1. Urban/Non-Urban Differences In Community Participation, Sense of Community, and Perceptions of the Environment among Individuals with Psychiatric Disabilities Greg Townley, PhD Eugene Brusilovskiy, M.U.S.A Mark S. Salzer, PhD For more information about this study or our center, please go to www.tucollaborative.org or send an email to eugeneby@temple.edu www.tucollaborative.orgeugeneby@temple.edu

2. Acknowledgment The contents of this presentation were developed under a grant from the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR; Grant # 90RT5021-02-00; Salzer, PI). However, the contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and endorsement by the Federal government should not be assumed.

3. Background There is a paucity of research on the impact of urbanicity on community living and participation experiences of adults with psychiatric disabilities (PD). Community participation (CP) and civic engagement Levasseur et al. (2015) found that CP of older adults did not differ across in metropolitan, urban and rural areas, but after controlling for potential confounders some differences were found. In more urban areas, higher CP was associated with greater proximity to neighborhood resources, while in rural areas, participation was associated with more years at residence CP may be more difficult for individuals with PD living in rural settings due to transportation barriers, greater stigma, and fewer community resources (McDonel et al., 1997). Greiner et al. (2004) found civic engagement (i.e., being active in a coalition or civic group) to be higher in rural areas compared to urban areas

4. Sense of community Rural and non-urban areas have traditionally been seen as offering higher levels of social capital, expressed through greater sense of community and social involvement (Hofferth & Iceland, 1998; Ziersch et al., 2009). Lower population density encourages connections between residents. Isolation and lower levels of public services in rural areas facilitate network cooperation, exchange, and voluntary activity (Ziersch et al., 2009). Stigma Older adults with untreated PD living in isolated rural counties had higher levels of perceived and internalized stigma than those in urban areas (Stewart et al., 2015). Cohesive social relations in rural settings can foster negative reactions to people with mental health problems due to fears of anything “out of the ordinary” (Wainer & Chesters, 2000) Background (Cont’d)

5. Perceptions of the built and social environment Very limited research comparing aspects of the built environment between urban and non-urban dwellers, particular among individuals with PD. – However, it is likely that individuals in urban settings will have more positive perceptions of their physical environments compared to non- urban dwellers due to greater proximity to resources and enhanced access/ walkability. Individuals in non-urban settings typically report stronger perceptions of safety and lower levels of crime compared to urban dwellers (Pain, 2000). Background (Cont’d)

6. Defining Urbanicity Here, we are utilizing two frequently used approaches to measure urbanicity: – U.S. Bureau of the Census provides block group (BG) level population density. In this study, urban census BGs have population density of 1000 people/mile 2 or more, and all surrounding BGs have a population density of 500 people/mile 2 or more Otherwise, BGs are non-urban – U.S. Department of Agriculture (USDA) uses Rural-Urban Continuum Codes (RUCCs), ranging from 1 (most urban) to 9 (most rural). County RUCCs are determined by population size and proximity to metropolitan areas. In this study, urban counties have RUCCs of 1 or 2 Non-urban counties have RUCCs of 3-9

7. We examine the relationships between urbanicity and a variety of community living and participation experiences. Because some community living experiences, such as CP and perceptions of the environment likely operate at an ecological level that is more proximal to individuals’ residences, we use U.S. Census (block group level) definition of urbanicity to test the following hypotheses: – H1: Individuals in urban settings will report higher rates of community participation than individuals in non-urban settings – H2: Individuals in urban settings will report more positive perceptions of the built environment than individuals in non-urban settings – H3: Individuals in urban settings will report lower perceptions of neighborhood safety compared to individuals in non-urban settings Research Hypotheses

8. As some community living experiences, such as sense of community, civic participation, and perceptions of stigma, likely operate at an ecological level that is more distal to participants’ homes, we use the USDA (county level) definition of urbanicity to test the following hypotheses: – H4: Individuals in urban settings will report higher rates of civic engagement than individuals in non-urban settings – H5: Individuals in non-urban settings will report higher levels of sense of community than individuals in urban settings – H6: Individuals in non-urban settings will report higher levels of perceived mental health stigma than individuals in urban settings Research Hypotheses (Cont’d)

9. Participants were 300 individuals with psychiatric disabilities receiving mental health services at 21 mental health agencies throughout the US – Average age: 46 (SD = 11.23) – 195 (65%) participants were white, while 105 (35%) were persons of color – 179 (60%) participants identified as female – 230 (77%) of participants reported a diagnosed mood disorder (e.g., major depression and bipolar disorder) – 128 (43%) of participants reported a diagnosed schizophrenia-spectrum disorder Participants

