Neighborhood effects on posthospitalization mortality: a population-based cohort study of the elderly in Chicago

The COVID-19 impact on STEMI disparities

ST-segment elevation myocardial infarction (STEMI) is a significant source of morbidity and mortality. Despite guideline-driven management and increased awareness of social determinants of health, there are persistent disparities in diagnosis, management, and outcomes. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected emergency department visitation, conditions and throughput. The aim of this study was to find any potential health disparities in patients who presented with STEMI during the COVID-19 pandemic by reviewing STEMI care data from April to September 2019 (pre-pandemic) and April to September 2020 (during the pandemic) for our hospital system. Patients with STEMI within 12 h of presentation were included in this study, and subdivided by age, gender, and race/ethnicity. We compared the turnaround times between emergency department arrival to intervention (electrocardiogram or catheterization) within the patient subgroups to find any notable differences. No statistically significant changes in turnaround times during either study period were found based on age, gender, or race/ethnicity for the STEMI interventions despite shifts in emergency department resources during the pandemic. This study helped assess the status quo in STEMI intervention for our health system and serves as a baseline for us to monitor gaps in care or areas of improvement. As healthcare systems institute new measures to promote equitable care, such as improving the accuracy of demographic data capture, establishing a baseline is an essential first step in evaluating the impact of these measures.

Socioeconomic environment and survival in patients after ST-segment elevation myocardial infarction (STEMI): a longitudinal study for the City of Vienna

OBJECTIVES

This study investigates the relationship between socioeconomic environment (SEE) and survival after ST-segment elevation myocardial infarction (STEMI) separately for women and men in the City of Vienna, Austria.

DESIGN

Hospital-based observational data of STEMI patients are linked with district-level information on SEE and the mortality register, enabling survival analyses with a 19-year follow-up (2000-2018).

SETTING

The analysis is set at the main tertiary care hospital of the City of Vienna. On weekends, it is the only hospital in charge of treating STEMIs and thus provides representative data for the Viennese population.

PARTICIPANTS

The study comprises a total of 1481 patients with STEMI, including women and men aged 24-94 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures are age at STEMI and age at death. We further distinguish between deaths from coronary artery disease (CAD), deaths from acute coronary syndrome (ACS), and other causes of death. SEE is proxied via mean individual gross income from employment in each municipal district.

RESULTS

Results are based on Kaplan-Meier survival probability estimates, Cox proportional hazard regressions and competing risk models, always using age as the time scale. Descriptive findings suggest a socioeconomic gradient in the age at death after STEMI. This finding is, however, not supported by the regression results. Female patients with STEMI have better survival outcomes, but only for deaths related to CAD (HR: 0.668, 95% CIs 0.452 to 0.985) and other causes of deaths (HR: 0.627, 95% CIs 0.444 to 0.884), and not for deaths from the more acute ACS.

CONCLUSIONS

Additional research is necessary to further disentangle the interaction between SEE and age at STEMI, as our findings suggest that individuals from poorer districts have STEMI at younger ages, which indicates vulnerability in regard to health conditions in these neighbourhoods.

Examining the effects of individual and neighbourhood socioeconomic status/wealth on hypertension among women in the Greater Accra Region of Ghana

Hypertension is one of the leading causes of morbidity and mortality among women in sub-Saharan Africa. Although research on the relationship between individual-level socioeconomic status (SES) and hypertension exists, to the best of our knowledge, limited empirical studies examined the effects of neighbourhood-level SES/wealth on the risks of living with hypertension in Ghana. Using data from the 2009 Women's Health Study of Accra (WHSA-II), and applying multilevel logistic regression, this study investigates the effects of both individual and neighbourhood wealth status on hypertension among women in the Greater Accra Region of Ghana. The results show that individual-level SES/wealth is a significant determinant of hypertension among Ghanaian women in Accra. Specifically, wealthy women are more likely to be hypertensive compared to poorer women. However, the effect of neighbourhood SES/wealth was attenuated after adjusting for individual-level SES/wealth. These findings suggest that it is important to develop health promotion programs targeted at a segment of SES group in the prevention, control and management of hypertension among women in the Greater Accra Region of Ghana.

Association of Retail Environment and Neighborhood Socioeconomic Status with Mortality among Community-dwelling Older Adults in the US: Cardiovascular Health Study

BACKGROUND

Few studies have examined the association of neighborhood environment and mortality among community-dwelling older populations. Geographic Information Systems (GIS)-based measures of neighborhood physical environment may provide new insights on the health effects of the social and built environment.

METHODS

We studied 4,379 community-dwelling older adults in the US aged ≥65 years from the Cardiovascular Health Study. Principal component analysis was used to identify neighborhood components from 48 variables assessing facilities and establishments, demographic composition, socio-economic status, and economic prosperity. We used a Cox model to evaluate the association of neighborhood components with five-year mortality. Age, sex, race, education, income, marital status, body mass index, smoking status, disability, coronary heart disease, and diabetes were included as covariates. We also examined the interactions between neighborhood components and sex and race (Black vs. white or other).

RESULTS

We identified five neighborhood components, representing facilities and resources, immigrant communities, community-level economic deprivation, resident-level socio-economic status and residents' age. Communities' economic deprivation and residents' socio-economic status were significantly associated with five-year mortality. We did not find interactions between sex or race and any of the five neighborhood components. The results were similar in a sensitivity analysis where we used ten-year mortality as the outcome.

CONCLUSIONS

We found that communities' economic status but not facilities in communities was associated with mortality among older adults. These findings revealed the importance and benefits living in a socio-economically advantaged neighborhood could have on health among older residents with different demographic backgrounds.

Investigating improvements in premature death in two rural, majority-minority counties in the south

This exploratory study investigates counties in the southeast United States with mortality outcomes that were better than might be expected given their sociodemographic profiles (i.e., positive deviance). This study seeks to understand the community characteristics with the potential to moderate the negative health outcomes typically associated with social, geographic, or economic disadvantages. This article describes the process used to identify positive deviants and reports on the findings from key informant interviews in positive deviant counties to identify community factors or practices that might contribute to positive deviance in the observed outcomes. County Health Rankings and Roadmaps 2015 data and mortality trends were examined to identify positive deviant counties. The inclusion criteria were median household incomes in the lowest tertile of their state, ≥ 33% African American, and premature mortality rankings (as measured by Years of Potential Life Lost-YPLL) in the top quartile within their state. After benchmarking county rates against national figures and retaining counties with significant improvement trends, two counties emerged as positive deviants, Dooly County, Georgia and Washington County, North Carolina. Key informant interviews (n = 11) were conducted with community stakeholders in the study counties to better understand the community characteristics that could lead to the observed outcomes. Interview data were analyzed using qualitative methods. Key informant interviews revealed three emergent themes: 1. accessibility and availability of healthcare, 2. the provision of a robust EMS system, and 3. coordination of county-funded services targeting vulnerable populations. The positive deviance framework provides a foundation for the identification of community factors or practices with the potential to create a 'culture of health' in communities at the greatest risk for adverse health outcomes. Our findings suggest that healthcare supported by the coordination of non-emergency transportation and health and social services across numerous stakeholders may have contributed to observed outcomes in the study counties.

