Associations of perceived neighborhood environment on health status outcomes in persons with arthritis

Gender and race, as well as individual-level socioeconomic status (SES) markers such as education, income and occupation are differentially associated with arthritis (i.e. incidence, disease severity, access to care and health outcomes) (1;2). In efforts to go beyond these individual-level determinants of health and contributors to health disparities, greater attention is now being given to understanding the influence of the neighborhood (or community) environment on health status outcomes and individual health behaviors. Area of residence can be particularly important given the uneven spatial distribution of goods, services, educational facilities, and resources through natural (e.g., geographic landmarks like lakes and mountains) and man-made clustering of individuals (e.g., political, economic or self-imposed segregation). Typically, there are three ways that researchers examine the effect of neighborhood on health: 1) through the use of administrative data (e.g., U.S. Census data), 2) through the use of trained raters who systematically observe and characterize the physical and/or social attributes of neighborhoods; and 3) through the use of self-reported perception of neighborhood conditions (3;4). While the independent effect of neighborhood socioeconomic status on outcomes like mortality, chronic disease, mental health, and health behaviors has been established in numerous studies of the general population {Kawachi, 2003 17103/id; Morland, 2002 11866/id}, as well as of older adults (7), the relationship between neighborhood SES and arthritis outcomes has only recently been established (8–12). Several studies conducted in the United Kingdom and the United States have examined the relationship of community SES and health outcomes in individuals with rheumatoid arthritis (8), inflammatory polyarthritis (9), systemic lupus erythematosus (SLE) (10), as well as prevalence and health-related quality of life in self-report arthritis (11;12), using aggregate measures like the Carstairs score, Townsend score, Index of Multiple Deprivation and US Census variables as indirect, ‘objective’ proxy for neighborhood characteristics. All have found that living in areas of greater deprivation is related to poorer arthritis-related outcomes (e.g., physical functioning, functional disability, depressive symptoms). In addition to these objective measures of the neighborhood environment, attention has been given to the significance of perceived neighborhood characteristics. Perceptions can be grounded in observable conditions (13) or there can be incongruities between perceived neighborhood environment and objective reality (14;15). It has been theorized that neighborhood perceptions are important to examine because they can elicit psychosocial or psychological processes (13;16–18), or even a physiological stress response that can affect mental and physical health (19;20). Current research aimed at better understanding which neighborhood attributes influence health are grounded in the practical and theoretical knowledge generated from decades of social science and public health research (5). Constructs borne out of psychology and sociology, such as social disorder and social cohesion, as well as public health infrastructure features like presence of sidewalks, have been developed as ways to more objectively measure neighborhood characteristics. Typically researchers identify constructs or neighborhood features of relevance to general (e.g., self-rated health) or specific health outcomes (e.g., cardiovascular or asthma outcomes) depending on their research question (3;5;21). In studies conducted with the general population, perceptions of both physical (e.g., quality, facilities, problems, walkability) and social (e.g., social cohesion, social control) aspects of neighborhood environment have been linked to self-rated health (22–24), physical functioning (25) and mental health outcomes (26–30), as well as health behaviors like smoking, drinking and walking for exercise (29). Among older adults, better self-rated health has been associated with perceiving higher quality of area facilities and neighborliness (31) and physical environment (16). Mobility disability has also been associated with lower perceived neighborhood safety among lower-income, retirement age adults (13). Neighborhood perceptions have also been shown to influence specific disease outcomes. Mujahid et al found that individuals who self-reported better neighborhood characteristics (e.g., walkability, availability of healthy foods, safety, and social cohesion) were less likely to be hypertensive, even after adjustment for individual-level characteristics of age, gender and SES (education and income) (32). Greater perceptions of neighborhood problems (e.g., traffic, noise, trash, smells, and fires) have been associated with lower quality of life, worse physical functioning and greater depressive symptoms among individuals with asthma, cross-sectionally (21) and prospectively (33). Greater perceptions of neighborhood problems were also associated with smoking and high blood pressure among adults with diabetes (34). To date, no one has examined the role of perceived neighborhood environment on the health outcomes of adults with arthritis. The purpose of this paper is to examine the association between four aspects of the perceived neighborhood environment (aesthetics, walkability, safety, and social cohesion) and self-report health status outcomes in a cohort of North Carolinians with self-report arthritis after adjustment for individual and objective neighborhood SES.