A multilevel analysis of urban neighborhood socioeconomic disadvantage and health in late life☆
Introduction
The associations between neighborhood context and various indicators of physical health are receiving growing empirical attention, and multiple studies have shown that poor health is partly a function of macro-level socioeconomic disadvantage (Pickett and Pearl, 2001, Robert and House, 2000, Ross and Mirowsky, 2001). However, much of this research is regionally circumscribed, or assumes similar effects across the life course, even though neighborhoods may be especially consequential for the aged as their exposure to the immediate environment lengthens and their spatial realms diminish with time (Glass & Balfour, 2003). In addition, many studies assume that similar processes operate in all residential areas, even though most neighborhood theories assume an urban setting in describing the impact of concentrated disadvantage (e.g., Raudenbush, 2003, Sampson, 2003). Thus, the generalizability of findings to older adults residing in theoretically relevant urban residential areas is limited.
The connections between various health indicators in late life can be seen as sequential: individual-level studies have described how chronic disease, for example, has a cascading effect, eventually leading to loss of physical functioning (Hayward, Miles, Crimmins, & Yu, 2000). Consistent with previous multidimensional operationalizations of health (Robert, 1998, Ross and Mirowsky, 2001), we conceptualize chronic disease as the initial catalyst for poor health, with daily living activity problems being a direct consequence, and with global health rating representing a subjective endpoint. By examining the associations between neighborhood socioeconomic status (SES) and physical health in a sequential framework, we begin to answer questions about where in this health “hierarchy” the environment may come in to play as an additional risk factor for negative health outcomes among the oldest adults.
For the present study, chronic illness is operationalized as cardiovascular disease (CVD), the leading cause of death among adults (Mokdad, Marks, Stroup, & Gerberding, 2000). Previous studies using age-heterogeneous samples find that residents of disadvantaged neighborhoods are at higher risk for CVD than residents of advantaged neighborhoods (Diez Roux et al., 1997, Diez Roux et al., 2001, Sundquist et al., 2004). Hypothesized mechanisms that drive this association include variation in access to healthcare, and variable social norms concerning smoking habits, diet, and physical activity. One study specifically focused on adults aged 65 years and older found similar associations (Nordstrom, Diez Roux, Jackson, & Gardin, 2004), attributed to differences in cumulative SES-patterned exposures over the life course.
In contrast, there is evidence that difficulties with physical functioning and disability are not directly related to neighborhood SES. Robert (1998) finds no effect of community-level SES on functional limitations after controlling for individual-level and family-level SES. Feldman and Steptoe (2004) report indirect associations between poor physical functioning and low neighborhood SES, via perceived neighborhood strain. Most studies do, however, find that perceiving oneself to be in poor health is significantly associated with residing in a disadvantaged neighborhood (e.g., Cagney et al., 2005, Kawachi et al., 1999, Lopez, 2004, Malmstrom et al., 1999, Patel et al., 2003, Robert, 1998, Wen et al., 2003, Yen and Kaplan, 1999), citing potential mechanisms similar to those discussed above for CVD. Again, however, little is known about these associations specifically among the oldest adults.
Operationalizations of neighborhood socioeconomic disadvantage vary widely across studies. Our approach underscores the importance of multiple dimensions of disadvantage—neighborhood poverty, unemployment, low education, and public assistance needs—which represent forms of “environmental press” (Lawton, 1982). If the “press” of a disadvantaged neighborhood outweighs a person's own competencies (e.g., health, age, monetary resources) to effectively deal with negative conditions, maladaptive behavior and/or poor health may arise. Favorable outcomes are most likely to occur when personal competencies and environmental press are balanced such that a zone of maximum comfort and performance is achieved. Thus, high or strong press may be harmful or beneficial, depending on its characteristic form and the outcome of interest, and the health connection between the person and their environment is not a simple product of exposure to noxious or beneficial stimuli, but rather a function of person-environment balance.
