COVID-19, Disability, and the International Classification of Functioning, Disability and Health: A Scoping Review of Early-Stage Pandemic Response.

Introduction: This study aimed to systematically identify the environmental factors that impacted people with disability during the COVID-19 pandemic. Methods: A scoping literature review was conducted using LitCOVID (January 1-July 31, 2020). Sixty-six articles met the inclusion criteria that (1) discussed disability and/or health conditions related to functioning and (2) considered environmental factors. A qualitative content analysis was conducted using codes from the WHO International Classification of Functioning, Disability and Health. Results: A total of 212 International Classification of Functioning, Disability and Health codes were used in the coding process. The most frequent codes referred to health services policies and public health guidelines. These policies, although generally considered facilitators for minimizing infection, were frequently identified as barriers to the health, participation, and human rights of people with disability. The lack of disability-specific population data was identified as a key barrier to planning and decision making. Conclusions: The social determinants of health for people with disability were not adequately considered in the acute phase of infection prevention at the population level. Integrating the International Classification of Functioning, Disability and Health in emergency management provides a tool to evaluate functioning and address barriers for those in need.

Comparison of two area-level socioeconomic deprivation indices: Implications for public health research, practice, and policy.

OBJECTIVES: To compare 2 frequently used area-level socioeconomic deprivation indices: the Area Deprivation Index (ADI) and the Social Vulnerability Index (SVI). METHODS: Index agreement was assessed via pairwise correlations, decile score distribution and mean comparisons, and mapping. The 2019 ADI and 2018 SVI indices at the U.S. census tract-level were analyzed. RESULTS: Index correlation was modest (R = 0.51). Less than half (44.4%) of all tracts had good index agreement (0-1 decile difference). Among the 6.3% of tracts with poor index agreement (≥6 decile difference), nearly 1 in 5 were classified by high SVI and low ADI scores. Index items driving poor agreement, such as high rents, mortgages, and home values in urban areas with characteristics indicative of socioeconomic deprivation, were also identified. CONCLUSIONS: Differences in index dimensions and agreement indicated that ADI and SVI are not interchangeable measures of socioeconomic deprivation at the tract level. Careful consideration is necessary when selecting an area-level socioeconomic deprivation measure that appropriately defines deprivation relative to the context in which it will be used. How deprivation is operationalized affects interpretation by researchers as well as public health practitioners and policymakers making decisions about resource allocation and working to address health equity.

Public transit stop density is associated with walking for exercise among a national sample of older adults.

BACKGROUND: Walking is the primary and preferred mode of exercise for older adults. Walking to and from public transit stops may support older adults in achieving exercise goals. This study examined whether density of neighborhood public transit stops was associated with walking for exercise among older adults. METHODS: 2018 National Health and Aging Trends Study (NHATS) data were linked with the 2018 National Neighborhood Data Archive, which reported density of public transit stops (stops/mile2) within participants' neighborhood, defined using census tract boundaries. Walking for exercise in the last month was self-reported. The extent to which self-reported public transit use mediated the relationship between density of neighborhood public transit stops and walking for exercise was examined. Covariates included sociodemographic characteristics, economic status, disability status, and neighborhood attributes. National estimates were calculated using NHATS analytic survey weights. RESULTS: Among 4,836 respondents with complete data, 39.7% lived in a census tract with at least one neighborhood public transit stop and 8.5% were public transit users. The odds of walking for exercise were 32% higher (OR = 1.32; 95% confidence interval: 1.08, 1.61) among respondents living in a neighborhood with > 10 transit stops per mile compared to living in a neighborhood without any public transit stops documented. Self-reported public transit use mediated 24% of the association between density of neighborhood public transit stops and walking for exercise. CONCLUSIONS: Density of neighborhood public transit stops was associated with walking for exercise, with a substantial portion of the association mediated by self-reported public transit use. Increasing public transit stop availability within neighborhoods may contribute to active aging among older adults.

Neighborhood Social Determinants of Health in Patients Seen in Neurology Movement Disorders Clinics.

Background and Objectives: Chronic health conditions are influenced by social determinants of health (SDH) including neighborhood-linked markers of affluence. We explored whether neighborhood socioeconomic factors differ in people with different types of clinical movement disorders (MDs). Methods: We conducted a retrospective study of patients seen in MD clinics at our center in 2021. Patient data were linked to the US National Neighborhood Data Archive linked to US census tract data. We evaluated variations in neighborhood socioeconomic factors across 8 different categories of MDs. Results: Compared with the neighborhoods of patients with Parkinson disease, neighborhoods of patients with cerebellar ataxias, functional movement disorders, and Huntington disease were characterized by higher proportions of people earning less than 15,000 US dollars/year, people receiving public assistance, and people with less than a high school diploma. Discussion: Neighborhood-linked SDH vary among different MDs. These findings have implications for public health interventions aimed at improving the care of people affected by MDs.

