Built Environment
and
Arthritis
Leigh F. Callahan, PhD
UNC School of Medicine
Thurston Arthritis Research Center
This talk will review…
• Framework for thinking about social determinants, health,
and health disparities
• Built Environment Definition
• Effect of Built Environment on:
– Older Adults/Chronic Disease in general
– Osteoarthritis Self-Management
– Physical Activity (Facilitators and Barriers)
– Perceived Neighborhood Environment and Health Status
Outcomes in Persons with Arthritis
• Disability, interventions and environmental barriers
Historical Overview
The seminal text on the influence of the
environment on health is Airs, Waters, Places,
written in the 5th Century BCE as part of the
Hippocratic medical corpus.
• It is believed that it was intended to help
Greek traveling physicians anticipate what
disease they were likely to encounter when
beginning practice in new, unfamiliar
towns.
• Airs, water and places refer to features of
climate and topography that were believed
to be found in different places.
• Urbanization triggered special interest in
the relationship between environment and
health in 17th century England
• Common observation during this period
was the greater healthiness of country
versus city dwelling
• Public health in England and America began
as response to social and health problems
of rapid industrialization
Social Determinants and
Health Disparities
• Today, disparities between and within
countries remain ubiquitous
• Increasing attention has been paid to distal, as
well as proximal determinants
Initially research focused on:
• Social position and explored
downstream determinants primarily
related to the individual.
• Mechanisms of human biology.
• Clinical issues of how people cope with
disease and disability.
Increasingly, research findings are
focusing on:
• The broader view of upstream
determinants related to the community
level.
• Variables such as built environment,
place of residence, work environment, or
wider social and economic policies of
society.
Built Environment: It is Everywhere
7 Components of the Built Environment
1. Products (e.g., tools, materials,
machines)
2. Interiors (enclosed space)
3. Structures (external forms)
4. Landscapes (combines natural and built
environment)
5. Cities (group structures and landscapes
for economic, social, cultural or
environmental reasons)
6. Regions (groups of cities and landscapes
having common political social, economic
and/or environmental characteristics)
7. Earth (includes components 1 through 6)
Bartuska TY & Young GL. The built environment : creative inquiry into design and planning. Menlo Park,
CA : Crisp Publications, c1994
Built Environment
Can be examined in terms of:
• individuals’ place of residence
(e.g., in-home modification; incorporating universal design –
raised toilet seats, door with, access ramps, no step
showers/tubs)
• the community and neighborhood of individuals
(e.g., available community resources)
Settings: Examined in the
National Health Interview Survey
“Thinking of your HOME situation, do problems with any of these things
on the list NOW limit or prevent your participation in home activities or
household responsibilities?”
“Thinking of COMMUNITY ACTIVITIES such as getting
together with friends or neighbors, going to church, temple, or another
place of worship, movies, or shopping, do problems with any of these
things on the list NOW limit or prevent your participation in community
activities?”
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Environmental Barriers
• Building design (stairs, bathrooms, narrow or heavy doors)
• Lighting (too dim to read, signs not lit, too bright, too distracting)
• Sound (background noise, inadequate sound system)
• Household or workplace equipment hard to use
• Crowds
• Sidewalks and curbs
• Transportation
• Attitudes of other people
• Policies (rental policies, eligibility for services, workplace rules)
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Participation Restriction due to
Environmental Barriers
HOME setting
5,359,739 million U.S. adults ages 18+
2.6% of the adult population
COMMUNITY setting
5,585,961 million U.S. adults ages 18+
2.7% of the adult population
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Home Barriers
Community Barriers
46%
have both
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Home Barriers by Age Group
100
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60
40
20
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Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Community Barriers by Age Group
100
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40
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Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Community and Health
• Place and health are ultimately linked, given that
goods and services, exposure to hazards, and the
availability of opportunities are all spatially
distributed.
• More attention is now being paid to the relationship
between the community/ neighborhood
environment and individual health.
Important Community Resources
and Services for the Older Adult
• Previous research indicates:
–
–
–
–
–
–
–
–
–
Medical care and hospital facilities
Social connections through family, friends, neighbors
Senior centers
Religious organizations
Available and accessible shopping
Transportation
Meal delivery
Household chore assistance
Living in a safe environment
References:
Feldman, P. H. & Oberlink, M. R. (2003). The AdvantAge Initiative: Developing community indicators to promote the health and well-being of older people. [Article]. Family and Community
Health, 26, 268-274.
Weierbach, F. & Glick, D. (2009). Community resources for older adults with chronic illness. Holistic Nursing Practice, 23, 355-360.
Study 1:
Perceived Barriers to Physical Activity Among
North Carolinians With Arthritis: Findings
From a Mixed-Methodology Approach.
Remmes Martin K, Schoster B, Meier A, Callahan LF. (2007) Perceived Barriers to Physical Activity
Among North Carolinians with Arthritis: Findings from a Mixed-Methodology Approach. North Carolina
Medical Journal. 2007; 68(6): 404-412.