Associations between obesity and neighborhood socioeconomic status: Variations by gender and family income status

Objectives

To analyze if the association between obesity and neighborhood socioeconomic status (SES) was moderated by gender and family income.

Methods

Data from 19,448 individuals 18 and older from the 2001–2008 National Health and Nutrition Examination Survey (NHANES) were geo-matched with social and built environment characteristics from the 2000 Census and other data sources. Objective height and weight measures were used to create body mass index (BMI) and obese status (BMI≥30). Tracts were divided into four quartiles using a composite factor score capturing neighborhood SES. Individuals were divided into four income groups by the income-to-poverty ratio (I/P). Multilevel regression analyses were performed.

Results

The association between neighborhood SES and obesity/BMI was more consistently significant among higher-income women than lower-income women. The same association was not found for men. Neighborhood built environment factors did not mediate the relationship between neighborhood SES and individual weight outcome.

Conclusions

Neighborhood SES had stronger and more consistent associations with obesity and BMI for women than men, and for higher-income women than lower-income women.

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Neighborhood SES was positively associated with healthy body weight for women but not men.

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Among women, the obesity/BMI and neighborhood SES link was more consistent for higher-income women than lower-income women.

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Men living in midlow-SES neighborhoods, not low-SES neighborhoods had the highest obesity rate.

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Variations in neighborhood built environment factors did not explain the association between neighborhood SES and obesity.

Neighborhood Deprivation and Unmet Health Care Needs: A Multilevel Analysis of Older Individuals in South Korea

Objectives

In this study the relationship between neighborhood deprivation and the unmet health care needs of elderly individuals (≥ 65 years) was examined. Some previous studies suggested that neighborhood characteristics affect access to health care, yet research on the unmet needs of older individuals is limited.

Methods

Multilevel logistic regression analysis was used to assess the relationship of neighborhood-level factors with unmet health care needs due to costs, adjusting for individual-level factors, in individuals ≥ 65 years in the 2017 Korean Community Health Survey (n = 63,388).

Results

There were 2.6% of elderly individuals who experienced unmet health care needs due to costs. Following adjustment for individual and neighborhood characteristics, the neighborhood deprivation in urban areas was found to have an inverse association with unmet needs (odds ratio = 0.50; 95% confidence interval = 0.24-1.06) for the most deprived quartile versus the least deprived quartile). However, in rural areas neighborhood deprivation was not a significant variable. Among the individual-level variables, household income was one of the strongest correlates with unmet needs in both urban and rural areas.

Conclusion

The present findings suggest that targeted policy interventions reflecting both neighborhood and individual characteristics, should be implemented to reduce the unmet health care needs of elderly individuals.

An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes

OBJECTIVE

To evaluate predictors of outcomes associated with an inpatient diabetes education and discharge support program for hospitalized patients with poorly controlled diabetes (glycated hemoglobin [HbA1c]>9%).

METHODS

Patients participated in individualized diabetes education conducted by a certified diabetes educator (CDE) that included an exploration of barriers and goal setting during hospitalization with telephone follow-up and communication with primary providers at discharge. Predictors of HbA1c reduction, successful follow-up, and readmission were analyzed.

RESULTS

There were 82 subjects, and 48% were insulin naïve. Patients with type 2 diabetes (T2D, n = 58) had a significant decrease in HbA1c at follow-up (-2.8%, P<.0001), while those with type 1 diabetes (T1D, n = 19) did not (+0.02%, P = .96). However, after adjustment for other factors, only increasing age, higher baseline HbA1c, earlier education, and initiation of basal insulin were significant predictors of reduction in HbA1c. Higher area level income and empowerment and earlier education were significant predictors of outpatient follow-up within 30 days. While 28% were admitted for severe hyperglycemia, only 1 patient was readmitted with severe hyperglycemia. Successful phone contact was 77% and 57% with and without the support of non-CDE assistants respectively, but all outcomes were similar.

CONCLUSION

The study suggests that an individualized inpatient diabetes education and transition program is associated with a significant reduction in HbA1c that is dependent on baseline HbA1c, older age, initiation of insulin, and earlier enrollment. Additional interventions are needed to ensure better continuity of care.

Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis

Background: The impact of socioeconomic differences on cancer survival has been investigated for several cancer types showing lower cancer survival in patients from lower socioeconomic groups. However, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure. Here, we conduct the first systematic review and meta-analysis on the association of individual and area-based measures of socioeconomic status with lung cancer survival.

Methods: In accordance with PRISMA guidelines, we searched for studies on socioeconomic differences in lung cancer survival in four electronic databases. A study was included if it reported a measure of survival in relation to education, income, occupation, or composite measures (indices). If possible, meta-analyses were conducted for studies reporting on individual and area-based socioeconomic measures.

Results: We included 94 studies in the review, of which 23 measured socioeconomic status on an individual level and 71 on an area-based level. Seventeen studies were eligible to be included in the meta-analyses. The meta-analyses revealed a poorer prognosis for patients with low individual income (pooled hazard ratio: 1.13, 95 % confidence interval: 1.08–1.19, reference: high income), but not for individual education. Group comparisons for hazard ratios of area-based studies indicated a poorer prognosis for lower socioeconomic groups, irrespective of the socioeconomic measure. In most studies, reported 1-, 3-, and 5-year survival rates across socioeconomic status groups showed decreasing rates with decreasing socioeconomic status for both individual and area-based measures. We cannot confirm a consistent relationship between level of aggregation and effect size, however, comparability across studies was hampered by heterogeneous reporting of socioeconomic status and survival measures. Only eight studies considered smoking status in the analysis.

Conclusions: Our findings suggest a weak positive association between individual income and lung cancer survival. Studies reporting on socioeconomic differences in lung cancer survival should consider including smoking status of the patients in their analysis and to stratify by relevant prognostic factors to further explore the reasons for socioeconomic differences. A common definition for socioeconomic status measures is desirable to further enhance comparisons between nations and across different levels of aggregation.

Neighbourhood socioeconomic position and risks of major chronic diseases and all-cause mortality: a quasi-experimental study

OBJECTIVES

This study estimated the health impacts of neighbourhood socioeconomic position (SEP) among public housing residents. Because applicants to public housing were assigned to housing projects primarily based on factors other than personal choice, we capitalised on a quasirandom source of variation in neighbourhood of residence to obtain more valid estimates of the health impacts of neighbourhood SEP.

DESIGN

Quasiexperimental study.

SETTING

Greater Metropolitan Toronto area, Canada.

PARTICIPANTS

Residents (24 019-28 858 adults age ≥30 years in 1994 for all outcomes except for asthma, for which the sample was expanded to 66 627 individuals age ≥4 years) of public housing on 1 January 1994.

OUTCOME MEASURES

Incident hypertension, diabetes, asthma, and acute myocardial infarction (MI) and all-cause mortality between 1 January 1994 and 31 December 2006. We used multivariate Cox proportional hazards models to estimate hazard ratios (HRs) for the associations between the quartile of census tract-level SEP and the risk of diagnosis of each health outcome as well as death from any cause.

