The Pathways To Obesity Health And Social Care Essay

There has been turning involvement in characteristics of the local life environment which might impact on wellness, evidenced by a quickly increasing figure of surveies documenting little country inequalities in morbidity and mortality and demoing associations between country want and wellness. Many of the more recent surveies are based on multilevel informations and analysis uniting information on single demographic and socio-economic determiners of wellness with country degree socioeconomic features. These are able to prove whether life in an country of concentrated want is associated with poorer wellness and whether this association is independent of a occupant ‘s ain societal and economic features. A reappraisal of these multilevel surveies conducted by Pickett and Pearl ( 2001 ) concluded that the grounds by and large shows that country want is related to morbidity, although the relationship is weaker and smaller in magnitude than the relationships between well-established single socioeconomic factors and morbidity.

Despite this addition in the figure of quantitative surveies, the grounds base remains limited in several respects. Area want is typically captured utilizing drumhead indexs of multiple want based on nose count features ( Townsend, Phillimore, & A ; Beattie, 1988 ; Carstairs & A ; Morris, 1991 ) . Although non ever explicitly stated, the underlying theoretical theoretical account is that there is an indirect way between indexs of multiple want and wellness. Basically, multiple want is correlated with characteristics of the local country that are credibly causally related to wellness. Macintyre and co-workers ( Macintyre, Ellaway & A ; Cummins, 2002 ) have commented that country effects are frequently a “ black box of slightly mystical influences on wellness ” and they and others have suggested that the analysis of specific local societal and physical environmental spheres should be considered in the topographic point of planetary drumhead steps ( Diez-Roux, 1998 ) .

Recent grounds has started to take out the “ black box ” of country effects by associating specific societal and physical environmental characteristics of little countries to wellness utilizing multilevel informations. Neighbourhood societal upset and elements of societal capital have been related to several results ( Lochner, Kawachi, Brennan & A ; Buka, 2003 ; ) . The cultural and political environment has besides been studied, though at a larger spacial graduated table ( Shaw, Dorling & A ; Davey Smith, 2002 ; Nelleman, Halpern, Leon & A ; Lewis, 1997 ) . Aspects of the built environment have besides been linked to fleshiness and its determiners ( Booth, Pinkston, & A ; Poston, 2005 ; Schootman, Andresen, Wolinsky, Malmstrom, Miller & A ; Miller, 2006 ) . Local services and substructure have received less attending in empirical research but there are some surveies that investigate their association with diet ( Wrigley, Warm & A ; Margetts, 2003 ; Cummins, Petticrew, Higgins, Findlay & A ; Sparks, 2005 ) and physical activity degrees ( Brownson, Baker, Housemann, Brennan & A ; Bacak, 2001 ; Giles-Corti & A ; Donovan, 2002 ) .

There are at least two major defects in the literature associating neighbourhood environment to wellness. First, the theoretical theoretical accounts associating the vicinity to wellness are by and large weak. Second, empirical research has tended to utilize merely a little figure of indexs to characterize vicinities. When several indexs of contextual spheres have been included in surveies, analyses have by and large non considered the complex relationships between the assorted indexs. Surveies have considered each index singly, combined them into a drumhead index or used multiple arrested development theoretical accounts to measure the consequence of one index whilst statistically commanding for the others. But how do the assorted contextual spheres relate to each other and how do they jointly influence wellness? What are the more conformable characteristics of vicinities and what are the mediating pathways associating these to occupants ‘ wellness?

Developments in statistical package now allow us to develop and prove theoretical theoretical accounts associating properties of vicinities to each other and to wellness. A structural equation patterning attack goes beyond simple description of the association between a given contextual characteristic and wellness in that it allows the research worker to develop a tract from a given feature, through other contextual features and single responses, to wellness position. Although causality can non be demonstrated unambiguously utilizing cross-sectional, experimental information this attack is a farther measure on the manner to placing suited points for environmental intercession.

Here we develop a theoretical model associating socio-relational features, the built environment and local installations and services to fleshiness. We so prove how good our theoretical account is supported by empirical informations. Throughout, we are concerned with developing the grounds base in a manner that will foreground potentially modifiable factors that are associated with fleshiness. We focus on local countries, typically bounded by nose count ward or ZIP code ( or zip codification ) sector boundaries, and frequently called vicinities as a short-hand. This degree is appropriate for sing the impact of societal dealingss, characteristics of the built environment and services and comfortss on wellness.

