Residential environments and cardiovascular risk

Neighborhoods and racial/ethnic differences in ideal cardiovascular health (the Multi-Ethnic Study of Atherosclerosis)

Using data from the Multi-Ethnic Study of Atherosclerosis baseline sample from 2000 to 2002 (N=5263; mean age=62) we examined cross-sectional racial/ethnic differences in ideal CVH, defined by the American Heart Association 2020 Impact Goals as a summary measure of ideal levels of blood pressure, fasting glucose, cholesterol, body mass index, diet, physical activity, and smoking. Using three different analytical approaches, we examined differences before and after adjustment for neighborhood socioeconomic, physical, and social environments. Significant racial/ethnic differences were present for all indicators of ideal CVH (excluding physical activity). Additional adjustments for neighborhood factors produced modest reductions in racial/ethnic differences. Future research is necessary to better understand the impact of neighborhood context on health disparities using longitudinal study designs.

The Social Determinants of Health Core: Taking a Place-Based Approach

INTRODUCTION

There is growing recognition that health disparities research needs to incorporate social determinants in the local environment into explanatory models. In the transdisciplinary setting of the Mid-South Transdisciplinary Collaborative Center (TCC), the Social Determinants of Health (SDH) Core developed an approach to incorporating SDH across a variety of studies. This place-based approach, which is geographically based, transdisciplinary, and inherently multilevel, is discussed.

METHODS

From 2014 through 2016, the SDH Core consulted on a variety of Mid-South TCC research studies with the goal of incorporating social determinants into their research designs. The approach used geospatial methods (e.g., geocoding) to link individual data files with measures of the physical and social environment in the SDH Core database. Once linked, the method permitted various types of analysis (e.g., multilevel analysis) to determine if racial disparities could be explained in terms of social determinants in the local environment.

RESULTS

The SDH Core consulted on five Mid-South TCC research projects. In resulting analyses for all the studies, a significant portion of the variance in one or more outcomes was partially explained by a social determinant from the SDH Core database.

CONCLUSIONS

The SDH Core approach to addressing health disparities by linking neighborhood social and physical environment measures to an individual-level data file proved to be a successful approach across Mid-South TCC research projects.

Change in Neighborhood Characteristics and Change in Coronary Artery Calcium: A Longitudinal Investigation in the MESA (Multi-Ethnic Study of Atherosclerosis) Cohort

BACKGROUND

Although some evidence shows that neighborhood deprivation is associated with greater subclinical atherosclerosis, prior studies have not identified what aspects of deprived neighborhoods were driving the association.

METHODS

We investigated whether social and physical neighborhood characteristics are related to the progression of subclinical atherosclerosis in 5950 adult participants of the MESA (Multi-Ethnic Study of Atherosclerosis) during a 12-year follow-up period. We assessed subclinical disease using coronary artery calcium (CAC). Neighborhood features examined included density of recreational facilities, density of healthy food stores, and survey-based measures of availability of healthy foods, walking environment, and social environment. We used econometric fixed-effects models to investigate how change in a given neighborhood exposure is related to simultaneous change in subclinical atherosclerosis.

RESULTS

Increases in density of neighborhood healthy food stores were associated with decreases in CAC (mean changes in CAC Agatston units per 1-SD increase in neighborhood exposures, -19.99; 95% confidence interval, -35.21 to -4.78) after adjustment for time-varying demographic confounders and computed tomography scanner type. This association remained similar in magnitude after additional adjustment for time-varying behavioral risk factors and depression. The addition of time-varying biomedical factors attenuated associations with CAC slightly (mean changes in CAC per 1-SD increase in neighborhood exposures, -17.60; 95% confidence interval, -32.71 to -2.49). Changes across time in other neighborhood measures were not significantly associated with within-person change in CAC.

CONCLUSIONS

Results from this longitudinal study provide suggestive evidence that greater access to neighborhood healthy food resources may slow the development of coronary atherosclerosis in middle-aged and older adults.

Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents' access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [-4.40 percentage points; 95 % confidence intervals (CI) -5.80, -3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.

Built Environment, Selected Risk Factors and Major Cardiovascular Disease Outcomes: A Systematic Review

INTRODUCTION

Built environment attributes have been linked to cardiovascular disease (CVD) risk. Therefore, identifying built environment attributes that are associated with CVD risk is relevant for facilitating effective public health interventions.

OBJECTIVE

To conduct a systematic review of literature to examine the influence of built environmental attributes on CVD risks.

DATA SOURCE

Multiple database searches including Science direct, CINAHL, Masterfile Premier, EBSCO and manual scan of reference lists were conducted.

INCLUSION CRITERIA

Studies published in English between 2005 and April 2015 were included if they assessed one or more of the neighborhood environmental attributes in relation with any major CVD outcomes and selected risk factors among adults.

DATA EXTRACTION

Author(s), country/city, sex, age, sample size, study design, tool used to measure neighborhood environment, exposure and outcome assessments and associations were extracted from eligible studies.

RESULTS

Eighteen studies met the inclusion criteria. Most studies used both cross-sectional design and Geographic Information System (GIS) to assess the neighborhood environmental attributes. Neighborhood environmental attributes were significantly associated with CVD risk and CVD outcomes in the expected direction. Residential density, safety from traffic, recreation facilities, street connectivity and high walkable environment were associated with physical activity. High walkable environment, fast food restaurants, supermarket/grocery stores were associated with blood pressure, body mass index, diabetes mellitus and metabolic syndrome. High density traffic, road proximity and fast food restaurants were associated with CVDs outcomes.

CONCLUSION

This study confirms the relationship between neighborhood environment attributes and CVDs and risk factors. Prevention programs should account for neighborhood environmental attributes in the communities where people live.

Neighborhood environment correlates of physical activity and sedentary behavior among Latino adults in Massachusetts

Background

U.S. Latinos experience high rates of cardio-metabolic diseases and have high rates of physical inactivity and sedentary behavior. Understanding the environmental factors associated with physical activity and sedentary behaviors among Latinos could inform future interventions. The purpose of this study is to explore the neighborhood environment correlates of physical activity and sedentary behavior in a sample of U.S. Latino adults.

Methods

Cross-sectional study of 602 Latino adults in Lawrence, MA. Survey assessments of physical activity, sedentary behavior, and neighborhood environment were verbally administered. The neighborhood environment scale assessed violence, safety, aesthetic quality, walkability, availability of healthy foods, social cohesion, and activities with neighbors.

Results

After controlling forage, gender, education, body mass index (BMI), and smoking status, two variables were associated with the outcomes of interest. Living in more walkable neighborhoods was associated with an increased likelihood of engaging in adequate levels of physical activity (>150 min per week, as recommended by the American College of Sports Medicine (ACSM)) (OR = 1.403, p = .018); and greater frequency of activities with neighbors was associated with greater sedentary behavior (β = .072, p = .05).

Conclusions

There were different neighborhood environment correlates of physical activity and sedentary behavior in this Latino community. Focusing on a greater understanding of the distinct social and physical environmental correlates of physical activity and sedentary behavior may provide important insights for reducing CVD risk and health disparities among Latinos.

