Association between neighbourhood deprivation and hypertension in a US-wide Cohort

Background

Socioeconomic status (SES) at the individual level is associated with hypertension risk. Less is known about neighbourhood level SES or how neighbourhood and individual level SES may jointly affect hypertension risk.

Methods

The Area Deprivation Index (ADI) includes 17 census-based measures reflecting neighbourhood SES. The ADI was linked to enrolment addresses of 47 329 women in the Sister Study cohort and categorised as ≤10% (low deprivation), 11%–20%, 21%–35%, 36%–55% and >55% (high deprivation). Hypertension was defined as either high systolic (≥140 mm Hg) or diastolic (≥90 mm Hg) blood pressure or taking antihypertensive medication. We used log binomial regression to investigate the cross-sectional association between ADI and hypertension and evaluated interactions between ADI and race/ethnicity and between ADI and individual SES.

Results

The highest ADI level of >55% was associated with increased prevalence of hypertension, compared with the lowest level of ADI≤10%, in a model adjusted for age, race/ethnicity, educational attainment and annual household income (prevalence ratio=1.26, 95% CI 1.21 to 1.32). We observed interaction between race/ethnicity and ADI (interaction contrast ratio (ICR)=1.9; 95% CI 0.94 to 2.8 comparing non-Hispanic Black women with ADI >55% to non-Hispanic White women with ADI≤10%) and between household income and ADI (ICR 0.38; 95% CI 0.12 to 0.65 comparing participants with household income ≤US$49 999 and ADI>55% to those with household income >US$100 000 and ADI≤10%).

Conclusions

These findings suggest that neighbourhood deprivation measured by ADI may be a risk factor for hypertension and that ADI may act synergistically with race/ethnicity and individual household income to contribute to hypertension.

Living in a block group with a higher eviction rate is associated with increased odds of preterm delivery

BACKGROUND

Housing instability is associated with adverse pregnancy outcomes. Recent studies indicate that eviction, which may affect a larger segment of the population than other forms of housing instability, is also associated with adverse pregnancy outcomes. However, these studies evaluate eviction across large areas, such as counties, so it remains unclear whether these patterns extend to individual-level pregnancy outcomes.

METHODS

We used data on a cohort of all singleton live births at a single Chicago hospital between March 2008 and March 2018 to investigate the associations between block-group eviction rates and individual adverse pregnancy outcomes. Eviction data were obtained from the Eviction Lab at Princeton University. Generalised estimating equations were used to estimate associations and account for correlations among individuals living in the same block groups.

RESULTS

Individuals living in block groups in the highest quartile for eviction filing rate were 1.17 times as likely to deliver preterm (95% CI: 1.08 to 1.27) and 1.13 times as likely to deliver a small for gestational age infant (95% CI: 1.03 to 1.25) as compared with individuals living in block groups in the lowest quartile. Further, tests for linear trend indicated that for each quartile increase in eviction filing rate, there was a corresponding increase in odds of adverse outcomes (p<0.05). Results were strongest in magnitude for those with low neighbourhood and individual socioeconomic status, who are most likely to be renters and affected by local eviction policies.

CONCLUSION

Our results suggest that individuals living in block groups with higher eviction rates are more likely to deliver preterm. Future research should explore associations of individual experience with eviction on adverse pregnancy outcomes and examine whether policies to improve tenant protections also impact pregnancy outcomes.

Does a physical activity supportive environment ameliorate or exacerbate socioeconomic inequities in incident coronary heart disease?

BACKGROUND

Efforts to reduce socioeconomic inequities in cardiovascular disease include interventions to change the built environment. We aimed to explore whether socioeconomic inequities in coronary heart disease (CHD) incidence are ameliorated or exacerbated in environments supportive of physical activity (PA).

