NEIGHBORHOOD FACTORS AND HEALTH
AMONG RESIDENTS LIVING IN A
MICROPOLITAN CITY IN IOWA
Erin Foster, BS
Amy Schumacher, MS
Christine Morris, MA
University of Iowa, College of Public Health
Iowa Governor’s Conference on Public Health
April 15th, 2015
Outline
◦ Introduction
◦ Methods
◦ Data
◦ Statistical Methods
◦ Results
◦ Discussion
◦ Implications
INTRODUCTION
Self-rated
health
Perceptions and realities of the
neighborhood environment
have been shown to
significantly impact health
BMI
Dietary
behaviors
Physical
activity
Self-Rated Health
◦ Physical and social disorder
◦ Examples: noise; crowding;
attachment to the neighborhood
◦ Social cohesion and capital
◦ Violence
◦ Walkability
https://www.firstoptiononline.com/wp-content/uploads/2013/09/14384598_xl.jpg
(Diez Roux & Mair, 2010; Franzini, Caughy, Spears, & Esquer, 2005; Rohrer, Pierce, & Denison, 2004; Wen, Hawkley, & Cacioppo, 2006)
BMI
◦ Access to recreational facilities
◦ Walkability
◦ Example: quality of sidewalks
◦ Physical disorder
◦ Density of fast food
restaurants
◦ Availability of healthy foods
https://www.flickr.com/photos/beaumontpete/4800039961/
(Black, Macinko, Dixon, & Fryer Jr, 2010; Boehmer, Hoehner, Deshpande, Ramirez, & Brownson, 2007; Diez Roux & Mair, 2010; Larson, Story, & Nelson, 2009;
Li, Harmer, Cardinal, Bosworth, & Johnson-Shelton, 2009)
Dietary Behaviors
◦ Access and availability to
supermarkets
◦ Greater selection of healthy foods 
increased food and vegetable
consumption
◦ Social disorder is also important
◦ Density of fast-food outlets
◦ Aesthetics
http://www.prweb.com/releases/2014/03/prweb11715139.htm
(Diez Roux & Mair, 2010; Keita, Casazza, Thomas, & Fernandez, 2011; Lopez, 2007; Larson et al., 2009; Litt et al., 2011; Zenk et al., 2009)
Physical Activity
◦ Environmental settings and resources
◦ Examples: gyms; treadmills; sidewalks
◦ Walkability
◦ Social cohesion
◦ Aesthetics
◦ Safety
http://www.nhlbi.nih.gov/health/educational/wecan/get-active/physicalactivity-guidelines.htm
(Ball, Bauman, Leslie, & Owen, 2001; Brownson, Baker, Housemann, Brennan, & Bacak, 2001; Centers for Disease Control and Prevention, 1999; Diez Roux &
Mair, 2010; Echeverria, Diez-Roux, Shea, Borrell, & Jackson, 2008; Saelens, Sallis, Black, & Chen, 2003; Strong, Reitzel, Wetter, & McNeill, 2013)
Gaps in Current Research
◦ Studies primarily conducted among neighborhoods in large, urban regions
◦ Less is known about neighborhoods in smaller regions, which tend to be more
dispersed and experience greater lack of resources
◦ More research needed among residents living in neighborhoods in Micropolitan
regions
◦ Regions with greater than 10,000 but fewer than 50,000 residents
Study Aim:
To explore the relationships between neighborhood perceptions, dietary behaviors,
physical activity, obesity and general health in residents of an Iowa Micropolitan
community
(Liese, Weis, Pluto, Smith, & Lawson, 2007; Powell, Slater, Mirtcheva, Bao, & Chaloupka, 2007)
Main Hypotheses
Proposed Model
H1: PA, F/V, and Fast Food will have a direct effect on BMI
Covariates
PA
F/V
Fast Food
BMI
Main Hypotheses
Proposed Model
H1: PA, F/V, and Fast Food will have a direct effect on BMI
H2: BMI will have a direct effect on Health
H3: PA, F/V, and fast food will have direct and indirect effects
on Health
Covariates
PA
F/V
BMI
Health
Fast Food
Main Hypotheses
Proposed Model
Covariates
H1: PA, F/V, and Fast Food will have a direct effect on BMI
H2: BMI will have a direct effect on Health
H3: PA, F/V, and fast food will have direct and indirect effects
on Health
H4: Neighborhood perceptions will have direct effects on PA,
F/V, and Fast Food
H5: Neighborhood perceptions will have direct and indirect
effects on BMI and Health
PA
F/V
BMI
Health
NBHD Percept.
