Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (2004) / Chapter Skim
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11 What Makes a Place Healthy? Neighborhood Influences on Racial/ Ethnic Disparities in Health over the Life Course
11 What Makes a Place Healthy? Neighborhood Influences on Racial/ Ethnic Disparities in Health over the Life Course
Pages 406-449
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From page 406... ...
This concern is captured by the search for so-called "neighborhood effects," which generally refers to the study of how local context influences the health and well-being of individuals in a way that cannot be reduced to the properties of the individuals themselves. Most of the research on neighborhood effects has focused on social and behavioral outcomes, including child cognitive and behavioral development, school dropout, educational attainment, crime and delinquency, substance use, sexual activity, contraceptive use, childbearing, income, and 406
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From page 407... ...
For example, whereas the sociological literature on neighborhood effects has taken a "process turn" in recent years and begun to focus more on the mechanisms that explain why neighborhoods matter (Sampson et al., 2002) , most research on the neighborhood context of health is still attempting to establish that context matters.
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From page 408... ...
Rather than engaging in a comprehensive literature review -- excellent reviews already exist (e.g., DiezRoux, 2001; Ellen et al., 2001; Pickett and Pearl, 2001; Robert, 1999; Yen and Syme, 1999) -- in this chapter we will focus on issues relating to the current state of research on neighborhoods and health, the dimensions of neighborhood environments that may be related to health, the pathways through which neighborhoods translate into specific types of health outcomes, how neighborhood effects intersect with the study of aging and the life course, and selection processes relating to the sorting of individuals into neighborhoods.
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From page 409... ...
WHAT DO WE KNOW ABOUT NEIGHBORHOODS AND HEALTH? One of the hallmarks of neighborhood effects research is its attention to the potentially confounding influences of individual-level attributes in making neighborhood-level inferences, either through the use of multilevel research designs and statistical methods, or through randomized experimental designs.
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From page 410... ...
One recent review (Pickett and Pearl, 2001) identified 25 multilevel studies of neighborhood effects on health, 23 of which reported significant associations between health and at least one measure of neighborhood socioeconomic status.
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From page 411... ...
, nearly all of the multilevel studies we reviewed found that after controlling for individual-level characteristics, there is still an association between neighborhood environments and health outcomes. However, these studies varied widely in the way they operationalized the concept of neighborhood and measured neighborhood characteristics, making it difficult to reach a conclusion about the magnitude and substantive importance of these effects.
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From page 412... ...
Neighborhood Context and Racial/Ethnic Disparities in Aging Health Given that race/ethnic minority groups are disproportionately exposed to disadvantaged social environments, it is not surprising that many researchers have looked to neighborhood environmental factors, such as residential segregation and the concentration of poverty, as potential explanations for racial/ethnic disparities in health (e.g., Williams and Collins, 1995b)
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From page 413... ...
. They found that the introduction of contextual variables reduced the mortality risk for African Americans and Puerto Ricans by 12 and 14 percent, respectively, but significant mortality disparities remained even after adjusting for neighborhood characteristics.
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From page 414... ...
In sum, although there is relatively little research on how the relation between neighborhood environments and health may vary across demographic subgroups, the available evidence suggests that racial/ethnic differences in neighborhood context may account for a large proportion of racial/ethnic disparities in health (focusing primarily on mortality) , but there is more disagreement on whether and how neighborhood effects vary across
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From page 415... ...
One problem with the current state of this research is that neighborhood characteristics are used somewhat interchangeably and with little theoretical justification in the search for neighborhood effects. Whereas many frameworks have been proposed for organizing individual-level predictors of health status into conceptual categories and for determining the order in which they should be entered into statistical models, health researchers are much less accustomed to thinking about neighborhood-level mechanisms and how they are interrelated.
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From page 416... ...
. Moreover, studies have shown that African-American neighborhoods are more likely to suffer from institutional risk factors such as the proliferation of liquor stores and insufficient supplies of prescription drugs at local pharmacies (LaVeist and Wallace, 2000; Morrison, Wallenstein, Natale, Senzel, and Huang, 2000)
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From page 417... ...
. A closely related group of neighborhood characteristics includes physical and geographic features of the local environment, such as natural amenities, street layout, and pollution.
