New Directions for Neighborhood Environmental Studies

in the WHI

- Discussion of an Ancillary Study Idea

Wenjun Li, PhD

Health Geography Lab

University of Massachusetts Medical School

Annual WHI Investigator Meeting

Washington, DC

May 3-4, 2012

Objectives• Discuss several issues we have encountered while

developing our Residential Environment And Coronary Heart Disease Risk Factors (REACH) Ancillary Study

The study focuses on neighborhood environmental influences on physical activity and dietary behaviors

• Challenges and opportunities

• Seeking your guidance

Accomplishments of WHI Environmental Studies

• A number of WHI environmental studies have made significant impact on national policy and regulatory work – such as studies on effects of air pollutions on health,

• The study on built environment and obesity (PI: Bird) generated wealth of data on neighborhood social and built environment, laid a solid foundation for advancing WHI (social and built) environment studies

• These studies usually focus on national or macro level issues, or identification of novel risk factors for chronic diseases or conditions

What’s Beyond?

• Beyond these accomplishments, what else and what more can we do?

• A potential theme: Use of WHI data to influence local public

health practice, binding academic research with community-based public health prevention programs, and to support community participatory research

Is It Even Possible?

• Yes!• We have positive experience in collaboration

with Massachusetts Department of Public Health (based on data sources other than WHI, e.g., BRFSS, hospital discharge data)

• More and better can be accomplished using WHI data, e.g., REACH – environmental influences on PA and diet

Is It Even Possible?

• Yes!• My group has positive experience in

collaboration with Massachusetts Department of Public Health (based data sources other than WHI) – several collaborative studies are ongoing

• We can accomplish the same using WHI datae.g., REACH – environmental influences on PA and diet (if it is ever got funded!)

• Several examples from my lab

Boston: Allston/Brighton

Boston: BB/BH, FW/KM, SB, SE

Boston: Hyde Park

Boston: Jamaica Plain

Boston: Mattapan

Boston: North/South Dorchester

Boston: Roslindale

Boston: Roxbury

Boston: West Roxbury

Brookline

Dedham, Needham

Milton

Newton

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70

Mobilize Boston Cohort Study (MBS)Covariate-Adjusted Fall Rates by Place of Falling

Outdoor

Indoor

8

-.4 -.2 0 .2Disparity index (logit)

3488

3487

3486

3485

3484

3483

3482

3481

Composition and Contextual Disparity Indicesby Worcester Neighborhoods

Cmposition and SESNeighborhood contextual

9

-.6 -.5 -.4 -.3 -.2 -.1 0 .1 .2 .3Disparity index (logit)

3488

3487

3486

3485

3484

3483

3482

3481

Disparities by Component and Worcester Neighborhoods

Demographic

Socioeconomic

Town-level contextual

Town-level unexplained

-.6 -.5 -.4 -.3 -.2 -.1 0 .1 .2 .3Disparity index (logit)

3488

3487

3486

3485

3484

3483

3482

3481

Disparities - Overalland Worcester Neighborhoods

Prevalence Estimates of Daily Consumption of 5 or More Serves of Fruits and Vegetables in Massachusetts Communities (2007)

02459

02465

02466

02458

0246802461

0246702460

0246402462

City of Newton

¸1

Miles

02169

02171

02170

City of Quincy ¸

1Miles

01604

01602

01606

0160501609

01603

01607

01610

01608

0 1 2 3 4 5Miles

City of Worcester

¸

01104

0110901119

01108

01151

01129

01105

01107

0112801103

City of Springfield

1̧Miles

01843

018410184001840

City of Lawrence

¸1

Miles

01852

01850

City of Lowell

¸1

Miles

01904

01905

01902

City of Lynn

¸1

Miles

027450274002746

02744

City of New Bedford¸

1Miles

02720

02721

02724

02723

City of Fall River

¸1

Miles

02138

02139

02140

0214202141

City of Cambridge

¸ 1Miles

0230102302

City of Brokton

¸0 1

Miles

Roxbury

Hyde

Park

Wes

t Rox

bury

Roslindale

Mat

tapa

n

Allston/Brighton

Sou

th D

orch

este

r

South BostonJamaica

Plain

Cen

tral

East Boston

North Dorchester

Charlestown

South End

Fenway/KenmoreBack Bay/Beacon Hill

0 1 2 3 4 5Miles

City of Boston

¸

0 10 20 30 40 50

Miles

¸Prevalence (%)