METHODS

We used data from the Reasons for Geographic and Racial Differences in Stroke study, which recruited US residents aged 45 or older between 2003 and 2007. Our analyses included participants at risk for incident CHD (n=20 808), followed until 31 December 2014. We categorised household income and treated it as ordinal: (1) US$75 000+, (2) US$35 000-US$74 000, (3) US$20 000-US$34 000 and (4)

RESULTS

We found a 25% (95% CI 1.17% to 1.34%) increased hazard of CHD per 1-category decrease in household income category. Adjusting for PA-supportive environments slightly reduced this association (HR=1.24). The income-CHD association was strongest in areas without walking destinations (HR=1.57), an interaction which reached statistical significance in analyses among men. In contrast, the income-CHD association showed a trend towards being strongest in areas with the highest percentage of green land cover.

CONCLUSIONS

Indicators of a PA supportive environment show divergent trends to modify socioeconomic inequities in CHD . Built environment interventions should measure the effect on socioeconomic inequities.

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Key Words

• cardiovascular disease
• neighborhood/place
• socio-economic

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MESH Headings Collapse

Grants

• DP5 OD026429 NIH HHS
• R01 AG049970 NIA NIH HHS
• U01 NS041588 NINDS NIH HHS

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Affiliation(s)

Pedro Gullon Public Health and Epidemiology Research Group, Universidad de Alcala de Henares Facultad de Medicina y Ciencias de la Salud, Alcala de Henares, Spain Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
Usama Bilal Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA Epidemiology and Statistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
Jana A Hirsch Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA Epidemiology and Statistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
Andrew G Rundle Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
Suzanne Judd Department of Biostatistics, University of Alabama at Birmingham College of Arts and Sciences, Birmingham, Alabama, USA
Monika M Safford Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, New York, USA
Gina S Lovasi Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA Epidemiology and Statistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA

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Association between neighbourhood characteristics and antidepressant use at older ages: a register-based study of urban areas in three European countries

BACKGROUND

Research evidence on the association between neighbourhood characteristics and individual mental health at older ages is inconsistent, possibly due to heterogeneity in the measurement of mental-health outcomes, neighbourhood characteristics and confounders. Register-based data enabled us to avoid these problems in this longitudinal study on the associations between socioeconomic and physical neighbourhood characteristics and individual antidepressant use in three national contexts.

METHODS

We used register-based longitudinal data on the population aged 50+ from Turin (Italy), Stockholm (Sweden), and the nine largest cities in Finland linked to satellite-based land-cover data. This included individual-level information on sociodemographic factors and antidepressant use, and on neighbourhood socioeconomic characteristics, levels of urbanicity, green space and land-use mix (LUM). We assessed individual-level antidepressant use over 6 years in 2001-2017 using mixed-effects logistic regression.

RESULTS

A higher neighbourhood proportion of low-educated individuals predicted lower odds for antidepressant use in Turin and Stockholm when individual-level sociodemographic factors were controlled for. Urbanicity predicted increased antidepressant use in Stockholm (OR=1.02; 95% CI 1.01 to 1.03) together with more LUM (OR=1.03; 1.01-1.05) and population density (OR=1.08; 1.05-1.10). The two latter characteristics also predicted increased antidepressant use in the Finnish cities (OR=1.05; 1.02-1.08 and OR=1.14; 1.02-1.28, respectively). After accounting for all studied neighbourhood and individual characteristics of the residents, the neighbourhoods still varied by odds of antidepressant use.

CONCLUSIONS

Overall, the associations of neighbourhood socioeconomic and physical characteristics with older people's antidepressant use were small and inconsistent. However, we found modest evidence that dense physical urban environments predicted higher antidepressant use among older people in Stockholm and the Finnish cities.

Association of census tract-level incarceration rate and life expectancy in New York State

BACKGROUND

Jail incarceration rates are positively associated with mortality at the county level. However, incarceration rates vary within counties, limiting the generalisability of this finding to neighbourhoods, where incarceration may have the greatest effects.

METHODS

We performed a cross-sectional analysis of census tract-level state imprisonment rates in New York State (2010) and life expectancy data from the US Small-area Life Expectancy Estimates Project (2010-2015). We modelled fixed-effects for counties and controlled for tract-level poverty, racial makeup, education, and population density from the American Community Survey (2010-2014), and violent crime data from the New York City Police Department (2010). We also examined interactions between incarceration rate and poverty, racial makeup, and population density on life expectancy.

