Perceived Physical and Social Residential Environment and Preterm Delivery in African-American Women

Abstract

Perceptions of the residential environment may be associated with preterm delivery (PTD), though few studies exist. Data from the Life-course Influences on Fetal Environments (LIFE) Study (metropolitan Detroit, Michigan, 2009–2011) were used to examine whether perceptions of the current social and physical environment were associated with PTD rates among postpartum African-American women (n = 1,411). Perceptions of the following neighborhood characteristics were measured with validated multi-item scales: healthy food availability, walkability, safety, social cohesion, and social disorder. No significant associations between perceived residential environment and PTD were found in the total sample. However, education significantly modified 4 of the 5 associations (all interaction P's < 0.05). In women with ≤12 years of education, significant inverse associations were observed between PTD rates and perceptions of the following neighborhood characteristics: healthy food availability (unadjusted prevalence ratio (uPR) = 0.81, 95% confidence interval (CI): 0.68, 0.98), walkability (uPR = 0.77, 95% CI: 0.64, 0.95), and safety (uPR = 0.73, 95% CI: 0.56, 0.95). Women with ≤12 years of education also had higher PTD rates with higher social disorder (age-adjusted PR = 1.54, 95% CI: 1.10, 2.17). Null associations existed for women with >12 years of education. The PTD rates of women with lower education may be significantly affected by the physical and social residential environment.

Preterm delivery (PTD), or delivery before 37 completed weeks of gestation, is a leading cause of infant death in the United States (1). Approximately 1 of every 6 infants born to African-American mothers is preterm (2). In 2012, the proportion of PTDs among African-American women was 1.6 times higher than that in whites (2). The long-standing racial disparity in PTD risk is not explained by traditional individual-level risk factors but may be partly attributable to complex mechanisms related to social inequities (3). For instance, African Americans, compared with whites, are more likely to reside in inadequate and adverse environments (4, 5).

It has been reported that objectively defined adverse residential environments are associated with adverse birth outcomes, including PTD (6). While US Census-derived data were used to establish early links between neighborhoods and adverse health outcomes, they offer little insight into which specific features of neighborhoods may be detrimental or the mechanisms through which these factors might affect PTD (7, 8). Further, Census measures of residential environment may be unequal proxies for “neighborhood” and “community,” and their spatial boundaries may not overlap with residents' perceptions (9, 10).

Even though objective measures of a residential environment influence residents' perceptions of the neighborhood context (11), subjective measures of a residential environment may provide importantly different information. For example, subjective measures may identify specific features of the physical and social environment that link neighborhoods to PTD. Subjective measures operate through the cognitive processes of individuals and may influence health through several pathways, including stress, psychological factors, and/or behavioral choices (12). It has also been hypothesized that subjective measures are more proximal determinants of health than objective measures (13).

Physical and social residential environments are distinct, though not mutually exclusive. The term “social environment” refers to the extent of neighborhood unity or disorganization, standards of reciprocity, community involvement, crime, socioeconomic makeup, and residential stability, whereas “physical environment” encompasses exposures to environmental health hazards, noise, and air pollution, as well as housing quality and community space (14).

While subjective measures are theoretically relevant predictors of PTD, the literature on associations between perceptions of physical and social residential environment and PTD in African Americans is limited to 2 studies whose results did not reach significance (15, 16). Even though few studies have examined the impact of both physical and social residential environment on PTD, it is plausible that they act contemporaneously to affect PTD, especially among high-risk groups. Therefore, our primary objective was to examine whether perceptions of neighborhood physical and social environment are associated with PTD rates among African-American women. Given that social causes of PTD may be interactive (17), we secondarily sought to test whether education modifies associations between subjective reports of residential environment and PTD. Effect modification may indicate that some groups are more vulnerable to, or buffered against, toxic conditions and/or that certain groups may report context differently (18).

METHODS

Study design

The Life-course Influences on Fetal Environments (LIFE) Study is a retrospective cohort study of the association between racism and PTD among African-American women. Enrollment occurred from 2009 to 2011. The primary objective of the study was to determine how racism is associated with PTD. Self-identified African-American women (≥18 years old) from the Detroit, Michigan, metropolitan area giving birth to singleton infants were recruited at a hospital in Oakland County, Michigan. Women were excluded from the study if they 1) did not speak English; 2) had intellectual disabilities, serious cognitive deficits, or significant mental illness, on the basis of medical history or any prior records; or 3) were currently incarcerated. In-person interviews were conducted during women's postpartum hospital stay, and medical history was abstracted from medical records. The final sample included 1,411 women, which represented 71% of the women approached for study participation. One woman was missing gestational age information and was excluded from the analysis.

