1. Neighborhoods and health: A social determinants of health and equity framework Dolores Acevedo-Garcia, PhD, MPA-URP Associate Professor, Bouvé College of Health Sciences Associate Director, Institute on Urban Health Research With funding from the W.K. Kellogg Foundation

2. Outline Social determinants of health and health equity Neighborhood effects Neighborhoods in context: residential segregation and geography of opportunity Data needs

3. Social determinants of health and health equity

4. Factors that influence health Genetics Life style (health behaviors) Health care Social determinants

5. “The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.” World Health Organization, Commission on Social Determinants of Health

6. The socioeconomic gradient in health, Whitehall study, UK (Van Rossum et al. 2000)

7. Social stratification and health (Diderichsen et al. 2001 in WHO Commission on Social Determinants, 2005) Social context Policy context Social position Disease or injury Social consequences of ill health Specific exposure

8. Social stratification Spatial stratification Health stratification

9. Life expectancy=77 Life expectancy=57

10. Social determinants of health Focus on upstream factors (versus downstream factors) Focus on population health and population subgroups Focus on equity Focus on a life course /developmental perspective Focus on relationships between sectors (e.g. housing and health; health and education)

11. What do we know about racial/ethnic disparities in health? Large disparities for many health outcomes; not a significant reduction over time. Not fully accounted for by genetic factors, health behaviors (diet, physical activity, smoking), access to health care. –E.g. racial disparities in birth outcomes

12. What do we know about racial/ethnic disparities in health? Not fully accounted for by racial/ethnic differences in individual level socioeconomic status (e.g. income, wealth, occupation, education). –Look at disparities in context, e.g. neighborhoods Large geographic variation in health outcomes across neighborhood and in extent of health disparities across cities/metros.

13. Acevedo-Garcia, Soobader & Berkman, 2005, The differential effect of foreign-born status on low-birthweight by race/ethnicity and education. Pediatrics. Acevedo-Garcia, Soobader & Berkman, 2007, Low birthweight among US Hispanic/Latino subgroups: The effect of maternal foreign-born status and education. Social Science & Medicine. Low birthweight rates by race/ethnicity, nativity, and maternal education, US 1998 0-11yrs 12yrs 13-15 yrs 16+ yrs

14. Neighborhood effects

15. What are neighborhoods effects? Independent effects of neighborhood conditions on health outcomes (above and beyond the effect of individual level variables). –What would a person’s health be under alternative neighborhood conditions g 0 (bad) and g 1 (good)? Example: Obesity (diet) –Family income –Availability of healthy food options

16. Some mechanisms through which neighborhoods may affect health Stress (crime, safety) Health behaviors, e.g. diet, smoking, physical activity : –Targeting (fast food, tobacco) –Neighborhood physical and social environment (playground quality, walkability, safety) Environmental pollutants Long term effects of limited access to high quality education

17. Why do we care about neighborhood effects? Some neighborhood characteristics may be amenable to change via public policy, political activism, community organizing –location of environmental hazards, recreation facilities, public housing; –density of alcohol outlets; –enforcement of tobacco control policy; –social capital, collective efficacy

18. Neighborhoods in context: residential segregation and geography of opportunity

19. 5/15/2015 Source: 2000 Census Redistricting File. Metro Boston Has a “Majority Minority” Core Along With Many Suburbs That Are Over 90% White

20. Kirwan Institute,Opportunity Mapping

21. Racial residential segregation is at the root of black-white health disparities Acevedo-Garcia 2000, 2001; Acevedo-Garcia & Lochner 2003; Acevedo-Garcia et al. 2003, 2004, 2008; Acevedo- Garcia & Osypuk, 2008; Osypuk & Acevedo-Garcia, 2008; Subramanian, Acevedo-Garcia & Osypuk, 2005; Williams & Collins 2001 Segregation constrains socioeconomic advancement of minorities, Increases exposure of minorities to unfavorable neighborhood environments, Leads to segregation in health care settings, which is associated with disparities in quality of treatment.