RESULTS

Living in a public housing project in the second highest neighbourhood SEP quartile (Q3) was associated with lower hazards of acute MI (HR=0.76, 95% CI 0.54 to 1.07; P=0.11), incident asthma (HR=0.80, 95% CI 0.67 to 0.96; P=0.02) and all-cause mortality (HR=0.86, 95% CI 0.73 to 1.01; P=0.06) compared to living in the lowest neighbourhood SEP quartile (Q1), although only the trend for incident asthma reached statistical significance (P for trend=0.04). By contrast, the associations corresponding to living in the highest versus lowest quartile of median household income (Q4 vs Q1) were neither consistent in direction nor significant. The inconsistent associations may partly be attributed to selection and status incongruity.

CONCLUSION

This study provides new evidence compatible with protective influences of higher neighbourhood SEP on health outcomes, particularly asthma.

Is a Patient's Current Address of Record a Reasonable Measure of Neighborhood Deprivation Exposure? A Case for the Use of Point in Time Measures of Residence in Clinical Care

Purpose: Interest is increasing in the use of geocoded patient address data to understand the effects that social determinants of health have on healthcare outcomes. Use of a patient's current address of record is often problematic given population mobility. Intragenerational economic mobility research suggests that patients will reside within neighborhoods with similar relative deprivation over time despite geographic mobility. The purpose of this study was to measure evidence of patient neighborhood deprivation persistence given a change in address of record.

Methods: A retrospective cohort study of patients receiving active care in an integrated delivery system in a high-mobility United States region. Neighborhood deprivation was measured using a block-group level area deprivation index. Neighborhood deprivation persistence was measured as the probability that an individual with an address of record change remained within a neighborhood with a similar deprivation score. Logistic regression was used to conduct multivariate analysis.

Results: Geographic mobility was highest among patients living in the most deprived neighborhoods versus least-deprived (odds ratio 1.75; 95% confidence interval: 1.71–1.79). Seventy-eight percent of all patients with a change of address did so to a neighborhood with a similar deprivation quintile. The probability that a random patient selected from the study had a change of address outside the same or neighboring quintile within a 1-year period ranged from 2% to 13%.

Conclusions: Neighborhood deprivation persistence was high among this population of patients from a high mobility region. A current address of record is a reasonable indicator of patient exposure to neighborhood deprivation within a 1–3-year timeframe that is useful in evaluating healthcare disparities.

Neighborhood Environmental Health and Premature Death From Cardiovascular Disease

Introduction

Cardiovascular disease (CVD) is the leading cause of death in the United States and disproportionately affects racial/ethnic minority groups. Healthy neighborhood conditions are associated with increased uptake of health behaviors that reduce CVD risk, but minority neighborhoods often have poor food access and poor walkability. This study tested the community-driven hypothesis that poor access to food at the neighborhood level and poor neighborhood walkability are associated with racial disparities in premature deaths from CVD.

Methods

We examined the relationship between neighborhood-level food access and walkability on premature CVD mortality rates at the census tract level for the city of Atlanta using multivariable logistic regression models. We produced maps to illustrate premature CVD mortality, food access, and walkability by census tract for the city.

Results

We found significant racial differences in premature CVD mortality rates and geographic disparities in food access and walkability among census tracts in Atlanta. Improved food access and walkability were associated with reduced overall premature CVD mortality in unadjusted models, but this association did not persist in models adjusted for census tract population composition and poverty. Census tracts with high concentrations of minority populations had higher levels of poor food access, poor walkability, and premature CVD mortality.

Conclusion

This study highlights disparities in premature CVD mortality and neighborhood food access and walkability at the census tract level in the city of Atlanta. Improving food access may have differential effects for subpopulations living in the same area. These results can be used to calibrate neighborhood-level interventions, and they highlight the need to examine race-specific health outcomes.

Neighbourhood disadvantage and behavioural problems during childhood and the risk of cardiovascular disease risk factors and events from a prospective cohort

Both low socioeconomic status (SES) and behavioural problems in childhood are associated with cardiovascular disease (CVD) in adulthood, but their combined effects on CVD are unknown. Study objectives were to investigate the effect of neighbourhood level SES and behavioural problems during childhood on the development of CVD risk factors and events during adulthood. Participants were from a longitudinal cohort (n = 3792, baseline: 6-13 years of age) of Montreal children, followed from 1976 to 2010. SES was a composite measure of neighbourhood income, employment, education, and single-parent households separately assessed from census micro data sets in 1976, 2001, and 2006. Behavioural problems were assessed based on sex-specific peer assessments. CVD events were from medical records. Sex-stratified multivariable Cox regression models adjusted for age, frequency of medical visits, and parental history of CVD. Males from disadvantaged neighbourhoods during childhood were 2.06 (95% CI: 1.09-3.90, p = 0.03) and 2.51 (95% CI: 1.49-4.22, p = 0.0005) times more likely to develop a CVD risk factor or an event, respectively, than males not from disadvantaged neighbourhoods. Aggressive males were also 50% more likely to develop a CVD risk factor or event. Females from disadvantaged neighbourhoods during childhood were 1.85 (95% CI: 1.33-2.59, p = 0.0003) times more likely to develop a CVD risk factor. Future studies should aim to disentangle the interpersonal from the socioeconomic effects on CVD incidence.

Aging in Activity Space: Results From Smartphone-Based GPS-Tracking of Urban Seniors

OBJECTIVES

Prior research emphasizes the importance of the residential neighborhood context during later life but little attention has been afforded to other areas that older adults encounter as they move beyond their residential environments for daily activities and social interactions. This study examines the predominance of the residential context within older adults' everyday lives.

METHOD

We provided 60 older adults in four New York City neighborhoods with iPhones, which captured Global Positioning Systems (GPS) locations at 5-min intervals over 1 week (n = 55,561) and 17 ecological momentary assessments (EMAs) over 4 days (n = 757) to assess real-time activities.

RESULTS

Older adults in our sample spent nearly 40% of their time outside of their residential tracts and they visited 28 other tracts, on average. Exercising, shopping, socializing, and social activities were especially likely to take place outside of residential tracts. Differences in residential and nonresidential poverty exposure vary across gender, race/ethnicity, education, car ownership, and residential areas.

DISCUSSION

Measuring activity space, rather than relying on residential tracts, allows examination of the social environments that are relevant for older adults' everyday lives. Variation in characteristics of activity spaces may be an underexplored source of differences in health and well-being during later life.

Ethnic-group socioeconomic status as an indicator of community-level disadvantage: A study of overweight/obesity in Asian American adolescents

Asian American children and adolescents are an under-investigated subpopulation in obesity research. Informed by a wide socioeconomic diversity among Asian American ethnic groups, this study explored ethnic-group socioeconomic status (SES) as an indicator of community-level disadvantage that may influence overweight/obesity in Asian American adolescents. We hypothesized that ethnic-group SES was inversely associated with overweight/obesity in Asian American adolescents. Multiple logistic regression models were fitted using a sample of 1525 Asian American adolescents ages 12-17 from pooled 2007-2012 California Health Interview Survey (CHIS) data. Age, gender, nativity, individual-level SES (income and education), and two lifestyle variables (fast food consumption and physical activity) were controlled for. We found that adolescents in high- or middle-level SES ethnic groups were far less likely to be overweight/obese than those in low-SES ethnic groups. Further, these relationships were more pronounced for foreign-born adolescents but not significant for U.S.-born adolescents. Ethnic-group SES may be a meaningful indicator of community-level socioeconomic disparities that influence the health of Asian Americans and, potentially, other populations with high proportions of immigrants of diverse socioeconomic and ethnic backgrounds.

