Direct and Indirect Associations Between the Built Environment and Leisure and Utilitarian Walking in Older Women.

BACKGROUND: The built environment predicts walking in older adults, but the degree to which associations between the objective built environment and walking for different purposes are mediated by environmental perceptions is unknown. PURPOSE: We examined associations between the neighborhood built environment and leisure and utilitarian walking and mediation by the perceived environment among older women. METHODS: Women (N = 2732, M age = 72.8 ± 6.8 years) from Massachusetts, Pennsylvania, and California completed a neighborhood built environment and walking survey. Objective population and intersection density and density of stores and services variables were created within residential buffers. Perceived built environment variables included measures of land use mix, street connectivity, infrastructure for walking, esthetics, traffic safety, and personal safety. Regression and bootstrapping were used to test associations and indirect effects. RESULTS: Objective population, stores/services, and intersection density indirectly predicted leisure and utilitarian walking via perceived land use mix (odds ratios (ORs) = 1.01-1.08, 95 % bias corrected and accelerated confidence intervals do not include 1). Objective density of stores/services directly predicted ≥150 min utilitarian walking (OR = 1.11; 95% CI = 1.02, 1.22). Perceived land use mix (ORs = 1.16-1.44) and esthetics (ORs = 1.24-1.61) significantly predicted leisure and utilitarian walking, CONCLUSIONS: Perceived built environment mediated associations between objective built environment variables and walking for leisure and utilitarian purposes. Interventions for older adults should take into account how objective built environment characteristics may influence environmental perceptions and walking.

Spatial heterogeneity in repeated measures of perceived stress among car commuters in Scania, Sweden.

BACKGROUND: Long commutes by car are stressful. Most research studying health effects of commuting have summarized cross-sectional data for large regions. This study investigated whether the levels of stress and individual characteristics among 30-60 min car commuters were similar across different places within the county of Scania, Sweden, and if there were changes over time. METHODS: The study population was drawn from a public health survey conducted in 2000, with follow-ups in 2005 and 2010. The study population was selected from the 8206 study participants that completed the questionnaire at all three time points. Commuting questions in the 2010 questionnaire assessed exposure concurrently for that year and retrospectively for 2000 and 2005. In total, 997 persons aged 18-65 and working 15-60 h/week had commuted by car 30-60 min at least at one time point. Geographically weighted proportions of stress among 30-60 min car commuters were calculated for each year and classified into geographically continuous groups based on Wards algorithm. Stress levels, sociodemographic characteristics and commuting characteristics were compared for areas with high and low stress in relation to the rest of the county. This novel methodology can be adapted to other study settings where individual-level data are available over time. RESULTS: Spatial heterogeneity in stress levels was observed and the locations of high and low stress areas changed over time. Local differences in stress among participants were only partly explained by sociodemographic characteristics. Stressed commuters in the high stress area in 2000 were more likely to maintain their commuting mode and time than those not stressed. Stressed commuters in the high stress area in 2000 were also more likely to have the same workplace location in 2010, while stressed commuters in the high stress area in 2010 were more likely to have the same residential location as in 2000. CONCLUSION: The relationship between commuting mode and time and stress is variable in place and time. Better understanding of commuting contexts such as congestion is needed in research on the health effects of commuting.

Relations of Neighborhood Environment Influences, Physical Activity, and Active Transportation to/from School across African American, Latino American, and White Girls in the United States.

BACKGROUND: Neighborhood environment influences may be particularly important for understanding physical activity (PA) patterns across ethnic subgroups of early adolescent girls. PURPOSE: This study examined relationships between neighborhood variables, moderate to vigorous physical activity (MVPA), and active transportation to/from school across African American, Latino American, and White early adolescent girls living in an urban/suburban community in the northwestern U.S.A. Relations between the neighborhood variables across ethnic groups also were examined. METHOD: The sample comprised 372 African American, Latino American, and White girls living in the U.S.A. (mean age = 12.06 years; SD = 1.69). RESULTS: Data were analyzed using multiple-sample structural equation modeling. Results showed that girls' MVPA was positively related to physical activity facility accessibility and negatively related to age. Active transport was positively related to physical activity facility accessibility, neighborhood walkability, and age, and negatively related to distance to the nearest school and household income. CONCLUSIONS: Findings highlight the importance of both perceived and objective neighborhood influences on girls' MVPA and active transport. Consistencies in findings across African American, Latino American, and White girls suggest that neighborhood-level PA promotion has the potential for broad impact across all three ethnic groups.