Theoretical model associating residential context to fleshiness

Fleshiness is a turning public wellness job ( Hedley, Ogen, Johnson, Carroll, Curtin & A ; Flegal, 2004 ; Prentice, 2006 ) . It has been estimated that over 100,000 extra deceases per twelvemonth in the US and an estimated cost of over a‚¤3.0billion in the UK can be attributed to fleshiness ( Flegal, Graubard, Williamson & A ; Gail, 2005 ) . It is a hazard factor for some of the prima causes of mortality, including cardiovascular disease, diabetes, shot, and some malignant neoplastic diseases. Fleshiness arises as an instability between energy consumption and outgo and as such a sedentary life style and hapless nutrition are cardinal modifiable determiners of fleshiness development. It is the chosen focal point of our survey because, in add-on to being a major public wellness challenge, its cardinal determiners may be shaped by characteristics of the local residential environment ( Morenoff, Diez Roux, Osypuk, & A ; Hansen, 2006 ; Hill & A ; Peters, 1998 ; Poston & A ; Foreyt, 1999 ) .

Concentrating on single fleshiness, we consider the contextual determiners of physical activity and diet and make a theoretical theoretical account based on bing literature and, wherever there is no back uping literature, we provide or extend bing models to include plausible causal tracts. Get downing with socio-relational facets of vicinities, surveies suggest that fright is reciprocally related to physical activity degrees and to fleshiness. Parental evaluation of neighbourhood safety is associated with childhood fleshiness ( Lumeng, Appugliese, Cabral, Bradley, & A ; Zuckerman, 2006 ) . Experiencing fright on the streets near one ‘s place and fright of being robbed, attacked or injured can take people to restrict their out-of-door physical activities ( Ross, 1993 ) . Walking for fittingness or pleasance is associated with safety, lower degrees of walking being reported by people who feel less safe ( Parkes & A ; Kearns, 2006 ) .

The experience of fright, feeling threatened and non swearing one ‘s neighbours gaining control elements of societal upset. Harmonizing to the “ broken Windowss ” theory, physical upset and societal upset are correlated and can reenforce each other in a barbarous rhythm ( Wilson & A ; Kelling, 1982 ) . The theory suggests that a neighbourhood physical upset ( such as a broken window ) acts as a signal that a community ‘s informal societal control is weak and uneffective against aberrant behavior. A big organic structure of research shows that those who perceive a higher incidence of incivilities have a greater fright of offense ( Austin, Furr & A ; Spine, 2002 ) . Violence is besides likely to impact upon societal upset, perchance by suppressing societal interaction ( Fullilove, Heon, Jimenez, Parsons, Green & A ; Fullilove, 1998 ) , increasing fright and detering occupants from swearing each other.

Land usage, notably assorted commercial-residential land usage, is associated with higher degrees of walking ( Doyle, Kelly-Schwartz, Schlossberg & A ; Stockard, 2006 ; Frank, Sallis, Conway, Chapman, Saelens & A ; Bachman, 2006 ) . Levels of physical activity are reported to be higher in topographic points with local athletics and leisure installations ( Giles-Corti & A ; Donovan, 2002 ) and in topographic points with attractive scenery ( Brownson et al, 2001 ) and Parkss and unfastened infinite with defined ‘destinations ‘ such as drama equipment and coffeehouse ( Sugiyama et al 2005 ) although surveies have been slightly under-powered to observe statistically important effects. Urban conurbation may deter walking. Morenoff and co-workers postulated that greater population denseness would be positively associated with walking because topographic points that people could walk to would be more closely situated ( Morenoff, Diez Roux, Osypuk & A ; Hansen, 2006 ) . In line with outlook, they found a positive association between population denseness and walking.

