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RESEARCH AND PRACTICE |
The authors are with the Department of Health and Social Behavior, Harvard School of Public Health, Boston, Mass.
Correspondence: Requests for reprints should be sent to Nancy Krieger, PhD, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (e-mail: nkrieger{at}hsph.harvard.edu).
Use of zip codes in US public health research is on the rise. As of February 2002, 230 articles were indexed by zip code in PubMed,1 all published since 1989. Fifty-two of these articles (23%) involved the use of censusderived zip code socioeconomic data (e.g., median household income) to investigate the effects of socioeconomic position on specified health outcomes (article citations are available on request from the authors).
To date, discussions regarding the use of zip code socioeconomic data for US public health research have focused chiefly on whether zip codes' larger population size (average: 30 000) and potentially greater socioeconomic heterogeneity would attenuate estimates of socioeconomic gradients in health detected using zip codes in comparison with estimates obtained via census tract (average population: 4000) or block group (average population: 1000) socioeconomic data.2–7 Unacknowledged in the public health literature, however, is the fact that zip codes differ from census tracts and block groups in other important ways, including spatiotemporal definition and stability.
Unlike census tracts, defined by the US Bureau of the Census as "small, relatively permanent statistical subdivision[s] of a county . . . designed to be relatively homogeneous with respect to population characteristics, economic status, and living conditions,"8(ppG-10–G-11) zip codes are "administrative units established by the United States Postal Service . . . for the most efficient delivery of mail, and therefore generally do not respect political or census statistical area boundaries."9(pA-13) Spanning in size from a single building or company with a high volume of mail to large areas that cut across states, "carrier routes for one zip code may intertwine with those of one or more zip codes" such that "this area is more conceptual than geographic."10
To "overcome the difficulties in precisely defining the land area covered by each zip code,"11 the US Census Bureau created a new statistical entity built from census blocks: the 5-digit zip code tabulation area (ZCTA), first used in the 2000 census.12 Of note, ZCTAs and zip codes sharing the same 5-digit code may not necessarily cover the same area (Table 1
),13 so that zip codes obtained via self-report or from addresses in medical records cannot be assumed to correspond to census-defined ZCTAs.
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Findings from the Public Health Disparities Geocoding Project17 illustrate the potential problems for health research of spatiotemporal zip code–census mismatches, even those dating from before the creation of ZCTAs. This project was designed to assess which area-based socioeconomic measures at which levels of geography (census tract, block group, and zip code) are most appropriate for monitoring socioeconomic inequalities in health. Health data from 2 states (Massachusetts and Rhode Island) and the 1990 census were used. Records were geocoded in 1999 by a firm whose accuracy we ascertained to be high (96%),18 and the firm, following standard practice, returned the most recent geocodes available.
Cancer incidence rates were one of the health outcomes addressed. We found that in Massachusetts (474 zip codes listed in the 1990 census), 17 376 (10.4%) of the 166 730 cancer cases occurring during 1987 to 1993 were geocoded to 193 zip codes not included in the 1990 census; 15 774 (90.8%) of these 17 376 cases were in one of 30 zip codes changed or established after the 1990 census.19–21 By contrast, in Rhode Island (70 zip codes listed in the 1990 census), only 0.7% (148) of the 19 766 geocoded cancer incidence records were matched to zip codes not included in the 1990 census.
In the case of colon cancer incidence in Massachusetts, moreover, the impact of excluding persons linked to zip codes not included in the 1990 census was substantial. Zip code–level analyses yielded socioeconomic gradients contrary to those observed via data at the tract and block group levels and contrary to those reported in the literature (Tables 2–4).22
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Acknowledgments |
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We thank Dr Daniel Friedman (assistant commissioner, Bureau of Health Statistics, Research and Evaluation, Massachusetts Department of Health) and Dr Jay Buechner (chief, Office of Health Statistics, Rhode Island Department of Health) for facilitating the Public Health Disparities Geocoding Project by providing data from their respective health departments and for their helpful comments on the article. We likewise thank the following individuals for helping us to access the mortality and cancer registry data: Alice Mroszczyk, Dr Susan Gershman, Mary Mroszczyk, and Ann R. MacMillan of the Massachusetts Department of Public Health and Dr John Fulton of the Rhode Island Department of Health.
