The association between neighbourhood social cohesion and hypertension management strategies in older adults.
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ABSTRACT: The positive effect of social cohesion on well-being in older adults has been well documented. However, relatively few studies have attempted to understand the mechanisms by which social cohesion influences well-being. The main aim of the current study is to identify social pathways in which social cohesion may contribute to well-being.Clinical Interventions in Aging 01/2014; 9:863-70. · 2.65 Impact Factor
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ABSTRACT: Diabetes-specific distress is an important psychological issue in people with diabetes. The neighborhood environment has the potential to be an important factor for diabetes distress. This study investigates the associations between neighborhood characteristics and diabetes distress in adults with type 2 diabetes. We used cross-sectional data from a community-based sample of 578 adults with type 2 diabetes from Quebec, Canada. Information on perceived neighborhood characteristics and diabetes distress was collected from phone interviews. We used factor analysis to combine questionnaire items into neighborhood factors. Information on neighborhood deprivation was derived from census data. We performed linear regressions for diabetes distress and specific domains of diabetes distress (emotional, regimen-related, physician-related and interpersonal distress), adjusting for individual-level variables. Factorial analysis uncovered 3 important neighborhood constructs: perceived order (social and physical order), culture (social and cultural environment) and access (access to services and facilities). After adjusting for individual-level confounders, neighborhood order was significantly associated with diabetes distress and all specific domains of distress; neighborhood culture was specifically associated with regimen-related distress; and neighborhood access was specifically associated with physician-related distress. The objective measure of neighborhood material deprivation was associated with regimen-related distress. Neighborhood characteristics are associated with diabetes distress in people with type 2 diabetes. Clinicians should consider the neighborhood environment reported by their patients with diabetes when assessing and addressing diabetes-specific distress.Journal of psychosomatic research 08/2013; 75(2):147-52. · 2.91 Impact Factor
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ABSTRACT: Purpose: The purpose of this study was to develop and test a hypothetical model which explains health behavior adherence in elderly people with prehypertension. The model was based on self-determination theory (SDT). Methods: Data were collected from June 21 to July 15, 2010, using self-report questionnaires. The participants were 140 elders with prehypertension who lived in D Metropolitan City. Collected data were analyzed using PASW 18.0 for descriptive statistics and correlation analysis and AMOS 5.0 for covariance structure analysis. Results: It appeared that the overall fit index was good with a score of 13.23 (pJournal of Korean Academy of Fundamentals of Nursing. 08/2012; 19(3).
The association between neighbourhood
social cohesion and hypertension
management strategies in older adults
SIR—Hypertension (HTN) affects one in three adults in
the USA [1, 2], and three in ten individuals in New York
City (NYC) . Roughly half of older adults, the fastest
growing age group in the USA, are currently hypertensive
[1, 3–5]. Given HTN’s increasing prevalence with age [2, 4–
9], and projected increases in the number of older adults,
morbidity and mortality related to HTN are likely to rise.
Yet while HTN is a major risk factor for cardiovascular
disease events [2, 6], research indicates that only slightly
over half of individuals with HTN have controlled blood
pressure, which suggests a need to encourage HTN man-
agement [6, 10].
Adherence to HTN management strategies may be
affected by neighbourhood-level factors [4, 11–13]. Several
studies demonstrated that such neighbourhood factors as
income level [11, 14, 15], availability of healthy food ,
safety and social cohesion  are associated with blood
pressure levels. Yet, little research has examined the effect
of neighbourhood social variables on health maintenance
behaviours , specifically among older adults . This
paper addresses this gap by examining the relationship
between neighbourhood social cohesion and the use of
HTN management strategies among older individuals who
participate in NYC senior centres.
Study design and data source
This is a cross-sectional study. The data are taken from the
2008 Health Indicators Project (HIP), a stratified sample of
1,870 older adults attending 56 randomly selected senior
centres in all five boroughs of NYC. The HIP survey is a
comprehensive structured instrument that used validated
standardised questionnaire items from national and local
Following informed consent, face-to-face interviews were
(English, Spanish, Russian, Chinese, Italian), taking an
average of 75 min to complete. Individuals were excluded if
they were younger than 60 years of age, were too ill to par-
ticipate, or did not speak the selected languages. The study
yielded a response rate of 76.7% and a refusal rate of
The analytic sample was restricted to 930 hypertensive HIP
participants who had complete data on all study variables.
