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
Outline
• Social determinants of health and health
equity
• Neighborhood effects
• Neighborhoods in context: residential
segregation and geography of
opportunity
• Data needs
Social determinants of health
and health equity
Factors that influence health
• Genetics
• Life style (health behaviors)
• Health care
• Social determinants
“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
The socioeconomic gradient in health,
Whitehall study, UK (Van Rossum et al. 2000)
Social stratification and health
(Diderichsen et al. 2001 in WHO Commission on Social Determinants, 2005)
Social position
Social context
Specific
exposure
Disease or injury
Policy context
Social consequences
of ill health
• Social stratification
• Spatial stratification
• Health stratification
Life expectancy=77
Life expectancy=57
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)
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
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.
birthweight rates by race/ethnicity,
nativity and
maternal
education, US 1998
LowLowbirthweight
rates
by
race/ethnicity,
nativity, and maternal education, US 1998
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
US-born
Foreign-born
Whites
0-11yrs
US-born
Foreign-born
Blacks
12yrs
0-11 years
US-born
Foreign-born
Latinos
13-15 yrs
12 years 13-15 years 16+ years
16+ yrs
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.
Neighborhood effects
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 g0 (bad)
and g1 (good)?
• Example: Obesity (diet)
– Family income
– Availability of healthy food options
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
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
Neighborhoods in context:
residential segregation and
geography of opportunity
Metro Boston Has a “Majority Minority” Core Along With Many
Suburbs That Are Over 90% White
4/13/2015
Source: 2000 Census Redistricting File.
Kirwan Institute,Opportunity Mapping
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; AcevedoGarcia & 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.
Hypersegregation and racial
disparities in preterm birth
Osypuk & Acevedo-Garcia, 2008, American Journal of Epidemiology
Figure 2. Racial Disparity in Predicted Probability Preterm Birth by
Metropolitan Area Hypersegregation and Maternal Age from Final
Model (in percentage points)
(random slope model)
Racial disparity in predicted probability .
preterm birth .(black minus white)
14%
12%
10%
8%
Racial disparity in
nonsegregated MAs
6%
Racial disparity
hypersegregated
MAs
4%
2%
0%
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
age
5/ 8/ 07
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)
Influences on Child Health
and Development
Neighborhood
Family
School
Child
Adult
Health,
education,
productivity,
earnings
There are large racial/ethnic
inequalities children’s access to
“opportunity neighborhoods and
schools”
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.
Pyramid Graph:
Hypothetical Equal Neighborhood Environment
for 2 Groups: A Mirror Image
Neighborhood
Poverty Rate
Black
Over 40%
White
30.1-40%
20.1-30%
10.1-20%
0-10%
100
75
50
25
0
25
50
Share of Children in Neighborhoods with Specified Poverty Rates
75
100
Metro Chicago
Poverty Composition of Neighborhoods of
Black v. White Children
Neighborhood
Poverty Rate
Black
Over 40%
White
30.1-40%
20.1-30%
10.1-20%
0-10%
100
75
50
25
0
25
50
75
Share of Children in Neighborhoods with Specified Poverty Rates
100
Metro Chicago
Poverty Composition of Neighborhoods of
Poor Black v. Poor White Children
Neighborhood
Poverty Rate
Poor Black
Over 40%
Poor White
30.1-40%
20.1-30%
10.1-20%
0-10%
100
75
50
25
0
25
50
75
Share of Children in Neighborhoods with Specified Poverty Rates
100
Metro Chicago
Poverty Composition of Neighborhoods of
All Black v. Poor White Children
Neighborhood
Poverty Rate
Over 40%
All Black
Poor White
30.1-40%
20.1-30%
10.1-20%
0-10%
100
75
50
25
0
25
50
75
Share of Children in Neighborhoods with Specified Poverty Rates
100
Share of Children Who Experience Double Jeopardy:
Live in BOTH Poor Families and Poor Neighborhoods (Percent)
Source: Acevedo-Garcia, Osypuk, McArdle & Williams, 2008
25
20.5
20
16.8
15
10
5
1.4
0
White
Black
Note: Poor neighborhoods are those with poverty rates over 20%.
Source: 2000 Census
Hispanic
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)
Justice in the Air: Tracking Toxic Pollution from
America's Industries and Companies to Our
States, Cities, and Neighborhoods, 2009
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?
Thank you
EXTRA SLIDES
birthweight rates by race/ethnicity,
nativity and
maternal
education, US 1998
LowLowbirthweight
rates
by
race/ethnicity,
nativity, and maternal education, US 1998
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
US-born
Foreign-born
Whites
0-11yrs
US-born
Foreign-born
Blacks
12yrs
0-11 years
US-born
Foreign-born
Latinos
13-15 yrs
12 years 13-15 years 16+ years
16+ yrs
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.
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”)
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.
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.
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 healthpromoting or health-damaging (i.e. assign it an
overall “score”)?