BACKGROUND/RATIONALE:
Independent of individual socio-demographic factors, area-level characteristics have been shown to influence a broad range of health outcomes. However, there is limited evidence about the association of neighborhood environment and health outcomes among veterans.

OBJECTIVE(S):
The primary aim of this study is to determine the relative contributions of neighborhood socioeconomic status, health system factors, and individual characteristics to veteran health status and mortality.

METHODS:
We used data from the Ambulatory Care Quality Improvement Project (ACQUIP), a 7-site, randomized trial of VA primary care patients. Information on personal socioeconomic indicators, co-morbid disease and Medical Outcomes Study 36-item short form (SF-36), were obtained from baseline enrollment data (n=15,889). We used the physical component scale (PCS) and mental component scale (MCS) scores to summarize overall physical and mental function. Mortality was assessed for 2 years after enrollment in the study. Census tracts were used as proxies for neighborhoods. A summary score was used to characterize the neighborhood socioeconomic (SES) environment. Data were analyzed with multilevel hierarchical models.

FINDINGS/RESULTS:
Neighborhood SES was independently associated with PCS and MCS scores among veterans (p < 0.05), controlling for individual socioeconomic status, self-reported co-morbid disease, smoking status, and health care access. In the lowest versus highest quartiles of neighborhood SES, adjusted mean PCS scores were 33.3 vs. 34.5 (p<0.001) and adjusted mean MCS scores were 46.9 versus 47.3 (p<0.001). PCS score was also significantly associated with street connectivity, a measure of walkability of a neighborhood (p<0.05). In adjusted analyses, survival was lower for veterans living in the lowest decile neighborhood SES area (HR 0.84, 95% CI 0.70, 0.99) compared to highest decile neighborhood SES.

IMPACT:
This project provides the first information about the contributions of neighborhood environment with veteran health status and mortality, controlling for health system factors such as access and distance to care, and personal health risks. Veterans living in lower SES neighborhoods have poorer health status and a higher risk of mortality. Independent of many individual level characteristics, we found that neighborhood SES was associated with physical and mental health status among veterans and that veterans living in more walk-able communities had higher physical functioning scores. Although the difference in adjusted PCS and MCS scores is modest at the individual level, our results are relevant to the large population of veterans who live in low SES neighborhoods and receive care at the VA. Further investigation may be warranted to determine the potential for neighborhood level interventions in high risk areas. Our results suggest that health policies may need to consider the areas where people reside, as both social context and individual level variables can provide a more complete understanding of the determinants of health. An understanding of how and to what extent characteristics of one's environment may alter health status are an essential first step to developing interventions (for example, the patient-centered medical home) to assist veterans who reside in communities with conditions unfavorable to their health.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Williams EC, McFarland LV, Nelson KM. Alcohol consumption among urban, suburban, and rural Veterans Affairs outpatients. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2012 Jul 31; 28(2):202-10. [view]
2. Nelson K, Taylor L, Lurie N, Escarce J, McFarland L, Fihn SD. Neighborhood environment and health status and mortality among veterans. Journal of general internal medicine. 2011 Aug 1; 26(8):862-7. [view]

Conference Presentations

1. Williams EC, Nelson KM. Rural and Urban Variations in Alcohol Consumption among Veterans Affairs Outpatients. Poster session presented at: Addiction Health Services Research Conference; 2010 Oct 26; Lexington, KY. [view]
2. Nelson KM, Lurie N, Escarce J, Taylor L, McFarland LV, Fihn SD. The Impact of Neighborhood Environment on Veteran Health Status. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
3. Nelson KM, Lurie N, Escarce J, Taylor L, McFarland LV, Fihn SD. The Impact of Neighborhood Environment on Veteran Health Status and Mortality. Presented at: Society of General Internal Medicine Annual Meeting; 2009 May 13; Miami, FL. [view]

DRA: Health Systems Science
DRE: Epidemiology
Keywords: Access, Minority, Quality of life
MeSH Terms: none