We selected the analytic sample by: (a) identifying respon-
dents who reported that a doctor or health care profession-
al had ever told them that they had high blood pressure
(n=1,024); (b) eliminating observations with missing data
in one or more study variables (n=174) and (c) restoring
neighbourhood-level independent variable: social cohesion.
Multiple imputation was accomplished by imputing 10
values for missing items with an ordinal logistic model.
We constructed six-related measures of HTN management.
The primary outcome was a simple unweighted count of
participants’ responses for nine binary (1=yes; 0=no)
(Supplementary data are available in Age and Ageing online).
Owing to small cell size in the lowest (0) and highest (9)
levels of HTN strategies, we collapsed categories, so that
the response variable regarding HTN strategies ranges from
1 to 7.
The five secondary outcome measures, subsets of the
primary measure, were constructed based on the results of
factor analysis. While factor model eigenvalues suggested
strong evidence for one valid underlying factor (supporting use
of the primary outcome variable), the five groupings clustered
in a rather intuitive fashion. As such, we created outcome
variables to represent groupings for secondary analysis.
Three of the secondary outcome variables are multi-
strategy summary variables. Health compromising behaviour
modifications included two strategies (reducing or quitting
smoking and reducing alcohol consumption). Combining
binary indicators as above, this summary variable ranged
from 0 to 2 (alpha=0.76). Equivalently constructed, Health
behaviours (dietary salt reduction, weight control/reduction
and additional exercise) ranged from 0 to 3 (alpha=0.52)
and Non-traditional HTN management strategies (dietary/
herbal supplements and health rituals) ranged from 0 to 2
(alpha=0.38). Medication use and home measurement of blood
pressure are single strategy outcomes, and were thus mea-
sured by binary variables (1=yes; 0=no).
listed in Appendix1
Explanatory variable of interest and covariates
Neighbourhood social cohesion
Neighbourhood social cohesion was measured by a scale
that was constructed using responses to the five survey
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Age and Ageing Advance Access published December 13, 2011
by guest on December 14, 2011
items listed in Appendix 1 (Supplementary data are avail-
able in Age and Ageing online). Scale creation for the social
cohesion variable used reverse-coded Likert responses (1=
very true to 4=not at all true) for the final two items and
summed responses over the five variables. In the resulting
scale (range: 5–20; alpha=0.75), higher values represent
stronger neighbourhood social cohesion.
Covariates were selected from six domains of individual-
level factors: demographic, health status/disability, mental
health, social support, expense difficulty and clinic access.
described in Appendix 1 (Supplementary data are available
in Age and Ageing online).
Frequencies (with per cent) and means (with standard
error) were employed to describe the sample. The multi-
variate analyses used Poisson regression for the composite
measures, and binomial logistic regression for the single-
item outcome variables. To increase interpretability, Poisson
regression coefficients were transformed to incidence rate
ratios (IRRs), and logistic regression estimates were
transformed to odds ratios. Continuous variables (social
cohesion, social support, physical disability and PHQ-9
depression) were standardised to reflect a one-standard de-
viation change in each variable on regression estimates. Our
models accounted for the multiple imputation of missing
values in the neighbourhood variable by averaging model
estimates over 10 full-model estimations. We statistically
Characteristics of the 930 hypertensive HIP participants are
presented in Table 1. Multivariate regression results are
Poisson regression results
Full set of hypertension management strategies (range: 1–7)
Social cohesion was positively associated with the compos-
ite (seven-factor) measure of HTN management in the fully
adjusted model (Table 2, column 2). For each one standard
deviation (1 SD) increase in neighbourhood social cohesion,
there was a 6% increase associated with the rate ratio of
HTN management (IRR=1.06; 95% confidence interval
Health compromising behaviour modification (range: 0–2)
Social cohesion was predictive of reducing or eliminating
smoking and drinking behaviours (Table 2, column 3).
Each 1 SD increase in social cohesion increased the rate
ratio of the health compromising behaviour modification
outcome by a factor of 1.32 (IRR = 1.32; CI = 1.13,
Health behaviours (range: 0–3)
Social cohesion was weakly associated with the outcome
that included salt reduction, weight loss and exercise as a
combined factor outcome (Table 2, column 4). Each 1 SD
increase in social cohesion increased the rate ratio of the
health behaviour by a factor of 1.03 (IRR=1.03; 95%
Non-traditional HTN strategies (0–2)
Social cohesion was not associated with non-traditional
HTN management strategies (Table 2, column 5).