Self-Reported Visual Difficulty and Daily Activity Limitations: The Moderating Role of Neighborhood Characteristics.

BACKGROUND AND OBJECTIVES: Understanding how neighborhood-level factors moderate the relationship between visual health and activity limitations could inform strategies for successful aging in place among older adults with sensory impairments. Guided by a vision loss impact framework, this study aims to examine whether neighborhood social cohesion and physical disorder moderate the association between visual difficulty and activity limitation. RESEARCH DESIGN AND METHODS: Secondary analyses were conducted using data from Round 5 of the National Health and Aging Trend Study. A 4-level indicator was used to indicate the visual difficulty. Neighborhood social cohesion and physical disorder were each measured using a 3-item scale. Summary scores were created for daily activity limitations. Ordinary least squares regressions were performed to test the study hypotheses. The complex survey design factors were applied. Missing data were handled using multiple imputations. RESULTS: Older adults reporting any type of visual difficulty experienced more limitations in self-care tasks, household activities, and mobility than those without visual difficulty. Neighborhood physical disorder moderated visual difficulty and activity limitations. Specifically, visual difficulty was associated with higher risk of activity limitations among participants perceiving physical disorder in the neighborhood compared to those perceiving no physical disorder. DISCUSSION AND IMPLICATIONS: The study findings suggest that the vision loss impact framework provides an integrative approach to identify the health needs of older adults with visual difficulty. Future research is needed to further understand the role of neighborhood in independent living among older adults with visual difficulty and to inform community-level interventions.

Enhanced Street Crossing Features are Associated with Higher Post-Stroke Physical Quality of Life.

BACKGROUND: Features of the physical environment may affect post-stroke recovery, but empirical evidence is limited. This study examines associations between features of the physical environment and post-stroke physical quality of life (PH-QOL). METHODS: The study sample included stroke survivors enrolled in the Caring for Adults Recovering from the Effects of Stroke project, a prospective cohort. Features of the physical environment surrounding participants' home addresses were audited using Google Earth. Audits captured information about crossings (e.g. curb-cuts; range 0-4), street segments (e.g. sidewalks; range 0-17.5), and a route (e.g. parks; range 0-27) near participants' home. Summary scores were categorized into tertials representing "few," "some," and "many" pedestrian-friendly features. Post-stroke PH-QOL was measured by the SF-12 (range 0-100) around 6 to 12-, 18-, 27-, and 36-months post-stroke. Linear mixed models were used to estimate PH-QOL over time. Chained multiple imputation was used to account for missing data. RESULTS: Two hundred and seventy-five participants were eligible, among whom 210 had complete data. Most participants lived in areas with "few" features to promote outdoor mobility. Participants living in environments with "some" crossing features had a 4.90 (95% CI: 2.32, 7.48) higher PH-QOL score across the observation period in comparison to participants living in environments with "few" crossing features. Features of the physical environment along street segments and routes were not associated with post-stroke PH-QOL. CONCLUSION: Crossing features are associated with post-stroke PH-QOL. Modifying features of the physical environment at nearby crossings, such as curb-cuts, may be a promising strategy for increasing PH-QOL.

Psychosocial Stress and Hypothalamic-Pituitary-Adrenal Axis Stress Reactivity: Variations by Race and Socioeconomic Status Among Adults at Risk of Diabetes.