Density and proximity of fast food restaurants and body mass index among African Americans.

OBJECTIVES: The purpose of this study was to address current gaps in the literature by examining the associations of fast food restaurant (FFR) density around the home and FFR proximity to the home, respectively, with body mass index (BMI) among a large sample of African American adults from Houston, Texas. METHODS: We used generalized linear models with generalized estimating equations to examine associations of FFR density at 0.5-, 1-, 2-, and 5-mile road network buffers around the home with BMI and associations of the closest FFR to the home with BMI. All models were adjusted for a range of individual-level covariates and neighborhood socioeconomic status. We additionally investigated the moderating effects of household income on these relations. Data were collected from December 2008 to July 2009. RESULTS: FFR density was not associated with BMI in the main analyses. However, FFR density at 0.5, 1, and 2 miles was positively associated with BMI among participants with lower incomes (P ≤ .025). Closer FFR proximity was associated with higher BMI among all participants (P < .001), with stronger associations emerging among those of lower income (P < .013) relative to higher income (P < .014). CONCLUSIONS: Additional research with more diverse African American samples is needed, but results supported the potential for the fast food environment to affect BMI among African Americans, particularly among those of lower economic means.

Exploring inter-rater reliability and measurement properties of environmental ratings using kappa and colocation quotients.

BACKGROUND: Available evidence suggest that perceptions or ratings of the neighborhood, e.g. as being green, walkable or noisy, are important for effects on health and wellbeing, also after controlling for objective measures of identical or similar features. When evaluating effects of the perceived environment, it is important that measurement properties and the reliability of the environmental ratings are evaluated before decisions about how these ratings should be handled in the statistical analyses are made. In this paper we broaden the usage of two association measures, the well-known kappa statistic and the novel colocation quotient (CLQ), to studies of inter-rater reliability and of associations between different categorical ratings in spatial contexts. METHODS: We conducted reliability analysis of a survey instrument for assessing perceived greenness at geographical point locations, here the close outdoor environment within 5-10 minutes walking distance from home. Data were obtained from a public health survey conducted in 2008 in Scania, southern Sweden (n =27 967 participants). RESULTS: The results demonstrate the usefulness of kappa and CLQ as tools for assessing reliability and measurement properties of environmental rating scales when used at geographical point locations. We further show that the two measures are interchangeable, i.e. kappa can be accurately approximated from CLQ and vice versa, but can be used for somewhat different purposes in reliability analyses. Inter-rater reliability between the nearest neighbors was demonstrated for all five items of the evaluated instrument for assessing perceived greenness, albeit with clear differences across the items. CONCLUSION: Reliability analysis employing kappa and CLQ can be used as a basis for informed decisions about, for instance, how dichotomizations of the ratings should be defined and how missing or indefinite ratings should be handled. Such reliability analyses can thus serve as guidance for subsequent epidemiological studies of associations between environmental ratings, health and wellbeing.

Evaluation of the placement of mobile fruit and vegetable vendors to alleviate food deserts in New York City.

INTRODUCTION: In 2008, the New York City (NYC) health department licensed special mobile produce vendors (Green Carts) to increase access to fruits and vegetables in neighborhoods with the lowest reported fruit and vegetable consumption and the highest obesity rates. Because economic incentives may push vendors to locate in more trafficked, less produce-deprived areas, we examined characteristics of areas with and without Green Carts to explore whether Carts are positioned to reach the intended populations. METHODS: Using ArcGIS software, we mapped known NYC Green Cart locations noted through 2013 and generated a list of potential (candidate) sites where Carts could have located. We compared the food environment (via categorizing "healthy" or "unhealthy" food stores using federal classification codes corroborated by online storefront images) and other factors that might explain Cart location (eg, demographic, business, neighborhood characteristics) near actual and candidate sites descriptively and inferentially. RESULTS: Seven percent of Green Carts (n = 265) were in food deserts (no healthy stores within one-quarter mile) compared with 36% of candidate sites (n = 644, P < .001). Most Carts (78%) were near 2 or more healthy stores. Green Carts had nearly 60 times the odds of locating near subway stops (P < .001), were closer to large employers (odds ratio [OR], 6.4; P < .001), other food stores (OR, 14.1; P < .001), and in more populous tracts (OR, 2.9, P <.01) compared with candidate sites. CONCLUSION: Green Carts were rarely in food deserts and usually had multiple healthy stores nearby, suggesting that Carts may not be serving the neediest neighborhoods. Exploration of Carts' benefits in non-food desert areas is needed, but incentivizing vendors to locate in still-deprived places may increase program impact.