The Relationship of Social Support and Neighborhood Perceptions among Individuals with HIV

Social support has been noted to improve health outcomes for individuals with HIV. Understanding how neighborhoods contribute to feelings of social support is beneficial to create environments where populations with HIV can be supported. This study assessed the relationship between neighborhood perceptions and social support with HIV management. A total of 201 individuals were recruited; individuals with HIV, 18 years or older, who were eligible to participate in the 2-hour interview. Psychiatric diagnostic interviews were conducted alongside assessments of social support and neighborhood perceptions; biomedical markers were abstracted from medical records. Correlations and linear regression analyses were performed to assess relationships between social support and neighborhood perceptions with HIV management biomarkers. The majority of the sample was male (68.8%) and African American (72.3%), with a mean age of 43.1 years. Overall, 78% were receiving combination antiretroviral therapy (cART) prescriptions, with 69% being virally suppressed. Fear of neighborhood activities was independently associated with receiving current cART. Reports of social support and neighborhood perceptions were highly correlated. Findings suggest that supportive home environments likely would improve perceptions of social support.

The Impact of Neighborhoods on CV Risk

Cardiovascular disease (CVD) continues to be the leading cause of death and a major source of health disparities in the Unites States and globally. Efforts to reduce CVD risk and eliminate cardiovascular health disparities have increasingly emphasized the importance of the social determinants of health. Neighborhood environments have emerged as a possible target for prevention and policy efforts. Hence there is a need to better understand the role of neighborhood environments in shaping cardiovascular risk. The MESA (Multi-Ethnic Study of Atherosclerosis) Neighborhood Study provided a unique opportunity to build a comprehensive place-based resource for investigations of associations between specific features of neighborhood physical and social environments and cardiovascular risk factors and outcomes. This review summarizes the approaches used to characterize residential neighborhood environments in the MESA cohort, provides an overview of key findings to date, and discusses challenges and opportunities in neighborhood health effects research. Results to date suggest that neighborhood physical and social environments are related to behavioral and biomedical risk factors for CVD and that cardiovascular prevention efforts may benefit from taking neighborhood context into account.

Women's Perceptions of Neighborhood Resources and Hazards Related to Diet, Physical Activity, and Smoking: Focus Group Results from Economically Distinct Neighborhoods in a Mid-Sized U.S. City

Purpose.

To investigate women's perceptions of neighborhood resources and hazards associated with poor diet, physical inactivity, and cigarette smoking.

Design.

After interviewing city officials and analyzing visual assessments, three economically distinct neighborhoods in a mid-sized city were selected.

Setting.

Salinas, California, a predominantly Latino city.

Methods.

Eight focus groups, conducted in Spanish or English in the three neighborhoods. Thematic coding of focus group transcripts identified key concepts. Women also mapped their perceived neighborhood boundaries.

Participants.

Women who had at least one child under age 18 living with them.

Results.

Women identified food stores, parks, recreation areas, and schools as key resources in their neighborhoods. They identified fast food restaurants, convenience stores, violent crime, gangs, and drug-associated issues as “hazards.” Distinctions between resources and hazards were not always clear cut. For example, parks were sometimes considered dangerous, and fast food restaurants were sometimes considered a convenient and inexpensive way to feed one's family. Women's perceptions of their neighborhood boundaries differed greatly by type of neighborhood—the perceived neighborhood area (in acres) drawn by women in the lower-income neighborhood was one-fourth the size of the area drawn by women in the higher-income neighborhood.

Conclusion.

This qualitative, exploratory study illustrates how resources and hazards in one's neighborhood cannot be viewed as having solely one dimension—each may influence health behaviors both positively and negatively.

Sex differences in the risk profile of hypertension: a cross-sectional study

OBJECTIVE

To assess the socioeconomic and behavioural risk factors associated with hypertension among a sample male and female population in India.

SETTING

Cross-sectional survey data from a Health and Demographic Surveillance System (HDSS) of rural West Bengal, India was used.

PARTICIPANTS

27 589 adult individuals (13 994 males and 13 595 females), aged ≥18 years, were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Hypertension was defined as mean systolic blood pressure (SBP) ≥140 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg, or if the subject was undergoing regular antihypertensive therapy. Prehypertension was defined as SBP 120-139 mm Hg and DBP 80-89 mm Hg. Individuals were categorised as non-normotensives, which includes both the prehypertensives and hypertensives. Generalised ordered logit model (GOLM) was deployed to fulfil the study objective.

RESULTS

Over 39% of the men and 25% of the women were prehypertensives. Almost 12.5% of the men and 11.3% of the women were diagnosed as hypertensives. Women were less likely to be non-normotensive compared to males. Odds ratios estimated from GOLM indicate that women were less likely to be hypertensive or prehypertensive, and age (OR 1.04, 95% CI 1.03 to 1.05; and OR 1.08, 95% CI 1.07 to 1.09 for males and females, respectively) and body mass index (OR 1.64, 95% CI 1.38 to 1.97 for males; and OR 1.32, 95% CI 1.08 to 1.60 for females) are associated with hypertension.

CONCLUSIONS

An elevated level of hypertension exists among a select group of the rural Indian population. Focusing on men, an intervention could be designed for lifestyle modification to curb the prevalence of hypertension.

Adverse childhood experiences and later life adult obesity and smoking in the United States

PURPOSE

Prior work demonstrates associations between physical abuse, household alcohol abuse, and household mental illness early in life with obesity and smoking. Studies, however, have not generally been in nationally representative samples and have not conducted analyses to account for bias in the exposure.

METHODS

We used data from the 1979 U.S. National Longitudinal Survey of Youth to test associations between measures of adverse childhood experiences with obesity and smoking and used an instrumental variables approach to address potential measurement error of the exposure.

RESULTS

Models demonstrated associations between childhood physical abuse and obesity at age 40 years (odds ratio [OR] 1.23; 95% confidence interval [CI], 1.00-1.52) and ever smoking (OR 1.83; 95% CI, 1.56-2.16), as well as associations between household alcohol abuse (OR 1.53; 95% CI, 1.31-1.79) and household mental illness (OR 1.29; 95% CI, 1.04-1.60) with ever smoking. We find no evidence of association modification by gender, socioeconomic position, or race and/or ethnicity. Instrumental variables analysis using a sibling's report of adverse childhood experiences demonstrated a relationship between household alcohol abuse and smoking, with a population attributable fraction of 17% (95% CI, 2.0%-37%) for ever smoking and 6.7% (95% CI, 1.6%-12%) for currently smoking.

CONCLUSIONS

Findings suggest long-term impacts of childhood exposure to physical abuse, household alcohol abuse, and parental mental illness on obesity and smoking and that the association between household alcohol abuse and smoking is not solely due to measurement error.