Fast Food
METHODS
Data: Ottumwa Community Survey
◦ Location: Ottumwa, Iowa
◦ Year: 2013
◦ Method: Random digit dial phone survey
◦ Sample size: 1087
◦ Topics: Demographics, health behaviors, neighborhood perceptions
◦ Data was weighted for age, gender, and ethnicity
◦ Data was multiply imputed
Weighting
◦ Sample
37% Male
63% Female
◦ Ottumwa (From 2010 Census)
48% Male
52% Female
Weighting
◦ Unweighted sample
◦ Weighted
Weighting
◦ Final Sample
48% Male
52% Female
Weighting
◦ Original Sample
54% Not Employed
46% Employed
◦ Weighted Sample
44% Not Employed
56% Employed
Statistical Methods
◦ Data management in SAS 9.4
◦ Demographics in SAS 9.4
◦ Structural equation modeling (SEM) in Mplus Version 7
◦ Each neighborhood scale tested separately
Factor Analysis
Structural Equation Modeling
Stress
Health
Structural Equation Modeling
Stress
Eating
Health
Structural Equation Modeling
Eating
Stress
Health
Structural Equation Modeling
Eating
Stress1
Stress2
Stress3
Stress
Health
Measures
Gender
Children
Ethnicity
Age
Education
Poverty
Getting 150 minutes
of physical activity
through travel and
leisure per week
Demographics
PA
F/V
Social Cohesion
Aesthetics
Safety
Walkability
Food Environment
Violence
Fast Food
Neighborhood Perceptions
Number of fruits
and vegetables
consumed per
day
Consumes fast
food in a typical
week
Body
Mass
Index
Rated health
as excellent,
very good, or
good
BMI
Self‐
rated Health
Neighborhood Measures
Social Cohesion
People around here are willing to help their neighbors.
People in this neighborhood generally get along with each other.
People in this neighborhood share the same values.
People in this neighborhood can be trusted.
Would you say….
Strongly agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree
Neighborhood Measures
Aesthetics
There is a lot of trash and litter on the street in my neighborhood.
There is a lot of noise in my neighborhood.
In my neighborhood, the buildings and homes are well-maintained.
The buildings and houses in my neighborhood are interesting.
My neighborhood is attractive.
There are interesting things to do in my neighborhood.
Would you say….
Strongly agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree
Neighborhood Measures
Safety
I feel safe walking in my neighborhood, day or night.
Violence is not a problem in my neighborhood.
My neighborhood is safe from crime.
Would you say….
Strongly agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree
Neighborhood Measures
Walkability
My neighborhood offers many opportunities to be physically active.
Local sports clubs and other facilities in my neighborhood offer many opportunities to get exercise.
It is pleasant to walk in my neighborhood.
The trees in my neighborhood provide enough shade.
In my neighborhood, it is easy to walk places
I often see other people walking in my neighborhood.
I often see other people exercising, such as jogging, biking, and playing sports, in my neighborhood
Would you say….
Strongly agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree
Neighborhood Measures
Food Environment
A large selection of fresh fruits and vegetables is available in my
neighborhood.
The fresh fruits and vegetables in my neighborhood are of high quality.
A large selection of low-fat products is available in my neighborhood.
Would you say….
Strongly agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree
Neighborhood Measures
Violence
A fight in your neighborhood in which a weapon was used.
Gang fights in your neighborhood.
A sexual assault or rape in your neighborhood.
A robbery or mugging in your neighborhood.
Hard drug use in your neighborhood. (heroin, meth, coke, crack, etc.)
Did this occur….