Relationships between the built environment and walking and weight status among older women in three U.S. States.

There are few studies of built environment associations with physical activity and weight status among older women in large geographic areas that use individual residential buffers to define environmental exposures. Among 23,434 women (70.0 ± 6.9 yr; range = 57-85) in 3 states, relationships between objective built environment variables and meeting physical activity recommendations via walking and weight status were examined. Differences in associations by population density and state were explored in stratified models. Population density (odds ratio [OR] =1.04 [1.02, 1.07]), intersection density (ORs = 1.18-1.28), and facility density (ORs = 1.01-1.53) were positively associated with walking. Density of physical activity facilities was inversely associated with overweight/obesity (OR = 0.69 [0.49, 0.96]). The strongest associations between facility density variables and both outcomes were found among women from higher population density areas. There was no clear pattern of differences in associations across states. Among older women, relationships between accessible facilities and walking may be most important in more densely populated settings.

Availability, accessibility and promotion of smokeless tobacco in a low-income area of Mumbai.

OBJECTIVE: To examine the role of accessibility, product availability, promotions and social norms promotion, factors contributing to the use of smokeless tobacco (ST) products in a typical low-income community of Mumbai community using Geographic Information System (GIS), observational and interview methodologies and to assess implementation of Cigatettes and other Tobacco Products Act (COTPA) legislation. RATIONALE: In India, the third largest producer of tobacco in the world, smokeless tobacco products are used by men, women and children. New forms of highly addictive packaged smokeless tobacco products such as gutkha are inexpensive and rates of use are higher in low-income urban communities. These products are known to increase rates of oral cancer and to affect reproductive health and fetal development. METHODS: The study used a mixed methods approach combining ethnographic and GIS mapping, observation and key informant interviews. Accessibility was defined as density, clustering and distance of residents and schools to tobacco outlets. Observation and interview data with shop owners and community residents produced an archive of products, information on shop histories and income and normative statements. RESULTS: Spatial analysis showed high density of outlets with variations across subcommunities. All residents can reach tobacco outlets within 30-100 feet of their homes. Normative statements from 55 respondents indicate acceptance of men's, women's and children's use, and selling smokeless tobacco is reported to be an important form of income generation for some households. Multilevel tobacco control and prevention strategies including tobacco education, community norms change, licensing and surveillance and alternative income generation strategies are needed to reduce accessibility and availability of smokeless tobacco use.

The effect of tobacco outlet density and proximity on smoking cessation.

OBJECTIVES: We examined the influence of tobacco outlet density and residential proximity to tobacco outlets on continuous smoking abstinence 6 months after a quit attempt. METHODS: We used continuation ratio logit models to examine the relationships of tobacco outlet density and tobacco outlet proximity with biochemically verified continuous abstinence across weeks 1, 2, 4, and 26 after quitting among 414 adult smokers from Houston, Texas (33% non-Latino White, 34% non-Latino Black, and 33% Latino). Analyses controlled for age, race/ethnicity, partner status, education, gender, employment status, prequit smoking rate, and the number of years smoked. RESULTS: Residential proximity to tobacco outlets, but not tobacco outlet density, provided unique information in the prediction of long-term, continuous abstinence from smoking during a specific quit attempt. Participants residing less than 250 meters (P = .01) or less than 500 meters (P = .04) from the closest tobacco outlet were less likely to be abstinent than were those living 250 meters or farther or 500 meters or farther, respectively, from outlets. CONCLUSIONS: Because residential proximity to tobacco outlets influences smoking cessation, zoning restrictions to limit tobacco sales in residential areas may complement existing efforts to reduce tobacco use.

The Mediating role of perceived discrimination and stress in the associations between neighborhood social environment and TV Viewing among Jackson Heart Study participants.