Participant Recruitment
Telephone Survey
N=2479
•Health status
•Chronic health conditions
•Community characteristics
•Health attitudes and beliefs
•Socio-demographic variables
Qualitative
Component
Focus Group Participants (N=21)
• Photographs & Photo-diaries
• Short Self-Administered Survey
N=32
Semi-Structured Interviews (N=11)
•Short Self-Administered Survey
Analyses
• Telephone Survey:
– Descriptive and bivariate analyses were conducted
on demographic variables, community &
neighborhood variables, and key community and
personal reasons for not being more physically
active. (STATA v.8)
• Qualitative Component
– All transcripts were transcribed verbatim
Interviews and photographs underwent content
analysis. (Atlas.ti version 5.0)
Places for Physical Activity
– Parks, walking tracks, and roads
– Gyms and pools (e.g. Curves, YMCA)
– Shopping malls
Barriers to Physical Activity
• The top 4 most frequently listed community reasons for
participants with and without arthritis were not enough
sidewalks, a rural environment, not enough recreational
facilities, and unattended dogs.
• Two community reasons for inactivity reached statistical
significance for those reporting versus those not reporting
arthritis: heavy traffic (p=0.004) and high crime (p=0.008).
Busy roadway without sidewalks
“Actually, to tell you the truth
I don’t walk in my
neighborhood, because the
area where I
live is not a safe place to
walk. It’s rural, we don’t have
sidewalks or it’s not wide
enough to be able to do that
because most of the time it’s
two lanes of cars are coming
up and down, so it’s just
really not safe to walk.”
Woman, age 50
Barriers to Physical Activity cont’d
• Built Environment
– Lack of access for those with disabilities
– Rural area
– Lack of sidewalks
– Heavy traffic
– Quality of cement surfaces
– Uneven surfaces
Study 2:
What community resources do older
community-dwelling adults use to manage
their osteoarthritis?
Remmes Martin K, Schoster B, Woodard J, Callahan LF. An examination of community environment for osteoarthritis by
older adults. Submitted, 32 pages.
Focus Groups
• Summer 2008
•
Convenience sampling
•
Eligibility criteria:
– Self-report Osteoarthritis (knee, hip or combination)
– Reside in Johnston County
• 6 Focus group discussions were conducted
– Each group consisted of 4-8 community members
– Each session lasted about 1 hour
– 2 facilitators led each group
• One is a resident of Johnston County (JW)
We asked participants…
– “what resources in your community help you to manage your arthritis” – with
resources relating to people, places and organizations
– “what resources do you believe would help you to manage your arthritis that are
not available in your community”
Analyses
– All transcripts were audio recorded and transcribed
verbatim
– We used the Corbin and Strauss self-management tasks to
guide the analysis of the focus group transcripts in
identifying community resources or services that
participants use for OA self-management.
– Content analyses were conducted using constant
comparison methodology1 to identify:
1)
2)
3)
emergent community resources that related to the three selfmanagement tasks;
facilitators or barriers to community resource use for OA
management, and
community environment characteristics for OA management.
1 Dye JF, Schatz IM, Rosenberg BA, Coleman ST. Constant comparison method: A kaleidoscope of data. The Qualitative Report. 2002 4(1/2).
Community Resources Important
for OA Management
Medical and Behavioral Management
•Community Aquatics Center
•Senior Center; Council on Aging;
Civic Center; Medical Mall
•Shopping Center
•Community Recreational Facilities
(e.g., walking trails)
•Religious Organization
(e.g., walking trails, health talks)
Role Management
•Community Transportation
(e.g., JCATS, Williams Transport)
•Pharmacy
•Rescue Mission; Meals on Wheels
•Library
•Shopping Areas
(e.g., grocery stores)
Community Built Environment
Characteristics Important for OA
Management
Access Ramps:
Accessibility, Location
Handicap Parking:
Availability, Location, Accessibility
Sidewalks: Availability,
Quality
Doors: Automatic vs. Manual
Walking Surfaces: Level,
Smooth Condition
Transportation
Built Environment Characteristics
cont’d
Lighting: Location, Sufficiency
Cub Cuts: Availability
Study 3:
Associations of Perceived Neighborhood
Environment on Health Status Outcomes in
Persons with Arthritis.
Martin KR, Schoster B, Shreffler J, and Callahan LF. Associations of Perceived Neighborhood Environment
on Health Status Outcomes in Persons with Arthritis. Arthritis Care and Research. Epub ahead of pirnt
Purpose
To examine the association between four
aspects of the perceived neighborhood
environment (aesthetics, walkability, safety,
and social cohesion) and health status
outcomes in a cohort of North Carolinians
with self-report arthritis, after adjustment for
individual and neighborhood SES covariates.
Perceived Neighborhood
Variables
• Physical1
– Aesthetic environment
– Walking/exercise environment
– Safety from crime
• Social2
– Neighborhood social cohesion and trust
1 Echeverria S, Diez-Roux A, Link B. Reliability of self-reported neighborhood characteristics. Journal of Urban Health. 2004; 18(4):682-701
2 Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel study of collective efficacy. Science. 1997 Aug
15:277(5328): 918-24
Statistical Analysis
• 696 participants self-reported one or more types of arthritis
or rheumatic condition in a telephone survey.