Ethnicity, socioeconomic status, and overweight in Asian American adolescents

Asian American children and adolescents are an under-investigated subpopulation in obesity research. This study aimed to identify specific profiles of Asian subgroups at high risk of adolescent overweight with special attention to Asian ethnicity, socioeconomic status (SES), and their interaction. Multiple logistic regression models were fitted using a sample of 1533 Asian American adolescents ages 12–17 from the 2007–2012 California Health Interview Survey (CHIS). In addition to Asian ethnicity and socioeconomic status (assessed by family income and parental education level), age, gender, nativity, and two lifestyle variables, fast food consumption and physical activity, were also controlled for in these models. Key predictors of overweight in Asian American adolescents included certain Asian ethnicities (Southeast Asian, Filipino, and mixed ethnicities), low family income (< 300% of the Federal Poverty Level), and being male. Multiplicative interaction terms between low family income and two ethnicities, Southeast Asian and Vietnamese that had the lowest SES among Asian ethnic groups, were significantly associated with greatly elevated odds of being overweight (ORs = 12.90 and 6.67, respectively). These findings suggest that high risk of overweight in Asian American adolescents associated with low family incomes may be further elevated for those in low-income ethnic groups. Future research might investigate ethnic-group SES as a meaningful indicator of community-level socioeconomic disparities that influence the health of Asian Americans.

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Southeast Asian and Filipino ethnicities were associated with adolescent overweight.

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Low family income was positively associated with Asian adolescent overweight.

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Ethnicity and low family income interacted to increase risk of adolescent overweight.

Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study

OBJECTIVE

The relationship between social capital and mortality is not clear-cut. There have been few longitudinal studies investigating this association so far. The objective was to assess the effect of different dimensions of social capital on mortality among adults of a Brazilian city.

STUDY DESIGN

This is a prospective multilevel study. Baseline data were obtained from a population-based random sample of 846 adults (aged 18 years or more) residing in 38 neighbourhoods (census blocks).

METHODS

Participants were interviewed in 2006-7 and their vital status investigated in 2013. Social capital was assessed by five scales (social cohesion, informal social control, neighbours' support, social action and political efficacy). The outcome was all-cause mortality. Data analysis used multilevel logistic regression models.

RESULTS

At the individual level social cohesion was positively related to mortality in the unadjusted model but this association lost significance after adjustment for other variables in multivariable models. At the neighbourhood level, high mortality rates were associated with low social action independently of demographic, socio-economic, behavioural and health-related variables.

CONCLUSION

We found more evidence for a contextual than individual level effect of social capital on mortality.

Environmental Predictors of US County Mortality Patterns on a National Basis

A growing body of evidence has found that mortality rates are positively correlated with social inequalities, air pollution, elevated ambient temperature, availability of medical care and other factors. This study develops a model to predict the mortality rates for different diseases by county across the US. The model is applied to predict changes in mortality caused by changing environmental factors. A total of 3,110 counties in the US, excluding Alaska and Hawaii, were studied. A subset of 519 counties from the 3,110 counties was chosen by using systematic random sampling and these samples were used to validate the model. Step-wise and linear regression analyses were used to estimate the ability of environmental pollutants, socio-economic factors and other factors to explain variations in county-specific mortality rates for cardiovascular diseases, cancers, chronic obstructive pulmonary disease (COPD), all causes combined and lifespan across five population density groups. The estimated models fit adequately for all mortality outcomes for all population density groups and, adequately predicted risks for the 519 validation counties. This study suggests that, at local county levels, average ozone (0.07 ppm) is the most important environmental predictor of mortality. The analysis also illustrates the complex inter-relationships of multiple factors that influence mortality and lifespan, and suggests the need for a better understanding of the pathways through which these factors, mortality, and lifespan are related at the community level.

Household and area income levels are associated with smoking status in the Korean adult population

Background

Some previous studies have suggested that area-level characteristics have effects on smoking. The aim of this study was to evaluate the associations between household income and area income on smoking in Korean adults.

Methods

This study was based on the Korean Community Health Survey (KCHS) performed in South Korea, between September and November 2009. In total, 222,242 subjects (103,124 men and 119,118 women) were included in the analysis. Information on smoking status was collected using a standardized questionnaire. Income status was determined by monthly household income. Household income was categorized as: <1 million won; <2 million won; <3 million won; and ≥3 million won. Area-level income categorized as quartiles. Data were analyzed using multilevel regression models. The analysis was conducted separately urban and rural, by sex.

Results

The lowest household income group had a higher risk of smoking than the highest household income group in both urban and rural areas for both men and women after adjusting for individual characteristics (urban men: odds ration [OR], 1.44; 95% confidence interval [CI], 1.36–1.53; rural men: OR, 1.33; 95% CI, 1.25–1.42; urban women: OR, 2.38; 95% CI, 2.06–2.76; rural women: OR, 1.51; 95% CI, 1.25–1.83). In men, the lowest area-level income group had a higher risk for smoking than the highest area-level income group in urban areas after adjusting for individual characteristics and household income (OR, 1.17; 95% CI, 1.02–1.33). In women, the lowest area-level income group had a lower risk for smoking than the highest area-level income group in rural areas after adjusting for individual characteristics and household income (OR, 0.52; 95% CI, 0.39–0.70). However, no association was observed between area-level income and smoking in rural areas for men or in urban areas for women.

Conclusions

The results showed that smoking is strongly associated with household income status in both men and women, and area-level income is partly associated with smoking. Effects of area-level income on smoking differed by sex and region. These findings suggest that area characteristics have contextual effects on health related behavior independent of individual characteristics.

Individual education, area income, and mortality and recurrence of myocardial infarction in a Medicare cohort: the National Longitudinal Mortality Study

Background

The Medicare program provides universal access to hospital care for the elderly; however, mortality disparities may still persist in this population. The association of individual education and area income with survival and recurrence post Myocardial Infarction (MI) was assessed in a national sample.

Methods

Individual level education from the National Longitudinal Mortality Study was linked to Medicare and National Death Index records over the period of 1991-2001 to test the association of individual education and zip code tabulation area median income with survival and recurrence post-MI. Survival was partitioned into 3 periods: in-hospital, discharge to 1 year, and 1 year to 5 years and recurrence was partitioned into two periods: 28 day to 1 year, and 1 year to 5 years.

Results

First MIs were found in 8,043 women and 7,929 men. In women and men 66-79 years of age, less than a high school education compared with a college degree or more was associated with 1-5 year mortality in both women (HRR 1.61, 95% confidence interval 1.03-2.50) and men (HRR 1.37, 1.06-1.76). Education was also associated with 1-5 year recurrence in men (HRR 1.68, 1.18-2.41, < High School compared with college degree or more), but not women. Across the spectrum of survival and recurrence periods median zip code level income was inconsistently associated with outcomes. Associations were limited to discharge-1 year survival (RR lowest versus highest quintile 1.31, 95% confidence interval 1.03-1.67) and 28 day-1 year recurrence (RR lowest versus highest quintile 1.72, 95% confidence interval 1.14-2.57) in older men.