The study protocol was approved by the institutional review boards at participating sites. All study participants gave written informed consent.

Outcome ascertainment

PTD was defined as delivery prior to 37 completed weeks of gestation. Gestational age was estimated from the medical record in a hierarchical fashion, with priority given to the provider's estimate of gestational age based on early ultrasound (between 6 and 20 weeks' gestation) (19). Early ultrasound estimates of gestational age (n = 692) were compared with other estimates, including date of the last menstrual period. In cases of inconsistency, the estimate based on the early ultrasound was used, unless it was implausible. When a gestational age estimate based on an early ultrasound was not available, the date of the last menstrual period was used (n = 465). In rare cases where both the early ultrasound and last menstrual period estimates of gestational age were missing or implausible, we used the provider's estimate from a late ultrasound (taken after 20 weeks' gestation) (n = 169) or the provider's estimate of gestational age at birth (n = 62), or the gestational age from the medical record at birth, if all else was missing (n = 22).

Perceived physical and social residential environment

Women reported characteristics of their current neighborhood (defined as “the area around where you live and around your house”) using valid, reliable multi-item scales. We created 5 neighborhood variables by summing the individual items for each of the following measures: social cohesion and trust (20–22), healthy food availability (21, 22), walking environment (21–23), social disorder (22), and danger/safety (21, 22, 24). Specific scale details are presented in Appendix Table 1. Reverse coding was performed as necessary for neighborhood questions, such that higher scale values indicated a better environment for all scales, except for disorder (higher values = more disorder). Internal consistency reliability of the scales was assessed with a standardized Cronbach's α (Table 1).

Table 1.

Results of Psychometric Analyses for 5 Scales Assessing the Association Between Neighborhood Physical and Social Environment and Preterm Delivery (n = 1,411), LIFE Study, Detroit, Michigan, 2009–2011

Scalea	Range of Scores	Mean Scale Score (SD)		Cronbach's α
		Term Delivery (n = 1,179)	Preterm Delivery (n = 231)
Social cohesion and trust	7–35	24.1 (4.8)	24.3 (4.9)	0.84
Healthy food availability	2–10	7.4 (2.2)	7.3 (2.2)	0.91
Walking environment	6–30	23.3 (4.1)	23.1 (4.1)	0.78
Social disorder	8–24	11.7 (4.6)	11.9 (4.7)	0.93
Danger and safety	6–30	21.3 (5.5)	20.8 (5.5)	0.90

Abbreviations: LIFE, Life-course Influences on Fetal Environments; SD, standard deviation.

^a For specific components of each scale, see Appendix Table 1.

Effect modifier

We tested whether a woman's self-reported educational attainment (defined as ≤12 years vs. >12 years) modified the associations between subjective residential environment and PTD. Our education variable reflected the highest level of education and accounted for multiple sources, including: number of completed years, year of high school graduation, alternative education (i.e., general equivalency, career academies, and technical training), and traditional college attendance and graduation. Cutpoints for education and other variables in this analysis were based on the sample distributions.

Potential confounders

The following self-reported variables were considered potential confounders because they were associated with PTD in our sample and/or were identified in the literature on neighborhoods and PTD: income (<$35,000/year, ≥$35,000/year), age (<35 years, ≥35 years), and marital status (married, not married).