• Outcomes measured were physical and mental functioning
(MOS SF-12v2 PCS and MCS); functional disability (HAQ);
depressive symptomatology (CES-D scored <16; ≥16).
• Covariates included participant socio-demographics (age,
race, and gender), health characteristics (body mass index
(BMI), and number of comorbid conditions), individual SES
measures (education, household income, occupation, and
home ownership), and neighborhood SES (block group
poverty rate).
• Multivariate regression and multivariate logistic regression
analyses were conducted using STATA v11.
Results
• Final adjusted models included all four perceived
neighborhood characteristics simultaneously. A one
point increase in perceiving worse neighborhood
aesthetics predicted lower mental health (B= -1.81,
p=0.034).
• Individuals had increased odds of depressive
symptoms if they perceived lower neighborhood
safety (OR: 1.36; CI: 1.04, 1.78, p=0.023) and if they
perceived lower neighborhood social cohesion (OR
1.42; CI: 1.03, 1.96, p=0.030).
Conclusions
• Study findings indicate that an individual’s
perception of neighborhood environment
characteristics, especially aesthetics, safety and
social cohesion, is predictive of health outcomes
among adults with self-report arthritis, even after
adjusting for key variables.
• Future studies interested in examining the role that
community characteristics play on disability and
mental health in individuals with arthritis might
consider further examination of perceived
neighborhood.
Disability, Interventions and
Environmental Barriers
• Arthritis example of disability/participation
restriction
• Intervention programs – CDC Arthritis
Program
• Intersection of effective programs and
environmental factors
• Putting both together
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Arthritis Disability
Intervention
Arthritis
(pathology)
Intervention
Severe Pain
(impairment)
Environmental Factors
Intervention
Activity
Limitation
(functional limitation)
DISABILITY
(participation)
Personal Factors
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Disability Profile
Percent (%) Among Adults with Arthritis
Adults with Arthritis
45
40
35
30
25
20
15
10
5
0
40.9
26.5
10.6
Severe Pain
Activity Limitation
Source: 2003 National Health Interview Survey
Participation Restriction
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Activity Limitation ≠ Participation Restriction
Social Participation
Restriction
(4.9 million)
Arthritis
Attributable
Activity
Limitation
(18.9 million)
4.0
million
0.9
million
Source: 2003 National Health Interview Survey, adults with arthritis
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Intersection
Disability -- Environmental Factors
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Activity Limitation + Environmental
Factors = Disability
Arthritis
(pathology)
Severe Pain
(impairment)
Activity
Limitation
(functional limitation)
Attend church
on Sunday
(participation)
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Case Study : Ethel
• 68 year old, retired widow
• OA left knee and both shoulders,
moderate-severe pain
• Extreme difficulty rising from chair,
going up/down steps, low endurance
• Wants to go to church on Sunday,
shopping with friends
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
AFEP @ Senior Center
• MD recommends an exercise program
• Friend suggests calling the local Senior
Center
• Offers the AFEP 2 days/week
• Transportation service available
• Attends class for 16 weeks
• Symptom and functional improvement
• 60% reduction in pain
• Can climb flight of stairs and walk ½ mile without a
cane
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Intervening to prevent disability
AFEP
Arthritis
(pathology)
AFEP
Reduced Pain
(impairment)
Improved
Function
(functional limitation)
Attend church
on Sunday
(participation)
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
To get to church…..
• ~ 10 block walk
• No sidewalks
• Cross 6 lane road
• No public transportation
• Uneven stone stairs, no
railing
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Activity Limitation + Environmental
Factors = Disability
AFEP
Arthritis
(pathology)
AFEP
Reduced Pain
(impairment)
Improved
Function
(functional limitation)
Attend church
on Sunday
(disability)
Environmental Factors
•No sidewalks, handrails
•No public transportation
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Remove environmental barriers
• Accessible public
transportation
• Senior shuttle service
• Handrails for steps
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Removing barriers to participation
AFEP
Arthritis
(pathology)
AFEP
Reduced Pain
(impairment)
Improved
Function
(functional limitation)
Attend church
on Sunday
(participation)
Environmental Factors
•No sidewalks, handrails
•No public transportation
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Improving participation among
older adults is a complex puzzle
Partnerships
Social
Support
Facilitative
environment
Public safety
Accessible and
appropriate
health care
Community
culture
Accessible
EB programs
Policies
Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA
Arthritis Program, U.S. Centers for Disease Control and Prevention
Funding Support
• National Institute of Health - National Institute
of Arthritis and Musculoskeletal Skin Diseases
(NIAMS)
Grant number: P60-AR49465-01
• National Institute of Arthritis and
Musculoskeletal Skin Diseases (NIAMS)
Grant number: RO1-AR-053-989-01