OBJECTIVE: Although stress is posited to play a key role in health disparities, the extent to which commonly used self-report psychosocial stress measures are related to neurobiological stress processes, especially across diverse populations, is unresolved. This study examined how two measures of psychosocial stress, perceived stress and domain-specific stress, covary with the acute neurobiological stress response. METHODS: The Richmond Stress and Sugar Study includes a racially and socioeconomically diverse cohort of adults at risk for type 2 diabetes ( n = 125; mean age = 57 years, 48% Black, and 61% high neighborhood socioeconomic status [SES]). Hypothalamic-pituitary-adrenal axis reactivity was assessed by salivary cortisol response to the Trier Social Stress Test (TSST), a laboratory stressor. RESULTS: Higher perceived stress was associated with a lower cortisol response to the TSST (-7.5%; 95% confidence interval [CI] = -13.1% to -1.5%) but was not associated with cortisol recovery after the TSST (3%; 95% CI = -0.6% to 6.8%). In contrast, domain-specific stress was not associated with cortisol response (-2.1%; 95% CI = -20.7% to 20.9%) but was inversely associated with cortisol recovery (3.7%; 95% CI = 0.6% to 7.0%). SES modified these associations: both perceived stress and domain-specific stress were associated with TSST cortisol response only among participants from high-SES neighborhoods. There was minimal evidence of effect modification by race. CONCLUSIONS: Both self-report measures of psychosocial stress were associated with hypothalamic-pituitary-adrenal axis reactivity to an acute stressor. These associations varied by perceived versus domain-specific measurement scales and by neighborhood SES. Further efforts to refine stress measures and clarify biological linkages between social status and health are needed.

Work at Age 62: Expectations and Realisations among Recent Cohorts of Americans.

Much remains unknown about how the 2008 Great Recession, coupled with the ageing baby boomer cohort, have shaped retirement expectations and realized retirement timing across diverse groups of older Americans. Using the Health and Retirement Study (1992-2016), we compared expectations about full-time work at age 62 (reported at ages 51-61) with realized labor force status at age 62. Of the 12,049 respondents, 34 per cent reported no chance of working full time at 62 (zero probability) and 21 per cent reported it was very likely (90-100 probability). Among those reporting no chance of working, there was a 0.111 probability of unmet expectations; among those with high expectations of working, there was a 0.430 probability of unmet expectations. Black and Hispanic Americans were more likely than whites to have unmet expectations of both types. Educational attainment was associated with higher probability of unexpectedly working and lower probability of unexpectedly not working. Baby boomers experienced fewer unmet expectations than prior cohorts but more uncertainty about work status at 62. Our findings highlight the unpredictability of retirement timing for significant segments of the U.S. population and the role of the Great Recession in contributing to uncertainty. Given the individual and societal benefits of long work lives, special attention should be paid to the high rates of unexpectedly not working at age 62.

"Well in in this neighborhood I have walked, not at all": Stroke survivors lived experience in the outdoor environment.

Stroke survivors face unique challenges in the outdoor environment when returning to their home community following a stroke. Challenges include navigating uneven terrain, social stigma, and adapting to changes in functioning. Outdoor environments may serve as potential points of intervention to promote independence and participation post stroke. This study aimed to understand lived post-stroke experience in the outdoor environment as it pertains to independent mobility. METHODS: Qualitative semi-structured interviews were conducted with 20 stroke survivors (8 males, 12 females; mean age 64.2 years: range 45 years-90 years). Participants were eligible if they were over the age of 45, could communicate in English, lived outside a nursing home, able to walk safely outdoors, were a minimum of six-months post stroke, and had no severe cognitive impairment. Interviews with participants were tape recorded, audio files were transcribed verbatim, codes were created and applied to transcripts, and themes were generated using interpretative phenomenological analysis. RESULTS: Post-stroke experiences in the outdoor environment were multidimensional. Three themes emerged from the stroke survivors' description of personal experiences in the outdoor environment. These themes included feelings of vigilance, employing adaptation strategies, and management of dynamic relations between the self and context. DISCUSSION: The findings highlight the post-stroke experience traversing the outdoor environment. Investing in the public outdoor environment to remove barriers and install facilitators could reduce feelings of apprehension and hypervigilance while walking in the outdoor environment. Future research is needed to evaluate the role of environmental interventions on hypervigilance in the outdoor environment post stroke.

The Relationship Between Environmental Exposures and Post-Stroke Physical Activity.