RESULTS

Life expectancy at the highest quintile of incarceration was 5.5 years lower than in the lowest quintile, and over 2 years lower in a fully-adjusted model. Census tract-level poverty and racial makeup both moderated the association between incarceration and life expectancy.

CONCLUSION

Census tract-level incarceration is associated with lower life expectancy. Decarceration, including alternatives to incarceration, and release of those currently incarcerated, may help to improve life expectancy at the neighbourhood level.

National movement patterns during the COVID-19 pandemic in New Zealand: the unexplored role of neighbourhood deprivation

Background

The COVID-19 pandemic has asked unprecedented questions of governments around the world. Policy responses have disrupted usual patterns of movement in society, locally and globally, with resultant impacts on national economies and human well-being. These interventions have primarily centred on enforcing lockdowns and introducing social distancing recommendations, leading to questions of trust and competency around the role of institutions and the administrative apparatus of state. This study demonstrates the unequal societal impacts in population movement during a national ‘lockdown’.

Methods

We use nationwide mobile phone movement data to quantify the effect of an enforced lockdown on population mobility by neighbourhood deprivation using an ecological study design. We then derive a mobility index using anonymised aggregated population counts for each neighbourhood (2253 Census Statistical Areas; mean population n=2086) of national hourly mobile phone location data (7.45 million records, 1 March 2020–20 July 2020) for New Zealand (NZ).

Results

Curtailing movement has highlighted and exacerbated underlying social and spatial inequalities. Our analysis reveals the unequal movements during ‘lockdown’ by neighbourhood socioeconomic status in NZ.

Conclusion

In understanding inequalities in neighbourhood movements, we are contributing critical new evidence to the policy debate about the impact(s) and efficacy of national, regional or local lockdowns which have sparked such controversy.

Intersectional community correlates of married women's experiences of male intimate partner physical violence in Bangladesh: a cross-sectional study

Background

In Bangladesh, little is known about community-level factors shaping married women’s experiences of male intimate partner physical violence (MIPPV); it is also unknown if these factors interact with each other. We examined the (1) association between four residential community characteristics defined by the attributes of ever married women in those communities–younger age, lower education, higher participation in earning an income and poverty; and (2) two-way interactions between these community-level MIPPV correlates.

Methods

We used a cross-sectional sample comprising 14 557 currently married women who were living with their spouses from 911 Bangladeshi communities. Data were collected during 13–22 August 2015. Conflict Tactics Scale-2 measured the outcome–women’s current MIPPV experiences; and multilevel logistic regression models predicted this outcome.

Results

Four community characteristics including higher proportions of women’s earning an income and achieving higher education were not associated with their increased likelihood of experiencing MIPPV. However, women living in higher earning participation, higher educated communities were significantly more likely to experience MIPPV than those in lower earning participation, higher educated communities (predicted probability, p=0.30, 95% CI 0.26 to 0.34 vs p=0.24, 95% CI 0.22 to 0.25).

Conclusion

This is the first study to examine interactions between women’s community-level MIPPV correlates in Bangladesh. Although we did not find support for the relationship between women’s most intersectional community-level locations and MIPPV, we did find a currently invisible vulnerable intersectional location: higher earning participation, higher educated communities. Bangladeshi violence against women prevention policies and programmes, therefore, need to engage with these particular communities to tackle head on male responses to these locations to reduce MIPPV.

Onset of type 1 diabetes mellitus in rural areas of the USA

BACKGROUND

In the USA, the epidemiologic features of type 1 diabetes are not well-defined across all 50 states. However, the advent of large nationwide insurance databases enables the investigation of where type 1 diabetes cases occur throughout the country.

METHODS

An integrated database from a large nationwide health insurer in the USA (Clinformatics Data Mart Database) was used, from 2001 to 2017. The database contained longitudinal information on approximately 77 million people.

RESULTS

The incidence of type 1 diabetes was greatest in areas of low population density across the 50 states. Individuals in the lowest population density areas had rates that were 2.28 times (95% CI 2.08 to 2.50) that of persons living in high-density areas. This association was consistent across various measures of rural status (p<0.001 for population density; p<0.001 for per cent rural as defined by the US Census Bureau; p=0.026 for farmland). The association between rural areas and the incidence of type 1 diabetes was evident across all four general regions of the USA.