Association of socioeconomic factors with body mass index, obesity, physical activity, and dietary factors in Belo Horizonte, Minas Gerais State, Brazil: The BH Health Study

Obesity prevalence is rapidly increasing in developing countries. Existing research investigating social patterning of obesity and its risk factors in Latin American urban contexts has inconsistent findings. This study analyzed a multistage household survey in adults in Belo Horizonte, Minas Gerais State, Brazil. Marginal models were used to examine the association of education and household and neighborhood income with body mass index (BMI), obesity, physical inactivity, and low fruit and vegetable intake after adjusting for age and ethnicity and stratifying by sex. BMI and obesity were inversely associated with education in women. BMI was positively associated with household and neighborhood income in men. Additionally, physical inactivity and low fruit and vegetable intake were inversely associated with education and household income in both men and women, and physical inactivity was inversely associated with neighborhood income in men. Understanding the drivers of these patterns will allow for development of appropriate policy and interventions to reduce cardiovascular disease risk in large cities in Latin America.

Spatializing Area-Based Measures of Neighborhood Characteristics for Multilevel Regression Analyses: An Areal Median Filtering Approach

Area-based measures of neighborhood characteristics simply derived from enumeration units (e.g., census tracts or block groups) ignore the potential of spatial spillover effects, and thus incorporating such measures into multilevel regression models may underestimate the neighborhood effects on health. To overcome this limitation, we describe the concept and method of areal median filtering to spatialize area-based measures of neighborhood characteristics for multilevel regression analyses. The areal median filtering approach provides a means to specify or formulate "neighborhoods" as meaningful geographic entities by removing enumeration unit boundaries as the absolute barriers and by pooling information from the neighboring enumeration units. This spatializing process takes into account for the potential of spatial spillover effects and also converts aspatial measures of neighborhood characteristics into spatial measures. From a conceptual and methodological standpoint, incorporating the derived spatial measures into multilevel regression analyses allows us to more accurately examine the relationships between neighborhood characteristics and health. To promote and set the stage for informative research in the future, we provide a few important conceptual and methodological remarks, and discuss possible applications, inherent limitations, and practical solutions for using the areal median filtering approach in the study of neighborhood effects on health.

Neighborhood Environments and Incident Hypertension in the Multi-Ethnic Study of Atherosclerosis

We examined relationships between neighborhood physical and social environments and incidence of hypertension in a cohort of 3,382 adults at 6 sites in the United States over 10 years of follow-up (2000-2011), using data from the Multi-Ethnic Study of Atherosclerosis. The sample was aged 45-84 years (mean = 59 years) and free of clinical cardiovascular disease and hypertension at baseline. Of the participants, 51% were female, 44% white, 23% Hispanic, 21% black, and 13% Chinese-American; 39% of participants developed hypertension during an average of 7.2 years of follow-up. Cox models were used to estimate associations of time-varying cumulative average neighborhood features (survey-based healthy food availability, walking environment, social cohesion, safety, and geographic information system-based density of favorable food stores and recreational resources) with incident hypertension. After adjustment for individual and neighborhood-level covariates, a 1-standard-deviation increase in healthy food availability was associated with a 12% lower rate of hypertension (hazard ratio = 0.88, 95% confidence interval: 0.82, 0.95). Other neighborhood features were not related to incidence of hypertension. The neighborhood food environment is related to the risk of hypertension.

Geographical clustering of incident acute myocardial infarction in Denmark: A spatial analysis approach

OBJECTIVES

To examine the geographical patterns in AMI and characterize individual and neighborhood sociodemographic factors for persons living inside versus outside AMI clusters.

METHODS

The study population comprised 3,515,670 adults out of whom 74,126 persons experienced an incident AMI (2005-2011). Kernel density estimation and global and local clustering methods were used to examine the geographical patterns in AMI. Median differences and frequency distributions of sociodemographic factors were calculated for persons living inside versus outside AMI clusters.

RESULTS

Global clustering of AMI occurred in Denmark. Throughout the country, 112 significant clusters with high risk of incident AMI were identified. The relative risk of AMI in significant clusters ranged from 1.45 to 47.43 (median=4.84). Individual and neighborhood socioeconomic position was markedly lower for persons living inside versus outside AMI clusters.

CONCLUSIONS

AMI is geographically unequally distributed throughout Denmark and determinants of these geographical patterns might include individual- and neighborhood-level sociodemographic factors.

Matching the Genotype in Resolution: Innovative Ways of Phenotype Capture

Social and spatial context are important determinants of morbidity and mortality. However, there is little clarity about the role of context for kidney disease specifically, particularly before the end stage. Meanwhile, research clarifying the clinical, cellular, molecular, and genetic causes of kidney disease is accelerating considerably. We postulate that without contextual information, even the most detailed biomedical information cannot fully capture the factors that ultimately drive the development and progression of kidney disease. The Nephrotic Syndrome Study Network is integrating detailed, state-of-the-art information on a social and spatial context to enable the exploration of the associations between the social environment and kidney disease. Here, we discuss the extant literature on social context and kidney disease, present information on sources of contextual information, and provide recommended further reading to facilitate future research on the contribution of the social context to kidney disease.

Making unhealthy places: The built environment and non-communicable diseases in Khayelitsha, Cape Town

In this paper, we examine how economic, social and political forces impact on NCDs in Khayelitsha (a predominantly low income area in Cape Town, South Africa) through their shaping of the built environment. The paper draws on literature reviews and ethnographic fieldwork undertaken in Khayelitsha. The three main pathways through which the built environment of the area impacts on NCDs are through a complex food environment in which it is difficult to achieve food security, an environment that is not conducive to safe physical activity, and high levels of depression and stress (linked to, amongst other factors, poverty, crime and fear of crime). All of these factors are at least partially linked to the isolated, segregated and monofunctional nature of Khayelitsha. The paper highlights that in order to effectively address urban health challenges, we need to understand how economic, social and political forces impact on NCDs through the way they shape built environments.

An Original Stepwise Multilevel Logistic Regression Analysis of Discriminatory Accuracy: The Case of Neighbourhoods and Health

BACKGROUND AND AIM

Many multilevel logistic regression analyses of "neighbourhood and health" focus on interpreting measures of associations (e.g., odds ratio, OR). In contrast, multilevel analysis of variance is rarely considered. We propose an original stepwise analytical approach that distinguishes between "specific" (measures of association) and "general" (measures of variance) contextual effects. Performing two empirical examples we illustrate the methodology, interpret the results and discuss the implications of this kind of analysis in public health.

METHODS

We analyse 43,291 individuals residing in 218 neighbourhoods in the city of Malmö, Sweden in 2006. We study two individual outcomes (psychotropic drug use and choice of private vs. public general practitioner, GP) for which the relative importance of neighbourhood as a source of individual variation differs substantially. In Step 1 of the analysis, we evaluate the OR and the area under the receiver operating characteristic (AUC) curve for individual-level covariates (i.e., age, sex and individual low income). In Step 2, we assess general contextual effects using the AUC. Finally, in Step 3 the OR for a specific neighbourhood characteristic (i.e., neighbourhood income) is interpreted jointly with the proportional change in variance (i.e., PCV) and the proportion of ORs in the opposite direction (POOR) statistics.