Dietary consumption is the 2nd cardinal determiner of fleshiness. Weight addition occurs when energy intake exceeds energy outgo but this is dearly-won and hard to mensurate accurately in big population surveies. Fruit and vegetable consumption is one facet of diet quality that is easier to mensurate and is reciprocally correlated with fleshiness ( He, Hu, Colditz, Manson, Willett & A ; Liu, 2004 ; Sturm & A ; Datar, 2005 ) . The increasing ingestion of convenience nutrients outside the place is another of import facet of diet that may associate to fleshiness ( Hill & A ; Peters, 1998 ) . Surveies from the US show that the presence of supermarkets is associated with a greater consumption of fruit and veggies and lower fat intake ( Morland, Wing & A ; Diez Roux, 2002 ) and that the comparative handiness of low fat and high fiber nutrients in local shops is associated with greater consumption of those nutrients ( Cheadle, Psaty, Curry et Al, 1991 ) . Less easy entree to a supermarket ( defined in footings of both propinquity and entree to a auto ) is associated with lower degrees of fruit and vegetable ingestion ( Rose & A ; Richards, 2004 ) and an association between figure of fast-food mercantile establishments and fleshiness rates has been found ( Maddock, 2004 ) .

Based on our reading of the literature, the hypothesised links between local socio-relational features, the local built environment, local services and fleshiness can be depicted as a diagram ( see Figure 1 ) and this provides the theoretical account for the analyses presented here. Features of the local societal and physical environment may impact fleshiness through encouraging physical activity ( by offering a clean and well-meaning environment to walk in and supplying local installations as finishs ) and through advancing healthy feeding ( by offering moderately priced healthful nutrients and non supplying easy entree to fast-food mercantile establishments ) .


Study participants and survey countries

Datas from the Health Survey for England ( HSE ) ( old ages 1994-1999 ) and the Scottish Health Survey ( SHS ) ( old ages 1995 and 1998 ) were combined to supply a big dataset which was representative of the general population of England and Scotland. Data from the HSE and SHS were collected by face-to-face interview in the participant ‘s place. The Health Surveys have achieved an estimated response rate runing from 69 % to 81 % . A random sample of ZIP code sectors is selected each twelvemonth, stratified by wellness authorization and per centum of families headed by person in a non-manual business. Within each ZIP code sector, a random sample of about 19 families is drawn from the little user Postcode Address File. Further inside informations on the study methodological analysis are given elsewhere ( Erens & A ; Primatesta, 1998 ; Shaw, McMunn & A ; Field, 2000 ) . Based on all ZIP code sectors represented in the combined 1994-1999 dataset, 438 were included in the present survey. The countries were selected as follows: 109 nose count wards in London and the sou’-east ( chosen in coupled undertakings utilizing other survey cohorts but where HSE participants besides happened to shack ) ; 68 wards in the remainder of England ( chosen indiscriminately from all wards with a lower limit of 40 HSE respondents stratified by population denseness and Carstairs want index ) ; 81 ZIP code sectors in Scotland ( chosen indiscriminately from all ZIP code sectors with a lower limit of 35 SHS respondents stratified as above ) . ( The SHS includes a smaller figure of participants than the HSE. ) Ward boundaries were converted to full and portion ZIP code sectors utilizing a look-up tabular array available from Manchester Information and Associated Services. Postcode sectors were hence used to specify neighbourhood boundaries in England and Scotland for analysis in this survey. Postcode sectors have an mean population of around 5,000 and are administrative units created for the administration of mail bringing. The sample of ZIP code sectors somewhat over-represented deprived and urban ZIP code sectors in England and under-represented disadvantaged ZIP code sectors in Scotland.

A sum of 12,605 Health Survey participants provided information on fleshiness and socio-demographic features and were linked to contextual information. There were no differences in the age, sex, societal category or fleshiness of participants who were linked and those who were non.

Contextual informations

Based on old work puting out a model bespeaking the assorted ways in which vicinities might run into basic human demands ( runing from air, H2O, nutrient and shelter through to instruction, housework, means of exchange and drama ) , efforts were made to garner information on 17 spheres considered of import for mundane life ( Macintyre, Ellaway & A ; Cummins, 2002 ) . Although there was a significant spread between an idealized dataset which captured these spheres and the available informations, more than 300 variables were obtained from a broad scope of primary and secondary beginnings. These contextual informations consisted of steps of local substructure and services and neighbourhood socio-relational features.

I ) Measures of local substructure and services

Secondary informations on steps of the local service and infrastructural environment were obtained from cardinal authorities sections, local governments, voluntary and public sector bureaus, commercial and industrial organisations. Variables capturing the undermentioned spheres were included in this survey: Crime ; Policing ; Physical delinquency ; High Street services ( local stores, fiscal services and health-related shops found in a typical little town in the UK ) ; Leisure centres ; Supermarkets ; Fast-food mercantile establishments ; Urban conurbation. These steps are described in Table 1 and a full lineation of the methods used and informations collected can be found elsewhere ( Cummins, Macintyre, Davidson & A ; Ellaway, 2005 ) .