INTRODUCTION: Post-stroke physical activity has widespread health benefits. Environmental exposures may shape post-stroke physical activity behavior. This study investigates the relationships between environmental exposures and post-stroke physical activity. METHODS: Stroke survivors (n=374) from a cohort of Black and White adults with post-stroke accelerometer data (2009-2013) were eligible for this study. Participants' home addresses were linked with secondary data to capture environmental characteristics, including annual density of neighborhood resources (e.g., parks, physical activity facilities, and intellectual stimulation destinations), 2010 neighborhood SES, 2010 neighborhood crime, and daily information on extremely cold days. Post-stroke light physical activity and moderate-to-vigorous physical activity were captured using accelerometers over a 7-day period. Linear regression and 2-part/hurdle models were used to estimate the relationship between the density of neighborhood resources with light physical activity and with moderate-to-vigorous physical activity, respectively. Analyses were conducted in 2021. RESULTS: A 10% increase in the number of extremely cold days was associated with 6.37 fewer minutes of daily light physical activity (95% CI= -11.37, -1.37). A 1-SD increase in neighborhood SES was associated with greater odds (OR=1.10, 95% CI=1.02, 1.19) of doing any moderate-to-vigorous physical activity. Among participants obtaining any moderate-to-vigorous physical activity, a 1-unit (count/km2) increase in destinations for intellectual stimulation was associated with 0.99 (95% CI=0.02, 1.97) more minutes of daily moderate-to-vigorous physical activity. All other environmental exposures were not associated with post-stroke light physical activity or moderate-to-vigorous physical activity. CONCLUSIONS: Environmental exposures may facilitate physical activity participation among stroke survivors. This study found that weather, neighborhood SES, and proximity to destinations for intellectual stimulation were associated with physical activity over and above individual factors.

Unmet Expectations About Work at Age 62 and Depressive Symptoms.

OBJECTIVES: Exiting the labor force earlier or later than planned is common, with predictable economic consequences. However, the mental health ramifications of such off-time events are not known but are important to promoting well-being in retirement. METHODS: Using the Health and Retirement Study (1992-2016), we created 6 groups based on the alignment of expectations about full-time work at age 62 (reported at ages 51-61) with realized labor force status after reaching age 62 (N = 10,421). Negative binomial models estimated the adjusted association between unmet expectations about work and depressive symptoms. RESULTS: Unexpectedly not working was associated with higher depressive symptoms than working as expected after adjusting for sociodemographic, economic, and health factors at the time of expectations (incidence rate ratio = 1.35, 95% confidence interval: 1.17-1.56). Additionally, adjusting for health declines and marriage dissolution between expectations and age 62 partially attenuated the association, but unexpectedly not working remained significantly associated with a 1.16 increase in the incidence rate of depressive symptoms. Unexpectedly working at 62 was not associated with depressive symptoms. Race/ethnicity interacted with expectation alignment (F(15,42) = 2.44, p = .0118) in that Hispanic respondents experienced an increase in depressive symptoms when working after unmet and unsure expectations compared to met expectations, whereas White respondents did not. DISCUSSION: Unlike working longer than expected, unexpectedly not working at age 62 was associated with depressive symptoms, even after accounting for health declines. Public and employer policies should assist workers in remaining in the labor force as long as planned and offer mental health supports for unexpected work exits.

Racial Segregation and Cognitive Function Among Older Adults in the United States: Findings From the Reasons for Geographic and Racial Differences in Stroke Study.

OBJECTIVES: Residential segregation is one of the fundamental features of health disparities in the United States. Yet little research has examined how living in segregated metropolitan areas is related to cognitive function and cognitive decline with age. We examined the association between segregation at the metropolitan statistical area (MSA) level and trajectories of age-related cognitive function. METHOD: Using data from Black and White older adults in the REasons for Geographic and Racial Differences in Stroke study (n = 18,913), we employed linear growth curve models to examine how living in racially segregated MSAs at baseline, measured by the degree of non-Hispanic Black (NHB) isolation and NHB dissimilarity, was associated with trajectories of age-related cognitive function and how the associations varied by race and education. RESULTS: Living in MSAs with greater levels of isolation was associated with lower cognitive function (b = -0.093, p < .05) but was not associated with rates of change in cognitive decline with age. No effects of living in isolated MSAs were found for those with at least a high school education, but older adults with less than a high school education had lower cognitive function in MSAs with greater isolation (b = -0.274, p < .05). The degree of dissimilarity was not associated with cognitive function. The association between segregation and cognitive function did not vary by race. DISCUSSION: Metropolitan segregation was associated with lower cognitive function among older adults, especially for those with lower education living in racially isolated MSAs. This suggests complex associations between individual socioeconomic status, place, and cognitive health.

Urban Neighborhood Characteristics and the Spatial Distribution of Home and Community-Based Service Organizations in Michigan Metropolitan Statistical Areas.