22. Hypersegregation and racial disparities in preterm birth Osypuk & Acevedo-Garcia, 2008, American Journal of Epidemiology

23. A definition of children’s health Children’s health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments. (IOM, 2004, Children’s Health: The Nation’s Wealth)

24. Influences on Child Health and Development Child School Family Neighborhood Adult Health, education, productivity, earnings

25. There are large racial/ethnic inequalities children’s access to “opportunity neighborhoods and schools”

26. Black and Latino children experience double and triple jeopardy Black and Hispanic children live in families that disproportionately experienced disadvantage. Disparities among individuals and families are exacerbated by vast inequalities in neighborhood and school environments. Inequalities go far beyond what can be explained by income differences: –Poor black and Hispanic children encounter environments considerably worse than poor white and Asian children.

27. WhiteBlack Neighborhood Poverty Rate Share of Children in Neighborhoods with Specified Poverty Rates 0

28. WhiteBlack Neighborhood Poverty Rate Share of Children in Neighborhoods with Specified Poverty Rates 0

29. Poor WhitePoor Black Share of Children in Neighborhoods with Specified Poverty Rates Neighborhood Poverty Rate 0

30. Poor WhiteAll Black Share of Children in Neighborhoods with Specified Poverty Rates Neighborhood Poverty Rate 0

31. Share of Children Who Experience Double Jeopardy: Live in BOTH Poor Families and Poor Neighborhoods (Percent) Source: Acevedo-Garcia, Osypuk, McArdle & Williams, 2008 Note: Poor neighborhoods are those with poverty rates over 20%. Source: 2000 Census

33. Data needs Health outcomes (by race/ethnicity, and socioeconomic status) Exposures (by race/ethnicity, and socioeconomic status) –Multiple exposures/risks Data on entire neighborhood distributions (not only “high risk”)-equity Policies (beyond neighborhood level)

35. Justice in the Air: Tracking Toxic Pollution from America's Industries and Companies to Our States, Cities, and Neighborhoods, 2009

36. Some questions for discussion Do you resonate with a “social determinants of health framework”? Are you already using it to collect data? Do you know the extent of health disparities in your city/metro?

37. Thank you

38. EXTRA SLIDES

39. Acevedo-Garcia, Soobader & Berkman, 2005, The differential effect of foreign-born status on low-birthweight by race/ethnicity and education. Pediatrics. Acevedo-Garcia, Soobader & Berkman, 2007, Low birthweight among US Hispanic/Latino subgroups: The effect of maternal foreign-born status and education. Social Science & Medicine. Low birthweight rates by race/ethnicity, nativity, and maternal education, US 1998 0-11yrs 12yrs 13-15 yrs 16+ yrs

40. Neighborhood effects on low birth weight Source: Buka et al. 2003 African American infants are twice as likely to be LBW than white infants Individual level maternal characteristics (e.g. age, marital status, smoking) explain only about 50% of this disparity LBW data for Chicago, IL (1994-1996), n=95,711 Average birth weight difference between whites and blacks –297 g before adjustment –154 g after adjustment for individual level factors –124 g after adjustment for “neighborhood cluster” level factors (“neighborhood social support”)

41. Racial/Ethnic Composition of the Child Population: 1980-2050 Note: Hispanics may be of any race. Racial groups include only non-Hispanic members. Multi-race data not available before 2000. Source: US Census Bureau estimates and projections. Projections use Constant Net International Migration Series.

42. A geography of opportunity framework for child development Residential and school segregation result in systematic racial/ethnic differences in the quality of developmental contexts of children. Residential/school segregation result in simultaneous exposure to challenging development contexts, which may lead to differences in child resilience, These differences result in racially/ethnically segmented trajectories of child development.

43. Our own neighborhoods What characteristics make your own neighborhood health-promoting? What characteristics make your own neighborhood health-damaging? Do you think that the characteristics of your neighborhood can influence your personal health? How? Could you describe your neighborhood as health- promoting or health-damaging (i.e. assign it an overall “score”)?