We found that neighborhood SES was associated with physical and mental health status and mortality among veterans, even after controlling for individual health risks and demographic factors, as well as health system factors such as access and distance to VA care. We also found that veterans who lived in more walkable neighborhoods had higher PCS scores. The current study allows for detailed analysis of individual, health system and community factors that are associated with health status among veterans who utilize the VHA. To our knowledge, this research provides the first information about the relationship of neighborhood environment and veterans’ health. Although the individual effects are modest, these decrements in health status are relevant across the large population of veterans living in areas with low socio-economic status. Self-rated health has been found to be a good predictor of subsequent morbidity and mortality.22
Our findings are consistent with previous studies from the UK that report the variation in health status by neighborhood SES is modest compared with individual level differences.35,36
In a study of a community dwelling cohort in England, area of residence was associated with physical functional health, with only a weak association with mental health function.35
In another study, one standard deviation increase in the Townsend deprivation score, a measure of neighborhood SES, was associated with a drop in PCS score of 0.3 points and a decrease in MCS score by 0.5 points.36
The VHA is the largest integrated health system in the United States. During the last several decades, VHA was transformed from a hospital-based system to a primary care system. As part of this process over 800 community-based outpatient clinics have been established to move care closer to where veterans live,37
and a new VHA initiative is currently being launched to establish Patient Centered Medical Homes. Individuals spend relatively very little time in physicians’ offices, and as such, community-based interventions must become a key component of chronic disease management,38
including efforts to address modifiable health factors in communities. An understanding of how and to what extent characteristics of one’s environment may alter health status are an essential first step to developing interventions to assist veterans who reside in communities with conditions unfavorable to their health. While it may be beyond the scope of the VA mission to change the community environment where veterans live, this study provides the first information about the relative contribution of the neighborhood environment on veteran health status and mortality, relative to health delivery system variables and individuals health risks.
There are several limitations to our study. Although we were able to geo-code 75% of addresses, similar to rates reported in the literature, geo-coding rates for non-metropolitan addresses were lower (50%). Hence, our findings may not be generalizable to veterans living in rural areas. Because the data on health status are cross-sectional, we cannot assume that the relationship with neighborhood SES is causal. Further, we relied on single point-in-time estimates for addresses. However, previous studies have shown low rates of residential mobility among older individuals and, for those who do move, high correlations of neighborhood characteristics over time.39
There is the potential for response bias from self-report of health status and health conditions. In addition, we cannot exclude the influence of selective migration into lower SES neighborhoods of those with worse health status. We were not able to examine the potential mediators of the relationship between neighborhood SES and health status that may include physiologic stress, perceived strain, resources to lead a healthy lifestyle, and social support.9–12
Our measures of walkability include residential density and street connectivity, but we do not have information on other features that may determine walking behavior such as land use mix or pedestrian infrastructure.18
The limitations of the study are balanced by the strengths, which include a large well defined cohort of veterans with extensive health status and biologic data and the use of relatively complete longitudinal data to assess the association of neighborhood SES and veteran mortality.
In conclusion, we found that neighborhood SES was associated with physical and mental health status among veterans and that veterans living in more walk-able communities had higher physical functioning scores. Although the effect size was modest for individual veterans, these results are useful in identifying factors that impact veteran health-related quality of life at the population level and targeting interventions to veterans living in high risk areas. Our results add to the growing body of evidence that both social context and individual characteristics provide a more complete understanding of the determinants of health. Further research is required to examine to impact of neighborhood environment on chronic disease management and healthy lifestyles among veterans and to determine how to prioritize VA public health activities.40