The informations were originally obtained at assorted spacial graduated tables. For the present analysis, all contextual variables were converted to postcode sector. For illustration, offense rate was measured at the local authorization degree ( mean population about 125,000 ) . Each ZIP code sector within a local authorization was given the same offense rate. Since offense rates are really improbable to be homogenous within local governments, this introduces extra mistake into the measuring of offense. This could bias the estimation of the association between offense rate and organic structure mass index, likely towards the void hypothesis of no association.

two ) Measures of neighbourhood socio-relational features

A reappraisal of the literature covering both theoretical development and empirical probe of neighbourhood socio-relational features was conducted ( Stafford, unpublished thesis ) . Based on this, a 70-item questionnaire was developed utilizing cognitive navigation techniques. Five points captured neighbourhood upset with possible responses on a 7 point Likert graduated table: “ Peoples would be afraid to walk entirely in this country after dark ” ; “ Neighbors are endangering ” ; “ Most people in this country ca n’t be trusted ” ; “ This country is ever full of litter and rubbish ” ; “ Vandalism and graffitos are a large job in this country ” ( see Table 1 ) .

The postal questionnaire was sent to a random sample of occupants aged 16 and over, selected from the electoral registry, populating in the same vicinities as participants in the two wellness studies. It is of import to observe that this questionnaire was non sent to Health Survey participants themselves and so the informations are external to wellness study informations. A sum of 12,403 questionnaires were returned giving a response rate of 42 % . This was lower than anticipated although is in line with response rates from similar vicinity studies. Within each vicinity, responses to each of the five points were aggregated by taking the mean mark for all respondents. More item on the design and proof of the study is given elsewhere ( Stafford, Bartley, Wilkinson, Boreham, Thomas, Sacker et al. , 2003 ) .


All contextual variables capturing local substructure and services and neighbourhood socio-relational features were linked to single degree Health Survey data through participant ‘s ZIP code. Permission to utilize the ZIP code information was obtained from Health Survey funders and chief research workers.

Results and other informations from the Health Survey for England and Scottish Health Survey

Sexual activity, age and societal category based on business were obtained by face-to-face interview. Social category was classified into 6 groups harmonizing to the Registrar General ‘s categorization. Height, weight, waist and hip perimeter were measured by a trained nurse in the participant ‘s place. Body mass index ( BMI ) captures overall fleshiness and was calculated as weight ( kilogram ) divided by the square of the tallness ( meters ) . It would hold been of involvement to include intermediate wellness behaviors ( notably physical activity and diet ) into the theoretical account but these were non collected in a consistent manner across the study old ages and across states. However, information on engagement in athleticss nines, gyms and exercising categories was available from the vicinity study. Neighbourhood mean athleticss engagement was included in the theoretical account as there may be a contagious disease consequence of local physical activity degrees. Figure 2 shows the information available in this survey that capture the theoretical theoretical account outlined in Figure 1.

Statistical methods

The intent of the survey was to look into the inter-relationships between assorted contextual spheres and their relationship with overall fleshiness and organic structure fat distribution. Some contextual spheres were modelled utilizing latent variables. Others were observed straight because they were the lone index for a peculiar sphere. In the first phase of the modeling, a measuring theoretical account was tested to measure how good the ascertained indexs captured the implicit in latent concepts utilizing collateral factor analysis ( Lawley & A ; Maxwell, 1971 ) . Once our measuring theoretical accounts had been confirmed, structural equation theoretical accounts associating all of the assorted spheres to BMI were applied. Health Survey participant ‘s sex, age and societal category were included in the concluding theoretical account as possible confounding factors. Mplus package was used for all the modeling ( Muthen & A ; Muthen, 2005 ) .

Robust upper limit likeliness appraisal methods were used to manage the bunch of participants within ZIP code sectors and the non-normality of several of the variables. Models were assessed utilizing three goodness of fit indices: the Chi-squared trial of theoretical account tantrum, the Comparative Fit Index and the Root Mean Square Error of Approximation. There are many goodness of fit indices for the appraisal of tantrum for structural equation modeling. Standardized factor burdens and way coefficients are presented throughout. Unstandardised theoretical account estimations with assurance intervals and goodness of fit statistics are presented in Appendix 1.