CONCLUSIONS

The predilection of type 1 diabetes in rural areas provides clues to potential factors associated with the onset of this autoimmune disease.

Neighbourhood disadvantage and depressive symptoms among adolescents followed into emerging adulthood

BACKGROUND

Residents of disadvantaged neighbourhoods report higher levels of depressive symptoms; however, few studies have employed prospective designs during adolescence, when depression tends to emerge. We examined associations of neighbourhood social fragmentation, income inequality and median household income with depressive symptoms in a nationally representative survey of adolescents.

METHODS

The NEXT Generation Health Study enrolled 10th-grade students from 81 US high schools in the 2009-2010 school year. Depressive symptoms were assessed with the Modified Depression Scale (wave 1) and the paediatric Patient-Reported Outcome Measurement Information System (waves 2-6). Neighbourhood characteristics at waves 1, 3, 4, and 5 were measured at the census tract level using geolinked data from the American Community Survey 5-year estimates. We used linear mixed models to relate neighbourhood disadvantage to depressive symptoms controlling for neighbourhood and individual sociodemographic factors.

RESULTS

None of the models demonstrated evidence for associations of social fragmentation, income inequality or median household income with depressive symptoms.

CONCLUSION

Despite the prospective design, repeated measures and nationally representative sample, we detected no association between neighbourhood disadvantage and depressive symptoms. This association may not exist or may be too small to detect in a geographically dispersed sample. Given the public health significance of neighbourhood effects, future research should examine the developmental timing of neighbourhood effects across a wider range of ages than in the current sample, consider both objective and subjective measures of neighbourhood conditions, and use spatially informative techniques that account for conditions of nearby neighbourhoods.

Influence of individual life course and neighbourhood socioeconomic position on dietary intake in African Americans: the Jackson Heart Study

OBJECTIVE

African Americans, especially those in the Southeastern USA, have different dietary behaviours from the general US population, and have the highest prevalence, incidence and mortality of diet-related disease outcomes, such as cardiovascular disease. However, there are scant data regarding factors such as socioeconomic position (SEP) across the life course that influence dietary behaviours in this high-risk population. Our aim was to examine the impact of life course and neighbourhood SEPs on dietary intake among African Americans.

PARTICIPANTS AND SETTING

Data for this cross-sectional analysis came from the community-based Jackson Heart Study (JHS). We analysed a total of 3948 JHS participants (mean age: 55.4±12.5; 63.9% women), who had complete dietary intake and covariate information.

METHODS

We examined the associations of childhood SEP (CSEP), adulthood SEP (ASEP) and neighbourhood SEP (NSEP) with 10 selected dietary intake measures, using multilevel log-gamma generalised linear regression models.

OUTCOME MEASURES

Dietary intake measures include daily saturated fat, sodium, protein, fibre, fruits and vegetables, whole grains, sugar-sweetened beverage, nuts, fish and processed meat.

RESULTS

In age, sex and total energy intake adjusted models, most dietary intakes were associated with these three SEP measures. After additional adjustment for other SEP measures, most of the significant associations with CSEP and NSEP were attenuated, except for the associations of fibre with CSEP (relative rate [RR] [95% CI] 1.05 [1.00-1.10]) and whole grains with NSEP (RR [95% CI] 1.28 [1.02-1.61]). The associations (shown as RR [95% CI]) between ASEP and sugar-sweetened beverage: 0.70 (0.59-0.83), processed meat: 0.75 (0.63-0.90), sodium: 0.99 (0.94-1.00), fibre: 1.10 (1.03-1.16), protein: 1.05 (1.01-1.09), fruits and vegetables: 1.21 (1.11-1.32), nuts: 2.13 (1.59-2.87), and fish: 1.57 (1.27-1.95) generally persisted after additional adjustment for both CSEP and NSEP. However, the association between ASEP and whole grains was attenuated.

CONCLUSIONS

High ASEP may have a more beneficial influence on dietary practices in African Americans than CSEP or NSEP.