RESULTS

For both outcomes, information on individual characteristics (Step 1) provide a low discriminatory accuracy (AUC = 0.616 for psychotropic drugs; = 0.600 for choosing a private GP). Accounting for neighbourhood of residence (Step 2) only improved the AUC for choosing a private GP (+0.295 units). High neighbourhood income (Step 3) was strongly associated to choosing a private GP (OR = 3.50) but the PCV was only 11% and the POOR 33%.

CONCLUSION

Applying an innovative stepwise multilevel analysis, we observed that, in Malmö, the neighbourhood context per se had a negligible influence on individual use of psychotropic drugs, but appears to strongly condition individual choice of a private GP. However, the latter was only modestly explained by the socioeconomic circumstances of the neighbourhoods. Our analyses are based on real data and provide useful information for understanding neighbourhood level influences in general and on individual use of psychotropic drugs and choice of GP in particular. However, our primary aim is to illustrate how to perform and interpret a multilevel analysis of individual heterogeneity in social epidemiology and public health. Our study shows that neighbourhood "effects" are not properly quantified by reporting differences between neighbourhood averages but rather by measuring the share of the individual heterogeneity that exists at the neighbourhood level.

Associations of perceived neighborhood safety and crime with cardiometabolic risk factors among a population with type 2 diabetes

Little is known about how neighborhood crime may relate to health in diabetes patients. We examined associations between individuals' perceptions of neighborhood safety or violent crime and stress, physical activity, body mass index (BMI) or hemoglobin A1c (HbA1c) in a sample (n=721) of adults (mean age:63) with diabetes. Self-reported neighborhood safety, violent crime, physical activity, and stress were collected and linked to clinical measures of BMI and HbA1c. Approximately 54% and 15% of patients reported neighborhood safety concerns and violent crimes, respectively. Any neighborhood safety concerns (β=1.14, 95% C.I. 0.04-2.24) and violent crime (β=2.04, 95% C.I. 0.34-3.73) were associated with BMI in adjusted analysis. Any violent crime was associated with class II-III obesity (BMI≥35) (OR=1.34, 95% C.I.: 1.02, 1.75). There were no significant associations between neighborhood safety concerns or violent crime with stress, physical activity, or HbA1c. Neighborhood safety is associated with BMI and obesity. Further studies, including longitudinal designs, are needed to study how people with diabetes may be influenced by a sense of poor personal safety in their neighborhoods.

Local Actors' Frames of the Role of Living Conditions in Shaping Hypertension Risk and Disparities in a Colombian Municipality

Conditions in the social and physical environment influence population health and risk for CVD, including hypertension. These environmental conditions are influenced by the decisions of public officials, community leaders, and service providers. Examining the frames that local decision makers bring to understanding hypertension can provide important insights into the decisions that they make about strategies for addressing this problem in their jurisdiction. The goal of this study was to examine the frames that local decision makers in Quibdó, Colombia, bring to understanding hypertension risk, and in particular, whether and how they use frames that encompass associations between living conditions and hypertension risk. Data for this qualitative study were collected using a stratified sampling strategy. Semi-structured interviews were conducted in 2012 with 13 local decision makers and analyzed using a framework approach. Participants linked the structural conditions experienced in Quibdó, including displacement, limited economic opportunities, and the infrastructure of the city, to hypertension risk through multiple pathways, including behavioral risk factors for hypertension and physiologic responses to stress. They described the social patterning of these factors across socioeconomic, racial/ethnic, and gender hierarchies. Although several conditions associated with hypertension risk are widely distributed in the city's population, social processes of marginalization and stratification create additional disadvantages for those on the lower rungs of the social hierarchy.

Environment and Its Influence on Health and Demographics in South Korea

As the prevalence of overweight and obesity has been increasing in South Korea, it is critical to better understand possible associations between environmental surroundings and general health status. We characterize key health test readings and basic demographic information from 10,816 South Koreans, obtained from two Ubiquitous Healthcare (U-Healthcare) centers that have distinct surrounding neighborhood characteristics. One is located in a rural area in Busan, the other is located in an urban area in Daegu surrounded by a highly crowded residential and commercial business area. We analyze comprehensive health data sets, including blood pressure, body mass index, pulse rate, and body fat percentage from December 2013 to December 2014 to study differences in overall health test measurements between users of rural and urban U-Healthcare centers. We conduct multiple regression analyses to evaluate differences in general health status between the two centers, adjusting for confounding factors. We report statistical evidence of differences in blood pressure at the two locations. As local residents are major users, the result indicates that the environmental surroundings of the centers can influence the demographics of the users, the type of health tests in demand, and the users’ health status. We further envision that U-Healthcare centers will provide public users with an opportunity for enhancing their current health, which could potentially be used to prevent them from developing chronic diseases, while providing surveillance healthcare data.

Residential Proximity to Major Roadways and Lung Cancer Mortality. Italy, 1990-2010: An Observational Study

BACKGROUND

Air pollution from road traffic has been associated to an increased risk of lung cancer. Herein, we investigated the association between lung cancer mortality and residence near Italian highways or national major roads.

METHODS

Information on deaths for lung cancer registered from 1990 to 2010 and stratified by age, gender, and urban or rural municipality of residence at death were obtained from the National Institute of Statistics. Distance between the centroid of the municipality of residence and closest major roadways was considered as a proxy of pollution exposure. Relative Risks (RR) and 95% confidence intervals (CI) were computed using Poisson log-linear models adjusted for age, calendar period, deprivation index, North/South gradient, and urban/rural status.

RESULTS

A gradient in risk for lung cancer mortality was seen for residents within 50 meters (m) of national major roads. In particular, in rural municipalities a statistically significant increased risk for lung cancer death was observed in both sexes (RR = 1.27 for distance <25 m vs. 500-1999 m, 95% CI 1.17-1.42, in men; RR = 1.97, 95% CI 1.64-2.39, in women). In urban municipalities, weak risks of borderline significance were documented in both sexes (RR = 1.06, 95% CI 0.99-1.15 in men; and RR = 1.09, 95% CI 0.97-1.22 in women). No statistically significant association emerged between residence within 100 to 500 m from highways and RRs of death for lung cancer.

CONCLUSIONS

In Italy, residing near national major roads, in particular in rural municipalities, was related to elevated risks of death for lung cancer.

Neighborhood and Individual Socioeconomic Status and Asthma Incidence in African American Women

OBJECTIVE

Individual socioeconomic status (SES) has been associated with asthma incidence but whether neighborhood SES has an influence is unknown. We assessed the contributions of neighborhood socioeconomic status (SES), neighborhood housing density, neighborhood racial composition, and individual SES to the development of adult-onset asthma in Black women, accounting for other known or suspected risk factors.

DESIGN AND PARTICIPANTS

Prospective cohort study conducted among 47,779 African American women followed with biennial health questionnaires from 1995 to 2011.

METHODS AND MAIN OUTCOME MEASURES

Incident asthma was defined as new self-report of doctor-diagnosed asthma with concurrent use of asthma medication. We assessed neighborhood SES, indicated by census variables representing income, education, and wealth, and housing density and % African American population, as well as individual SES, indicated by highest education of participant/spouse. Cox proportional hazards models were used to derive multivariable hazard ratios (HRs) and 95% CIs for the association of individual SES and neighborhood variables with asthma incidence.