Conclusions

Despite the Medicare entitlement program, disparities related to individual socioeconomic status remain. Additional research is needed to elucidate the barriers and mechanisms to eliminating health disparities among the elderly.

Early results of Massachusetts healthcare reform on racial, ethnic, and socioeconomic disparities in cardiovascular care

BACKGROUND

Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex.

METHODS AND RESULTS

Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63-0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74-0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01-1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform.

CONCLUSIONS

Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.

The effects of socioeconomic incongruity in the neighbourhood on social support, self-esteem and mental health in England

Analyses of neighbourhood socioeconomic characteristics and health indicators consistently show that health is worse in poorer neighbourhoods. However, some studies that examined neighbourhood effects separately for individuals of different socioeconomic position found that poor people may derive health benefits from living in poor neighbourhoods where they are socioeconomically congruous. This study investigates whether such patterns may be driven by psychosocial factors. The sample consisted of 4871 mothers in the Millennium Cohort Study aged 14-53. The outcomes analysed were neighbourhood friendship, emotional support, self-esteem and depression or anxiety. Neighbourhood status was classified by residents' educational and occupational status derived from the 2001 Census. We used multilevel logistic regression, adjusting for mothers' socio-demographic characteristics: first analysing health by neighbourhood status separately for the highest and lowest status mothers, then testing for modification in the association between neighbourhood status and health, by individual status. Results show that for highest status mothers, living in mixed or high status neighbourhoods compared to low status neighbourhoods significantly reduced the odds of having no friends in the neighbourhood by 65%. Living in high status neighbourhoods compared to low status neighbourhoods also significantly reduced the odds of depression or anxiety for highest status mothers by 41%. No associations were found for emotional support or self-esteem amongst highest status mothers. No associations were found for any outcome among lowest status mothers. In conclusion, low status mothers in England did not have better social support, self-esteem, or mental health when living in low status neighbourhoods compared to high status neighbourhoods; any benefits of socioeconomic congruity may have been counteracted by neighbourhood deprivation. Nevertheless, we found that mothers of high status do have significantly better neighbourhood friendship and mental health when living in socioeconomic congruity within neighbourhoods. Whether these associations are causal or are another reflection of material advantage remains unclear.

The association between neighborhood socioeconomic status and clinical outcomes among patients 1 year after hospitalization for cardiovascular disease

Residing in lower socioeconomic status (SES) neighborhoods is associated with increased risk of morbidity and mortality. Few studies have examined this association for cardiovascular disease (CVD) outcomes in a treated population in New York City (NYC). The purpose of this study was to determine the relationship between neighborhood level poverty and 1-year clinical outcomes (rehospitalization and/or death) among hospitalized patients with CVD. Data on rehospitalization and/or death at 1-year were collected from consecutive patients admitted at a university medical center in NYC from November 2009 to September 2010. NYC residents totaled 2,198. U.S. Census 2000 zip code data was used to quantify neighborhood SES into quintiles of poverty (Q1 = lowest poverty to Q5 = highest poverty). Univariate analyses were used to determine associations between neighborhood poverty and baseline characteristics and comorbidities. A logistic regression analysis was used to calculate odds ratios for the association between quintiles of poverty and rehospitalization/death at 1 year. Fifty-five percent of participants experienced adverse outcomes. Participants in Q5 (9 %) were more likely to be female [odds ratio (OR) = 0.49, 95 % confidence interval (CI) 0.33-0.73], younger (OR = 0.50, 95 % CI 0.34-0.74), of minority race/ethnicity (OR = 18.24, 95 % CI 11.12-29.23), and have no health insurance (OR = 4.79, 95 % CI 2.92-7.50). Living in Q5 was significantly associated with increased comorbidities, including diabetes mellitus and hypertension, but was not a significant predictor of rehospitalization/death at 1 year. Among patients hospitalized with CVD, higher poverty neighborhood residence was significantly associated with a greater prevalence of comorbidities, but not of rehospitalization and/or death. Affordable, accessible resources targeted at reducing the risk of developing CVD and these comorbidities should be available in these communities.

Factors associated with home discharge among veterans with stroke

OBJECTIVE

To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs.

DESIGN

Retrospective observational study.

SETTING

Veterans Affairs facilities nationwide.

PARTICIPANTS

Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (N=12,565).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Discharge location after hospitalization.

RESULTS

There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]=1.23; 95% confidence interval [CI]=1.11-1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (OR=.04; 95% CI=.03-.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (OR=.61; 95% CI=.50-.74) or other central nervous system hemorrhage (OR=.78; 95% CI=.63-.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (OR=1.36; 95% CI=1.07-1.73) were more likely to return home. Evidence of congestive heart failure (OR=.85; 95% CI=.76-.95), fluid and electrolyte disorders (OR=.86; 95% CI=.77-.96), internal organ procedures and diagnostics (OR=.87; 95% CI=.78-.97), and serious nutritional compromise (OR=.49; 95% CI=.40-.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge.

CONCLUSIONS

We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning.

The difference-in-difference method: assessing the selection bias in the effects of neighborhood environment on health

This paper uses the difference-in-difference estimation approach to explore the self-selection bias in estimating the effect of neighborhood economic environment on self-assessed health among older adults. The results indicate that there is evidence of downward bias in the conventional estimates of the effect of neighborhood economic disadvantage on self-reported health, representing a lower bound of the true effect.

Residential racial composition and black-white obesity risks: differential effects of neighborhood social and built environment

This study investigates the association between neighborhood racial composition and adult obesity risks by race and gender, and explores whether neighborhood social and built environment mediates the observed protective or detrimental effects of racial composition on obesity risks. Cross-sectional data from the 2006 and 2008 Southeastern Pennsylvania Household Health Survey are merged with census-tract profiles from 2005–2009 American Community Survey and Geographic Information System-based built-environment data. The analytical sample includes 12,730 whites and 4,290 blacks residing in 953 census tracts. Results from multilevel analysis suggest that black concentration is associated with higher obesity risks only for white women, and this association is mediated by lower neighborhood social cohesion and socioeconomic status (SES) in black-concentrated neighborhoods. After controlling for neighborhood SES, black concentration and street connectivity are associated with lower obesity risks for white men. No association between black concentration and obesity is found for blacks. The findings point to the intersections of race and gender in neighborhood effects on obesity risks, and highlight the importance of various aspects of neighborhood social and built environment and their complex roles in obesity prevention by socio-demographic groups.

Cumulative exposure to neighborhood context: consequences for health transitions over the adult life course

Over the last two decades, research has assessed the relationship between neighborhood socioeconomic factors and individual health. However, existing research is based almost exclusively on cross-sectional data, ignoring the complexity in health transitions that may be shaped by long-term residential exposures. We address these limitations by specifying distinct health transitions over multiple waves of a 15-year study of American adults. We focus on transitions between a hierarchy of health states, (free from health problems, onset of health problems, and death), not just gradients in a single health indicator over time, and use a cumulative measure of exposure to neighborhoods over adulthood. We find that cumulative exposure to neighborhood disadvantage has significant effects on functional decline and mortality. Research ignoring a persons' history of exposure to residential contexts over the life course runs the risk of underestimating the role of neighborhood disadvantage on health.