Logistic regression results
Social cohesion was not associated with medication man-
agement of HTN (Table 2, column 6).
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Marriage or partnered
Less than HS
More than HS
Medical clinic in your neighbourhood
All HTN strategies
Health compromising behaviours
Table 1. Sample characteristics (n=930)
Variable namen (%)a
HTN, hypertension; HS, high school.
aContinuous variables are reported from imputation models with mean and
by guest on December 14, 2011
Home measurement of blood pressure
Social cohesion was associated with 24% increase in the log
odds (OR=1.24; CI=1.05, 1.48) of measuring blood
pressure at home (Table 2, column 7).
This study evaluated the relationship between neighbour-
hood social cohesion and HTN management strategies
among hypertensive older individuals attending senior
centres in NYC. Our principal finding is that individuals
who perceive higher social cohesion in their neighbour-
hoods practice more comprehensive HTN management. A
secondary finding, revealed upon disaggregating the man-
agement strategies, is that there are especially salient effects
of social cohesion on eliminating or reducing undesirable
health habits, such as smoking and alcohol use, and on
home measurement of blood pressure. Otherwise, we
found a rather modest association between neighbourhood
social cohesion and behavioural strategies (salt reduction,
weight loss and exercise).
Several previous investigations have reported that neigh-
bourhood determinants may influence health behaviours
[12, 14, 16–21], a conclusion that our study’s results at least
indirectly endorsed. Our discovery of a null association
between social integration and medication use supports a
study by Morenoff et al., in which they report no relation-
ship between neighbourhood context and taking HTN
A number of limitations of this study must be high-
lighted. First, the cross-sectional design precludes any infer-
ence of causality. Second, our sample was not drawn from
a true catchment area, which means that assessments of
neighbourhood attributes may correspond to the geograph-
ic areas in which study participants reside, rather than the
data collection area (i.e. senior centre). Third, the HTN
data are self-reported, and are not accompanied by clinical
blood pressure measurements. Finally, our analyses imply
that more HTN management strategies are essentially
better. This may not be so, especially where an herbal
remedy may adversely interact with a pharmaceutical treat-
ment or an unsupervised or physically inappropriate exer-
cise regimen is harmful.
This research adds to the literature by demonstrating the
potential importance of neighbourhood social factors,
which underscores the need for clinicians to treat chronic
disease with a multifactorial approach  that recognises the
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Social cohesion1.06 (1.03, 1.10)*** 1.32 (1.13, 1.55)** 1.03 (1.00, 1.07)*
60–65 Ref.Ref. Ref.
66–74 0.98 (0.91, 1.06)0.90 (0.59, 1.39) 0.93 (0.85, 1.01)
75–840.92 (0.84, 1.01) 0.67 (0.37, 1.39)91 (0.82, 1.00)
85+0.79 (0.69, 0.90)***0.80 (0.48, 1.31)0.80 (0.69, 0.91)**
Female sex 1.07 (1.00, 1.13)*0.81 (0.63, 1.04) 1.10 (1.03, 1.18)**
Married or partnered0.97 (0.92, 1.03) 0.80 (0.61, 1.04) 1.00 (0.95, 1.07)
Asian 0.88 (0.78, 1.00)0.41 (0.22, 0.77)**0.85 (0.71, 1.01)
Black1.14 (1.06, 1.23)***1.06 (0.67, 1.68)1.13 (1.05, 1.21)**
Hispanic1.15 (1.04, 1.27)**1.19 (0.71, 1.97)1.11 (1.00, 1.23)*