Neighbourhood walkability and the incidence of diabetes: an inverse probability of treatment weighting analysis

BACKGROUND

People living in highly walkable neighbourhoods tend to be more physically active and less likely to be obese. Whether walkable urban design reduces the future risk of diabetes is less clear.

METHODS

We used inverse probability of treatment weighting to compare 10-year diabetes incidence between residents living in high-walkability and low-walkability neighbourhoods within five urban regions in Ontario, Canada. Adults (aged 30-85 years) who were diabetes-free on 1 April 2002 were identified from administrative health databases and followed until 31 March 2012 (n=958 567). Within each region, weights reflecting the propensity to live in each neighbourhood type were created based on sociodemographic characteristics, comorbidities and healthcare utilisation and incorporated into region-specific Cox proportional hazards models.

RESULTS

Low-walkability areas were more affluent and had more South Asian residents (6.4%vs3.6%, p<0.001) but fewer residents from other minority groups (16.6%vs21.7%, p<0.001). Baseline characteristics were well balanced between low-walkability and high-walkability neighbourhoods after applying individual weights (standardised differences all <0.1). In each region, high walkability was associated with lower diabetes incidence among adults aged <65 years (overall weighted incidence: 8.2vs9.2 per 1000; HR 0.85, 95% CI 0.78 to 0.93), but not among adults aged ≥65 years (weighted incidence: 20.7vs19.5 per 1000; HR 1.01, 95% CI 0.91 to 1.12). Findings were consistent regardless of income and immigration status.

CONCLUSIONS

Younger adults living in high-walkability neighbourhoods had a lower 10-year incidence of diabetes than similarly aged adults living in low-walkability neighbourhoods. Urban designs that support walking may have important benefits for diabetes prevention.

Characteristics of the built environment and spatial patterning of type 2 diabetes in the urban core of Durham, North Carolina

BACKGROUND

Few studies examine relationships between built environment (BE) and type 2 diabetes mellitus (T2DM) using spatial models, investigate BE domains apart from food environment or physical activity resources or conduct sensitivity analysis of methodological choices made in measuring BE. We examine geographic heterogeneity of T2DM, describe how heterogeneity in T2DM relates to BE and estimate associations of T2DM with BE.

METHODS

Individual-level electronic health records (n=41 203) from the Duke Medicine Enterprise Data Warehouse (2007-2011) were linked to BE based on census block. Data on housing damage, property disorder, territoriality, vacancy and public nuisances were used to estimate BE based on four different construction methods (CMs). We used race-stratified aspatial and spatial Bayesian models to assess geographic heterogeneity in T2DM and associations of T2DM with BE.

RESULTS

Among whites, a 1 SD increase in poor quality BE was associated with a 1.03 (95% credible interval 1.01 to 1.06) and 1.06 (95 % credible interval 1.02 to 1.11) increased risk of T2DM for poor quality BE CM1 and CM2, respectively. Among blacks/African Americans, associations between T2DM and BE overlapped with the null for all CMs. The addition of BE to white models reduced residual geographic heterogeneity in T2DM by 4%-15%, depending on CM. In black/African-American models, BE did not affect residual heterogeneity.

CONCLUSION

Associations of T2DM with BE were sensitive to CM and geographic heterogeneity in T2DM differed by race/ethnicity. Findings underscore the need to consider multiple methods of estimating BE and consider differences in relationships by race/ethnicity.

Differential vulnerability to neighbourhood disorder: a gene×environment interaction study

BACKGROUND

Type 2 diabetes (T2D) is preventable, it is increasing in prevalence and it is a major risk factor for morbidity and mortality. Importantly, residents of neighbourhoods with high levels of disorder are more likely to develop T2D than those living in less disordered neighbourhoods and neighbourhood disorder may exacerbate genetic risk for T2D.

METHOD

We use genetic, self-reported neighbourhood, and health data from the Health and Retirement Study. We conducted weighted logistic regression analyses in which neighbourhood disorder, polygenic scores for T2D and their interaction predicted T2D.