Often, Sometimes, Rarely, Never
RESULTS
Descriptive Statistics
Demographics
Female
Children in household
Latino
Average Age
52.28%
38.14%
8.52%
48.21
Graduated high school
In poverty
87.22%
33.04%
Descriptive Statistics
Variables of Interest
> 150 Minutes of PA per week
Overweight (BMI 25 to 29.9) or Obese (BMI 30 or above)
49.23%
67.69%
Eat fast food in a typical week
Average # of F/V per day
Reported excellent, very good, good health
77.61%
3.03
77.49%
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
PA
Health Behaviors
BMI
Health
Fruit & Veggie
Consumption
BMI
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.105
0.762
0.02
0.13
0.14
0.08
0.26
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Social Cohesion
Fruit & Veggie
Consumption
BMI
Social
Cohesion
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.058
0.951
0.03
0.13
0.15
0.08
0.27
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Aesthetics
Fruit & Veggie
Consumption
BMI
Aesthetics
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.061
0.918
0.03
0.13
0.15
0.08
0.27
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Food Environ.
Food Environment
PA
BMI
Fruit & Veggie
Consumption
BMI
Food
Environ.
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.042
0.997
0.04
0.15
0.18
0.08
0.28
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Food Environ.
Food Environment
PA
Health
Fruit & Veggie
Consumption
BMI
Food
Environ.
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.042
0.997
0.04
0.15
0.18
0.08
0.28
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Safety
Fruit & Veggie
Consumption
BMI
Safety
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.065
0.963
0.03
0.14
0.15
0.08
0.27
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Walkability
Walkability
PA
BMI
Fruit & Veggie
Consumption
BMI
Walkability
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.058
0.942
0.07
0.14
0.18
0.08
0.26
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Walkability
Walkability
PA
Health
Fruit & Veggie
Consumption
BMI
Walkability
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.058
0.942
0.07
0.14
0.18
0.08
0.26
Demographics:
Gender
Children
Ethnicity
Age
Education
Poverty
Violence
Fruit & Veggie
Consumption
BMI
Violence
Eating Fast
Food
Good SelfRated Health
Getting 150
Minutes of PA
RMSEA
CFI
F/V
FF
PA
BMI
Health
0.052
0.944
0.02
0.15
0.15
0.09
0.27
Model Fit and R2
Model Fit
R2
Model
RMSEA
CFI
F/V
FF
PA
BMI
Health
Structural
0.105
0.762
0.02
0.13
0.14
0.08
0.26
Social Cohesion
0.058
0.951
0.03
0.13
0.15
0.08
0.27
Aesthetics
0.061
0.918
0.03
0.13
0.15
0.08
0.27
Food Environ.
0.042
0.997
0.04
0.15
0.18
0.08
0.28
Safety
0.065
0.963
0.03
0.14
0.15
0.08
0.27
Walkability
0.058
0.942
0.07
0.14
0.18
0.08
0.26
Violence
0.052
0.944
0.02
0.15
0.15
0.09
0.27
DISCUSSION &
IMPLICATIONS
Direct Effects
NBHD Item
F/V
Cohesion
X
Aesthetics
X
Food Environ.
X
Safety
X
Walkability
X
Violence
FF
PA
BMI
Health
X
X
X
X
X
X
X
X
Partial Mediation
Indirect Effects
Self-Rated
Health
PA
Full Mediation
BMI
Food
Environ.
Walkability
Physical
Activity
Physical
Activity
BMI
Food
Environ.