Neighborhood socioeconomic disparities and 1-year case fatality after incident myocardial infarction: the Atherosclerosis Risk in Communities (ARIC) Community Surveillance (1992-2002)

BACKGROUND

Declines in case fatality post-myocardial infarction (MI) have been observed over the past 3 decades. Few studies report socioeconomic disparities in survival post-MI.

METHODS

We assessed 1-year case fatality among 9,116 incident MI patients included in the Atherosclerosis Risk in Communities community surveillance from 1992 to 2002. Addresses of hospitalized MI patients were geocoded by a commercial vendor and linked to year 2000 United States Census tract-level neighborhood income (nINC) data. We estimated case fatality odds ratios and 95% CIs with a multinomial logistic model to quantify the association between nINC tertile and case fatality, comparing short- (within 28 days) and long-term (29-365 days) case fatality to no death 1 year post-MI.

RESULTS

Overall, 1-year age-adjusted case fatality rates were highest among MI patients living in low-nINC areas, followed by medium- and high-nINC areas, respectively. We found significant odds ratio modification by race (P < .10) and formed race-nINC strata with high-nINC whites as the referent group. In multivariable models adjusting for age, gender, study community, and year of MI, low-nINC whites and low- and medium-nINC blacks had higher short-term case fatality than high-nINC whites. Low- and medium-nINC blacks had higher long-term case fatality compared with high-nINC whites.

CONCLUSIONS

Differences in short- and long-term case fatality by neighborhood socioeconomic factors have not been systematically studied in the United States. Surveillance efforts can be expanded to incorporate measures of the neighborhood context to examine these associations over time.

Heart failure and socioeconomic status: accumulating evidence of inequality

AIMS

Socioeconomic status (SES) is a powerful predictor of incident coronary disease and adverse cardiovascular outcomes. Understanding the impact of SES on heart failure (HF) development and subsequent outcomes may help to develop effective and equitable prevention, detection, and treatment strategies

METHODS AND RESULTS

A systematic literature review of electronic databases including PubMed, EMBASE, CINAHL, and the Cochrane Library, restricted to human subjects, was carried out. The principal outcomes were incidence, prevalence, hospitalizations, mortality, and treatment of HF. Socioeconomic measures included education, occupation, employment relations, social class, income, housing characteristics, and composite and area level indicators. Additional studies were identified from bibliographies of relevant articles and reviews. Twenty-eight studies were identified. Lower SES was associated with increased incidence of HF, either in the community or presenting to hospital. The adjusted risk of developing HF was increased by ∼30-50% in most reports. Readmission rates following hospitalization were likewise greater in more deprived patients. Although fewer studies examined mortality, lower SES was associated with poorer survival. Evidence defining the equity of medical treatment of patients with HF was scarce and conflicting.

CONCLUSIONS

Socioeconomic deprivation is a powerful independent predictor of HF development and adverse outcomes. However, the precise mechanisms accounting for this risk remain elusive. Heart failure represents the endpoint of numerous different pathophysiological processes and 'chains of events', each modifiable throughout the disease trajectories. The interaction between SES and HF is accordingly complex. Disentangling the many and varied life course processes is challenging. A better understanding of these issues may help attenuate the health inequalities so clearly evident among patients with HF.

Is collective efficacy age graded? The development and evaluation of a new measure of collective efficacy for older adults

Objectives. Community processes are key determinants of older adults' ability to age in place, but existing scales measuring these constructs may not provide accurate, unbiased measurements among older adults because they were designed with the concerns of child-rearing respondents in mind. This study examines the properties of a new theory-based measure of collective efficacy (CE) that accounts for the perspectives of older residents. Methods. Data come from the population-based Chicago Neighborhood Organization, Aging and Health study (N = 1,151), which surveyed adults aged 65 to 95. Using descriptive statistics, correlations, and factor analysis, we explored the acceptability, reliability, and validity of the new measure. Results. Principal component analysis indicated that the new scale measures a single latent factor. It had good internal consistency reliability, was highly correlated with the original scale, and was similarly associated with neighborhood exchange and disorder, self-rated health, mobility, and loneliness. The new scale also showed less age-differentiated nonresponse compared to the original scale. Discussion. The older adult CE scale has reliability and validity equivalent to that of the existing measure but benefits from a more developed theoretical grounding and reduced likelihood of age-related differential nonresponse.

Examining the Racial Crossover in Mortality between African American and White Older Adults: A Multilevel Survival Analysis of Race, Individual Socioeconomic Status, and Neighborhood Socioeconomic Context

We examine whether individual and neighborhood socioeconomic context contributes to black/white disparities in mortality among USA older adults. Using national longitudinal data from the Americans' Changing Lives study, along with census tract information for each respondent, we conduct multilevel survival analyses. Results show that black older adults are disadvantaged in mortality in younger old age, but older black adults have lower mortality risk than whites after about age 80. Both individual SES and neighborhood socioeconomic disadvantage contribute to the mortality risk of older adults but do not completely explain race differences in mortality. The racial mortality crossover persists even after controlling for multilevel SES, suggesting that black older adults experience selective survival at very old ages. Addressing the individual and neighborhood socioeconomic disadvantage of blacks is necessary to reduce mortality disparities that culminate in older adulthood.

Integrating social epidemiology into public health research and practice for maternal depression

The impact of maternal depression on women and their families has been well documented. Given the prevalence and impact of this problem, one important strategy is to strengthen and expand our public health approaches. Although principles of social epidemiology are increasingly used in the field of maternal and child health, few public health efforts to address maternal mental health have incorporated ecosocial frameworks such as community connectedness, quality of social relationships, and social capital. One method to augment current public health approaches to maternal depression is through the incorporation of a perspective focusing on community, cohesion, group membership, and connectedness--a concept often described as social capital. We describe the relevance of this ecosocial perspective for mental health promotion programs for mothers.

Socioeconomic status, Medicaid coverage, clinical comorbidity, and rehospitalization or death after an incident heart failure hospitalization: Atherosclerosis Risk in Communities cohort (1987 to 2004)

BACKGROUND

Among patients with heart failure (HF), early readmission or death and repeat hospitalizations may be indicators of poor disease management or more severe disease.

METHODS AND RESULTS

We assessed the association of neighborhood median household income (nINC) and Medicaid status with rehospitalization or death in the Atherosclerosis Risk in Communities cohort study (1987 to 2004) after an incident HF hospitalization in the context of individual socioeconomic status and evaluated the relationship for modification by demographic and comorbidity factors. We used generalized linear Poisson mixed models to estimate rehospitalization rate ratios and 95% CIs and Cox regression to estimate hazard ratios (HRs) and 95% CIs of rehospitalization or death. In models controlling for race and study community, sex, age at HF diagnosis, body mass index, hypertension, educational attainment, alcohol use, and smoking, patients with a high burden of comorbidity who were living in low-nINC areas at baseline had an elevated hazard of all-cause rehospitalization (HR, 1.40; 95% CI, 1.10 to 1.77), death (HR, 1.36; 95% CI, 1.02 to 1.80), and rehospitalization or death (HR, 1.36; 95% CI, 1.08 to 1.70) as well as increased rates of hospitalization compared to those with a high burden of comorbidity living in high-nINC areas. Medicaid recipients with a low level of comorbidity had an increased hazard of all-cause rehospitalization (HR, 1.19; 95% CI, 1.05 to 1.36) and rehospitalization or death (HR, 1.21; 95% CI, 1.07 to 1.37) and a higher rate of repeat hospitalizations compared to non-Medicaid recipients.