RESULTS

Greater perceptions of neighbourhood disorder (OR=1.11, p<0.001) and higher polygenic scores for T2D (OR=1.42, p<0.001) were each significantly and independently associated with an increased risk of T2D. Furthermore, living in a neighbourhood perceived as having high levels of disorder exacerbated genetic risk for T2D (OR=1.10, p=0.001). This significant gene×environment interaction was observed after adjusting for years of schooling, age, gender, levels of physical activity and obesity.

CONCLUSION

Findings in the present study suggested that minimising people's exposure to vandalism, vacant buildings, trash and circumstances viewed by residents as unsafe may reduce the burden of this prevalent chronic health condition, particularly for subgroups of the population who carry genetic liability for T2D.

Renovations of neighbourhood parks: long-term outcomes on physical activity

BACKGROUND

Neighbourhood parks are places designed to support physical activity, but are often underutilised. Park renovations are major improvements to the quality of these spaces and usually attract more park users. This study assessed changes in the use of six San Francisco neighbourhood parks and park-based physical activity levels over a 6-year period, during which five of the six parks were renovated.

METHODS

We used direct observation to assess park-based physical activity. We used a stepped-wedge study design at three time points in all six parks over 6 years (before all parks were renovated, after two parks were renovated and after an additional three were renovated) to evaluate the short-term and long-term effects of park renovations.

RESULTS

Levels of moderate-to-vigorous physical activity (MVPA) and metabolic equivalent hours expended in the parks increased overall, most immediately after renovation. Age groups responded differently with the largest increases in park use and MVPA among adults and children under age 12, with no changes among teens and seniors.

CONCLUSIONS

Park renovations attracted more users and increased park-based MVPA than non-renovated parks and sustained increases over time for adults and children, but not teens or seniors. Park renovations that consider and provide facilities that support varied levels of physical activity and cater to all age groups may foster increased park-based physical activity that can be sustained.

Neighbourhood racial/ethnic residential segregation and cardiometabolic risk: the multiethnic study of atherosclerosis

BACKGROUND

Racial residential segregation has been linked to adverse health outcomes, but associations may operate through multiple pathways. Prior studies have not examined associations of neighbourhood-level racial segregation with an index of cardiometabolic risk (CMR) and whether associations differ by race/ethnicity.

METHODS

We used data from the Multi-Ethnic Study of Atherosclerosis to estimate cross-sectional and longitudinal associations of baseline neighbourhood-level racial residential segregation with a composite measure of CMR. Participants included 5015 non-Hispanic black, non-Hispanic white and Hispanic participants aged 45-84 years old over 12 years of follow-up (2000-2012). We used linear mixed effects models to estimate race-stratified associations of own-group segregation with CMR at baseline and with the rate of annual change in CMR. Models were adjusted for sociodemographics, medication use and individual-level and neighbourhood-level socioeconomic status (SES).

RESULTS

In models adjusted for sociodemographics and medication use, high baseline segregation was associated with higher baseline CMR among blacks and Hispanics but lower baseline CMR among whites. Individual and neighbourhood-level SES fully explained observed associations between segregation and CMR for whites and Hispanics. However, associations of segregation with CMR among blacks remained (high vs low segregation: mean difference 0.17 SD units, 95% CI 0.02 to 0.32; medium vs low segregation: mean difference 0.18 SD units, 95% CI 0.03 to 0.33). Baseline segregation was not associated with change in CMR index scores over time.

CONCLUSION

Associations of own-group racial residential segregation with CMR varied by race/ethnicity. After accounting for SES, living in a more segregated neighbourhood was associated with greater risk among black participants only.

Neighbourhood looking glass: 360º automated characterisation of the built environment for neighbourhood effects research

Background

Neighbourhood quality has been connected with an array of health issues, but neighbourhood research has been limited by the lack of methods to characterise large geographical areas. This study uses innovative computer vision methods and a new big data source of street view images to automatically characterise neighbourhood built environments.

Methods

A total of 430 000 images were obtained using Google’s Street View Image API for Salt Lake City, Chicago and Charleston. Convolutional neural networks were used to create indicators of street greenness, crosswalks and building type. We implemented log Poisson regression models to estimate associations between built environment features and individual prevalence of obesity and diabetes in Salt Lake City, controlling for individual-level and zip code-level predisposing characteristics.

