.56) 2.86* (1.17, 7.03)

1.25 (0.61, 2.56) 2.79* (1.14, 6.86)

1.24 (0.61, 2.54) 2.73* (1.11, 6.70)

1.21 (0.59, 2.48) 2.77* (1.12, 6.85)

Residence by size of city [large city] Small to medium size city Rural towns

1.55* (1.03, 2.32) 1.12 (0.63, 2.01)

1.59* (1.06, 2.38) 1.14 (0.64, 2.04)

1.61* (1.07, 2.41) 1.19 (0.66, 2.13)

1.55* (1.03, 2.33) 1.19 (0.66, 2.14)

Educational attainment [college or more] Less than high school High school graduate

2.58** (1.35, 4.93) 1.20 (0.73, 1.98)

2.58** (1.35, 4.93) 1.18 (0.72, 1.95)

2.56** (1.34, 4.89) 1.17 (0.71, 1.93)

2.73** (1.42, 5.24) 1.20 (0.73, 1.98)

Family income [high] Low Middle Missing

2.57** (1.37, 4.82) 1.49 (0.81, 2.72) 2.09* (1.08, 4.04)

2.48** (1.32, 4.69) 1.48 (0.81, 2.71) 2.02* (1.04, 3.92)

2.31* (1.22, 4.37) 1.44 (0.79, 2.63) 2.00* (1.03, 3.88)

2.43** (1.29, 4.57) 1.45 (0.79, 2.65) 2.02* (1.04, 3.93)

Intercept (SE) -2LL -2LL(Delta to Model 1)

1.05** (1.03, 1.07)

1.05** (1.03, 1.07)

1.05** (1.03, 1.08)

1.05** (1.03, 1.08)

0.94

0.95

0.95

0.97

(0.64, 1.38)

4.88** (0.60) 747.75

(0.64, 1.40)

4.47** (0.69) 746.47 1.28


po0:05;

o0:01. Reference category for daily activity limitations is None. See text for more information. All other reference categories are in [ ]. 95% confidence intervals are in ( ). For all models, n ¼ 1000. Source: Quality of Korean Life Survey.

(0.65, 1.41)

4.11** (0.69) 743.00 4.75*

(0.65, 1.42)

4.14** (0.72) 744.44 3.31

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educated counterparts. Low and missing family income are strongly associated with an elevated risk of daily activity limitations. Models 2 through 4 separately add each of specific perceived neighborhood variables. Here, only perception of neighborhood safety shows a significant effect on this health outcome. That is, when an individual perceives his/her neighborhood being unsafe, he/she is significantly more likely to suffer from daily activity limitations, net of other individual risk factors in Korea. Although odds ratios for neighborhood satisfaction (Model 2) and satisfaction of relationship with neighbors (Model 3) are not statistically significant, they are more than the unity, and may have been significant if the sample size were larger as reflected in their confidence intervals that barely include unity. Inclusion of perceived neighborhood characteristics in these models does not results in notable changes in the significance or magnitude of odds ratios for individual demographic and SES characteristics, compared to those in Model 1, except for odds ratio of low family income in Model 3. With significant protective influence of perceived neighborhood safety, the disadvantage of low family income, compared to high family income, decreases by 10%.

Discussion It appears from the descriptive analyses that negative perceptions of neighborhood quality are associated with the poorer health among adult Koreans. Although this relationship was more pronounced in the case of selfrated health status, the same pattern of association was found among the other two health indicators studied. Moreover, all three variables of perceived neighborhood characteristics seemed to have some measurable effect on Korean adult health, despite the variation in the strength and significance of the association. When the relationship between each health outcome and perceived neighborhood characteristics is adjusted for individual demographic and SES risk factors in multivariate analyses, the patterns of association observed in the descriptive analyses remain almost unchanged. Note that we conceptualized self-rated health status and emotional health as more subjective measures and/or psychological aspects of health, as opposed to daily activity limitations, that represent objective and/or physical aspects of health. Given this, it is an interesting finding that one’s perception of neighborhood characteristics has a protective effect not only on the psychological or subjective aspects but also, at least to some extent, on the physical or objective aspects of health in Korea. Thus, our findings from Korea are consistent with the previous studies conducted on Western societies that document the importance of how individuals perceive or are satisfied with their

neighborhood characteristics and their psychological and physical health (e.g., Roberts, 1998; Ellaway & Macintyre, 1998; Middleton, 1998; Sampson et al., 1997; Ross, 2000a, b). There is a finding that is worth particular attention and discussion regarding the relationship of perceived neighborhood profiles and an individual’s family income. That is, the adverse effect of low family income on individual health is considerably moderated by the inclusion of perception variables in this analysis. For self-rated health status and emotional health, all three perceived neighborhood characteristics considered in the current study narrowed the gap between high and low family income individuals by 6 to 28%, and even for daily activity limitations neighborhood safety moderated the adverse effect of low family income, as compared to high family income, by 10%. These findings indicate that Koreans of low family income tend more, than high family income individuals, to have negative perception or a low level of satisfaction of their neighborhood, and that to improve their perception of neighborhood profiles would result in the promotion of health for this population. Then the next logical question is whether or not neighborhoods where low income families reside are actually unsafe, provide unsatisfying amenities, and have undesirable neighbor relationship in Korea, as to result in negative perception among individuals of low family income. In Western society, particularly in the US, it is common for the actual conditions of neighborhoods of poor individuals to be associated with disadvantaged physical features and a high level of social disorder. That is why Ross and Mirowsky (2001) and Hadley-Ives et al. (2000) find that the adverse effect of disadvantaged or undesirable neighborhood conditions on individual health is mediated considerably by the effect of an individual’s perception of a neighborhood’s physical conditions. Unfortunately, we do not have any resources in the current study to examine if such a paradigm of neighborhood disadvantage, negative perception, and adverse health exists in Korean society. Based on Cho’s previous findings—one of the few attempts to investigate the relationship between objective area characteristics and individual health in Korea – we maintain that no association would exist between objective neighborhood conditions and the resident’s perception of them (Cho, 2002). Neither significant nor substantial effects were found between objectively measured neighborhood characteristics, while individual perceptions of neighborhoods clearly affected health in the present study. One could even conclude that perceived neighborhood characteristics are a more prominent risk factor than are objective or contextual neighborhood characteristics for the health of Koreans. However, caution should be exercised in directly comparing these two studies, since different