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From page 418... ...
argues that prolonged exposure to high-stress neighborhood environments can take a cumulative toll on maternal health in the form of "weathering." Although there is relatively little research on crime and health, some evidence shows that fear of crime may be a key mechanism in explaining the effects of neighborhood structural characteristics on self-rated health and mental health (Aneshensel and Sucoff, 1996; Chandola, 2001; Cutrona, Russell, Hessling, Adama Brown, and Murray, 2000; Geis and Ross, 1998; Ross and Jang, 2000; Ross et al., 2000) and that higher neighborhood crime is associated with a greater risk of low birthweight (Collins and David, 1997; Morenoff, 2003; Zapata, Rebolledo, Atalah, Newman, and King, 1992)
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NEIGHBORHOOD INFLUENCES 419 1998; Ross and Jang, 2000; Ross et al., 2000)
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found that the neighborhoods with higher levels of reciprocal exchange among neighbors and participation in local voluntary associations are protective against the risk of low birthweight, even after adjusting for a large set of sociodemographic, behavioral, and biomedical individual-level risk factors. A recent study of middle-aged women in Sweden shows that greater levels of neighborhood social participation also increases the use of hormone replacement therapy (HRT)
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From page 421... ...
PATHWAYS TO HEALTH: SPECIFICITY, NATURAL HISTORY, AND LIFE COURSE We now consider how future research could improve our understanding of the pathways through which neighborhoods come to affect health by proposing three related ideas that we believe are useful for better understanding how neighborhoods might affect racial/ethnic disparities in aging and health: (1) why we need to think about specific outcomes related to neighborhood effects on health, (2)
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From page 422... ...
MORENOFF AND JOHN W LYNCH Neighborhood Effects and the Specificity of Health Outcomes The first idea involves conceptualizing "health." Obviously health is multidimensional and cannot be captured in a single outcome, although there are many useful summary measures of health, such as overall mortality and life expectancy, and measures that tap into disease burden as well as death, such as disability-adjusted life years (DALY)
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From page 423... ...
Neighborhood Effects and the Natural History of Different Health Outcomes The second and related principle is to consider the natural history of different types of health outcomes and at which stage in the natural history of an outcome neighborhood environments might be most relevant. For many health outcomes, especially chronic disease outcomes,
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This clearly implicates disparities in a large array of different health outcomes and implicates different mechanisms. Neighborhood Effects and the Life Course The third principle also relates to the first two and involves considering life-course processes (Kuh and Ben Shlomo, 1997)
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have detailed the risk factors for incident coronary heart disease according to stages of the life course: · Maternal health, development, and diet before and during pregnancy · Parental history of CHD
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MORENOFF AND JOHN W LYNCH · Low birthweight · Socioeconomic deprivation from childhood onward · Stress from childhood onward · Poor growth in childhood · Short leg length in childhood · Obesity in childhood · Certain infections acquired in childhood · Poor diet from childhood onward · High blood pressure in late adolescence · High serum cholesterol in late adolescence · Smoking from late adolescence onward · Little physical activity from late adolescence onward · High blood pressure in adulthood · High serum cholesterol in adulthood · Obesity in adulthood · Job insecurity and unemployment in adulthood · Short stature in adulthood · Binge alcohol drinking in adulthood · Diabetes and components of syndrome X in adulthood · Elevated fibrinogen and other acute phase reactants in adulthood · Certain infections acquired in adulthood This list summarizes factors that are putative CHD risk factors and of particular interest from a life-course perspective, according to their period of influence.
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From page 427... ...
If we consider the schema presented in Figure 11-1 as a representation of some of the factors involved in the natural history of CHD across the life course, we could ask many questions about the potential for neighborhood processes to affect CHD at one or more points in time. Neighborhood effects on CHD are likely to be stronger at some stages than others.
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From page 428... ...
The life-course approach to chronic diseases such as CHD in adulthood -- and therefore the life-course approach to disparities in the distribution of chronic diseases in adulthood -- attempts to move beyond an epidemiology that concentrates on individual-level risk factors acting in a relatively instantaneous and supposedly independent manner. This search for instantaneous and independent contributors to risk is partly an outcome of the underlying model of disease causation, captured in the well-known metaphor of the "web of causation." Although the idea of a complex web of causal components -- even a web of multilevel contextual causal components -- is certainly useful, it does not explicitly include a temporal component and masks the fact that what we observe at any point in time as an array of adult risk factors for CHD is the result of interlacing multilevel chains of biological and social exposures that have coevolved over time.
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From page 429... ...
