Neighborhoods and disability in later life

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Abstract

This paper uses the US Health and Retirement Study to explore linkages between neighborhood conditions and stages of the disablement process among adults aged 55 years and older in the United States. We consider multiple dimensions of the neighborhood including the built environment as well as social and economic conditions. In doing so, we use factor analysis to reduce indicators into eight neighborhood scales, which we incorporate into two-level logistic regression models along with controls for individual-level factors. We find evidence that economic conditions and the built environment, but not social conditions, matter. Neighborhood economic advantage is associated with a reduced risk of lower body limitations for both men and women. We also find for men that neighborhood economic disadvantage is linked to increased chances of reporting personal care limitations, particularly for those aged 55–64 years, and that high connectivity of the built environment is associated with reduced risk of limitations in instrumental activities. Our findings highlight the distinctive benefits of neighborhood economic advantage early in the disablement process. In addition, findings underscore the need for attention in the design and evaluation of disability-prevention efforts to the benefits that accrue from more physically connected communities and to the potential harm that may arise in later life from living in economically disadvantaged areas.

Introduction

A growing literature has documented associations between characteristics of environments in which people live and various health outcomes (e.g., reviewed in Kawachi & Berkman, 2003). Historically, such inquiries have flowed from concerns regarding the implications of economic inequalities, benefits of social capital, and role of the state in promoting health (illustrated, e.g., by Szreter & Woolcock, 2004 and related commentaries by Kawachi et al., 2004, Muntaner, 2004, and Smith & Lynch, 2004). Attention in this literature to older adults has been comparatively thin (Glass and Balfour, 2003, Morenoff and Lynch, 2004), despite findings that associations between neighborhoods and health are the strongest among adults around retirement age (Robert & Li, 2001). There also may be important gender differences in these patterns, with greater effects for women's health (Stafford, Cummins, Macintyre, Ellaway, & Marmot, 2005), although these differentials have not been explored fully for older adults.

Notably, older adults face much higher risks of functional decline than other age groups, and older women are more likely to experience activity limitations than men (Institute of Medicine, 2007). Functional declines and subsequent disability have implications for medical and long-term care expenditures, transfer payments through public programs, and the quality of life of older adults and their caregivers. Consideration of the potentially negative consequences of remaining in neighborhoods that are ill-equipped for seniors and identification of potentially protective elements may help bolster programs to defer disability and facilitate aging in place. Thus, the link between residential environment and late-life disablement is of particular interest.

Studies of late-life disability traditionally have ignored the role that the neighborhood environment plays in the disablement process (Stuck et al., 1999). In the United States, regional variation in late-life disability prevalence has been established (Lin, 2000, Lin and Zimmer, 2002), but variation on a more local level has been examined in only four U.S. studies. Balfour and Kaplan (2002) studied 883 persons aged 55 years and older in Alameda County, California between 1994 and 1995. They found that functional loss was related to self-reported problems with neighborhoods, including excessive noise, inadequate lighting at night, heavy traffic, and limited public transportation. Clarke and George (2005) examined the role of the built environment in the disablement process for 4154 adults aged 65 years and older from central North Carolina. Using survey responses linked to 1990 census-tract data, they found that older adults reported greater independence in instrumental activities of daily living (e.g., shopping, managing money, household chores) when they lived in environments with more land use diversity and that among those with functional limitations housing density was inversely related to self-care disability. A third study (Schootman et al., 2006) examined the risk of onset of lower body limitations among 563 middle-aged African Americans around St. Louis, Missouri (aged 49–65 years at baseline). Using surveyors' assessments of neighborhood conditions, the authors found that people living in areas with 4–5 vs 0–1 fair/poor conditions were more than three times as likely to develop a lower body limitation. And, in the only nationally focused U.S. study of neighborhoods and functional status that we could identify, Robert (1998) found for adults aged 25–96 years that the percentage of households receiving public assistance was positively associated and the percentage of families with >$30,000 income in 1980 dollars was inversely associated with the chances of having functional limitations, but that these associations were no longer significant once individual-level education and income were taken into account. Studies of Britain have provided similar results. For example, Bowling and Stafford (2007) recently demonstrated that both objective measures of neighborhood affluence and subjective measures of perceived neighborhood qualities were associated with physical functioning among the 65 years and older population, but these associations were no longer significant once adjustment was made for individual-level factors.