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aspects of neighborhood features were analyzed within them. It would have been possible to make a direct comparison or examine the relationship between objective neighborhood disadvantage and perception if individual perceptions on the variables objectively measured in Cho (2002) were included in the current study. Accordingly, we do not have enough evidence yet to conclude that the negative perception of neighborhoods is indeed attributed to real disadvantage of an objective or contextual nature in Korea. Regarding the relationship between individual risk factors and health outcomes, overall patterns of association are not much different from the general findings based mostly on Western societies. For instance, age is a strong predictor of health conditions, with marital status also partly explaining the risk of adverse health conditions. It appears that women are more vulnerable than men to psychological or emotional conditions, while no differences in the odds of daily activity limitations are found, consistent with the wellknown hypothesis that women are more susceptible to adverse psychological symptoms than men due to differences in social role expectations (Verbrugge, 1989). A recent study in Korea reports that women have notably higher negative mental health status as compared to men due to the differences in the occupancy of social roles and resources between genders (Han, Lee, Ok, Ryff, & Marks, 2002). That is, gender discrepancy in psychological distress is largely attributable to social expectation based on traditional norms that discriminate women from educational opportunity and labor force participation in Korean society. Koreans with low family income are at a substantially higher risk of both physical and emotional health problems. Of interest is the effect of educational attainment. Among Koreans, it is well-accepted that education is one of the most important elements of life. They tend to invest greatly in the quality and quantity of their own, as well as their children’s education. Accordingly, the level of education that one achieves is a crucial determinant of various aspects of Korean life, including their quality of life and health. Given this, it is easy to expect that educational attainment would be negatively associated with the increased probability of health problems. Indeed, this pattern was observable in this study for daily activity limitation status. However, for the cases of self-rated and emotional health, our results showed an opposite pattern, whereby people with only a high school diploma were less likely to be disadvantaged than their college attended/attending counterparts, with the least educated respondents being most disadvantaged, an expected finding. This may suggests that Koreans with a higher level of education (college or more) are actually more likely to suffer from psychological conditions and in turn assess their health negatively, compared to their high school graduated

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counterparts, possibly due to frequent and substantial exposure to mental stresses attached to their occupations. However, it can also be understood as a tendency of somatization among those with a college education. They may, in fact, be in good health but just tend to believe that they have health problems, because higher levels of education include an increase in knowledge and information on health and illness with an accompanying increase of health concerns. Further, college experience or degree increases personal and social expectation, which in turn may lead to mental strain when these expectations are not fulfilled or satisfied within society. Indeed, the increased unemployment rate and forced early retirement of many Koreans after the economic crisis of the late 1990s may have elevated the strain of discrepancy between expectation and reality among highly educated individuals in Korea. Our study is limited in at least the following two ways. First, we have documented the effect of perceived neighborhood characteristics on individual health throughout this paper. Even though we introduced a recent study by Latkin and Curry (2003), a study that empirically investigated the casual relationship between perceived neighborhood disorder and depression, the reciprocal effect of perceived neighborhood quality and health (particularly subjective and/or psychological health) may actually exist in Korean society. Particularly, individuals with depressive symptoms or mental health problems may encounter difficulties in making and maintaining a good relationship with neighbors due to self-selection and social rejection (Johnson, 1991). Unfortunately, there have not been data sets that can be utilized for the investigation of theoretical causality between social risk factors, including perceptions of neighborhood quality, and individual health in Korea (e.g., longitudinal data). Second, we have considered perceived neighborhood characteristics only, with respect to their impact on individual health. It would have been more comprehensive to investigate the impact of neighborhood quality on individual health, if both objectively measured contextual features of neighborhoods and subjectively measured perceptions of them were simultaneously analyzed. By doing this, it would be possible to investigate whether or not the effect of contextual characteristics on individual health exists, and, to reveal if this is mediated by the subjectively perceived neighborhood characteristics, as observed in contemporary US society (e.g., Ross & Mirowsky, 2001). We were not able to address and examine such issues here due to data limitations. Future research should pay more attention to analyzing the theoretical causality between subjective neighborhood measures and health in Korean society. The mechanisms concerning how perception of neighborhood quality affects both psychological and physical health of Korean should also be examined. Recently, serious concerns have risen

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regarding residential clustering by socioeconomic groups in Korea (Yoon, 1998). If this phenomenon becomes more apparent and pronounced, the objective and subjective features of neighborhoods should have an even greater influence on quality of life, including health, among individual Koreans. Despite these caveats, the rarely examined findings concerning the relationship between perceived neighborhood characteristics and health outcomes in Korea should stimulate national and international discourse on this important topic.

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