Statistical analysis

Univariate and bivariate statistics were used to describe the data, with Wilcoxon rank-sum and χ² tests used to assess group differences for continuous and categorical variables, respectively. Pearson correlations were estimated among neighborhood variables. We estimated prevalence ratios for PTD and associated 95% confidence intervals, using log-binomial regression models, for each model separately (25). In order to interpret our results as the PTD rate among women in the 75th percentile of the distribution for each neighborhood scale versus women in the 25th percentile, we rescaled the continuous exposure variables by dividing by their corresponding interquartile range. On the basis of our causal model (Figure 1), the association between perceptions of the neighborhood and PTD could be confounded by age, income, and marital status, could partially operate through mental health, and could vary by educational attainment. The 10% change-in-estimate criterion identified confounders (26). All variables were assessed for missing data, and listwise deletion was employed. The proportion of missing data was low for most variables, although income was missing for 11% of the sample (n = 155); in log-binomial models adjusting for income, the sample size was 1,256. In a sensitivity analysis, we used a sequential regression multivariate imputation method (IVEware (http://www.isr.umich.edu/src/smp/ive/)) for missing income, using 20 replicate data sets (27). Potential moderation by educational attainment of the associations between perceived physical and social residential environment and PTD was assessed with an interaction term (each tested separately) for interaction between education and each neighborhood scale in separate log-binomial models. For models stratified by educational attainment, unadjusted results are presented (except for disorder-PTD, which was adjusted for age); because the variability of other socioeconomic variables (like income and marital status) was reduced in educational strata, these variables were not controlled. For stratified models, education-specific interquartile ranges were used for rescaling exposure variables. Nonpositivity—the situation where certain segments of the study population experience only 1 level of the exposure (7, 28, 29)—is often ignored in observational studies (30). As a result, we checked our data for violations of positivity by examining the tabular distributions of quintiles of each neighborhood scale by educational attainment (≤12 years vs. >12 years). Two-sided P values less than 0.05 and 95% confidence intervals (for the prevalence ratios) that excluded 1 were considered significant. All analyses were conducted using SAS, version 9.3 for Windows (SAS Institute, Inc., Cary, North Carolina).

Figure 1.

A causal model of the association between perceptions of the residential environment and preterm delivery.

RESULTS

Table 1 shows descriptive statistics for the 5 neighborhood variables. Internal consistency reliability was high for each scale. There was no significant difference in the mean value for each scale, comparing term deliveries (n = 1,179) with preterm deliveries (n = 231). Pearson correlations among the different neighborhood scales were moderate, with the strongest correlation being that between disorder and safety (−0.68), followed by walkability and safety (0.61) (not shown). Further, walkability was similarly correlated with disorder and food availability (both approximately 0.50), while correlations between social cohesion and food availability were weaker (0.26) (not shown).

Table 2 shows the demographic characteristics of study participants. The mean age of the study participants was 27 years; more than half of the women were married or cohabitating, and more than 70% had >12 years of education. Considering only the number of completed years of education, the distribution of women in the lower education group was as follows: 7–8th grade, 4 women; 9–10th grade, 37 women; 11th grade, 102 women; and 12th grade, 307 women (not shown). Significant heterogeneity existed for type of education (i.e., traditional brick-and-mortar college, online career academy, technical school, etc.) among persons reporting >12 years of education (not shown). Women who reported an annual income of <$35,000 had a nonsignificant increase in PTD rates (29%) compared with women of higher income. The median amount of time that the women had resided in their current neighborhood was 2 years, and nearly 50% resided in the city of Detroit. Neither length of time in the current neighborhood nor city of residence was significantly associated with PTD rates. We confirmed positivity, in that individuals with ≤12 years and >12 years of education were represented across the entire range of each neighborhood scale variable (not shown).

Table 2.

Demographic Characteristics of Study Participants and Prevalence Ratios From Bivariate Log-Binomial Regression Models of Neighborhood Physical and Social Environment and Preterm Delivery (n = 1,411), LIFE Study, Detroit, Michigan, 2009–2011^a

Characteristic	Term Delivery (n = 1,179)		Preterm Delivery (n = 231)		Prevalence Ratio	95% Confidence Interval
	No.	%	No.	%
Age, years
18–19	104	8.8	15	6.5	0.87	0.51, 1.48
20–24	358	30.4	75	32.5	1.20	0.87, 1.65
25–29	319	27.0	54	23.4	1	Referent
30–34	227	19.3	43	18.6	1.10	0.76, 1.59
≥35	171	14.5	44	19.0	1.41	0.99, 2.03
Marital status
Single	549	46.9	106	46.3	1	Referent
Married or cohabitating	621	53.1	123	53.7	1.02	0.81, 1.30
Education, years
≤12	334	28.3	64	27.7	1	Referent
>12	845	71.7	167	72.3	1.03	0.79, 1.34
Annual incomeb
<$35,000	537	51.4	125	59.0	1.29	1.00, 1.66
≥$35,000	507	48.6	87	41.0	1	Referent
Urbanicity of residence
City of Detroit	557	49.1	109	48.7	0.99	0.78, 1.25
Detroit suburb	578	50.9	115	51.3	1	Referent
Duration of residence in current neighborhood, months
≤24	671	56.9	130	56.3	1	Referent
>24	508	43.1	101	43.7	0.98	0.78, 1.24

Abbreviation: LIFE, Life-course Influences on Fetal Environments.

^a One woman was missing data on gestational age, and 155 women were missing data on income.

^b Because of listwise deletion, the sample size was 1,256.