10. Community Participation: Modified, 22-item version of the Temple University Community Participation (TUCP) scale (Salzer, Brusilovkiy, Prvu- Bettger, & Kottsieper, 2014). Built Environment: 7-item version of the HES-Neighborhood Quality Scale (Kloos & Shah, 2009). Neighborhood Safety: 3-item version of the HES-Safety Scale (Kloos & Shah, 2009). Civic Engagement: Sum total of participation in three civic activities: donating money to charitable causes, voting, and protesting/ demonstrating. Sense of Community: Modified, 12-item version of the Sense of Community Index-2 (Chavis, Lee & Acosta, 2008). Stigma: 12-item Devaluation and Discrimination Scale (Link et al., 1989). Measures

11. After providing informed consent, individuals completed a paid phone survey including a series of questions about community participation, loneliness, perceptions of their neighborhoods, mental health symptoms, stigma, sense of community, and quality of life. Procedures

12. Levels of Urbanicity for Study Participants Census DefinitionUSDA (RUCC) Definition Our StudyUSA†Our StudyUSA ‡ Urban 71% (n=213)80%69% (n=207)76% Non-Urban 29% (n=87)20%31% (n=93)24% Notes: † http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/defined.html ‡ http://www.ers.usda.gov/data-products/rural-urban-continuum-codes/documentation.aspx

13. Participant Map

14. We examine the relationships between urbanicity and a variety of community living and participation experiences. Because some community living experiences, such as CP and perceptions of the environment likely operate at an ecological level that is more proximal to individuals’ residences, we use U.S. Census (block group level) definition of urbanicity to test the following hypotheses: – H1: Individuals in urban settings will report higher rates of community participation than individuals in non-urban settings – H2: Individuals in urban settings will report more positive perceptions of the built environment than individuals in non-urban settings – H3: Individuals in urban settings will report lower perceptions of neighborhood safety compared to individuals in non-urban settings Research Hypotheses

15. Results: Hypotheses 1-3 Urban (n = 213) Non-urban (n = 87) T-Test Cohen’s d MeanS.D.MeanS.D.tP H1: Community Participation TUCP- total # of participation days53.9742.842.9832.22.57<.050.31 TUCP- total #of participation areas7.823.416.923.342.07<.050.27 H2: Built Environment (Neighborhood Quality) 3.550.743.360.682.09<.050.26 H3: Social Environment (Neighborhood Safety) 3.290.933.510.8-1.98<.050.25 Block Group Level Definition of Urbanicity from the U.S. Census is used here.

16. County Level (RUCC) Definition of Urbanicity from the USDA is used here. Results: Hypotheses 4-6 Urban (n = 213) Non-urban (n = 87) T-Test Cohen’s d MeanS.D.MeanS.D.tP H4: Civic Engagement0.79 0.560.652.42<.050.32 H5: Sense of Community2.520.752.220.693.29<.010.42 H6: Perceived Stigma3.560.983.880.98-2.56<.050.33

17. This study represents one of the first attempts to assess the impact of urbanicity on important community inclusion experiences for adults with psychiatric disabilities We found that participants in urban settings reported higher levels of community participation compared to individuals in non-urban settings. – This is in line with our expectations and is likely a result of individuals in urban settings having greater access to stores, services, and other activity locations; as well as greater access to resources such as transportation and walkable roadways. We also found that participants in urban settings reported more positive perceptions of the built environment but lower perceptions of neighborhood safety. This is consistent with our hypotheses as well as findings in the literature. As expected, civic engagement was higher among participants living in urban counties, while perceptions of mental health stigma were stronger among individuals in non-urban counties. Discussion

18. Contrary to our hypothesis and suggestions in the literature, we found that individuals living in urban counties had higher rates of sense of community than individuals in non-urban counties. – It is likely that sense of community and social capital operate differently for individuals with psychiatric disabilities compared to members of the general population due to factors such as increased isolation, marginalization and societal stigma of mental illness. Future studies should include more objective indicators of the environment, including population demographics from the Census, neighborhood walkability, access to transportation, and distance from participant residences to various community resources. Environmental influences on community living and participation experiences of individuals with PD is an understudied area. This study illuminates important differences between individuals residing in urban and non-urban areas and informs targets for interventions aimed at increasing community participation, sense of community, and aspects of the built and social environment. Discussion (Cont’d)

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