CONCLUSIONS

Comorbidity burden appears to influence the association among nINC, Medicaid status, and rehospitalization and death in patients with HF.

Ninety-day mortality after intertrochanteric hip fracture: does provider volume matter?

BACKGROUND

Research on the relationship between orthopaedic volume and outcomes has focused almost exclusively on elective arthroplasty procedures. Geriatric patients who have sustained an intertrochanteric hip fracture are older and have a heavier comorbidity burden in comparison with patients undergoing elective arthroplasty; therefore, any advantage of provider volume in terms of mortality could be overwhelmed by the severity of the hip fracture condition itself. This study examined the association between surgeon and hospital volumes of procedures performed for the treatment of intertrochanteric hip fractures in Medicare beneficiaries and inpatient through ninety-day postoperative mortality.

METHODS

The Medicare 100% files of hospital and physician claims plus the beneficiary enrollment files for 2000 through 2002 identified beneficiaries who were sixty-five years of age or older and who underwent inpatient surgery for the treatment of an intertrochanteric hip fracture with internal fixation. Provider volumes of intertrochanteric hip fracture cases were calculated with use of unique surgeon and hospital provider numbers in the claims. Fixed effects regression analysis using generalized estimating equations was used to model the association between hospital and surgeon intertrochanteric hip fracture volume and inpatient through ninety-day mortality, controlling for age, sex, race, Charlson comorbidity score, subtrochanteric fracture, prefracture nursing home residence, Medicaid-administered assistance, surgical device, and year. The unadjusted inpatient, thirty, sixty, and ninety-day mortality rates and adjusted relative risks are reported.

RESULTS

Between March 1, 2000, and December 31, 2002, 192,365 claims met inclusion criteria and matched with provider information. The unadjusted inpatient, thirty-day, sixty-day, and ninety-day mortality rates were 2.91%, 7.92%, 12.34%, and 15.19%, respectively. Patients managed at lower-volume hospitals had significantly higher (10% to 20%) adjusted risks of inpatient mortality than those managed at the highest-volume hospitals. By sixty days postoperatively, the increased mortality risk persisted only among patients managed at the lowest-volume hospitals (six cases per year or fewer). Patients who were managed by surgeons who treated an average of two or three cases per year had the highest mortality risks when compared with patients managed by the highest-volume surgeons.

CONCLUSIONS

Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures. Unlike the situation with elective arthroplasty procedures, our findings do not indicate a need to direct patients with routine hip fractures exclusively to high-volume centers, although the higher mortality rates found in the lowest-volume hospitals warrant further investigation.

Marital status and the epidemiology and outcomes of sepsis

BACKGROUND

Sepsis is a major public health problem. Social factors may affect health behaviors, economic resources, and immune response, leading to hospitalization for infection. This study examines the association between marital status and sepsis incidence and outcomes in a population-based cohort.

METHODS

We analyzed 1,113,581 hospitalizations in New Jersey in 2006. We estimated risk-adjusted incidence rate ratios (IRRs) for sepsis among divorced, widowed, legally separated, single, and married subjects using population data from the American Community Survey. We used multivariable logistic regression to estimate marital status-specific hospital mortality.

RESULTS

We identified 37,524 hospitalizations for sepsis, of which 40% were among married (14,924), 7% were among divorced (2,548), 26% were among widowed (9,934), 2% (763) were among legally separated, and 26% (9355) were among single subjects. The incidence of hospitalization for sepsis was 5.8 per 1,000 population. The age, sex, and race-adjusted IRR for hospitalization with sepsis was greatest for single (IRR = 3.47; 95% CI, 3.1, 3.9), widowed (IRR = 1.38; 95% CI, 1.2, 1.6), and legally separated (IRR = 1.46; 95% CI, 1.2, 1.8) subjects compared with married (referent). We observed that single men and women and divorced men had greater odds of in-hospital mortality compared with married men; widowed and legally separated men and all ever-married women had no excess mortality during hospitalization for sepsis.

CONCLUSIONS

Hospitalization for sepsis is more common among single, widowed, and legally separated individuals, independent of other demographic factors. Among patients hospitalized for sepsis, single and divorced men and single women experience greater hospital mortality, highlighting the need to characterize the potentially modifiable mechanisms linking marital status to its greater burden of critical illness.

Neighborhood environment in studies of health of older adults: a systematic review

CONTEXT

Epidemiologists and public health researchers are studying neighborhood's effect on individual health. The health of older adults may be more influenced by their neighborhoods as a result of decreased mobility. However, research on neighborhood's influence on older adults' health, specifically, is limited.

EVIDENCE ACQUISITION

Recent studies on neighborhood and health for older adults were identified. Studies were identified through searches of databases including PsycINFO, CINAHL, PubMed, Academic Search Premier, Ageline, Social Science Citation Index, and Health Source. Criteria for inclusion were as follows: human studies; English language; study sample included adults aged > or =55 years; health outcomes, including mental health, health behaviors, morbidity, and mortality; neighborhood as the primary exposure variable of interest; empirical research; and studies that included > or =10 neighborhoods. Air pollution studies were excluded. Five hundred thirty-eight relevant articles were published during 1997-2007; a total of 33 of these articles met inclusion criteria.

EVIDENCE SYNTHESIS

The measures of objective and perceived aspects of neighborhood were summarized. Neighborhood was primarily operationalized using census-defined boundaries. Measures of neighborhood were principally derived from objective sources of data; eight studies assessed perceived neighborhood alone or in combination with objective measures. Six categories of neighborhood characteristics were socioeconomic composition, racial composition, demographics, perceived resources and/or problems, physical environment, and social environment. The studies are primarily cross-sectional and use administrative data to characterize neighborhood.

CONCLUSIONS

These studies suggest that neighborhood environment is important for older adults' health and functioning.

Neighborhood environment in studies of health of older adults: a systematic review

CONTEXT

Epidemiologists and public health researchers are studying neighborhood's effect on individual health. The health of older adults may be more influenced by their neighborhoods as a result of decreased mobility. However, research on neighborhood's influence on older adults' health, specifically, is limited.

EVIDENCE ACQUISITION

Recent studies on neighborhood and health for older adults were identified. Studies were identified through searches of databases including PsycINFO, CINAHL, PubMed, Academic Search Premier, Ageline, Social Science Citation Index, and Health Source. Criteria for inclusion were as follows: human studies; English language; study sample included adults aged > or =55 years; health outcomes, including mental health, health behaviors, morbidity, and mortality; neighborhood as the primary exposure variable of interest; empirical research; and studies that included > or =10 neighborhoods. Air pollution studies were excluded. Five hundred thirty-eight relevant articles were published during 1997-2007; a total of 33 of these articles met inclusion criteria.