Self-Rated
Health
Physical
Activity
Self-Rated
Health
Walkability
BMI
Physical
Activity
Implications: Social Cohesion
◦ Association between social cohesion and
self-rated health consistent with literature
◦ Also associated with F/V
◦ No association between social cohesion and
physical activity found
◦ Neighborhood social cohesion is important
to consider when developing interventions
to:
◦ Improve fruit and vegetable consumption
◦ Improve self-rated health
libraryeuroparl.files.wordpress.com/2013/09/fotolia_51660186_subscription
.jpg?w=350&h=200&crop=1
Implications: Aesthetics
◦ Association between aesthetics and F/V
consistent with other studies
◦ No association between aesthetics and
PA found
◦ Neighborhood aesthetics is important
to consider when developing
interventions to:
◦ Improve fruit and vegetable consumption
http://www.cityoflacrosse.org/images/pages/N2762/P7070001.JPG
Implications: Food Environment
◦ Consistent with other studies, food environment was
associated with dietary behaviors and BMI
◦ Also associated with PA and self-rated health
◦ Neighborhood food environment is important to
consider when developing interventions to:
◦ Improve fruit and vegetable consumption
◦ Improve self-rated health
◦ Increase physical activity levels
◦ Reduce fast food consumption
◦ Decrease BMI
◦ Strong point of intervention
http://cdn1.sph.harvard.edu/wpcontent/uploads/sites/56/2012/10/preventing_obesit
y-food_environment.jpg
Implications: Safety
◦ Association between safety and fruit and
vegetable consumption
◦ No association between safety and PA found
◦ Neighborhood safety may be important to
consider when developing interventions to:
◦ Improve fruit and vegetable consumption
http://www.pdnachicago.com/attachments/Image/events/Safety_first.jpg
Implications: Walkability
◦ Associations between walkability and BMI, PA,
self-rated health is mostly consistent with
literature
◦ Also associated with F/V
◦ Neighborhood walkability is important to
consider when developing interventions to:
◦
◦
◦
◦
Improve fruit and vegetable consumption
Increase physical activity
Improve self-rated health
Reduce BMI
◦ Strong point of intervention
http://cdn.citylab.com/media/img/citylab/legacy/2012/09/10/kaid2.jpg
Implications: Violence
◦ Association between violence and self-rated
health consistent with literature
◦ Also associated with FF
◦ Neighborhood violence is important to
consider when developing interventions to:
◦ Reduce fast food consumption
◦ Improve self-rated health
https://img.washingtonpost.com/wpapps/imrs.php?src=https://img.washingtonpos
t.com/blogs/wonkblog/files/2014/05/3292423645_870bdf4452_z.jpg&w=1484
Final Implications
◦ Neighborhood perceptions play an important role in health behaviors and
outcomes in Micropolitan regions
◦ Imperative to assess the physical and social environment of these neighborhoods
◦ Food environment in particular a potentially strong point of intervention
◦ Future research could explore relationships that warrant further clarification
(i.e., walkability and BMI; influence of food environment)
Strengths and Limitations
Limitations
◦ Testing one neighborhood factor at a
time
◦ Self-report data
◦ Cross-sectional
Strengths
◦ Validated measures
◦ Large sample size
Acknowledgements
◦ This presentation was supported by Cooperative Agreement Number 1-U48DP00190201 from the Centers for Disease Control and Prevention. The findings and conclusions
in this report presentation are those of the author(s) and do not necessarily represent the
official position of the Centers for Disease Control and Prevention.
◦ Department of Community and Behavioral Health
◦ Dr. Parker
◦ Dr. Baquero
◦ Dr. Daniel-Ulloa
References
◦ Ball, K., Bauman, A., Leslie, E., & Owen, N. (2001). Perceived environmental aesthetics and convenience and company are associated with walking for
exercise among Australian adults. Preventive medicine, 33(5), 434-440.
◦ Black, J. L., Macinko, J., Dixon, L. B., & Fryer Jr, G. E. (2010). Neighborhoods and obesity in New York City. Health & place, 16(3), 489-499.
◦ Boehmer, T., Hoehner, C., Deshpande, A., Ramirez, L. B., & Brownson, R. C. (2007). Perceived and observed neighborhood indicators of obesity
among urban adults. International journal of obesity, 31(6), 968-977.
◦ Brownson, R. C., Baker, E. A., Housemann, R. A., Brennan, L. K., & Bacak, S. J. (2001). Environmental and policy determinants of physical activity in
the United States. American journal of public health, 91(12), 1995-2003.
◦ Centers for Disease Control and Prevention. (1999). Neighborhood safety and the prevalence of physical inactivity--selected states, 1996. Morbidity and
Mortality Weekly Report, 48(7), 143.
◦ Diez Roux, A. V., & Mair, C. (2010). Neighborhoods and health. Ann N Y Acad Sci, 1186, 125-145. doi: 10.1111/j.1749-6632.2009.05333.x
◦ Echeverria, S., Diez-Roux, A. V., Shea, S., Borrell, L. N., & Jackson, S. (2008). Associations of neighborhood problems and neighborhood social
cohesion with mental health and health behaviors: the Multi-Ethnic Study of Atherosclerosis. Health Place, 14(4), 853-865. doi:
10.1016/j.healthplace.2008.01.004
◦ Franzini, L., Caughy, M., Spears, W., & Esquer, M. E. F. (2005). Neighborhood economic conditions, social processes, and self-rated health in lowincome neighborhoods in Texas: A multilevel latent variables model. Social science & medicine, 61(6), 1135-1150.
