Built Environment and Arthritis

1. Built Environment and Arthritis Leigh F. Callahan, PhD UNC School of Medicine Thurston Arthritis Research Center

2. 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

3. 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.

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. Built Environment: It is Everywhere 7 Components of the Built Environment Products (e.g., tools, materials, machines) Interiors (enclosed space) Structures (external forms) Landscapes (combines natural and built environment) Cities (group structures and landscapes for economic, social, cultural or environmental reasons) Regions (groups of cities and landscapes having common political social, economic and/or environmental characteristics) 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

10. 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)

11. 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

12. 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

13. 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

14. 46% have both Home Barriers Community Barriers Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA Arthritis Program, U.S. Centers for Disease Control and Prevention

15. Home Barriers by Age Group Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA Arthritis Program, U.S. Centers for Disease Control and Prevention

16. Community Barriers by Age Group Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA Arthritis Program, U.S. Centers for Disease Control and Prevention

17. 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.

18. 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.

19. 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.

20. Participant Recruitment • Telephone Survey • N=2479 • Health status • Chronic health conditions • Community characteristics • Health attitudes and beliefs • Socio-demographic variables • Focus Group Participants (N=21) • Photographs & Photo-diaries • Short Self-Administered Survey Qualitative Component N=32 • Semi-Structured Interviews (N=11) • Short Self-Administered Survey

21. 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)

22. Places for Physical Activity • Parks, walking tracks, and roads • Gyms and pools (e.g. Curves, YMCA) • Shopping malls

23. 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).

24. 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

25. 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

26. 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.

27. 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”

28. 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: • emergent community resources that related to the three self-management 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).

29. Community Resources Important for OA Management

30. Community Built Environment Characteristics Important for OA Management Access Ramps: Accessibility, Location Handicap Parking:   Availability, Location, Accessibility Sidewalks: Availability, Quality Walking Surfaces: Level, Smooth Condition Doors: Automatic vs. Manual Transportation

31. Built Environment Characteristics cont’d Lighting: Location, Sufficiency Cub Cuts: Availability

32. 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

33. 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.

34. 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

35. 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.

36. 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).

37. 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.

38. 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

39. Arthritis Disability Intervention Intervention Intervention Arthritis (pathology) Activity Limitation (functional limitation) Severe Pain (impairment) DISABILITY (participation) Environmental Factors Personal Factors Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA Arthritis Program, U.S. Centers for Disease Control and Prevention

40. Disability Profile Adults with Arthritis Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA Arthritis Program, U.S. Centers for Disease Control and Prevention Source: 2003 National Health Interview Survey

41. Activity Limitation ≠ Participation Restriction Social Participation Restriction (4.9 million) Arthritis Attributable Activity Limitation (18.9 million) 0.9 million 4.0 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

42. Intersection Disability -- Environmental Factors Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA Arthritis Program, U.S. Centers for Disease Control and Prevention

43. Activity Limitation + Environmental Factors = Disability Arthritis (pathology) Activity Limitation (functional limitation) Severe Pain (impairment) 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

44. 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

45. 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

46. Intervening to prevent disability AFEP AFEP Arthritis (pathology) Improved Function (functional limitation) Attend church on Sunday (participation) Reduced Pain (impairment) Slide courtesy of: Jennifer M. Hootman, PhD, ATC, FACSM, FNATA Arthritis Program, U.S. Centers for Disease Control and Prevention

47. 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

48. Activity Limitation + Environmental Factors = Disability AFEP AFEP Arthritis (pathology) Improved Function (functional limitation) Reduced Pain (impairment) 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

49. 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

50. Removing barriers to participation AFEP AFEP Attend church on Sunday (participation) Arthritis (pathology) Improved Function (functional limitation) Reduced Pain (impairment) • 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