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Footnotes |
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Accepted for publication March 15, 2002.
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References |
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 TOP References |
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2. Krieger N, Williams D, Moss N. Measuring social class in US public health research: concepts, methodologies and guidelines. Annu Rev Public Health.1997;18:341–378.[Medline]
3. Krieger N. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health.1992;82:703–710.
4. Geronimus AT, Bound J. Use of census-based aggregate variables to proxy for socioeconomic group: evidence from national samples. Am J Epidemiol.1998;48:475–486.
5. Diez Roux AV, Kiefe CI, Jacobs DR Jr, et al. Area characteristics and individual-level socioeconomic position indicators in three population-based epidemiologic studies. Ann Epidemiol.2001;11:395–405.[Medline]
6. Fiscella K, Franks P. Impact of patient socioeconomic status on physician profiles: a comparison of census-derived and individual measures. Med Care.2001;39:8–14.[Medline]
7. Diez Roux AV. Investigating neighborhood and area effects on health. Am J Public Health.2001;91:1783–1789.
8. US Bureau of the Census. Geographical areas reference manual. Available at: http://www.census.gov/geo/www/garm.html. Accessed February 12, 2002.
9. Census of Population and Housing, 1990: Summary Tape File 3 Technical Documentation. Washington, DC: US Bureau of the Census; 1991.
10. US Bureau of the Census. Geographics changes for census 2000 + glossary. Available at: http://www.census.gov/geo/www/tiger/glossary.html. Accessed July 3, 2001.
11. US Bureau of the Census. Census 2000 zip code tabulation areas (ZCTAs). Available at: http://www.census.gov/geo/ZCTA/zcta.html. Accessed February 12, 2002.
12. US Bureau of the Census. Zip code tabulation area (ZCTA) frequently asked questions. Available at: http://www.census.gov/geo/ZCTA/zctafaq.html. Accessed February 12, 2002.
13. US Bureau of the Census. Census 2000 zip code tabulation areas technical documentation. Available at: http://www.census.gov/geo/ZCTA/zcta_tech_doc.pdf. Accessed February 12, 2002.
14. Address Information Products Technical Guide. Memphis, Tenn: US Postal Service National Customer Support Center; 2001.
15. Office of Social and Economic Data Analysis. The zip code resource page: tools and resources related to US zip codes. Available at: http://www.oseda.missouri.edu/uic/zip.resources.html. Accessed: February 24, 2002.
16. Range L, Clay T, Oliva G. California Child and Youth Injury Hot Spot Project 1995–1997, Volume 3: Technical Guide. Sacramento, Calif: California Dept of Health Services, Maternal and Child Health Branch; 2000:59–67.
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21. Zip Code Changes for the Boston Area Effective July 1, 1998. Dorchester, Mass: US Post Office; 1998.
22. Kogevinas M, Pearce N, Susser M, Bofetta P, eds. Social Inequalities in Cancer. Lyon, France: International Agency for Research on Cancer; 1997. IARC scientific publication 136.
23. Richards TB, Croner CM, Rushton G, Brown CK, Fowler L. Geographic information systems and public health: mapping the future. Public Health Rep.1999;114:359–373.[Medline]
24. Moore DA, Carpenter TE. Spatial analytic methods and geographic information systems: use in health research and epidemiology. Epidemiol Rev.1999;21:143–161.
25. Pamuk ER. Social class inequality in mortality from 1921 to 1972 in England and Wales. Popul Stud.1985;39:17–31.
26. Wagstaff A, Paci P, van Doorslaer E. On the measurement of inequalities in health. Soc Sci Med.1991;33:545–557.
27. Davey Smith G, Hart C, Hole D, et al. Education and occupational social class: which is the more important indicator of mortality risk? J Epidemiol Community Health.1998;52:153–160.[Abstract]
28. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vital Stat Rep. October 7, 1998;47(3).
29. Casper ML, Barnett E, Halverson JA, et al. Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality. Morgantown, WVa: Office for Social Environment and Health Research, West Virginia University; 1999.
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