title: Neighborhood environment and health status and mortality among veterans.
abstract: BACKGROUND
  The VHA is the largest integrated US health system and is increasingly moving care into the communities where veterans reside. Veterans who utilize the VA for their care have worse health status than the general population. However, there is limited evidence about the association of neighborhood environment and health outcomes among veterans.
  
  
  OBJECTIVE
  The primary aim of this study is to assess the relative contribution of neighborhood environment, health system, and individual characteristics to health status and mortality of veterans.
  
  
  METHODS
  Information on personal socio-economic indicators, existing medical conditions and health status were obtained from baseline data from a multi-site, randomized trial of primary care patients (n = 15,889). The physical component scale (PCS) and mental component scale (MCS) summarized health status. Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized the neighborhood socio-economic environment and walkability. Data were analyzed with multilevel hierarchical models. Analyses of health status were cross-sectional. Mortality analyses were longitudinal as participants were followed for an average of 722.5 days to ascertain vital status.
  
  
  RESULTS
  Neighborhood SES was associated with PCS and MCS scores, controlling for individual socio-economic status, self-reported co-morbid disease, smoking status, and health care access. In the lowest versus highest quartiles of neighborhood SES, adjusted PCS scores were 34.4 vs. 35.4 (p < 0.05) and adjusted MCS scores were 46.2 versus 47.0 (p < 0.05). PCS score was also significantly associated with neighborhood walkability (p < 0.05). Mortality was lower for veterans living in neighborhoods with the highest decile neighborhood SES (HR 0.78, highest vs. lowest decile 95% CI 0.63, 0.97).
  
  
  CONCLUSIONS
  Veterans living in lower SES neighborhoods have poorer health status and a higher risk of mortality, independent of individual characteristics and health care access. Neighborhood walkability was associated with higher PCS scores.
authors.affiliation: Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA 98108, USA. Karin.Nelson@va.gov
authors.forename: Karin
authors.initials: K
authors.lastname: Nelson
authors.forename: Leslie
authors.initials: L
authors.lastname: Taylor
authors.forename: Nicole
authors.initials: N
authors.lastname: Lurie
authors.forename: José
authors.initials: J
authors.lastname: Escarce
authors.forename: Lynne
authors.initials: L
authors.lastname: McFarland
authors.forename: Stephan D
authors.initials: SD
authors.lastname: Fihn
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D004777:Environment; D005260:Female; D006304:Health Status; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009043:Motor Activity / Q000502:physiology; D012111:Residence Characteristics; D012189:Retrospective Studies; D012931:Social Environment; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology; D014728:Veterans