Neighborhood racial income inequality and cognitive health.

INTRODUCTION: Neighborhood socioeconomic status (SES) has been linked to dementia, but the distribution of SES within a neighborhood may also matter. METHODS: Data from 460 (47% Black, 46% White) older adults from the Michigan Cognitive Aging Project were linked to census tract-level data from the National Neighborhood Data Archive (NaNDA). Neighborhood SES included two composites reflecting disadvantage and affluence. Neighborhood racial income inequality was the ratio of median incomes for White versus Black residents. Generalized estimating equations examined associations between neighborhood factors and cognitive domains. RESULTS: Neighborhood racial income inequality was uniquely associated with worse cognitive health, and these associations did not differ by participant race. Neighborhood disadvantage was only associated with worse cognitive health among Black participants. DISCUSSION: Both the level and racial distribution of SES within a neighborhood may be relevant for dementia risk. Racial differences in the level and impact of neighborhood SES contribute to dementia inequalities. HIGHLIGHTS: Black participants lived in neighborhoods with lower socioeconomic status (SES) than White participants, on average. Neighborhood SES and racial income inequality were associated with worse cognition. Effects of neighborhood racial income inequality did not differ across racial groups. Effects of neighborhood SES were only evident among Black participants.

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.

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.

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.

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 influence of walkability on broader mobility for Canadian middle aged and older adults: An examination of Walk Score™ and the Mobility Over Varied Environments Scale (MOVES).

Neighborhood built environments may play an important role in shaping mobility and subsequent health outcomes. However, little work includes broader mobility considerations such as cognitive ability to be mobile, social connections with community, or transportation choices. We used a population-based sample of Canadian middle aged and older adults (aged 45 and older) from the Canadian Community Health Survey-Healthy Aging (CCHS-HA, 2008-2009) to create a holistic mobility measure: Mobility over Varied Environments Scale (MOVES). Data from CCHS-HA respondents from British Columbia with MOVES were linked with Street Smart Walk Score™ data by postal code (n=2046). Mean MOVES was estimated across sociodemographic and health characteristics. Linear regression, adjusted for relevant covariates, was used to estimate the association between Street Smart Walk Score™ and the MOVES. The mean MOVES was 30.67 (95% confidence interval (CI) 30.36, 30.99), 5th percentile 23.27 (CI 22.16, 24.38) and 95th percentile was 36.93 (CI 35.98, 37.87). MOVES was higher for those who were younger, married, higher socioeconomic status, and had better health. In unadjusted models, for every 10 point increase in Street Smart Walk Score™, MOVES increased 4.84 points (CI 4.52, 5.15). However, results attenuated after adjustment for sociodemographic covariates: each 10 point increase in Street Smart Walk Score™ was associated with a 0.10 (CI 0.00, 0.20) point increase in MOVES. The modest but important link we observed between walkability and mobility highlights the implication of neighborhood design on the health of middle aged and older adults.

Developing a comprehensive measure of mobility: mobility over varied environments scale (MOVES).

BACKGROUND: While recent work emphasizes the multi-dimensionality of mobility, no current measure incorporates multiple domains of mobility. Using existing conceptual frameworks we identified four domains of mobility (physical, cognitive, social, transportation) to create a "Mobility Over Varied Environments Scale" (MOVES). We then assessed expected patterns of MOVES in the Canadian population. METHODS: An expert panel identified survey items within each MOVES domain from the Canadian Community Health Survey- Healthy Aging Cycle (2008-2009) for 28,555 (weighted population n = 12,805,067) adults (≥45 years). We refined MOVES using principal components analysis and Cronbach's alpha and weighted items so each domain was 10 points. Expected mobility trends, as assessed by average MOVES, were examined by sociodemographic and health factors, and by province, using Analysis of Variance (ANOVA). RESULTS: MOVES ranged from 0 to 40, where 0 represents individuals who are immobile and 40 those who are fully mobile. Mean MOVES was 29.58 (95% confidence interval (CI) 29.49, 29.67) (10th percentile: 24.17 (95% CI 23.96, 24.38), 90th percentile: 34.70 (CI 34.55, 34.85)). MOVES scores were lower for older, female, and non-white Canadians with worse health and lower socioeconomic status. MOVES was also lower for those who live in less urban areas. CONCLUSIONS: MOVES is a holistic measure of mobility for characterizing older adult mobility across populations. Future work should examine individual or neighborhood predictors of MOVES and its relationship to broader health outcomes. MOVES holds utility for research, surveillance, evaluation, and interventions around the broad factors influencing mobility in older adults.