Other 1.06 (0.96, 1.17)0.79 (0.44, 1.42) 1.00 (0.89, 1.12)
<HS1.12 (1.01, 1.24) 2.94 (1.24, 6.98)*1.09 (0.93, 1.29)
Completed HS1.10 (0.98, 1.22)2.26 (1.01, 5.09)*1.09 (0.93, 1.29)
>HS 1.16 (1.03, 1.31)*2.72 (1.09, 6.77)*1.15 (0.97, 1.36)
Completed college1.18 (1.05, 1.32)**2.77 (1.26, 6.10)*1.13 (0.96, 1.33)
Physical disability1.03 (1.00, 1.06)** 1.03 (0.91, 1.16)1.04 (1.01, 1.07)*
Mental health1.00 (0.98, 1.02)0.95 (0.82, 1.11) 0.98 (0.95, 1.01)
Expense difficulty 1.00 (0.94, 1.06)1.13 (0.89, 1.44) 0.98 (0.92, 1.05)
Social support1.01 (0.99,1.04)0.92 (0.81, 1.03)1.01 (0.98, 1.04)
Medical clinic 0.99 (0.92, 1.06)0.88 (0.58, 1.33)1.02 (0.95, 1.10)
Table 2. Influence of neighbourhood variables on hypertension management strategies (n=930)
Variable name Poisson regressionLogistic regression
All HTN strategies Health compromising
Health behaviours Non-traditionalMedication Measure BP
1.05 (0.91, 1.21)1.21 (0.98, 1.50)1.24 (1.05, 1.48)*
1.12 (0.73, 1.71)
0.95 (0.61, 1.47)
0.40 (0.20, 0.82)*
1.33 (0.87, 2.02)
0.76 (0.53, 1.07)
1.26 (0.63, 2.55)
1.38 (0.74, 2.56)
0.73 (0.32, 1.66)
1.71 (1.09, 2.68)*
0.76 (0.44, 1.31)
1.08 (0.63, 1.84)
0.63 (0.37, 1.07)
0.55 (0.29, 1.03)
1.15 (0.83, 1.59)
1.27 (0.94, 1.72)
0.91 (0.51, 1.65)
2.11 (1.43, 3.12)***
2.02 (1.30, 3.14)**
1.58 (0.71, 3.50)
1.66 (0.80, 3.46)
1.24 (0.62, 2.49)
0.57 (0.33, 1.00)
1.06 (0.39, 2.86)
1.48 (0.89, 2.45)
1.44 (0.94, 2.20)
1.99 (1.30, 3.04)**
2.61 (1.38, 4.94)**
0.79 (0.46, 1.37)
0.72 (0.42, 1.23)
0.86 (0.47, 1.57)
0.75 (0.40, 1.40)
1.09 (0.96, 1.24)
1.12 (0.97, 1.29)
1.26 (0.95, 1.68)
1.24 (1.08, 1.42)**
1.03 (0.72, 1.49)
2.36 (0.82, 6.84)
2.30 (0.81, 6.50)
1.83 (0.55, 6.04)
1.83 (0.66, 5.06)
1.47 (1.10, 1.95)**
1.09 (0.85, 1.40)
0.60 (0.38, 0.95)*
1.28 (1.03, 1.59)*
0.69 (0.38, 1.25)
0.77 (0.37, 1.58)
0.95 (0.44, 2.07)
1.26 (0.64, 2.49)
1.87 (0.82, 4.25)
0.93 (0.77, 1.12)
1.22 (1.03, 1.45)*
0.81 (0.59, 1.10)
1.03 (0.89, 1.19)
0.93 (0.66, 1.32)
HS, high school.
by guest on December 14, 2011
relevance of neighbourhood social influences [17, 20, 22].
Our findings warrant further examination of social eco-
logical pathways that encourage health-protective beha-
viours in older adults.
• Higher social cohesion was related to increased use of
hypertension management strategies.
• Hypertension affects one in three adults in the United
States with increasing prevalence with age.
• To reduce morbidity, challenges of chronic disease man-
agement must be addressed.
Funding for the Health Indicators Project was provided by
the Mayor’s Office of New York City and administered by
the New York City Department for the Aging.
Supplementary data mentioned in the text is available to
subscribers in Age and Ageing online.
Conflicts of interest
MIEKE FRY SCHMITZ1,*, NANCY GIUNTA2, NINA S. PARIKH3,
KATHERINE K. CHEN4, MARIANNE C. FAHS5, WILLIAM T GALLO5
1Public Health, CUNY School of Public Health at Hunter College,
425 East 25th Street, New York, NY 10010-2590, USA
Tel: (+1) 212 481 7672; Fax: (+1) 212 481 3791.
Email: firstname.lastname@example.org, email@example.com
2Hunter College School of Social Work, New York, NY, USA
3Brookdale Center for Healthy Aging and Longevity of Hunter
College, City University of New York, New York, NY, USA
4Department of Sociology, City College of New York and the
Graduate Center, CUNY, New York, NY, USA
5CUNY School of Public Health at Hunter College and the
Graduate Center, New York, NY, USA
*To whom correspondence should be addressed
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