Built Environment and Arthritis

Built Environment Built Environment and and

ArthritisArthritis

Leigh F. Callahan, PhDUNC 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 Everywhere7 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)

“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?”

Settings: Examined in the National Health Interview Survey

“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, FNATAArthritis 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, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Participation Restriction due to Environmental Barriers

HOME setting5,359,739 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 populationSlide 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, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Home Barriers by Age Group

0

20

40

60

80

100

building design

sidewalks/curbs

equipment

transportation

lightingsound

crowdspolicies

attitudes

50+ <=49Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA

Arthritis Program, U.S. Centers for Disease Control and Prevention

Community Barriers by Age Group

0

20

40

60

80

100

50+ <=49Slide 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.

Telephone Survey

N=2479•Health statusHealth status

•Chronic health conditionsChronic health conditions•Community characteristicsCommunity characteristics•Health attitudes and beliefsHealth attitudes and beliefs•Socio-demographic variablesSocio-demographic variables

Participant Recruitment

Qualitative Component

N=32

Focus Group Participants (N=21)• Photographs & Photo-diaries• Short Self-Administered Survey

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 Ilive 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) emergent community resources that related to the three self-

management tasks; 2) facilitators or barriers to community resource use for OA

management, and 3) 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).

Medical and Behavioral Management Role Management•Community Aquatics Center •Community Transportation

(e.g., JCATS, Williams Transport)•Senior Center; Council on Aging; Civic Center; Medical Mall •Pharmacy

•Shopping Center •Rescue Mission; Meals on Wheels•Community Recreational Facilities (e.g., walking trails)

•Library

•Religious Organization (e.g., walking trails, health talks)

•Shopping Areas (e.g., grocery stores)

Community Resources Important for OA Management

Community Built Environment Characteristics Important for OA

Management

Access Ramps: Accessibility, Location

Doors: Automatic vs. Manual

Transportation

Sidewalks: Availability, Quality

Walking Surfaces: Level, Smooth Condition

Handicap Parking:  Availability, Location, Accessibility

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, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Arthritis Disability

Arthritis (pathology)

Severe Pain (impairment)

Activity Limitation

(functional limitation)

DISABILITY(participation)

Intervention Intervention Intervention

Environmental Factors Personal Factors

Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Disability Profile Adults with Arthritis

26.5

10.6

40.9

0

5

10

15

20

25

30

35

40

45

Severe Pain Activity Limitation Participation RestrictionPerc

ent (

%) A

mon

g Ad

ults

with

Arth

ritis

Source: 2003 National Health Interview SurveySlide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA

Arthritis Program, U.S. Centers for Disease Control and Prevention

Activity Limitation ≠ Participation Restriction

ArthritisAttributable

Activity Limitation

(18.9 million)

Social Participation Restriction(4.9 million)

4.0 million

0.9 million

Source: 2003 National Health Interview Survey, adults with arthritisSlide 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, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Arthritis (pathology)

Severe Pain (impairment)

Activity Limitation

(functional limitation)

Attend church on Sunday

(participation)

Activity Limitation + Environmental Factors = Disability

Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATAArthritis 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, FNATAArthritis 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, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Arthritis (pathology)

Reduced Pain (impairment)

Improved Function

(functional limitation)

Attend church on Sunday

(participation)

AFEP

Intervening to prevent disabilityAFEP

Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATAArthritis 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, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Arthritis (pathology)

Reduced Pain (impairment)

ImprovedFunction

(functional limitation)

Attend church on Sunday(disability)

AFEP

Environmental Factors•No sidewalks, handrails•No public transportation

Activity Limitation + Environmental Factors = Disability

AFEP

Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATAArthritis 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, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Arthritis (pathology)

Reduced Pain (impairment)

Improved Function

(functional limitation)

AFEP

Environmental Factors•No sidewalks, handrails•No public transportation

Removing barriers to participationAFEP

Attend church on Sunday

(participation)

Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATAArthritis Program, U.S. Centers for Disease Control and Prevention

Improving participation among older adults is a complex puzzle

Accessible EB programs

Facilitative environment

Public safety

Community culture

Accessible and appropriatehealth care

PartnershipsSocial Support

Policies

Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATAArthritis 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