Living in a neighborhood with dense HCBS organizations can promote older adults' health and well-being and may mitigate health disparities generated by living in materially deprived urban neighborhoods. Using 2016 US County Business Patterns and the American Community Survey (2013-2017), focused on 516 ZIP Codes in Michigan Metropolitan Statistical Areas, this study examines the association between neighborhood characteristics and the relative density of businesses offering services for older adults and persons with disabilities (e.g., senior centers, adult day service centers, personal care) and businesses offering home health care. Results from a series of spatial econometric models show that social care organization density tends to be high in neighborhoods with a greater number of residents who have a bachelor's degree, who are older, and who are in poverty. Home health care density was not explained by neighborhood factors. Multiple neighborhood socio-demographic indicators explain the spatial distribution of social care organizations.

Access to primary care and cognitive impairment: results from a national community study of aging Americans.

BACKGROUND: Despite a growing burden of Alzheimer's Disease and related dementias (ADRD) in the US, the relationship between health care and cognitive impairment prevention is unclear. Primary care manages risk causing conditions and risk reducing behaviors for dementia, so we examine the association between individual and area-level access to primary care and cognitive impairment in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. METHODS: REGARDS participants with a cognitive assessment and vascular measurements at their baseline visit were included in this cross-sectional analysis. Cognitive impairment was defined as a Six-Item Screener (SIS) score < 5. Primary care supply, primary care utilization and emergency department (ED) utilization were measured at the primary care service area (PCSA) level based on participant's address. Individual access to care was self-reported. Models were adjusted for confounding by demographics, socioeconomic status and behavioral risk factors. RESULTS: Among 25,563 adults, living in a PCSA with low primary care supply was associated with 25% higher odds of cognitive impairment (OR 1.25 CI 1.07-1.45). Not having a regular source of medical care was associated with 14% higher odds of cognitive impairment (OR 1.14 CI 1.02-1.28), and living in a PCSA with high emergency department utilization was associated with 12% higher odds of cognitive impairment (OR 1.12 CI 1.02-1.23). CONCLUSIONS: Our results are an important first step in understanding how health care may prevent cognitive impairment. They highlight the importance of primary care and suggest future work clarifying its role in preventing cognitive decline is imperative.

Can Neighborhood Social Infrastructure Modify Cognitive Function? A Mixed-Methods Study of Urban-Dwelling Aging Americans.

Objectives: Socialization predicts cognitive aging outcomes. Neighborhoods may facilitate socially engaged aging and thus shape cognition. We investigated places where older adults socialized and whether availability of these sites was associated with cognitive outcomes. Methods: Qualitative analysis of interviews and ethnography with 125 older adults (mean age 71 years) in Minneapolis identified where participants socialized outside of home. This informed quantitative analysis of a national sample of 21,151 older Americans (mean age at baseline 67 years) from the Reasons for Geographic and Racial Differences in Stroke study. Multilevel generalized additive models described associations between access to key social places and cognitive function and decline. Results: Qualitative analysis identified eateries, senior centers, and civic groups as key places to socialize. We identified significant positive associations between kernel density of senior centers, civic/social organizations, and cognitive function. Discussion: Specific neighborhood social infrastructures may support cognitive health among older adults aging in place.

Associations of Neighborhood Walkability and Walking Behaviors by Cognitive Trajectory in Older Adults.

BACKGROUND AND OBJECTIVES: Lawton's Ecological Model of Aging suggests that associations between environment and mobility differ based on individual factors such as cognitive decline. RESEARCH DESIGN AND METHODS: Virtual walkability audits were conducted within 1/8 mile of residences of older adults (n = 545; average age = 82; 57% female; 33% Black) who had been enrolled in the Health, Aging, and Body Composition (Health ABC) cohort for 10 years. The primary outcome was self-reported walking in past week and the secondary was mobility disability, self-reported difficulty to walk » mile. Linear mixed models of general cognitive function over the prior 10 years calculated participant-specific slopes; those below 0 were cognitive decliners. Logistic regression models, adjusted for demographics and neighborhood socioeconomic status, tested associations between each walkability variable and each mobility outcome. Interaction terms between walkability and cognitive status were tested and walkability analyses stratified on cognitive status where p for interaction < .2. RESULTS: In the sample, 57.4% reported walking, 24.2% reported mobility disability, and 51% were cognitive decliners. Sidewalk quality was related to walking in cognitive maintainers; slope was related in decliners. Mixed land use (odds ratio [OR] = 1.61; 95% confidence interval [CI]: 1.12, 2.30) and senior residence (OR = 2.14; 95% CI: 1.27, 3.60) were related to greater walking, regardless of cognitive status. Mixed land use was related to less mobility disability in decliners and abandoned properties were related to greater mobility disability in maintainers. DISCUSSION AND IMPLICATIONS: Policy-level interventions targeted at walkability, including improved sidewalk quality and increasing mixed land use could support walking in older adults, regardless of cognitive status.