RESULTS

During a 16-year follow-up period, 1520 women reported incident asthma. Neighborhood factors were not associated with asthma incidence after control for individual SES, body mass index, and other factors. Compared with college graduates, the multivariable HR for asthma was 1.13 (95% CI 1.00-1.28) for women with some college education and 1.23 (95% CI 1.05-1.44) for women with no more than a high school education.

CONCLUSIONS

Individual SES, but not neighborhood SES or other neighborhood factors, was associated with the incidence of adult-onset asthma in this population of African American women.

Are neighborhoods causal? Complications arising from the 'stickiness' of ZNA

Are neighborhoods causal? The answer remains elusive. Armed with new multilevel methods, enthusiasm for neighborhoods research surged at the turn of the century. However, a wave of skepticism has arisen based on the difficulty of drawing causal inferences from observational studies in which selection to neighborhoods is non-random. Researchers have sought answers from experimental and quasi-experimental studies of movers vs. stayers. We develop two related concepts in this essay in the hopes of shedding light on this problem. First, the inceptive environment into which persons are born (which we term ZNA for Zip code Nativity Area) exerts a potentially powerful causal impact on health. Detecting that causal effect is challenging for reasons similar that obtain in other fields (including genetics). Second, we explicate the problem of neighborhood 'stickiness' in terms of the persistence of neighborhood treatment assignment, and argue that under-appreciation of stickiness has led to systematic bias in causal estimates of neighborhoods proportional to the degree of stickiness. In sticky contexts, failure to account for the lasting influences of ZNA by adjusting for intermediate individual socioeconomic and health variables on the causal pathway can result in neighborhood effects estimates that are biased toward the null. We follow with an example drawn from evidence of neighborhood 'stickiness' and obesity. The stickiness of ZNA cautions us that experimental evidence may be insufficient or misleading as a solution to causal inference problems in neighborhood research.

Leisure-time physical activity in the vicinity of Academias da Cidade Program in Belo Horizonte, Minas Gerais State, Brazil: the impact of a health promotion program on the community

Abstract This study analyzed leisure-time physical activity among 1,621 adults who were non-users of the Academias da Cidade Program in Belo Horizonte, Minas Gerais State, Brazil, but who lived in the vicinity of a fitness center in operation (exposed Group I) or in the vicinity of two sites reserved for future installation of centers (control Groups II and III). The dependent variable was leisure-time physical activity, and linear distance from the households to the fitness centers was the exposure variable, categorized in radial buffers: < 500m; 500-1,000m; and 1,000-1,500m. Binary logistic regression was performed with the Generalized Estimation Equations method. Residents living within < 500m of the fitness center gave better ratings to the physical environment when compared to those living in the 1,000 and 1,500m buffers and showed higher odds of leisure-time physical activity (OR = 1.16; 95%CI: 1.03-1.30), independently of socio-demographic factors; the same was not observed in the control groups (II and III). The findings suggests the program’s potential for influencing physical activity in the population living closer to the fitness center and thus provide a strategic alternative for mitigating inequalities in leisure-time physical activity.

Exploring ecological, emotional and social levers of self-rated health for urban gardeners and non-gardeners: A path analysis

RATIONALE

The social, emotional, and mental health benefits associated with gardening have been well documented. However, the processes underlying the relationship between garden participation and improvements in health status have not been sufficiently studied.

METHODS

Using population-based survey data (n = 469 urban residents), objective street environment data, and area-level measures, this research used a path analytic framework to examine several theoretically based constructs as mediators between gardening history and self-reported health.

RESULTS

The results showed that garden participation influenced health status indirectly through social involvement with one's community, perceived aesthetic appeal of the neighborhood, and perceived collective efficacy. Gardeners, compared to non-gardeners, reported higher ratings of neighborhood aesthetics and more involvement in social activities, whereas aesthetics and involvement were associated with higher ratings of collective efficacy and neighborhood attachment. Collective efficacy, but not neighborhood attachment, predicted self-rated health. Gardening also directly influenced improved fruit and vegetable intake. The physical and social qualities of garden participation may therefore stimulate a range of interpersonal and social responses that are supportive of positive ratings of health.

CONCLUSION

This research suggests that community planners and health professionals should aim to strengthen the social and aesthetic relationships while designing environments and policies as a way to ignite intermediate processes that may lead to improved health status.

Household income and adolescent blood pressure in a Chinese birth cohort: "Children of 1997"

The inconsistent relation of national income with population blood pressure raises questions as to whether social comparisons of relative income at individual or neighbourhood level may be more relevant than absolute income. We examined the associations of absolute household income (income per se), absolute neighbourhood median income (average income among geographically-proximate households), relative household income [deprivation using Yitzhaki index, or rank by position] (differences in income or rank compared with others) and relative neighbourhood income inequality [Gini coefficient] (income gap within a neighbourhood) with blood pressure z-score, prehypertension or hypertension at ∼13 years using a fixed effects multilevel linear or logistic model in a Chinese birth cohort (n = 5063, 61% of follow-up). Absolute household or neighbourhood income was not associated with adolescent blood pressure. Greater relative household income deprivation was associated with higher diastolic blood pressure (0.01 z-score per USD 128 difference in Yitzhaki index, 95% confidence interval (CI) 0.005 to 0.02), so was lower relative household income rank (-0.10, 95% CI -0.15 to -0.04), but relative neighbourhood income inequality was not, when considering each income measure separately. Such associations remained when considering all income measures together. Income measures were not associated with prehypertension or hypertension. Relative household income (greater deprivation or lower rank) were positively associated with adolescent blood pressure independent of absolute household income while absolute or relative neighbourhood income had little contribution, suggesting social comparisons at a key developmental stage could be relevant. Clarifying specific effects of socioeconomic position across the life-course could inform interventions.

Invited Commentary: Fundamental Causes, Social Context, and Modifiable Risk Factors in the Racial/Ethnic Inequalities in Blood Pressure and Hypertension

Racial and ethnic inequalities in blood pressure and hypertension have been well documented, but their causes remain unclear, making efforts to reduce these inequalities challenging. In this issue of the Journal, Basu et al. (Am J Epidemiol. 2015;182(4):345-353) address this gap in our knowledge by using an econometric approach to examine the role of 4 conventional risk factors for hypertension. Their results suggest that targeting certain risk factors will reduce racial inequalities in the prevalence of hypertension. However, racial differences in modifiable risk factors are enmeshed within disparate socioenvironmental contexts which are in turn determined by inequalities in the distribution of social, economic, and political resources and constraints. A small but growing body of literature suggests that targeting the intermediate risk factors that link racial group membership to hypertension, rather than the context or the inequalities in the distribution of resources and constraints, will ultimately result in little change in hypertension inequalities, increase these inequalities, or even create inequalities in poor mental health.