A disadvantaged advantage in walkability: findings from socioeconomic and geographical analysis of national built environment data in the United States.

Urban form-the structure of the built environment-can influence physical activity, yet little is known about how walkable design differs according to neighborhood sociodemographic composition. We studied how walkable urban form varies by neighborhood sociodemographic composition, region, and urbanicity across the United States. Using linear regression models and 2000-2001 US Census data, we investigated the relationship between 5 neighborhood census characteristics (income, education, racial/ethnic composition, age distribution, and sex) and 5 walkability indicators in almost 65,000 census tracts in 48 states and the District of Columbia. Data on the built environment were obtained from the RAND Corporation's (Santa Monica, California) Center for Population Health and Health Disparities (median block length, street segment, and node density) and the US Geological Survey's National Land Cover Database (proportion open space and proportion highly developed). Disadvantaged neighborhoods and those with more educated residents were more walkable (i.e., shorter block length, greater street node density, more developed land use, and higher density of street segments). However, tracts with a higher proportion of children and older adults were less walkable (fewer street nodes and lower density of street segments), after adjustment for region and level of urbanicity. Research and policy on the walkability-health link should give nuanced attention to the gap between persons living in walkable areas and those for whom walkability has the most to offer.

The Impact of Weather on Mobility and Participation in Older U.S. Adults.

OBJECTIVES: We examined the impact of weather on the daily lives of US adults to understand which populations are most vulnerable to various weather conditions. METHODS: Data came from a 2013 supplement to the University of Michigan-Thomson Reuters Surveys of Consumers, a nationally representative telephone survey of 502 adults in the contiguous United States. We used logistic regressions to assess the odds of mobility difficulty and participation restriction during different weather conditions, as well as age group differences. RESULTS: Ice was most likely to change the way respondents got around (reported by 47%). In icy conditions, participants had difficulty leaving home (40%) and driving (35%). Facing ice, older adults (≥ 65 years) had twice the odds of having great difficulty leaving home (odds ratio [OR] = 2.22; 95% confidence interval [CI] = 1.12, 4.42) and curtailing work or volunteer activities (OR = 2.01; 95% CI = 1.01, 4.06), and 3 times the odds of difficulty driving (OR = 3.33; 95% CI = 1.62, 6.86) as younger respondents. We also found significant differences in mobility and participation by gender and region of residence. CONCLUSIONS: Weather can affect social isolation, health, well-being, and mortality among older US adults.

Changes in the built environment and changes in the amount of walking over time: longitudinal results from the multi-ethnic study of atherosclerosis.

Lack of longitudinal research hinders causal inference on the association between the built environment and walking. In the present study, we used data from 6,027 adults in the Multi-Ethnic Study of Atherosclerosis who were 45-84 years of age at baseline to investigate the association of neighborhood built environment with trends in the amount of walking between 2000 and 2012. Walking for transportation and walking for leisure were assessed at baseline and at 3 follow-up visits (median follow-up = 9.15 years). Time-varying built environment measures (measures of population density, land use, number of destinations, bus access, and street connectivity) were created using geographic information systems. We used linear mixed models to estimate the associations between baseline levels of and a change in each built environment feature and a change in the frequency of walking. After adjustment for potential confounders, we found that higher baseline levels of population density, area zoned for retail, social destinations, walking destinations, and street connectivity were associated with greater increases in walking for transportation over time. Higher baseline levels of land zoned for residential use and distance to buses were associated with less pronounced increases (or decreases) in walking for transportation over time. Increases in the number of social destinations, the number of walking destinations, and street connectivity over time were associated with greater increases in walking for transportation. Higher baseline levels of both land zoned for retail and walking destinations were associated with greater increases in leisure walking, but no changes in built environment features were associated with leisure walking. The creation of mixed-use, dense developments may encourage adults to incorporate walking for transportation into their everyday lives.

Social Integration among Adults Aging with Spinal Cord Injury: The Role of Features in the Built and Natural Environment.

A growing number of adults are aging with spinal cord injury (SCI) acquired earlier in life. Social integration is important for health and participation after SCI. However, little is known about the role of the community built environment for supporting social integration among adults aging with SCI. Using a structured telephone survey with 182 adults aging with SCI in the Midwestern United States, we found that more community built environment facilitators (e.g., curb cuts, automatic doors, paved surfaces) and fewer barriers (e.g., gravel surfaces, crowds) significantly increased the odds of regularly engaging in both formal and informal social activities.

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.

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.

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.

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.

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.

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.

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.

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.

"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.