◦ Keita, A. D., Casazza, K., Thomas, O., & Fernandez, J. R. (2011). Neighborhood perceptions affect dietary behaviors and diet quality. J Nutr Educ Behav,
43(4), 244-250. doi: 10.1016/j.jneb.2009.07.004
References
◦ Larson, N. I., Story, M. T., & Nelson, M. C. (2009). Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med, 36(1),
74-81. doi: 10.1016/j.amepre.2008.09.025
◦ Li, F., Harmer, P., Cardinal, B. J., Bosworth, M., & Johnson-Shelton, D. (2009). Obesity and the built environment: does the density of neighborhood
fast-food outlets matter? American Journal of Health Promotion, 23(3), 203-209.
◦ Litt, J. S., Soobader, M.-J., Turbin, M. S., Hale, J. W., Buchenau, M., & Marshall, J. A. (2011). The influence of social involvement, neighborhood
aesthetics, and community garden participation on fruit and vegetable consumption. American journal of public health, 101(8), 1466-1473.
◦ Lopez, R. P. (2007). Neighborhood risk factors for obesity. Obesity (Silver Spring), 15(8), 2111-2119.
◦ Rohrer, J., Pierce, J., & Denison, A. (2004). Walkability and self-rated health in primary care patients. BMC family practice, 5(1), 29.
◦ Saelens, B. E., Sallis, J. F., Black, J. B., & Chen, D. (2003). Neighborhood-based differences in physical activity: an environment scale evaluation.
American journal of public health, 93(9), 1552-1558.
◦ Strong, L. L., Reitzel, L. R., Wetter, D. W., & McNeill, L. H. (2013). Associations of perceived neighborhood physical and social environments with
physical activity and television viewing in African-American men and women. Am J Health Promot, 27(6), 401-409. doi: 10.4278/ajhp.120306-QUAN127
◦ Wen, M., Hawkley, L. C., & Cacioppo, J. T. (2006). Objective and perceived neighborhood environment, individual SES and psychosocial factors, and
self-rated health: An analysis of older adults in Cook County, Illinois. Social science & medicine, 63(10), 2575-2590.
◦ Zenk, S. N., Lachance, L. L., Schulz, A. J., Mentz, G., Kannan, S., & Ridella, W. (2009). Neighborhood retail food environment and fruit and vegetable
intake in a multiethnic urban population. Am J Health Promot, 23(4), 255-264. doi: 10.4278/ajhp.071204127
Multiple Imputation
ID
1
2
3
4
5
6
7
Gender (1 = Female)
1
0
1
1
0
0
1
Fruits & Veggies/Day HS Grad (1 = Yes)
3.5
0
.
1
4.2
.
1.9
1
3.2
0
.
1
1.2
0
Multiple Imputation
ID
1
2
3
4
5
6
7
Gender (1 = Female)
1
0
1
1
0
0
1
Fruits & Veggies/Day HS Grad (1 = Yes)
3.5
0
.
1
4.2
.
1.9
1
3.2
0
.
1
1.2
0
Multiple Imputation
ID
1
2
3
4
5
6
7
Imputation 1
Gender (1 = Female)
Fruits & Veggies/Day HS Grad (1 = Yes)
1
3.5
0
0
2.7
1
1
4.2
0
1
1.9
1
0
3.2
0
0
4.6
1
1
1.2
0
Multiple Imputation
ID
1
2
3
4
5
6
7
Imputation 2
Gender (1 = Female)
Fruits & Veggies/Day HS Grad (1 = Yes)
1
3.5
0
0
2.5
1
1
4.2
1
1
1.9
1
0
3.2
0
0
4.9
1
1
1.2
0
Multiple Imputation
ID
1
2
3
4
5
6
7
Imputation 3
Gender (1 = Female)
Fruits & Veggies/Day HS Grad (1 = Yes)
1
3.5
0
0
2.3
1
1
4.2
0
1
1.9
1
0
3.2
0
0
4.1
1
1
1.2
0
Multiple Imputation- OCS Data
Imputation 1 Imputation 2 Imputation 3 Imputation 4 Imputation 5
1.2237
1.2250
1.2255
1.2260
1.2274
Final mean using imputed data: 1.2255 fruits per day