Complete informations on age, sex, societal category, all relevant contextual variables and BMI were available for 6848 participants. Table 2 summarises the demographic features and fleshiness for included participants. There were no differences in age, sex, societal category or fleshiness for complete instances compared with instances with losing contextual informations and the estimations were similar when instances with losing informations on some of the variables were included. For brevity, merely theoretical accounts utilizing complete instances are presented.

Measurement theoretical account

A individual order factor capturing neighbourhood upset ( generated from happening neighbors endangering, non swearing neighbors, fright, hooliganism and litter ) fitted the informations good ( Table 3 ) . Another individual order factor capturing high street installations ( based on health-related shops and fiscal services ) besides fitted the informations good. Distance to post office, figure of libraries and figure of bingo halls did non lade on this factor. Number of libraries and lotto halls were non related to either index of fleshiness and were dropped from the analysis. Distance to post office was retained in the theoretical account as a individual point forecaster of fleshiness.

Structural equation theoretical account

The concluding structural theoretical account capturing relationships between the assorted environmental features and BMI is presented in Figure 3. The information fitted the a priori theoretical account good ( Chi-squared trial of theoretical account fit 360.7 on 171 grades of freedom, RMSEA 0.013 ) . As expected, neighbourhood upset was greater in topographic points with higher offense rates and was associated with policing degrees. Areas with greater Numberss of particular constables had lower degrees of societal upset. However, the figure of constabulary officers was positively associated with societal upset. This counterintuitive determination is discussed subsequently. A positive association between marks of physical delinquency and vicinity upset was found. In countries of greater vicinity upset, aggregative degrees of engagement in athleticss nines and activities were lower.

Adjusting for age, sex and societal category, occupant ‘s BMI was negatively associated with mean athleticss engagement rate, high street installations and propinquity to a station office. There was no direct association between vicinity upset and BMI. However, there was an indirect association. BMI was linked to perturb through mean athleticss engagement rate ( indirect way coefficient 0.013 P & lt ; 0.05 ) . The associations between the figure of swimming pools, figure of local supermarkets and population denseness and BMI did non accomplish statistical significance but were in the expected way. ( A theoretical account including the presence of McDonald ‘s eating houses did non meet so this variable was dropped from the analysis. Simple correlativity analysis indicated really low correlativity between BMI and McDonald ‘s eating houses so its skip from the concluding theoretical account is improbable to hold a significant impact on other estimations. )

BMI increased by 0.62kg/m2 for each 10 twelvemonth addition in age and was 1.30kg/m2 higher in societal category V compared with societal category I ( estimations calculated from Appendix 1 ) . Comparing the 75th and 25th centile of mean athleticss engagement, average BMI was 0.23kg/m2 lower in topographic points with greater engagement. For population denseness, the corresponding average difference in BMI was 0.36kg/m2 and for supermarkets it was 0.44kg/m2.


Several local determiners of fleshiness were identified in this survey. Neighbourhood upset is positively associated with fleshiness. Access to local high street installations, propinquity to a station office and population denseness are besides associated with lower fleshiness. Previous work suggests that degrees of fleshiness are higher in economically deprived countries, even after taking single factors such as sex, age and societal category into history ( Ellaway, Anderson & A ; Macintyre, 1997 ; van Lenthe & A ; Mackenbach, 2002 ; Kinra, Nelder & A ; Lewendon, 2000 ) . Our findings illustrate the ways in which specific characteristics of the residential environment are associated with organic structure size. They highlight vicinity upset and entree to local high street installations as possible determiners of fleshiness in the local population.

Our survey goes a measure further in seeking to place upstream determiners of fleshiness, moving through vicinity upset, some of which autumn within the remit of local public sector service suppliers. Patroling is one environmental factor that is linked to neighbourhood upset in our survey and which might be conformable to alteration. Greater Numberss of particular constables are associated with lower vicinity upset. Particular constables differ from the regular constabulary force in that they are trained voluntaries who provide a nexus between the regular constabulary force and the local community. Our findings could bespeak that the nature of their work is effectual in cut downing neighbourhood upset. Alternatively, particular constables may police countries where there is less offense and upset, therefore liberating up regular constabularies resources for higher offense and upset countries. In line with this account, we found that the figure of regular constabulary officers is associated with higher upset. A positive correlativity between offense rates and constabulary Numberss has been demonstrated and discussed elsewhere: constabularies resources may impact upon offense but every bit, offense may take to an addition in police Numberss ( Machin & A ; Marie, 2005 ) . Another account is that constabulary officers are employed in undertaking offenses which are unrelated to neighbourhood upset and so are diverted from activities which may impact on upset.