Table 3 shows the results of log-binomial regression analyses assessing the relationship between PTD rates among women in the 75th percentile of each physical and social residential environment scale versus women in the 25th percentile, overall and by education. In the total sample, none of the 5 neighborhood variables were associated with PTD in bivariate or adjusted models. We then tested whether educational attainment modified the associations between residential environment and PTD. The P values for interactions between education and walkability, food availability, safety, and disorder were all less than 0.05. In models stratified by education, we found no significant associations between subjective residential environment and PTD among women with >12 years of education. However, among women with ≤12 years of education, PTD rates were significantly lower with higher perceptions of walkability (prevalence ratio (PR) = 0.77, 95% confidence interval (CI): 0.64, 0.95), food availability (PR = 0.81, 95% CI: 0.68, 0.98), and safety (PR = 0.73, 95% CI: 0.56, 0.95). Further, in women with ≤12 years of education, higher perceived disorder was associated with significantly higher rates of PTD (age-adjusted PR = 1.54, 95% CI: 1.10, 2.17). Lastly, we found no associations between perceived neighborhood cohesion and PTD, either overall or in education-specific models. Results using imputed income were comparable (not shown).

Table 3.

Prevalence Ratios for Preterm Delivery in the 75th Percentiles of 5 Physical and Social Residential Environment Scales Versus the 25th Percentiles (Log-Binomial Regression Analyses), Overall and by Education, LIFE Study, Detroit, Michigan, 2009–2011

Scalea	Total Sample (n = 1,256)b				Educational Statusc
	Unadjusted		Adjustedd		No College (n = 399)		Some College (n = 1,012)		P for Interactione
	PR	95% CI	PR	95% CI	PR	95% CI	PR	95% CI
Walkability	0.93	0.80, 1.07	0.92	0.79, 1.07	0.77	0.64, 0.95	1.02	0.86, 1.21	0.03
Food	0.95	0.82, 1.11	0.96	0.82, 1.13	0.81	0.68, 0.98	1.06	0.88, 1.29	0.03
Safety	0.91	0.79, 1.06	0.91	0.78, 1.06	0.73	0.56, 0.95	1.01	0.84, 1.22	0.04
Cohesion	1.08	0.77, 1.53	1.04	0.73, 1.45	0.95	0.46, 1.99	1.18	0.73, 1.90	0.64
Disorder	1.06	0.92, 1.24	1.05	0.89, 1.23	1.54	1.10, 2.17	0.95	0.80, 1.12	0.02

Abbreviations: CI, confidence interval; LIFE, Life-course Influences on Fetal Environments; PR, prevalence ratio.

^a For specific components of each scale, see Appendix Table 1.

^b For analyses of the total sample, 155 persons missing information on income were excluded; as a result, the sample size was 1,256.

^c In the models stratified by education, results for disorder were adjusted for age; results for all other scales were unadjusted.

^d In analyses of the total sample, results for walkability were adjusted for income; results for food were adjusted for marital status and income; results for safety were adjusted for income; results for cohesion were adjusted for age and income; and results for disorder were adjusted for age and income.

^e Interaction between education and the respective neighborhood scale.

As we noted in our causal model, we postulated that depressive symptoms would be a mediator and not a confounder. However, as a sensitivity analysis, we tested an alternative causal model that considered depressive symptoms as a cause of both neighborhood perceptions and PTD. Under this model specification, we adjusted our models for depressive symptoms using the Center for Epidemiologic Studies Depression Scale (dichotomized at >23 points) and found significant attenuation of estimates (from 35% for disorder to 84% for food availability).

DISCUSSION

To our knowledge, we are the first investigators to report significant associations between PTD and subjective aspects of the residential environment in the less educated subset of our African-American sample. Specifically, we found that among women without a postsecondary education, those who reported better residential environments, in terms of walkability, food availability, safety, and lower disorder, had significantly lower PTD rates. No significant associations between subjective residential environment and PTD were found for women with >12 years of education. The results of existing studies of the association between perceived residential environment and PTD among African Americans were in the expected direction but nonsignificant. For example, Dole et al. (15) found that white women who perceived their neighborhoods as unsafe had a nonsignificant increase in risk of PTD compared with those who perceived their neighborhoods as safe (relative risk = 1.4, 95% CI: 0.9, 2.3). However, perceived neighborhood safety was not associated with PTD in analyses restricted to African-American women. Giurgescu et al. (16) also did not find a significant relationship between perceived neighborhood disorder or crime and PTD in a sample of 72 African-American women. However, these studies did not examine potential effect modification by educational attainment of the association between neighborhood perceptions and PTD. We also found null associations between subjective residential environment and PTD in the overall sample. Our results suggest that PTD rates in women with lower educational status may be more sensitive to neighborhood context than those of women with higher levels of education.