OBJECTIVES: The aim of this study was to test the mediating role of perceived discrimination and stress on associations between perceived neighborhood social environment (PNSE) and TV viewing. METHODS: Baseline data were used for 4716 participants (mean age = 55.1 y; 63.4% female) in the Jackson Heart Study (JHS), a large prospective cohort study of African Americans in Jackson, Mississippi. One binary TV viewing outcome was created: ≥4 h/day versus <4 h/day. PNSE variables included neighborhood violence, problems (higher value = more violence/problems), and social cohesion (higher value = more cohesion). Mediators included perceived lifetime discrimination, daily discrimination, and chronic stress (higher value = greater discrimination/stress). Multivariable regression was used with bootstrap-generated 95% bias-corrected confidence intervals (BC CIs) to test for mediation adjusting for demographics, health-related and psychosocial factors, and population density. RESULTS: Neighborhood violence, problems, and social cohesion were indirectly associated with TV viewing through lifetime discrimination (OR = 1.03, 95%BC CI = 1.00, 1.07; OR = 1.03, 95%BC CI = 0.99, 1.06 [marginal]; OR = 0.98, 95%BC CI = 0.94, 0.99, respectively) and chronic stress (OR = 0.95, 95%BC CI = 0.90, 0.99; OR = 0.96, 95%BC CI = 0.92, 0.99; OR = 1.05, 95%BC CI = 1.01, 1.10, respectively). Daily discrimination was neither directly nor indirectly associated with TV viewing. CONCLUSIONS: Each PNSE variable was indirectly associated with TV viewing via lifetime discrimination and perceived stress, but not with daily discrimination among JHS participants. Unexpected directionality of mediating effects of lifetime discrimination and chronic stress should be replicated in future studies. Further research is also needed to pinpoint effective community efforts and physical environmental policies (e.g., installing bright street lights, community policing) to reduce adverse neighborhood conditions and psychosocial factors, and decrease TV viewing and subsequent cardiovascular disease risk.

Spatial dimensions of research on alcohol and sexual risk: a case example from a Mumbai study.

Alcohol's role in unprotected sex is an important issue in the spread of HIV. Research on alcohol use in many countries has found complex relationships between individual characteristics, places where people drink, and consumption patterns. Data on drinking and leisure time activities and locations from in-person surveys with 1,239 young men aged 18-29 living in low-income communities in Mumbai, India, were analyzed. For every pair of men, an index of association measured the degree of similarity in their reported activities in specific communities. Multidimensional scaling of the similarity matrix revealed men who engaged in similar activities in the same communities. Hierarchical grouping classified men based on their activity dimensions. The ten groups of men, distinguished by their activities in particular communities, also differed in alcohol consumption, number of non-spousal sex partners, and level of unprotected sex. Understanding where activities take place is important in designing venue-based interventions to reduce health risk behaviors leading to the spread of HIV/AIDS.

Choropleth map legend design for visualizing community health disparities.

BACKGROUND: Disparities in health outcomes across communities are a central concern in public health and epidemiology. Health disparities research often links differences in health outcomes to other social factors like income. Choropleth maps of health outcome rates show the geographical distribution of health outcomes. This paper illustrates the use of cumulative frequency map legends for visualizing how the health events are distributed in relation to social characteristics of community populations. The approach uses two graphs in the cumulative frequency legend to highlight the difference between the raw count of the health events and the raw count of the social characteristic like low income in the geographical areas of the map. The approach is applied to mapping publicly available data on low birth weight by town in Connecticut and Lyme disease incidence by town in Connecticut in relation to income. The steps involved in creating these legends are described in detail so that health analysts can adopt this approach. RESULTS: The different health problems, low birth weight and Lyme disease, have different cumulative frequency signatures. Graphing poverty population on the cumulative frequency legends revealed that the poverty population is distributed differently with respect to the two different health problems mapped here. CONCLUSION: Cumulative frequency legends can be useful supplements for choropleth maps. These legends can be constructed using readily available software. They contain all of the information found in standard choropleth map legends, and they can be used with any choropleth map classification scheme. Cumulative frequency legends effectively communicate the proportion of areas, the proportion of health events, and/or the proportion of the denominator population in which the health events occurred that falls within each class interval. They illuminate the context of disease through graphing associations with other variables.

Prediction of activity mode with global positioning system and accelerometer data.