18.4 - 20.0

20.1 - 25.0

25.1 - 30.0

30.1 - 35.0

35.1 - 45.0

Insufficient data

11

Figure I Obesity Prevalence of Massachusetts Communities (2005)

01904

01905

01902

City of Lynn

¸1

Miles

027450274002746

02744

City of New Bedford¸

1Miles

02459

02465

02466

02458

0246802461

0246702460

0246402462

City of Newton

¸1

Miles

02169

02171

02170

City of Quincy ¸

1Miles

01604

01602

01606

0160501609

01603

01607

01610

01608

016HH

01612

01611

0 1 2 3 4 5Miles

City of Worcester

¸

Roxbury

Hyde

Park

Wes

t Rox

bury

Roslindale

Mat

tapa

n

Allston/Brighton

So

uth

Do

rch

este

r

South BostonJamaica Plain

Cen

tral

East Boston

North Dorchester

Charlestown

South End

Fenway/KenmoreBack Bay/Beacon Hill

Harbor Islands

0 1 2 3 4 5Miles

City of Boston

¸

01104

01109

01118

01119

01108

01151

01129

01105

01107

0112801103

City of Springfield

1̧Miles

0 10 20 30 40 50

Miles

¸Prevalence (%)

10.7 - 15.0

15.1 - 17.5

17.6 - 20.0

20.1 - 22.5

22.6 - 25.0

25.1 - 27.5

27.6 - 30.0

30.1 - 32.5

32.6 - 38.0

Insufficient data

01852

0185401850

City of Lowell

¸1

Miles

01843

018410184001840

City of Lawrence

¸1

Miles

0230102302

City of Brokton

¸0 1

Miles

02138

02139

02140

02142

02141

City of Cambridge

¸ 1Miles

02720

02721

02724

02723

City of Fall River

¸1

Miles

Figure II Priority Classification of Massachusetts Communitiesfor Obesity Control (2005)

01604

01602

01606

0160501609

01603

01607

01610

01608

016HH

01612

01611

0 1 2 3 4 5Miles

City of Worcester

¸

Roxbury

Hyde P

ark

Wes

t R

oxbu

ryRoslindale

Mat

tapa

n

Allston/Brighton

So

uth

Do

rche

ste

r

South BostonJamaica P

lain

Cen

tral East Boston

North Dorchester

Charlestown

South End

Fenway/KenmoreBack Bay/Beacon Hill

Harbor Islands

0 1 2 3 4 5Miles

City of Boston

¸

0272002721

02724

02723

City of Fall River

¸0.9Miles

0 10 20 30 40 50Miles

¸Priority class

1 Hotspots: highest priority for intervention

2 Hotspots: highest priority for enhanced surv.

3 High priority: intervention & enhanced surv.

4 High priority: intervention

5 Moderate priority: intervention & enhanced surv.

6 Moderate priority: intervention

7 Low priority: intervention

8 Lowest priority: met national objective(<15%)

02459

02465

02466

02458

0246802461

0246702460

0246402462

¸1

Miles

02169

02171

02170

City of Quincy ¸

1Miles

01104

01109

01118

01119

01108

01151

01129

01105

01107

0112801103

1̧Miles

City of Newton

01843

018410184001840

City of Lawrence

¸1

Miles

City of Lowell

01852

0185401850

¸ 1Miles

02138 02139

0214002142

02141

City of Cambridge

¸1Miles

0230102302

City of Brokton

¸1Miles

01904

01905

01902

City of Lynn

¸1

Miles

027450274002746

02744

City of New Bedford¸

1Miles

City of Springfield

REACH Study Concept

Better Nutrition

Environment

Neighborhood

Higher SES

Higher levels of PA

Better diet

Behaviors

Perceived Nutrition

Environment

Better PA Environment

Perceived PA Environment

Knowledge Gaps• Influence of neighborhood environment (NE) on behaviors

• Influence of perceptions of NE on behaviors

• Correlations between perceptions and reality (obj. measures)

• How do perceptions and objective measures of NE jointly contribute to behavior?

Additive or multiplicative? Necessary or sufficient?

• How do perceptions and actual NE conditions differ among rural and urban, and white and black neighborhoods?

