Multiple contexts of exposure: Activity spaces, residential neighborhoods, and self-rated health

doi:10.1016/j.socscimed.2015.10.040

Social Science & Medicine

Volume 146, December 2015, Pages 204-213

https://doi.org/10.1016/j.socscimed.2015.10.040 Get rights and content

Highlights

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Residential and activity space disadvantage independently affect self-rated health.
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We find evidence of a contextual incongruence hypothesis.
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Residents who live and spend time in very dissimilar places report worse health.
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Activity space disadvantage mediates the health effects of residential disadvantage.
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Exposure to activity space disadvantage matters more for residents of disadvantaged areas.

Abstract

Although health researchers have made progress in detecting place effects on health, existing work has largely focused on the local residential neighborhood and has lacked a temporal dimension. Little research has integrated both time and space to understand how exposure to multiple contexts – where adults live, work, shop, worship, and seek healthcare – influence and shape health and well-being. This study uses novel longitudinal data from the Los Angeles Family and Neighborhood Survey to delve deeper into the relationship between context and health by considering residential and activity space neighborhoods weighted by the amount of time spent in these contexts. Results from multilevel cross-classified logistic models indicate that contextual exposure to disadvantage, residential or non-residential, is independently associated with a higher likelihood of reporting poor or fair health. We also find support for a contextual incongruence hypothesis. For example, adults living in the most disadvantaged neighborhoods are more likely to report poor or fair health when they spend time in more advantaged neighborhoods than in more disadvantaged ones, while residents of more advantaged neighborhoods report worse health when they spend time in more disadvantaged areas. Our results suggest that certain types of place-based cumulative exposures are associated with a sense of relative neighborhood deprivation that potentially manifests in worse health ratings.

Introduction

Notwithstanding significant improvements in the ability of researchers to detect neighborhood effects on health, substantial theoretical, conceptual, and methodological challenges remain (for reviews, see Chaix et al., 2009, Cummins et al., 2007, Diez-Roux, 2001, Macintyre et al., 2002, Pickett and Pearl, 2001, Sampson, 2012). As these and other scholars have pointed out, connecting people to place requires moving beyond conventional definitions of the “neighborhood” that only consider the residential census tract. Individuals are usually exposed to a myriad of contextual environments throughout the course of the day (e.g., workplace, grocery store, health clinic), and these cumulative exposures could have indelible impacts on health and well-being (Chaix et al., 2009, Kwan, 2012, Matthews, 2011). A continued focus on the residential neighborhood as the key contextual space for health has likely contributed to many of the weak and mixed findings reported in the extant literature on neighborhoods and health (Diez-Roux, 2001, Inagami et al., 2007). Shifting attention to activity spaces – the varied geographic contexts in which individuals conduct their daily activities – affords an opportunity not just to evaluate more holistically the importance of contextual environments for individual well-being, but to investigate the importance of residential environments in relation to similar or dissimilar non-residential places (activity spaces) where individuals also spend time.

Paramount to activity space approaches is the incorporation of both time and space (Cummins et al., 2007, Kwan, 2012, Matthews, 2011, Matthews and Yang, 2013). Indeed, prior work has shown that adults not only frequently spend much of their time outside the residential environment (Basta et al., 2010, Jones and Pebley, 2014, Kwan, 2004), but they also perceive their neighborhood in ways that do not align with the rigidity of census tract boundaries (Coulton et al., 2001, Pebley and Sastry, 2009). It is equally salient to understand the temporal dimension of an individual's exposure to various contexts, and how this exposure not only changes over a number of years but also over a number of hours during the day (Chaix et al., 2009, Kwan, 2009, Kwan, 2012, Matthews and Yang, 2013, Perchoux et al., 2013). Yet, previous scholarly efforts have been either cross-sectional and/or suffer from a lack of information on the locations and duration of time spent outside the residential neighborhood (Diez-Roux and Mair, 2010, Macintyre et al., 2002, Matthews, 2011). Such spatiotemporal examinations are indeed rare and can therefore contribute key insights into how we conceptualize and pursue neighborhood effects on health more generally.

Relying on static census boundaries is problematic for several documented reasons (e.g., Diez-Roux and Mair, 2010, Matthews, 2011). First, if the goal is to examine the impact of external environments that are conducive to or repress healthy living, it is unreasonable to assume that only some of the places adults spend time are important for their health and well-being. People often traverse multiple neighborhoods throughout the course of each day (e.g., to work, grocery store, health clinic, place of worship), and the features of individuals' activity spaces are often quite different than those of their residential neighborhood (Basta et al., 2010, Jones and Pebley, 2014, Kestens et al., 2010, Zenk et al., 2011). It is therefore likely that exposure to these and other contexts will have direct impacts on health behaviors and outcomes in important ways, as well as mediate or moderate the health effects of the residential environment (Chaix et al., 2009, Inagami et al., 2007, Kwan, 2009, Kwan, 2012, Matthews, 2011, Vallée et al., 2010, Zenk et al., 2011).