PURPOSE: The primary aim of this pilot study was to assess how well the combination of global positioning system (GPS) and accelerometer data predicted different activity modes. METHODS: Ten adults (seven male, three female; 23-51 yr) simultaneously wore a GPS unit and accelerometer during bouts of walking, jogging/running, bicycling, inline skating, or driving an automobile. Discriminant function analysis was used to identify a parsimonious combination of variables derived from accelerometer counts and steps and GPS speed that best classified mode. A total of 29 bouts were used to develop this classification criterion. This criterion was validated using two datasets generated from the complete collection of minute-by-minute values from all bouts. RESULTS: Model development with "calibration" data showed that two accelerometer variables alone (median counts and steps) resulted in 26 of 29 bouts (90%) being correctly classified. Prediction of activity mode using counts and steps in a minute-by-minute "validation" dataset (N = 200) was 86.5%. Using three variables from the accelerometer and GPS (median counts, steps and speed) resulted in correct classification in 27 of 29 activity bouts in the "calibration" data (93%). In the "validation" dataset comprising 200 min, the combination of accelerometer counts and steps and GPS speed were able to correctly classify 91% of the observations. Walking and bicycling minutes were correctly classified most frequently (96%). In another "validation" dataset consisting of activity bouts, this combination of variables resulted in correct classification in 42 of 43 bouts (98%). CONCLUSION: This pilot study provides evidence that the addition of GPS to accelerometer monitoring improves physical activity mode classification to a small degree. Larger studies among free-living individuals and with an expanded range of activities are needed to replicate the current findings and further determine the merits of using GPS with accelerometers for mode identification.

Spatial Associations of Multiple Chronic Conditions Among Older Adults.

Multimorbidity, the presence of two or more chronic conditions in an individual, presents a major challenge for meeting the health care needs of older adults. This study advances understanding of multiple chronic conditions by using local colocation quotients to reveal spatial associations for five chronic conditions (arthritis, diabetes, heart disease, hypertension, and pulmonary disease) in a statewide panel of older adults in New Jersey. Among adults with three or more conditions, large concentrations of Arthritis-Heart Disease-Pulmonary Disease, Arthritis-Hypertension-Pulmonary Disease, and Diabetes-Heart Disease-Hypertension were observed, each triad located in different regions of the state. Individuals with other triads of conditions, in contrast, were distributed among all older adults in the sample as expected with no areas of local concentration. The study provides gerontologists with a new and effective method for uncovering geographical patterns in combinations of chronic conditions among the populations they serve, thereby enabling more effective interventions.

Spatiotemporal meta-analysis: reviewing health psychology phenomena over space and time.

Individual studies of health psychology are samples taken in particular places at particular times. The results of such studies manifest multiple processes, including those associated with individual, sample, intervention, and study design characteristics. Although extant meta-analyses of health phenomena have routinely considered these factors to explain heterogeneity, they have tended to neglect the environments where studies are conducted, which is ironic, as health phenomena cluster in space and times (e.g., epidemics). The settings in which study participants live, work, and recreate can be characterised by such environmental factors such as disease, weather, local and broad economic trends, the level of stigmatisation of minority groups, and allostatic load due to all causes. We introduce spatiotemporal meta-analysis, designed to address heterogeneity in study environments. We list potential challenges in developing spatiotemporal meta-analyses, and discuss future directions for this form of systematic reviewing methodology. Logically, to the extent that relevant spatiotemporal information on environmental conditions is available and varies widely, it can help to explain variability in study results that is not explained by individual, sample, study, or intervention features.

A Spatial Analysis of Body Mass Index and Neighborhood Factors in Community-Dwelling Older Men and Women.

The spatial distribution of obesity among the older population can yield insights into the influence of contextual factors associated with this public health problem. We tested the relationship between neighborhood-level characteristics and body mass index (BMI) using global and local spatial statistics of geographic clustering, using data derived from a random-digit-dial sample of 5,319 community-dwelling adults aged 50 to 74 residing in 1,313 census tracts in New Jersey. Geographically weighted regression modeled associations between BMI clusters and neighborhood characteristics, including metrics of structure, safety, demographics, and amenities. Across the sample panel, average BMI was 28.62 kg/m(2) for women and 28.25 kg/m(2) for men. There was significant spatial clustering of obesity by census tract, varying by gender across the state. Neighborhood characteristics were more strongly related to BMI for women than men. This research illuminates the role of neighborhood contextual factors and will assist community planners, officials, and public health practitioners as they address the rise in obesity.

Spatial analysis of skilled birth attendant utilization in Ghana.