Results

Computer vision models had an accuracy of 86%–93% compared with manual annotations. Charleston had the highest percentage of green streets (79%), while Chicago had the highest percentage of crosswalks (23%) and commercial buildings/apartments (59%). Built environment characteristics were categorised into tertiles, with the highest tertile serving as the referent group. Individuals living in zip codes with the most green streets, crosswalks and commercial buildings/apartments had relative obesity prevalences that were 25%–28% lower and relative diabetes prevalences that were 12%–18% lower than individuals living in zip codes with the least abundance of these neighbourhood features.

Conclusion

Neighbourhood conditions may influence chronic disease outcomes. Google Street View images represent an underused data resource for the construction of built environment features.

Differences in declining mortality rates due to coronary heart disease by neighbourhood deprivation

BACKGROUND

Cardiovascular disease (CVD) is the main cause of death in most industrialised countries, including those in Europe. The mortality rates due to coronary heart disease (CHD), one of the most serious CVD conditions, have been decreasing in most European countries during the last decades. However, whether the trends over time in CHD mortality rates differ depending on neighbourhood deprivation has rarely been investigated.

METHODS

For each year of the study period, 1988-2012, in Sweden, age-standardised mortality rates were calculated for three different types of neighbourhoods, characterised by a Neighbourhood Deprivation Index. Joinpoint regression was used to investigate potential changes in age-standardised mortality rates by neighbourhood deprivation and over time.

RESULTS

Over the study period, age-standardised mortality rates due to CHD were consistently the highest in the deprived neighbourhoods and the lowest in the affluent neighbourhoods. We observed a statistically significant overall decline, ranging from 67% to 59%, in the age-standardised CHD mortality rates for each level of neighbourhood deprivation. Furthermore, the decline for the affluent neighbourhoods was significantly higher compared with the decline in the deprived neighbourhoods.

CONCLUSION

Age-standardised CHD mortality rates decreased significantly in Sweden between 1988 and 2012. This decline was more pronounced in the affluent neighbourhoods, which indicates that the improvements in prevention and treatment of CHD have not benefited individuals residing in deprived neighbourhoods to an equal extent. Knowledge of time trends in CHD mortality by level of neighbourhood deprivation may help guide decision-makers in the development of appropriate healthcare policies for deprived neighbourhoods.

Associations between neighbourhood characteristics and depression: a twin study

BACKGROUND

Depression is an important contributor to the global burden of disease. Besides several known individual-level factors that contribute to depression, there is a growing recognition that neighbourhood environment can also profoundly affect mental health. This study assessed associations between three neighbourhood constructs-socioeconomic deprivation, residential instability and income inequality-and depression among adult twin pairs. The twin design is used to examine the association between neighbourhood constructs and depression, controlling for selection factors (ie, genetic and shared environmental factors) that have confounded purported associations.

METHODS

We used multilevel random-intercept Poisson regression among 3738 same-sex twin pairs from a community-based twin registry to examine the association between neighbourhood constructs and depression. The within-pair association controls for confounding by genetic and environmental factors shared between twins within a pair, and is the main parameter of interest. Models were adjusted for individual-level income, education and marital status, and further by neighbourhood-level population density.

RESULTS

When twins were analysed as individuals (phenotypic model), all neighbourhood constructs were significantly associated with depression. However, only neighbourhood socioeconomic deprivation showed a significant within-pair association with depression. A 10-unit within-pair difference in neighbourhood socioeconomic deprivation was associated with 6% greater depressive symptoms (1.06, 95% CI 1.01 to 1.11); the association did not substantially change in adjusted models.

CONCLUSION

This study provides new evidence linking neighbourhood socioeconomic deprivation with greater depression. Future studies should employ longitudinal designs to better test social causation versus social selection.

Understanding bias in relationships between the food environment and diet quality: the Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND

The relationship between food environment exposures and diet behaviours is unclear, possibly because the majority of studies ignore potential residual confounding.