Interrater Reliability of Historical Virtual Audits Using Archived Google Street View Imagery.

Impaired mobility occurs in up to half of community-dwelling older adults and is associated with poor health outcomes and high health care costs. Although the built environment impacts mobility, most studies of older adults lack information about environmental-level factors. In-person observational audits can be utilized but cannot assess the historical environment. We applied a 78-item checklist to archived Google Street View imagery to assess historical residence access and neighborhood characteristics. Interrater reliability between two raters was tested on 50 addresses using prevalence-adjusted and bias-adjusted kappa (PABAK). The mean PABAK for all items was .75, with 81% of the items having substantial (PABAK ≥ .61) or almost perfect (PABAK ≥ .81) agreement. Environmental assessment using archived virtual imagery has excellent reliability for factors related to residence access and many neighborhood characteristics. Archived imagery can assess past neighborhood characteristics, facilitating the use of historical environment data within existing cohorts.

The impact of weather on summer and winter exercise behaviors.

BACKGROUND: Outdoor exercise is an enjoyable way for individuals to improve fitness, but it is dependent on weather conditions. This study examines the association between weather conditions and outdoor exercise after adjustment for age, sex, race, and socioeconomic status. METHODS: We used data representative of American adults from the University of Michigan/Thomson Reuters June 2013 surveys of consumers (core and supplement) to investigate self-reported exercise behavior in summer and winter. Multivariate multinomial logistic regression models estimated the odds of delayed or indoor exercise compared with outdoor exercise. RESULTS: Of the 502 respondents, 16.3% did not regularly exercise outdoors (i.e., at least once a week), and many would delay exercise both in summer (51.8%) and winter (43.9%). Individuals listing rain as the predominant adverse weather condition had 3.33 times higher odds of exercising indoors (95% confidence interval (CI): 1.34-8.28) and 3.49 times higher odds of delaying exercise (95%CI: 1.69-7.21) compared with those mentioning heat as the predominant adverse condition. Individuals for whom ice or snow was an adverse winter weather condition were more likely to delay exercise (odds ratio (OR) = 3.34; 95%CI: 1.19-9.36), compared with those concerned with cold. CONCLUSION: This study found that race, age, and education exacerbate the negative effects of adverse weather conditions on the decision to exercise outdoors. Accordingly, any recommendation for an individual to exercise outdoors should be combined with an evaluation of the individual's outdoor environment along with strategies for the individual to continue exercising, indoors or outdoors, when adverse weather is present.

Difficulty and independence in shopping among older Americans: more than just leaving the house.

BACKGROUND: The built, social and economic environments are associated with disability, but knowledge of how these environmental characteristics simultaneously influence older adults' ability to shop independently is limited. OBJECTIVE: We investigated cross-sectional associations between the outdoor home, local neighborhood and macrosocioeconomic levels of the environment and shopping difficulty and interactions between environmental factors and shopping difficulty. METHODS: Using nationally representative data from a study of Medicare-eligible adults, we conducted a cross-sectional secondary data analysis to examine associations between the environment and difficulty shopping (N = 5504). RESULTS: Sidewalk conditions, broken steps, neighborhood social cohesion and neighborhood socioeconomic disadvantage were associated with more difficulty shopping, although health factors partially accounted for associations between broken steps and disadvantage and shopping difficulty. The association between social cohesion and shopping difficulty also depended on the degree of socioeconomic disadvantage in the neighborhood. CONCLUSIONS: Overall, results suggest that factors in the outdoor and local neighborhood environment influence the ability to shop independently for older adults, but that it also may depend on the socioeconomic context of the neighborhood. Interventions aimed at improving the built environment directly outside of older adults' homes and helping increase social cohesion among neighbors, has the potential to reduce difficulty in carrying out this important activity. Implications for rehabilitation Built features of the outdoor home environment including sidewalks and broken steps influence whether older adults are able to safely leave their home to conduct daily activities such as shopping, so it is important that clinicians and rehabilitation professionals are aware of these challenges when helping their patients resume daily activities such as shopping. The physical condition and safety of the immediate outdoor home and neighborhood environment is critical for maintaining independence and well-being for older adults, which is critical for physical rehabilitation as well as maintenance of essential activities such as shopping. Living in more socially cohesive neighborhoods may aid in physical rehabilitation efforts by helping older adults feel more comfortable and able to shop independently in neighborhoods with social and economic disadvantages.