There is modest evidence that neighborhood significantly influences the health of older adults. However, the analytic approach of many of the studies limited their ability to identify specific neighborhood factors associated with health for older adults. While the study subjects of all of the studies discussed here were age 55 and older, the research questions and methods did not necessarily assess nor take into consideration characteristics specific to the older population, such as their physical mobility, ability to drive, habits around driving, or chronic conditions that might limit mobility. Theories of environmental aging suggest that as people age and their mobility declines, their residential neighborhood environment may become more relevant to their health and wellbeing. Yet the existing research does not consistently support this model. Future research should focus on the characteristics of neighborhoods that provide the most support and the most threat to older adults specifically. Finally in the U.S. specifically, the proportion of racial/ethnic minorities in the older adult population is steadily increasing. Based on studies included in this review and other neighborhood and health research, the racial/ethnic composition of one’s neighborhood is associated with health in different ways depending on the race/ethnicity of the study subject.65, 73, 86, 87
Below key findings of the reviewed literature and how future research can more specifically investigate how neighborhoods and more broadly, place, might affect health of older adults in the 21st
century are elaborated.
Neighborhood-level SES was the strongest and most consistent predictor of a variety of health outcomes. This is both a noteworthy finding and it also reflects a limitation of this body of literature. It is noteworthy given that studies using individual-level measurements of SES have reported smaller gradients among older adults compared to younger populations. Measurement of SES is problematic among older adults because traditional markers – income, education, and occupation – have different meanings at older ages.88, 89
The finding that neighborhood SES is consistently associated with health in older adults confirms that the influence of deprivation persists to the oldest ages. Several studies of older adults have evaluated individual SES across the lifespan;90–93
results suggest a cumulative effect of poverty such that multiple periods of deprivation throughout the lifespan greatly increase the risk of poor health in late life. Only one study in this review specifically evaluated the influence of neighborhood SES across the lifespan.67
Additional studies incorporating measures of neighborhood across the lifespan are needed. The consistency of the effect of neighborhood SES on health of older people also reflects the fact that it is the most commonly studied neighborhood characteristics in the literature, perhaps due to the relative ease of obtaining these data from census and other administrative sources.
Very few studies directly measured neighborhood features or context that may be relevant for understanding the influence of neighborhoods on health. The studies that directly evaluate factors which are modifiable by intervention – specific problems or specific physical and social resources – are informative for developing policy solutions to improve health among older adults. The positive association between physical environment, perceived or objective, and physical activity behavior was fairly consistent. A majority of older adults are inactive 94, 95
and physical inactivity is linked to quality of life, morbidity, and mortality 96–99
. Additional research is needed to determine if the physical environment is associated with these [downstream] health outcomes. Further, studies that measured perceived neighborhood physical or social resources and problems generally showed stronger associations than those using objective measures of resources and problems (see for example, Michael et al., 200655
). This suggests that objective and perceived measures may be differentially related to health, and it would be useful to include perceived as well as objective measures in future studies. While policy solutions to objective neighborhood problems are perhaps more clear (e.g., improving walkability by adding sidewalks or clustering residential development near retail/employment), health promotion programs may successfully improve negative perceptions about neighborhood environment with some benefits for health.100
All of the studies reviewed here defined neighborhood as some designated geographic area in which the study participant lived, whether it was an administrative unit such as a census tract or a perceived area tied to the wording of a survey question. For frail older adults or older adults who have compromised mobility and minimal social ties to other people who can provide transportation support, the proximal environment could be more relevant. Older adults, however, are a highly heterogeneous group; many are very active and comfortably drive cars to varied destinations.101, 102
The idea that people engage in a variety of activities in multiple locations, often at some distance from their immediate neighborhoods, is not new to sociologists or geographers.103, 104
Incorporating these concepts into future research would permit researchers to delve deeper into the linkages between place and health for older adults.
Aging research has documented various racial/ethnic and SES disparities in health among older adults.105–107
One of the four primary goals of the U.S. National Institute on Aging’s strategic plan to address racial/ethnic disparities among older adults is to “advance understanding of the development and progression of disease and disability that contributes to health disparities in association with genetics, environmental/SES, mechanisms of disease, epidemiology and other risk factors.”108
It is valuable to do more studies with racially/ethnically diverse communities, perhaps incorporating community-based participatory research (CBPR) methods.109
CBPR methods include community members as experts. Including community members in the research team ensures the usefulness of the research to community residents. These methods could involve older neighborhood residents in identifying neighborhood factors and mechanisms which influence their health. This participatory approach would improve the a priori
models linking neighborhood to health in this age group. Recent studies have shown success in including older community members in neighborhood research and advocacy efforts.55, 110
Fully including older community members as research partners will be valuable in creating neighborhood efficacy and sustaining advocacy efforts over time. It has been noted that older adults are in a perfect position to be advocates for the greater good of their communities due to the fact that they have “the benefit of life experience, the time to get things done, and the least to lose by sticking their necks out.”111
Some additional methodologic issues require discussion. Specifying a priori models and hypotheses for the association between (and among) specific neighborhood exposures and in relation to specific behavioral pathways to health outcome would allow for more rigorous evaluation of the putative associations. As mentioned in the quality assessment section, the majority of the evidence is from cross-sectional studies. Reverse causation is a possible explanation of positive associations in cross-sectional studies; specifically, poor health or health behaviors may be a cause rather than a result of neighborhood residence. Observed associations could also be spurious. Prospective studies are needed. Further, it is essential that studies evaluate neighborhoods as well as health prospectively so that the influence of change in neighborhoods on health may be more clearly articulated. Failure to account for length of residence may confound the results.
This review does have limitations. Some of the criteria for which articles to include were arbitrary. By including studies with 10 or more neighborhoods, case studies of single neighborhoods were excluded and qualitative studies were more likely to be excluded. These types of studies provide other valuable information about specific neighborhoods and are able to take into consideration local history and culture. The search criteria prioritized specificity at the cost of sensitivity. If neighborhood was not the primary exposure variable, the study was excluded possibly overlooking studies in which neighborhood might have had a strong but unanticipated effect. It is suspected that these studies would be cross-sectional, not contributing to the current gap in longitudinal studies. Another limitation is that a specific set of literature databases were searched. The Web of Science was not searched. It is possible that articles may have missed by not including it as one of the databases. Reference lists of included articles were reviewed to identify additional articles potentially missed by the database search. Finally, the age criterion of studies that featured adults aged ≥55 years precludes including studies that included a sample with wider age spans and also compared how neighborhood might be associated differently by age category.