The association of neighborhood characteristics with sleep duration and daytime sleepiness

BACKGROUND

Neighborhood characteristics have been linked to health outcomes. Various mechanisms link neighborhoods and health outcomes; sleep patterns may be 1 contributor; however, little is known about the social determinants of disordered sleep. We examined the association of neighborhood characteristics with sleep duration and daytime sleepiness.

METHODS

Participants (n = 801) enrolled as pairs (55 without pair), from 10 churches in the Stroke Health and Risk Education project; 760 were included for analysis (41 withdrew). Sleep duration (hours of sleep at night) and daytime sleepiness (adaptation of Berlin questionnaire; range, 0-3 [more daytime sleepiness]) were self-reported. Neighborhood characteristics included disadvantage, per capita violent crime (census tract level), and safety (self-reported and individual level). We fit generalized linear mixed models and multinomial and binomial logistic regression models to examine the associations between neighborhood characteristics and sleep outcomes while accounting for the clustering within churches and pairs, before and after adjustment for self-reported confounders (age, gender, income, education, body mass index, depressive symptoms, hypertension, and diabetes).

RESULTS

The mean hours of sleep duration is 6.7 ± 1.2, and the mean daytime sleepiness is 0.8 ± 0.9. Neighborhood characteristics were not associated with sleep duration. Higher perceived neighborhood safety was associated with an 18.4% lower odds of daytime sleepiness in the unadjusted model (odds ratio, 0.82 [95% confidence interval, 0.69-0.96]). The association was attenuated in the fully adjusted model. Neighborhood disadvantage and violent crime were related to lower daytime sleepiness; however, associations were not statistically significant.

CONCLUSION

Self-reported neighborhood safety was associated with lower daytime sleepiness. Future exploration of the pathways linking neighborhood characteristics and sleep is warranted.

Making unhealthy places: The built environment and non-communicable diseases in Khayelitsha, Cape Town

In this paper, we examine how economic, social and political forces impact on NCDs in Khayelitsha (a predominantly low income area in Cape Town, South Africa) through their shaping of the built environment. The paper draws on literature reviews and ethnographic fieldwork undertaken in Khayelitsha. The three main pathways through which the built environment of the area impacts on NCDs are through a complex food environment in which it is difficult to achieve food security, an environment that is not conducive to safe physical activity, and high levels of depression and stress (linked to, amongst other factors, poverty, crime and fear of crime). All of these factors are at least partially linked to the isolated, segregated and monofunctional nature of Khayelitsha. The paper highlights that in order to effectively address urban health challenges, we need to understand how economic, social and political forces impact on NCDs through the way they shape built environments.

Examining the cross-sectional and longitudinal association between diurnal cortisol and neighborhood characteristics: Evidence from the multi-ethnic study of atherosclerosis

We examined cross-sectional and longitudinal associations between neighborhood socioeconomic status, social cohesion and safety and features of the diurnal cortisol curve including: area under the curve (AUC), wake-to-bed slope, wake-up, cortisol awakening response (CAR, wake-up to 30 min post-awakening), early decline (30 min to 2 h post-awakening) and late decline (2 h post-awakening to bed time). In cross-sectional analyses, higher neighborhood poverty was associated with a flatter early decline and a flatter wake-to-bed slope. Higher social cohesion and safety were associated with higher wake-up cortisol, steeper early decline and steeper wake-to-bed slope. Over 5 years, wake-up cortisol increased, CAR, early decline, late decline and wake-to-bed slope became flatter and AUC became larger. Higher poverty was associated with less pronounced increases in wake-up and AUC, while higher social cohesion was associated with greater increases in wake-up and AUC. Adverse neighborhood environments were cross-sectionally associated with flatter cortisol profiles, but associations with changes in cortisol were weak and not in the expected direction.

The Relationship of Adverse Childhood Experiences to PTSD, Depression, Poly-Drug Use and Suicide Attempt in Reservation-Based Native American Adolescents and Young Adults

Adverse childhood experiences (ACEs) are associated with numerous risk behaviors and mental health outcomes among youth. This study examines the relationship between the number of types of exposures to ACEs and risk behaviors and mental health outcomes among reservation-based Native Americans. In 2011, data were collected from Native American (N = 288; 15-24 years of age) tribal members from a remote plains reservation using an anonymous web-based questionnaire. We analyzed the relationship between six ACEs, emotional, physical, and sexual abuse, physical and emotional neglect, witness to intimate partner violence, for those <18 years, and included historical loss associated symptoms, and perceived discrimination for those <19 years; and four risk behavior/mental health outcomes: post-traumatic stress disorder (PTSD) symptoms, depression symptoms, poly-drug use, and suicide attempt. Seventy-eight percent of the sample reported at least one ACE and 40 % reported at least two. The cumulative impact of the ACEs were significant (p < .001) for the four outcomes with each additional ACE increasing the odds of suicide attempt (37 %), poly-drug use (51 %), PTSD symptoms (55 %), and depression symptoms (57 %). To address these findings culturally appropriate childhood and adolescent interventions for reservation-based populations must be developed, tested and evaluated longitudinally.

Impact of neighborhood socioeconomic conditions on the risk of stroke in Japan

Background

Neighborhood deprivation has been shown in many studies to be an influential factor in cardiovascular disease risk. However, no previous studies have examined the effect of neighborhood socioeconomic conditions on the risk of stroke in Asian countries.

Methods

This study investigated whether neighborhood deprivation was associated with the risk of stroke and stroke death using data from the Japan Public Health Center-based Prospective Study. We calculated the adjusted hazard ratios of stroke mortality (mean follow-up, 16.4 years) and stroke incidence (mean follow-up, 15.4 years) according to the area deprivation index (ADI) among 90 843 Japanese men and women aged 40–69 years. A Cox proportional-hazard regression model using a shared frailty model was applied.

Results

The adjusted hazard ratios of stroke incidence, in order of increasing deprivation with reference to the least deprived area, were 1.16 (95% CI, 1.04–1.29), 1.12 (95% CI, 1.00–1.26), 1.18 (95% CI, 1.02–1.35), and 1.19 (95% CI, 1.01–1.41), after adjustment for individual socioeconomic conditions. Behavioral and psychosocial factors attenuated the association, but the association remained significant. The associations were explained by adjusting for biological cardiovascular risk factors. No significant association with stroke mortality was identified.

Conclusions

Our results indicate that the neighborhood deprivation level influences stroke incidence in Japan, suggesting that area socioeconomic conditions could be a potential target for public health intervention to reduce the risk of stroke.

Cross-sectional associations between residential environmental exposures and cardiovascular diseases

BACKGROUND

Prior research examining neighbourhood effects on cardiovascular diseases (CVDs) has focused on the impact of neighbourhood socio-economic status or a few selected environmental variables. No studies of cardiovascular disease outcomes have investigated a broad range of urban planning related environmental factors. This is the first study to combine multiple neighbourhood influences in an integrated approach to understanding the association between the built and social environment and CVDs. By modeling multiple neighbourhood level social and environmental variables simultaneously, the study improved the estimation of effects by accounting for potential contextual confounders.