Thus, a study of obesity may find no evidence of contemporaneous neighborhood effects after controlling for individual dietary patterns, but these dietary patterns may carry with them the indirect effects of prior exposure to neighborhoods in which fresh fruit and vegetables were not widely available and dietary norms promoted less healthy nutritional practices. SELECTION PROCESSES Tilly (2002)
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From page 430... ...
. In the following section we consider how selection processes may distort estimates of neighborhood effects and racial/ethnic health disparities in nonexperimental research through a case study of mortality in Chicago neighborhoods.
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In addition to the possibility that less healthy people are selectively sorted into the most disadvantaged neighborhood environments, we argue that in some contexts it is equally possible that less healthy people may be selectively sorted into more affluent neighborhood environments. A Case Study of Mortality in Chicago Neighborhoods In this section we present the results of a multilevel analysis on mortality in Chicago neighborhoods to illustrate the connection between neighborhood environments and racial/ethnic disparities in mortality, and also to suggest how attending to selection processes may be critical to advancing our understanding of these disparities.
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These factor scores have been used in previous research on Chicago neighborhoods and the details of the principal components analysis are reported elsewhere (Sampson et al., 1997)
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From page 433... ...
Because race/ethnicity is now fully interacted with the other characteristics in the model, the racial/ethnic group coefficients in model 3 are no longer comparable to those in models 1 and 2. We focus our discussion of these results on the association between neighborhood disadvantage and mortality, and its implications for racial/ ethnic mortality disparities, because concentrated disadvantage is such a pivotal construct in neighborhood health research.
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From page 434... ...
1,000. Census Neighborhood-Level Coefficient 0.20 0.95 2.70 0.07 0.39 0.01 0.44 4.88 by and and multiplied Statistics concentration been Vital Individual level have disadvantage ª Chicago level stability 11-3 American American American American American race immigrant American American ª squared cubed African Hispanic Other ge African Hispanic Other African Hispanic Other African Hispanic Other African Hispanic Other African Hispanic Other African Hispanic Other ªCoefficients SOURCE: TABLE Variable Individual A Age Age Female Neighborhood Concentrated Hispanic Residential Intercept
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From page 435... ...
As is the case in previous mortality research, we observe a black-white crossover in the mortality hazard curves, but with a distinctive twist involving the level of neighborhood disadvantage. At younger ages, African Americans living in highly disadvantaged neighborhoods (75th percentile of disadvantage)
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From page 436... ...
At the same time, those who survive to older ages in more disadvantaged neighborhoods may be selectively less frail because they have had to overcome greater ecological risks. These are examples of selection processes that would result in the counterintuitive greater mortality risk in affluent compared to disadvantaged neighborhood environments.
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From page 437... ...
, as opposed to a strategy of constructing neighborhood indicators based on a single individual's report of his or her neighborhood. Another trend in this direction is the recent advance in collecting observational data on the physical and social features of neighborhood environments.
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From page 438... ...
Researchers should thus attempt not only to control for selection, but also to study such processes more directly by collecting information on residential histories and integrating this analysis into the study of neighborhood effects on health. Understanding residential histories would also address concerns we have raised about the life course and timing of an individual's exposure to neighborhood environments.
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From page 439... ...
ENDNOTES 1. Some public health researchers also use neighborhood variables, such as Census tract income, as proxies for unmeasured characteristics at the individual level, such as socioeconomic status (Alter et al., 1999; Geronimus and Bound, 1998; Krieger, 1992)
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From page 440... ...
. Life course perspectives on coronary heart disease, stroke and diabetes.
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From page 441... ...
. Capturing social process for testing mediational models of neighborhood effects.
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From page 442... ...
. Neighborhood environments and coronary heart disease: A multilevel analysis.
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From page 443... ...
. People, places and coronary heart disease risk factors: A multilevel analysis of the Scottish Heart Health Study archive.
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From page 444... ...
. A life course approach to chronic disease epidemiology.
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. Neighborhood effects and self-selection.
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From page 446... ...
. Neighborhood risk factors for low birthweight in Baltimore: A multilevel analysis.
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From page 447... ...
. Assessing "neighborhood effects": Social processes and new directions in research.
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From page 448... ...
. Cardiovascular risk factors and the neighbourhood environment: A multilevel analysis.
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From page 449... ...
. Neighborhood social environment and risk of death: Multilevel evidence from the Alameda County study.
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