METHODS

We used 20 years (1985-1986, 1992-1993 2005-2006) of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study across four US cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; Oakland, California) and instrumental variables (IV) regression to obtain causal estimates of longitudinal associations between the percentage of neighbourhood food outlets (per total food outlets within 1 km network distance of respondent residence) and an a priori diet quality score, with higher scores indicating higher diet quality. To assess the presence and magnitude of bias related to residual confounding, we compared results from causal models (IV regression) to non-causal models, including ordinary least squares regression, which does not account for residual confounding at all and fixed-effects regression, which only controls for time-invariant unmeasured characteristics.

RESULTS

The mean diet quality score across follow-up was 63.4 (SD=12.7). A 10% increase in fast food restaurants (relative to full-service restaurants) was associated with a lower diet quality score over time using IV regression (β=-1.01, 95% CI -1.99 to -0.04); estimates were attenuated using non-causal models. The percentage of neighbourhood convenience and grocery stores (relative to supermarkets) was not associated with diet quality in any model, but estimates from non-causal models were similarly attenuated compared with causal models.

CONCLUSION

Ignoring residual confounding may generate biased estimated effects of neighbourhood food outlets on diet outcomes and may have contributed to weak findings in the food environment literature.

Investigating associations between the built environment and physical activity among older people in 20 UK towns

Background

Policy initiatives such as WHO Age Friendly Cities recognise the importance of the urban environment for improving health of older people, who have both low physical activity (PA) levels and greater dependence on local neighbourhoods. Previous research in this age group is limited and rarely uses objective measures of either PA or the environment.

Methods

We investigated the association between objectively measured PA (Actigraph GT3x accelerometers) and multiple dimensions of the built environment, using a cross-sectional multilevel linear regression analysis. Exposures were captured by a novel foot-based audit tool that recorded fine-detail neighbourhood features relevant to PA in older adults, and routine data.

Results

795 men and 638 women aged 69–92 years from two national cohorts, covering 20 British towns, were included in the analysis. Median time in moderate to vigorous PA (MVPA) was 27.9 (lower quartile: 13.8, upper quartile: 50.4) minutes per day. There was little evidence of associations between any of the physical environmental domains (eg, road and path quality defined by latent class analysis; number of bus stops; area aesthetics; density of shops and services; amount of green space) and MVPA. However, analysis of area-level income deprivation suggests that the social environment may be associated with PA in this age group.

Conclusions

Although small effect sizes cannot be discounted, this study suggests that older individuals are less affected by their local physical environment and more by social environmental factors, reflecting both the functional heterogeneity of this age group and the varying nature of their activity spaces.

Evaluation of the health impact of an urban regeneration policy: Neighbourhood Renewal in Northern Ireland

BACKGROUND

Neighbourhood Renewal (NR) was launched in Northern Ireland (NI) in 2003 to revive the social, economic and physical fabric of 36 deprived communities, characterised by a legacy of sectarian conflict. This study evaluates the impact of the policy on health over a decade.

METHODS

A merged panel of secondary data from the British Household Panel Survey (2001-2008) and Understanding Society (2009-2012) yields longitudinal information on respondents for 12 years.We conducted a controlled before and after investigation for NR intervention areas (NRAs) and three control groups-two groups of comparably deprived areas that did not receive assistance and the rest of NI. Linear difference-in-difference regression was used to identify the impact of NR on mental health, self-rated health, life satisfaction, smoking and exercise. Subgroup analysis was conducted for males and females, higher and lower educated, retired, unemployed and home owner groups.

RESULTS

NR did not have a discernible impact on mental distress. A small, non-significant trend towards a reduction in the gap of good self-rated health and life satisfaction between NRAs and controls was observed. A 10% increase in probability of rating life as satisfying was uncovered for retirees in NRAs compared with the rest of NI. Smoking in NRAs declined on par with people from control areas, so a NR influence was not obvious. A steady rise in undertaking weekly exercise in NRAs compared with controls was not statistically significant.

CONCLUSIONS

Area-based initiatives may not achieve health gains beyond mainstream service provision, though they may safeguard against widening of health disparities.