• How to establish causal links between environmental factors and health behaviors

• What are the implications of each of the above to community-based prevention strategies and public health policy and practice?

The Biggest Knowledge Gap• How to use rich WHI data to guide local public health practice

and prevention• Is it possible to better bridge WHI clinical/epidemiologic

research and routine public health practice and policy work?• Can WHI make more, immediate impact at the local level

without losing its national perspective?

The Need for New Directions and Innovative Approaches

• A number of secondary data analysis projects attempt to fill the noted gaps

• Such studies may be limited by lack of concurrent measures of participant perceptions, and objective measures of behaviors and participant neighborhood environments

• As a result, it requires a large sample size to detect modest associations (due to large measurement errors and bias), and study results are limited to documenting cross-sectional associations

• Unable to provide community-specific data

• While these studies increase our knowledge and provide important information for public health practice, what more and what else can be done?

• New directions and innovative approaches may be needed

A Possible New Direction

While increasing knowledge is important, the power of knowledge is realized only in practice.

A new research question:Can we make WHI data more relevant to

specific communities, so that they can inform local public health practice, and to support community participatory research?

Innovative Study Design

• Geographically and racially diverse sample of participants, to ensure generalizability of the study results

• Concurrent longitudinal measures of perceptions, behaviors (self-report and objective) and actual environment

• Use of innovative environmental survey instruments that are relevant to local conditions

• Use of novel statistical approach to ensure applicability to public health practice, and to generate actionable information

Spatial/Local Relevance: Stratified, Area-based Sampling and Recruitment

of Participants

• Select neighborhoods by characteristics (rural vs. urban, white vs. black)

• Select adequate numbers of participants from each neighborhood

• Controlled sampling of subpopulations

• Consequence: increased power, enhanced representativeness, and increased possibility of producing locally relevant data for local public health agancies

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Distribution of Participants at Medstar Site (N=2496)

!( Medstar

num_subj

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1 - 5

6 - 10

11 - 20

21 - 50

51 - 120

Temporal Relevance: Concurrent, Prospective Data Collection

Outcomes

PA, Diet, BMI, Perceptions of PA & nutrition environment

Individual-level covariatesSociodemographic, depression, anxiety, lifestyle, comorbid

conditions, medications, ADL, lower extremity problems, fall history

Prospective, Concurrent Neighborhood-Level Measures

Physical Activity Environment

e.g., Older Pedestrian Environment Survey (OPES)

Nutrition Environment

e.g., Community Nutrition Environment Evaluation Data System (C-NEEDS)

Neighborhood SES, land use and resources

To be derived using GIS based on American Community Surveys, US Census 2010, business statistics, state GIS data

Innovative Analytic MethodsResearch to inform practice:

• Use of small area estimations to generate locally relevant data to inform public health practice

• Use of source-specific disparity indices to help understand the relative contributions of individual- and domain-specific neighborhood factors to disparities in PA and Diet

Overview of REACH Ancillary Study

• A prospective cohort study of 1,500 older women living in communities

• Types of community: rural vs. urban; white vs. black• Each participant will be followed for 1 year• Participant PA, diet, sedentary behaviors, and perceptions of

environment will be measured concurrently with objective measures of their residential neighborhoods

• New participant and neighborhood data will be integrated with concurrent WHI data

Specific Aims

Aim 1: To examine the associations between objective measures and participant perceptions of neighborhood PA environment; and the extent to which measured and perceived PA environments are related to actual levels and location of PA.

Aim 2: To examine the associations between objective measures and participant perceptions of neighborhood nutrition environment; and the extent to which measured and perceived nutrition environments are related to actual levels and sources of dietary intake.

Aim 3: To determine the extent to which the above associations differ among urban, suburban and rural neighborhoods; and among neighborhoods with and without high concentrations of African American residents.

Implications to WHI Study Design

If geographic context is properly factored into the design of next WHI extension, we can potentially add new features to the WHI, transforming a traditional large cohort study to a large, longitudinal, national public health surveillance network. Such a network can provide all that WHI already has, but can provide community-specific data to support local public health practice, policy work and community participatory research.

The WHI extension renewal is coming, it is not too early to consider the design issues.

Discussion & Next Steps

• Guidance from NHLBI scientists• Advice from WHI scientists