Association of the Neighborhood Built Environment With Incident and Prevalent Depression in the Rural South

Christopher E. Anderson, PhD, MSPH¹; Stephanie T. Broyles, PhD²; Maeve E. Wallace, PhD, MPH³; Lydia A. Bazzano, MD, PhD¹; Jeanette Gustat, PhD, MPH¹ (View author affiliations)

Suggested citation for this article: Anderson CE, Broyles ST, Wallace ME, Bazzano LA, Gustat J. Association of the Neighborhood Built Environment With Incident and Prevalent Depression in the Rural South. Prev Chronic Dis 2021;18:200605. DOI: http://dx.doi.org/10.5888/pcd18.200605.

PEER REVIEWED

Abstract

Introduction

A neighborhood’s built environment is associated with physical activity among its residents, and physical activity is associated with depression. Our study aimed to determine whether the built environment was associated with depression among residents of the rural South and whether observed associations were mediated by physical activity.

Methods

We selected 2,000 participants from the Bogalusa Heart Study who had a valid residential address, self-reported physical activity (minutes/week), and a complete Center for Epidemiologic Study–Depression (CES-D) scale assessment from 1 or more study visits between 1998 and 2013. We assessed the built environment with the Rural Active Living Assessment street segment audit tool and developed built environment scores. The association between built environment scores and depression (CES-D ≥16) in geographic buffers of various radii were evaluated by using modified Poisson regression, and mediation by physical activity was evaluated with mixed-effects models.

Results

Depression was observed in 37% of study participants at the first study visit. One-point higher physical security and aesthetic scores for the street segment of residence were associated with 1.07 times higher (95% CI, 1.02–1.11) and 0.96 times lower (95% CI, 0.92–1.00) baseline depression prevalence. One-point higher destination scores (ie, more commercial and civic facilities) in radius buffers of 0.25 miles or more were associated with 1.06 times (95% CI, 1.00–1.13) the risk of depression during follow-up. Neighborhood poverty (defined as percentage of residents with incomes below the federal poverty level and dichotomized at 28.3%) modified cross-sectional and longitudinal associations. Associations were not mediated by physical activity.

Conclusion

The built environment was associated with prevalence and risk of depression, and associations were stronger in high-poverty neighborhoods. Built environment improvements to promote physical activity should take neighborhood context into consideration to minimize negative side effects on mental health in high-poverty communities.

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Tables

Table 1. Characteristics of Participants (N = 2,000) Included in Analyses Evaluating the Cross-Sectional and Longitudinal Associations of the Built Environment Around the Residence and Depression in a Rural Population, Bogalusa Heart Study, 1998–2013

Characteristic	Cross Sectional		Longitudinal
	N = 2,000	P Valuea	N = 1,006b	P Valuea
Age, y, mean (SD)	38.27 (8.63)	.03	36.79 (4.96)	.05
BMI, mean (SD)	29.79 (8.03)	.18	29.63 (8.20)	.89
Follow-up duration, y, mean (SD)	0.00 (0.00)	1.00	10.68 (3.17)	.90
CES-D scorec at baseline, mean (SD)	15.08 (10.27)	.93	13.24 (9.84)	.75
Depressed at baseline, n (%)	740 (37.00)	.77	321 (31.91)	.46
Male, n (%)	862 (43.10)	.15	410 (41.46)	.77
Black, n (%)	672 (33.60)	.22	303 (30.64)	.79
≥High school education, n (%)	838 (41.90)	.002	548 (58.80)	.64
Household income ≥$15,000, n (%)	1,285 (64.25)	.87	718 (72.67)	.99
Married, n (%)	1,063 (53.15)	.19	611 (61.78)	.22
Have health insurance, n (%)	1,216 (60.80)	.08	635 (68.13)	.06
Employed, n (%)	1,596 (79.80)	.54	833 (84.23)	.26
Home owner, n (%)	1,445 (72.25)	<.001	779 (78.77)	.008
In good health, n (%)	1,288 (64.40)	.22	878 ( 89.32)	.76
Current smoker, n (%)	590 (29.50)	.06	292 (29.03)	.91
Former smoker, n (%)	523 (26.15)	.06	300 (29.82)	.91
Consumed alcohol in last year, n (%)	1,206 (61.25)	.22	628 ( 63.50)	.18
Any physical activity, n (%)	1,436 (72.90)	.67	858 (86.75)	.79
Walking (min/wk), mean (SD)	83.29 (245.56)	.76	82.45 (250.18)	.27
Physical activity (min/wk), mean (SD)	175.77 (386.90)	.38	181.34 (375.15)	.07

