摘要：Objectives. To strengthen existing evidence on the role of neighborhoods in chronic disease onset in later life, we investigated associations between multiple neighborhood features and 2-year onset of 6 common conditions using a national sample of older adults. Methods. Neighborhood features for adults aged 55 years or older in the 2002 Health and Retirement Study were measured by use of previously validated scales reflecting the built, social, and economic environment. Two-level random-intercept logistic models predicting the onset of heart problems, hypertension, stroke, diabetes, cancer, and arthritis by 2004 were estimated. Results. In adjusted models, living in more economically disadvantaged areas predicted the onset of heart problems for women (odds ratio [OR] = 1.20; P < .05). Living in more highly segregated, higher-crime areas was associated with greater chances of developing cancer for men (OR = 1.31; P < .05) and women (OR = 1.25; P < .05). Conclusions. The neighborhood economic environment is associated with heart disease onset for women, and neighborhood-level social stressors are associated with cancer onset for men and women. The social and biological mechanisms that underlie these associations require further investigation. Currently, 8 out of 10 older adults in the United States have at least 1 chronic condition. 1 Reports of many common chronic conditions, such as heart disease, arthritis, diabetes, and some cancers, have been increasing, as have the costs associated with their treatment. 2 , 3 Although the etiology of such conditions varies greatly, a rapidly growing literature has documented associations between characteristics of the neighborhoods in which older people live and late-life morbidity. The most studied neighborhood feature in this context is economic disadvantage. Studies have established that living in economically deprived areas is associated with higher risks of heart disease, 4 – 11 stroke, 12 – 14 hypertension, 6 , 15 , 16 and a greater number of chronic conditions, 17 , 18 but lower cancer incidence. 19 – 21 These effects, which appear to be greater for women than for men, 6 , 9 – 11 , 19 , 22 often attenuate but are not completely eliminated after individual-level factors are taken into account. Numerous mechanisms have been postulated as underlying the linkage between economic deprivation and chronic conditions. In reviewing cardiovascular disease mechanisms, for example, Diez Roux discussed how social and physical aspects of poor neighborhoods may influence individual risk factors (e.g., physical activity, diet, smoking, and the ability to recover from stress), which in turn may influence more proximate biological risk factors (e.g., blood pressure, diabetes, body mass index, blood lipids, and inflammation). 23 Recently, the literature has begun to address noneconomic features of neighborhoods, such as the social and built environments, and their relation to health in later life. 16 , 20 , 24 – 28 The social environment refers to relations among people living in a particular area and encompasses concepts such as connectedness to and similarity with neighbors and social disorder. The built environment refers to factors related to man-made elements including housing quality, businesses, street design, pollution, and crowding. Like the linkage between poor neighborhoods and cardiovascular disease, the relationship between the social and built environments and later-life morbidity is likely to be complex, operating through physiologic stress as well as health behaviors such as physical activity and diet and access to providers. However, measures of the social and built environment have typically been absent from analyses that include measures of economic disadvantage, thus making it difficult to sort out these influences. More generally, conclusions that can be drawn from the growing number of studies devoted to neighborhood influences on late-life health remain limited in several respects. First, most studies highlight the relationship between a single neighborhood facet and 1 chronic condition. This approach precludes comparisons across conditions, and also limits interpretation, because aspects of the economic, social, and built environment are likely to be correlated. Second, only about one third of studies to date have examined disease incidence, 4 , 5 , 10 , 11 , 15 , 20 , 22 , 29 , 30 whereas remaining studies have focused on prevalence. The latter confounds influences of the neighborhood on disease onset with its effects on survival and therefore provides only limited insight into disease etiology. Third, with few exceptions, 17 , 18 studies focusing on the United States have drawn data from a limited number of communities, thus the generalizability of the results is uncertain. Fourth, indicators of individual-level circumstances often have been quite limited; consequently, the effect of neighborhood-level factors may be confounded by unmeasured individual-level factors. Fifth, selection into neighborhoods along health dimensions may bias findings, yet studies to date have not attempted to control for circumstances that may act as a proxy for neighborhood exposures earlier in life. Finally, despite evidence that chronic disease etiology and expression may differ for older men and women, 31 – 33 gender-specific investigations have been the exception rather than the norm. We aimed to enhance this literature by adopting a richer characterization of the neighborhood that draws on previously validated scales reflecting the economic, social, and built neighborhood environment. We explored associations between these scales and the reported onset of 6 of the most commonly reported late-life conditions: hypertension, heart problems, stroke, diabetes, cancer, and arthritis. We hypothesized that all 3 domains—the economic, social, and built environments—would contribute to increased risks of chronic conditions in later life. To explore these hypotheses, we used a large, nationally representative sample of US adults aged 55 years or older from the Health and Retirement Study (HRS). 34 The HRS includes excellent contemporaneous measures of income and assets, as well as retrospective measures of health and wealth earlier in life. We therefore were better able than previous studies to isolate the contribution of neighborhood-level socioeconomic components. Moreover, the large sample sizes allowed us to stratify the analyses for men and women.