This effect modification by education aligns with other evidence that socioeconomic status, age, race, or sex may affect perceptions of neighborhoods (31). Individuals living in the same neighborhood can perceive and experience their neighborhood differently (18). It is therefore not surprising that PTD rates among women with low educational attainment would be affected by perceptions of the residential environment, while no such association was found in college-educated women. In a study that investigated associations between objective indicators of neighborhood disadvantage and perceptions of danger in neighborhoods, less educated individuals perceived more danger than those with more education (18). It may be that women who are less educated are more susceptible to the stress induced by residing in an adverse neighborhood, whereas women with higher levels of education may have more capacity to buffer such stressful conditions.

It is unclear why we observed significant associations between PTD and 4 of the neighborhood scales but no associations for social cohesion and trust. “Social cohesion and trust” refers to the degree of connectedness, shared resources, and reciprocal moral support among groups of individuals (32), and it differs from our other neighborhood scales by its explicit focus on social relationships. As has been reported in other studies (33), we observed significant correlations of perceived cohesion with disorder and safety. However, despite the correlations, perceptions of cohesion and trust may be less relevant to PTD. Future studies among African-American women may provide more insight into how cohesion, disorder, and safety overlap and interact at the neighborhood level, and how they impact health in general and birth outcomes in particular.

PTD is thought to be a syndrome, with multiple mechanisms and causes (34). Since most spontaneous PTDs do not have an apparent etiology (34), more research on maternal characteristics, including stress during pregnancy and throughout the life course, is warranted, especially given that the level of psychosocial stress experienced by women is modified by their social and economic position (35). For African-American women, psychological processes may better explain stress-related differences in adverse birth outcomes than do behavioral risk factors, especially since the racial disparity is not completely attributed to behavioral influences (36). Exposure to stress as a result of major life events, chronic strain, residential environment, and several sources simultaneously have all been shown to be independent risk factors for PTD (37) and may operate through any of several physiological pathways, including neuroendocrine pathways (38), systemic immune cell activation (38), and vascular pathologies (36).

Assuming that stress may be one mechanism linking subjective reports of the residential environment and PTD, it would be important for future researchers to investigate how women cope with stress during pregnancy and to help them increase their coping skills (39). In the only prospective study carried out a large cohort, Dole et al. (15) reported higher PTD risk for African-American women who minimized or detached from the source of stress. Even though Lazarus and Folkman (40), who pioneered the study of coping, were clear that this type of work should take place within the milieu of a specific stressful circumstance, most of the existing literature has failed to determine the sources of stress most pertinent to pregnant women. Results from qualitative studies should be able to identify which stress-managing techniques African-American women utilize. For instance, Abdou et al. (41) reported that low-income minority women used time with friends for venting emotions and laughing as a way to cope with stressors. Unfortunately, the coping skills most relevant to minority women are not represented in the standard coping assessment tools. In our study, women with >12 years of education appeared to be resilient against the potential negative influences of their residential environment, which may have been due, at least in part, to their personal characteristics and/or resources (e.g., psychosocial resources or social networks).

Our study has several strengths that distinguish it from the existing literature. To our knowledge, we are the first to report moderation by educational status of the association between subjective features of the residential environment and PTD rates among African-American women. Next, we recruited women in the immediate postpartum period (before hospital discharge), which allowed us to include women who received late or no prenatal care, as well as earlier yet interrupted or sporadic care—as compared with other studies of birth outcomes, which recruited women during pregnancy. Our approach increased the likelihood of heterogeneity of PTD risk in the cohort, as well as the generalizability of our findings. Although the racial disparity in PTD has been well documented, few studies have used primary data collection for social risk factors that might be most relevant for African-American women. While our results fill a gap in the literature in terms of identifying a potential preventive factor in a high-risk racial group, these results may have broader implications that extend to all women, despite race/ethnicity.

