1. Incorporating neighborhood context into the study of health outcomes Jennifer F. Culhane, MPH, PhD Drexel University College of Medicine Department Of Obstetrics and Gynecology

2. OUTLINE How are neighborhoods defined? How are neighborhoods characterized and what are sources of neighborhood data? How can neighborhood conditions affect health? What is the scientific evidence in support of this idea? What are the major challenges in this field?

3. Neighborhood Definitions Administrative units –blocks –block groups- counties –census tracts- states Political units - wards- State Senatorial Districts - City Counsel Districts- State Rep. Districts Service Districts - health districts- fire battalion boundaries - police districts- school boundaries - recreation districts- postal zip codes Self-defined neighborhood boundaries - shared environment - natural boundaries

4. Census Tract verses Block Group

5. Police Districts

6. Recreation Districts

7. School District Boundaries

8. Characterize Neighborhoods What Types of Data Do You Need? Endogenous data: aggregates of individual characteristics, e.g., poverty rate, percent married, percent female headed households, percent unemployed – indirect measures Direct measures: measure of the built environment like “walkability”

9. Sources of Neighborhood-level Data Administrative and public health data at the address level Census data at the block, block group, and census tract level Proprietary data Primary data collection

10. Sources of Data

11. Direct Mechanisms Community Social Environment  Social relationships  transmit information  Neighborhood cohesion  social control  Shared cultural norms and values  Civic participation  demand services  Access to education and employment Community Service  Grocery stores  Recreational opportunities  Health care facilities  Retail stores Physical Environment  Toxicants  Noise  Poor housing

12. Indirect Mechanisms Chronic Stress Selye, 1956 “General Adaptive Response”  Alarm, resistance, exhaustion.  Repeated cycles lead to cumulative damage to organism. McEwen & Stellar, 1993—Allostatic Load  The cost of maintaining stability through change Mental Health  Negative Emotions  Depression  Anger/hostility

13. How Does Neighborhood Stress Get Under Your Skin?

14. Biological Mediators to Stressful Exposures

15. Conceptual Framework

16. Neighborhood Effects: Evidence Community context consistently has a “modest association” with numerous health outcomes.  25 studies reviewed  Developed countries  Individual-level attributes controlled for  23/25 had significant neighborhood effects Reviewed in Pickett & Pearl, J. Epidemiol Community Health, 2001; 55

17. Neighborhood-Level Effects have been found in: All cause mortality Chronic disease among adults Self-rated health Long-term disability Cardiovascular symptoms or disease Respiratory function Health Behaviors (i.e.,-smoking, sexual practices) Domestic Violence Low birth weight and preterm birth

18. Neighborhood Effects Vary… In nature and intensity at different life stages By gender By age By family structure By individual-level attributes

19. What are the Challenges? 1.What is the theory linking contextual variable and outcome of interest? 2.What is context? –Geographic? Work, Religious affiliations, Clubs, Social Networks ? 3.What contextual-level variables should be measured? 4.What is the spatial range of a contextual variable? 5.What statistical techniques should be employed? 6.Limitations of a cross-sectional design-when to measure context? 7.What individual-level characteristics need to be controlled for? endogeniety vs. over control

20. Over Control vs. Endogeneity

21. Social Conditions as Fundamental Cause

22. Endogeneity

23. Endogeneity vs. Over control Smoking may be the proximal cause but neighborhood distress may be the “true” distal cause. Or, for some reason, people who smoke are “selected” into neighborhood #1 thus neighborhood characteristics have no ‘true’ association to risk of low birth weight

24. Endogeneity vs. Over Control The “selection” or “confounding” issue is the key problem in observational studies of neighborhood effects. Epidemiology has attempted to account for this by adjusting for numerous individual-level attributes- confounding. The “nagging” problem is that these individual- level attributes may be mediators and not confounders. Ana V. Dies Roux, Social Science & Medicine 58 (2004) 1953-1960

25. Individual and Neighborhood Effects Neighborhood ANeighborhood B

26. Individual and Neighborhood Effects Neighborhood A Neighborhood B Individual Attribute Protection

27. Individual and Neighborhood Effects Neighborhood A Neighborhood B Individual Attribute Protection Neighborhood Characteristic Protection

28. Key Messages Neighborhoods can be defined in many ways The definition of ‘neighborhood’ must be appropriate for the research question Many different types of data can be used to characterize neighborhoods There are plausible direct and indirect pathways by which neighborhood conditions can affect health

29. Key Messages There are numerous challenges in studying the effect of neighborhood conditions on health In the arena of reproductive outcomes neighborhood conditions may be a fruitful avenue for explaining the race/ethnic difference in preterm birth