METHODS

Data were collected using a cross-sectional survey (n = 2411) across 87 census tracts (CT) in Toronto, Canada, and commercial and census data were accessed to characterize the residential environment. Multilevel regressions were used to estimate the associations of neighbourhood factors on the risk of CVD.

RESULTS

Exposure to violent crimes, environmental noise, and proximity to a major road were independently associated with increased odds of CVDs (p < 0.05) in the fully adjusted model. While reduced access to food stores, parks/recreation, and increased access to fast food restaurants were associated with increased odds of CVDs in partially adjusted models (p < 0.05), these associations were fully attenuated after adjusting for BMI and physical activity. Housing disrepair was not associated with CVD risk.

CONCLUSIONS

These findings illustrate the importance of measuring and modeling a broad range of neighborhood factors--exposure to violent crimes, environmental noise, and traffic, and access to food stores, fast food, parks/recreation areas--to identify specific stressors in relation to adverse health outcomes. Further research to investigate the temporal order of events is needed to better understand the direction of causation for the observed associations.

The impact of home safety on sleep in a Latin American country

OBJECTIVES

We sought to assess the impact of feelings of safety in one's neighborhood and home on sleep quality and sleep duration.

DESIGN

The design is a cross-sectional survey using face-to-face interviews, as part of the Argentine Social Debt Observatory assessment.

SETTING

The setting is a nationwide data from Argentina.

PARTICIPANTS

There are 5636 participants aged 18 years and older.

INTERVENTION (IF ANY)

N/A.

MEASUREMENTS

The relationships between both subjective sleep quality and self-reported sleep duration, categorized as short (<7 hours), normal (7-8 hours), and long (>8 hours) with safety in one's neighborhood and one's home, were analyzed. Age, sex, obesity, neighborhood socioeconomic status, and education were included as covariates.

RESULTS

Feeling unsafe in one's home was strongly associated with poorer sleep quality and with short sleep duration. Feeling unsafe in one's neighborhood was initially associated with reduced sleep quality but was no longer significant after controlling for home safety. In contrast, we found no correlation between safety measures and long sleep. In analyses stratified by sex, feeling unsafe in one's home was associated with poor sleep quality in women but not in men.

CONCLUSIONS

Our findings suggest that safety in the home has an important effect on both sleep quality and duration, particularly among women. In contrast, after accounting for safety in the home, neighborhood safety does not impact sleep. Further research is warranted to identify mechanisms underlying the sex differences in susceptibility to poor sleep quality and shorter sleep duration, as well as to assess whether interventions addressing safety in the home can be used to improve sleep and overall health.

Neighborhood environment and intimate partner violence: a systematic review

Intimate partner violence (IPV) is an important global public health problem, affecting women across the life span and increasing risk for a number of unfavorable health outcomes. Typically conceptualized as a private form of violence, most research has focused on individual-level risk markers. Recently, more scholarly attention has been paid to the role that the residential neighborhood environment may play in influencing the occurrence of IPV. With research accumulating since the 1990s, increasing prominence of the topic, and no comprehensive literature reviews yet undertaken, it is time to take stock of what is known, what remains unknown, and the methods and concepts investigators have considered. In this article, we undertake a comprehensive, systematic review of the literature to date on the relationship between neighborhood environment and IPV, asking, "what is the status of scholarship related to the association between neighborhood environment and IPV occurrence?" Although the literature is young, it is receiving increasing attention from researchers in sociology, public health, criminology, and other fields. Obvious gaps in the literature include limited consideration of nonurban areas, limited theoretical motivation, and limited consideration of the range of potential contributors to environmental effects on IPV--such as built environmental factors or access to services. In addition, explanations of the pathways by which place influences the occurrence of IPV draw mainly from social disorganization theory that was developed in urban settings in the United States and may need to be adapted, especially to be useful in explaining residential environmental correlates of IPV in rural or non-U.S. settings. A more complete theoretical understanding of the relationship between neighborhood environment and IPV, especially considering differences among urban, semiurban, and rural settings and developed and developing country settings, will be necessary to advance research questions and improve policy and intervention responses to reduce the burden of IPV.

Associations of neighborhood area level deprivation with the metabolic syndrome and inflammation among middle- and older- age adults

Background

The study examines the association of neighborhood socioeconomic deprivation and metabolic syndrome with inflammation.

Methods

The analysis included 19, 079 black and white participants from the REasons for Geographic And Racial Differences in Stroke Study who were age > 45 years at baseline. Logistic regression examined whether neighborhood deprivation was associated with increased odds of METS and CRP-MetS.

Results

Among black adults, residing in the most deprived neighborhoods was associated with increased odds of obesity (p < .01), lower HDL (p < .001), high blood pressure (p < .01), elevated fasting glucose (p < .001), inflammation (p < .01), and CRP-MetS (p < .001). Among white adults, neighborhood deprivation was associated with higher waist circumference (p < .001), lower HDL (p < .001), higher triglycerides (p < .01), higher glucose (p < .001), higher BMI (p < .0001), higher blood pressure (p = .01), METS (p < .001), inflammation (p < .01) and CRP-MetS (p < .001).

Conclusions

These findings highlight the role of neighborhood socioeconomic deprivation on METS and CRP-MetS for black and white adults. Interventions tailored to address the contextual effects of deprived neighborhoods may reduce the observed neighborhood disparities.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1319) contains supplementary material, which is available to authorized users.

Where Are the Fresh Fruits and Vegetables?: A Systematic Exploration of Access to Food Stores Offering Fresh Fruits and Vegetables as Told by Midwestern African American Women

This exploratory study systematically examined Midwestern African American women's (n = 273) access to food stores offering more than 5 fresh fruits and vegetables daily. Access to potential (within 0.5 miles of household) and realized (where participant buys fruits and vegetables most often) food stores was assessed. Descriptive analyses revealed that participants lived closer to food stores not offering more than 5 fresh fruits and vegetables daily. Participants purchased fresh fruits and vegetables from food stores that were an average of 1.2 miles further than the closest food stores offering more than 5 fresh fruits and vegetables daily to their household. Results highlight complexities of the food environment and the need to further investigate factors influencing food-related behaviors.

Neighborhood effects in a behavioral randomized controlled trial

Randomized controlled trials (RCTs) of interventions intended to modify health behaviors may be influenced by neighborhood effects which can impede unbiased estimation of intervention effects. Examining a RCT designed to increase colorectal cancer (CRC) screening (N=5628), we found statistically significant neighborhood effects: average CRC test use among neighboring study participants was significantly and positively associated with individual patient's CRC test use. This potentially important spatially-varying covariate has not previously been considered in a RCT. Our results suggest that future RCTs of health behavior interventions should assess potential social interactions between participants, which may cause intervention arm contamination and may bias effect size estimation.