Environmental press can be equated with “environmental hazard,” which is identified by Catalano and Pickett (2000) as a mechanism by which the specific etiological connection between neighborhood characteristics and health may arise. The assumption is that environmental hazards such as abandoned housing, public deviance, and high crime rates are concomitant to areas characterized by high poverty, high unemployment, low education, and low income, and that exposure to these hazards is threatening and/or stressful. Exposure to or virulence of these hazards varies over space, and coping with adverse circumstances generated by these hazards requires both physical and behavioral adaptation (Catalano & Pickett, 2000), which may be taxing to the individual, leading to poor health. The actual biological mechanism by which poor health may manifest is conceptualized, for example, in terms of allostatic load (McEwen, 1998), which proposes that health outcomes reflect the cumulative impacts of biological dysregulations across multiple biological regulatory systems (e.g., cardiovascular, immune, autonomic), systems that are stress responsive (McEwen, (1998), McEwen, (1993)). Thus, the threat aroused by environmental hazards leads to a stress response, which is physiologically consequential to the body.
There may also be limited resources available to residents in disadvantaged areas that can assist them to effectively cope with the stress engendered by their environment. For example, such areas are often characterized by a lack of medical screening facilities, health clinics, and health promoting social organizations, which can be considered “acquired resources” that influence the ability to cope with hazards (Catalano & Pickett, 2000). Without such coping resources available to them, residents in disadvantaged neighborhoods may have their health care needs unmet, placing them at elevated risk for untreated chronic conditions. They may also disproportionately turn to unhealthy coping behaviors, such as cigarette smoking, which is associated with exposure to chronic stress (Kassel, Stroud, & Paronis, 2003). Thus, the lack of coping resources in disadvantaged neighborhoods may lead to erosions in the health of its residents.
The purpose of this study is to address gaps in the empirical literature on neighborhood risk factors for poor health in late life by examining a series of health domains (chronic disease [CVD], functional ADL limitations, global health rating) and testing whether and how urban neighborhood socioeconomic disadvantage—which we conceptualize as a form of environmental hazard—affects each domain. Establishing the nature of some basic relationships between the socioeconomic environment and health among the oldest adults is an essential first step in furthering our understanding of how social context may have health consequences for the rapidly aging population. Knowledge about these relationships will also inform the development of theory that specifies the mechanisms by which such associations may arise. Our specific analytic goals are threefold: (1) to determine whether there is significant neighborhood variation in these three hierarchically conceptualized health domains among U.S. urban adults aged 70 years and older; (2) to determine whether neighborhood variation is explained by sociodemographic and health risk factors at the individual-level; and (3) to examine whether neighborhood-level socioeconomic disadvantage is significantly associated with individual-level health, net of individual-level factors.
Section snippets
The sample
Survey data are from the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD), a U.S. national probability sample in 1993 of noninstitutionalized persons born in 1923 or earlier (i.e., people aged 70 years or older) (Soldo, Hurd, Rodgers, & Wallace, 1997). Subjects were selected using a multistage area probability design and a dual-frame sample of Medicare recipients. Within sampled households, one age-eligible individual was sampled; when that person had a spouse, he or she was
Results
Individual-level characteristics of the weighted sample are shown in Table 1. Females outnumber males, the average respondent is in their late 70s, most are non-Hispanic White, nearly half are widowed, average education levels approximate high school graduation, and both income and wealth are variable. Over half report having ever smoked cigarettes, the typical participant is slightly overweight (Gallagher et al., 2000), nearly half have high blood pressure, the average participant is not
Discussion
Our results indicate that there is significant neighborhood variation in self-reported physician-diagnosed CVD, ADL difficulty, IADL difficulty, and self-rated poor health among older persons living in U.S. urban areas. There are also overall associations between these health outcomes and neighborhood socioeconomic disadvantage. However, the variation in CVD, ADL difficulty, and IADL difficulty, and the associations with neighborhood-level disadvantage, are explained by individual-level
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2016, Preventive MedicineCitation Excerpt :The findings of this study are consistent with previous single-level studies conducted in the United States and the United Kingdom (Feldman & Steptoe, 2004; Beard et al., 2009), which found that individuals living in more disadvantaged neighborhoods experienced poorer physical function than those in more advantaged neighborhoods. However, the only previous multilevel study (Wight et al., 2008) from the United States found no association between neighborhood disadvantage and physical function, after adjusting for individual-level factors. There are a number of possible explanations for the differences found between our study and those of Wight et al. (2008): including the sample age at the time at which data was collected, differences in the method of calculating area-level disadvantage, and geographical differences in the sampling of participants.
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This research was supported by a grant from the National Institute on Aging (R01 AG022537, Carol S. Aneshensel, Principal Investigator).