In interpreting the results of this study, several limitations should be considered. The generalizability of our results may be limited to women with similar ethnic, socioeconomic, and residential characteristics, especially given that the study participants were recruited from 1 hospital. If women with PTD differentially report exposures, recall bias would be an issue. However, in studies of congenital malformations specifically designed to evaluate the potential for recall bias related to adverse outcomes, little evidence of recall bias has been found in mothers' exposure reports (42–44). Further, in previous work by our group, we have demonstrated no evidence of recall bias with regard to a range of social and psychosocial environmental factors (45). However, given that 18% of the births taking place in Detroit, Michigan, are preterm (which is one of the highest rates in the United States) (46), the intractable and persistent PTD disparity among African-American women (2), and the adverse political, population, and economic patterns of this area (47), more research on this population is warranted. Our results were sensitive to our specification of the causal model; however, growing evidence suggests that depressive symptomology is downstream of neighborhood features (48–50). As a result, adjustment of the association between perceived neighborhood context and PTD by depressive symptomology would overcontrol and result in bias towards the null (39). Women may have lived in other neighborhoods prior to or during the index pregnancy and may have experienced different stressors while living in those neighborhoods. Because of the retrospective nature of our study, we were not able to analyze changes in residence over time or make causal inferences. It is also possible that results from our overall and stratified analyses were confounded by predictors of residential selection (51). For the former models, we assessed confounding by several predictors of neighborhood moves (including age, marital status, and income) and found that few of these variables consistently confounded the associations of interest. While education is often categorized as <12 years, 12 years, and >12 years, more than 70% of our study population reported >12 years of education, which precluded further stratification in the lower-education group. We also did not adjust for income or marital status in these models because of insufficient variability in these potential confounders within educational strata. It is also possible that women with higher and lower educational attainment live in neighborhoods with different levels of adversity; however, in our study, we observed sufficient numbers of women within both education strata, across the entire range of each neighborhood scale. Finally, only 25% of the PTDs (n = 58) were medically indicated, which precluded us from considering potential effect modification of perceived residential environment and PTD by the circumstance initiating delivery. When we excluded the women with medically indicated PTDs, only perceptions of disorder remained a significant predictor among women with ≤12 years of education. However, there is no consensus in the literature about whether subtypes of PTD truly differ in terms of etiology (52).

In summary, our findings suggest that the association of perceived residential environment with PTD may vary by educational status. Specifically, PTD rates in women with ≤12 years of education may be significantly affected by perceptions of their neighborhood. If we are to understand the causes of disparate birth outcomes in this high-risk population, a deeper understanding of the complex and dynamic relationships between individual and environmental factors is necessary.

Appendix Table 1.

Statements and Questions Used to Assess Perceptions of the Physical and Social Residential Environment in the LIFE Study (n = 1,411), Detroit, Michigan, 2009–2011

Social cohesion and trust (4-point Likert scale: strongly agree, agree, disagree, strongly disagree)

1. I live in a close-knit neighborhood.

2. People in my neighborhood are willing to help their neighbors.

3. People in my neighborhood generally don't get along with each other.

4. People in my neighborhood do not share the same values.

5. People in my neighborhood can be trusted.

Healthy food availability (4-point Likert scale: strongly agree, agree, disagree, strongly disagree)

1. A large selection of fresh fruits and vegetables is available in my neighborhood.

2. A large selection of low-fat products is available in my neighborhood.

Walkability (4-point Likert scale: strongly agree, agree, disagree, strongly disagree)

1. It is pleasant to walk in my neighborhood.

2. The trees in my neighborhood provide enough shade.

3. In my neighborhood it is easy to walk to places.

4. I often see other people walking in my neighborhood.

5. I often see other people exercise in my neighborhood.

6. There are stores within walking distance of my home.

Social disorder (3-point Likert scale: a big problem, somewhat of a problem, not a problem)

1. How much of a problem is litter, broken glass, or trash on the sidewalks and streets?

2. How much of a problem is graffiti on buildings and walls?

3. How much of a problem are vacant or deserted houses or storefronts?

4. How much of a problem is drinking in public?

5. How much of a problem is people selling or using drugs?

6. How much of a problem are groups of teenagers or adults hanging out in the neighborhood and causing trouble?

7. How much of a problem is noise in the neighborhood?

8. How much of a problem is yelling or fighting?

Danger and safety (5-point Likert scale: strongly agree, agree, neither agree nor disagree, disagree, strongly disagree)

1. Many people in your neighborhood are afraid to go outside at night.

2. There are areas of this neighborhood where everyone knows “trouble” is expected.

3. You're taking a big chance if you walk in this neighborhood alone after dark.

4. I feel safe walking in my neighborhood.

5. Violence is a problem in my neighborhood.

6. I feel very safe from crime in my neighborhood.

Abbreviation: LIFE, Life-course Influences on Fetal Environments.