Abbreviations: BMI, body mass index; CES-D, Centers for Epidemiologic Studies–Depression.
^a P values were assessed with analysis of variance for categorical variables and Pearson correlation coefficient for continuous variables and are for the association of participant characteristics with the (continuous) overall built environment score for the street segment of residence.
^b Longitudinal sample; includes only those study subjects with 2 or more observations.
^c CES-D score ≥16 indicates depression. CES-D scores can range from 0 to 60.

Table 2. Neighborhood Characteristics of Participants (N = 2,000) Included In Analyses Evaluating the Cross-Sectional and Longitudinal Associations of the Built Environment Around the Residence and Depression in a Rural Population, by Depression Status, Bogalusa Heart Study, 1998–2013

Variable	Cross Sectional			Longitudinala
	Depressedb (n = 740)	Not Depressed (n = 1,260)	P Valuec	Depressedb (n = 568)	Not Depressed (n = 438)	P Valuec
Street segment of built environmentd
All features, mean (SD)	10.55 (4.32)	10.49 (4.49)	.77	10.41 (4.17)	10.34 (4.43)	.78
Path, mean (SD)	2.31 (2.35)	2.20 (2.40)	.32	2.08 (2.22)	2.11 (2.37)	.83
Pedestrian safety features, mean (SD)	3.21 (1.81)	3.03 (1.81)	.03	3.02 (1.83)	2.94 (1.89)	.51
Aesthetics, mean (SD)	2.99 (1.47)	3.28 (1.60)	<.001	3.33 (1.55)	3.30 (1.57)	.76
Destinationse, mean (SD)	0.61 (1.22)	0.54 (1.14)	.20	2.92 (1.11)	2.94 (1.11)	.90
Physical security, mean (SD)	3.41 (1.45)	3.19 (1.32)	<.001	0.52 (1.10)	0.51 (1.13)	.73
Land use, mean (SD)	1.61 (0.90)	1.67 (0.95)	.17	1.67 (0.98)	1.66 (0.90)	.85
Contextual variables
Population density, mean (SD)	556.75 (1,575.20)	603.25 (1,189.66)	.46	536.30 (1,774.73)	520.84 (839.53)	.86
Percentage povertyf, mean (SD)	30.06 (10.23)	27.20 (11.22)	<.001	28.75 (10.58)	28.41 (11.00)	.39

Abbreviation: CES-D, Centers for Epidemiologic Studies–Depression.
^a Longitudinal sample; includes only those study subjects with 2 or more observations.
^b CES-D score ≥16 indicates depression. CES-D scores can range from 0 to 60.
^c P values for comparison of depressed and not-depressed subjects are from t tests.
^d Built environment scores summarize features of street segments assessed with the Rural Active Living Assessment street segment audit tool, overall and within domains of features, with higher numeric scores indicating the presence of more features thought to promote physical activity. Scores have the following ranges: overall (2–29), path (0–9), pedestrian safety (0–10), aesthetics (0–6), destinations (0–11), physical security (0–6), and land use (0–5).
^e Includes commercial and civic facilities.
^f Neighborhood poverty was defined as the percentage of residents in a census tract living below the federal poverty level.

Table 3. Association of Neighborhood Built Environment Scores^a With Prevalence and Incidence of Depression Among Participants (N = 2,000), Bogalusa Heart Study, 1998–2013