BACKGROUND: Maternal mortality is a major health problem in most resource-poor settings, especially in sub-Saharan Africa. In Ghana, maternal mortality remains high and births attended by skilled health professionals are still low despite the introduction, in 2005, of free maternal health care for all women seeking care in public health facilities. OBJECTIVES: This study aimed to explore geographical patterns in the risk of not utilizing a skilled birth attendant during childbirth in women of different socioeconomic backgrounds in Ghana. METHODS: Global and Geographically Weighted Odds Ratios (GWORs) were used to examine the spatially varying relationships between low socioeconomic status (low education and low income) and non-utilization of skilled birth attendants based on data from the Ghana Demographic and Health Survey (GDHS) 2008. RESULTS: Low education and low income were associated with non-use of skilled birth attendants. The GWORs revealed a north-south spatial variation in the magnitude of the association between non-use of skilled birth attendants and low education (Log GWOR ranged from 0.75 to 9.26) or low income (Log GWOR ranged from 1.11 to 6.34) with higher values in the north. CONCLUSIONS: The relationship between low socioeconomic status and the non-use of skilled birth attendants in Ghana is geographically variable. Effective governmental and non-governmental interventions are needed to address these regional inequalities.

Virtual and actual: relative accuracy of on-site and web-based instruments in auditing the environment for physical activity.

OBJECTIVES: To assess the relative accuracy and usefulness of web tools in evaluating and measuring street-scale built environment characteristics. METHODS: A well-known audit tool was used to evaluate 84 street segments at the urban edge of metropolitan Boston, Massachusetts, using on-site visits and three web-based tools. The assessments were compared to evaluate their relative accuracy and usefulness. RESULTS: Web-based audits, based-on Google Maps, Google Street View, and MS Visual Oblique, tend to strongly agree with on-site audits on land-use and transportation characteristics (e.g., types of buildings, commercial destinations, and streets). However, the two approaches to conducting audits (web versus on-site) tend to agree only weakly on fine-grain, temporal, and qualitative environmental elements. Among the web tools used, auditors rated MS Visual Oblique as the most valuable. Yet Street View tends to be rated as the most useful in measuring fine-grain features, such as levelness and condition of sidewalks. CONCLUSION: While web-based tools do not offer a perfect substitute for on-site audits, they allow for preliminary audits to be performed accurately from remote locations, potentially saving time and cost and increasing the effectiveness of subsequent on-site visits.

Neighborhood characteristics and depressive symptoms of older people: local spatial analyses.

Depressive symptoms in community-dwelling older people significantly increase the risk of developing clinically diagnosable depressive disorders. Knowledge of the spatial distribution of depressive symptoms in the older population can add important information to studies of neighborhood contextual factors and mental health outcomes, but analysis of spatial patterns is rarely undertaken. This study uses spatial statistics to explore patterns of clustering in depressive symptoms using data from a statewide survey of community-dwelling older people in New Jersey from 2006 to 2008. A significant overall pattern of clustering in depressive symptoms was observed at the state level. In a subsequent local clustering analysis, places with high levels of depressive symptoms near to other places with high levels of depressive symptoms were identified. The relationships between the level of depressive symptoms in a place and poverty, residential stability and crime were analyzed using geographically weighted regression. Significant local parameter estimates for the three independent variables were observed. Local parameters for the poverty variable were positive and significant almost everywhere in the state. The significant local parameters for residential stability and crime varied in their association with depressive symptoms in different regions of the state. This study is among the first to examine spatial patterns in depressive symptoms among community-dwelling older people, and it demonstrates the importance of exploring spatial variations in the relationships between neighborhood contextual factors and health outcomes.

A community-engaged approach to select geographic areas for interventions to reduce health disparities.

BACKGROUND: While neighborhood-based approaches to eliminate health disparities are on the rise, there is little guidance on how researchers may engage with community partners to select geographic areas for interventions to reduce health disparities. We aimed to identify a small geographic area to target interventions to improve diabetes-related outcomes. OBJECTIVES: We describe lessons learned from a community-engaged approach to specify the geographic area of focus. METHODS: A community-academic partnership of more than 20 organizations collaborated to develop and employ a 5-stage process to specify a target area for diabetes preventions and control activities. LESSONS LEARNED: A coalition with local knowledge and ties to the community can develop criteria and direct a process leading to selection of a geographic area, increased research capacity, and strengthened relationships among partners. CONCLUSION: A participatory approach can be effective in defining a geographic area for targeting interventions to reduce health disparities.