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. 2025 Feb 5;194(2):480-489.
doi: 10.1093/aje/kwae183.

The health implications of cumulative exposure to contextual (dis)advantage: methodological and substantive advances from a unique data linkage

Wei Xu  1 , Christina Kamis  2 , Megan Agnew  3   4 , Amy Schultz  3 , Sarah Salas  4   5 , Kristen Malecki  6 , Michal Engelman  4   5
Affiliations

The health implications of cumulative exposure to contextual (dis)advantage: methodological and substantive advances from a unique data linkage

Wei Xu et al. Am J Epidemiol. .

Abstract

Deleterious neighborhood conditions are associated with poor health, yet the health impact of cumulative lifetime exposure to neighborhood disadvantage is understudied. Using up to 5 decades of residential histories for 4177 adult participants in the Survey of the Health of Wisconsin (SHOW) and spatiotemporally linked neighborhood conditions, we developed 4 operational approaches to characterizing cumulative neighborhood (dis)advantage over the life course. We estimated their associations with self-reported general health and compared them with estimates using neighborhood (dis)advantage at the time of study enrollment. When cumulative exposures were assessed with the most granular temporal scale (approach 4), neighborhood transportation constraints (odds ratio [OR] = 1.21; 95% CI, 1.08-1.36), residential turnover (OR = 1.20; 95% CI, 1.07-1.34), education deficit (OR = 1.17; 95% CI, 1.04-1.32), racial segregation (OR = 1.20; 95% CI, 1.04-1.38), and median household income (OR = 0.85; 95% CI, 0.75-0.97) were significantly associated with risk of fair or poor health. For composite neighborhood disadvantage, cumulative exposures had a stronger association (OR = 1.05; 95% CI, 1.02-1.08) than the cross-sectional exposure (OR = 1.03; 95% CI, 1.01-1.06). Single-point-in-time neighborhood measures underestimate the relationship between neighborhood and health, underscoring the importance of a life-course approach to cumulative exposure measurement.

Keywords: health; life course; neighborhoods; residential history.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Dimensions of neighborhood (dis)advantage across urban and rural contexts (A) and impacts of cumulative neighborhood (dis)advantage across the life course on individual health and population health inequalities (B), Survey of the Health of Wisconsin, United States, 2008-2019. Panel B depicts stylized patterns of exposure to neighborhood advantage (in green, top) and disadvantage (pink, bottom) over the life course that lead to growing cumulative inequality. Individual characteristics influence both the exposure to neighborhood context and the impact of those contextual exposures on individual health and health inequalities between population subgroups.
Figure 2
Figure 2
ANOVA analysis of differences in exposures to contextual (dis)advantage generated from the cross-sectional approach and the 4 approaches for life-course cumulative (dis)advantage, Survey of the Health of Wisconsin, United States, 2008-2019. The horizontal line in each box represents the median value. The end of the lower whisker is the first quartile minus 1.5 times the IQR, and the end of the upper whisker is the third quartile plus 1.5 times the IQR. Between-group differences were compared using 2-sample t tests with cross-sectional exposure as the reference group. *P <.05; **P <.01; ***P <.001. ANOVA, analysis of variance.
Figure 3
Figure 3
Predicted probability of self-reported fair or poor health across cross-sectional and life-course cumulative composite neighborhood disadvantage from fully adjusted models, Survey of the Health of Wisconsin, United States, 2008-2019.
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