Built Environment Score	Buffer Around Residence Unit
	0.00 mi	0.25 mi	0.50 mi	1.00 mi	1.50 mi
Cross-sectional, prevalence rate ratio (95% CI)
Overall	1.01 (0.99–1.02)	1.01 (0.99–1.03)	1.01 (0.99–1.03)	1.00 (0.98–1.03)	1.00 (0.98–1.02)
Path	1.01 (0.98–1.04)	1.02 (0.99–1.05)	1.02 (0.98–1.05)	1.01 (0.97–1.05)	1.01 (0.97–1.06)
Pedestrian safety	1.03 (1.00–1.06)	1.03 (0.99–1.08)	1.04 (0.98–1.09)	1.03 (0.97–1.09)	1.02 (0.96–1.08)
Aesthetics	0.96 (0.92–1.00)	0.97 (0.92–1.02)	0.97 (0.91–1.02)	0.96 (0.90–1.02)	0.95 (0.88–1.02)
Destinationsb	1.04 (0.99–1.10)	1.04 (0.97–1.10)	1.04 (0.97–1.12)	1.02 (0.94–1.12)	1.02 (0.93–1.13)
Physical security	1.07 (1.02–1.11)	0.97 (0.84–1.12)	1.02 (0.87–1.21)	1.03 (0.86–1.24)	1.00 (0.82–1.22)
Land use	0.98 (0.92–1.04)	0.97 (0.89–1.05)	0.95 (0.86–1.05)	0.92 (0.83–1.03)	0.95 (0.85–1.06)
Longitudinal, risk ratio (95% CI)
Overall	1.00 (0.99–1.01)	1.01 (0.99–1.02)	1.01 (0.99–1.03)	1.01 (0.98–1.03)	1.00 (0.98–1.03)
Path	1.00 (0.97–1.02)	1.00 (0.97–1.03)	1.01 (0.97–1.04)	1.00 (0.96–1.04)	0.99 (0.95–1.04)
Pedestrian safety	1.01 (0.98–1.04)	1.00 (0.97–1.04)	1.01 (0.97–1.05)	1.00 (0.96–1.04)	1.00 (0.95–1.05)
Aesthetics	1.00 (0.97–1.04)	1.01 (0.97–1.06)	1.02 (0.97–1.07)	1.02 (0.97–1.08)	1.02 (0.96–1.08)
Destinationsb	1.01 (0.97–1.06)	1.06 (1.00–1.13)	1.07 (1.01–1.14)	1.08 (1.01–1.15)	1.07 (1.00–1.15)
Physical security	1.00 (0.96–1.05)	1.11 (0.96–1.28)	1.15 (0.97–1.36)	1.13 (0.94–1.37)	1.10 (0.90–1.35)
Land use	1.00 (0.95–1.06)	0.99 (0.92–1.05)	0.99 (0.93–1.07)	0.97 (0.90–1.05)	0.96 (0.88–1.05)

^a Built environment scores summarize features of street segments assessed with the Rural Active Living Assessment street segment audit tool, overall and within domains of features, with higher numeric scores indicating the presence of more features thought to promote physical activity. Measures of association represent the relative prevalence or risk of depression associated with a 1-point increase in the specified built environment score. Scores have the following ranges: overall (2–29), path (0–9) pedestrian safety (0–10), aesthetics (0–6), destinations (0–11), physical security (0–6), and land use (05).
^b Includes commercial and civic facilities.

Table 4. Association Between Neighborhood Built Environment Scores and Change in CES-D^a, Participants (N = 1,006)^a, Bogalusa Heart Study, 1998–2013

Built Environment Scorec	CES-D Slope Differenceb for 1-Point Increase in Built Environment Score
	Buffer Around Residence Unit
	0.00 mi		0.25 mi		0.50 mi		1.00 mi		1.50 mi
	β (SE)	P Value	β (SE)	P Value	β (SE)	P Value	β (SE)	P Value	β (SE)	P Value
Overall	0.02 (0.05)	.67	0.00 (0.06)	.98	−0.03 (0.07)	.69	−0.11 (0.08)	.16	−0.17 (0.08)	.04
Path	−0.07 (0.09)	.40	−0.09 (0.11)	.41	−0.09 (0.12)	.46	−0.22 (0.14)	.13	−0.40 (0.16)	.01
Pedestrian safety	−0.06 (0.11)	.60	−0.20 (0.14)	.16	−0.35 (0.16)	.03	−0.52 (0.17)	<.01	−0.57 (0.19)	<.01
Aesthetics	0.26 (0.13)	.04	0.51 (0.16)	<.01	0.67 (0.19)	<.01	0.71 (0.23)	<.01	0.76 (0.26)	<.01
Destinationsd	0.08 (0.16)	.64	0.17 (0.24)	.49	0.05 (0.27)	.86	−0.10 (0.33)	.76	−0.36 (0.41)	.38
Physical security	0.44 (0.14)	<.01	0.22 (0.53)	.69	0.57 (0.62)	.36	0.46 (0.74)	.54	0.54 (0.84)	.52
Land use	0.27 (0.22)	.21	0.47 (0.27)	.08	0.55 (0.30)	.07	0.69 (0.34)	.04	0.71 (0.38)	.06