Beyond simply conceptualizing the neighborhood as a local spatial unit, another limitation of past research is that it has largely failed to take into account how long adults are exposed to places that may impact their health, most often simply assuming that individuals only spend time and are only influenced by their place of residence. This static approach to neighborhood effects induces a nontrivial amount of contextual uncertainty; that is, determining the most suitable geographic context to detect a true causal effect, as well as the timeframes in which people are exposed across various contexts on a daily basis (Diez-Roux and Mair, 2010, Kwan, 2012). It is imperative, then, that researchers conceptualize neighborhoods as personal exposure areas by accommodating the multiple spaces – residential and non-residential – and time spent in these contexts (Chaix et al., 2009, Matthews and Yang, 2013, Perchoux et al., 2013).

A modest amount of empirical research has examined the independent and cumulative effects of activity spaces and residential neighborhoods on health. Inagami et al. (2007), for example, utilize cross-sectional information on Los Angeles County residents and find that non-residential SES suppresses the effect of residential SES on self-rated health. Vallée et al., 2010, Vallée et al., 2011) find cumulative effects of activity space and residential features on cervical cancer screening and depression in Paris. Using travel surveys to map individual mobility patterns in Montreal and Quebec City, Kestens et al. (2012) find that the effect of food environment exposure when considering both local and activity space contexts is stronger than when considering just residential context. Another study uses GPS tracking data in Detroit to show that residential neighborhood exposures are weakly associated with dietary behaviors, while fast-food density along participants' activity paths correlate with obesity-related behaviors (Zenk et al., 2011). Again, the implication from each of these recent studies is that relying on local neighborhood measures alone may misrepresent an individual's full exposure area and, consequently, the true association between context and health.

Borne out of a growing consensus that the “neighborhood” encompasses far more than just a static residential unit, researchers are proposing new methodological approaches to detecting contextual effects on health. By all indications, however, recent work continues to be exploratory and suffers from several methodological limitations, not the least of which is a lack of longitudinal data to better understand the dynamics of context (Kwan, 2012, Matthews and Yang, 2013). To be sure, this is a nontrivial point as evidenced by the ongoing debate surrounding such thorny methodological issues as selection bias when estimating neighborhood effects (see Chaix et al., 2013, Jokela, 2014, Oakes, 2014). The challenge in addressing both the spatial and temporal dimensions of individuals' contextual exposures is therefore to not only ascertain information about where and how much time they spend in various locations, but also to gather data over time to gauge how changes in individuals and the places in which they live and visit transform health and well-being.

In this article, we provide such an empirical investigation employing data from the Los Angeles Family and Neighborhood Survey (LAFANS) to assess the role of time and space in the relationship between activity spaces, residential neighborhoods, and self-rated health. Our analysis of these data contributes to our understanding of how context influences health and well-being in several important ways. First, this research takes advantage of novel survey data that contain detailed information on several locations where people conduct their daily activities (e.g., work, shop, worship) to derive measures of activity spaces. Second, it goes further than past work and presents a more accurate depiction of adults' contextual exposures by estimating the amount of time respondents spend in both residential and non-residential areas. Finally, this paper is the first to use longitudinal survey data to analyze how changes in residential neighborhood and activity space contexts, as well as shifts in individual and household circumstances, influence self-rated health. With such rich data and detail, we are able to assess not only the direct effects of non-residential context on health, but also the ways in which non-residential context might shape residential context effects.

Past research on neighborhood effects has long implicated residential structural conditions (i.e., concentrated disadvantage) as being independently associated with unhealthy outcomes (e.g., Pickett and Pearl, 2001, Robert, 1998, Ross, 2000, Ross and Mirowsky, 2001, Sampson, 2012). In other words, urban residents who are disproportionately exposed to social features of disadvantage, such as high concentrations of poverty and unemployment, are more apt to suffer from worse physical and mental health than residents of more advantaged neighborhoods (see Sampson et al., 2002). There are several explanations as to why local disadvantage is associated with poorer individual health above and beyond individual characteristics, but predominantly researchers implicate a lack of important resources and amenities, like access to adequate jobs, schools, police protection, and healthy foods in poor neighborhoods, as well as a lack of social cohesion that facilitates the exchange of health-promoting resources and behaviors (Sampson et al., 2002). These same kinds of disadvantage exposures in areas where people traverse throughout the day could also directly affect self-rated health in negative ways. The central idea is that health status is negatively impacted by excessive exposure to these contextual stressors above and beyond individual characteristics. As such, a first set of hypotheses addresses the independent health effects of adults' residential, non-residential, and overall contextual exposures.