Conclusions that can be drawn from this literature are limited in several respects. First, very few studies have been national in scope; hence, the generalizability of findings has been limited. Second, studies have adopted varied ages to identify older adults (e.g., 55+, 65+, 49–65 years) or no age restriction at all. Third, definitions of disability have varied, with some studies combining measures of underlying impairments in function (climbing stairs, walking) with reports of difficulty with activities that facilitate living independently (shopping, cooking) and more severe limitations in personal care activities (bathing, dressing). Fourth, studies generally explore only a few neighborhood features, and measures of such features vary across studies, with some observed, some perceived, and others obtained through linkages to secondary data. Fifth, indicators of individual-level socioeconomic status have been quite limited; thus, disentangling associations with individual vs neighborhood-level resources remain an important task. Sixth, despite evidence that the disablement process differs for men and women (Wray & Blaum, 2001) limited sample sizes have generally precluded investigation of gender-specific associations. Finally, if individuals sort themselves into different kinds of neighborhoods along health dimensions, as a recent U.K. study suggests they do (Norman, Boyle, & Rees, 2005), then estimates of neighborhood effects on the risks of disability could be biased (Evans et al., 1992, Manski, 1993, Tienda, 1991).

In this paper, we expand on this literature to explore linkages between neighborhood features and functioning among U.S. adults aged 55 years and older. Using the U.S. Health and Retirement Study (HRS), a large, nationally representative survey of older adults, we consider neighborhood features reflecting the built environment and social and economic conditions. We use factor analysis to reduce indicators to eight scales, which we include in multi-level models adjusted for individual-level characteristics. Because the HRS includes excellent measures of income and assets, we are better able than previous studies to isolate the contribution of neighborhood-level socioeconomic components. Large sample sizes allow us to stratify analyses for men and women. Further, because of the survey's panel design we can explore for a limited 2-year time period, whether significant cross-sectional relationships are being introduced by moves related to disability status.

Section snippets

Framework

Drawing upon Krause (1996) and Taylor, Repetti, and Seeman (1997), we highlight three overarching neighborhood domains that may affect late-life health and functioning: the built environment, the social environment, and the economic environment. Such domains are not strictly mutually exclusive, but generally divide along a neighborhood's physical features, its social fabric, and the economic characteristics of individuals living in the area.

The built environment may operate on late-life health

Data

The HRS (2002), funded by the U.S. National Institute on Aging and conducted by the University of Michigan (NIA U01AG009740), collects extensive information on health, demographic, and socioeconomic characteristics of respondents aged 50 years and older and their spouses. The HRS has a complex, multi-stage sample design with geographically-based clustering and stratification. This panel survey is replenished every 6 years and sample weights adjust for non-response and loss to follow-up so that

Methods

To guide selection of neighborhood measures, we first reviewed the literature to identify pre-existing scales. We found that such scales (e.g., reflecting economic depravation or social connectedness) most often had been developed with younger adults, in small-area studies, and with a relatively narrow range of measures. Moreover, measures available to us from national data sources overlapped, but did not correspond perfectly, with these scales. To identify a broader set of items for inclusion

Sample and tract characteristics

Table 1 provides estimates of individual-level sample characteristics. Lower body limitations are highly prevalent in this population: 54% of men and nearly 70% of women aged 55 years and older report having at least one lower body limitation. About 12% of men and 15% of women report having at least one IADL limitation. Estimates of ADL limitation are of a similar magnitude.

Compared to the average U.S. neighborhood, HRS respondents tend to live in tracts that have more pollution and crime, more

Discussion

Our analysis has produced several new insights into the role of neighborhoods in later-life functioning and disability. Living in more economically advantaged areas was associated with lower chances of limitations in lower body functioning for both men and women. These effects were not inconsequential in terms of size: all else being equal, the risk of lower body limitations was 3–5 percentage points lower for older persons living in neighborhoods that rank at the upper quartile of economic

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    This research was funded by the National Institute on Aging (R01AG024058). Funding for RAND's Center for Population Health and Health Disparities was provided through NIEHS P50 ES12383. We thank Rizie Kumar and Carol Rayside. The views expressed are those of the authors alone and do not represent the funding agencies or authors' employers.

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