Abbreviation: CES-D, Centers for Epidemiologic Studies–Depression.
^a Longitudinal sample; includes only those study subjects with 2 or more observations.
^b CES-D slope was expressed as the rate of change in depressive symptom severity per 10 years of follow-up (depressive symptom severity was assessed as a continuous CES-D score that can range from 0 to 60, with higher scores indicating more severe depressive symptoms).
^c Built environment scores summarize features of street segments assessed with the Rural Active Living Assessment street segment audit tool, overall and within domains of features, with higher numeric scores indicating the presence of more features thought to promote physical activity. Associations represent the difference in the rate of change of depressive symptom severity over 10 years for a 1-point increase in the specified built environment score. Scores have the following ranges: overall (2–29), path (0–9), pedestrian safety (0–10), aesthetics (0–6), destinations (0–11), physical security (0–6), and land use (05).
^d Includes commercial and civic facilities.

Table 5. Percentage of the Observed Association of Neighborhood Built Environment Scores^a With CES-D Slope^b Mediated by Physical Activity, Participants (N = 1,006)^c Bogalusa Heart Study, 1998–2013

Built Environment	CES-D Slope Differenceb, Percentage Mediation (95% CI) by Physical Activity
	Buffer Around Residence Unit
	0.00 mi	0.25 mi	0.50 mi	1.00 mi	1.50 mi
Overall	−5.92 (−20.12 to 4.33)	16.4 (−167.44 to 211.48)	−1.44 (8.23 to −12.09)	−0.06 (2.71 to −2.87)	0.23 (2.21 to −1.60)
Path	1.55 (7.87 to −3.70)	−0.51 (4.48 to −5.87)	0.50 (6.32 to −4.98)	0.40 (3.16 to −2.09)	0.35 (2.06 to −1.13)
Pedestrian safety	−0.84 (7.40 to −9.65)	0.40 (3.71 to −2.62)	0.24 (2.32 to −1.67)	0.35 (1.92 to −0.98)	0.55 (2.17 to −0.70)
Aesthetics	−2.83 (−6.59 to −0.29)	-0.31 (−1.83 to 1.01)	−0.13 (−1.38 to 1.04)	−0.15 (−1.53 to 1.12)	−0.18 (−1.59 to 1.10)
Destinationsd	1.72 (−8.11 to 12.72)	0.79 (−5.58 to 7.70)	5.94 (−17.02 to 32.96)	−2.47 (10.41 to −17.04)	−0.92 (3.16 to −5.63)
Physical security	1.07 (−0.12 to 2.97)	−3.20 (−14.77 to 6.20)	−2.03 (−7.17 to 1.75)	−2.19 (−9.18 to 3.31)	−0.96 (−7.01 to 4.43)
Land use	2.48 (−0.66 to 7.21)	2.27 (−0.05 to 5.89)	2.29 (0.06 to 5.76)	1.83 (−0.05 to 4.78)	1.65 (−0.25 to 4.60)

Abbreviation: CES-D, Centers for Epidemiological Studies–Depression.
^a Built environment scores summarize features of street segments assessed with the Rural Active Living Assessment street segment audit tool, overall and within domains of features, with higher numeric scores indicating the presence of more features thought to promote physical activity. Associations represent the percentage of the slope difference for a 1-point increase in the specified built environment score that is mediated by physical activity. Scores have the following ranges: overall (2–29), path (0–9), pedestrian safety (0–10), aesthetics (0–6), destinations (0–11), physical security (0–6), and land use (05).
^b CES-D slope was expressed as the rate of change in depressive symptom severity per 10 years of follow-up (depressive symptom severity was assessed as a continuous CES-D score that can range from 0 to 60, with higher scores indicating more severe depressive symptoms).
^c Longitudinal sample; includes only those study subjects with 2 or more observations.
^d Includes commercial and civic facilities.

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