Residents besides appear to be less swearing and to experience more fearful and threatened in their vicinities where greater subdivisions of the land prevarication vacant and derelict. Derelict and vacant land is land which can non be developed for good usage without intervention and includes contaminated and unsightly land ( Scots Executive National Statistics, 2004 ) . Transforming these countries into utile infinites, be they residential, commercial or more attractive green infinites, could better occupants ‘ perceptual experiences of their local environment, take chances for antisocial behavior and promote occupants to be more physically active. Our findings suggest that this may, in bend, be associated with lower fleshiness for occupants.

The presence of local high street services and propinquity to a station office is besides related to fleshiness. The high street services factor comprised of health-related installations ( pharmaceuticss, lens makers and tooth doctors ) and fiscal services. It is likely that several other retail mercantile establishments are besides located in the same locality as retail installations tend to constellate together through agglomeration economic systems of graduated table. Having a varied choice of local comfortss within walking distance may promote occupants to walk ( instead than to drive ) when they need mundane goods and services and may supply a more contributing environment in which to walk for leisure. This factor could besides be capturing the full scope of independent and multiple-owned local food market, convenience and eating house nutrient proviso, which may impact fleshiness through dietetic forms. As awaited, population denseness is negatively correlated with fleshiness. In line with Morenoff and co-workers ( Morenoff, Diez Roux, Osypuk & A ; Hansen, 2006 ) , we hypothesised that population denseness indicates propinquity of topographic points that people could walk to. The association between swimming pools/supermarkets and fleshiness was in the expected way but did non make statistical significance. The informations were limited in that we were merely able to capture local authorization run swimming pools.

Our survey highlights the links between the assorted environmental spheres. Features of the built environment and public service proviso are related to neighbourhood upset. In the burgeoning societal capital literature there has been a inclination for research workers to concentrate on societal capital and to disregard the socioeconomic context and the function of other local services. Our findings provide some support for societal capital as a mediating variable associating arguably more straight conformable environmental factors – the built environment and public services – to fleshiness.

This is one of the first and largest surveies to pattern direct plausible tracts associating the local residential environment to a specified wellness result. It used structural equation theoretical accounts to prove these tracts and employed methods which allow for the bunch of participants within local countries. However, some restrictions should be acknowledged. Chief among these is the deficiency of available informations depicting the residential environment. We were interested in several spheres for which it was non possible to happen suited indexs. We besides theorised links between environmental features and occupant ‘s physical activity and diet, but single informations on these intermediate wellness behaviors were non available. Given the experimental nature of the survey, we can non dismiss the possibility that self-selection explains some of the associations seen here. For illustration, people for whom physical activity is of import may take to populate in countries which are well-stocked with athleticss installations. Note, nevertheless, that we have adjusted for personal socioeconomic place and this is a cardinal determiner of a individual ‘s ability to take where to populate. Our survey has broad geographical coverage but is cross-sectional and so we were unable to look at local societal procedures associating to behavioral and wellness alteration. In-depth surveies would supply complementary information and may be particularly utile in turn toing the deficiency of longitudinal informations associating the residential environment to wellness. In line with most other quantitative surveies, environmental informations were obtained for administrative boundaries and these do non needfully fit occupant ‘s psychologically defined local country. In fact, occupants are likely to comprehend the boundaries of their local country otherwise from one another, possibly harmonizing to their life phase, their usual agencies of conveyance, their mobility and a host of other factors. It may non be possible to hold a standard definition of local country which is appropriate for everyone. This is an ongoing challenge for wellness surveies of the residential environment. Some environmental informations were merely available at local authorization territory degree and misclassification mistake is likely to be higher for these variables. For illustration, the offense rate is non homogenous within a local authorization so some offense rate will be underestimated in some countries and overestimated in others. This reduces the power of the survey to observe associations between offense and vicinity upset.