Hypothesis 1a

On average, overall contextual disadvantage, residential disadvantage, and activity space disadvantage will be independently associated with poorer health evaluations.

Hypothesis 1b

Increases in overall contextual disadvantage, residential disadvantage, and activity space disadvantage over time will increase the likelihood of reporting poorer health.

A principal objective of this research is to ascertain whether and how activity space (or non-residential) exposures influence and shape the effects of residential context on perceptions of overall health status. Activity space disadvantage might alter the health impacts of residential disadvantage through an indirect pathway – in the case of mediation or suppression – or through moderation. First, adults' exposure to disadvantage outside of their place of residence might reduce the effect, or mediate the association, between residential context and health. For instance, urban residents who spend a significant amount of time in non-residential neighborhoods will presumably be less affected by their residential characteristics. Thus,

Hypothesis 2a

Activity space disadvantage will mediate the effect of residential disadvantage on the probability of reporting poorer health.

Alternatively, past research has demonstrated that individuals' exposure to extralocal areas suppresses the influence of local conditions (Crowder and South, 2008, Crowder et al., 2011, Inagami et al., 2007). The detection of a suppression effect of activity space disadvantage would not only suggest that significant variation in local disadvantage is explained by extralocal disadvantage, but also that omitting this information leads to an underestimation of the residential neighborhood effect of disadvantage exposure on health self-reports. Accordingly,

Hypothesis 2b

Activity space disadvantage will suppress the effect of residential disadvantage on the probability of reporting poorer health.

Our work departs from recent studies by considering how disadvantage exposure outside the local neighborhood might moderate the health impacts of residential disadvantage. Given that disadvantaged neighborhoods are directly related to negative health outcomes, people who routinely travel and spend time in equally or more disadvantaged areas are presumably exposed to the compounded effects of concentrated disadvantage. The possibility therefore exists that adults' exposure to residential disadvantage combines with disadvantaged activity space environments to place those individuals at a special heightened risk for more deleterious health reports.

Alternatively, we test a contextual incongruence hypothesis. From this line of reasoning, people who traverse activity locations markedly dissimilar than their residential environments might report worse health. We base this hypothesis on previous research demonstrating that impoverished individuals living in more affluent neighborhoods may be inclined to view their more advantaged neighbors and neighborhood conditions as a point of reference in how they view their own well-being (see Stafford and Marmot, 2003). Likewise, more advantaged individuals living in advantaged areas but who spend time in more disadvantaged contexts may lose some of the protective elements associated with higher SES and healthier residential communities. While this idea is based on an individual–neighborhood interaction, we examine whether contextual incongruence applies to a residential-activity space interaction, especially given recent empirical evidence on Los Angeles reporting that, on average, people spend time in non-residential areas that are quite different than their residential neighborhoods (Jones and Pebley, 2014). A final set of hypotheses therefore addresses how activity space contexts might moderate the effect of residential context on self-rated health:

Hypothesis 3a

Activity space disadvantage interacts with residential disadvantage in additive ways such that people spending time in high disadvantaged residential and non-residential neighborhoods report poorer health.

Hypothesis 3b

Activity space disadvantage interacts with residential disadvantage such that people living in high disadvantaged areas are more likely to report poorer health when spending time in high advantaged non-residential areas. Conversely, people living in high advantaged areas are more likely to report worse health when spending time in high disadvantaged non-residential areas.

Section snippets

Data sources

This paper uses restricted-access longitudinal data from the Los Angeles Family and Neighborhood Survey (LAFANS). LAFANS was conducted in two waves, in 2000–2002 and 2006–2008, and is based on a stratified random sample of 65 neighborhoods (census tracts) in Los Angeles County, including an oversample of poor neighborhoods. In Wave 1, LAFANS randomly selected and interviewed adults and children living in 3085 households across the 65 sampled tracts, including an oversample of households with

Results

In Table 3, we begin by conceptualizing the neighborhood as including all the areas in which adults conduct many of their daily activities, not just the residential census tract. Recall from our example in Table 1 that here we create neighborhood measures weighted by the relative amount of time the respondent spends in each context, including their respective residential neighborhood (note that we refer to these measures under the heading ‘Contextual Exposure’ in Table 3). For ease of

Discussion and conclusion

This research uses novel longitudinal data from the Los Angeles Family and Neighborhood Survey to provide new empirical insights into whether and how exposure to various contexts shape individuals' self-rated health. To this end, we create measures of respondents' residential, activity space, and overall contextual exposures by integrating the amount of time respondents spend in each context. Multilevel cross-classified logistic regression models assess the independent effects of residential

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