What shape is your neighbourhood? Investigating the micro geographies of physical activity

Being physically active has demonstrated health benefits, and more walkable neighbourhoods can potentially increase physical activity. Yet not all neighbourhoods provide opportunities for active lifestyles. This paper examines the social context of being active in local and non-local places. We use a social practice theoretical framework to examine how residents talk about and make sense of physical activity and places, contrasting individual and neighbourhood factors. In 2010, fourteen focus groups were held in four neighbourhoods varying by walkability and area-level deprivation (two Auckland and two Wellington, New Zealand), and with participants grouped by gender, ethnicity, and employment. Focus groups elicited discussion on where local residents go for physical activity, and the opportunities and barriers to physical activity in their local area and beyond. Thematic analyses compared across all groups for contrasts and similarities in the issues discussed. Neighbourhood walkability factors appeared to shape where residents engage with public places, with residents seeking out good places. Individual factors (e.g. employment status) also influenced how residents engage with their local neighbourhoods. All groups referred to being active in places both close by and further afield, but residents in less walkable neighbourhoods with fewer local destinations drew attention to the need to go elsewhere, notably for exercise, being social, and to be in pleasant, restorative environments. Being physically active in public settings was valued for social connection and mental restoration, over and above specifically 'health' reasons. Residents talk about being active in local and non-local places revealed agency in how they managed the limitations and opportunities within their immediate residential setting. That is, factors of place and people contributed to the 'shape' of everyday residential environments, at least with regard to physical activity.

The Wisconsin Assessment of the Social and Built Environment (WASABE): a multi-dimensional objective audit instrument for examining neighborhood effects on health

BACKGROUND

Growing evidence suggests that mixed methods approaches to measuring neighborhood effects on health are needed. The Wisconsin Assessment of the Social and Built Environment (WASABE) is an objective audit tool designed as an addition to a statewide household-based health examination survey, the Survey of the Health of Wisconsin (SHOW), to objectively measure participant's neighborhoods.

METHODS

This paper describes the development and implementation of the WASABE and examines the instrument's ability to capture a range of social and built environment features in urban and rural communities. A systematic literature review and formative research were used to create the tool. Inter-rater reliability parameters across items were calculated. Prevalence and density of features were estimated for strata formed according to several sociodemographic and urbanicity factors.

RESULTS

The tool is highly reliable with over 81% of 115 derived items having percent agreement above 95%. It captured variance in neighborhood features in for a diverse sample of SHOW participants. Sidewalk density in neighborhoods surrounding households of participants living at less than 100% of the poverty level was 67% (95% confidence interval, 55-80%) compared to 34% (25-44%) for those living at greater than 400% of the poverty level. Walking and biking trails were present in 29% (19-39%) of participant buffer in urban areas compared to only 7% (2-12%) in rural communities. Significant environmental differences were also observed for white versus non-white, high versus low income, and college graduates versus individuals with lower level of education.

CONCLUSIONS

The WASABE has strong inter-rater reliability and validity properties. It builds on previous work to provide a rigorous and standardized method for systematically gathering objective built and social environmental data in a number of geographic settings. Findings illustrate the complex milieu of built environment features found in participants neighborhoods and have relevance for future research, policy, and community engagement purposes.

Impact of psychosocial factors on cardiovascular morbimortality: a prospective cohort study

BACKGROUND

Whilst it is well known that psychosocial determinants may contribute to cardiovascular diseases (CVD), data from specific groups are scarce. The present study aims to determine the contribution of psychosocial determinants in increasing the risk of cardiovascular events (myocardial infarction and stroke), and death from CVD, in a high risk adult population.

METHODS

Longitudinal prospective study of 7263 patients (57.5% women), mean age 67.0 (SD 6.2) free from CVD but at high risk, with a median follow-up of 4.8 years (from October 2003 to December 2010). The Hazard Ratios (HRs) of cardiovascular events (myocardial infarction, stroke, and death from cardiovascular causes) related to educational attainment, diagnosed depression (based on medical records), and low social support (number of people living in the household) were estimated by multivariate Cox regression models.

RESULTS

Stroke incidence was associated with low educational level in the whole population (HR: 1.83, 95% CI: 1.09-3.09), and especially in men (HR: 2.11, 95% CI 1.09-4.06). Myocardial infarction and CVD mortality were not associated with any of the psychosocial factors considered.

CONCLUSION

Adults with low educational level had a higher risk of stroke. Depression and low social support were not associated with CVD incidence.

TRIAL REGISTRATION

Clinical trial registration information unique identifier: ISRCTN35739639.

Neighborhood ethnic composition, spatial assimilation, and change in body mass index over time among Hispanic and Chinese immigrants: Multi-Ethnic Study of Atherosclerosis

OBJECTIVES

We investigated relations between changes in neighborhood ethnic composition and changes in body mass index (BMI) and waist circumference among Chinese and Hispanic immigrants in the United States.

METHODS

We used Multi-Ethnic Study of Atherosclerosis data over a median 9-year follow-up (2000-2002 to 2010-2012) among Chinese (n = 642) and Hispanic (n = 784) immigrants aged 45 to 84 years at baseline. We incorporated information about residential moves and used econometric fixed-effects models to control for confounding by time-invariant characteristics. We characterized neighborhood racial/ethnic composition with census tract-level percentage Asian for Chinese participants and percentage Hispanic for Hispanic participants (neighborhood coethnic concentration).

RESULTS

In covariate-adjusted longitudinal fixed-effects models, results suggested associations between decreasing neighborhood coethnic concentration and increasing weight, although results were imprecise: within-person BMI increases associated with an interquartile range decrease in coethnic concentration were 0.15 kilograms per meters squared (95% confidence interval [CI] = 0.00, 0.30) among Chinese and 0.17 kilograms per meters squared (95% CI = -0.17, 0.51) among Hispanic participants. Results did not differ between those who did and did not move during follow-up.

CONCLUSIONS

Residential neighborhoods may help shape chronic disease risk among immigrants.

Perceived neighbourhood social cohesion and myocardial infarction

BACKGROUND

The main strategy for alleviating heart disease has been to target individuals and encourage them to change their health behaviours. Although important, emphasis on individuals has diverted focus and responsibility away from neighbourhood characteristics, which also strongly influence people's behaviours. Although a growing body of research has repeatedly demonstrated strong associations between neighbourhood characteristics and cardiovascular health, it has typically focused on negative neighbourhood characteristics. Only a few studies have examined the potential health enhancing effects of positive neighbourhood characteristics, such as perceived neighbourhood social cohesion.

METHODS

Using multiple logistic regression models, we tested whether higher perceived neighbourhood social cohesion was associated with lower incidence of myocardial infarction. Prospective data from the Health and Retirement Study--a nationally representative panel study of American adults over the age of 50--were used to analyse 5276 participants with no history of heart disease. Respondents were tracked for 4 years and analyses adjusted for relevant sociodemographic, behavioural, biological and psychosocial factors.

RESULTS

In a model that adjusted for age, gender, race, marital status, education and total wealth, each SD increase in perceived neighbourhood social cohesion was associated with a 22% reduced odds of myocardial infarction (OR=0.78, 95% CI 0.63 to 0.94. The association between perceived neighbourhood social cohesion and myocardial infarction remained even after adjusting for behavioural, biological and psychosocial covariates.

CONCLUSIONS

Higher perceived neighbourhood social cohesion may have a protective effect against myocardial infarction.