Context: Natural amenities including green and blue space, topography, and climate affect health. It is unclear if this relationship holds true in a population of chronically ill primary care patients. Objective: To explore the relationship between natural amenities and physical and mental function in the chronically ill. Human Subject Review: Approved by the University of Vermont IRB. Design: Cross-sectional analysis using patient survey data from a multi-center randomized control trial, Integrating Behavioral Health and Primary Care. Setting: 41 Primary Care Practices in 10 states. 3,352 adults with chronic medical (heart disease, diabetes, lung disease, or arthritis) and behavioral (mood disorder, insomnia, substance abuse, chronic pain, or irritable bowel syndrome) conditions. Main and Secondary Outcome Measures: Mental and physical function (DASI, GAD-7, PHQ-9, and PROMIS-29). USDA Natural Amenities scale at the county level. Anticipated Results: The natural amenities scale ranges from -6.4 (Grand Forks, North Dakota) to 11.2 (Ventura, CA). We expect anxiety, depression, pain interference, and fatigue to decrease as natural amenities increase. Likewise, we expect physical function, sleep, and participation in social activities to increase as natural amenities increase. However, we do not expect a linear relationship. We hypothesize that once natural amenities hit a threshold, the impact on health will become negligible, with the majority of the impact happening at the lower end of the scale. Above ~1, we suspect diminishing returns of improved health, as has been observed in the income and happiness literature. Once some criteria are met (milder, sunnier winters, less humid summers, some variation in topography or access to some blue and green space) for a favorable natural environment, other county level competing factors (urban/rural status, built environment) will replace the impact of the natural amenities on mental and physical health.
Outcomes to be reported: Multivariable regressions describing the relationships between the natural amenities scale and DASI, GAD-7, PHQ-9, and PROMIS-29 subdomains and summary scores, potentially adjusting for age, sex, race, ethnicity, marital status, income, education, at the individual level and social deprivation index, urban-rural status, and population density at the census tract level.