EVIDENCE SYNTHESIS

The measures of objective and perceived aspects of neighborhood were summarized. Neighborhood was primarily operationalized using census-defined boundaries. Measures of neighborhood were principally derived from objective sources of data; eight studies assessed perceived neighborhood alone or in combination with objective measures. Six categories of neighborhood characteristics were socioeconomic composition, racial composition, demographics, perceived resources and/or problems, physical environment, and social environment. The studies are primarily cross-sectional and use administrative data to characterize neighborhood.

CONCLUSIONS

These studies suggest that neighborhood environment is important for older adults' health and functioning.

Environments for healthy ageing: a critical review

Population health outcomes are shaped by complex interactions between individuals and the environments in which they live, work and play. Environments encompass streets and buildings (physical environment), attitudes, supports and relationships with others (social environment), as well as social and political systems and policies. The impact of environments on the physical, mental health and functioning of individuals has emerged as a growing body of research in population health and health disparities. Yet, the majority of studies in this area do not focus on older adults even though older adults are particularly susceptible to the characteristics of their local environments. In this paper we review the current state of the health literature on physical environments for healthy ageing, using the International Classification of Functioning Disability and Health as a framework. Collectively, the literature emphasizes the role of supportive, barrier-free environments particularly for older adults who are at greater risk for disability and poor health. As part of our review we identify conceptual as well as methodological limitations in the current literature, including (i) a theoretical and empirical neglect of the underlying mechanisms behind the person-environment relationship; (ii) a lack of studies using nationally representative samples; (iii) over-reliance on cross-sectional data; and (iv) a need for better definition and measurement of person-centered environments. We conclude by offering some suggestions and directions for future research in this area.

Associations of social networks with cancer mortality: a meta-analysis

This meta-analysis integrates results of 87 studies on the associations of perceived social support, network size, and marital status with cancer survival. In controlled studies, having high levels of perceived social support, larger social network, and being married were associated with decreases in relative risk for mortality of 25%, 20%, and 12%, respectively. Moderator analyses revealed that never married patients had higher mortality rates than widowed and divorced/separated patients. Associations of social network with mortality were stronger in younger patients, and associations of marital status with mortality were stronger in studies with shorter time intervals, and in early-stage cancer. Relationships varied by cancer site, with stronger associations of social support observed in studies of patients with leukemia and lymphomas and stronger associations of network size observed in studies of breast cancer. Further randomized intervention studies are needed to test causal hypotheses about the role of social support and social network for cancer mortality.

Contextual effects of built and social environments of urban neighborhoods on exercise: a multilevel study in Chicago

PURPOSE

Examine the contextual effects of neighborhood built and social environments on exercise.

DESIGN

Cross-sectional, multilevel study.

SETTING

City of Chicago.

SUBJECTS

A probability sample of Chicago adult residents (response rate = 55%).

MEASURES

The exercise measures were based on two questions: "How often a week on average do you work out or exercise?" (N = 3530) and, "Did you exercise regularly in the last year?" (N = 907). Neighborhood social environment was measured by socioeconomic and social capital indicators. Neighborhood built environment was captured by pedestrian injury rate, residential density, distance to subway or parks, land use mix, and access to neighborhood amenities.

ANALYSIS

Random effects logit and multinomial models.

RESULTS

For weekly workout/exercise, individuals with access to restaurants and bars were more likely to report one to three times of weekly exercise (OR = 1.08; 95% CI: 0.99, 1.19) and four times or more weekly exercise (OR = 1.14; 95% CI: 1.03, 1.26) compared with those who reported no weekly exercise. For regular exercise in the past year, access to restaurants and bars (OR = 1.24; 95% CI: 1.05, 1.46) and neighborhood social environment (OR = 1.37; 95% CI: 1.11, 1.69) were significant. The social environment effects were stronger for women.

CONCLUSIONS

Neighborhood social and built environments are both important for exercise independent of an individual's background.

Neighborhood-level cohesion and disorder: measurement and validation in two older adult urban populations

OBJECTIVES

Drawing from collective efficacy and social disorganization theories, we developed and validated measures of neighborhood-level social processes.

METHODS

Data came from 2 large, population-based cohort studies of urban-dwelling older adults, the Chicago Neighborhood and Disability Study (CNDS, n = 3,882) and the Baltimore Memory Study (BMS, n = 1,140). Data on neighborhood social processes were collected from residents using a standardized instrument identical in the 2 studies. We used confirmatory factor analysis and descriptive statistics to explore reliability and validity of the neighborhood-level measures.

RESULTS

Confirmatory factor analysis indicated 2 latent factors: social cohesion and exchange (i.e., observations of and interactions with neighbors) and social and physical disorder (i.e., neighborhood problems and unsafe conditions). Neighborhood-level measures of cohesion and disorder showed moderate to high levels of internal consistency (alphas = .78 and .85 in CNDS and .60 and .88 in BMS). Inter-resident agreements were low (intra-neighborhood correlation coefficients = .08 and .11 in CNDS and .05 and .33 in BMS). Cohesion showed a modest, positive association with a composite measure of neighborhood socioeconomic status (SES). Disorder showed a strong, negative association with neighborhood SES.

CONCLUSIONS

Findings provide initial evidence of the reliability and construct validity of these neighborhood-level social process measures.

Black and white chains of risk for hospitalization over 20 years

Drawing from the life course perspective, racial disparities in hospitalization are considered in light of a chain of risk. We ask whether race influences admission to, length of stay in, and mortality following hospitalization. Analyses address these questions with data from a national longitudinal sample of adults to assess racial disparities in the hospitalization experience (n = 6,833). Survey data were merged with hospital records abstracted over 20 years of observation. Multivariate analyses revealed that there were no racial differences in admission, but that black adults generally had longer stays. When isolating each stay prospectively, black adults had longer stays during the first, third, and fourth hospitalizations. Post-hospital mortality after the first stay was also higher for black adults than for their white counterparts, even after controlling for morbidity and status resources. The findings suggest that the racial disparities in hospital length of stay and mortality are explained by the cumulative effects of social and health inequalities over the life course.

Widowhood and mortality among the elderly: the modifying role of neighborhood concentration of widowed individuals

The effect of death of a spouse on the mortality of the survivor (the "widowhood effect") is well-established. We investigated how the effect of widowhood on mortality depends on the neighborhood concentration of widowed individuals in the United States. We developed a large, nationally representative, and longitudinal dataset from Medicare claims and other data sources characterizing 200,000 elderly couples, with nine years of follow-up (1993-2002), and estimated multilevel grouped discrete-time hazard models. In neighborhoods with a low concentration of widowed individuals, widowhood increased the odds of death for men by 22% and for women by 17%, compared to 17% for men, and 15% for women in neighborhoods with a high concentration of widowed individuals. Our findings suggest that neighborhood structural contexts - that provide opportunities for interacting with others and favoring new social engagements - could be potential modifiers of the widowhood effects and as such requires more systematic consideration in future research of widowhood effects on well-being and mortality.